A forty-five-year-old Hispanic gentleman became well known to the health system after presenting frequently with shortness of breath and abdominal pain. His primary care physician ordered multiple laboratory tests and radiologic scans which were unrevealing, and he was seen as both a gastroenterologist and a cardiologist who found no organic explanation for his symptoms. He was ultimately diagnosed with functional pain. During his most recent visit to the emergency department for recurrent symptoms, the physician on call reviewed his records and experienced a visceral reaction of frustration, as though he wanted to grab the man by his shoulders and yell, “Don’t you see that you might be suffering from hypochondriasis and that all of these tests and visits are a waste of your time and energy?” Instead, he checked a few labs and an abdominal X-ray “just to make sure everything was all right” and sent the patient on his way – but this time with a referral to a psychiatrist.
The gentleman did not, of course, want to consider the fact that he exhibited recognizable signs of health anxiety, but decided that at the very least, he would have someone to talk to at a point that he felt discarded by everyone else. At his first visit with the psychiatrist, the man revealed that he was recently divorced, had lost his job, and had a child in high school burdened by mental health issues. Over the course of the next few visits, they explored together with the man’s feelings of frustration, grief, and loss and with his permission, his psychiatrist called his primary care provider to discuss his recommendations including not only starting an antidepressant but also avoiding any further lab or radiographic workup unless something particularly new or life-threatening seemed to arise. The gentleman’s presentations to his medical providers grew fewer and farther between, and his physical symptoms diminished over time.
This case is not unusual, and each time we hear a similar story we are prompted to think, “Why couldn’t the doctors just have listened in the first place? Why did it take a hundred negative tests and several sets of specialists to diagnose plain old anxiety?” Patients seek out physicians not only for diagnosis and treatment of “organic” pain, but for pain which results from suffering in this day-to-day world, pain which transcends the body and derives from the psyche. This pain cannot be diagnosed or treated through pharmaceutical or technological means. The physician’s task is to determine an appropriate diagnosis, workup, and treatment for all types of pain – but this does not involve simply testing, scanning, and medication. The diagnosis needs science for cure, but the illness needs the physician to adequately address the pain of the entire person.
This leads to even more questions about the nature of physicians and medical training itself: What are the personality traits of the physicians that would have been able to diagnose this gentleman correctly without the extensive workup? Are those traits innate, learned, or a combination of the two? If the traits are innate, how do we distinguish them early on and encourage those who possess them to go into medicine? If they are learned, how do we teach them to our medical students?
We believe that in many cases, medical training not only does not select for or cultivate such personality traits but actively selects and develops barriers against them. Medical school acceptance is based primarily on undergraduate grades, scores on the MCAT test, and only cursorily on the subjective ratings of an admissions interview which, as the joke goes, “only exists to screen out the really crazy people.” As a result, matriculating medical students are pre-selected for traits other than compassion and interpersonal interactions, and in one study spirituality, emotional engagement, and relationships were three of the five most frequently cited qualities that medical students were wary of showing about themselves in medical school.[i] Then, often as the first definitive experience of medical school, the medical student learns to work with a dead body; the cadaver does not talk and no one has to listen. Throughout the remainder of medical school, attention is paid to perseverance, competition, academic excellence and discipline breeding isolation, long hours of service and chronic lack of sleep. It is then that the student becomes a master at learning to shut down empathy. The living patient is not the primary component of education until the third year, and by then the preference is set for objective reasoning and testing versus empathy and compassion.
Internship and residency, the cornerstone of clinical training, are also closely associated with changes in mood and further loss of empathy. Depression, anger, and fatigue increase, and empathetic concern decreases[ii] – the exact opposite of characteristics one would hope physician training would cultivate. Even more unfortunate, empathy seems to stabilize at this level over the remainder of training rather than increase.[iii] Lack of empathy is closely correlated with burnout, a psychological state of emotional exhaustion, and depersonalization. Residents have well-documented high rates of burnout quoted as high as 50-75% in some studies,[iv] and burnout has further been associated with self-reported suboptimal patient care practices.[v] Though residency is undoubtedly a time during which a physician develops essential clinical skills, personality may actually regress. Science triumphs, but humanity is lost.
In an era of almost miraculous technological advances in science and medicine, the public’s growing dissatisfaction with the physician-patient relationship is almost unequivocal. There is a sense that the caring, empathic dimension described by most patients as a crucial chip in recovery and treatment is lacking.[vi] When considering what accounts for success in the treatment of their medical conditions, patients cite a variety of factors, yet when pressed for a single response, the majority answer is “the relationship” between the patient and a clinical provider.[vii] Similarly, psychotherapists from many schools agree on the point that it is the relationship that heals and is the cornerstone of successful treatment and a precondition for positive change.[viii],[ix]
The time has come for change, both in the way we select physicians and in the way we train them. The mere presence of such abundant research regarding physicians and empathy is an acknowledgment that the problem exists, and there are many who actively seek to develop solutions. Empathy can be learned, and there are several innovative medical school curricula which seek to teach it.[x] The relatively recent development of “core competencies” (including interpersonal skills and communication and professionalism) along with the introduction of a milestone-based system for resident assessment may lead to a redefinition of what makes a ‘successful’ resident.[xi] For practicing clinicians, the emerging idea of ‘patient-centered’ care aims to redefine medical care to those aspects of care that are most important to the patient. Though teaching and learning empathy involves the much deeper study and more dedication of spirit than the rote memorization required to learn a biochemical pathway or a differential diagnosis, we should not attempt to eradicate it on the path of least resistance towards scholarly success, but instead make a concerted effort to develop it in our physicians, both young and old.
We cannot hope to dissect body from a mind in the diagnosis and treatment of disease, and in particular, pain, because after all, we are all human, and physiological and psychological experiences are one and the same. As we reexamine the presentation of our case patient from an empathy-based perspective, the repeated and progressively frustrating negative workup makes little sense because it fails to reach the patient and take into account the fact that that this man had lost his wife, job, and his sense of self. Instead of ordering test after test, a relentlessly empathic provider would, alongside and following the initial medical workup, ask question after question to push the patient into a difficult self-examination which ultimately reaches the core of the problem and is the first step toward solving it. We believe that the sustaining force in the patient-clinician relationship is the clinician’s empathetic commitment to the patient’s welfare.
[i] Rabow MW, Evans CN, and Remen RN. Professional formation and deformation: Repression of Personal Values and Qualities in Medical Education. Fam Med 2013; 45: 13-18.
[ii] Bellini LM, Baime M, and Shea JA. Variation of mood and empathy during the internship. JAMA 2002; 287: 3143-46.
[iii] Bellini LM and Shea JA. Mood Change and Empathy Decline Persist during Three Years of Internal Medicine Training. Acad Med 2005; 80: 164-67.
[iv] Ripp J, Babyatsky M, Fallar R et al. The incidence and predictors of job burnout in first-year internal medicine residents: a five-institution study. Acad Med 2011; 86: 1304-10.
[v] Shanafelt TD, Bradley KA, Wipf JE, and Back A. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002; 136: 358-67.
[vi] Stetten D Jr. Coping with blindness. N Engl J Med 1981; 305: 458-60.
[vii] Angell M. The quality of mercy. N Engl J Med 1982; 306: 98-99.
[viii] Grencavage LM and Norcross JC. Where are the commonalities among the therapeutic common factors? Prof Psychol Res Pr 1990; 21: 372-78.
[ix] Weinberger J. Common factors aren’t so common: The common factors dilemma. Clinical Psychology: Science and Practice 1995; 2: 45-69.
[x] Batt-Rawden SA, Chisolm MS, Anton B, and Flickinger TE. Teaching empathy to medical students: an updated, systematic review. Acad Med 2013; 88: 1171-77.
[xi] Nasca TJ, Philibert I, Brigham T, and Flynn TC. The next GME accreditation system – rationale and benefits. N Engl J Med 2012; 366: 1051-56.