(Photography by Kevin Van Paassen)
How empathy retains the humanism in patient-doctor rapport
Dr. Matthew Cesari spends a lot of his time in a laboratory, peering at human tissue through a microscope. It’s rare that he will meet with an actual patient. Still, the director of surgical pathology at Sunnybrook believes that empathy is an essential component of his job.
“I try to humanize the specimen,” he explains. “We are dealing with tissues that have been removed from a person. I want to always remember there’s a human being at the other end, and that the work we do will have a tremendous impact on that patient.”
The job of a pathologist is to analyze tissue specimens – “mostly cancer, but not always,” he says – and then submit a diagnostic report that will, ultimately, influence the therapy a patient receives. Accuracy is crucial.
“When you’re not necessarily dealing with the [actual] patient, it’s much easier to fall into a routine mindset,” Dr. Cesari notes. “By reminding yourself that patients are not just case numbers, it keeps you sharper. It’s like having an interaction with the patient, even if the patient isn’t there. For me, it makes the work more valuable. It’s more than just issuing a report, it’s consulting on a human problem.”
At the other end of the patient spectrum is Dr. Debbie Selby, a physician in Sunnybrook’s Palliative Care Unit. Interacting daily with people who are nearing the end of their lives, Dr. Selby sees empathy as a given. “I don’t walk around thinking about being empathic,” she says. “To me, that’s inherent in what you’re doing, which is figuring out the best options for them.”
This is the skill she attempts to teach her students – the ability to be sensitive to the patient’s needs, beyond the obvious. “There’s a difference between listening and hearing,” she notes. “It’s the ability to hear, and not just look at the numbers, that really matters. And that can be really hard, particularly for trainee doctors, who are still working at learning a vast body of knowledge. They can become obsessed with the facts and figures.”
When caring for patients at the palliative stage, Dr. Selby says it’s important to focus on who the patient is. “Who is this person? What is important to this person? What does this person need from me to make their path easier?”
For Dr. Selby, it may be as simple as sitting on the edge of a patient’s bed during daily rounds, arranging for another patient to be taken outside to enjoy the sunshine, or discussing medical details in depth with a third patient.
“It’s about tailoring the treatment to the patient’s needs,” she points out. “Is that empathy or is that just sensible medicine?”
To that question, Dr. Ari Zaretsky, Sunnybrook’s chief of psychiatry and vice-president of education, would answer, “Both!” An ardent proponent of “narrative medicine” – the official term for the integration of empathy into medical practice – Dr. Zaretsky warns that as health care becomes ever more dependent on complex technology, something vital may be at risk.
“Medicine is becoming extremely technologically sophisticated and scientifically based, and that’s a good thing on many levels,” he says. “But there’s a danger of losing the humanism, both in medicine and in the doctor-patient relationship. It’s very important to retain the humanism.”
The narrative medicine movement emerged about two decades ago as an effort to encourage medical practitioners to pay close attention to their patients’ personal stories (their narratives) in order to maintain that human connection, even while remaining steeped in the necessary science.
“When you listen closely to a patient’s experience of illness, it’s not the same as just knowing the facts and figures of the illness,” Dr. Zaretsky explains.
The benefits of narrative medicine go both ways. “Generally, patients do better with empathic treatment,” he says. It can also be a way to reduce burnout among health-care professionals, especially in high-pressure places, like the intensive care unit. It helps them to “retain their hope and their sense of meaning,” he notes.
Dr. Zaretsky sees narrative medicine as the wave of the future. Already, major medical schools, like the University of Toronto (U of T), are integrating it into their programs. “It’s a way to counterbalance the head with the heart,” he says. “Otherwise, you’re probably going to have patients feeling that their doctors are robots.”
Ben Fung, a third-year medical student at U of T, understands the attraction to technology. “It’s immediate,” he says, “and it provides so much more information to work with than ever before.” But he believes it must be properly integrated into the narrative process.
“History-taking is the most important aspect of our medical decision-making,” he declares.
“In the past, the patient in front of you was all you had – their narrative and the physical examination. In the end, 90 per cent of [the medical information] comes from the patient interview. Only 10 per cent of the time do you need the extra tests to confirm diagnosis.”
According to Fung, the new generation of trainees is embracing narrative medicine, with its importance being heavily emphasized in the curriculum. “Perhaps there has been a cultural change,” he speculates. “Medical students are being taught to hold onto those idealistic feelings that motivated them to come into medical school.”
It’s a misconception, Fung notes, that narrative medicine takes a long time, that it’s arduous and low-yield. “It does not take a lot of effort. It could be one small question, a physical gesture, and one or two reassuring words. We must never forget that the patient is a person, not just a problem to be solved.”