Emotions by rote: when empathy is scripted

Something bothered me last week while blogging about teaching medical students to deliver bad news to patients.

Although training and practice can help develop and reinforce effective, empathetic communication skills in medical students as well as doctors, I kept having the nagging thought that this wasn’t the whole story. Is delivering bad news merely about following the six steps of the SPIKES protocol? Would I want a conversation involving bad news to be packaged as a carefully learned formula? Don’t patients sense the difference between rote platitudes and genuine caring?

Then… eureka! an article appearing in the New York Times the same day captured it exactly.

Dr. Timothy Gilligan, co-director of the Center for Excellence in Healthcare Communication at the Cleveland Clinic, and Dr. Mikkael Severes, director of the leukemia program at the Cleveland Clinic, nailed it: Doctor-patient communication isn’t something you can readily force or script or reduce to “10 Easy Techniques For Demonstrating Empathy.” Although good communication is an essential skill for any health care practitioner, it should be real, not faked.

From their article:

No communications course will magically transform lifelong introverts to hand-holders and huggers. At the same time, we must ensure that we are not converting people who genuinely care about their patients into people who only sound as if they care. Having physicians sound like customer service representatives is not the goal.

For those doctors who are emotionally challenged, communications courses can provide the basics of relating to other human beings in ways that, at the very least, won’t be offensive. But for the rest of us, we should take care to ensure the techniques and words we learn in such courses don’t end up creating a barrier to authentic human contact that, like the white coats we wear, make it even harder to truly touch another person.

As one of those “lifelong introverts”, I take exception to the implication that introverted clinicians need fixing so they can give more hugs. Introversion and good communication are not mutually exclusive, and introverted doctors may in fact be better than many extroverts at listening to their patients.

But Drs. Gilligan and Severes raise important questions about the degree to which empathy can be taught and the unintended consequences of trying to program clinicians into better communicators.

Reactions to their article were almost as fascinating as the article itself. A sample:

- “Patients usually come to us because they hurt. They’re suffering, and most of their suffering isn’t from tumors or low platelet counts; it’s from their own normal emotions in response to being sick: depression, anger, confusion, loneliness, anxiety, and so on. We might be able to fix their lesions, but we can address their emotions only by listening to them, and that’s a more sublime skill than repeating, ‘Go on’ or ‘How does that make you feel?’”

- “Providing education and skill sets to improve communication will only go so far. Addressing issues around emotional intelligence is the core of the problem.”

- “As a physician, I find It amazing that anybody could write about problematic interactions between doctors and patients without noting the 2,000 pound gorilla in the room: what our healthcare system pays doctors for. The less time doctors spend with each patient, the more patients they are able to see and the more money they can make. If you pay doctors the same whether they talk to patients for five minutes or 45 minutes, guess which they are most likely to do.”

- “Most of these technically brilliant but interpersonally stunted doctors are either married, have friends, and successful careers, meaning that they must have some social skills. I’m not sure the issue has anything to do with being introverted or geeky. I think it might have a lot to do with arrogance and not seeing the patient as a person.”

I’ve heard some health care workers say scripts help them stay focused, especially in difficult situations. Others find scripts restrictive, even a bit silly, and would rather allow the conversation to flow naturally.

What do you suppose patients and families prefer – empathy that’s clumsily expressed but sincere, or all the right words with no feeling behind them?

5 thoughts on “Emotions by rote: when empathy is scripted

  1. Either would be better than what we experienced when my father was given the news. The doctor had no bedside manner and was cruel. Since then I’ve been told of others who have had the same experience with this same doctor. It leaves an indelible mark even after 19 years.

  2. I agree with Louise. Empathy,is a must.
    If you are a doctor and you do not have empathy or the ability to express it,you need to learn and practice the skill. Empathy and displaying compassion
    for those suffering and their family members should come naturally,if not, learn how to imitate! It really is about delivering the best possible, patient centered care,right?

  3. Yes – health care providers need help delivering uncomfortable news – I’ve been there too – however – as Anne noted, scripts can be a helpful jumping off point for providers who aren’t sure what to say – but they shouldn’t replace real feelings and real empathy. I think usually health care providers are not unfeeling, it’s just hard to tell someone that they will die and there isn’t anything else they can do except to help keep the patient comfortable. Thank you, Anne, your your great blog to address so many health care issues!

  4. Surgeons seem to have the worst reputations for being jerks. And most of the introverts I know are actually more compassionate and better listeners than the extroverts.

    Plus, I hate to play devil’s advocate here, but you have to let doctors dissociate somewhat from their patients or they’re either not going to be able to be objective or they’re going to be eaten alive and exhausted by constant empathy.

    While I don’t want a doctor to be cruel, I don’t really expect or want hugs and feelings from one either. I want great medicine backed with science and statistics from my doctor, delivered in a straightforward (but not rude, cruel or nasty) fashion. I can go home and get a hug from a friend.

    Maybe the real lesson here is that different people have very different expectations of doctors–and maybe it would be good to be able to choose between the very different doctors available for help.

  5. I think it’s a question of balance. Although it helps to be naturally empathetic, there seems to be both art and skill in how doctors communicate with patients, especially when the news is bad. It has to be cultivated through training, time, practice and experience. Some people have to work harder at this than others but it doesn’t mean they can’t become at least reasonably skillful.

    Scripting isn’t a substitute for authentic communication but I do think it can be a helpful tool, either as a starting point or as an anchor to come back to if the conversation starts going in the wrong direction. In emotional situations, it can sometimes be hard to think straight, even when you’re an experienced communicator. I agree with Kari – when there’s too much emotion, the doctor can’t be effective.

    It’s really pretty amazing to see how many medical schools are starting to look for well-rounded students, not just those who score high in the MCAT, and the emphasis being placed on teaching good doctor-patient communication. I think they’re getting the importance of this, so I have reason to feel optimistic about the future.

    I’m working on another blog entry about teaching medical students to give bad news, so stay tuned. :)

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