Clinical Scenario
You are seeing an established patient today, a 78-year-old female with a recurring history of imbalance and dizziness. She is a favorite patient of yours, with a keen mind and happy disposition. Your differential diagnoses in the past have centered on cardiovascular etiologies, and you are working with her new personal physician to provide regular evaluation and recommendations for balance improvement. The patient’s husband typically has accompanied her to the semi-annual office visits. As you enter the room, you note that the patient is alone, with an unusually downcast demeanor. As you and the visiting medical student greet the patient, you immediately sense that all is not well with her. You sit next to her, grasp her hand, and inquire what is wrong. She tells you that her husband of 55 years passed away last month, and she is completely lost. Her personal physician, a young man not long out of residency, has prescribed anti-anxiety medications to her, but owing to his busy practice, has not had time to listen to her and support her despondency. She claims he is always on his computer during her visits and doesn’t seem to be interested in listening, unlike her previous physician, who cared for her for decades before she retired from medical practice.
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August 2019The patient begins crying, and you realize this could be a pivotal point in the patient–physician relationship, as well as a teaching moment for the physician-to-be in the room. You also have a very busy schedule today, so you have to decide how to address the patient’s needs at this very moment.
How would you handle this case?
Discussion
The medical profession has long held a contract with society to care for the physical, mental, and emotional needs of the individual patient. It has previously been clear that a physician was not merely a scientist or technician who utilized knowledge of medicines, surgery, and other therapies in a totally disengaged manner, but rather a healer who was devoted to the care of the entire person, and to whom the patient-physician relationship had significant meaning.
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There has been a social expectation that physicians would possess and exhibit the special qualities (virtues) of altruism, empathy, and compassion, and the presence of these qualities in applicants to medical school and residency programs has been a part of the evaluation process. However, an expectation of the ideal qualities in a physician and the reality of their presence can be quite different. No physician has “perfect” virtue, and the illegal, immoral, and unprofessional activities of a small number of physicians over the years has diminished the profession’s reputation in society. Additionally, time constraints, electronic health records, governmental regulations, and so many other onerous external and internal forces may have strained a physician’s ability to practice beyond the necessary science and mechanics of addressing disease processes.
This scenario raises the concern whether altruism, empathy, and compassion are still valued virtues in “modern” medicine, or whether patients have come to expect something else in the provision of their healthcare by physicians.
To evaluate this question, one must first address whether these virtues, previously held to be important qualities in a physician, are inherent, learned, or both. Being an “ethical” physician most likely requires a sense of dedication to the patient, devotion to providing the best possible healthcare and conducting oneself, as a physician, in a manner that reflects positively on the profession by adhering to the principles of autonomy, beneficence, non-maleficence, and social justice. This author has decided that, by the time an individual matriculates at medical school, he or she will not have matured into a fully ethical person, but that this capability is one of life-long improvement and learning. This is a positive viewpoint that the overwhelming majority of physicians want to be ethical and strive to conduct themselves in an ethical fashion. The question then becomes whether these virtues of altruism, empathy, and compassion are still germane to the practice of medicine in these evolving and challenging times.
A corollary to the above question might be: “Why do young women and men want to be physicians?” Is it because they are interested and competent in biology, mathematics, bioengineering, social psychology, or applied analytics, or are they attracted to a profession that is over-
archingly dedicated to the higher ideals of the comprehensive care of persons in need? Perhaps it is not a binary choice, but rather a spectrum of reasons lying between pure science and pure altruism. Do patients still value the textbook traits and virtues of physicians, or would they prefer a clear-thinking scientist or one technically expert over one with a kind and compassionate bedside manner? Has the expectation for a Dr. Marcus Welby given way to a desire for a Dr. Gregory House? Is rationality valued over empathy? Can a modern-day physician/surgeon possess both?
Virtues in Modern Practice
Foundational to addressing these questions is a consideration of each of the virtues—altruism, empathy, and compassion—in the context of the modern practice of otolaryngology–head and neck surgery. Altruism is generally considered to be the “unselfish caring for others” in the specific sense of an individual’s person and health. Some definitions might also use the term “disinterested” to convey an objective aspect of health care, so as not to allow one’s personal feelings to influence one’s professional capability for decision making and health recommendations. It may well be that this admonition to be disinterested leads some to believe that empathy and compassion have no place in patient care, as they may tend to disallow the disinterested (dispassionate) evaluation of a patient.
This author, after 49 years of being a physician, does not believe that being dispassionate with respect to patient evaluation and decision making negates the ability to be compassionate to patients with regard to their physical, mental, or emotional challenges. Altruism may well be the desire to help others through our range of capabilities from the scientific approach to disease to humanist support for the person with the disease. Altruism in its purest form insists on a “one-way good deed,” where the giver of care does not expect anything in return. Can we as reimbursed otolaryngologists consider ourselves to be altruistic in delivering medical care to patients when we are paid to do so? Can we still claim the moral high ground when receiving six- to seven-figure salaries? These questions are being raised by ethicists and philosophers when examining fee-for-service healthcare systems. This author’s viewpoint is that, yes, one can be altruistic as a compensated physician, although noted with an asterisk that explains the potential diminution of its purity because of compensation. But, it is the best we have in a practical world.
Are the virtues of altruism, empathy, and compassion still germane to the practice of medicine in these evolving and challenging times?
Empathy is, in a sense, one’s resonance with the feelings and difficulties being experienced by the patient—an understanding possibly based on our own experiences, and in part by our knowledge of such difficulties seen over years of patient care. It reflects a sense of concern for another human being, and is not just limited to our patients. What the patients are experiencing can inform our own understanding of the impact of their disease or circumstances on their health in some manner. Thus, empathy is understanding. Compassion has been described as “empathy with a purpose,” the purpose being a desire to help the patient through the difficulty, whether by expert medical care or by an interaction that conveys our understanding of the difficulties they are facing. Sometimes, compassion is best expressed by listening. Occasionally, a permissible touch of support is appropriate. Above all, maintaining an attitude and intent that supports the dignity of the patient and her confidentiality is required.
It is held that “patient-centered medical care” would encompass these virtues on the part of the physician, and that is a salutary goal. There has been a concern raised recently that a physician may suffer personally from both feeling and demonstrating empathy and compassion to patients, which might contribute to the phenomenon of “burnout.” We know that burnout is, indeed, a real-life concern, which could lead to either changes in the way physicians practice (employed, limited hours) or how they approach patients (diminished emotional engagement). Could this also lead to a self-selection by those considering a career in medicine to avoid engaging patients with empathy and compassion, or possibly changing the type of applicant to one who may see a medical career as one requiring only skills in science, technology, engineering, and mathematics? This author realizes that his viewpoint of the requirements for a physician to practice ethically, and to embody the virtues of altruism, empathy, and compassion, may be part and parcel of what has been called “nostalgic”
professionalism. Yet, each day in the clinic or operating room, there remains sufficient evidence that these qualities are still present in students, residents, and colleagues, and in a sufficient volume to continue to maintain faith in the future of virtuous physicians in our profession.
In the clinical scenario, we see a patient who is suffering the loss of her best friend and husband, and who may benefit from the nostalgic approach to understanding her suffering. We should set an example for the medical student about empathy and compassion, listening to the patient’s pain and taking the time to validate her emotions and support her dignity. Yes, we may get behind in the schedule, but for this patient and the time you spend with her, you will be a physician in the true sense. And, instead of feeling “burned out” with stress, we might actually feel good about making her feel better through our demonstrated empathy and compassion.
“The good physician treats the disease; the great physician treats the patient who has the disease.”—William Osler.
Dr. Holt is professor emeritus in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.