A few years ago, Dan McCunney, 35, sought out medical care for what he thought was a heart attack. He felt dizzy and lightheaded, and his blood pressure and heart rate were elevated. He started driving to the hospital on the recommendation of nurses at an urgent care clinic, but then felt so out of sorts behind the wheel that he pulled over and called 911.
After an overnight stay at the emergency room, and countless tests, doctors ruled out any heart-related issues. The next morning, a doctor diagnosed McCunney’s symptoms as a response to stress. (He later recognized this scare as his first panic attack.) He asked the doctor what to do if the same thing happened again. “Well, we all have stresses in life, so you’ll have to find a way to deal with that,” McCunney remembers the doctor saying.
The doctor’s reply left a lasting impression. “Not having any frame of reference for what I was feeling,” McCunney says, “to hear the doctor say ‘we all have stress’ was really dismissive of an issue that was really scary for me at the time.”
At cross purposes
A physician’s attitude in the exam room can have a profound impact on how patients feel about their healthcare experiences. In one 2014 survey, people tended to say they cared more about bedside manner, or the way a doctor interacts with patients, than overall effectiveness of care when assessing doctors. Compassionate interactions with doctors can affect patient health outcomes too; a different 2014 study found that patients had lower levels of blood pressure and pain when they saw doctors who communicated clearly and made eye contact while speaking.
But recent research suggests that doctors don’t always see their own bedside manner the same way patients do. In one 2018 study, doctors tended to overestimate how empathetic they seemed to patients. “Physicians’ view of their own empathy may be at worst incorrect and at best biased,” study authors wrote. A 2014 study similarly found that first-year residents rated themselves as more empathetic than standardized patients (e.g., medical actors) found them.
“To really express empathy you have to actually say stuff; you can’t just sit there and feel kindly.”
“I think students and residents are of good will, they feel that they’re kind and caring people, so they evaluate themselves on that basis,” says Dennis H. Novack, a dean at the Drexel University College of Medicine and one of the study’s co-authors. “To really express empathy you have to actually say stuff; you can’t just sit there and feel kindly. You have to say things like, ‘How are you doing with all this? Oh gosh, that is difficult.’ You have to give them some idea that you know what they’re going through.”
At Drexel, Novack helps teach medical students positive interactions with standardized patients; he wants to make sure the next generation of doctors develops emotional intelligence, not just clinical knowhow. Students learn strategies for interviewing patients in a way that builds trust. For example, they practice asking questions about patients’ lives and validating their emotions by saying things like, “Of course you’re upset, anyone in your situation would be.”
The No.1 complaint from patients, Novack says, is that doctors aren’t listening to them. “Patients have concerns, worries, fears. They don’t know what the hell is going on most of the time and they don’t share that unless the doctor gives them an opportunity and listens and reassures in a way that’s not false reassurance.”
Sometimes, patients don’t feel heard because providers don’t ask the right questions — or any questions beyond the clinical basics. Thanks to increased patient loads and other demands on doctors’ schedules, appointments have gotten shorter. That makes it even more important for both patients and doctors use their time in the exam room effectively. Research has shown that patients think visits last longer when doctors do simple things like sit down during conversations, make eye contact and ask patients about their lives beyond their blood pressure readings.
During McCunney’s hospital stay, his doctors could have inquired about his mental health and the sources of stress in his life. “I would have preferred that she said, ‘I know it feels like something is wrong and it’s probably scary and I can certainly understand that. A lot of times anxiety and stress can mimic these sorts of [cardiac] symptoms,’” McCunney says.
Noticing people, not just symptoms
On her 19th birthday, Austin-based Yasmin Hamou woke up to severe (and off-schedule) menstrual bleeding that persisted throughout the day. When Hamou, now 22, started complaining about her difficulty walking and distorted vision, her friends escorted her to an emergency room near her college campus.
Hamou made it clear to the ER doctor that she was scared. “I’m trying to make conversation, I’m trying to get him to help me, to comfort me, to make sure I’m not going to die,” she remembers. “[But instead], it was straight to the point: I’m going to try and figure out what’s wrong with you.”
She wished the doctor had taken a minute to consider her situation — she was young, visibly upset and alone at the ER on her birthday — and then offer the reassurance she was looking for.
Detached interactions have only become more prevalent with the widespread use of technology in the exam room, says Helen Riess, a physician, director of the empathy and relational science program at Massachusetts General Hospital and co-founder of Empathetics, an empathy skills training program for medical professionals. When physicians and nurses are too focused on checking boxes on a computer to make eye contact with a patient, it can contribute to a lack of bedside manner and increased burnout in physicians, an already pervasive issue in medicine. “The irony is the direction healthcare’s been going makes people almost like the secondary priority to all the documentation and all the other parts of the healthcare responsibilities,” says Riess, who also wrote the book the The Empathy Effect.
Empathetics training is designed to remind doctors of the humanity in healthcare, Riess says. She advises medical professionals to clear their minds of previous distractions before walking into an exam room, to approach the encounter with curiosity, and to look at the bigger picture: “I think one of the biggest impediments to a compassionate engagement is to make a quick diagnosis or reach a conclusion based on only a few words the patient said instead of really giving them time to say why they’re there and what are they worried about.”
But patients also need to consider the challenges healthcare providers are working against. From the vast array of information medical students are expected to master, to the minutiae of billing and keeping up electronic medical records, other concerns sometimes take priority over bedside manner. “A lot of students,” Novack says, “although they value [bedside manner], may not emphasize their learning of all these skills because they’re worried about mastering the biomedical material.”
For this reason, Riess notes, patients should make an effort to be direct and tell doctors what’s really bothering them. “I think it’s very common for patients to have something on their minds that they need permission or support before they’ll come out with their main concern,” Riess says. “Many times they’ll come in with a physical complaint but the thing they’re more worried about is how is this going to affect my job? Or, is this going to affect my relationship?”
The patient half of the equation
But what if a doctor’s behavior prevents a patient from truly voicing their concerns? When Kate Sloan, then 19, asked her primary care physician about switching from the pill to an IUD, the doctor responded in a way that struck Sloan as “slut-shaming.” Sloan, who lives in Toronto, had told her doctor that she was bisexual and in her first relationship with a man. “She wanted to wait until I was in a serious relationship before she would let me get the IUD,” Sloan explains. “Then she wrote me a script for birth control pills. I felt really condescended to. I wondered if she acted that way because I had a history of dating women. I wondered if she thought dating guys was a phase or something.”
Sloan, now 27, still sees that same doctor, explaining that she doesn’t want to deal with the stress of finding a new one. But now, she withholds information to avoid judgment. “I’ve never disclosed to my doctor that I’m polyamorous based on other incidences with her,” Sloan says. “I think she would interpret it as irresponsible behavior.”
“Fat shaming is one of the most common unprofessional communications on the wards. It’s unacceptable.”
Clamming up in the exam room can work against patients, Novack says, because lifestyle habits often play a role in diagnosis. If a doctor isn’t aware of, say, a past eating disorder, they might realize that new symptoms are part of a larger issue.
Of course, physicians shouldn’t make snap judgments, but Novack says it happens a lot: “Fat shaming is one of the most common unprofessional communications on the wards. It’s unacceptable.”
Patients also have a responsibility to provide feedback if a physician interaction rubs them the wrong way, Riess says. If a patient feels comfortable addressing doctor rudeness in the moment, she suggests asking the doctor to sit down or move away from their computer. If patients are too intimidated to bring up issues in person, Riess recommends reaching out to a patient advocate, who can then reach out to the hospital or practice on their behalf. “Patients need to feel empowered to ask for the time and the presence that they need,” she says. “I think that would give some clinicians a little reminder that there’s a human being here that needs my attention.”
Ideal doctor-patient interactions come down to focused attention, Novack says, and an unbiased look at the patient’s whole life, from their nutrition to their employment status. “A patient needs a doctor who listens to who this patient is, what their experience is, what their hopes are, what their concerns and fears are.”