Thursday, May 14, 2015

The Doctor is like a Drug, and Empathy is the Mechanism of Action

This was originally written in March, 2015:

It seems like the medical world is catching up with Michael Balint!   A headline on a recent Kaiser Health News posting says "Efforts to Instill Empathy among Doctors are Paying Dividends"  This is actually a well written article that highlights a number of efforts to teach physicians a contemporary variation of the old notion of ‘bed side manner.’  These newer programs are based on neurophysiology, have a hint (but only a hint) of an awareness of true psychosomatic medicine (stay tuned for another posting on this topic!), bring attention to one’s own emotional state and provide evidence of the benefit of listening to the patient’s story in the form of trusting relationships and reduced burnout.  They go by catchy names like Oncotalk, Vital Talk, and Empathetics: The Neuroscience of Emotions.  Google these program names - I think you will be impressed.  They come from programs at Duke and Mass General, and there is also a reference in this article to the well known Narrative Medicine program at Columbia as well as the Jefferson Empathy Scale from Philadelphia’s Jefferson Medical School system.  

However, all these programs beg the question of what is the best way to teach empathy!   There seems to be a tension - especially among medical trainees - between more didactic approaches (such as the programs identified above) on the one hand, and more inductive or socratic approaches - like Balint groups or other reflective activities - on the other hand.   In my own teaching experiences, I have heard medical students describe emotion laden situations and literally say “I did not know what to say!”  How sad and scary and what a lost opportunity.  It seems to me that the more didactic programs fit right into the typical learning paradigm for medical students and residents - tell me what I need to know and what I should do.  What does it mean when  a patient looks puzzled in response to hearing a new diagnosis?  What should I say in response?  This kind of approach may actually be helpful to a resident who has not paid attention to their own or to other people’s facial expressions.  It may also be helpful to provide a number of alternate responses.  However, it will be crucial to help residents learn to engage their own personhood in reaction to patient struggles.

In turn, this typical medical learning paradigm may help to understand why more emotion based and inductive approaches are less comfortable for medical professionals in training.  These approaches require physicians to shift gears, so to speak.  They require engaging different parts of our brains - or at least integrating our left and right brains - to better understand “What is needed in this situation.”  If the only time residents have to shift gears is for this once or twice a month, hour long Balint (or other reflective) group process, it is no wonder that they may question what this is all about and say you have not explained how this will help me treat patients.  I think about the adage “When I’m wrestling with alligators, it is difficult to remember that my goal was to clear the swamp.”  Somehow, ‘just’ listening doesn’t seem like it will help me figure out what’s happening for or to this patient - especially in the context of off the chart numbers from their blood tests or alarming results from a scan!  However, the reminder “Don’t answer a feeling with a fact” is easier, and maybe more comfortable than trying to access one’s own emotions.  Maybe if my choices are to be an 'expainaholic' (as referred to in the Kaiser article) or to be a listener, being a listener becomes possible.

Medical training, practice and economics are so tied into rapid diagnosis, proper laboratory tests, appropriate use of scans and other technology, and judicious choices of specialist referrals that it is easy to forget one of Osler’s maxims: “It is better to know what kind of person has the disease than to know what kind of disease the person has.”  
Not only are physicians and other medical professionals lulled into a “What can I do for the patient” mentality, they forget that listening to the patient’s story can be a billable ‘procedure.’  So often, I hear residents tell a story of being the first person to whom a patient has shared her history of abuse, and then say they did nothing for that patient.  This is a teaching moment that is not didactic - it is human!  And this resident and her colleagues who hear the story of this encounter also learn by being touched emotionally by the trusting relationship inherent in this report.  All medical professionals have this opportunity to have their humanity stirred by patient revelations, and all the patients who have such a professional to talk to have begun a process of healing.  It is our human being-ness, not our human doing-ness that is the mechanism of action in this our patient’s healing process.  


Philip Hopkins, a member of one of Balint's first group seminars, has quoted Balint (in Integrated Medicine: the Human Approach, H. Maxwell, ed.): “The discussion quickly revealed - certainly not for the first time in the history of medicine - that by far the most frequently used drug in general practice was the doctor himself…”  Hopkins adds “…there was no pharmacology described anywhere about this important ‘drug’.”  This is in contrast to “… carefully controlled experiments with which every new drug is introduced…”  Maybe the focus on empathy is a beginning of developing a pharmacology of that drug we call the doctor.


  1. posted by Donald E. Nease on 3/26/15:
    Brilliant post, Jeff! It makes me think that our efforts to train young clinicians in relationships and emotional aspects of care are rather like attempting to teach Drivers Ed without any actual driving time on the road. Balint groups give learners a chance to drive the twisty and often scary roads of emotional interplay in a safe and supportive setting.

  2. posted by Amy Ellwood on 4/6/15:
    I echo Don's comments. Well done Jeff!

  3. posted by Dave Schneider on 4/6/15:
    Since ~2000, I've thought about Balint groups as sort of "Medical McLuhanism" (nerdy, I know, but wait). Just as "the medium is the message," the healer acts as both the medium and the message--the drug "doctor," the "drug (we) use with patients all the time." We extend the range of the individual, and of healing itself. In this way, we participate in healing in a miraculous manner. Jeff's article captures this idea beautifully, and without the nerdiness. I haven't written my McLuhan paper yet.

  4. posted by crule on 5/7/15:
    I agree that adjusting the "dose" of Balint is crucial to build these skills and it truly can help the doctor in training see themselves as the therapeutic agent as opposed to adding one more drug to a patient's med list.

  5. Jeff,
    Thank you for sharing your blog with members on the PPA listserv! I'm a psychologist practicing in a primary care clinic which is going through some tension as physicians work to reduce the quantity of narcotic and anxiolitic medications prescribed. Your thoughts on listening, vulnerability, and the different ways that empathy can be learnt, as well as well as felt, have helped me shift towards a more optimistic and helpful attitude in supporting both the clinicians and patients in working towards better health.
    I want to ask your thoughts about the blog, or excerpts from it, being shared with medical providers or the HR administrator that is attempting to coordinate training for medical and support staff. I think that a few articles would resonate and help our providers feel understood and less resistant to the support we are trying to provide. At present there's something of a stalemate and a feeling that asking for empathy means "taking their [patients'] side."
    Please let me know what you'd be comfortable with, and know that your writing has already been important just via my browsing!

    Much Appreciated!