A friend told me that as a young Naval officer he had been admitted to the hospital for a surgical procedure. He said,
“I won’t forget looking up one morning at the surgeon, who had the stump of a cigar stuck in his mouth. He glared at me and said ‘Lieutenant, no one has ever died at Bethesda Naval Medical Center from an overdose of sympathy.’”
He laughed and observed that the times had changed, but that the remark had helped him get moving again.
There has been a lot of press given to data showing that more and more physicians are reporting symptoms of burnout. There are all sorts of recommended solutions, but an editorial by Melnick and Powsner, titled “Empathy in the Time of Burnout” caught my eye. They note Medicare’s HCAHPS score means that physicians and hospital administrators must optimize communication and responsiveness to maximize revenue. So many hospitals have started “etiquette” programs. They agree that polite behavior will tend to improve patient scores, but
“…the results characterize the transaction, not the connection—how staff cared for patients not whether staff cared about patients.”
Said another way, politeness is not the same thing as empathy. Politeness is a way of interacting with the customer that is an almost universal expectation—you don’t tip the surly waiter, for instance. Empathy, on the other hand,
“…can therefore be defined at three levels: as an attitude (affective), as a competency (cognitive), and as a behavior. Empathy’s affective and cognitive elements are beyond the behavioral components that etiquette checklists encourage and HCAHPS measures. That is to say, etiquette checklists establish a floor, not a ceiling, for empathy and subsequently for patient experience…
Before we rush to add empathy measurements to HCAHPS, it would be wise to consider that measurement fatigue contributes to burnout. Adding empathy measurements might reduce empathy: a perverse Hawthorne effect. We can imagine burnt-out physicians practicing with good etiquette. It is less likely overworked, frustrated physicians will provide reliably empathetic care.”
After considering some of the things that might be done to respond to the changes in physician work, they turn back to the key question.
“Etiquette or empathy? Most want both from their physicians. But, in this time of increasing physician burnout, American health care seems to be focusing on etiquette. Etiquette may suffice; courteous, clean, and dependable goes a long way when ‘caring for strangers in bureaucracies.’ Consider how well pizza, donut, and coffee shops do in America: reliably served, if not the best for our health. Genuine, empathetic physician-patient relationships may have become more of an ideal like gourmet cuisine, than routine fare. However, empathy is at the heart of patient care and without it, physicians cannot meet the expectations of our calling, measured or not. A health care system hoping for more substantial physician-patient relationships must invest in the well-being of its caregivers.”
In recent articles, I have discussed the changes in the nature of physician work in some detail and then an article on the improved outcomes physician-led medical organizations experience. While they may seem unrelated, perhaps the root connection is empathy. Experienced clinicians understand the importance of empathy, and have some ability to judge qualitatively whether another clinician does or does not have a capacity to practice with empathy.
Perhaps it is the ability to see an individual, not a group, that counts. As our medical organizations have grown larger and more complicated, those in charge of setting the direction are increasingly removed from discrete individuals. Staff become FTE’s and patients become “encounters” or “admissions.” Somehow, we must remain sensitive to the underlying reality that there is a real human being who is suffering, fearful, in pain, and/or dying and it is up to real, fallible clinicians to try and ameliorate that suffering, fear, and pain. The industrial model of health care has its utility, and in some areas is better than the “cottage industry” model of previous medical practice. But the cottage industry approach has its value, too. When we discard that value, we find we don’t much like industrial health care either as patients or as providers.
13 January 2017
 Melnick ER, Powsner SM. Empathy in the Time of Burnout. Mayo Clin Proc 2016;91(12):1678-1679. doi. 10.1016/j.mayocp.2016.09.003.
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