Sympathy/empathy and social and economic dysfunction

I had a knee operated on last Thursday.  Having had almost exactly the same thing done on the other knee a couple of years ago, I told my doctor I wasn’t that happy with the way I was treated, and asked if he could suggest anyone else. Though it’s a very minor procedure, it’s still a massively complex process – getting all the people with the right skills and equipment in the same room and getting it all to happen at the right time.  So I can’t complain.  But at least by the standards of today, it was not particularly flash. Nothing terrible went wrong.  On the other hand just like the old days, and just as in courts today, all the ‘customers’ queue up and wait their turn. In this case the customers all turn up at 7.00 am even though no operations are on till at least 8.00 am.  So you’re there so all the professionals can suit themselves about what order things are done in – and also rearrange you if it suits them.  Finding out I was third on the list from the hospital, the doctor’s rooms were very put out and told me that there was no list and I coudln’t know I was third on it.  I told them I couldn’t turn up till 7.20 so as to reduce my waiting time.  Still I turned up bleary eyed at 7.20 and sat in a waiting room watching the channel 9 morning show – not so flash – until around 8.20.  I was supposed to be being seen by the aneasthetist and the physio during this time, but wasn’t. 

Then a nice lady took me into a room and started ‘inducting’ me to the op – asking all the same questions I had provided on the form that I’d handed in.  She explained that this was for other forms.  She asked which knee it was, and wrote ‘right knee athroscopy’ somewhere (yet again). I was asked which knee it was about four times before theatre, and eventually was relieved to see as I was about to be rolled into the theatre someone mark up my right shin with a big black arrow. That seemed much more fail safe than asking the same question sufficiently often that there arose a small chance that I’d eventually get it wrong.  

Things suddenly sped up as the lady inducting me told me that the first operation couldn’t proceed and it was a big one – because they didn’t have the right equipment there.  So everyone was in a hurry.  She started shaving my knee. Given that it hurt I suggested that I’d be happy to do it myself, which she agreed to. (I could have done this in the shower or with my electric razor that morning and least got off to a start that she could have finished to the doctors specs.  Anyway . . . as I was shaving my knee, the physio came in and started telling me what exercises to do when I got home.  I explained to her that I couldn’t take this in as I was shaving my knee, thinking that her session should involve more than reading out the descriptions of four exercises without me being able to do them and so in such a way that, in my distracted state, I couldn’t take them in in two minutes. I was incensed at all this, but just didn’t show it and let her talk at me and ignored her for two minutes and off she hopped. No point in upsetting people when they’re about to weild the knife and you’re unconscious.

The appointment with the aneasthetist?  Well I was wheeled towards the theatre and parked next to it – next to four others.  So I thought I’d be waiting a while.  But no.  Someone brought me a heated blanket (very nice it was too – the one real ‘customer focused’ touch and improvement on my last op) and off I was wheeled into the theatre – a scary place where about ten people peer at you like you’re a piece of meat and you’re literally manhandled onto a thin slab you even feel you might fall off.  The aneathetist shook my hand and introduced themself.  He had my file, so since the most important things were on that, I wasn’t too alarmed, but if that’s a consultation, I’m a monkey’s uncle.  (In the previous op I saw my anaesthetist a few days before and an hour before the op). I told my new aneasthetist that last time I got really unpleasant hiccups for days afterward. He said that could happen. 

Anyway in went the needle, and off I went waking up 90 minutes later. The young nurse who was looking after me was nice enough.  Nurses empathy is an interesting thing. They’re busy as hell – or often are. And they see a lot of awful pain.  Not only is it hard not to be hardened by that, and to think that wimps (like me for instance) need to toughen up a little.  But they inflict a lot of the pain – at least minor pain like injections and so on. And from the best a certain kind of (limited) insouciance is a kind of favour to the patient – to help them ignore what is best ignored.  

Be that as it may, when I woke up I could tell almost instantly by her demeanour that, despite or perhaps as indicated by her endlessly calling me ‘darling’, my young nurse couldn’t give a damn about any of this. She was just doing her job.  Fair enough. It didn’t really matter in my case, but she was the kind to proudly wake you up at three am to give you your sleeping tablets. 

But then when it was time for me to go, they got me a wheelchair.  And the wheelchair required me to bend my leg.  But if you’ve just had a knee operation it’s sufficiently painful, that it is essentially impossible to bend your leg.  The nurses greeted my own inability to bend my leg with disdain and impatience and suggested I cross my legs and indeed, there was a position in which it was possible, if somewhat painful for me to exit the building and get into a car.  I was not particularly surprised, but nevertheless amazed if that makes sense, infuriated and dumbfounded that such a simple thing as getting fittings on the wheelchairs fit for the purpose they were being used for day in day out had not been done.

Our society and economy is of course full of such arrangements, of basic failures of commonsense which somehow come down to failures of emphathy/sympathy, from the attempt to see it from the others’ point of view.  On arriving back home from the hospital I listened to the news reporting of a boy lost in the bush who rang 000 seven times on each occasion being stuffed around and kept on hold because he couldn’t give a street address. AAP reports that “Coroner Carl Milovanovich, who investigated the death, said in a report handed down Thursday that ambulance call center staff lacked empathy”.

In fact Milovanovich is the Deputy Coroner and on reading his report (pdf) it wasn’t as bad as the press reporting. It was actually a difficult situation with the mobile line dropping out constantly.  And the staff did kind of try – but all of them in a hopeless kind of way, one of the operators repeatedly referring to the now deceased as ‘darling’ without finding out his name.  ‘Darling’ seems to cover a multitude of absences of mind. The Deputy Coronor found a panoply of problems 

This inquest has identified that in all the calls made by David Iredale to the Ambulance Service there was a lack of empathy and call takers lacked the skills and or ability to elicit and effectively record vital information that was crucial. The preoccupation with a regimented system that was designed to elicit an address resulted in the loss of a window of opportunity that may have resulted in a different outcome. 

In fact, if her Mum is to be believed, and I do believe her, at least one of the operators was empathetic, if not in an effective way. Renee Waters’ rang her Mum after the shift “very upset at how helpless she felt.” As well she might have. The other two, Laura Meade and Stacey Dickens, a 30-year veteran of the call centre and their Mums seem to have kept their heads down.  Then again the system itself and the training the operators got wasn’t very empathetic was it?  It wasn’t built, and they weren’t trained to solve problems that their empathy, their being able to put themselves in their ‘customers’ position might have allowed them to solve.

This kind of issue is actually a big thing in the private sector.  A panoply of topics are related to it – but they’re very low status in economics.  They’re things like ‘customer focus’, ’employee alignment or engagement (with corporate mission or goals). Firms behave as if these things have to be thought about, endlessly strategised about – because they’re difficult. But economics has paid very little attention to these things.  Indeed, one of the more tendentious but popular definitions of economics – Economics is the science which studies human behavior as a relationship between given ends and scarce means which have alternative uses corals the discussion away from the question of the quality and co-ordination of those inputs. Although of course one can shoehorn pretty much anything into a definition like that by broadening the definition of means, the whole point of a lot of management systems is that things like human sympathy are not ‘scarce ends’ but rather ends that require certain kinds of approaches to uncover. Today in economics it is implicitly assumed that ‘customer focus’ will be a function of market conditions. If there’s lots of competition then there’s an incentive for customer focus, but less so if there’s more monopolistic conditions.  But compare the market for tradesmen to the market for appliances. Plumbers and other tradies provide lousy service in many ways – don’t provide us with what we want (an integrated service where we don’t clean up after them and have to hire a painter to fix things they’ve left).  Apple on the other hand has quite a lot of monopoly power, but it’s monopoly power is built around customer focus (and to some extent leading customers and shaping their desires). 

Economics didn’t always distance itself from these things.  As readers of this blog will know, the foundations of Adam Smith’s system for interpreting social and economic phenomena revolve around sympathy.  Sympathy means something deeper and less ‘sentimental’ than it is often taken to be. At its heart, I’ve argued that Smith focuses on sympathy as a kind of social epistemology.  He thinks – surely correctly – that society can’t function without eople having psome understanding of each other and says that we know no way that can happen except by the imaginitive process of people putting themselves, however imperfectly in others’ shoes. 

Note that sympathy in the sense meant by Smith is foundational and precedes his economics.  Indeed in lectures predating The Wealth of Nations having proposed an inate tendency to ‘truck, barter and exchange’ as  the singular principle around which he will build his economics * Smith casually offers an even more fundamental principle – the human drive to persuade.**

If we should enquire into the principle in the human mind on which this disposition of trucking is founded, it is clearly the naturall inclination every one has to persuade.

Thus the fundamental process of the market setting a price is in essence a communicative one, and it requires sympathy of a kind – not of the sentimental kind, but of the imaginative kind.  Though Smith is taken to be the advocate of ‘mere’ self interest, his descriptions of self interest in a bargain are actually at pains to point out that self-interest is not enough.  Self love is useless without sympathy – not in the sense that one necessarily sympathises with the person with whom one is interacting in the market, but in the sense that one seeks to understand them – in order to appeal to their self interest – and the only way to do this is with sympathy or by putting oneself in their shoes.  

Man continually standing in need of the assistance of others, must fall upon some means to procure their help [Note that this is the exact opposite of the person blindly asserting their self interest]. This he does not merely by coaxing and courting; he does not expect it unless he can turn it to your advantage or make it appear to be so. Mere [self] love is not sufficient for it, till he applies in some way to your self love. A bargain does this in the easiest manner. When you apply to a brewer or butcher for [for] beer or for beef you do not explain to him how much you stand in need of these, but how much it would be your interest to allow you to have them for a certain price

Modern business has taken this insight to heart, putting great efforts into addressing the self love of their customers. And though management philosophies of the past did tend to regard this as essentially unproblematic – as something that could be arranged automatically enough by the application of incentives in just the way that economists assume that the issue will be dealt with providing market structure is sufficiently competitive – well they’ve come to realise that it just aint so.  That there’s lots of money to be made, lots of value to be extracted, from paying great attention to the process by which a firm orchestrates its relationship with employees and their relationship with each other, with the way in which it communicates with its customers, and indeed other  ‘stakeholders’.  There are of course economists who think the same thing.  But attention to these things is, shall we say, nowhwere near ‘top of mind’ amongst economists.  Which is a pity.  

*   This is what, in his lectures on Rhetoric, Smith calls the Newtonian Method.
** One way in which it is more fundamental than the tendency to truck barter and exchange is that the desire to persuade is present in animals, as Smith goes to some pains to explain when he sets out how young animals beg food from their elders and from their masters.


We just received an invoice from the anaesthetist. $80 for the “initial consultation” ie shaking my hand, asking if I had any questions and telling me that yes, I was right, general anaesthetics could induce unpleasant sustained periods of hiccups.

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12 years ago

You should have your next knee operation in India or Thailand. They are paying attention, and they didn’t even have to read Adam Smith to ‘get it’.

12 years ago

Not just India or Thailand — There are many places where you don’t wait half an hour or more for most medical/dental appointments, including those that are not trying to get into medical tourism. I imagine part of the problem is culturally specific, in that if some proportion of people don’t turn up on time for things, everybody suffers for it.

Don Arthur
Don Arthur
12 years ago

I think you’re right about economics. It’s as if all our interactions with each other are modeled after relations between people and things:

1. Purchase thing (eg pack of Tim Tams)
2. Consume thing
3. Derive utility

I don’t think it’s a model that can cope with situations where what people are ‘consuming’ is the contents of people’s minds.

Smith has some wonderful insights into people’s craving for things like respect and status.

Arlie Russell Hochschild has a great book titled ‘The Managed Heart: Commercialization of Human Feeling’ that shows how companies extract ’emotional labour’ from their staff. For example, flight attendants:

The deepest appeal in the Delta training program was to the trainee’s capacity to act as if the airplane cabin (where she works) were her home (where she doesn’t work). Trainees were asked to think of a passenger as if he were a “personal guest in your living room.” The workers’ emotional memories of offering personal hospitality were called up and put to use, as Stanislavski would recommend (p 105).

There’s a tension here. Because as Smith realised, people want more than a ritual of politeness or professionalism, they want other people to actually care about them — personally. They want to be genuinely special to other people.

But when this is taken into the workplace, built into training programs and brought under management control, it becomes a kind of acting or performance. Presumably some customers manage to suspend their disbelief while others are deceived into thinking that the people whose time they pay for really do enjoy serving them.

Of course some people go into customer service because they really do like to make other people happy. But it’s a difficult thing to keep up day after day. There’s always a need for some acting.

12 years ago

I recently attended a local public hospital for some tests on my eyes. When I arrived I found that it had two reception desks, Reception 1 and Reception 2. I had no indication as to which one I should go to and there was nobody else to ask. After waiting for 10 minutes at Reception 1 some worker looked at my letter and said I was at the wrong desk.

While I had been there however I overheard a couple of interesting conversations.

An elderly woman who was ahead of me was berated for being three hours late and told that the people she had come to see had all gone. “Your letter clearly says 10 o’clock,” said the desk clerk. “No,” said the woman, it says 1 o’clock.” “No, 10 o’clock”. “Oh dear, I thought it was 1 o’clock. It’s my eyes, you see.” The time had been hand written in small numerals with a faint ball-point pen.

Another woman ahead of me asked, “how long will I have to be here?” “No idea,” said the clerk. It depends on how many patients turn up. We had a session this morning where 14 were supposed to come but five didn’t show up.”

When I got home I said to my wife, “if I have a dental appointment made more than two or three days ahead, the practice always rings me two days beforehand to remind me of the date and time. If the hospital did that, maybe there would be far fewer no shows.” (Appointments at the hospital unit I attended are typically scheduled 4-8 weeks in advance.)

My wife has worked in the public sector hospital system. “There’s no way they would phone anyone,” she said. The system doesn’t work like that.

There are some other discouraging things that I noticed, but this is enough for one post.

The only other time I have attended a public hospital in recent years was (a different hospital) at its respiratory unit for an asthma assessment. It could not have been more different. I had been given precise instructions as to where to go. The unit was functioning on schedule. I didn’t have to wait. I was impressed by the general organisation and atmosphere of the place – not at all like the other one.

Clearly, it is a mistake to generalise about hospitals on the basis of a sample of one, but it is still bloody irritating to be poorly treated.

Francis Xavier Holden
12 years ago

nic – was this public or private?

mikem – the better public hospitals regularly ring or SMS people re appointments

Francis Xavier Holden
12 years ago

Epworth Richmond is a private hospital with the only public time-critical emergencies.