Taking Time for Empathy

By PAULINE W. CHEN, M.D.
27 sept 2008--I would like to believe that I am a compassionate doctor. But when I must convey bad news to a patient, one of the first things I worry about is time.
One of the most challenging, and potentially rewarding, aspects of being a doctor is responding and acknowledging patients’ fear, anger, frustration and sadness. But I have always believed that it takes more time to listen and answer empathetically — time that is hard to ignore when you know there are other patients who have been waiting a long time outside to see you.
A paper this week in a medical journal, though, has made me think a little differently about time and empathy. The study, in The Archives of Internal Medicine, found that physicians overwhelmingly miss opportunities to express empathy to their patients.
Listening to transcripts and recordings of 20 conversations between men with lung cancer and their doctors, Dr. Diane Morse of the University of Rochester School of Medicine and her colleagues identified 384 “empathic opportunities” in the discussions — moments when a doctor might respond with a few words to address patient concerns ranging from fear of illness and death, to mistrust about care and the health care system, to confusion about treatment.
They found that the physicians missed 90 percent of opportunities to respond empathetically to their patients.
One of the reasons for this staggering statistic, the investigators suggest, is lack of time. “In a busy clinic,” the authors wrote, “physicians may believe that there is no time for empathic responses.”
As I read the paper, I remembered one particular afternoon in clinic spent with a man in his late 50s who had liver cancer.
The man, wiry and stooped, had immigrated some 30 years earlier and had worked in restaurants in the Los Angeles area. Accompanying him was his daughter, a radiant 20-something graduate student who spoke comfortably, confidently, in the English that was her first language.
She had researched her father’s diagnosis on the Internet and had arranged to have him seen in our clinic. She wanted to know if we could take out her father’s tumor.
After examining her father, I stepped out of the room to join the other surgeons viewing his CAT scans. As we crowded around the pictures, the tumor emerged — a dark circle in the middle of the man’s liver. View after view, the circle seemed only to widen, an ominous black hole that threatened to swallow what little normal liver was left.
I wanted to scream for the man and his daughter. Instead, I whispered a series of expletives directed at the tumor, then stepped back into the examining room, bracing myself for what would be a hard and, I believed, long conversation. I had to tell this family that the tumor was inoperable.
I had had these kinds of conversations in the past and could only imagine how difficult it would be for this patient and his daughter. I wanted to be compassionate with them, to take the time to listen and to acknowledge their fears and concerns.
But I also did not want to open the floodgates of emotion on an afternoon when the waiting room was overflowing.
In the end, I decided to take the time to listen to the man and his daughter, to ignore for a few moments the clock on the wall.
What surprises me, reflecting back on that interaction, is that despite all the questions and moments of deep emotion that came up during our conversation, the entire visit did not take nearly as long as I had imagined it would. And clinic that afternoon did not run any later than usual.
It did not take more time to be open to the man and his daughter’s emotional needs and to acknowledge them with a few words.
The results of Dr. Morse’s study have already made their way onto the Internet. “For Some Doctors, Empathy Is in Short Supply,” the headlines read.
But the statistic about doctors’ missed empathic opportunities is not, I believe, what is so intriguing about her study.
What is most interesting — and, I believe, most important — about this study is that empathy, expressed throughout a patient-doctor encounter, may actually help to alleviate problems with time.
Or at least not exacerbate them to the extent that many doctors, including myself, fear.
Dr. Morse and her colleagues found that while patients brought up important emotional issues throughout a visit, their doctors tended to express the bulk of their empathy toward the end of that visit.
When doctors did not respond to initial opportunities to be empathetic, patients would try repeatedly, throughout the rest of the visit, to elicit that support in some way.
In other words, too little empathy, or empathy expressed too late in an encounter, may actually result in longer visits.
When the doctors did respond in a way that explicitly recognized patient emotions, patient responses were not long, as some of us might imagine. Instead, patients usually responded with one or two words, or a single sentence.
There is, then, no floodgate.
Not long after I spoke to that man with liver cancer in clinic, I received a note from his daughter:
I just wanted to say thank you deeply for all your assistance and care regarding my father. Finding out my father has cancer has consumed me and my family emotionally and physically. Meeting you and the entire team calmed my heart more than you can know.
We had finished our visit in time, and it was, I believe, worth every minute.