Monday, August 22, 2005

Improving Empathy in Medical Training

Used worldwide, The Empathy Belly  has proven itself to be an extremely beneficial teaching tool resource for medical students, obstetrical physicians and allied professionals in the fields of Maternity Health Care and Education. By wearing The Empathy Belly they significantly increase their understanding and sensitivity about the pregnant condition. Consequently they are better trained, more effective, and more likely to establish genuine rapport with the pregnant women in their care. For obvious reasons, this is especially true for service providers who are male, or women who have never experienced a full-term pregnancy.
No thanks.  But seriously, we all know that many doctors need to be more empathic.  A Google search on the string, "empathy in medical training" gets about 745,000 hits (including the one above).  Many medical schools have incorporated empathy training into their curricula.  Even so, the problem persists.  We see articles in the NYT such as Awash in Information, Patients Face a Lonely, Uncertain Road, which I was going to post about, until I saw that Shrinkette already did.

From NYT:
Ms. Gaines, bald, tumor-ridden and exhausted from chemotherapy, was reeling. "I'm not a doctor!" she shouted. "I'm a criminal defense lawyer! How am I supposed to know?"

This is the blessing and the burden of being a modern patient. A generation ago, patients argued for more information, more choice and more say about treatment. To a great extent, that is exactly what they have received: a superabundance of information, often several treatment options and the right to choose among them.

As this new responsibility dawns on patients, some embrace it with a sense of pride and furious determination. But many find the job of being a modern patient, with its slog through medical uncertainty, to be lonely, frightening and overwhelming.
From Shrinkette:
Hasn't serious illness almost always been a lonely, uncertain road? The best doctors make that road easier to bear. But this article says that many patients feel abandoned by their doctors, and adrift in the system. It's hard to imagine a satisfying solution.
Also see the NYT article, Sick and Scared, and Waiting, Waiting, Waiting, for an additional perspective on the problem.  

Later, I encountered a physician's essay on the topic of empathy: Empathy: Lost or Found in Medical Education? (Medscape: free registration required) by Sonal Singh, MD; that inspired me to write this post.

What can be done about the lack of empathy among physicians?  To answer that, one first must learn what already has been done.  Recently, the Josiah Macy Foundation funded a study, the Macy Initiative in Health Communication.  According to a report in Academic Medicine:
Sixty-five percent of medical schools teach communication skills, usually in the preclinical years; however, communication skills learned in the preclinical years may decline by graduation. [...]

The three schools use a variety of methods to teach third-year students in each school a set of effective clinical communication skills.
Moving some of the instruction to the third year is a good idea, because it is impossible to learn the skills properly, outside of a clinical context.  (The first two years are spent mainly in classroom instruction.)  Also, of course, communication skills are only a part of being empathic.  Plus, communication is, by definition, a two-way process; you can't solve the problem by having only one person learn the skills.  The solution has to involve medical training centers, medical practice settings, the physician's ongoing efforts at self-education and self-improvement, and the the patients.

First, in regard to medical training programs: the points learned in the Macy study are important.  The instruction tends to loose effect shortly after it is taught, and it is more effective when taught in a clinical -- as opposed to a classroom -- context. It would make sense, then, to incorporate the instruction into residency training programs, as well as continuing medical education programs.  It would not take a lot at any one time, to be effective.  What would make it effective would be to give the subject at least some attention at every opportunity.  

In addition, for such instruction to be effective, it would have to be pertinent.  How to make it seem pertinent?  Try this, from Archives of Internal Medicine (Vol. 154 No. 12, June 27, 1994):
The doctor-patient relationship and malpractice. Lessons from plaintiff depositions

H. B. Beckman, K. M. Markakis, A. L. Suchman and R. M. Frankel
Department of Medicine, Highland Hospital, Rochester, NY 14620.

BACKGROUND: The current literature does not provide an answer to the question, "What prompts patients to sue doctors or hospitals?" Not all adverse outcomes result in suits, and threatened suits do not always involve adverse outcomes. The exploration of other factors has been hampered by the lack of a methodology to contact plaintiffs and elicit their views about their experience in delivered health care. This study employed the transcripts of discovery depositions of plaintiffs as a source of insight into the issues that prompted individuals to file a malpractice claim. [...]

CONCLUSIONS: In our sample, the decision to litigate was often associated with a perceived lack of caring and/or collaboration in the delivery of health care. The issues identified included perceived unavailability, discounting patient and/or family concerns, poor delivery of information, and lack of understanding the patient and/or family perspective. Particular attention should be paid to the postadverse-event consultant-patient interaction. [emphasis added]
If that does not impress trainees with the pertinence of the subject, perhaps this would: collect evaluations, from patients, of the performance of medical students and residents.  Just knowing that people are paying attention often results in improved behavior.  

Second, with regard to medical practice settings, it is important for the institution to have a culture that is self-correcting.  If a practitioner sees an instance of poor empathy, she or he should feel free to point it out; furthermore, the person who made the error should be receptive to corrective feedback.  It turns out that there is already a good article on the subject, in an AMA Virtual Mentor Vignette, here.  

Each institution has its own culture, and that culture determines what behaviors are acceptable, and what topics are acceptable topics for conversation.  Physicians need to take a leadership role in encouraging others to give corrective feedback.  Perhaps more importantly, they need to model the graceful receipt of such feedback.  "Thank you for pointing that out," is always good.   Remember the principle of Ostler's  Aequinimitas.  
Cultivate, then, gentlemen, such a judicious measure of obtuseness as will enable you to meet the exigencies of practice with firmness and courage, without, at the same time, hardening "the human heart by which we live."
In an essay (Medscape link), Dr. James Dykes elaborated:
Now I teach Duke medical students. I tell them that although "objectivity" is important in the practice of medicine, it is often misunderstood. When the great physician Sir William Osler (1849-1919) wrote his treatise on the importance of "objectivity," he used the Latin term "aequanimitas," which can be translated as equanimity. To practice with equanimity, we must cultivate inner peace.
Also remember: the giving and receiving of such feedback actually helps build a sense of teamwork and camaraderie.  This may seem counterintuitive; at first glance, it may seem that one member of the team criticizing another would be destructive.  But done properly, in the context of a healthy institutional culture, it actually is constructive.

Third, in regard to physicians' ongoing self-education and self-improvement: this is a personal thing.  As physicians, we all worry about missing the next retroperitoneal abscess, or the next case of idiopathic hemochromatosis.  That's why we rush home from the clinic, ignore our spouses and children, and breathlessly page through the latest copy of Archives of Medical Obscuranta, groaning every time the pager goes off.  

Next time, try this: pay attention to you spouse and kids.  They know more about empathy than you ever will.  They will even teach you, if you would just pay attention every once in a while.  Like everything else in medicine, the best way to learn it, is to watch an expert do it.

Fourth, perhaps the most difficult: just as communication is a two-way process, so is empathy.  We don't have an empathy training belly that patients can wear, to learn what it is like to be a doctor.  

I think what would help, would be for patients and physicians to have a shared model of what their interactions are about.  I find that it helps to look at it this way:  Suppose you own an auto body shop.  You are an expert on auto body repair.  You want to advertise your business, so you go meet with an advertising specialist.  The two of you sit down.  Each of you is an expert on something.  Together, you combine your expertise to figure out what to do.

In a medical setting, the doctor is an expert on the subject of medicine; the patient is an expert on the subject of the patient.  The patient will always know more, about himself or herself, than the doctor will.  They both are experts in their respective fields, and they should interact as two experts do:  each listening to the other, each respecting the other, each appreciating that the other knows more about the other's area of expertise, and each deferring to the other when appropriate.  

The nice thing about empathy, is that if we all learn to do it better, we all will benefit.  If it is true in medical settings, it also is true in other settings.  

As Dr. Dykes said in the essay that inspired this post, "we must cultivate inner peace."  It is a lifelong process.

Categories: medicine, being nice
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A great analysis on empathy in medical training. Have spoken and worked with a few docotrs myself, I have come to realise that it is not taught at medical school but yet it is expected they have a full understanding of. It might be mentioned now and then in passing but never ever dealth with as a subject. Well i guess it is one of those life skills people are expected to have before going on to med school

Esy Martinez
HealthCareerNet - Physician Jobs Search
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