Why it’s Difficult for your Doctor to Show Compassion
How our doctors should adapt to provide optimal care in a world of Evidence-Based Medicine
My patient
Algorithms. We all love algorithms. In medicine, we’ve become increasingly proficient at using algorithms to accurately diagnose patients, custom-tailor therapy, and provide survivability statistics. The humanistic touch of medicine becomes lost amid quantitative objective outcomes for each patient. We shouldn’t forget the strong therapeutic affect a physician’s listening ear can provide to struggling patients.
“Why is this happening to me?”
A common question asked of me by patients, particularly as I deliver news of a new diagnosis. One of my patients, a sweet, older woman who’d been healthy up to this point and had recently become a great-grandmother, came into clinical for a regular wellness check-up. Her lab results showed that she developed diabetes, which is not an uncommon occurrence in the United States.
“Maam, your lab work showed that your blood glucose is elevated. This is often a first sign of developing diabetes,” I say to her. The polite smile she wore since the start of the visit quickly faded, and a paleness entered her rosy cheeks. “Why is this happening to me?” she replies with a quivering voice and a tear glistening on her eyelid.
At this point, evidence-based medicine flies out the window, and social intelligence takes over. It would have been easy for me to ramble about the pathophysiology, risk factors, treatments, prognosis, and lifestyle modifications that take place in patients with diabetes. However, my patient’s question wasn’t asking for that. Instead, I used FIFE (Feelings, Ideas, Fears, Expectations) questions to explore what had caused the emotions I was observing in my patient.
45-minutes later, our discussion had meandered from her husband’s death, to her daughter’s health issues, to the patient’s financial insecurities, and finally to her excitement about being a new great-grandparent.
Where we stand today
The transition from intuition-based medicine to evidence-based medicine (EBM) was complex but inevitable. With the advent of computers, data storage capabilities, and analytical processes, it was only a matter of time that healthcare attempted to improve patient care by standardizing guidelines and recommendations through rigorously supported research. The US healthcare system became focused on a fee-for-service model that rewarded physicians for volume-based care.
Recently, however, the US has shifted to a value-based model that reimburses positive clinical outcomes and patient satisfaction. While EBM is crucial in our society of technology, information, and resource sharing, it has also allowed for the distancing of the doctor-patient relationship. In its place, there is a doctor-researcher relationship in which there is over-reliance on published research and less attention to the outcomes, relationships, and understanding of the patients’ situations.
For instance, if a patient presents in our clinic with hypertension, we quickly know how to diagnose the condition and what to prescribe to fix it, but how much thought is given to the chances that the patient will still be taking the medication in 1 year?
Future steps
I believe that there is a form of medical practice beyond EBM. One such way of practice is called interpersonal medicine, which suggests that patient care is improved through “a series of meaningful interactions focused on motivation, engagement, empowerment, conviction, and resilience”.
The notion that meaningful interactions lead to improved outcomes is unsurprising since the shift to value-based care meant that physicians are reimbursed for their effectiveness rather than volume. Press Ganey, a survey widely distributed to assess patient satisfaction, has shown that better physician communication is associated with a 19% improvement in patient compliance to therapy and positive outcomes.
It’s important to note that our US population has shifted from infectious disease and trauma as primary causes of mortality to chronic illnesses, such as heart disease, diabetes, and obesity. Also, patients with substance abuse and psychiatric conditions are increasingly present in primary care offices.
Why is virtue ethics important in medicine?
Medical ethics has become increasingly important, particularly in 21st-century medicine, where our technological advances have allowed life-sustaining measures to be administered passed one’s ability to live a meaningful life.
I’ve discovered that ethics in medicine are valued differently than by the majority of our population.
For instance, in the classic trolley experiment taught in philosophy classes, the majority would say it’s morally acceptable to change the trolley’s path so that it kills only one person instead of five. Perhaps that may be ethically acceptable using Kantian’s utilitarian approach where the action is morally “good” if each individual’s life has equal meaning; therefore, mathematically, it makes sense to save five rather than one.
However, who are we to decide whose life has more, less, or equal meaning to another’s?
In medicine, utilitarianism is difficult to morally defend because it would, for instance, allow us to “kill”, or not deliver our best care, to an organ donor in efforts to transplant those organs to a group of people. We don’t do this in medicine because healthcare providers don’t, and shouldn’t, judge an individual’s worth on face value. To expand this notion is to say that each patient deserves our best care and has a moral right to healthcare.
Aristotelian Virtue ethics is a better philosophy for healthcare providers. Instead of judging patients, I would evaluate my characteristics to decide whether a particular action is morally “good”. Virtue ethics are applicable, especially in our practice of EBM where, as mentioned above, we can sustain human life, but potentially cause more suffering for the patient or family in the process.
I think it’s easy to forget that patients suffer more than just their physical symptoms. Often, we need to consider how much they’re suffering from the treatment and how much their illness affects their psychosocial wellness.
Unfortunately, medicine is commonly viewed as a dichotomy; there are the patients’ physical symptoms, and then there is everything else. However, I believe it’s essential to integrate virtue ethics and the concept of interpersonal medicine to create an understanding of each patient that views their mind, body, and soul in unison.
To do so requires mindfulness, personal reflection, and brutal honesty about one’s characteristics.
What happened to my patient?
“Thank you for listening to me,” she said, as I escorted her to the check-out desk.
“It was truly my pleasure, and I hope we’ve created a mindset to keep you feeling well for years to come,” I responded.
The patient returned in a week to discuss the management of her diabetes. She worked with our interprofessional team to create the best treatment plan for herself and continued to attend her scheduled appointments.
Interpersonal medicine works. We should all expect it from our doctors.
