Practical Wisdom – Part 6: The Erosion of Empathy

In Part 3 we addressed Schwartz & Sharpe’s (S & S) treatment of empathy in their landmark book, and how that relates to doctoring.  It is a very complex topic, which is why they loop back to re-visit it numerous times, and why I choose to do so here.  The erosion of empathy among physicians begins early.  In fact, S & S cite evidence that it begins in medical school.  All information is framed, and no frame is neutral.  “In the context of  this argument, it is tempting to look back to prior decades as a kind of golden age of wisdom in the medical profession, a time when doctors wisely dispensed advise to soon-to-be-satisfied patients.  And indeed, until the late 1960s and early 1970s, the norm of physician paternalism – the doctor knows more and knows best – dominated.  But the paternalism of earlier forms of medical care was no exemplar of practical wisdom.  The faith placed in the absolute knowledge of the doctor was just as unwise a rule as is the principle of radical autonomy.”  S & S proceed to give examples of the increasing commoditization of the medical profession, and the price one pays when institutional bureaucracy and bean counting erodes the doctor-patient relationship.  A radical autonomy in which the patient winds up at odds with the doctor isn’t the answer.  The answer lies in true collaboration and a restoration of empathy.

A cousin, who is a nurse anesthetist, sent me an article last week that addresses some of these issues.  Consider the following:

“With both the prestige and income of being a doctor dwindling in recent years, the demand for practitioners with better people skills has surged. An increasing number of physicians are choosing shift work at a hospital—where working well with colleagues is essential— over setting up a more autonomous private practice. And the rise of nurse practitioners and physician assistants working side by side with medical doctors has further eroded physicians’ once undisputed place at the top of the clinical pecking order.”

“Despite this sea change, nurturing hands-on skills, and the people skills that go with them, still isn’t a priority at most medical schools. “There is a fairly severe mind-body split in medicine and medical education,” notes Dr. Molly Cooke, an internist at the University of California at San Francisco and co-author of a report from the Carnegie Foundation for the Advancement of Teaching on the urgent need to rethink how doctors are trained in the United States.

Some schools have tried to fix the problem by adding courses on humanism or “doctoring,” with mixed success. Students often view the touchy-feely sessions as a waste of their precious free time, since their content is barely addressed in the standardized, multiple-choice exams they must pass in order to be licensed and land a residency.”

So here’s the bottom line.  Ophthalmologists are among our best referral sources.  No, not because they refer patients directly to us to any significant degree.  It’s because as a rule they persist with paternalism and non-empathic authoritarianism that is still taught in most medical schools and reinforced during Residency training.    There are exceptions to the rule, much as there are exceptions to any generalization that all VT-ODs are exemplars of empathy. Yet it is fair to say that those of us who have succeeded over the course of long careers have mastered the art of empathy.  And I sense that nothing puzzles an ophthalmologist more than an autonomous patient who finds the contrast with a Doctor of Optometry who takes the time to listen empowering.

– Leonard J. Press, O.D., FCOVD, FAAO

8 thoughts on “Practical Wisdom – Part 6: The Erosion of Empathy

  1. Len, no comment is necessary on this topic. You and the author quoted were right on the $$$. But, with regard to the Morning Glory infant I have the following questons;
    1. What did you “scope” in the better O.S.?
    2. What did dynamic retinoscopy show in the O.S?
    3. Has anyone considered an EW CL for the O.D?

    Many years ago I received a call from Children’s Hospital ophthalmology dept in Philadedlphia asking if I had a certain power lens for a six day old infant that had undergone lens extraction for congenital cataracts. Someone there knew me and knew that I had a large inventory of many different lenses. I did in fact have the high plus Permalens that was needed. The parents were directed to my office and I inserted the lenses in both eyes. They were well tolerated by the patient. Well, she didn’t have any complaints! In my case the mother was a contact lens wearer herself and we were able to instruct her on how to remove, clean and re-insert the lenses. Good luck with this interesting case. I hope to read about it at some future time in one of the journals.

    chuck allen

    • Thanks, Chuck. OS scoped apx;. +1.00 distance and near. Am not thinking of putting any Rx in place yet, but will monitor closely on her return. First order of business is to get at least some quality time patching of OS in place. Will then consider uni-nasal occlusion of OS, and since it’ll be in a spectacle frame, will then look at Rx for OD. Consider that since she is visually impaired OD at this, point, the withholding of the minus lens OD essentially gives her magnification which I like at this point. A 14 month old still has plenty of the day spent engaged in near activities. The amount that the fovea is dragged in ROP, and eccentric viewing, will play a large role in how we manage the case.

  2. Dr. Press,

    You said “It’s because as a rule they persist with paternalism and non-empathic authoritarianism that is still taught in most medical schools and reinforced during Residency training.” Perhaps not so ironically, this is very much the same attitude towards instruction and practice that my class were exposed to in the medical component in optometry. It seems that schools frequently pursue the highest grade applicants, then cry ‘Success!’ when they beat their previous high GPA average. Still, medical and optometric colleges avoid/ignore the wisdom of colleges of education and require NO instructional training or background of their own professors and instructors. This leaves a wide knowledge and experience gap in curricular design and implementation, a gap that can only be filled haphazardly by the instructor’s personal ideals and pecadillos. This can mean simply poor instruction, but frequently enough it means that students must learn to deal with an ego at the front of the class instead of providing meaningful care.

    No, ophthalmology/medicine are not the only areas where humanism is replaced by something, well, less useful or desirable in instruction. While I agree with the general premise that medical training being somewhat detached from the patients that are the raison d’etre of the profession, optometry does not have exclusive license to provide caring service, or interested and caring doctors. Corollary: Not all ODs can or do provide caring humane service, and not all OMDs don’t.

  3. superb essay, Len. I might add that one of the prime factors in contributing to the poor communication skills of physicians and their empathy-deficit is the poor education and negative role modeling provided in medical school by professors who are not clinicians and who have never directly interacted with patients.

  4. Great blog, as always, Len. Reminded me of a recent article in The Economist on alternative medicine. It was a blistering attack on alternative medicine, but did conceed that MD’s could learn a lot from the alternative medicine community about communication, empathy, and just taking time to talk to patients. You can read it at:

    • Thanks for the kind words, Rob, and thanks for sharing that piece from The Economist. I’ve always maintained that our position in the field provides an interesting control over the placebo effect. Rarely are we first in line to deal with our patients. More commonly they have seen many other professionals prior to us. If all we’re giving them is TLC, they would have responded to the placebo effect before and not be in our chairs. That is, unless the field of “real medicine and “real” education has become so cold and indifferent that our caring approach would be a “real” placebo effect (pardon the paradox). Wouldn’t that be a powerful self-indictment of our critics?

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