1. Patients want real clinical relationships with undistracted clinicians

In the Ivory Tower Medical Center where I trained and worked as a faculty member, I gained the painful awareness that the mandates for professional survival—research, publishing, grantsmanship, followed distantly by teaching and even more distantly by patient care—were often at odds with what it seemed to me that patients needed, such as connections to an individual clinician over time. In managed care or community hospital settings, other pressures—such as mandates to see certain numbers of patients, or time limits on numbers of or lengths of clinical encounters—may conflict with optimal clinical care. Our patients want and need human connections with caregivers who are going to be around, and who have time to spend with them.

2. Patients want to know what to expect from their relationships with us, such as when they'll receive a return phone call or how to reach the doctor after hours

Any of you who have been patients in recent years know that the “standard of care” for returning phone calls is not so great. Superficially, this can be explained away merely as a function of growing patient volumes, overworked clinicians, and the limits on the kind of clinical information that can be communicated by phone. But if I were the patient, how could I trust, let alone allow myself to be reliant upon, a pain service that sometimes kinda sorta calls back and doesn't know who I am when it does? Most of the time we're fighting an uphill battle to sell our patients on the idea that they're actually entitled to seek adequate pain control, against all manner of personal and societal taboos. I've got news: Sometimes pain crises don't happen between 9 and 5. We have to gratify our patients' often tentative efforts to contact us by providing prompt, reliable, and helpful responses. At Cedars, our patients learn they'll get same-day callbacks Monday–Friday and an on-call pain doc 24/7 who carries a roster with a list of our patients' pain problems and meds; almost always, the on-call pain doc has already met and evaluated the patient clinically. That on-call doctor is supported by a 24-h treatment area that provides pretty much anything you could get on an inpatient unit, just more promptly, and that represents a welcome alternative to the ER, where we know pain is generally unwelcome and not particularly well treated.

3. Patients want their pain clinicians to be skillful

As we all know, its not just opioids or more opioids in good cancer pain management. Our patients want us to be skillful about understanding all aspects of their pain experience—what pain means to them; what attributions they make about changes in their pain for better and worse; how they feel about the meaning and purpose of suffering. They want us to be skillful about evaluating the psychological, social, spiritual, and life contexts of their pain. They want us to be skillful about assessing their pain's pathophysiology. They want us to be skillful in communicating to them how, and with what tools, we think we can best manage the pain, and they want us to make the pain better. They want good pain control with no side effects; sometimes they fear pain medicines more than chemotherapy. Patients want us to help them communicate about pain treatments to often skeptical or misinformed family members.

4. Patients want us to be dispensable and indispensable

Nobody wants to have pain; when its present, and severe, we're pretty important to our patients. One of my favorite things is to watch patients who we've met and helped through a pain crisis then develop conditioned analgesia, so in the future they get comfortable when the pain nurse just walks into the room. But when pain is absent or minimal, we might also represent an unpleasant reminder of a bad time. Therefore, we need to let our patients have a part in regulating the intensity of their relationships with us.

It is unoriginal to point out that a lot of societal and personal ambivalence about cancer, death, and dying gets worked out around pain and symptom management. There are many wonderful examples of this in Ira Byock's (1997) book Dying Well, which so poignantly describes a hospice doctor's experiences with some of his dying patients. Byock often perceives profound change happening in his patients as they approach death. But their trust and comfort with him are hard-won; many patients arrive at palliative care like they've gotten off the train at the wrong station, with understandable misgivings about the whole enterprise. Are they being abandoned by their cancer doctors? Are they now officially hopeless cases? Will they be required to give up valued relationships with nurses, doctors, and other clinicians they've come to count on?

Many of our patients come to our pain service with unexpressed misgivings about our motives, our drugs, our competence, and about the encoded messages their doctors sent them by pointing them our way. One patient with whom we worked beautifully for a couple of years confessed a few months into knowing us that she had considered us the Cancer Center's “death squad,” and was convinced when her cancer doctor called us in that he had thrown in the towel. So a primary task, of course, is to build trust. Generally we achieve this by collaborating to provide effective and rapid pain relief. But we've also learned that our patients value the sincerity of our efforts at managing their pain as just about as important as the actual level of relief achieved. Some of the patients for whom we've felt we've achieved the least actual analgesia have rated their satisfaction with pain services extraordinarily highly and have emphasized in their comments the importance of their perceptions of our hard work and good intentions.

As a psychiatrist, I'm not a stranger to the idea that both patients and colleagues might have some misgivings about me. Some of it, I think, comes from the old “he's not a real doctor, anyway” refrain. Another aspect of the mistrust comes from our cultural dubiousness about subjective symptoms and people who treat them: After all, depression, anxiety, and pain are all symptoms you can tell somebody about, but there isn't an accepted lab test for any of them, which makes some people question whether they really exist. As treaters who more or less accept at face value patients' reports about their subjective symptoms, we may be perceived as soft, vague, or unscientific.

In psychiatric residency training, I was taught an ironic maxim about clinical cause and effect. It went something like “anything that goes wrong with a patient after he/she's been referred to a psychiatrist has got to be the fault of the psychiatrist or the psychiatrist's drugs.” Sadly, this clinical pearl translates nicely to palliative care. One example of this is the “blame it on the opioids” reflex that comes out of the mouths of our generally brilliant and wise colleagues. We all know that, by definition, reflexes involve peripheral nerve pathways that are suppressed by higher brain centers. If the higher brain centers are switched off, knee-jerk reactions keep occurring. Such is the case when opioids get blamed for bowel obstructions caused by advancing disease, or respiratory symptoms caused by malignant effusions, or focal neurological symptoms caused by brain metastases. These are not malevolent attributions—remember, a reflex doesn't require cortical function—and, in fact, they're entirely understandable as the least onerous and most preferable explanations for distressing new problems in our patients; on the other hand, and much more insidiously, the “blame the opioids” reflex reawakens our patients' barely sleeping and generally inaccurate fears about the fundamental scariness of their pain meds, often casting paralyzing doubt on their evolved trust in us and their pain regimens.

So what I mean by “dispensable and indispensable” is, I hope, a bit clearer: Our patients and our colleagues need for us somehow to have the personal and professional grace to be at once scrutinized and needed; to be devalued and idealized; to be vilified and reconstituted; and finally, to be most present and available at a time when others may feel they have little else to offer.

5. Patients need us to be accurately empathic

In a perfect world, we palliative care clinicians would get to witness every interaction our patients have with their cancer team, their families, their internet chatmates, and their inner somatosensory apparatus—in other words, all their data sources—so that we could help process all the disparate information. Sometimes our patients feel like they've landed on Mars. After a week of escalating bone pain, a young woman with metastatic breast cancer described to me her oncologist's furrowed brow as he carefully and caringly parsed his interpretation of the bone scan results to show “new but healing metastases.” This kind of doublespeak was for her a source of iatrogenic misery: Though it may in the moment have avoided a painful reckoning, its hollowness over time generated anxiety, mistrust, and assailed appropriate hope. We can be helpful by recognizing the bewilderment or cognitive dissonance, confirming to our patients that they aren't crazy, and helping them find their voices to begin again to try to make sense of things.

Empathy is finally getting serious attention in the medical literature. In a study published just last month, a group of medical educators from Philadelphia measured empathic abilities in more than 700 physicians using a validated scale (Hojat et al., 2002). The researchers defined clinical empathy as “… a cognitive attribute that involves an ability to understand the patient's inner experiences and perspective and a capability to communicate this understanding.” Their findings won't surprise us: Women physicians scored generally higher empathy ratings than men (this result approached but did not quite achieve statistical significance) and, controlling for gender, physicians in the more cognitively oriented fields of psychiatry, internal medicine, pediatrics, emergency, and family medicine had statistically significantly higher mean empathy ratings than anesthesiologists, orthopedists, neurosurgeons, radiologists, ob/gyns, and general surgeons. In their conclusion, the authors wonder whether the differences among specialists reflect the results of socialization and training in residency, or perhaps simply uncover more hard-wired traits that govern who pursues what specialty in the first place. Though we all know people whose empathic capacities defy these stereotypes, the findings, which confirm common biases about who chooses what, might have important implications for future training and allocation of clinical responsibilities. For example, in an optimal setting, perhaps anesthesiologists and internists together would obtain informed consent for surgeries; possibly radiation oncologists and nurses or social workers would together talk with patients about the risks and benefits of a course of treatment; or maybe empathy scores above a certain minimum would be required for oncologists to be granted clinical privileges to perform the procedure of making a hospice referral.

Jodi Halpern (2001), a psychiatrist-ethicist-philosopher, has recently published a book challenging static definitions of empathy such as the one offered up in the study just mentioned. Halpern agrees that empathy requires from the clinician the capacity to resonate with, or indirectly experience, the affects of the patient, but suggests that the clinician should actually use his/her own emotional reactions to those affects as a guide for understanding the patient and responding helpfully. It is not uncommon, for example, when caring for a patient who is feeling overwhelmed and helpless, for clinicians themselves to feel related emotions of ineffectiveness or inability to help. The ordinary clinical response would be for most clinicians to try to act definitively to “do something” to comfort the patient and rid him/herself of the uncomfortable affect. Though “doing something” like giving a dose of pain medication may be helpful, Halpern advocates also for the imaginative use by the clinician of the received affect as another way of offering comfort: the comfort that comes from feeling understood. While these ideas may seem quite elementary to trained psychotherapists, they are groundbreaking as applied to ordinary day-to-day medical care. Emotional resonance with patients does not inherently threaten our objectivity or effectiveness, and may enhance it.

How does this bear on what we do all day? Accurate empathy is crucial to meaningful dialogue about pain and symptom management and end of life care. Our emotional resonance with patients helps us understand when patients have the psychological reserves to take on crucial decision making, and allows us to help them pace themselves and manage the doses of stressors. Sometimes we must recognize that patients who are paralyzed by pain, fear, or intractable hopelessness may have temporarily lost their capacity for free-agency and future-oriented care planning. Other times we may come to see that the barriers to addressing important clinical issues come primarily from the clinician side, and must be moved out of the way for the well-being of the patient.