Doctors' struggle to show compassion

Dr. Manoj Jain, an infectious disease specialist in Memphis, reflects on the reasons physicians struggle to show patients compassion in an article in yesterday's Washington Post. But while there have been studies showing medical student losing compassion for patients in the course of their training, there is evidence that compassion can be effectively taught in physician training programs.

Compassion can perhaps be taught to physicians and health care providers in any number of ways. But compassion may ultimately come down to teaching physicians how to effectively communicate with patients in emotional circumstances. Doctors may feel compassion but may have a hard time expressing it. But training in compassionate communication, helping doctors come up with what exactly to say to a patient, may help them express the compassion they feel.

Teaching with patients, from the beginning

The New York Times had an article today about a medical school program that is turning the traditional medical student schedule on its head. New York University is now exposing students to patients from their very first day as medical students, rather than waiting until they are third year students as many traditional programs do.

NYU is not the first program to introduce a patient element in the first year of medical school. But such efforts point to medical schools' awareness that the process of medical education can be emotionally draining. Students who lose sight of why they are training to be doctors may find themselves experiencing "empathy erosion." Patient contact from the beginning helps these physicians in training remember they are learning not to treat diseases, but to treat patients.

When words, and friends, fail

An essay in The New York Times today highlights the difficulty of going through a health crisis and having friends seemingly disappear. Psychologists are beginning to explore what people experience when they are witness to other's traumas. Part of the difficulty, is that words fail, and friends don't know what to say to a sick friend or how to help. The other difficulty is not so much a lack of empathy, but too much empathy. When a healthy friend can picture herself or her child as sick as the sick friend, it may give them cause to pull away from that friend in need.

Sometimes the right words and the right actions don't come naturally. But knowing our own fears and vulnerabilities may help us think twice and reach out to those in need.

The value of patient stories

The New York Times Health section had a compelling article today about the value of patient stories and memoirs. Their value may not be in their literary style, many may in fact be lacking literacy polish. The true value of these stories may be the stories themselves. There is therapeutic value to the story, both for the reader and the writer. They inform us of the human condition, the very real emotional pain that goes into illness, and perhaps remind us of the need for empathy toward each other.

Fellow inmates provide hospice care in prisons

The New York Times had a compelling article about the growing geriatric prison population and how some prisons are starting hospice programs to provide care for the aging population. Some of the programs use prison volunteers, other prisoners to visit and provide comfort to the dying prisoners, who may not have family members who will visit in their dying days. The programs appear to have a dual benefit, both for the dying prisoners and for the prison volunteers. The dying receive some comfort at the end of life; the volunteers make a human connection with another person and learn to express empathy and emotions many have buried for a long time.

There are some challenges with programs like this, especially the risk that dying prisoners will pass pain medications the volunteers, who can sell them to the general prison population. But the prison volunteers can provide a compassionate ear in a way that a guard or nurse simply cannot.

Patients feeling abandoned by their doctors

Dr. Pauline Chen reports on a study published in the Archives of Internal Medicine which examines the emotions of physicians, caregivers and patients near the end-of-life. Many patients and caregivers reported feeling abandoned by their physicians. Physicians were aware that patients might feel abandoned, and even believed they were taking steps to prevent it, but patients still reported feeling abandoned in their last hours. Dr. Anthony Back, lead author of the study, attributed the misunderstanding to physicians who may not realize the importance of closure to patients. And patients may not be able, or think they need to, speak up.

You can find the article here and the comments here.

What do you think?

Should you warn about bad news?

What is the best way to break bad news? Some communication research suggests that clinicians should give a"warning shot" prior to giving the patient bad news. Something like "The news I have to share may be upsetting." The idea is that preparing the patient for the prospect of bad news allows the patient to better prepare for and process the information. If bad news is just sprung, the patient may not hear anything else after the upsetting news and may be too upset to talk about important issues such as next steps. But is it possible that classifying news as upsetting may be more upsetting than just breaking news to a patient without prior qualification? Rather than qualifying information beforehand, maybe clinicians should instead give patients time to process the information before moving on to the next topic.

What do you think? What is the role of the warning shot?

Can empathy be taught?

Dr. Pauline Chen's column this week in the New York Times examined a new study about empathy skills training published in Academic Medicine. Dr. Chen reflects on her own experiences and the prevailing attitude that bedside manner is either something you have or something you don't have. But the results of the study in Academic Medicine indicate training can have some effect on physicians of all experience levels. And young physicians can certainly learn from the examples of their attending physicians, for better or for worse.

But what does it mean? Can empathy be taught? Or is it something you either have or don't have? You can find the article here and comments here.

burnout in medical education

The New York Times published an article yesterday about burnout and suicidal ideation among medical students. No one is surprised that medical school is hard. That’s perhaps an understatement. But combine the massive amount of information you are supposed to absorb with an ultra-competitive environment, and the thought that complete failure is just one slip-up away, and you have a group of students ripe for complete burnout or worse. The other implication of this is that such completely burned out students lose the ability or desire to empathize or effectively communicate with their patients. They are just trying to get through the day.

The question is whether anything can be done about this. Medical school is hard. There is a vast amount of information you simply have to learn in a limited period of time. Practicing medicine is hard. There are a million decision that need to be made, many of them a matter of life or death. There is nothing you can do to change that. But can or should medical school try to change or soften the environment in which the students learn?

The comments on this article were varied; everything from those who exhort students saying “Medical school is hard. Deal with it, quit whining, or find another profession,” to those who believe the model for how medical students and residents are educated must be completely turned on its head. Is it a matter of screening incoming medical students better to measure who will be able to handle the high-pressure environment or is it a matter of monitoring students mental health better before the stress gets dangerously high? But if such burnout impacts the students’ ability to ultimately practice medicine, most would agree that something needs to be done.

You can find the article here: http://www.nytimes.com/2008/10/31/health/chen10-30.html?partner=permalink&exprod=permalink

And the comments here: http://well.blogs.nytimes.com/2008/10/30/the-misery-of-the-med-student/

missed opportunities for empathy

The Washington Post printed an article today about a study published in The Archives of Internal Medicine about missed opportunities for physicians to express empathy for patients. The study was between lung cancer patients and their thoracic surgeons or oncologists. The relationship of a cancer patient and physician is complex, not only because of complex treatment plans, but because patients are also dealing with emotional issues such as the loss of identity and the fear of death. Patients reach out to physicians, but physicians may feel more comfortable talking about biomedical issues rather than emotional issues, which don't have an easy answer.

You can find the article here: http://www.washingtonpost.com/wp-dyn/content/article/2008/09/22/AR2008092201894.html

So what do you think? What steps can physicians take to better prepare for emotional encounters?

Empathy and communication

The New York Times printed an interesting article about a new program to teach health care workers and others what its like to be elderly. Participants engage in a series of simple activities, but while wearing equipment that limits the range of movement, sight and touch, simulating the day-to-day life of an elderly person. It is hoped that the tangible experience of feeling what it is like to be elderly will foster sensitivity toward elderly patients, clients and customers. This improved empathy also has the potential to foster better communication between generations, as the younger generation can catch just a glimpse of the physical limitations that may inhibit their elders.

You can find the article here: http://www.nytimes.com/2008/08/03/us/03aging.html?ex=1375588800&en=d3b42e922a1c4746&ei=5124&partner=permalink&exprod=permalink

knowing the vulnerability of being a patient

Dr. Richard Friedman, professor of psychiatry at Weill Cornell Medical College wrote an interesting piece in The New York Times today about psychiatrists knowing themselves as they explore the minds of their patients http://www.nytimes.com/2008/02/19/health/19mind.html?ex=1361250000&en=94fd6ed3fad82e9c&ei=5124&partner=permalink&exprod=permalink.

Psychiatry is unlike any other medical specialty, and in no other specialty is the relationship between doctor and patient as important. As Dr. Friedman says "If your cardiologist does not have the best bedside manner but effectively treats your hypertension, you might not be happy, but at least you are heading in the right medical direction. In contrast, if you do not have a rapport with your therapist, then the treatment is useless."

The psychiatry field is changing and the role of therapy in training psychiatrists is diminishing. Dr. Friedman says it was once common for psychiatry residents to undergo psychotherapy themselves, but the practice is becoming less common. But the psychiatrists who have undergone therapy can better understand the anxiety, frustration and vulnerability that comes with being a psychiatry patient. These psychiatrists would better understand all that their patients are experiencing.

Dr. Friedman does make an interesting point that therapists bring their own history to the therapeutic relationship. It seems a therapist who has explored his or her own feelings would be better equipped to explore his or her patient's feelings.

Empathy in cancer care

The New York Times highlighted an article recently published in the Journal of Clinical Oncology. A little bit of empathy can go a long way in helping patients understand and stick with their treatment.

You can find the article here: http://www.nytimes.com/2008/01/08/health/08seco.html?ex=1357448400&en=8203887449e399dc&ei=5124&partner=permalink&exprod=permalink.

And the abstract is here: http://jco.ascopubs.org/cgi/content/abstract/25/36/5748.

This article got my attention because it parallels the research we are doing at MCW about quality communication. Empathy is an important aspect of clinical care. It shows the humanity of the doctor and potentially offers the patient hope. But when patients open up about emotions, doctors rarely engage in the discussion and too often, divert the conversation back to science and medicine. But the good news is that younger doctors and those who identify themselves as socioemotional responded better to emotional cues. Emphasis and training on addressing the emotions of health care will help doctors be better equipped to respond to their patients' emotional, as well as physical needs.

Last Lecture

I came across a New York Times blog about a Washington Post article about Carengie Mellon Professor Randy Pausch. Earlier in September, he took part in the Last Lecture series, a series of lectures in which professors are asked to think deeply about the topics that most capture them and to give a hypothetical final speech about the topic. But for Professor Pausch, this isn't hypothetical. He is dying of pancreatic cancer. But he refuses to feel sorry for himself or let others feel sorry for him. He even did one-arm push-ups on stage. He took the stage to encourage others to pursue their dreams and to overcome roadblocks on the path to your dreams. He encouraged his colleagues and loved ones to continue to do great things without him.

Here's a link to a clip of the speech:
http://link.brightcove.com/services/link/bcpid452319854/bctid1199157902

Here's the full two hour lecture from Carnegie Mellon:
http://www.etc.cmu.edu/global_news/?q=node/42

Here's someone who is making sure he shares his final thoughts with those he loves and in doing so inspiring us all to go for our dreams.

Empathy in communication

With physicians pressed for time, it can be difficult enough to effectively communicate with patients, let alone communicate with empathy. Most physicians realize it is important to speak empathetically, but many fail in their efforts.

One of the indicators of quality physician communication we are testing at MCW is empathy. One of the scales we looked at comes from Robert Smith, MD and his book The Patient's Story. Smith uses the mnemonic NURS to help physicians effectively empathize with patients.

Name the emotion: "That sounds sad for you."

Understand the patient's emotion: "I've never had this happen, but I can see how deeply it hurts."

Respect the patient's difficulties: "I like the way you've hung in there and kept fighting."

Support the patient and show this is a partnership: "I'm here to help any way I can. Together, you and I can get to the bottom of this."

Small steps can make a world of difference in making a patient feel confident in the words and actions of his or her physician.