Healing

Empathy vs Compassion

I recently read a fascinating book by psychologist Paul Bloom called Against Empathy: The Case for Rational Compassion. In this post I will discuss this book in more detail as well as review other evidence about the difference between empathy, theory of mind, and compassion. I will also discuss how Bloom’s book has been misused by some right wing Christians.

Empathy

Definition of Empathy

Most definitions of empathy include vicariously feeling the same emotions as another person and understanding another person’s perspective. Psychologists separate these two things. Vicariously feeling another person’s emotions or pain is called emotional empathy. It is neurologically distinct from understanding another person’s perspective, which is called cognitive empathy or theory of mind. Bloom focuses his critique on emotional empathy, not theory of mind.

Emotional Empathy

Emotional empathy is hard wired into us. It is a mostly unconscious response to another person’s distress. It can motivate us to be kind and helpful to the person or people who elicit this response. It can also lead to harm and even violence. Much more about that later in this post. Emotional empathy is a system 1 response. I’ll explain what that means below.

System 1 and System 2 modes of thinking

System 1 and system two are descriptions of of two ways that our minds operate. It is a somewhat simplified model, but it is consistent with current neuroscientific research. The best accessible description of system 1 and system 2 is a book by Daniel Kahneman called Thinking, Fast and Slow. I highly recommend reading it.

System 1 is what we use for most routine tasks in our lives. It is our fast, automatic, intuitive and emotional mode of thinking. It operates without conscious awareness and relies on mental shortcuts to make quick judgments and decisions. System 1 is essentially our brain’s “autopilot” mode, constantly monitoring our surroundings and making rapid assessments. It is essential to our lives, but , it’s also important to be aware of its limitations. It can sometimes lead to errors in judgment, particularly when dealing with complex or unfamiliar situations. 

System 2 thinking is a deliberate, conscious, and effortful process used for complex tasks and decisions. It is characterized by logical reasoning, careful analysis, and consideration of multiple factors. Unlike System 1 (fast, intuitive thinking), System 2 requires focused attention and effort.

Emotional empathy as a system 1 mode of thinking

Emotional empathy happens without our conscious awareness. It is contextual. Bloom cites research that emotional empathy is influenced by what we think about the person we are empathizing with and how we judge the situation that person is in. In one study subjects were shown videos of people in pain said to be suffering from AIDS. Some of the people in the videos were described as having gotten AIDS from intravenous drug use and some were described as having gotten AIDS from a blood transfusion. Subjects showed much more empathy for the people who were described as having gotten AIDS from a blood transfusion than those described as having gotten AIDS from intravenous drug use.

Emotional empathy is also influenced by the group to which the other person belongs. Is it one of Us or one of Them? There was a study of a painful shock to the hand in European soccer fans. One person was shocked while others witnessed the person who was shocked. Subjects showed more empathy if the person was a fan of the subject’s team and much less empathy if the person was a fan of the opposing team. All of these responses were shown to be below the level of consciousness. When subjects were asked about the reason for the difference in their empathy scores, they denied that there was any bias.

Does high emotional empathy correlate with good behavior?

People do vary in how empathic they are. On one end of the spectrum are people who have a high emotional empathy response, and on the other end of the spectrum are people who have very little emotional empathy. We would expect that people with a high emotional empathy response would be more likely to take action to help. People with high emotional empathy feel peoples’ distress more strongly and this should motivate them to help if for no other reason than to reduce their own distress. Another way that they could reduce their distress, however, is to escape rather than help. We would also expect that people with very low emotional empathy would have more cruel or violent behavior.

It turns out that there is almost no correlation with empathy and good or bad behavior. A meta-analysis of all the studies showed that low empathy has no association with aggression, and high empathy has minimal to no effect on good behavior. To quote Bloom, “Being high in empathy doesn’t make one a good person and being low in empathy doesn’t make one a bad person.”

Emotional empathy as a spotlight

Emotional empathy acts like a spotlight. To quote Bloom again, “making visible the suffering of others making their troubles real, salient and concrete.” The spotlight effect is a weakness as well as a strength. When you point a spotlight at something, everything else is in darkness. What you see depends on where you point the spotlight. This focus effect makes you more vulnerable to bias. It also leads to something called “the identifiable victim effect.” This sets up a situation where one identifiable victim elicits more emotional empathy than than a thousand victims. Stalin once said “One death is a tragedy; one million deaths is a statistic.” We also see this effect in deaths from the COVID pandemic. Eighty percent of Americans do not know anyone who died from COVID, though over a million Americans died from the COVID pandemic. The people who died were disproportionately elderly, black or poor. For people outside of those groups there was no emotional empathy spotlight effect. That is likely why so many people were not convinced that COVID was a serious disease.

The dark side of emotional empathy

Emotional empathy where there is conflict between groups can exacerbate conflict, even wars. People on one side feel empathy for members of their group who feel they have been harmed by the other side. Empathy with your side leads to the desire to punish the perpetrators. Of course people in the group on the other side of the conflict feel emotional empathy for the people on their side and therefore want to punish the other group. In these kind of situations emotional empathy exacerbates rather than mediates conflict between groups.

Burnout

People in the helping professions (doctors, nurses, therapists) do not do well when they experience high emotional empathy with all their clients. Experiencing the pain and suffering of patients, even though empathic suffering is not as severe as the suffering of the patient, is not pleasant. Over time, symptoms of burnout can develop. These include fatigue, poor concentration, lack of energy and effectiveness, cynicism and detachment.

Manipulating emotional empathy

The emotional empathy response can be manipulated for good causes, but also for things that are morally suspect or wrong.

Charities

Charities understand that eliciting emotional empathy will increase donations. They do this by showing images of individual people or animals who are obviously in distress. Stories go with the images about the suffering of this individual person or animal. Since we have an increased emotional empathy response to children in distress, the charity ads often use images of children. The emotional empathy response is not a good way to decide which charities should get your donations. Some charities do much more good for a lot more people than others. All charities, both good and not so good use the same techniques to manipulate emotional empathy. There is a better way to decide which charities should get your donations. More about that later in this post.

Politicians

Politicians often highlight individual people to manipulate the emotional empathy response to recruit people to vote for them or to take one side or the other in political and policy battles. Once again, this is not a good way to choose which politician or which policies you want to support.

The Christian right

There have been several recent books by right wing Christian authors who have cherry picked Paul Bloom’s critique of emotional empathy. Essentially anything or anyone that elicits empathy that contradicts their view of Christianity is termed “toxic empathy.” This is just another manipulation of empathy in a negative sense that promotes a particular religious viewpoint.

Compassion

Definition of compassion

Psychologist Paul Gilbert defines compassion as basic kindness with a deep awareness of the suffering of oneself and of other living things coupled with the wish and the effort to relieve that suffering.

Compassion as system 2 thinking

Understanding (rather than feeling) the suffering of a person or group of people uses system 2 thinking. That understanding facilitates the desire to help in the most effective way possible. Determining the most effective way to help requires logical reasoning, analysis, and consideration of multiple factors. These are characteristics of system 2 thinking.

Awareness of the vast amount of suffering in the world does not mean that an individual person can help relieve the suffering of all sentient beings. Compassion involves choosing both how and whom one can help the most.

Compassion in the helping professions

As noted above, emotional empathy alone can lead to burnout. It can also lead to less than ideal doctor-patient relationships. Patients are not interested in doctors or nurses feeling their pain. They want compassionate competent care. Doctors, nurses and therapists must of necessity maintain a certain emotional distance from their patients in order to provide that compassionate care. Compassionate care clearly involves mostly system 2 thinking. Unlike emotional empathy, understanding and compassion lead to the opposite of burnout. Multiple studies have shown that compassionate care is good for both patients and their clinicians. Here is a link to a review of a book by Dr. Anthony Mazzarelli and Dr. Stephen Trzeciak: Wonder Drug: Scientific evidence that serving others is best medicine.

Compassion training

It is possible to enhance compassion through training. For over a thousand years buddhists have practiced a form of meditation on compassion called “loving kindness” meditation. It involves both compassion for self and then expanding to family, friends, and eventually all sentient beings. Here is a link to a website that describes this kind of meditation: Metta Meditation: A Complete Guide to Loving-Kindness. There are many other ways to enhance one’s ability to be compassionate including cognitively based compassion training, Stanford multidisciplinary research based training, as well as many others. They have all been shown to increase compassion, which in turn leads to helping others. Once again compassion for self and others is as good for the helper as it is for the one who is helped

Bottom Line

You cannot turn off emotional empathy, nor should you even try. It is an automatic system 1 response. When combined with understanding and compassion it is always a good thing. It makes suffering visible and salient. The important thing is to learn to recognize your emotional empathy system 1 response and then engage your system 2 understanding and compassion. Emotional empathy by itself is not good or bad, but can be either. Your capacity for understanding and compassion (which is essentially kindness) can be enhanced by training. We definitely need more kindness in our world today.

The Power of the Unconscious Mind: How to Access it for Healing and Improving Health

I’m going to spend some time in this post writing about the neuroanatomy and function of the conscious and unconscious mind. Hopefully I will be able to clear up some common misconceptions about both. I will then write about the amazing power of the unconscious to facilitate healing from both physical and psychological injuries as well as to decrease pain from dental and surgical procedures. Finally I will write about how to use self hypnosis techniques to access the power of the unconscious.

The Conscious Mind

We intuitively feel that our conscious mind makes up the largest part of who we are. Through our 5 senses we feel that we observe the real world, that is, what we see, hear, touch, smell and taste is out there in the world just the way we perceive it. That is an illusion, however. We perceive what is important for our survival. We see only a small part of the electromagnetic spectrum. We cannot see ultraviolet, for example, but bees can. We hear sounds of only certain frequencies. Dogs can hear ultrasonic frequencies, and dogs’ sense of smell is thousands of times better than ours. We do not directly sense the world. Information from our sense organs is extensively processed in the brain. We sense only a representation of the outer and inner world that our brains create. Furthermore a vast amount of sensory information is coming from our environment, both internal and external, being processed by our sense organs, and we become conscious of only a tiny part of that input. Our conscious minds can process about 50 bits of information per second. If that sounds like a lot, remember that internet download speeds are measured in millions of bits per second. The parts of your brain and spinal cord that are below the level of consciousness process about 11 million bits of information per second!

Carl Jung once described the conscious mind as like a cork floating on the sea of the unconscious. Modern neuroscientists have shown that his analogy was very accurate.

An example may make this point better. As you are reading this blog, you are seeing the letters and words upright. What is actually happening is the light and dark pattern of this sentence is focused by the lenses of your eyes into upside down two dimensional images on your retinas. A great deal of processing goes on in your brain so that what you actually perceive is right side up, has color and is three dimensional. All of that processing is below the level of consciousness. Furthermore, the high resolution part of your retinas, called the fovea can see only a small area at a time. Your eyes are constantly scanning back and fourth and up and down seeing only a tiny bit at a time and yet you perceive your visual world as whole. Finally your ability to read sentences and extract meaning rather than seeing individual letters and/or words is a learned pattern that has become automatic. Most of the process of reading is therefore done below the level of consciousness.

The Unconscious Mind

As you can see from the section above, the vast majority of the processing our brains do is below the level of consciousness. The unconscious mind controls our heart rate, our blood pressure, our breathing, our bowel function and all the things that are are necessary for our survival that we don’t have to think about to make them happen. The unconscious also contains all of our of automatic skills, such as playing the piano, riding a bicycle, or playing tennis. It is the source of stored memories, fantasies and dreams. It takes over patterns that we have learned over time to simplify our lives. Many of these patterns are necessary and helpful, such as brushing our teeth. Some patterns are not so helpful, such as phobias, anxiety and fear, or unhealthful habits such as smoking, excessive drinking or compulsive drug use.

All of these things are patterns of connections in the brain. We used to think that brain connections once made could not be changed, but scientists have since found out that not only can brain connections be changed, but they are constantly changing. This is called neuroplasticity. It is normal to grow new brain cells and to change their connections.

Can we change unhealthy patterns in the unconscious mind?

The short answer is yes! While the unconscious mind is generally not accessible to the conscious mind (that’s why it’s called the unconscious, after all), there are ways to influence the unconscious mind and to change unhealthy connections.

Altered States

The state of mind that we are in most of the time is called the waking state. Our conscious mind is controlling our actions (well sort of). There are other states of mind, often referred to as altered states or trance states. These are familiar to all of us. A perfect example is watching a movie or a television show. We get so wrapped up in the story that we lose awareness of all of our other surroundings. Sometimes people talk to us while we are paying rapt attention and we don’t even hear them. Reading a really good book creates the same altered state. Have you ever been driving somewhere and suddenly found yourself having arrived at your destination, but you don’t remember any of the details of the trip? Another altered state of consciousness or trance. If the word trance bothers you, think about the word entranced. We all know what that means. These altered states or trances are no different.

It turns out that once we get the conscious mind out of the way (entranced) the unconscious mind becomes accessible to change. The spontaneous trance states like television watching or driving while in a trance don’t change any connections, but it is possible to intentionally go into a trance state and purposefully change connections in the unconscious mind.

Hypnosis

Many people find this word scary, but all it means is going into a trance state (which we do spontaneously all of the time) and changing some connections in the unconscious mind. That can happen accidentally and accidental changes are often not healthy ones.

So all hypnosis is really self hypnosis. Some people, called hypnotists, become very good at helping us enter trance states and facilitate positive changes in connections in the unconscious mind. Good hypnotists, however are few and far between. Most people who advertise themselves as hypnotists are not very good. A few people respond to them and they say the rest can’t be hypnotized. They blame their incompetence on the people they are trying to help!

You don’t have to find a skilled hypnotist in order to make positive changes in the connections of the unconscious mind. There are tried and true techniques that allow you to purposefully enter a trance state and make all sorts of positive changes in the unconscious. Furthermore you can activate pathways in the brain and spinal cord that release endorphins and norepinephrine that eliminate or markedly reduce pain. You can use these techniques at the dentist or for medical procedures that would normally cause pain.

Self Hypnosis

There are three things you need to do before each self hypnosis session.

  1. Decide how long your self hypnosis session will last. Twenty to thirty minutes is plenty.
  2. Decide what change you want to make. You can say it out loud or just think it. The change needs to be positive. The unconscious is very literal and it does not understand “not.” If you frame your change as “I’m not going to smoke anymore” The unconscious will take that as a command to keep smoking. A positive wording might be “I will just do things that improve my health.” Once you have framed a positive change, your unconscious mind will take over once you are in a trance. You don’t have to, nor should you repeat the instructions for change while you are in a trance.
  3. State out loud or in your mind how you want to feel after the session. It will either be “I will feel rested and refreshed” or “I will be tired and ready for sleep.” If you are doing your session just before bedtime you would say “I will be tired and ready for sleep.” Any other time of day you would likely want to feel rested and refreshed.

Induction of Trance

Going into a trance on purpose is called an induction. There are many ways of inducing trance, but I’m going to give you two very simple ones. You can try them both and see which one you like better. The first one was invented by Mike Mandel, a Canadian hypnotist. The second one has been around a long time and no one knows who invented it.

Incremental Eye Closure Induction

Find a quiet place where you are unlikely to be interrupted. Be sure to silence your phone. Sit in a comfortable chair and pick something to look at above your eye level. As you stare at whatever you have chosen, start paying attention to your breathing. With each out breath let your eyelids close a tiny bit. You will find yourself progressively relaxing, and by the time your eyelids close completely you will be in a trance. The trance will continue to deepen for a while with each out breath. You don’t need to do anything at this point except enjoy feeling relaxed and comfortable. Your unconscious mind will take care of the rest and you will find yourself returning to your waking state after the length of time you specified. You will feel great, rested and refreshed or tired and ready to go to sleep depending on which state you specified beforehand.

Instant Eye Closure Induction

Same instructions as above about a quiet place and a comfortable chair. As you inhale deeply, roll your eyes up as high as you can. As you exhale, close your eyelids with your eyes still rolled up, let your head drop forward and completely relax. You will instantly be in a trance. Your trance will deepen with each out breath. Once again, simply enjoy feeling so relaxed and let your thoughts go wherever they will. Your subconscious will bring you back to your waking state at whatever time you specified before the induction.

Practice

I would suggest that you do this self hypnosis exercise for at least 20 minutes a day (More is okay too). You will find with practice that it gets easier and quicker to induce a deep trance. Either eye closure method works as what’s called an anchor. As you practice you will find eventually that simply closing your eyes induces a trance. If you have to have any procedure that usually causes pain, you can give your unconscious mind instructions to feel relaxed and comfortable during the procedure and then put yourself in a trance during the procedure.

Bottom Line

Our conscious minds can only process 50 bits per second while our unconscious minds can process 11 million bits per second. The vast majority of mental processing takes place below the conscious level. Unhealthy connections in the unconscious mind take place by accident when we are in spontaneous trance states. It is possible to remove unhealthy connections and create new healthy connections by self hypnosis techniques. These technique can also diminish or eliminate pain from dental and/or medical procedures. Regular practice creates “anchors” that produce trance very quickly.

Healing – Long Term Relationships

I’m back to my series of posts about healing relationships. Hopefully it will not be necessary to return to posts about COVID, but if new developments happen that require some explanation, I will go back to posting about COVID.

In our dysfunctional health care system, health systems seem to think that clinicians are interchangeable like widgets. Since healthcare is a product, it does not matter who provides the product. Relationships between clinicians and patients are nice, but not really necessary. Many primary care organizations make very little attempt to make sure that patients are scheduled with their own clinician when they make appointments. As we shall see, clinician-patient relationships, the longer the better, are not only nice but essential for both patients and clinicians.

It used to be common for clinicians to stay in their communities for a long time. I started doing family medicine in Batesville, Arkansas in 1979 and stayed there for twenty years. That is distinctly uncommon today. Clinicians (both doctors and nurse practitioners) move every few years.

I am convinced that the healing aspect of clinician-patient relationships takes years to fully develop. In my own experience, I think it takes at least five years for me to begin to develop healing relationships with my patients. It can happen more quickly with patients who have chronic illnesses and need to be seen frequently, but that is the exception rather than the rule.

Abiding

In my research patients and doctors talked about how important it is for patients to feel that they are known by their physicians, that is known as people, not just a vehicle for disease. Knowing someone takes time. We used the term “abiding” to describe these long term relationships. It is a kind of intimacy that both clinicians and patients described as like being members of a family. Here is how one patient described abiding: “I think after years and years and years and years it’s like…a marriage. You and your doctor have a marriage.” Another patient said, “She knows who I am first of all. She knows exactly who I am. She knows my thoughts and my way of understanding things.” One doctor described abiding this way: “There’s being there for the big events, whether that’s birth or death or the diagnosis of something bad, or being there when they need you to be there, pushing other things away in order to be there in a way that’s more substantial.”

Abiding also means not abandoning patients even when all the pills and technology have been tried and patients are still suffering. If just listening to a patient’s story of suffering and having compassion for him/her is all that a clinician can do, then he/she needs to do that. As I discussed before, curing may not be possible, but healing can still happen. As one patient said, “He never gave up on me. And that means a lot.”

Trust

Trust means feeling safe. It means that you can tell your clinician anything and you will not feel judged. It means confidence in the competence of your clinician. It means knowing that promises will be kept. It takes time for trust to develop. As one physician said, “That’s something that you can’t do right away. You have to sort of earn that.”

Earning trust does not meant that trusted clinicians never make mistakes. But when they do make a mistake they tend to admit it. That often actually enhances trust. As one patient said, “He had the courage to say, ‘Well, I made a mistake.’ That endeared him to me forever.”

What to look for in your doctor

If you are lucky enough to have a trusted clinician who has been with you for a long time, then treasure that relationship. Always insist on seeing that clinician unless you have an emergency and your clinician is not available. There is nothing you can do to keep your clinician from moving or retiring, but to the best of your ability, choose someone who has been in your community for a long time, because that clinician is more likely to value long term relationships with patients.

Healing – Understanding Power in Doctor Patient Relationships

It seems to me that many healthcare organizations assume that doctor/patient encounters are transactions between equals. Much of the healthcare organization language reflects this idea. Doctors and nurse practitioners are called ”providers.” That is supposed to be inclusive language, but rather than that, it characterizes doctors or nurse practitioners as providing something (health care) to consumers (patients). While empowering patients is a laudable goal, characterizing the clinician-patient encounter as similar to selling shoes is not. I prefer the term clinician, which includes doctors and nurse practitioners.

I want to be clear that I am not advocating for a return to the paternalistic (perhaps authoritarian is a better word) model of “Doctor knows best.” This kind of relationship, where the doctor decides what the diagnosis is and what the treatment will be without regard for patient’s preferences or values is disappearing (although not fast enough) and good riddance to it.

On the other hand, there is an inherent asymmetry of power in relationships between clinicians and patients and pretending that it does not exist will not make it go away. When patients are ill, frightened that something bad may be wrong with them, they do not comparison shop. They go to a clinician they feel like they can trust to help them. A good clinician provides the best science in diagnosis and treatment tailored to this particular patient; her values, her preferences, her personality.

Empowering patients

Good clinicians empower the patient as much as possible. They do this in several ways. They listen carefully as I discussed in the previous post. They create a partnership with patients. As one patient said in one of my interviews, “one thing I really appreciated with [my doctor] is like we’re a partnership.” 

Good clinicians also empower patients by translating medical jargon into understandable language and by giving them information they can use to manage their own illness. As one patient said, “He explained what I needed to do going forward, the life change it would take, you know the medication, the eating habits, and everything to try and keep it from happening again.”

Using clinician power

Sometimes, clinicians need to carefully use power to push resistant patients to take actions that are important for their health. As one patient with HIV infection said, “…that’s why I really need, someone to push me, tell me you have to do those things. That’s one of the reasons that I’m still here.”

Good clinicians have an intuitive understanding about when and how to push patients based on assessments of patients’ needs and strength of relationships. One physician described it this way: “…sometimes you’re the coach and sometimes you’re the boss and sometimes you’re the sibling and sometimes you’re the doctor.”

What to look for in your doctor

Here are some red flags that suggest you should look for another doctor.

  1. Your clinician has already made up her mind about treatment and pays no attention to your concerns.
  2. Your clinician lectures you about your bad health habits
  3. Your clinician gives you whatever medicine you ask for that you have found on the internet without discussion of whether it is appropriate for you.
  4. Your clinician uses medical jargon that you don’t understand.

There are good clinicians out there that know how to use power appropriately in the context of relationship. Most of the time that means empowering patients, but it also means knowing when to push when necessary for the patient’s benefit. If you don’t have one like that, keep looking.

Healing

My last post about placebo (or context) effects was one example of the innate healing capacity of our body-minds. During my 40 years practicing medicine, I learned that the quality of my relationships with patients had about as much to do with how well they did as the medicines and treatments that I gave them. That observation led me to research into how doctor-patient relationships can promote healing and how people make their journey of healing. This post and the next few posts will explore how healing happens. By healing, I don’t necessarily mean being cured, although that can happen too. The definition of healing that I found in my research was: healing means being cured when possible, reducing suffering when cure is not possible and finding meaning beyond the illness experience. If you would like to read the original research paper you can link to it here

This post will be about one of the characteristics of healing doctor-patient relationships that we call Valuing

Valuing

Valuing means very simply to see every patient as a person of worth. One of the patients put it this way in describing his physician: “Everybody who walks in front of her is the same.… She doesn’t care what kind of insurance you have, what color you are, how big you are, how small you are.”

When clinicians see every patient as a person of worth then certain characteristics of the relationship follow.

Finding ways to connect with patients

The doctors that I interviewed looked for ways to connect with patients, partly to help them care what happens to them. One of the doctors said ”I try to love every single patient. And I especially try to love those I initially hate. There has to be some reason why I want them to get better.”

Presence

People in my interviews talked about how important it was for their doctor to give them his/her full attention during their visit. Presence means not looking at his watch, not looking at the computer for most of the visit and not talking on the telephone during the visit. It means looking directly at the patient, paying careful attention to their story and not interrupting until the patient has finished telling their story of illness. As one patient reported, “…she is totally directed and focused on you when she is with you.… This is your time.”

Sufffering With

Another part of valuing is experiencing the patient’s suffering. This is not quite the same as empathy, but more like compassion. One physician described this as “dwelling for a moment in their pain, in their misery, not letting it float off our backs.”

Relativity of Time

When I talk about this research to audiences of doctors, their first response is ”I would love to do all those things, but time pressure is such that I have only 15 minutes for each patient encounter. There is no time to be present and connect with patients.” My response is that if you give your full attention to the patient in that 15 minutes, they will experience that as much longer. One of the doctors I interviewed felt that staying on time was very important, and most of his visits were about 15 minutes. This is what one of his patients said:  “Well he sat there and he listened. And he never rushed you out of the office. You took as long as you needed.”

One of the things I always did after I listened to the patient’s story was to ask the question ”Is there anything else you need to talk to me about today?” That question frequently led to the real reason for the visit. We might or might not have time to completely address all of the issues at that visit, but patients felt that they were heard, and that was important to them. I learned to ask that question because when I didn’t, often when my hand was on the doorknob to leave the exam room, the patient would say ”By the way doc..” and then I would hear the real reason for the visit after having spent the whole visit dealing with something else.

What to look for in your doctor

Hopefully many of you have a primary care doctor that values you in the ways I have described. Here are some red flags that suggest you might look for another doctor. 1. Your doctor interrupts you to ask questions after a few seconds. 2. Your doctor types on the computer for most of the visit and talks to you over her shoulder. 3. Your doctor stands while he talks to you and does not sit down. 4. Your doctor talks about himself for a good part of the visit. 4. Your doctor keeps looking at her watch.

Unfortunately all these things are much more common than they should be. There are doctors and nurse practitioners out there who truly value their patients as whole people and are present with them during visits. If you don’t have one like that, keep looking.

The next post will be about how doctors and patients manage power in relationships.