The difference between sympathy and empathy
Sympathy is, in its most basic form, feeling bad for someone. It isn’t really concerned with their emotions as such, but you see their situation, feel compassion that they’re in it, but can’t really understand (or makes no effort to understand) what it is really like for that person.
With empathy, you see the situation, and can put yourself in their place. You can understand their emotions, why they are feeling like they do, and can communicate this to them. This bit is important, otherwise they’ll just think you’re being sympathetic.
In my experience, which I admit is limited, people, and by extension I mean patients, prefer empathy to sympathy. Sympathy is often seen to be an expression of feeling sorry for someone but without really putting any effort into understanding how that situation affects them. Empathy makes you seem like you care.
Even if you haven’t been in a situation yourself, you can still express a certain degree of empathy for any situation. We have all felt the basic emotions at some point in our life; happy, sad, loss, anger. Even if your feelings of loss are limited to a pet or distant relative, you can expand on that feeling to get some idea of how your friend feels when her father dies. While they probably won’t appreciate you comparing their situation to the loss of a goldfish (and you don’t have to say it out loud, in fact, in that situation I would never compare their experiences to yours, even if yours is worse), you still can get some idea of how they feel.
Sympathy = I’m sorry
Empathy = I understand
“Again, some of the students spoke to me, while others did not. One let his hand linger too long on my shoulder as he thanked me and turned to walk away: creepy. Another remained stony-faced as he fumblingly examined me, never saying a word: really creepy. So inept was he that I decided not to lean forward, thus making my heart more difficult for him to hear. (Doctors who don’t earn the trust of their patients, by the way, are more likely to be sued in a malpractice claim.) I didn’t become a full-fledged person until the 10th exam, this one at the hands of a student with short combed-forward hair and rectangular wire-rims. “Hi, my name is Ben,” he said with a warm, professional smile as he looked me in the eye and shook my hand. I was instantly at ease. ”—An account of the interactions between 2nd year HMS students and a volunteer ‘patient’ at Mass Gen. for Patient-Doctor II.
Cracks in the Confidence
I saw my rheumatologist on the 5th. It was a long appointment (that I wrote about here)— we spent just over an hour discussing just about every aspect of my chronic illness and state of being. If you have been following this blog for a while now, you may be aware that I have been in a downward shift since my surgery in September, and even more so since I moved seven hours north and went back to university.
As my doctor and I discussed this downward spiral and the first half of Spring semester, I saw something in her I had not seen before: cracks.
I confided in her about having to sacrifice my lifelong dream of medical school and explained that I am failing a relatively easy class due to the brain fog and cognitive decline. I could tell it disappointed her to hear this. She looked up from writing in my chart and said, “It might not always be like this.”
It’s just that one word: “might.” Up until this point, my doctors had all been very firm in language that I would find a medication that puts me into remission. Was very firm in her comments that I will get my life back. She was fighting for me and has been a true RA Warrior right along with me. This was the first time it clicked for me that she and I both are on the same page: the disease is incurable. There’s nothing like having seven words put your denial in check. For the first time in a long time, I was literally frozen with a moment of panic— What if I continue to get worse like this for the rest of my life? The fear, the panic…it’s paralyzing. It truly takes your breath away to think about another sixty or so years of suffering and pain, of hair loss and rashes, of brain fog, of doctors, tubes, tests, needles, infusions, surgeries, scares, hospital stays… The only thing I can compare the feeling to is the most terrified you have ever been from a single thought: perhaps the first realization that death means not existing, perhaps the though of losing a loved one. That moment when you (literally) shake the thought out of your head because the fear of something so unknown, so unprecedented is fully encompassing? That was what I felt in that moment and at the same time, I felt my own confidence crack; what if I’m one of those patients that doesn’t respond to any medication, ever?
And then of course I go back to repeating to myself: well, what if I am one of those patients that does respond to medication? And I go back to holding onto that little bit of hope that remission—whatever “remission” really means— is possible. I remember that there are gems to be found, people to be treasured, things to enjoy despite a lifelong battle with my immune system, and I’m okay again.
Seeing my physician show her disappointment, however startling, let me know that I have the right doctor— someone that understands this disease— the real disease, not the seemingly benign list of symptoms you read about in the news or see on pharmaceutical commercials— and cares enough to be disappointed when I don’t respond to treatment and decline rapidly. But it also made me think back to that article I posted last month written by a physician to patients with chronic disease and how my own physician must feel, knowing that her patient is not responding as well as we hoped to her treatment plan. As hard as it is for us as patients, we cannot deny that it is equally difficult for others to watch many of us lose parts of our lives, dreams and much of our identities in the process. That’s not to say we don’t gain new life lessons, opportunities, and identities—we do—but there is a constant cycle of loss and grief that our loved ones and perhaps our physicians, in their own way, endure with us.
This also leads me to a recent NY Times article I read discussing the struggle physicians face over telling the truth and finding a balance with transparency and truthfulness. Where does a physician draw the line between giving a patient false hope and taking away hope?
While a majority of the nearly 2,000 doctors polled believed that physicians should never lie to patients or fail to inform them of the risks and benefits of a procedure or treatment, a large number also revealed that they had not been completely honest or transparent over the past year. More than half had described a patient’s prognosis more optimistically than warranted. More than 10 percent had said something untrue.
I appreciated my physician’s honesty and transparency, and studies suggest that most patients prefer this to be the case as well. When dealing with terminal diseases in both senses of the word, a lack of transparency feeds not just false hope (which isn’t always a bad thing. Hope in the face of suffering gives patients a reason to persevere), but a lack of understanding of the disease and its severity. When I was initially diagnosed, I had no idea that this had no cure, could impact every part of the body, and often does not respond to treatment in the way I thought it was supposed to. I wish someone had been upfront with me about this rather than me discovering this over time and by interacting through other patients. I was hardly emotionally prepared for this journey when first diagnosed, and I do believe that even just a bit more honesty and transparency would have been helpful, perhaps with the suggestion to seek out a psychologist to help me cope with the upcoming challenges I was about to endure.
For my physician readers, how do you find this balance in your practice? For my patient readers, what do you prefer in a physician? Someone that acknowledges that the disease often does not respond to treatment and has no cure? Or someone that is less likely to acknowledge these hard facts and feed you the hope you may or may not need? Is there a balance?
Have you experienced a similar moment? Share your thoughts below!
I was wondering what is your take on being patient focused and how do you want incorporate that into you practice? like listening to the patient and not being "I'm the doctor I know best." In my Nursing school I saw this video on this women who had Cushing's and went to several doctors who told her she was just fat stop eating, exercise more, etc... not listening to her in that she was extremely dieting, working out and the weight came on pretty much over night. which struck the curiosity.
I believe what you are referring to is paternalism. In our curriculum, we do spend some time discussing the idea of patient-centred care and what that entails. I think the faculty has done a great job on that front.
While paternalism was a more common practice in the past, now we are coming around to the concept of a doctor-patient partnership. Information should be presented clearly, both parties should be on the same level, and both parties should come to a decision together. A doctor who decides for a patient may miss important considerations that the patient has.
Similarly, keeping an open mind helps you build a better picture of what is happening and gives you a better outcome. It is a chance to brainstorm ideas and a chance to build a stronger doctor-patient relationship. As Sir William Osler said: “Listen to the patient; he is telling you the diagnosis.”
We must always remember that the patient is still a person, and has the right to be heard, has the right to knowledge, and the right to decide for themselves what they want for their therapy. As physicians, it is important to respect that and work together towards a therapy that both parties can agree on.
Another 55 word story from Family Medicine residents
Big sister comes along with mommy to her appointment.
“Do you want to hear baby sister’s heart, Sophie?”
“Where is your heart?”
“I don’t have one.”
“Are you excited about your sister’s arrival?”
“Will you come next time with mommy?”
“Yes, but only if I can have lots of stickers!”
Electronic Medical Records and George Orwell
Have you noticed how many cameras have been installed on stoplights? And not just at busy intersections. Everywhere. The intersection without a spy camera is the exception, it seems. What are these cameras for? Are we supposed to feel better because “big brother is watching?” Are these cameras there for our safety? Fans of the police state would say “there’s no harm in just collecting data, is there?” “No harm in just watching.”
This is how I would recommend you look at the prevalence of electronic medical records. Your health information, once digitalized, is not secure. Why is the federal government actually paying physicians to convert their medical record systems to EMR? And punishing them with lower Medicare payments if they don’t! There’s no harm in collecting this information in this sharable way, is there? There’s no harm in sharing this with Uncle Sam, is there? Don’t think this will be used as a rationing tool? Really?
Government at the state and federal level claims that none of the medical privacy laws apply to them. I think they want our health information and they want it very badly so that they can “allocate scarce health resources in the most efficient manner.” There’s always some government creep that thinks he/she can do this better than the market. This EMR craze is very troubling stuff and I would encourage you to be very careful with your health information. Your medical records are your business and your physician’s business only. Transforming this information into an electronic database is the first step toward begging someone in our wonderful government to do something about whatever inequities they think they have found.
G. Keith Smith, M.D.
Benedict Arnold, M.D.
This blog is reprinted from Dec. 16th, 2011.
Imagine for a moment that you are a fly on the wall listening to the following exchange. Take some deep breaths and try to take in the following conversation that actually happened last week. Before I reveal the conversation I further want you to imagine that you have just had surgery on your shoulder. Your surgery didn’t go well. You developed an infection. Familiar with our website you are still confused about why your co-pay at the big hospital was more than the entire bill would have been at the Surgery Center of Oklahoma. You still don’t understand why your family practice doctor sent you to the surgeon he did. You told him you liked the surgeon you used before and sure liked the Surgery Center of Oklahoma. Your family doctor didn’t seem phased by your comments. Ok. Here we go.
Setting: a large hardware store Actors: A highly respected orthopedic surgeon practicing in Oklahoma City and a family medicine doctor who has been a hospital employee for about 2 years.
Surgeon: Hey, how’s it going? Haven’t seen you in a while. Come to think of it, I haven’t seen any patients from you in a while either. Are you doing ok? Has my office staff been responsive when you have called?
Family Doc: I’m doing ok. You just don’t understand how things are and how they are going to be, that’s all.
Surgeon: What are you talking about?
Family Doc: You’ve refused to become a hospital employee and you’ve refused to play ball and now you’re going to see what that means. I am not going to send you any more patients until you start doing surgeries at my employer’s new facility.
Surgeon: Really? Is the operating crew there experienced? What do they have to offer the patients that the Surgery Center of Oklahoma isn’t providing? Is their infection rate low? Are the patients paying less out of pocket if they go there?
Family Doc: That’s besides the point. None of that matters. If I send them to you, that’s where you have to go. That’s just the way it is.
Surgeon: Ok. I understand. You should expect to be the subject of a blog by my friend Dr. Smith. Take care!
Now you are beginning to understand why, with your infected shoulder and having paid a fortune for your surgery, you wound up in the hands of a surgeon other than the one you already liked and knew was good. Your family doc was compromised. What sort of leverage does the big hospital employer have? How can they make him act this way, not in your best interest? Your family doc has a performance graph. The hospital employer has hired an army of accountants to make sure that he is earning his keep. Your family doc gets “credit” for the charges he generates not only in his office but for the referrals he makes. He also gets punished for the referrals he makes that don’t generate revenue for the hospital. If, for instance, he sends a surgical referral to a surgeon who decides that the best place for the patient to have surgery is a facility other than the one employing your family doc, then it’s BIG POINTS OFF for your family doc. Enough points off, not enough credits and his contract is subject to re-negotiation. That means that the hospital is going to cut his pay. A lot. A 50% cut in pay is not unheard of. Or, he could be let go entirely. This wouldn’t be so bad if it weren’t for the fact that he is prohibited in the contract terms from seeing patients that are currently in his practice. Or the clause that prohibits him from working within 50 miles of Oklahoma City. Or the $50,000 “tail” provision on his malpractice insurance, payable upon termination of his contract. Yes, I could go on.
In short, your family doc, if he is indeed an employee of a hospital, is incentivized to refer you to a surgeon that is not the best for you, but rather is the best for him. Ouch. Kind of pisses you off to read this when it’s put that way, huh? Do I blame the family doc? Yes, of course. He is a collaborator. Vichy. He has sold out. He has violated his oath. Pathetic. And you, the patient, are the victim.
Are there private practice physicians and surgeons who are abusive of patients and their wallets? Sure. Referrals made to private practice abusers are usually made out of ignorance, though, and time and experience teaches primary care docs to avoid these guys. But hospital employed family docs are forced to become mercenaries for their own self-preservation. Nothing compares to the institutionalization of this mercenary approach to medicine. Beware the physician working for a hospital. He’s more than likely not working for you.
G. Keith Smith, M.D.
Making Joseph Goebbels Proud
This is propaganda. This is from the cartel. Here is my analysis of their article.
Do some surgeons do unnecessary surgery? I used to think that surgeons who do unnecessary surgery do so whether they have an ownership interest in a facility, or not. I now know that those who are most likely to engage in this practice are not the facility owners. I know this because facilities like mine shun unethical surgeons, as the risk of this unethical practice is shared by all of the partners. No one in my partnership wants to be associated with charlatans. These unethical individuals tarnish the reputations of everyone around them. Anesthesiologists in big hospitals that have no say about which surgeons they work with, are forced to act as accomplices when saddled with unethical and incompetent surgeons. As physician owners we have control of who works at our facility and just as important, who doesn’t. Talented and ethical surgeons migrate to facilities they can own partly so they don’t have to associate with the unethical and incompetent. They also have control of quality issues and benefit from efficient service unavailable to them at the big hospitals. Participating in a share of the profits inclines the owners to explore further efficiencies and invariably leads to an ownership “pride” that serves as insulation against any temptation to include the charlatans. ”The Surgery Center of Oklahoma? That’s my facility!” Our partners have no problem proclaiming this to anyone within ear shot.
A note on context. Unnecessary surgical procedures are more of an indictment of the absence of free market discipline than an indictment of unethical doctors. Government and other third party payment arrangements financially separate the physician from the patient and unnecessary surgery is a predictable consequence. The article linked to above uses worker’s compensation case data as a reference. There is no more dysfunctional third party arrangement than worker’s compensation.
Do surgeons do more surgery once they work at a more efficient, physician-owned facility? Here is the story of one of our surgeons. A typical surgical day was 3 ear tube placement surgeries, 4 tonsillectomies and two sinus surgeries. At the big hospital he was scheduled to begin at 730am. He never started before 8:00 or 8:15 for some reason. The “turnover time” (the time it takes to clean a surgery room and get it ready for the next case) was usually 45 minutes to 1 hour, so he “lost” an hour between cases. This surgical schedule, these 9 cases, took all day. It was not uncommon for him to operate past 5pm with a schedule like this. And this was before the implementation of the electronic medical records system. Now it is much worse, adding an additional 20-35 minutes to the “turnover times.”
This same surgeon will finish this surgical schedule at our facility before noon. Utilizing multiple surgical suites and overstaffing our anesthesia group allows us to “gang up on him.” He has two operating rooms and two operating crews and two anesthesiologists. He has no down time between cases. This is not rocket science. This is the best utilization of his time and that of the facility.
What does he do with the half a day he now has, that he wouldn’t have if he’d done these surgical procedures at the hospital? This hardworking surgeon was able to spend the afternoon in his clinic. The more patients a surgeon sees and the more time spent in their clinic, the more likely they will discover surgical illness. So now he does more surgery. Patients can get in to see him easier because he has this clinic time that essentially was created by his participation in our facility. His larger surgical caseload is hardly an indictment of his ethics.
The last paragraph of the article attempts to link physician “self-dealing” with the increase in the cost of medical care. Answer me this: why is it unethical for physicians to own their own facilities and it’s not unethical for facilities (hospitals) to own their own doctors? Don’t you find it interesting that physician ownership is singled out in this article as increasing the cost of care and not the fact that the big hospitals charge 10 times what we do at our facility…for the same procedure!? Do you think that hospital fees 10 times what we charge are a slight motivation for hospitals and their employed doctors to perform unnecessary surgeries? What kind of surgeons benefit a hospital that charges ten times what we do? How about those individuals known for performing unnecessary surgery?
No mention of any of these considerations in the article. I hope that more and more people see this as the vicious propaganda that it is. Also keep in mind that the insurance companies make more money (through the PPO repricing scheme) by dealing with hospitals charging giant fees, as they are awarded a percentage of the amount they “save” a plan by “repricing” claims. Let me make this very clear. Insurance companies want and seek facilities that issue gigantic bills. This is the primary reason insurance companies have aligned themselves with the giant hospitals in smear campaigns against physician owned facilities. These bankrupting hospital bills also provide cover for the claim that “health costs are up compared to last year,” justifying an increase in insurance premiums from year to year, an increase upon which brokerage commissions rely.
The good news is that I haven’t seen pathetic articles like this for a long time. Big hospitals and insurance companies haven’t hurled unfounded insults like this for years. That this specious argument has surfaced once again is a sign of desperation on their part, I think, a sign that their cartel is in trouble like never before. Physician-owned facilities are the worst nightmare of this bunch, particularly one like ours that has posted prices online, revealing without a doubt, the extent to which the cartel has robbed and bilked the sick.
G. Keith Smith, M.D.