Monthly Archives: March 2012

Empathy and Medical Education: Remembering the Art of Caring

When dealing with patients and families coping with life threatening illness, one of a physician’s greatest interventions may be that of empathy.  Defined simply, empathy is the responsiveness to the emotional state of another person—we try to understand another’s experience.  It is a process that requires effort and intention.  Sympathy is an awareness of another person’s situation and is an almost “autonomic” type response.  Sympathy is important and is part of what humanizes a caregiver but Empathy is integral to a successful doctor-patient relationship.

Many studies of medical students have indicated that empathy is lacking.  A study published in Academic Medicine in 2009 indicated that empathy in fact actually declines during the 3rd (Clinical) year.  In this study, 456 students were followed and completed the Jefferson Scale of Physician Empathy (a reliable, validated survey) at different times during their medical school careers.  During the first two years, scores remained consistent—however a significant decline was noted in the third year and persisted until graduation.  There were no gender or eventual specialty related differences—it occurred across the board.  What a paradox—after 2 years of dissection and sitting in lectures, empathy declines when the short white coats are adorned and students become face to face with patients for the first time.

In my opinion, empathy should be the basis of all patient care and the cornerstone of the doctor-patient relationship.  We must find a way to cultivate empathy in medical education.  Medical school admission officers must select applicants that have potential to truly care for the sick.  Medical school deans and other leaders must demand and emphasize inclusion of doctor patient relationship training in the standard curriculum.  We must prepare our students for practice in a world full of challenges and change.  Our patients face increasing stresses outside of illness including job loss, financial ruin, drug and alcohol addiction and family crisis.  These patients put their trust in their physician.  We as providers must provide not only a proper diagnosis but emotional support and genuine human kindness as well.

I can think of many barriers to empathy in medicine and medical education—all good excuses.   I believe that some of the most compelling are the current lack of empathetic role models, negative experiences on the wards, time pressures and academic grade pressures, and an over-reliance on technology and testing.  (Remember 80% of the diagnosis is made with a good H &P).  Students are driven to be the “best of the best”—that’s who we typically select to fill our medical school classes.  More emphasis needs to be placed on the way we interact with patients, families and each other.  We, as mentors, must model empathy in patient care every day.  It’s just good medicine.

So, next time you go into a room on rounds, take a moment and sit by the bedside.  Talk to the patient and family and truly ask and understand the answer to the question “How are you feeling today?”

Ala carte’ Specialty Medicine overseas: May I have a Pina Colada with my Cardiac surgery please?

I was travelling home from my vacation in Paradise with family on Friday when I was delayed on the tarmac (imagine that!).  As all electronic devices were shut down I was relinquished to reading every single page of the Delta magazine in the seatback pocket while we waited an hour for an important “piece of paper “ to be delivered to the cockpit (the ground crew was clearly on island time).  While turning page after page of articles on which restaurant in LA was the most hip currently, I came across a large section in the magazine featuring Americans going abroad to pay cash for Medical care.  The section was a 6-page layout (some of which was paid advertising) touting ways to ensure great care in far-away places such as Thailand or India or the sun-splashed island resort destinations of the Bahamas or Antigua.  The medical clinics went on to discuss the benefits of combining vacation with medical procedures all while “saving” lots of money.  Privacy, exceptional care and beautiful beaches; it sounds crazy right?  Maybe not if you are not independently wealthy or well insured.

Certainly we  have all heard of large clinics in India where uninsured or underinsured Americans could go to have coronary artery bypass grafting and other advanced procedures by well qualified physicians at a mere fraction of the cost here in the US.   Once home I began to delve deeper into the overseas medical care market.  I was surprised to see that the industry was growing and actively recruiting US trained and certified specialists.  Many exotic locations were advertised.  There does seem to be an international certification entity that is involved in facility accreditation—also many physicians have reputable European or US based medical school diplomas or post- graduate training.

In 2007, an estimated 750,000  Americans travelled abroad for medical care and it is estimated that by the end of 2012 medical tourism is expected to be a 12million dollar industry.  As physicians we encounter potential medical tourists every single day–those that are underinsured or uninsured.  Many of our patients struggle to make co-pays.  Interestingly, medical tourism also attracts patients from countries that have universal health care–often seeking choice and better access.  Typically, surgical procedures cost 50-90% less than the average cost for the identical procedure in the US.  Overseas costs are less due to lower provider wages, less expensive devices, less malpractice, and less third party payors.

On the positive side, patients may receive world-class care at a fraction of the cost.  For instance, instead of a $100,000 to 150,000+ bill on cardiac surgery in the US, a patient may only pay $8000 cash in India including travel and accommodations.  US hospitals are rigorously monitored and undergo scrutiny from many agencies.  On the downside, if a procedure goes badly outside of the US, patients have very little recourse.  Medical malpractice lawsuits are something of an American pastime and aren’t provided for in many places overseas.  There are published accounts of patients who have gone overseas and paid cash for plastic surgery procedures only to arrive back in the US in pain and in need of more procedures at home to correct “botched surgery”.

We must carefully look at the forces that have created this new booming industry.  At home, many are uninsured and those with insurance face large financially burdensome deductibles or unreasonable co-pays.  Physician salaries and reimbursements are declining.  It makes perfect sense that both the consumer and the provider turn to non-US based alternatives.  Our healthcare system is in crisis.  IF we as PHYSICIAN providers do not continue to work to involve ourselves in healthcare reform, many US patients and all the best doctors may be greeting one another on a beach in Costa Rica–while sipping a Pina Colada.