Tuesday, September 30, 2008


There was a study published last week in the Archives of Internal Medicine that indicated many doctors don’t demonstrate empathy even when their patients seem to ask for it. This particular study examined a number of encounters where patients were being treated for lung cancer, and the physicians were either oncologists or surgeons. The researchers concluded that doctors were able to express empathy only about 10 percent of the time. Physicians appeared more comfortable discussing medical concerns and shifted the conversation away from emotional issues, including fears and anxieties about death and dying.

It would seem that discussing things like death and dying would be difficult for anyone, but studies have indicated that patients who are shown empathy are more likely to be satisfied with their care and have better knowledge about their condition. Still, empathy is not something one can learn – as they say, you either have it or you don’t. Some people, including doctors, are just better at it than others.

This whole discussion led us to thinking – what about the physicians who need to disclose and apologize following an adverse event? How difficult, in those cases, must it be to empathize with the patient and/or family member? Would an ordinarily compassionate and empathetic clinician be less so because of other complicating factors? We have identified a number of barriers to honest and compassionate communication with patients following an adverse, and possibly preventable, event. These would include the clinician’s shame, humiliation, and feelings of incompetence as well as the culture of fear surrounding the medical-legal issues. Quite simply, these discussions can be extremely uncomfortable to have.

A full disclosure and empathetic apology can be charged with extraordinary emotion, for both the patient and the physician. We would favor a “team” approach – oftentimes the expertise of someone from Social Work, Patient/Family Services, or Chaplaincy is needed. Also, the clinician directly involved may not possess the requisite communication skills. In any case, institutions need to adopt communication policies that encompass these difficult situations. They need to have clear processes and procedures in place that are understood by all providers throughout the organization. Most importantly, hospitals need to train staff, develop tools that can be accessed by anyone at anytime, and have a system of support in place for patients and families as well as clinicians.


Anonymous said...

You might be surprised to know that patients and families often have empathy for you, the health care professional, when things go wrong. This can be more of a two-way street than you think.

Megan said...

I think empathy is a skill that most everyone can learn, and that some people are naturally better at it than others. Many people struggle with the question, "How can I share someone else's pain, but not bring it home with me?" It is often easier to remain stoic than to keep that balance.

It is also much easier to show empathy to someone when you are a neutral party, or have been in a similar situation. It is unrealistic to expect that a clinician directly involved with an adverse patient event could immediately put aside his or her own emotional response and be able to show true empathy to the patient. Apologies under these circumstances come out at best insincere and at worst detrimental to the patient (and the clinician).

Proper wording is critical, as well. A clinician may be trying to communicate, "This should not have happened", but a patient may understand it as, "What you think happened could not have happened." Helpful suggestions about how the event could have been prevented can be perceived by the patient as blaming the victim.

Patients need the opportunity to express how they were harmed by an adverse event. Hospitals and caregivers are fairly good at addressing the patient's physical needs after adverse event. But they tend to completely discount a patient's emotional or mental health needs--to the point of declaring that if there was no physical harm from an adverse event, it should be categorized as a "minor error". But the patient may feel more long-term affects from the mental-health aspects of the event than the physical ones.

I agree with the team approach, with added emphasis on support for the clinician as part of the initial response, as this appears to be the area with the largest gap and high risk. Perhaps an addition would be resources for affected clinicians to confidentially discuss their own feelings of fear, frustration or anger about the event so that these are not carried over into conversations with the patients.

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