Not the Last Word: Viscosupplementation, Opioid Overuse, and the Excesses of Empathy

According to the 13th law in the novel The House of God [15], excellence in medical care delivery requires doing “as much nothing as possible.” That adage was offered tongue-in-cheek, of course, but it contains a large kernel of truth: It is easy to overdo things, and too much medicine can make us sicker and poorer [3].

One area where we are not doing enough nothing as possible is moderate knee arthritis. For instance, despite the evidence showing that the benefits of hyaluronic acid (HA) injections are “small and of questionable clinical importance” [7], physicians are injecting oceans of this stuff into arthritic knees. At present, more than USD 1.75 billion is currently spent on HA injections. Worse, the market is expected to grow by more than 50% in the next 4 years [10].

It is not like we don’t know the truth. A meta-analysis [11] of 89 studies—cited more than 300 times according to PubMed—concluded HA injections are “associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events”. As such, the American Academy Orthopedic Surgeons issued a Clinical Practice Guideline [8] strongly advising against HA injections. A commentary in American Family Physician stated it plainly too: “Hyaluronic acid [is] ineffective for knee osteoarthritis” [12].

Granted, it is “difficult to get a man to understand something, when his salary depends on his not understanding it” as the writer Upton Sinclair once said [13]. But I think physicians’ failure to absorb the message goes beyond the (relatively small) fees earned by pushing HA. Rather, the growing use of HA rests partially on the presence in many physicians of two personality traits, both purposefully cultivated by medical admissions committees: Namely, a propensity for empathy and a propensity for action.

Without a doubt, empathy and action usually are worthwhile in medicine. Physicians should connect with their patients; and when physicians are called to do something for their patients, physicians should do it (even if the call comes in the middle of the night). Yet the interaction between these two usually good traits might impede a physician from speaking honestly and saying, “I am sorry, but I have nothing to offer you.”

Given the lack of effective treatments for moderate arthritis and the pressure for empathetic action, it’s no surprise that so much HA, an expensive medicine that offers clinically irrelevant benefits, has made its way from syringe to synovium.

Wasting money on medicines with clinically irrelevant benefits is not the worst of all worlds, of course. Calamity comes when empathy and action conspire to promote treatments that are downright damaging—the overuse of narcotic pain medicines, for example, leading to our so-called opioid epidemic.

The opioid epidemic has many causes [4], but excessive physician empathy, coupled with an inability to stand pat, no doubt played a role. Yes, the pharmaceutical industry must be blamed for its crafty marketing message—that pain is an enemy to be vanquished, no matter what the cost. Yet this message resonated so well only because so many physicians were bred with a double dose of the empathy and action alleles.

Between the two traits, the tendency to overact is probably the less worrisome. We always can count on inertia to retard motion, and in a fee-for-service market, reducing the size of fees might reduce the volume of services (though not always [1]). The problem of excess empathy is a little trickier, because, Bloom’s work [2] notwithstanding, there is little pushback against this seemingly admirable trait. In fact, the more common argument is that empathy levels are too low. For example, when Samuel Shem, the author of The House of God, reflected on his work decades after the book was published, he saw fit to add Law 15: “Learn empathy. Put yourself in the other person’s shoes, feelingly” [14].

I have great respect for Dr. Shem and his work, but Law 15 can be misguided. I don’t serve my youngest son well by always putting myself in his shoes, feelingly or otherwise; if I did, we’d compromise and have ice cream for breakfast 15 days a month. Similarly, patients are not always well-served when their physicians empathize too much.

Society gains when physicians, having nothing to offer, offer nothing at all. Too much empathy can get in the way of that.

Samuel Shem MD, DPhil

Professor of Medicine in Medical Humanities, NYU Medical School

Author of The House of God

It’s good to read a sensible, thoughtful, and helpful essay on empathy. A quick story—my story. I was a runner, and I noticed worsening pain in one knee. An orthopaedic surgeon made little contact, but after looking at my radiograph said, laughing: “You’re going to need a total hip replacement.” Hip? I thought knee! He talked at me for a while, but I didn’t remember anything. Lack of empathy, and lack of successfully doing nothing. I then consulted Dr. William H. Harris, who basically invented total hip surgery. A tidily dressed elder man—in coat and tie—he sat behind his desk as we chatted. He said there was no rush for surgery.

“How will I know when?” I asked.

“It’s called ‘the necktie sign,’” he said. “When you reach over my desk and grab my necktie and say, ‘Now!’”

He did a great nothing, connecting through his relaxed attentiveness, and humor—I’d call it empathy. I felt remarkable relief and gratitude.

Law Number 13 is the most important one in the novel. I originally wrote: “The delivery of medical care is to do nothing.” But then I paused. My muse whispered: “—as much nothing as possible.” As the Fat Man, a character in The House of God, says: “Doing nothing is doing something—in fact, sometimes everything!” [15]. The question is: Can you as a doctor do nothing “in relationship” so the patient feels that you see and hear her clearly, and you sense the patient feeling seen and heard? That’s mutual empathy. And it really does deliver care. There is one issue for physicians who avoid doing knee injections: Money—the doctors’ financial incentive. This, of course, is part of “gaming the codes” of the messed-up private insurance industry—a crippler of our doctors’ lives.

Do physicians show “too much empathy”? The current state of medicine is infested with computer screens. These were designed for billing, not patient care. Patients, looking at the backs of their physicians as we click away on our screens, often imagine that this provides them with better care. It does not. It provides better care, only, for billing—and is better only for the money it makes for the various bosses. In this environment, any empathic moment is needed. To move a big wheel, you have to put your shoulder to it fully, sometimes crudely. I don’t think you can show too much empathy. Empathy does not mean losing yourself. It means having a self-with-other moment. Dr. Bernstein says that if he puts himself in his son’s shoes, he’d gratify the boy’s wish for “ice cream for breakfast 15 days per month.” However, in showing empathy, you do not abandon yourself (in this case, your parental wisdom and power). Empathy, in fact, empowers. You are most likely to succeed in transmitting your fatherly wisdom if—and only if—he senses you are “being with him” in whatever you say. (“Being with” is the Fat Man’s term for empathy).

A helpful hint on empathy with anyone, including patients: “Be at the emotional distance at which empathy is possible.” For your son, very close. For your most-difficult patient who’s hounding you for useless knee goo or lethal opiates, quite far.

Anna Lembke MD

Medical Director, Addiction Medicine at Stanford University School of Medicine

Author of Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop

Finally someone—a physician of all people—dares to write about the “excesses of empathy.” Is such a thing even legal? Where are the thought police? The plenitude of administrators from patient relations, The Joint Commission, and Press-Ganey all will be descending soon. True sacrilege.

I am delighted to find a kindred spirit in Dr. Bernstein. Empathy is oversold and overbought in today’s medical profession. Indeed, the hours spent teaching medical students and residents to “be empathic” in the absence of providing quality care, represents the worst hypocrisy of our field.

The model of the empathic physician as the iconic healer did not always exist. Approximately 150 years ago, doctors were fearsome creatures, wielding tools and potions that inevitably wrought pain. Self-trained barber-surgeons set broken bones and pulled teeth without the benefit of anesthesia. Hydropaths used the painful application of water, steam, and ice to promote healing. Even after the advent of anesthesia, leading surgeons were reluctant to adopt it, convinced that pain promoted healing (by boosting the cardiovascular and immune response), not to mention the spiritual benefits. The historian Martin S. Pernick writes, in A Calculus of Suffering, “The emotional ability to inflict vast suffering was perhaps the most basic of all professional prerequisites” for the early 19th century surgeon [9].

By the middle of the 19th century, our modern conception of the physician as empath came into vogue. In 1860, the Philadelphia Bulletin published the following: “Assuredly it is not a pulseless, tideless being that is derived to officiate at the couch of sickness. Rather is the man most acceptable as a physician who most approximates the feminine type; who is kind, and gentle, and cautious, and sympathetic and truthful, and decidedly modest” [5]. But how and why did this transformation occur?

Simply put, we invented better tools to fight disease and mitigate pain (antiseptics, antibiotics, synthetic opioids, and the bore-needle syringe, among others). But as Pernick writes “competition encouraged both orthodox and alternative healers to adopt each other’s least painful practices” [9].

Indeed! The empathic physician is a byproduct of a fee-for-service medical system on a grand-scale, something I call the “Toyotaization of medicine”, wherein assembly-line healthcare turns patients into customers and doctors into waiters [6]. The practice of medicine today is ruled by the P-paradigm: Palliate pain, prescribe pills, perform procedures, protect privacy, and please patients.

Where has it gotten us? The current opioid epidemic is first and foremost an epidemic of overprescribing, and the empathic physician, as Dr. Bernstein suggests, is at least partially to blame. Some of the most egregious cases of opioid overprescribing I have seen have been perpetrated by well-intended physicians guided by the erroneous belief that empathy alone is enough. Empathy is important, and sometimes it’s all we have, but it cannot be practiced at the exclusion of evidence and common sense.

Where do we go from here? Let’s bring back that outspoken, gritty, iconoclastic physician who’s not afraid to utter the truth and ruffle a few feathers. And let’s remember that true empathy implies not just a regard for the patient’s feelings in the moment, but a regard for their overall well-being, past, present, and future, including the potential unintended negative consequences of the care we are providing.