The Missing Ingredient for Effective Health Care Reform…Empathy

For some years I have been following Dr. Brian Goldman, a veteran ER physician and one of Canada’s most trusted medical broadcasters. His CBC radio show “White Coat, Black Art” tackles tough issues, makes sense of “bafflegab” and highlights important new innovations. His book “The Secret Language of Doctors” is an illuminating view inside of the medical system and a great read.

I went to his Vancouver Institute lecture in Vancouver in January entitled: “Disrupt Me + Engage You: The Health Care Revolution”. I couldn’t wait to hear what he had to say about system change in the health field and I was not disappointed. As you may recall from previous posts I think justice reform has a lot to learn from innovation efforts in other disciplines.

He began by describing the healthcare world’s current focus on “patient and family-centred care” i.e. putting patients at the centre. While this has been the mantra in the field for over a decade progress on the front lines has been mixed. He referred to his participation at Kingston General Hospital in a focus group of “patient experience advisors” (former patients or family members who serve as volunteers) who described how patients are afraid to speak up because they are worried that their care would be compromised, how they felt demeaned and how they had no one to advocate for them within the system.

He then described how care professionals use a secret language to prevent others from understanding the real meaning. The most common example is the term “frequent flyers” – those who visit the hospital frequently. Many have chronic diseases and need genuine care. He said that 75% of health care expenditures deal with this group of people. He noted that while in the business world they would be very valued customers, in the publicly funded health system they are not valued.

Other examples include “silver tsunami” (seniors are the fastest growing segment of society), “gomer” (can mean many things including “get out of my emergency room”), “dyscopia” (a made up word to mean inability to cope), and “failure to die” (someone who lingers near death).

To Dr. Goldman all of these stories reveal a fundamental lack of empathy in the health system – an “empathy gap”. He defines empathy as “the ability to use imagination to put yourself in another person’s place and act accordingly”. While he says that human beings are hard-wired to be empathetic training, stress and technology conspire to steal it away. The empathy gap hurts the care professional as much as it hurts the patient and he believes it is the new frontier for health care improvement.

What is contributing to the empathy gap in the health system? Dr. Goldman suggested a number of factors including:

  • Medical culture undervalues soft skills
  • Care professionals are not selected for empathy
  • Training: care professionals are trained for acute treatment (broken bones, appendicitis etc.). They do not receive much training for chronic disease or mental health/addiction issues.
  • Fear of failure: “Frequent flyers” create anxiety because their ailments cannot be treated or cured. Care professionals feel the futility of trying to help these people and they may feel that they have “failed”
  • Care professionals don’t want to be sued
  • It is easier to invent slang than to fix the root causes of these problems
  • Technology: increased technology presents a double-edged sword. It increases efficiency but distracts doctors from paying attention to their patients in a real way
  • Specialization and fragmented care: the current system allows each care professional to do their job without anyone taking responsibility to “care” about the patient
  • Rigid rules in fee schedules: caring takes time.

Many of these correlate closely with justice system issues.

Dr. Goldman recognizes the challenges but sees empathy-building as a real opportunity for positive change. His next book will be on the subject of empathy in healthcare (watch for it!). You can watch a similar presentation on YouTube. His fascinating presentation went on to detail some of the innovations he has already uncovered that give hope for a better future including:

  • Locating services closer to “medical hotspots”
  • Nurse practitioners
  • Physician assistants
  • Allowing paramedics to treat older patients on the spot instead of just transporting them to hospitals
  • Live well health coaches
  • Patient engagement: patient experience advisors serving on hospital committees (like at Kingston General)
  • Emergency room waiting time apps
  • Online apps rating care professionals
  • Virtual clinics using teleconferencing tools
  • Moving the investment from bricks and mortar and acute care to front end primary care

There are many lessons we can learn from other contexts that are also struggling with system change. But perhaps we should first stop and seriously consider the issue of empathy. Without that how can we really put the justice system user at the centre?


  1. Am not totally sure given the focus of blog post, its connection to a legal blog such as Slaw.

    However some comments:
    *the best things we could each hope for is a loved one locally, advocating for us intelligently, when we are quite ill, unable etc.
    *current health care system across Canada, makes it quite difficult to get non-drug therapeutic mental health counseling at length, without costing some money or less desired options.
    *broad public education on local changes can be problem. I just learned of what “urgent care” centre (via a newspaper article) meant vs. going to emergency services at a hospital when one just has a fever, etc. There’s an urgent care centre in my area but I didn’t know what that meant.

    I am dimly aware it might be one’s home provincial legal aid centre to advise on legal information re powers of attorney, elder abuse, home worker aide requirements, etc. if a person cannot navigate Internet for best sources of information initially or even know of local non-profit organizations that might specialize in providing legal information or general client support to navigate the health care system.

  2. I agree with Kari Boyle’s essential point: Law should strive to be innovative and empathetic to the people we serve.

    Why are the Rules of Civil Procedure written so incoherently, when we know the numbers of self-represented litigants are rising?

    Why don’t we look at the individuals and companies who seek justice as the centre of the justice system and change the system accordingly.

    There are hundred of little things we could do to make life easier for litigants:

    1. Increase the use of technology — videoconference, teleconference — to avoid the expense of personal attendances;

    2. Allow people to provide copies of identification and attest to information without the need of a Commissioner or lawyer;

    3. Allow the court system to use secure email — if the banks can do it, so can we;

    4. Allow filing of most documents by email;

    5. Emphasize the use of plain language — nothing that a Grade 9 student could not understand unless technical language is really needed or the parties are clearly professional and sophisticated.

    Some of these changes require a vast investment in technology; others just require a change in mind-set. As a profession, we can make a huge difference in making law more accessible and empathetic.

    Great article, Kari. I’m a fan of Dr. Goldman, too!

  3. I agree strongly that much is to be learned from comparing these and other complex systems – as a stay-at-home MBA that’s been my hobby for years. I worked in health care for 8 years, have analyzed public schooling for 20 years, and have now experienced the legal system through the public interest SRL lens for 4, and have noted with fascination the changes these systems have gone through (and not gone through) over the years. The most interesting phenomenon is the tendency for each of these systems to copy each other’s failures rather than each other’s successes. And that, sadly, is where the empathy bandwagon goes – straight to the heart of getting worse.

    That there is a need for increased empathy toward clients, there is no doubt – but let’s play a semantic game and call it empathetic behaviour, not empathy. And let’s also question the assumption that you’ve going to get more empathetic behaviour by hammering service providers over the head and yelling at them that they need to be more empathetic. No: empathetic behaviour is an outcome of what a system does, it’s misunderstood as an input.

    What the good doctor you quote misses is something I observed over my working years – sometimes the most empathetic, caring, and – watch for it: COMPETENT – health care providers were the ones that laughed the hardest about the patients in the clinic office after seeing the patient. The phrase “failure to die” sprang originally from – or at least was used in my day – as an expression of deep understanding of what a patient was going through. What we see in health care today after already decades of empathy training is care that is, often, more impersonal and no more sincere than it once was. But here’s the key point: I’m betting it’s also less COMPETENT. Count me up the medical errors before telling me about the empathy problem.

    In short, the single most empathetic thing that a health care professional can do for their patient is to be good at their job. No one goes to the hospital for sympathy. They’d prefer their care dished up with sympathy, sure, but given a choice, rude competence will win out over sympathetic ineptness for most people.

    Exactly the same rule prevails in law. When people go to see a judge* they would like to be treated nicely. But they want their case decided well. Given a choice, do you think they’d rather have a nice judge who is kind of unclear on the law, or a tough as nails judge who gets every point right? Look no further than American Idol for your answer: all the contestants were more interested in what Simon Cowell thought than what the rest thought put together.

    *The asterisk in the previous paragraph goes to this point: Yes, people come to the law to put their cases before judges, not lawyers. That’s a key point that the access to justice movement hasn’t addressed yet. It’s become a meme to compare doctors with lawyers, and teachers with doctors. But when you line these systems up, what you actually get is that judges and principals are equivalent to doctors, while teachers and lawyers are more comparable to nurses. There are significant differences, of course, including routes of entry to these occupations and who carries liability insurance, but based on what clients want, when they are after justice they want to see a judge.

    There is a theme in all these different areas of work, namely that one has to dehumanize and decontextualize the task at hand to get the work done. One has to see similarities and differences between cancer cases regardless of who presents with them. Thus, disabling empathy is a necessary work skill. It may also be a survival skill for service providers. The news the other day was of the high rate of suicide among first responders. It may be that it would be far better if we taught them to be less empathetic because the work can inherently be so personally intrusive. Finally, disabling empathy is also a necessary skill for equalizing access to service. If more likeable people got better medical care or better access to legal services, um, that wouldn’t really be so good.

    Here’s my suggestion: instead of trying to teach people to care more, just teach them better manners. It doesn’t really matter, in the end, whether the service provider cares. It matters that they do their work in a way that leaves the client feeling good, and that they go home healthy and intact themselves at the end of the day. Emphasizing manners rather than empathy is, I think, far more respectful in the end of both clients and service providers, because this isn’t supposed to be a close personal relationship.

    And to the good doctor, the same advice as I’ve previously given here to the law community: stick to your knitting. Do what you’re good at. If you want to talk about system design, please, talk to a professional. All you’re able to do is see the symptoms, and you need to talk to someone who can give you a diagnosis and an effective prescription. Unless, of course, you do what SRLs and patients are doing these days: learning as much as you can about a new discipline so you can do it yourself. But the doctor is assuming his existing skill set will enable him to solve a system problem, and he’s going in precisely the wrong direction.

  4. “The most common example is the term “frequent flyers” – those who visit the hospital frequently. Many have chronic diseases and need genuine care. He said that 75% of health care expenditures deal with this group of people. He noted that while in the business world they would be very valued customers, in the publicly funded health system they are not valued.” In all likelihood “frequent flyers” are of the category or categories of senior and/or low-income. Meaning that this all revolves around socio-economics and the system.

    As is stated “they would be very valued customers, in the business world” I suppose the implication being – given that they could afford to pay the very high price of receiving “good” service. Is this really about empathy or equality?

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