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.

10 thoughts on “Whatever Happened to Bedside Manner?

  1. 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.

  2. Does empathy have to take time?

    One point of contention that rose from the recent study on physician empathy is that expressing the emotion takes an inordinate amount of time. Something that is in very short supply these days for doctors.

  3. 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.

  4. Although they teach patient-centered communication and bed side manners, there is still such a disconnect between the preclinical years of medical school and what actually happens on the wards.
    As a student myself, sometimes the amount of knowledge to be learned and processed is so overwhelming that I become more of a computer spewing out data than a human.

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  6. Medical ethics tends to be understood narrowly as an applied professional ethics, whereas bioethics appears to have worked more expansive concerns, touching upon the philosophy of science and issues of biotechnology.
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  7. 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

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