Empathy: How an idea forever changed my approach to patients

As an incurable compulsive introspect, I tend to brood, ponder, contemplate, and (of course) muse on “big ideas,” such as:

  • What makes people choose things which cause themselves harm?
  • Are some people better people than others, or are they just more skilled at hiding their problems?
  • Is pain really a bad thing, or is our aversion to it a sign of human weakness?
  • Does God ever wear a hat?
  • Do dogs watch Oprah?
  • Why did I put “big ideas” in quotes?

Tough questions.

Lately I’ve been contemplating the nature of human awareness:

  • Is self-awareness (the ability to think of ourselves in the third person) a uniquely human trait, and is lack of self-awareness the essence of mental illness?
  • Is empathy, or other-awareness the highest of human traits?  Is this what the biblical idea of being “made in the image of God” really means?

Yeah, that’s a lot deeper than about dogs watching Oprah.  The second of these questions seems to be a very important dividing point in people’s ability to have good relationships with others.  Our ability to put ourselves into the place of others, pondering their motives, thoughts, and emotions, goes a very long way in helping us develop deep relationships and avoiding causing inadvertent pain.

It also seems to be a trait that is in short supply in our health care system.  I am amazed and deeply disturbed by how callously many my patients have been treated by some of my colleagues.  Patients are seemingly treated as a commodity, a necessary evil required for billing of services.

I do understand that doctors and nurses are drained of their ability to show compassion by a system that puts them in an adversarial relationship with patients, hospital administrators, insurance companies, lawyers, and their fellow doctors and nurses.  That feeling of burnout in me was one of the big reasons I left my old practice.  Either I had to change my compassion, or my situation.

Still, I am appalled at how many times patients’ worries are not addressed, their pain is questioned, and their truth is doubted.  More and more, patients are assumed to be manipulating, exaggerating, or making things up, and so must disprove these assumptions to get any kind of good care.  Seeing this in the people I worked with was the other big reason I left my practice to do things differently.

While I think it’s probably part of my DNA to be more compassionate than most, there is one event that affected me more than any other — a moment where I suddenly saw things so differently that it dramatically changed my approach to my patients.

Ironically, my turning point was on a trip sponsored by a drug company to Puerto Rico.  Yes, I know, I know, this kind of thing is now viewed as an act of evil avarice.  They were trying to buy my prescribing habits by offering me all sorts of nice things.  In my defense, I was young, not very rich, had four kids, and had never been able to afford a real family vacation.  These kinds of perks were very common at that time, and I did still have to pay for my family to go with me.

Plus, as you will soon see, things didn’t quite turn out all that well.  Karma, I guess.

The drug company sponsored event was at the end of the week, and we arrived early in the week so we could go to different parts of the island and see the sights.  After enjoying the beaches on the east coast and the rain forest central Puerto Rico, we arrived on the west coast city of Rincon — the surfing capital of the island.

On the second day in Rincon, I got the delusion that I was: a) younger than I was, and b) far more coordinated than I am.  I tried bodysurfing.  The six foot surf unfortunately broke quite close to the beach, which turns untrained bodysurfer into a projectile launched at great speed into 6 inches of water.  As my face was about to be planted into the sand, I put my arm up to protect my face and (more importantly) my neck.  The result: a fractured surgical neck of my right humerus.

While I immediately knew something was seriously wrong, I didn’t know it was a fracture.  In my pain-induced confusion, I allowed myself to be convinced that the people on the beach (in various stages of inebriation) knew something about first aid for shoulder injuries.  After a few attempts to locate my “dislocated shoulder” (and several offers of alcoholic anesthesia), I was still in really bad pain, and decided that perhaps I should seek the opinion of a real doctor.

I will skip my adventures in the Puerto Rican health care system (now a blur of oxycodone-clouded memories of Spanish-speaking soap operas, paper linens over my wet, sandy body, and my cries of “mucho dolor” to the radiology tech as she tried to twist my arm to get a better picture).  I will also skip my time at the drug company conference (also experienced in an oxycodone-induced blur).

Not long after I came home, I met up with a surgeon who also recently had broken the same ironically-named bone a few months earlier.  He got a smug look on his face as he bragged, “I was back doing surgery after four weeks.”  Four weeks seemed like a long time to be out of work, but it gave me some idea of what to expect.

But after four weeks of healing, with the first two devoted to immobilization and oxycodone, and the second two to the cruelty of physical therapists seemingly unaware that I had fractured my shoulder, I was not anywhere near to being functional.  I couldn’t lie down in bed, and I could barely move my arm without significant pain.

The words of my surgeon colleague echoed in my head as I walked into the orthopedists office for another x-ray, exam, and opportunity to satiate the sadistic needs of my physical therapist.  Chris was doing surgery at four weeks?  I could barely scratch my nose.  What is wrong with me?  Am I a wimp?  Am I really feeling this much pain?  I asked my orthopedist why our surgeon friend had such an easier go of this same fracture.  Was he different?  I was desperately trying to escape the obvious proof of my membership in the brotherhood of wusses.  He told me he didn’t know, and said he’d get back to me.

After a few weeks of doubting my pain and my manhood, my orthopedist happily informed me that Chris had a mid-shaft fracture, which is far quicker to heal than my fracture of surgical neck of that bone.  I was off the hook!  I wasn’t the king of the whiners!  My pain was real!

It took nearly 4 months before I could lie flat in bed, and almost a year before I was mostly pain-free.  But as I pondered my incredible self-doubt and shame over my pain, I realized something: many of my patients have that same fear.  Here I was, with as good of a reason to feel pain as anyone could have, and I was doubting my own experience as being valid.  How much more of these feelings of doubt and shame do people with fibromyalgia, chronic back pain, or chronic fatigue feel?

This idea changed forever how my approach to my patients.  Instead of judging whether a person’s symptoms were “real or not,”  I try to reassure them that I believe them and didn’t doubt their reality.  Over time, I’ve come to believe that my patients almost always tell me the truth about their experiences.  The problem comes when they do one of two things: either try to self-diagnose, mixing up their theories with their symptoms; or they exaggerate their symptoms to get medical people to believe them.  People are so used to being doubted that they feel they have to make the story more dramatic (resulting usually in decreasing their credibility).

This brings me back to the idea of other-awareness, or empathy.  My experience of self-doubt about my experience of pain taught me one of the most important aspects of my patients’ psyches.  They are afraid. They feel vulnerable.  They desperately want to be heard, understood, and believed.

Fortunately for me and my patients, my new office is centered on communication, not documentation.  As opposed to the rest of the health care system that seems driven to depersonalize doctors, nurses, and patients, my office is all about relationship.  I used to have to offer compassionate and empathetic care despite the system we lived in, but now I am rewarded for it.

I like to think that at least some of my colleagues who have lost the emotional energy to care about patients’ needs would gain it back if given the opportunity in my environment.  My degree of emotional burnout last year was, in large part, due to my refusal to stop caring.  It’s sad when a system built to care for people squeezes compassion out of those whose job it is to give that care.  The need for reform is more than just a financial one, it is a human, personal, and spiritual one.

Once we solve that problem, we can turn our thoughts to the harder questions, like whether dogs watch Oprah.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at Musings of a Distractible Mind.

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  • http://doctor-rob.org/ Dr. Rob

    Sadly, docs often disbelieve and marginalize the stories of their patients.

    I understand that self-awareness is not unique, but the degree of it, and especially the “other awareness” is, in my observation, what ennobles certain people and a lack of it degrades others. We most admire those who have both qualities in abundance.

  • DoubtfulGuest

    I appreciate your post, Dr. Lamberts. Thanks for recognizing that patients are accused of faking more and more these days. Having experienced this myself, I agree that the bar is getting lower. As in, patients can be labeled with no evidence whatsoever of malingering. You all have tests to look for evidence of faking. But your literature says you can get false positives in an anxious or elderly patient who’s actually striving to be over-compliant. Not knowing how to put the whole picture together is not “inconsistent findings”. Like Carl Sagan said, “Absence of evidence is not evidence of absence”.

    It looks to me like primarily a resource distribution issue. I did not have an immediately life-threatening situation, nor did I present it as such. I said I thought it was serious, in a non-emergency way. When the correct diagnosis was found, it turned out that my “seriousness ranking” was pretty accurate. I needed the diagnosis ASAP, but there were lots of people in the overall system who needed to be taken care of more urgently. I see two main problems 1) Sub-optimal self-awareness on doctors’ parts as to why they react negatively to a patient, and 2) Constraints by the system and third-party payors on honest discussions about resource distribution and diagnostic uncertainty. Fewer people would be harmed with a “faking” label if we could have straightforward conversations:

    “I have no idea what the heck is going on with you. We probably can’t get you a diagnosis this week or even this year. But we can alternate between looking for different things and watchful waiting, okay? I’ll do all I can to help you, even if that’s not much right now.”

  • dlo

    Well the problem in the understanding, treatment and consideration of a patient in pain has a very definitive structural basis that could and should be changed. Medical undergraduate education has yet to reform curriculum to bring the discoveries of basic science of pain (bench to bed) to students and the practitioners of today and tomorrow. If the presenting symptom for seeking healthcare is pain, then this is a serious deficit that needs redress. What creates more difficulty is the issue of multitasking and overwork required of most if not all clinical physicians. Multitasking (and emotional and physical fatigue) is known to cause diminution of empathic responses in the human brain. (See Marcel Just’s fMRI study in the journal, NeuroImage). Multitasking also increases clinical mistake propensities and also decreases work quality and efficiency, a serious issue in acute and complex diagnoses and treatment plans. (See Skerett’s article “Multitasking — a medical and mental hazard at healh.harvard.edu)

    A structural problem calls for a structural solution: reform of medical school curricula, employing health care ‘scribes’ to alleviate physician distraction in patient chart documentation, expert peer mentorships in clinical areas, recognizing the limits of the human brain in task-based practices, mindfulness training for all healthcare providers (theatre training as an example). Another issue will be the knowledge of integrative health practices in creating optimal treatments for pain that can lower pharmaceutical dosages of opioids while insuring successful individually-oriented biopsychosocial treatment for a patient in pain.

  • http://www.thenutritionista.ca/ Erin @ thenutritionista.ca

    This is a fantastic article and I wish more doctors were as empathetic towards their patients as Dr. Lamberts. In the world of endometriosis and pelvic pain patients are seldom listened to or believed. The average diagnostic delay from symptom onset is 7-11 years, all the while we are treated like we are crazy, over-dramatic, drug-seeking, promiscuous, abused, somatizing hysterics who can’t handle their period. After all, attitudes towards women’s health and pain have not changed much over the years. No one wants to admit this though; this has become the standard of care.

    Even though it is externally invisible and can only be definitively diagnosed surgically, the pain, suffering and the impact it has on our lives is very real. Sadly most doctors don’t see it this way and choose to ignore us instead. Empathetic doctors are a rare gem indeed.

    • DoubtfulGuest

      Yes! It makes no sense because endometriosis is so common. So much research shows it’s an endocrine, autoimmune, and neurological disease. Are you getting good care now? I hope so. If not, I could recommend a group of doctors, but they’re probably quite a distance from you.

  • DoubtfulGuest

    Very insightful and funny comment. I had been wondering how to “like a thread”, so you steered me in the right direction. thanks!