The quest for empathy in academic oncology

I’ve recently come off the inpatient service, where I cared for a patient whom I’m trying to bring to allogeneic transplant. She is young and has refractory leukemia.

Unfortunately, two re-induction regimens have proved unsuccessful and I’m running out of options, although there are a few left and we are trying one now.

Through one of our nurse coordinators, I heard the patient recently had a conversation during which she talked about how the success of the next regimen was in “God’s hands.” This was a sentiment I was accustomed to hearing from patients, but in this instance, I was told, she worried about me and how I would feel if the regimen were unsuccessful. She wanted to take the responsibility for the regimen’s success away from me.

I had a similar experience just a few weeks before with another patient who also had refractory leukemia — this time after an allogeneic transplant — with a prognosis even more guarded. We had been through a lot together, and he also worried about me. One afternoon in clinic, he invited me into prayer. Holding my hand, with his wife by his side, he prayed for God’s blessing and strength to guide my hands.

What could possibly allow these two individuals with refractory leukemia to care about my needs in this way? Reflecting upon each instance, I knew the answer was in the feelings I had for each of these patients in return, feelings of a common struggle, shared suffering, the same essential humanness — in a word, empathy.

William Wood

I recently began thinking about characteristics within the modern environment of academic oncology — and not just medical training itself — that threaten empathy. A few came to mind.

Over-reliance upon population-based data

I firmly believe in good-quality evidence-based medicine, especially in an area of practice in which the toxicities of therapy are substantial.

With that said, our focus on trial data sometimes can lead us to simplistically view treatment strategies as right or wrong, winners or losers — that someone with presentation X should always receive management Y.

This sometimes causes us to lose sight of the unique presentations, values, preferences and personalities with which our patients come to us, so that for a given presentation, three different answers might be equally appropriate.

Therapeutic nihilism

Some of us practice in fields where cure — or even a satisfactory response — is fairly unlikely, and bad outcomes are common. When we lose hope, it is hard to identify — and empathize — with the hope to which our patients cling.

Our treatment decisions in this context sometimes can feel arbitrary to us. That threatens empathy because, for our patients, choices about cancer treatment never seem arbitrary.

Therapeutic narcissism

Others of us — myself included — practice in areas in which cure always seems at least possible, even if the chances are low. Sometimes, we imagine the only barriers to cure are a lack of effort or creativity on our parts as physicians, which, of course, discounts the importance of disease biology and the toxic consequences of our treatments. Or, we look at high-risk presentations as absolute indications to exert our therapeutic will to achieve a cure.

The problem, of course, is the chance of cure is never absolute, measured in probabilities and affected by immeasurable factors. The risks and consequences, in terms of short- and long-term toxicities — and sometimes even treatment-related death or permanent disability — are substantial.

Therapeutic narcissism threatens empathy because it causes us to overlook the very human concerns and preferences that our patients use to construct their own assessments of the risks and benefits of treatment.

A corollary to this is our belief that, because we engage in such high-stakes decision-making, we are positioned to unilaterally decide upon and treat almost any presentation that we see, no matter how unusual or complex — sometimes inadequately appreciating the accessible intellectual expertise that resides among individuals who happen to have seen more of these unusual or complex cases.

If our perception of our own human capabilities and limitations is skewed, however, can we properly empathize with the humanness of our patients?

The research imperative

In academic medicine, we are evaluated by our ability to produce and publish research that contributes to advancement of the field. Although that is an important and noble cause, research agendas are influenced by multiple competing factors, not all of which are patient-centered.

The premium placed on trial enrollment and accrual threatens empathy when we forget that potential participants are patients first and foremost.

I have come across studies at multiple institutions that I would not recommend to a family member or friend, based on my clinical understanding and appraisal of the trial question and design. Allowing our own patients to sign on to these studies to achieve our enrollment goals would seem to indicate that we are valuing them at a lower standard, again threatening the physician–patient human equality that empathy implies.

Preserving empathy

If these are threats to empathy, then what preserves empathy?

I believe anything that preserves our humanness or allows us to appreciate the humanness of others improves our ability to be empathic.

Efficient clinical operations and scheduling that allow us to spend a few extra minutes with each patient qualifies. Sitting down in a patient’s hospital or exam room rather than standing with one hand on the door qualifies, too.

It is important for us to ask ourselves whether the research we engage in asks the best possible questions to improve patient outcomes. If it doesn’t, should we pass up easier opportunities for career advancement so we can engage in work that is as meaningful as possible?

We should remember our patients come to us with unique values, preferences and fears, and that different answers to the same treatment dilemmas may be appropriate for different patients.

We need to celebrate our own humanness if we can value that in others, so taking time for friends, family and extra-medical interests may in the end benefit our own patients, too.

These are just a few thoughts — perhaps most are intuitive — but I hope this opens up a discussion about what it means to be empathic in academic oncology and what we can do to preserve this most fundamental aspect of doctoring.

William Wood, MD, is assistant professor of medicine in the division of hematology/oncology at the University of North Carolina in Chapel Hill. He may be reached at william_wood@med.unc.edu. Disclosure: Dr. Wood reports no relevant financial disclosures.

For more information:

• Sledge GW. Oncology Times. 2011;doi:10.1097/01.COT.0000406628.66918.1f.