Seeming and Being Empathetic

“The most important thing is sincerity. Once you can fake that, you’ve got it made.”
George Burns

The Empathy Exams is a good piece about medical actors. You should read it.

Most of the communication skills classes I took in medical school eschewed outside actors in favor of role-plays among different medical students – where one of us was the doctor and the other the patient. I can’t say we took these entirely seriously.

I remember one skit, performed in front of the entire class, where a female classmate (playing the doctor) was supposed to present me (the patient) with my test results. She chickened out at the last second and asked if we could switch places, which we did.

So I introduced myself as Dr. Alexander, she introduced herself as Mrs. Murphy, and we briefly talked about her imaginary family and how her imaginary husband was doing. Then I checked my script – written by the professor when he was still expecting a male patient – and found I was supposed to be diagnosing prostate cancer. So I shrugged and thought “what the hell” and diagnosed her with prostate cancer. She, consummate actress that she was, nearly jumped out of her chair: “I can’t have prostate cancer!” Totally deadpan, I answered “That’s what everyone always says – it can’t possibly happen to me.”

Needless to say, we didn’t get much empathy-teaching done that session. Other popular failure modes for our role-plays included actors being silly or overdramatic (“NO! YOU HAVE RUINED MY LIFE WITH YOUR STUPID DIAGNOSIS! I WILL SUE YOU FOR EVERYTHING YOU ARE WORTH!”), deliberately obtuse (“Severe heart failure? Does that mean I can’t go through with my plan to run a double marathon up and down Mt. Everest?”), or just giggling the whole session about our classmates being asked to play husband and wife couples (yes, 25 – 30 year old medical students giggle about pretend marriages exactly the same as schoolchildren).

But the few times we had professional medical actors – usually during exams – were Serious Business. I especially remember my USMLE2CS, a big licensing exam. The Kaplan test prep book (of course there are Kaplan test prep books that teach you empathy) gave a variety of somewhat cargo-cultish seeming advice, like suggestions to use ‘transition sentences’: “Now I am going to wash my hands”, or “Now I am going to ask you questions about your smoking habits”. The general feeling among us students was that the medical actors were dangerous beasts for whom any deviation from script, anything other than the preprogrammed responses, would produce fits of emotion followed by examination failure.

Ms. Jamison’s article confirms what I suspected: that the actors and actresses also feel uncomfortable and stilted by their fixed lines.

So we get this very interesting situation where both sides are trying to stick to a script of awkward preprogrammed responses while avoiding all real human emotion. And when they succeed, we declare victory and say we have taught how to connect to people.


The thing is, I know why this happens. It makes perfect sense from the inside.

Most people have a story of some doctor who treated them brusquely or unkindly. If you don’t have one yourself, you probably hear about it in the media. It’s a legitimate problem. Eventually someone tells medical schools “Hey, a lot of doctors are jerks. Fix this.”

It is possible that a parent, getting the chance to raise a child from infancy and spend nearly every waking moment with them, might be able to rescue someone otherwise fated to become a jerk. Might be able to teach them to read other people’s feelings, to connect with them, and to express that connection in a socially acceptable way.

A professor who gets six one-hour sessions with a class of two hundred? Not likely.

So since they can’t teach actual empathy, they teach programmed responses. The patient is in pain? You say “I see you look like you’re in pain. That must be really hard.” Patient is depressed? You say “I see you look like you’re depressed. That must be really hard.” Patient is bleeding from a huge gaping wound in her abdomen? You say “I see you look like you’re bleeding from a huge gaping wound in your abdomen. That must be really hard.” St. Francis of Assisi it is not, but the point is that it’s grade-able by rubric. When the actor clutched her abdomen and screamed, did the student say “I see you look like you’re in pain?” A plus plus! Did they say something else? Time for remedial training.

I recently learned that standardized tests are written by a team consisting of psychologists and lawyers. The psychologists are there to choose questions that test the appropriate skills. The lawyers are there to make sure all the questions will stand up in court when someone sues the standardized test company because their kid got a bad score.

That same article explains the effect this has on what sort of questions are allowed. You can’t ask “What was the moral of this story?” or “What is the symbolism here?” because if the issue was brought before a judge, and counsel for the prosecution says that the story symbolized the ennui of modern life, and counsel for the defense says that the story symbolized the sorrow of mortality, no one can really prove their case beyond just “Well, that was how it seemed to me, c’mon, look at the text!” So all questions must be obviously based on things in the text: you can only ask if a story was about ennui if it the sentence “This story is about ennui” is somewhere in the story.

I imagine a counterfactual world where doctors are not taught empathy through programmed scripts, and not graded by rubric. A medical student meets a medical actor, and the student tells the actor she has cancer, and there is some sincere discussion afterwards, one human being to another. And then the grader decides if the student was properly empathetic, if she would genuinely want him as her doctor…

…and then if the student fails, he accuses the examiner of racism, and says she ruined his promising medical career. And the examiner doesn’t have a leg to stand on, because she just didn’t feel the student was empathetic enough, and the examiner’s feelings aren’t going to be any kind of a defense.

(if you think this is a purely hypothetical concern, think again)

But a rubric that says to give plus one point if the student says “I see you look like you’re in pain”, minus one point otherwise – that will provide a defense.

And then if doctors are still jerks, the medical school can just shrug and say “Well, we taught them empathy! They even passed our exams! See! A plus plus! It’s not our fault if they don’t use their training!”


But maybe it’s good preparation. Because actual caring is not enough. You also have to pretend to care.

I remember, one of my first few months of internship, listening to a patient – not a PTSD patient or anything, just someone presenting with something totally different like bipolar disorder or drug addiction – explain the brutal abuse he suffered as a child. And the whole time, I was thinking “Oh god oh god this is the worst thing I’ve ever heard I want to go home and cry.”

And then he finished his story and I had to say something. And I didn’t want to say “Oh god oh god this is the worst thing I’ve ever heard I want to go home and cry”, because I was supposed to be Competent Medical Professional, and Competent Medical Professionals don’t go home and cry every time they hear a sad story.

And I also didn’t want to say “Okay, I’ll tick ‘yes’ to the child abuse checkbox; moving on to the next item, have you ever smoked marijuana?”

And I also didn’t want to say “I’m sorry”, because various Head Honchos in the hospital have launched a crusade against the word ‘sorry’ because it sounds like an admission of fault.

And I also didn’t want to say “I see you look upset about being brutally abused as a child. That must be very hard for you.” Because then I would have shown up on his Tumblr the next day.

(I see these stories all the time. “I really opened my heart to this doctor, told him every last detail of the brutal abuse I suffered as a child, and he just sat there and said ‘You look very upset’. YOU F@#KING THINK SO? You think I’m upset about being beaten every time my father was drunk, beaten so bad I was afraid I’d broken bones? I’m sure glad I spent however much money to talk to you so you could tell me I looked upset! Because I need a privileged abled white guy to judge my opinions as valid, otherwise they don’t count, right? Man, doctors are all the same, they just respond to your pain with a stock phrase because they don’t think anyone with an illness can really be human.” Doctors read these, and we’re sorry, but empathy is hard.)

There was a sense in which I had already transgressed; I had forced him to bring up this event from his life because “was patient abused as a child?” was a box on my Medical History Taking Rubric. If he had brought it up for some reason – to get my help in arresting the abuser, to ask for charity, even to seek psychotherapy – we could have pursued that reason and it would have defused the moment. Instead it got brought up for no reason that I had to ask, and once asked, he had to tell me. It floated there in the air, a brute fact. The fact that I actually cared quite a lot didn’t make the socially necessary ritual of Pretending To Care any easier.

So I said: “Gaaaaaaaaaah!”

This may, in retrospect, not have been the most appropriate comment. My only excuse was that all these complicated thoughts about what I did and didn’t want to say were mostly after the fact, and at the time, I just heard this horrible story about child abuse, and my gut reaction was “Gaaaaaaaaaah!”. And my brain’s filter, which is usually pretty good, failed to catch me in time to do anything but give my gut reaction.

And my patient was mildly startled, and I quickly deflected the encounter through the deft manuever of moving on to ask if he had ever smoked marijuana.


Jamison writes:

Empathy isn’t just something that happens to us—a meteor shower of synapses firing across the brain—it’s also a choice we make: to pay attention, to extend ourselves. It’s made of exertion, that dowdier cousin of impulse. Sometimes we care for another because we know we should, or because it’s asked for, but this doesn’t make our caring hollow. The act of choosing simply means we’ve committed ourselves to a set of behaviors greater than the sum of our individual inclinations: I will listen to his sadness, even when I’m deep in my own. To say “going through the motions”—this isn’t reduction so much as acknowledgment of the effort—the labor, the motions, the dance—of getting inside another person’s state of heart or mind.

Partners, parents, siblings, children of a sick person – they probably need to exert themselves to cultivate empathy. They’re going to have to put up with a sick person 24/7, long after their initial burst of compassion has worn off.

Nurses probably need to exert themselves to cultivate empathy as well. They have to deal with sick patients through every moment of their hospital stay, respond to their pleas, deal with their sometimes disgusting bodily issues.

But as a new resident, I have it easy. In my interactions with patients, empathy is not a scarce resource, doesn’t require exertion or extension. My interactions with patients are short and emotionally fraught – getting someone with excruciating abdominal pain to lie still long enough to examine them, telling someone they have a very serious disease, having to hear the details of a history of child abuse. It’s not hard to remain empathetic for a twenty minute appointment after telling someone they have cancer, when you know you won’t be called on to do anything more strenuous than prescribe a medication. Heck, it would be hard not to feel empathy in that situation.

What requires exertion is channeling the impulse. Neither repressing it entirely to avoid awkwardness, nor just letting it all out in an unfiltered “Gaaaaaaah!”

I am getting better at this. One of my mentors taught me the important technique of having a tissue box near me at all times. If someone gets into an emotional situation, I unobtrusively place the tissue box closer to them, which signals that I suspect they’re upset and I’m okay with it, without bludgeoning them over the head with the fact. Sometimes questions work: “Are you okay?”, “Is there anything I can do to help?”, “Do you want to talk about this more, or do you want to move on?”

And part of what I had to do was unlearn my habits from communication classes and empathy exams. In the exams your goal is always very virtue-ethics-y: to demonstrate that you are The Kind Of Doctor Who Feels Empathy. In real life, your goal is consequentialist: there’s a person in pain in front of you, and you need to figure out how to help them. In what I think is C. S. Lewis’ phrase, you need to get out of your own head and do what’s best for the patient. Which sometimes involves reference to the content of my own head – all psychiatrists know that the therapeutic relationship is one of the most powerful weapons in medicine – but only if the patient cares what’s in there.

Which they very often don’t. Now if I get a patient like the one who told the child abuse story, I’ll be more likely to just put on my best Concerned Face and ask something like “How are you doing with that now?” And a surprising amount of the time, the patient will say “I’ve put that behind me, it’s not really an issue anymore.”

I don’t know if, on the deepest level, that’s true. If I were doing psychoanalysis, I’d want to pick and prod at that claim. But in the context of a medical history? I push the tissue box toward them in case they need it, wait a couple of seconds to see if anything else is coming out, and then say “Okay, and can you tell me if you ever smoked marijuana?”

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80 Responses to Seeming and Being Empathetic

  1. Andy says:

    The thing with the tissue box sounds like a very useful workaround to the problem of “Can’t really say anything not-wrong.”

    • Fnord says:

      And it seems like something that could be taught and tested, even.

      • Anonymous says:

        Until patients start to learn about it, and it becomes a “Doctor who is pretending to care about you” cliche in their minds.

    • Julia says:

      I find that clients, no matter how messy their faces, won’t normally take a tissue until I push the box closer to them. I think they’re not sure if they can just take things off the desk.

  2. jsalvatier says:

    Have you read Nonviolent Communication by Marshall Rosenburg? I think it does a pretty decent job of systematizing empathy. If you’ve read it, I’d be curious to hear your thoughts on it. If not, I definitely recommend it.

    • Scott Alexander says:

      I haven’t. I listened to a short online class about it once and it seemed a good guide to not shooting yourself in the foot in ways that I wouldn’t expect most clever people to do anyway. I didn’t feel like I got much out of the class, but the book might be different.

      • jsalvatier says:

        I think of it as teaching me to paint little causal diagrams for other people, so that they more clearly understand my mental state. And to see other people mental states in a similar way.

        needs —> feelings <— observations
        need for order — > frustration <— see dirty dishes in the sink

      • ESRogs says:

        One simple technique that I took from it is the “empathy guess” where you ask the person if they’re feeling a specific feeling. So instead of asking, “How are you feeling?” or making a statement like, “It looks like you’re feeling sad.” you ask, “Are you feeling sad?”

        It’s a subtle distinction, but it seems to make a difference. Attempting to actually guess the emotion* (but still posing it as a question) seems to make people feel more welcome to share how they’re feeling and to connect, even if the guess is wrong. I think this is because it shows that you actually want to know how they’re feeling (vs something like “Are you okay?” which might just sound perfunctory), and it puts them in charge of interpreting their own emotions.

        * And in true NVC form you’re supposed to also guess a need behind the feeling as well, but I find it difficult to come up with both at the same time in the flow of conversation.

    • Jo McHale says:

      I endorse the comment about the value of Nonviolent Communication (NVC) – and share the concern about how to teach it.
      Offering a guess about how someone is feeling, rather than making a statement, helps to make it sound sincere, as another respondent has already pointed out.
      Sometimes, silence and a concerned expression with appropriate eye contact is sufficient. It conveys ‘I am with you’ in a very powerful way.
      If a patient is showing a lot of emotion (maybe in response to a diagnosis), something like ‘It seems very hard to talk about this right now. Is that because you’re shocked and worried about your future?’ might open up a dialogue and enable a discussion about what really lies behind the emotion.
      I liked the suggestion to make a gentle inquiry ‘How are you doing with that right now?’ when the painful story emerged. I agree that the anwer ‘I’m OK’ might not be strictly true, but the very fact that the doctor acknowledges the story and shows willingness to listen further sends the message ‘You matter’. And that nonjudgmental acceptance lies at the heart of a successful therapeutic relationship.
      And yes, it’s complicated.

  3. Elizabeth says:

    You seem to be contrasting godawful programmed responses from your communications classes with non-godawful programmed responses you developed independently (“How are you doing with that now?” ).

    It’s not clear that the lesson here is “Scripts and rubrics are unempathetic while intuitively-generated responses are empathetic” – I weakly believe that, for example, CfAR could create a good, gradeable, script-based communication curriculum for doctors.

    • Geirr says:

      The important thing isn’t that it be gradeable, it’s that it must not be open to hostile interpretation; that’s why the committee includes the lawyers.

    • Scott Alexander says:

      That is a very good point.

      On the other hand, I do feel like there is an incentive difference between signaling empathy and dealing with a patient constructively.

      Very obvious nuclear-grade signals of empathy, like “It looks like you are sad. I realize that must be hard for you” are very very obvious signals of empathy, but in real life obvious signals might be counterproductive because it looks like you’re trying to use an obvious signal of empathy, which is different from actually being empathetic. There might be a degree to which empathy is anti-inductive, since (say) if you knew that every medical school teaches a certain stock empathy phrase, then hearing a doctor say that stock empathy phrase would no longer sound empathetic. It’s not completely anti-inductive, because knowing that someone cares enough to fake empathy is a good first step, but it’s complicated.

      • Douglas Knight says:

        No, I don’t think empathy, especially medical empathy, is anti-inductive. You only expect something to be anti-inductive if you expect people to be learning about it. Why would you expect patients to keep up with medical tricks for empathy? Maybe that’s an argument for not talking about them too loudly, but I don’t think “5 tricks doctors use to fool you” is going viral.

  4. Elizabeth says:

    I also really liked your point about pretending to care being important, even when you really do care. This isn’t recognized widely enough.

    • Andy says:

      Something someone told me while I was learning workarounds for my mild Aspergers: “When you want someone to know how you feel, you have to show it, even when you think they know. Because nobody knows what’s going on in your head but you.”

  5. Russel says:

    Is there a clear and preemptive phrase to let a doctor know he doesn’t need to focus on empathy? If I know he cares about me, regardless of what he signals, I’d rather he focus on my injury. I don’t want him to waste his time thinking up ways to show me he cares.

    Especially given the effort to show emotion. I’d rather he spend that effort on everyone else, to whom it’ll mean more.

    • Geirr says:

      No, not really. This is like treating Crocker’s Rules as a rule instead of evidence; People lie, people sue, and I would bet money on people who said something spiritually similar to your wishes still being less likely to sue the more empathetic doctor. Also, if you’re seeing a doctor who’s not a Resident, the empathy, fake or not is a habit; it’s likely more work to change protocol for this patient than not to.

    • Kerry says:

      It’s more likely a doctor will show empathy well with another patient if she practices showing it with every patient (including you!) so she can develop the habit.

    • Scott Alexander says:

      No, and even though this seems like a good idea I know very few examples of explicit social protocol-setting working outside very small and insular communities of geeks.

      If there were a proper science of signaling I think this would be one of its laws. Something like “Giving someone the option to send a simple signal about informal social interaction creates social pressure to signal one way or the other, which may or may not lead to a new norm but won’t stay stable with people having the option”.

  6. Anon says:

    Why didn’t you post your beloved one of your beloved “trigger warnings” before a blog post that described a woman’s capricious decision to get an abortion, something I find very upsetting? I was completely disgusted and angered by the woman’s irresponsibility that led to her taking the life of her child. “The risk [of having unprotected sex] made you feel close to those boys, how you courted the incredible gravity of what your bodies could do together.” “Oh how utterly charming and literary to make terrible decisions that you won’t have to pay for. Someday you’ll be able to write a blog post about it, and people will link to it and say how brave and radical you are. You go girl!”

    Of course, as a functioning adult, I’m able to deal with the occasional anger at the world without falling apart. My broader point is that it’s absurd to include trigger warnings because there’s always something that can upset someone, and you can’t account for all of that, so why walk on eggshells for your favorite victims?

    • suntzuanime says:

      If you didn’t need a trigger warning then it doesn’t seem like Scott was in the wrong to fail to provide one.

    • Scott Alexander says:

      Both because I don’t usually include trigger warnings for external links, and because I wasn’t aware you were triggered by stories about abortion.

      If you swear on a stack of Bibles that you are actually triggered by abortion to the point where you strongly prefer not to read anything with abortions in it, I will trigger-warn stories about abortion from now one.

      (If too many people take advantage of this offer, I will raise the bar to n > 1 people swearing on said stack of Bibles to have such trigger, but for now I’m willing to take it on your request alone)

      • lmm says:

        That seems like a peculiar choice of bar; I’d happily swear on a stack of bibles to quite a lot of things.

        • Steve says:

          The difficulty of obtaining access to a stack of bibles, even temporarily, is probably enough to bar the most casual transgressors.

      • Anon says:

        I actually do prefer not to read stuff like that and did feel very angry and upset afterward. But don’t worry about it. I’m able to put things in perspective, so that I don’t think being angry and upset is the worst thing in the world.

    • misha says:

      You use the phrase “favorite victims” in a derogatory fashion but what’s actually wrong with it? Everyone will have something they’re sensitive to, but you’re much more likely to care about what your friends are sensitive to. By virtue of being you friends (or more cynically, tribal allies) they’re your “favorite” victims. Trigger Warnings are both a signal to certain groups of people that you care about them and want to be polite and useful to those people. Including any trigger warnings at all also frames you as someone who is willing to accept people can be hurt by writing which automatically makes you someone more appealing to engage with to people who can feel triggered.

      Plus it helps weed out dicks who like to complain about “beloved trigger warnings”

      • Anon says:

        I don’t think Scott has rational reasons for choosing favorites. Just whoever the favorite victims of the Left are, which doesn’t seem based on any objective measure of suffering.

        • Multiheaded says:

          “Only objective suffering matters!”
          [Scumbag Reactionary.jpg]
          “Abortion is the worst!”

          P.S.: someone should make that meme template for real; shoop a scumbag hat onto a portrait of Joseph de Maistre.

        • Alexander Stanislaw says:

          After a quick search here are the some of Scott’s trigger warning topics: profanity, rape jokes, incest, racism, potential parents, dying people, physical disabilities.

          There is no obvious left-right bias there unless dying is a unique left problem (in which case sign up as a member of the right!).

          Also, you obviously haven’t read this

        • Scott Alexander says:

          I continue to be confused by this. Like, you seem to think I’m favoring the Left’s designated victim groups, but I’ve specifically condemned this in what has to be the article you read to know I support trigger warnings in the first place.

          For example, I wrote “My triggers are important, your triggers are invalid” solutions…end up with powerful groups able to enforce their triggers, and weak groups being told to “just man up”.

          I think that the reason that minority groups invented victimology and you didn’t is, in fact, correlated with minority groups being victimized more. However, I agree with you that this isn’t always true and there is no rigorous way to determine who gets a trigger warning and who doesn’t. So far it hasn’t been a big problem so I haven’t codified one for this blog. If enough people think it’s important, I will codify one, probably along the lines of “If three people request one seriously” solution I proposed before.

        • Multiheaded says:

          I think that the reason that minority groups invented victimology and you didn’t is, in fact, correlated with minority groups being victimized more.

          Minority groups might’ve invented victimology as more of an instinctive stopgap solution (in retrospect justified by postmodern ethics), after the older support structures – like tighter-knit activist groups and the feeling of belonging to universalist, solidarity-based political movements – began to disappear for complicated reasons. This essay, which originated the phrase “The personal is political”, is instructive – the author very clearly saw the “personal” as an integral but undervalued part of collective leftist politics, not the foundation of a subjective and essentially counter-Enlightenment movement. Yet that’s essentially how it’s taken today. (See the near-disappearance of collective economic justice from feminist and anti-racist discourse, etc.)

          P.S. I probably need to check more of my privilege, though.

          I defend SJ because I feel it responds to some important needs today, but like you I fear that it can’t advance progress in the wider sense because of its rejection of Enlightenment meta-level things. Additionally, it appears well-calibrated to a low-trust atmosphere, and while of course that’s a reaction to the conditions of marginalized minorities, it contradicts the end goal of a high-trust world with less systemic aggression. It is a long-overdue backlash to real problems, but far from optimal politically.

        • SJ isn’t just an adaptation to a low-trust environment, it damages trust by encouraging people to assume hostile motivations from rather small signals.

        • Andy says:

          SJ isn’t just an adaptation to a low-trust environment, it damages trust by encouraging people to assume hostile motivations from rather small signals.

          Though I prefer a strain in social justice where empathy is very important – understanding why someone can cause harm even with good intent, and trying to teach through others’ good intentions and privilege without as much condemnation.

    • hf says:

      Listen to me very carefully. There must be something I could type that could enrage you and cause you to behave irrationally. (Some would say you’ve already done so in the parent comment. What, concretely, did you hope to achieve?) If I knew you well enough, and had enough malign intelligence, I could drive you to behave in ways that would make you seem clinically insane, because humans have design flaws. You are not exempt. (You are not a special and rational snowflake.)

      Now, do you mean to say such exploits can’t happen by accident – even in nerdy conversations that would never happen to most people elsewhere, e.g. because standard social rules forbid them? (Do you think some deity watches over us to prevent this?) Or are you asserting that people who say they suffer more metaphorical cuts and abrasions from society, and this leaves them more open to such “triggers” (e.g. from people they considered friends or allies) are usually lying or mistaken? Or do you just think we shouldn’t care? (Moral considerations aside, are sensitive people allowed to be important to such fields as AI theory, or do the gods prevent that too?)

      Mind you, I keep saying the name “Content Note” seems better in multiple ways than “Trigger Warning”.

      • Anon says:

        “If I knew you well enough, and had enough malign intelligence, I could drive you to behave in ways that would make you seem clinically insane, because humans have design flaws.”

        Yeah obviously if you tortured me and stuff, I’d lose my bananas a bit. I don’t see what the point is though.

        “Or do you just think we shouldn’t care?”

        Uh yeah I don’t care at all. I mean, I guess in a purely utilitarian sense I do care a little if people are butthurt because it’s net negative utility. But yeah I’ll get back to your hurt feelings when I’m done with starvation.

    • ozymandias says:

      It is very nice for you that you’re functional and you don’t fall apart because you read certain ideas, but might I gently suggest that content warnings are generally aimed at people who *aren’t* functioning and *do* fall apart? I mean, do you get upset at “warning: may contain nuts” labels because you personally do not go into anaphylactic shock?

      • Anon says:

        The only way to become functional is for people to stop babying you. Folks have said some awful things to me in my day, and that’s why it doesn’t bother me as much.

        • ozymandias says:

          I am pretty sure there would be a lot of combat veterans interested in your exciting new “the reason you have PTSD flashbacks when you hear cars backfiring is because the military babied you” theory.

        • jsalvatier says:

          That’s one theory, but it’s not an obviously correct theory, and many people disagree with it.

      • Randy M says:

        >”I mean, do you get upset at “warning: may contain nuts” labels because you personally do not go into anaphylactic shock?”

        Not upset per se, but I do find it ridiculous when it is on, for example, a can of mixed nuts.

        • Fnord says:

          This is a rule design problem, and indeed somewhat analogous to the test question design problems discussed here recently. “Well, it obviously contains nuts” is not an objective standard.

        • ozymandias says:

          Back when I blogged I used to feel confused about whether I should put “content warning: rape” on posts with titles like “Rape Of Men In The Military Continues Unpunished.”

  7. T. Greer says:

    I remember how surprised I was when I moved to Rochester, MN (home of the Mayo Clinic). I had met many doctors before. I am a member of a religion that has many more doctors than can be found in the average population (LDS- “Mormon”). I was not looking forward to moving to a new congregation where everyone would be a doctor.

    I was surprised with what I found. Almost every doctor I met – with a few exceptions – were some of the kindest, friendliest, and generally most empathetic people I’ve met, well, anywhere. I was a bit mystified. These people were doctors, right?

    I later found out from a member of the congregation who was fairly high up in the clinic administration that this was by design. The clinic specializes in long term stays. Through internal studies they discovered that there was a relationship between patient recovery during these long term stays and how valued patients felt by the doctors and nurses who helped them. So they decided they would only hire doctors who were genuinely kind and empathetic people.

    I always wondered how they determined if someone was empathetic enough to get in.

    • Scott Alexander says:

      Can you explain why Mormonism has more doctors than average?

      • MugaSofer says:

        I understand – from an ex-mormon friend – that they place a heavy emphasis on Doing Good Works, and thus indeed do rather a lot of good works.

        Or maybe it’s just because Mormons are more successful than baseline? I’ve heard that’s a thing.

  8. Viliam Búr says:

    Writing from another country… the response “I see you look like you’re bleeding from a huge gaping wound in your abdomen. That must be really hard.” would be a huge improvement from the typical “Stop screaming!”

    Despite all the failures, even the pretending-to-be-emphatetic programs provide real benefits to the patients.

    • Scott Alexander says:


      Part of the problem is that medicine is a very immigrant-loaded profession. A lot of doctors come from countries that have different social norms and don’t believe in empathy in the same way we do or express it differently in ways natives might not catch or understand. See the linked article that immigrants are something like fifteen times more likely to fail their exams than non-immigrants.

      If this is a large part of the problem, it’s probably politically impossible to point this out, so they just end up teaching everyone basic scripts and hoping that people who already understand American culture ignore them (like I mostly do) and default to ordinary American conversational norms.

      • Maribou says:

        first – this is a wonderfully written, engaging, and delightful article.

        second – I think there is a big difference between an individual suing an examining body, and a group of people saying “this looks like systematic bias to us, you need to figure out why this happens”

        third – while I am not a medical student or a medical school professor, I do work with extremely bright students from a range of cultures, many of whom are international students, in a professional capacity where I am responsible for both training and evaluating them. It seems to me *at least* equally possible that “American” cultural norms – really, from the med schools I’ve seen, upper-middle-class British-descended-cultural norms – are non-universal enough that “empathetic behavior” only flags on the test as empathetic if it is culturally-specific. I suppose if the vast majority of patients were also upper-middle-class folks of British-descended cultures, that would be a significant reason to judge by that precise cultural standard…. as it is, I have to think that there are a lot of communities who would be better served by something other than that standard.

  9. Jack V says:

    That’s really interesting.

    I’ve often thought that I *expect* doctors to fake empathy. I don’t expect that the 1000th time you see someone in pain, you empathise as much as the first time. But ideally you recognise it matters equally much to patients #1 and #1000 and can fake it reasonably well. And it’s not just about being nice, it’s a bit much to expect patients to read up in advance “if your doctor is rude and brusque, you’re still entitled to ask questions before agreeing to anything, and must tell him/her about any other symptoms even if he/she thinks they’re stupid and don’t matter.”

    • Q says:

      My words ! I do not require emphatic remarks, all I need is the doctor not being rude and brusque, so that I do not have to channel my willpower to assertivity. Jack V, are you in the USA ?

  10. Kokomo says:

    “What was the moral of this story?”

    Rationalised emotion, deontology. Let us, as far as one can, elaborate and weaken the relationship between emotion and morality; let the causality be bidirectional.

    • Multiheaded says:

      let the causality be bidirectional

      I agree. Which worldviews attempt to restrict one of the directions? Authoritarianism and fundamentalism for emotion-to-morality, sure, but also (stereotypical) modern liberalism for morality-to-emotion; “being yourself”, repressive desublimation and so on – probably that’s an over-correction of the older systems.

      I find Lacanian stuff, like Zizek, to be insightful on the subject – even if it’s frankly hard to comprehend in places. Basically this Freudian line of thought says that in a liberal climate, instead of feeling guilty for disobeying patriarchal authority, you feel guilty for not going along with your desires, faking or not expressing your empathy, etc – as if you’re betraying yourself. Warm-and-fuzzy liberalism is not libertinism and abandon as the strawman goes, it’s another order of duty and control that just works in a different way.

      • Scott Alexander says:

        +1 insightful. I wish I could hire you to follow me around at all times and give one-sentence summaries of what Continental philosophy I encounter is saying.

      • Andy says:

        Warm-and-fuzzy liberalism is not libertinism and abandon as the strawman goes, it’s another order of duty and control that just works in a different way.

        From my reading of (mostly progressive) spec-fic and fantasy, I’d agree with this. Though that may be that “duty” is simply a good way to get a main character into a situation, and libertinism and abandon make for very poor conflicts and thus boring stories.

  11. JPH says:

    Just commenting to say great writing. This is better quality storytelling than many newspapers today.

  12. An interesting piece, to say the least.

    Having been treated by quite a few doctors recently, the thing I most often feel when discussing my medical history with them is guilt. Most of them seemed like they would berate me if it turned out that I hadn’t been taking my medication in exactly the right way or if my lung function tests revealed I wasn’t nearly as sick as I was letting on or whatever. They were perfectly nice to me and certainly didn’t say anything along those lines, but it was the vibe I got. Is this a thing or am I just crazy?

    • Anonymous says:

      I find myself lying to doctors without even realizing it.

    • Scott Alexander says:

      Berating sounds wrong, but doctors are specifically taught to very strongly express the importance of certain health behaviors.

      For example, there are very good studies that show that a doctor discussing the importance of quitting smoking at every visit significantly increases the chance of a patient quitting. Since every quit you get increases the patient’s life expectancy a couple of years, this is probably the single most important thing you can do as a doctor, and quite possibly even if you are a brilliant diagnostician/prescriber/etc the *majority* of the life-years you save will come from this source.

      Likewise, the percent of people who end up in a psychiatric hospital because they stopped their psychiatric medication that was working perfectly well for them is amazing, and since each hospitalization costs either the patient, the insurance company, or the state upwards of $10,000, and since the really hard intellect-requiring work of figuring out the proper medication has already been done, this seems to me like a huge waste and a huge problem and I do try to always impress upon patients the importance of sticking to their meds (while also being very receptive to their complaints about side effects and stuff and trying to figure out if some other option might be better)

      So I guess the question is how you would like doctors to express the importance of things without coming across as berating. This seems like a very hard problem (I’m pretty sure the nicer parts of social justice have the same issue) and I don’t have a good answer.

      • Anonymous says:

        The lying I do is more behavior that I won’t change, or disagree with the doctor over. Ex:
        I once had a doctor ask me if I had ever used “protein powder supplements”, as in whey powder. I told him no because I didn’t want to argue with him that whey is just milk protein and not some special food apart from all others.
        Or I’ll lie about my caffeine use because my home BP readings show an insignificant difference in BP from caffeine.

        But more generally, I think people lie to doctors when doctors frame behaviors as things people are morally obligated to do, rather than things that are healthy. Compare “You SHOULD exercise” to “Exercise will benefit your health” — the first is more likely to make one feel guilty in my opinion. “Shoulds” often elicit tired “I know”s.

      • anon1 says:

        I’ve had a dentist berate me for the way my gums bled when cut, and say this was obviously because I wasn’t flossing. Since I’d been flossing daily for the previous six months, I was pretty angry and definitely felt less desire to floss thereafter. This is the kind of behavior you really don’t want to see from a doctor.

      • Any thoughts or research on what happens when doctors tell patients to lose weight?

  13. Randy M says:

    We had a few projected empathy failure moments last year when the doctors & administrators were having my wife sign consent forms spelling out every end result and potential complication of a surgical eviseration and asking things like “what’s wrong?” and “are you okay?” when she was emotional.
    But in the end all’s well that end’s well, and I prefer the empathy errors to the billing errors (which we had) and of course to treatment errors (which I don’t think we did have).

  14. Anon says:

    Scott, I don’t see a way to reply to your comment directly, but thanks for the blog post. I was referring to your trigger warnings in other posts, not to that post on the topic. Now I understand your policy. Even though I disagree with it, it’s at least consistent. I on the other hand support the South Park philosophy of “everything’s fair game, no apologies”.

    I personally don’t need trigger warnings, but I wanted to let you know that talk of abortion can be sincerely upsetting to some people. And yes, some people are mocking me as a reactionary (I’m actually a libertarian), and I sort of see why. But even though I can objectively understand that abortion isn’t that bad from a suffering perspective, abortion has been so cross-wired with infanticide in my brain that I literally have the same reaction to both. And there are many people who feel the same way (actually a slight plurality of Americans, I believe, feel abortion is morally wrong).

    • Andy says:

      And yes, some people are mocking me as a reactionary (I’m actually a libertarian), and I sort of see why.

      Off topic: It’d be fascinating to read an analysis on what I suspect to be very fertile common ground between NeoReactionaries and Libertarians. Personally, my stereotype (yes, this is a massive overgeneralization and I admit it) of a NeoReactionary is someone who used to be a Libertarian and came to the conclusion that they’d never get a majority to support their pet policies, so they went as far from democracy as they could get.

      • Multiheaded says:

        Personally, my stereotype (yes, this is a massive overgeneralization and I admit it) of a NeoReactionary is someone who used to be a Libertarian and came to the conclusion that they’d never get a majority to support their pet policies, so they went as far from democracy as they could get.

        That’s funny, I see it the opposite way; many (but not nearly all) right-libertarians are small-r reactionaries who believe that their reactionary agendas can be implemented successfully in the absense of “progressive” bureaucracies, influential liberal elites and grassroots radicalism (“mobs” and “looters”).

        • Andy says:

          Most of mine comes from watching someone I knew in meatspace go from a Ron Paul libertarian to somewhere around Jim’s-Blog-ward in the space of about a year and a half, from 2008 to mid-2009. Especially around the time of Obama’s election, he started defending ballot box segregation, quoting Founding Fathers about the dangers of democracy, and by the end of our acquaintance, he was pretty poisoned on the idea of “the people” having anything to do with policy. I’d try to determine where he is now, but that wouldn’t be good for either of us, given the acrimony around our parting ways.
          One anecdote, and certainly not data, but that, and finding a current NeoReactionary’s old digital trove of libertarian and anti-socialist texts, went a long way toward forming my mental image. Though people, in all their strange and wonderful diversity, could really have gone either way, from reaction to right-libertarianism, and from right-libertarianism to Reaction.

      • Kokomo says:

        So they went as far from democracy as they could get.

        “I believe in democracy” said the progressive, lying. Again, it’s barely even a concept.

        • Kokomo says:

          Also, you can fuck off now. Arguments and ideas stand on their merits, not a series of inaccurate sociological or psychological interpretations with an inbuilt progressive bottom line.

          If you want to understand the ideas of “someone like me”, just read what I have (in recent memory) said. How to improve the chances of a positive singularity: internal reprogramming, external sculpting in time. (I welcome strong criticism from any apparently sincere person, which is why e.g. I used to link to this blog. Obviously it would take a hell of a lot to recreate that situation ¯\_(ツ)_/¯)

        • Andy says:

          “I believe in democracy” said the progressive, lying. Again, it’s barely even a concept.

          Say better, as long as we’re on the subject of what people believe, I believe that decisions of public policy can be more effective and have more legitimacy when soliciting a wide variety of input and ratifying through elections.
          And I wasn’t really thinking of you when I wrote that post, I was thinking along the lines of James Donald and (Not a Reactionary but someone who’s spoken against democracy) Peter Thiel. And generally staying away from the various incarnations of the “Singularity” concept, since I don’t understand it at all.
          From the “fuck off” line, I seem to have offended you, and I apologize, even if I honestly don’t understand how.

  15. Paul Torek says:

    And I didn’t want to say “Oh god oh god this is the worst thing I’ve ever heard I want to go home and cry”, because I was supposed to be Competent Medical Professional

    And yet, in the right context, that is probably one of the best things you could possibly say to someone if they are still affected by that trauma. And it’s a damn good bet that they are, if they are coming in for psychological issues, even if those issues don’t present as PTSD.

    • ozymandias says:

      I dunno, most of the people I know with really awful childhood trauma would be really annoyed at a doctor who did that. (This is possibly just me selecting for people who deal with trauma through detachment and flippancy.)

  16. Q says:

    The psychological checkbox questionaries seem to be very insensitive devices. Are you really obligated by law to do them when you first meet the patient ?
    I have an unpleasant experience with a young psychotherapist (not psychiatrist) who did this checkbox on our very first session. I really did not feel like answering some of the questions. But he waited at each one with his eyebrows raised. After almost a year, I changed the therapist, and, surprisingly, the new one did not ask these questions, at least not all of them.
    …But, even though I write this, it is a nitpicking, really. From medical doctors, all I want is that they are not actively mean to me. I do not believe even in the USA, the worst issue is not knowing how to express you are sorry for patients suffering. If it is so, USA is heaven. But I suspect, you probably just did not meet enough doctors from the position of a patient.
    Anyway, in my country, women during labor are told to shut up if they scream too much. Or yelled at, if they do not immediately position themselves correctly for epidural anesthesia, because the movements are clumsy due to contractions. On a lesser scale, I count as active harm, if the doctor interrupts patients speech all the time and does not give him those two extra seconds to finish a sentence and describe the symptoms.

    • Scott Alexander says:

      We’re not required by law to do those questionnaires, but it is almost always a good idea. A lot of people are *really bad* at saying what’s wrong with them if you just ask. I can’t tell you how many times a patient’s just been at the office for a checkup, and I ask “Anything wrong?” and they say “Nope, everything’s fine”, and then I run through a long list “Any chest pain?” “No, I told you everything was fine” “Any headache?” “No, I told you everything was fine!” “Any shortness of breath?” “No, I…actually, I have been having shortness of breath lately, really bad!” and then they turn out to have some terrible lung disease I almost missed.

      And it’s always tempting to skip over some boxes, but it’s not always a good idea. It has not happened to me, but I have heard stories of people who don’t bother asking elderly people if they’re sexually active with multiple partners, because, cmon, elderly people, and then their problem eventually gets traced back to an STD.

      The trick seems to be finding a way to get all the information without it being *obvious* that you are just ticking boxes on a sheet. Really good doctors can just sound like they’re having a conversation with you about your health while still getting most of what they need. But this takes a lot of skill and I don’t blame people who haven’t acquired it yet.

      • Sniffnoy says:

        Sounds like a rather more useful questionnaire than the ones I have to fill out when I go to a doctor, which ask things like if I’ve had any shortness of breath ever.

  17. Pingback: Linky Friday #56 | Ordinary Times

  18. duckofdeath says:

    I actually had pretty much this exact experience (asking a question about child abuse for a stock questionnaire and hearing a horrifying story about the patient’s abusive childhood) however rather than this happening to me as a resident, it happened a few months ago in my first year family practice rotation i.e. THE VERY FIRST REAL-LIFE PATIENT I EVER INTERVIEWED SOLO :p