Pathways to Compassionate Care

"It is easier to act your way into a new way of thinking than it is to think your way into a new way of acting."

This aphorism, noted by UCSF physician Christopher Moriates in his insightful essay "A Few Good Words," serves to justify one approach to improving healthcare communication.  The idea, he admits, seems too simple to be important - that we change a small behavior as a first step to opening ourselves up to our patients, and to creating greater connection.  Specifically, he recommends that we simply stop asking patients "Do you have any questions," and ask, instead, "What questions do you have?"

The use of open-ended questions like this is just one of a whole toolset of "micro-skills" that are shared as part of our day-long Relationship-centered Communication (R.C.C.) course, designed specifically for Northwell physicians in collaboration with the Academy for Communication in Healthcare.

The curriculum is predicated on several assumptions.  One is that while attitudes influence our behavior, the converse - that deliberate actions shape attitudes - is also true.  A second is that we feel empathy for our patients more often than we express it.  It follows logically that patients are deprived of the emotional benefits of feeling cared about whenever their physician is experiencing - but not communicating - this state of mind called empathy.  (In Buddhist thought, the same state is described as "compassion."  More on that shortly.)  The prescription brought to learners in the RCC curriculum addresses this gap with specific empathic behaviors - described by terms like reflection, legitimation and exploration - that physicians can adopt in their day-to-day practice.

Legitimation, for example, is a technique whereby the physician "legitimizes" the patient's emotional relationship to his problem - "I understand.  Most people with chest pain like that would be afraid..."

Yet a third assumption is that there is a need for physicians to create "relationship" and communicate caring irrespective of how we actually feel about the patient. Most seasoned practitioners admit that we don't always feel real connection with our patients.  This is human nature. At such times, professionalism dictates that we "fake it."  Some people might object to what seems like dishonesty, but when burdened by fatigue or challenged by a patient's hostility, oppositionality or lack of gratitude, sometimes we recognize the need to shoulder on, relying on sound habits of bedside interaction that are serviceable irrespective of whether there is authentic empathy for that patient in that moment.  It is not, after all, our duty to like every person we treat, but it is most definitely our obligation to treat every patient with courtesy, respect and diligence.

I've just read Medicine and Compassion, the co-production of David Shlim and Chokyi Nyima Rinpoche, a physician and an Buddhist monk, and I'm afraid the authors of this wonderful book would disagree with any defense of well-intentioned artifice.  Their view, in short, is that we can't really fake it.  When one considers the philosophical foundations of Buddhism, this conclusion comes as no surprise.  In their world view, thoughts and emotions create real effects in the real world.  The authors note:

"A benevolent frame of mind can ease the suffering of other beings, and a malevolent frame of mind can cause immense suffering."  

How one achieves this "benevolent frame of mind" --  which is also called "compassion" or "loving-kindness" --  is a much longer story.  It is a story worth pursuing, however.  In walking the path of meditation, in seeking to understand our connectedness, in pursuing "enlightenment,"  there are benefits for our own happiness as well as for our capacity to be present to our patients.  It is this attentiveness that our patients may need most as they confront the forms of suffering that are so familiar in the kingdom of the sick.

By All Means, Let’s Wow the Customer and Exceed Her Expectations. But Let's Get On With Taking Better Care of Patients (Which Is The Only Way To Improve HCAHPS Scores)

Among the most pervasive myths in contemporary healthcare is that HCAHPS is merely the new Press-Ganey and that generic efforts to improve “satisfaction” will help organizational performance on these metrics.

In what ways is this a myth?  First, whereas the Press Ganey tools ask consumers to rate aspects of care on a continuum of satisfaction, HCAHPS only asks about frequency.  The words “how often” precede all but two questions on the survey.  “How often did nurses explain things in a way you could understand.”  The fact that Nurse Smith is an awesome communicator and cared for the patient during much of his stay has essentially no bearing on deciding whether the best answer is “Sometimes, Usually, or Always.”  (In HCAHPS scoring, only “always” is scored in the numerator).

Where have we seen this kind of scoring before?  The answer is in the Joint Commission’s Core Measures, where top decile performance requires that the healthcare team accomplishes specific actions 100% of the time.  That might be the frequency with which influenza vaccine is administered to eligible patients, or aspirin to patients experiencing symptoms of AMI.  Providing exemplary service to cardiovascular patients is one thing; building process reliability to do one simple thing without fail requires another approach.

Is this analogy really valid?  Yes.  First, the same philosophy of quality improvement that underlies the Core Measures was at work in designing HCAHPS.  The goal was to encourage organizations to build reliable processes that ensure that they do what they intend to do for the patient, every time (or nearly so).  If there is going to be variation in care, let that variation be planned - around the needs of the patient - rather than as the accidental byproduct of inconsistency.

Additionally, almost all of the HCAHPS measures were designed to improve aspects of care that drive clinical outcomes of interest.  “Before giving you any new medicine, how often did staff explain side effects in a way you could understand” is not the kind of question that would ever be included in a patient satisfaction survey.  Performance in the domains of Nurse Communication, Physician Communication, Medications, Care Transitions and Discharge all align with important outcomes, including medication adherence, medication errors, readmission, markers of disease management (such as hemoglobin A1C in diabetic patients), 30-day readmission and, in the case of AMI, 1-year mortality.

Some have argued that “exceeding expectations” by emphasizing customer service could improve the “hospital rating” questions (there are two).  There may be some truth to this…but with caveats.  The first is that not every such effort drives this metric to the degree that we might guess.  Focusing strategically on what actually matters to patients is key.  Another is that CMS doesn’t treat these "hospital rating" metrics as special.  Together, they comprise just 18% of the Patient Experience measure set (which itself comprises 22% of the CMS Stars Rating report card).   So lets focus on helping patients by improving those aspects of hospital quality that are targeted by HCAHPS.  Some such efforts are well underway in our hospital.

In my next post: more about those efforts, and how the Relationship-Centered Communication course brings to the bedside evidence-based “micro-skills” that improve patient outcomes even as they help physicians to be more efficient, relieve our workplace stress and bring us greater joy in practice.     

Cappuccino and the Prefrontal Cortex - a Boston Diary

Three days at the Massachusetts General Hospital Psychiatry Academy's Child and Adolescent Psychopharmacology course (March 2-4, 2018) left me with a few thoughts. First, the coffee bar at the Back Bay's Eataly is worth a visit, if only to stay mentally charged between lectures at this high power conference, which covers everything from the molecular genetics of Bipolar 1 to the relative merits of stimulant and non-stimulant class agents in ADHD (Attention Deficit Hyperactivity Disorder).  Second, as pointed out by Dr. Joseph Biederman (Chief, Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD Director at MGH and co-director of this course), all of the behavioral health conditions discussed in this program have been the subject of myths and popular misunderstanding.  True as this is for autism, tic disorders, depression, bipolar disease, anxiety and schizophrenia, it is probably ADHD that is most prone to distortion in the press and popular culture.

(See "Five Myths About ADHD" below.)

 Here's what else.  I spend a lot of my time looking at healthcare through the lens of quality improvement - a perspective and a toolkit that treats variation in care as something to be eliminated, while standardization is reinforced.  It relies on measurement of care delivery at scale,  and sees health encounters as a set of inputs and outputs.  By stark contrast, during 25 hours or so of lectures and discussion, the international thought leaders who were the faculty for this course spoke very little - if at all - about variation or standardization.

Instead, there was much discussion of individualized care -- and why there was no one-size-fits-all solution to mood disorders, or anxiety, and certainly not for ADHD or autism.  The emphasis was on understanding the rapidly changing scientific landscape, the best approaches to assessment and how therapeutics must be modified to meet the individual circumstances of our patients. Ultimately, it seems to me, this contrast is essentially about the difference between the delivery of healthcare to populations, and the practice of Medicine, which remains, principally, about the care of individual patients with their own unique situations, needs, responses to treatment and preferences.  This is not to say that one enterprise is inherently better or more valuable than the other.

It is to say, however, that they are distinctly different.  Were healthcare like a forest, a few paved roads in that forest would be the things we can and should standardize, and then measure and improve.  A vastly larger area would represent the forest itself,  laced with trails cleared to varying degrees.  We walk those trails with our patients, and sometimes we must walk where there is no trail at all.  But in this is the challenge and the joy of medical practice. 


FIVE MYTHS ABOUT ADHD

MYTH 1. It is always safer to avoid medications to treat ADHD

The outcomes associated with under-treated ADHD go far beyond the classroom. Individuals with this condition experience greater rates of tobacco and alcohol use during adolescence and beyond, each with their own known morbidity and mortality. Accident rates appear to be increased by 250% in affected individuals. In a placebo-controlled study of lisdexamfetamine on “surprise” driving events, Biederman and colleagues found that medication reduced the probability of motor vehicle collision by more than 60%. Finally, the effective treatment of ADHD appears to be important to reduce the effects of common co-morbid conditions, including low self-esteem, social isolation, depression and conduct disorders, with consequences that include encounters with law enforcement and suicidality. In a 10-year, prospective cohort study, compared with untreated patients, individuals treated for ADHD with stimulant medications experienced lower rates of anxiety, depression and ODD (Pediatrics 124(1):71, 2009).

MYTH 2. If nothing else, avoiding medication for ADHD at least reduces the risk of illicit substance use in adolescents with this disorder

Despite concerns about psychostimulants as “gateway” drugs, in reality, untreated patients with ADHD experience significantly higher rates of substance use disorders (SUD) than individuals who receive effective therapy with stimulant medications.

MYTH 3. Children who can play video games for “hours at a time” can’t have ADHD

Symptoms of inattention and distractibility are context dependent. A better measure of these symptoms involves an assessment of the child’s performance when carrying out a task in which he is not naturally interested.

Myth 4. ADHD is a subjective diagnosis with no known biological markers

Multiple lines of evidence support the concept that ADHD is a distinct brain disorder, albeit one with multiple genetic and environmental risk factors. Functional MRI comparisons between ADHD patients and normal controls demonstrate differences in frontosubcortical networks involving the (ventromedial, dorsolateral and orbitofrontal) prefrontal cortex, parietal cortex and the basal ganglia - neural networks which appear to support attention, executive control, anticipation and reward. Additionally, studies have begun to elucidate the complex genetics of ADHD and other neuropsychiatric conditions.

MYTH 5. Children always “outgrow” ADHD

The typical trajectory of ADHD involves improvements in impulsivity and hyperactivity over time, while inattentiveness tends to persist. Studies have documented a worldwide prevalence of 5% among adults. This is a highly prevalent and highly morbid condition in the adult population, and one that is therefore worthy of significant attention by primary care physicians.

Reflections on Bioethics -- Where Next?

First, the bad news.

Bioethics consultation services like ours are an endangered enterprise.  For one thing, there is no apparent business case.  Physicians, nurses, social workers and others spend professional time at this work without an off-setting revenue stream.  Yes, it is true that at least some consultations result in "foregoing life-extending treatment." (This issue is so common in the field that it gets its own acronym - FLET).   And FLET, in turn, reduces cost, thereby improving margin.  On the other hand, nothing imperils the legitimacy of an ethics service more profoundly than equating its success with savings to the healthcare delivery system.  Additionally,  a contingent of respected physician leaders going back over the last 30 years have expressed suspicion of ethics services, opining privately - and sometimes publicly - that Bioethics isn't necessary, or shouldn't be, "if physicians would just act ethically."

This shouldn't come as a surprise.  Indeed, the whole field of Bioethics emerged as a backlash against technological Medicine and the prevailing mid-20th century view that doctors are the most qualified arbiters of what treatment is "right" for the patient - even for value-laden choices with profound consequences. What followed might have been an era of shared decision making that recognized the physician as the expert in what could be done, based on the best medical science, and the patient as the expert in what should be done, based on her personal values and preferences.  What followed instead, to some degree, has been a simmering antagonism between health professionals, patients and families over the authority to decide, and as a corollary, objection to "outsiders" (i.e. the Ethics consultants) insinuating themselves into the doctor-patient relationship.

And Now the Good News...

The December meeting of our Bioethics Committee was so well attended that we had to have more handouts made - twice.  The agenda was so full that we needed to prioritize.  And the conversation was so energetic (and diverse and thoughtful) that, as chair, I had two problems - how to keep the meeting from segueing from Robert's Rules to something more closely resembling conversation at a large Holiday dinner...and getting a motion to adjourn at the end of our scheduled hour with dialogue among physicians, administrators, a clergyman, a nurse and a social worker going full tilt.  There was something else special about the meeting - more members of our Board of Directors attended this meeting than ever before in its history. (There were four in all, including the Chairman of the Board.)


The question is why?  Why this interest, this engagement and the sense that this is vitally important work?  Notwithstanding the observation of one member, that Bioethics Committees should be in the business of working themselves out of a job" [by educating and inculcating ethical principles at the bedside],  moral distress among caregivers remains an urgent issue.  Failures of communication and trust between families and doctors still happen.  And deciding whether an intervention is extending life or prolonging death remains an everyday challenge.  As a trustee so aptly noted, "you should really call this the Snowflake committee, because every case is unique."

How We Got Here

On a personal note, my own discovery of Bioethics began as an undergraduate at Georgetown University in the 1970's and closely paralleled the development of the field as a whole.  At that time, this was a new term for a still-new field, and a course on the topic was offered in the Philosophy Department by a junior faculty member named Tom Beauchamp (pronounced in the Southern and decidedly un-French way: BEE - champ). 

Among the luminaries writing at the time was Dr. Edmund Pelligrino, an internist whose views on the matter proceeded from his Roman Catholicism and from a philosophy of Medicine grounded in the set of obligations that bind doctor and patient.  Warren Reich, over at the new Kennedy Institute, a GU affiliated program, was working on an Encyclopedia of Bioethics.  As it would happen, my own professor had recently written - together with James Childress - the authoritative textbook for the field highlighting their own intellectual infrastructure for a clinical Bioethics that we now rely on to such a degree that many of my colleagues likely believe it was handed down from the ancients.

Along the way, someone gave Beauchamp's approach a proper name: Principlism.

This is the idea, in brief.  Ethical conflicts in the hospital can best be understood in terms of four principles; hence the name.  One of these is respect for Autonomy, the patient's right to make decisions about his own body. A second principle - nonmaleficence - is to avoid harm.  'Primum non nocere' enjoins and prohibits the physician from doing anything that would cause injury to the patient, and requires him to direct his very best effort to comply with this moral precept.  A third principle is closely related; that is, that the physician shall act always in the patient's best interest.  Known as "beneficence," this mandate is shared in varying degrees with other learned professions where a fiduciary relationship exists between the professional and the one seeking professional service.  Finally, principlists refer to a notion of distributive justice to describe a moral responsibility to apply healthcare resources in a way that is essentially fair and equitable.

A purely principlist account of moral conflict would refract each clinical case through the lens of (often colliding) principles.  A physician receives an ambiguous result from a test for cancer, and asks the patient to repeat it.  Full disclosure would involve telling the patient that the news may be very bad (or maybe not).  Sharing this information would support the patient's right to information about his own health (Autonomy principle).  However, providing it would likely distress the patient, while doing nothing to advance his situation (raising considerations of Beneficence and Non-maleficence).  Therefore, telling the patient only that a repeat test is needed is an attractive option.  Whether this course of action is morally justified requires parsing the strength of arguments on behalf of these conflicting values.

Based on our experiences with the Ethics Consultation service, there are at least three other factors that come to bear in many, if not all cases.  One is medical information.  Good ethics starts with good Medicine.  (I have been reminded of this time and again by our committee's only card-carrying PhD Bioethicist, Dr. Robert Cassidy.)

The healthcare team and the family are at loggerheads over the question of PEG (feeding tube) insertion for a patient with advanced Alzheimer's dementia.  One side feels the procedure is necessary to "protect" the patient from aspiration pneumonia and malnutrition.  The other feels that this is an unnatural invasion at the end of life.  It should matter to us to know that studies have found no life extension benefit from this intervention for patients in this end-of-life circumstance. 

A second issue is communication.  So often, when family members are in conflict with the caregiving team, it is because messaging has been inconsistent or ineffective.

The fact is that our patients tell us about this every month, because we ask them.  One whole domain in the federal HCAHPS survey involves physician communication, and one question specifically asks how often doctors "explain things in a way you understand."  Month after month, more patients say that doctors treat them "with courtesy and respect" than answer positively to the question on clear communication.  We mean well.

Finally, there is a question of understanding.  When patients or families are in conflict with caregivers, there is, by and large, a reason.  It is our obligation to find out what it is.  But this takes time, something that is in chronically short supply in the modern hospital.  Nonetheless, getting the right medical facts, ensuring clear communication and being curious enough about the patient and family and their values and preferences and motivations - all of this is part of our job and necessary to obtaining the best outcomes for those who come to us for care.

I titled this blog entry with a question: "Where next" for Bioethics?  But I have taken up enough space for now.  Lets return to this in 2018.  Best wishes to all for a fulfilling, meaningful, ethical New Year!

Why Promoting Immunization is Frustrating, Time Consuming and Financially Counterproductive...But Crucial

"In 2015 pneumococcal conjugate vaccine, as the children’s formulation is called, reached the Bangladeshis, and Saha’s research team is intently tracking its progress. If PCVs prove as effective around the world as vaccine experts hope, they promise both a greatly lowered mortality rate—that’s many thousands of small children staying alive instead of dying before they’re old enough to start school—and much less nonmortal sickness. Less of the rapid pneumonia breathing; less of the fever, the sucking chest, the rattling cough, the blue lips, the bedside watch by parents pulled away from the paid work that supports their other children. Less … suffering, I kept hearing Saha and his Bangladeshi colleagues say, as though sensing that an outsider might need help appreciating the stakes.

"Because from the vantage of a country like the United States, it can be easy to imagine that the most pressing vaccine challenge of 2017 lies in convincing certain communities of skeptical parents that they really ought to inoculate their kids. Those efforts are important, to be sure. But even more urgent—more ambitious, more complex, involving many governments and billions of philanthropic dollars—is the international collaboration to get new vaccines to children in the developing world, where to this day the suffering caused by vaccine-preventable disease is as vivid and nontheoretical as the frantic families Saha sees every day in the halls of Dhaka Shishu."

Source: Here's Why Vaccine are so Crucial, by Cynthia Gorney; National Geographic Magazine, November 2017.  

(See: https://www.nationalgeographic.com/magazine/2017/11/vaccine-health-infection-global-children/)

WITH THE SUPPORT OF THE AMERICAN CANCER SOCIETY and Northwell's Oncology service line, a group of Huntington Hospital pediatricians and other child health professionals are collaborating to increase the rate of adolescents immunized with the human papilloma virus (HPV) vaccine known as Gardasil.  This is one of two vaccines (the other being hepatitis B vaccine) that were specifically developed to prevent potentially fatal cancers.

As noted in this month's National Geographic, the US is among a relatively small number of countries where the problem of under-immunization is decidedly NOT about access.  In fact, the CDC maps that depict immunization rates by state and locale tell a strange and interesting story: financially challenged places like Mississippi significantly outperform downstate New York, Colorado and the San Francisco Bay Area when it comes to immunizing children.  For that matter, the vaccination rate in poverty-stricken Belize is far higher than in the US overall.  

The reasons are not mysterious.  The phenomenon of "vaccine reluctance" has been so well studied that national meetings of our professional societies routinely include symposia on the topic, and research studies on how to combat it increase in number every year.  

At its core, vaccine reluctance represents a movement - a backlash - that calls into question both the science of vaccinology and the motives of the many organizations, from the WHO to the CDC, IDSA, AAP, AAPF and many others that seek to educate the general public about the following facts:

1.  Vaccine-preventable diseases continue to pose a threat to children and adults.

2.  Vaccines are among the safest pharmaceuticals on the market.

3.  The list of known, severe vaccine side effects has almost nothing in common with the list of fearsome (but mythical) side effects that are highlighted on dozens of "anti-vax" websites, and instill in thousands of parents...not certainty about the issue, but just enough doubt to cause serious damage to our national program of immunization.

What are the main drivers of this retreat from a preventive strategy that has been called the most important contribution of the 20th century?  One is certainly the very success of immunization in making previously dreaded diseases less visible, among them: diphtheria, with its throat pain, fever and suffocating airway obstruction; measles - highly contagious, red eyes, cough, fever and rash, resulting now and again in pneumonia or brain infection; and pneumococcus - agent of plain vanilla middle ear infection, but also of death-dealing sepsis, and bacterial meningitis.

Additionally, human nature is such that giving a health infant something that could make them even a little sick, or that carries even a very, very small risk of more serious harm, seems like a bad idea, even if those harms or risk are outweighed by the risks of NOT immunizing, by a large margin.

Perhaps the most potent influence on our nation's vaccine program is the social/cultural/political trend toward a kind of libertarianism that is distrustful of government, authority figures and mandates.  As Senator Rand Paul (a physician) has stated, "I think this is a question of freedom...the government doesn't own your children...parents own their children."   To the extent that science itself is seen as just one voice in the marketplace of ideas, it is no more surprising that the guidance of infectious disease experts would be dismissed as would the conclusions of climate scientists.  We are, after all, living in an era of "alternative facts."

The Huntington team convened for the first time earlier this month, to define our goals and the way forward.  Several studies have tried to determine what interventions lead to higher immunization rates and which do not.  It seems that more information doesn't necessarily improve this outcome; at least one published study found the opposite effect, when an informational strategy was applied to a previously vaccine-reluctant group of parents.  Neither does a shared decision-making model.

In fact, the most interesting study of the last few years found that the patients of clinicians who took a "presumptive" approach were more likely to be immunized that those who took a more tentative, "collaborative" stance.  (The latter group would generally open the conversation with some version of 'how do you feel about immunizing Alice with the HPV vaccine today?'  The 'presumptive' clinician, on the other hand, is likely to conclude the visit with 'I'm going to order a lipid panel for Alice, and she's due for her first dose of HPV vaccine today.  The nurse will be in with that in a few minutes.  What questions do you have?')

I'll keep you posted on our progress.  

WHO poster depicts disease burden of HPV and the vaccine program that prevents it

  

Can you hear me now?

This past week I had the opportunity to orient a large group of incoming residents to our hospital, providing some background on our institution but also giving them "the benefit of my opinion" on many matters relating to healthcare and the profession of Medicine.

I asked for a show of hands.  How many of you treat every patient with courtesy and respect?  Listen carefully to your patients? Explain things in a way they can understand?  The good news is that all the hands went up.  I haven't conducted this survey with our attending staff, but I believe that except for some (understandable) eye-rolling, the honest answers would be the same.

The bad news is that our patients don't agree.  Or, at least one time out of five they don't.  What does this tell us?

Hospitals and health systems like ours are devoting more attention than ever to physician communication skills.  In fact, it was to audit a day-long medical communication program, soon to be rolled out to our doctors, that I spent a day recently in Northwell's own university, known as CLI, the Center for Learning and Innovation.   I was already convinced that this is something we need, and that the investment of time in an effective training program could be worthwhile.  What I came away with was a sense of how much there is to learn and practice, a reminder that we can all improve (no matter how good we think we are), and that this matters in a host of ways to the patients and families who seek our care.

If you ask most physicians of my generation what they were taught about communicating with patients - at least during formal training - they will tell you how they learned to "take a history."   This is a process that begins with a "chief complaint" (it would seem that patients are, by definition, "complainers") and includes a "history of the present illness" followed by the "past medical history" and so forth.  A moment's reflection reveals, however, that understanding the data set necessary to work toward a diagnosis - important as this may be - is not the same as knowing how to communicate effectively.

(When pressed, most of us can recite at least one pearl - that we ought to sit down when we speak with the patient "because this makes it seem like we're there twice as long." It seems to be true, by the way. But mastering a single knot does not an expert sailor make.)

How do we know we need to improve?  Simply put, because we ask our patients how we're doing every day.  The questions I asked our new residents are the same questions that patients receive as part of the federal survey known as HCAHPS.

For several reasons, communicating effectively with patients and families is harder now than it ever was before.  Consider that in the past, when patients experienced durable relationships with their primary physician, who then became the physician-of-record during times of hospital care, the dynamics were quite different.  The patient chose the physician, and if the relationship didn't work, the patient chose another physician.  A long-term relationship meant that the parties really knew one another.  There was a bond, and there was confidence both in the physician's skill and in his commitment to the patient's best interest.  Care was also less complex, with fewer interventions and fewer consultations.

The contemporary hospital-based physician faces a very different scene.  Emergency physicians, hospitalists and intensivists practice in teams.  There is no pre-existing relationship with the patient, and patients are passed from one provider to another. (I am reminded of the traumatized foster child, passed from one home to another, reluctant to trust or form relationships at all...).  Consistent messaging becomes increasingly difficult, as differing communication styles intersect with bona fide differences of opinion superimposed on the dynamics of acute illness where priorities change from day to day.

In this setting, its not that effective, empathic communication isn't possible.  To the contrary, it is more important than ever, exactly because it isn't easy.  In the framework of education, we could say that the requirements are threefold - knowledge, of what comprises effective communication; skills, which means practice; and attitudes, referring to the extent to which we recognize and value relationship-based care as a foundation to creating the outcomes we want for our patients.  For many of us, exceptional skill in this domain is also foundational to our sense of professional pride and accomplishment, to what we mean when we call ourselves "physicians."

  

Empathy in Healthcare

One of my favorite experiences is running a didactic session for our Family Medicine residents  once (and often twice) each month.  Last week, however, I was a little nervous.  Having covered a lot of the core child health topics since the beginning of the academic year, I thought it time to tackle something "different" - the nascent field known as Narrative Medicine.

If Narrative Medicine (NM) has a founder, it would be Columbia internist Dr. Rita Charon. NM burst into our collective consciousness in 2004 with the publication of her seminal Perspectives essay in the New England Journal entitled "Narrative and Medicine."  Her thesis was that the telling and hearing of the patient's story - not his medical history, but his personal, self-defining narrative - constitutes a creative act, essential to the relationship between physicians and patients, and necessary to our understanding of the patient and his "dis-ease."

If Narrative Medicine is the answer, I asked our group, what is the question?  That is to say, what ailments (ours and our patients') does this new (or not-so-new) philosophy address?  One answer comes from a body of research that seeks to understand what happens to trainees between their entry to medical school and the completion of graduate training.  More exactly, what happens to their ability to recognize and connect with personal suffering, to their capacity for empathy?  

I was quite surprised to learn several years ago that empathy can be measured.  At least that is the view of the researchers who created the Jefferson Scale of Physician Empathy (JSPE).  What is even more interesting is that this validated tool has been applied in a number of research studies to the trajectory of empathy in physicians and other health professionals over time.  It turns out that those who choose Medicine enter training with a full measure of this desirable trait - more than the average person, in fact.  According to a meta-analysis of 18 studies published in 2011, the sad fact is in what happens next - empathic capacity declines.  Substantially.  For some, things get better later on, after residency and fellowship, but not for all.  

What causes this erosion of empathy?  Several factors have been proposed.  Most often discussed in teaching circles is a process of acculturation wherein a set of beliefs, attitudes and behaviors are role-modeled by more senior trainees to their younger reports.  Not only are these behaviors not sanctioned by leadership, they generally conflict dramatically with the stated mission and vision of our institutions of medical education - hence the term "hidden curriculum."  Another factor is the very frequency with which trainees encounter human suffering.  Because this suffering is a "normal" feature of the healthcare environment, the sensibilities necessary to feel for another are challenged and blunted.   As George Eliot noted in her novel Middlemarch,

"We do not expect people to be deeply moved by what is not unusual. That element of tragedy which lies in the very fact of frequency has not yet wrought itself into the coarse emotion of mankind and perhaps our frames could hardly bear much of it..." 

Narrative practice, whatever its other merits, seeks to serve as a corrective and an antidote to the hidden curriculum.  In an essay of the same name, NYU physician Jerome Lowenstein once asked "can empathy be taught"?  Since is it evident that empathy can be un-learned on the wards, perhaps, the argument goes, this novel approach to focusing attention on the humanity, the subjective and deeply personal experiences of those who seek our care, and those who provide it,  may mitigate this threat to our ability to be the physicians we intended to be. 

We should hope so.  It has been established that patient outcomes (including Hgb A1C levels in diabetic patients) are impacted by physician empathy.  There is a measure of this quality to be found in nationally-collected and publicly-reported patient experience data. ("During this hospital stay...how often did doctors listen carefully to you?").  Finally, we ourselves are impacted.  It has been observed that one feature of physician burn-out, an increasingly prevalent problem, is a sense of disconnection from our patients and of ineffectiveness in our work.  Empathic connection is exactly the inverse of burn out.  Dr. Lawrence Smith, founding dean of our heath system's School of Medicine, has stated as much by asserting that finding the stories of our patients is the best prevention for burn out.  It is curiosity about our patients and their lives, and indeed our privileged access to their most personal aspirations and fears, that creates a foundation for trust, and both defines us and sustains us as physicians.