Whatever Happened to Bedside Manner?

I’ve said it before, and I’ll say it again: the doctor-patient relationship is just that—a relationship, a mutual connectedness between two human beings, each with their own values, dispositions, and priorities. Like all relationships, this one is complex, but there is a single concept that manages to capture a lot of what doctors are expected to bring to their partnership with patients: empathy.

Empathy is key to what we’ve traditionally called “bedside manner,” or the ability of doctors to identify with the concerns and emotions of their patients in order to reassure them and more generally ensure effective communication. Every one of us probably has an intuitive understanding of why empathy is a valued trait in doctors, but it’s worth exploring the issue further—especially since it seems to be in short supply amongst today’s doctors, in part thanks to the rigors of medical school.

We’re not talking about warm and fuzzy nonsense here. Empathy is “more than a nice idea,” say Donald Scott and William R. Harper, two professors at the University of Chicago, “it’s a pragmatic skill that stands at the center of the patient-doctor connection, on which so much else depends.” That skill isn’t just about feeling for patients, but also about expressing those feelings, through words, body language, and tone. In 2006, Harper gave the University of Chicago Magazine an example of empathy’s importance: “If the connection is strong, the patient is more likely to follow a doctor’s recommendations. You can order the fanciest test in the world but if the patient does not buy into it, it doesn’t matter.”

The best way for patients to ‘buy into’ treatments is to feel that their doctors understand and appreciate their situation.  “Irrespective of the disease, when you find someone who will feel for you, you feel better,” U of C neuroscientist Jean Decety told the university magazine. Indeed, studies show that a stronger doctor-patient relationship contributes to improved health outcomes by ensuring that health situations are clearly understood and patient priorities are met. Empathy also reduces the burden on the friends and family who care for terminally ill patients.

Clinical research notwithstanding, most of us probably don’t need convincing that empathy is important in a doctor. Empathy and its components—communication, identification, and connection—are regularly cited as patients’ top concerns when it comes to choosing doctors. A 2005 Wall Street Journal/Harris Interactive poll reported that patients’ first priority is to have a doctor with strong interpersonal skills: eighty-five percent of Americans said that it was “extremely important” for their doctor to act respectfully toward them, and 84 percent said the same for listening carefully and being “easy to talk to.” A 2004 Harris poll of 2,267 U.S. adults found that respondents cared more that doctors listened to their concerns and questions than they did about doctors being up-to-date on the latest medical research and treatment. And a review of 25 surveys on doctor-patient relationships in a 2001 edition of The Lancet said doctors with good bedside manners had a better impact on patients than physicians who were less personal.

Clearly, empathy is a desirable trait in doctors. So how do physicians stack up to our empathic ideal? While it’s impossible to generalize about some universal level of medical empathy, a steady stream of research suggests that, at the very least, reality doesn’t live up to the bedside ideal. 

One of the more startling of such studies comes from Eastern Washington University, which surveyed 224 of its undergraduates in 2003 to get a sense of how career aspirations squared with empathy levels. Researchers asked students about their professional plans for the future and tested them through two assessments of empathy: the so-called Hogan's Empathy Scale, which measures an individual's ability to understand another's viewpoint, and the Balanced Emotional Empathy Scale (BEES), which measures an individual's ability to feel what another person is feeling.

Researchers divided the cohort into seven career groups: mental health; education; allied health professions (e.g. medical assistants, nutritionists, device technicians); medical professions (including physicians, dentists, and veterinarians); business; science; and law. Somewhat surprisingly, they found that “people planning medical careers were significantly less empathetic than those planning careers in nonmedical mental health or education” and that future medical professionals’ empathy levels were not higher than students planning careers in business, science, or law in any statistically significant way. It’s probably safe to say that most of us value empathy in our doctors more than we do in, say, our stockbrokers—so there’s something unsettling about the study’s findings.

Of course, this is not to say that all would-be doctors are cold-blooded. In fact, one study in the March 2008 edition of Academic Medicine reported that entering male medical students do in fact score higher on empathy scales that males not pursuing medicine. But don’t take too much solace in this fact: in terms of empathy, it’s all downhill once students enter medical school, which is largely focused on competition, prestige, and scientific aptitude.

In the March study, researchers from the University of Arkansas for Medical Sciences tested medical students from the classes of 2001-2004 through BEES at the beginning of every one of their four years at medical school. Simply put, the authors found that “the first three years of medical education significantly decreased students'…empathy,” as measured by the BEES, which asks student questions about specific situations and has them report the intensity of their emotional response (e.g. do emotions linger with them after seeing intense films?). While it’s hard to pinpoint the exact culprit for this decline researchers locate the problem in the general ‘boot camp’ feel of medical school, where students often feel abused by their mentors and role models, are quickly fatigued by relentless training, and lack patient continuity that could solidify a professional understanding of patients as three-dimensional partners in the treatment process.

The trajectory of this decline differed depending on the gender and specialty of the student: “entering female students had empathy scores that were comparable with those of the normal female population until after completion of the junior year, when they dropped below the norm,” while “entering male students…had empathy scores that were significantly higher than those in the normal population”—but saw their empathy drop to normal levels after their freshman or junior year, depending on their specialty.

Generally speaking, empathic students were found to pursue “core specialties,” characterized by continuity of patient care (family medicine, pediatrics, internal medicine, OBGYN, and psychiatry). Other students pursued “noncore specialties,” or those fields “where there is less interpersonal contact and continuity of care…for instance, emergency medicine, surgery, radiology, pathology.” Pulmonary oncology would also fall in this category, and a new study from the University of Rochester, published this week in the Archives of Internal Medicine, provides a glimpse into how these specialists respond to patients.

In the study, researchers analyzed 20 recorded and transcribed doctor-patient interactions from a larger observational study of 137 patients who were consulting with thoracic surgeons and oncologists for surgical diagnoses of lung cancer or a pulmonary mass. The authors looked at transcripts to pinpoint moments in the doctor-patient interaction where doctors had a chance to show that “they identify with and understand what another person is going through.” (A simple example is responding to a terminally ill patient who says ‘I told my family about it yesterday’ by replying ‘that must have been difficult.’) All in all, researchers found 384 ‘empathic opportunities’ where physicians could have or did responded to patient comments or worries with some sort of personal response—but they did so on only 30 occasions, ignoring 90 percent of the opportunities to connect with a patient.

Most of the time doctors shifted to "biomedical questions and statements” when confronted with emotional, expressive patients—a dynamic which can make an outside observer cringe. Consider the transcript snippet below:

Patient: No, sir, I've never had a heart attack, Supposedly, I worked very hard when I was a young man, a young boy. I was doing a man's labor and I was always told I had a good strong heart and lungs. But the lungs couldn't withstand all that cigarettes...
Physician: Yeah.
Patient: Asbestos and pollution and second-hand smoke and all these other things, I guess.
Physician: Do you have glaucoma?

Now, before condemning doctors as soulless monsters, it’s important to keep in mind that they need to keep some sort of scientific distance from their work. No one wants a physician who’s a sobbing mess when times get tough. In that sense, medical school serves the vital function of toughening up doctors and helping them see medical crises as problems with solutions, rather than as heart-breaking catastrophes. And they’re pretty good at doing so: in October of last year, Chicago’s Decety compared the reaction of doctors to those of laypeople upon watching a video of patients receiving a painful acupuncture treatment. When laymen saw the video, the parts of the brain associated with pain, emotion, and empathy were activated by the images—but in doctors’ brains those circuits were suppressed, and instead there was activity in the areas associated with logical thinking and calculation.

Still, the key is not going too far in either direction—not too hard, not too soft—and evidence suggests that there’s no reason to be concerned that doctors are the latter. So how can we better train the doctors of the future in the art of empathy? 

One creative strategy is to use actors as teachers in medical schools. In 2003, the Washington Post reported on one class that had been held at the University of Texas-Houston and Columbia University, taught by a stage actor, called “The Craft of Empathy.” The course “shows doctors-in-training how to use actors' techniques to become aware of the emotional subtext of patient encounters,” such as teaching them “ways to use their bodies and facial expressions to convey openness [and] telegraphing a response even if they think that they are too tired and stressed-out to summon one.”

Virginia Commonwealth University has a similar course, whose design has been crafted through research. In 2004, 20 medical students at Virginia Commonwealth University entered a study where 16 of them began a program directed by professors from the theater department that trained them in the language, gestures, and expressions of empathy. Researchers found that scores “for the…group [that took the theater class] were significantly better than those in the control group for empathetic communication, relating to the listener, nonverbal communication, respect for dignity, and overall impression” when dealing with patients.

Of course, in the end it’s going to take more than acting lessons to help institutionalize empathy. The biggest problem, as noted by the University of Arkansas research team, is the organization and priorities of medical school. The main issue is life at medical school outside of the formal class curriculum—what experts call the “informal” and “hidden” curricula. The informal curriculum is the social environment in which students interact with each other and faculty, while the hidden curriculum is “a set of influences that function at the level of organizational structure and culture (e.g., advertising the amount of National Institutes of Health dollars the institution garners or espousing the need for basic science rather than humanities courses when applying to medical school).” In other words, institutionalizing empathy is an issue of building relationships within medical schools and emphasizing new priorities in the organizational culture.

The Indiana University School of Medicine provides a good example of how a med school can address these issues. Some of the reforms it has  pursued over the past decade to grapple with its informal and hidden curricula include new teaching and achievement awards associated with compassion, more opportunities for student feedback, a greater emphasis on mentorship, and use of websites and blogs to encourage more interactive learning. In general, the emphasis is on highlighting the importance of the “human” side of medicine, as opposed to only rewarding or emphasizing its technical dimensions.

The key principle behind these admirable reforms is that there needs to be a sort of renaissance in bedside manner—that, as Judy Ruggle of the Medical College of Ohio put it to the American Medical Association in 2005, “bedside manners…matter,” because “healing is relationship-driven.” It’s hard to say it any better than that.

Comments

[Ddx:dx]

Excellent discussion of the empathy trait, but it is just one of many traits for a physician. I think your point is about the relative value placed on it from the Medical Industrial Education system. But empathy can make you rich too.
I was Chief of Staff for a small hospital when we were made aware by an insurance company that an Orthopedic doc on our staff did 10x more shoulder surgeries than any other orthopod they knew of. I knew he did alot, but come to think of it he had priviledges at two other hospitals in the area. When we got their numbers it was amazing.Ten or fifteen a week.
These were shoulder scopes for "pain"....The question became, were they indicated? No one could answer this. Even the "experts" hedged. We asked the guy to go to a "doc analysis" center. He agreed. Their conclusion:
He made up his mind quickly.
He was not open to criticism.
But he scored the highest on empathy of anyone they had measured. The practice patients LOVED him....
And he was an excellent surgeon. Few complications.
And how does one do a double blind trial on this one? Maybe his empathy was as effective as the scope....
Personally, my empathy skills drop off at about 2AM.

[Number Needed To Treat]

As always, an excellent post on a complex subject. All too often the medical blogosphere treats subjects like this with contempt and dismisses them instead of providing critical analysis.

After reading the original study that brought all of the attention to this subject, my initial thoughts turned to the training of physicians as well. However, in addition to the explanation you've provided here, I think another important mechanism is at work here. The training of doctors requires learning large (very large) volumes of complex concepts in relatively short times. This process takes up much of an individual's cognitive capacity and leaves little left over for dealing with subjects not explicitly taught. For example, when a medical student first begins to see patients, he or she is so consumed with pulling on their recent courses in biochemistry, anatomy, physiology, etc and focused on fitting the presentation of the patient into specific diagnostic categories that little attention may be paid to the patient's "emotional presentation." Although this is clearly not ideal, it is necessary. A physician must first devote attention to the scientific facts of a case before being able to address emotional concerns. As med students become residents, residents become attendings, and attendings move on to senior positions, they obviously become more familiar with diagnoses and treatments, thus allowing them to focus more of their attention on empathizing with the patient. However, if a doctor has spent several years in training focusing solely on the biomedical aspects of cases, this bad habit will be formed by the time they gain enough experience to devote time and attention to the emotional state. The role of ensuring good "bedside" practices falls to senior physicians. Some training in the classroom may be useful, but ultimately it is the example mentors set that will improve this problem.