Care and car­ing

As doc­tors learn clin­i­cal em­pa­thy, they find that pa­tients ben­e­fit from care that comes with ‘good bed­side man­ner’

The Washington Post - - FRONT PAGE - BY SAN­DRA G. BOODMAN

Be­yond bed­side man­ner, clin­i­cal em­pa­thy is now con­sid­ered vi­tal.

The pa­tient was dy­ing and she knew it. In her mid-50s, she had been bat­tling breast can­cer for years, but it had spread to her bones, caus­ing un­re­lent­ing pain that re­quired hos­pi­tal­iza­tion. Jeremy Force, a first-year on­col­ogy fel­low at Duke Uni­ver­sity Med­i­cal Cen­ter who had never met the woman, was as­signed to stop by her room last Novem­ber to dis­cuss her de­ci­sion to en­ter hospice.

Em­ploy­ing the skills he had just learned in a day-long course, Force sat at the end of her bed and lis­tened in­tently. The woman wept, telling him she was ex­hausted and wor­ried about the im­pact her death would have on her two daugh­ters.

“I ac­knowl­edged how hard what she was go­ing through was,” Force said of their 15-minute con­ver­sa­tion, “and told her I had two chil­dren, too” and that hospice was de­signed to pro­vide her ad­di­tional sup­port.

A few days later, he ran into the woman in the hall. “You’re the best physi­cian I’ve ever worked with,” Force re­mem­bers her telling him. “I was blown away,” he says. “It was such an honor.”

Force cred­its “On­cotalk,” a course re­quired of Duke’s on­col­ogy fel­lows, for the un­ex­pected ac­co­lade. De­vel­oped by med­i­cal fac­ulty at Duke, the Uni­ver­sity of Pitts­burgh and sev­eral other med­i­cal schools, “On­cotalk” is part of a bur­geon­ing ef­fort to teach doc­tors an es­sen­tial but of­ten over­looked skill: clin­i­cal em­pa­thy. Un­like sym­pa­thy, which is de­fined as feel­ing sorry for an­other per­son, clin­i­cal em­pa­thy is the abil­ity to stand in a pa­tient’s shoes and to con­vey an un­der­stand­ing of the pa­tient’s sit­u­a­tion as well as the de­sire to help.

Clin­i­cal em­pa­thy was once dis­mis­sively known as “good bed­side man­ner” and tra­di­tion­ally re­garded as far less im­por­tant than tech­ni­cal acu­men. But a spate of stud­ies in the past decade has found that it is no mere frill. In­creas­ingly, em­pa­thy is con­sid­ered es­sen­tial to es­tab­lish­ing trust, the foun­da­tion of a good doc­tor-pa­tient re­la­tion­ship.

Stud­ies have linked em­pa­thy to greater pa­tient sat­is­fac­tion, bet­ter out­comes, de­creased physi­cian burnout and a lower risk of mal­prac­tice suits and er­rors. Be­gin­ning this year, the Med­i­cal Col­lege Ad­mis­sion Test will con­tain ques­tions in­volv­ing hu­man be­hav­ior and psy­chol­ogy, a recog­ni­tion that be­ing a good doc­tor “re­quires an un­der­stand­ing of peo­ple,” not just science, ac­cord­ing to the Amer­i­can As­so­ci­a­tion of Med­i­cal Col­leges. Pa­tient sat­is­fac­tion scores are now be­ing used to cal­cu­late Medi­care re­im­burse­ment un­der the Af­ford­able Care Act. And more than 70 per­cent of hos­pi­tals and health net­works are us­ing pa­tient sat­is­fac­tion scores in physi­cian com­pen­sa­tion de­ci­sions.

While some peo­ple are nat­u­rally bet­ter at be­ing em­pathic, said Mo­ham­madreza Ho­jat, a re­search pro­fes­sor of psy­chi­a­try at Jef­fer­son Med­i­cal Col­lege in Philadel­phia, em­pa­thy can be taught. “Em­pa­thy is a cog­ni­tive at­tribute, not a per­son­al­ity trait,” said Ho­jat, who de­vel­oped the Jef­fer­son Scale of Em­pa­thy, a tool used by re­searchers to mea­sure it.

“The pres­sure is re­ally on,” said psy­chi­a­trist He­len Riess. The direc­tor of the em­pa­thy and re­la­tional science pro­gram at Mas­sachusetts Gen­eral Hos­pi­tal, she de­signed “Em­pa­thet­ics,” a se­ries of on­line cour­ses for physi­cians. “The ACA and ac­count­abil­ity for health im­prove­ment is re­ally height­en­ing the im­por­tance of a re­la­tion­ship” be­tween pa­tients and their doc­tors when it comes to boost­ing ad­her­ence to treat­ment and im­prov­ing health out­comes.

“De­mo­graph­ics and eco­nomics are driv­ing this,” said James A. Tul­sky, one of the de­vel­op­ers of “On­cotalk.” (The orig­i­nal course for on­col­o­gists has been adapted for other spe­cial­ties un­der the aegis of Vi­tal Talk.) “Baby boomers have higher ex­pec­ta­tions” and are less will­ing to tol­er­ate doc­tors they con­sider ar­ro­gant or un­ap­proach­able, added Tul­sky, direc­tor of the Duke Cen­ter for Pal­lia­tive Care. A 2011 study he headed that doc­tors who took the course in­spired greater trust in their pa­tients than those who did not.

While em­pa­thy cour­ses are rarely re­quired in med­i­cal train­ing, in­ter­est in them is grow­ing, ex­perts say, and pro­grams are un­der­way at Jef­fer­son Med­i­cal Col­lege and at Columbia Uni­ver­sity School of Medicine. Columbia has pio- neered a pro­gram in nar­ra­tive medicine, which em­pha­sizes the im­por­tance of un­der­stand­ing pa­tients’ life sto­ries in pro­vid­ing com­pas­sion­ate care.

While the cur­ric­ula dif­fer, most fo­cus on self-mon­i­tor­ing by doc­tors to re­duce de­fen­sive­ness, im­prove lis­ten­ing skills (one study found that, on av­er­age, doc­tors in­ter­rupt pa­tients within 18 sec­onds) and decode fa­cial ex­pres­sions and body lan­guage. Some pro­grams use ac­tors as sim­u­lated pa­tients and pro­vide feed­back to in­di­vid­ual doc­tors.

Too busy for em­pa­thy

“In the 1980s, when I trained, the em­pha­sis was on med­i­cal knowl­edge and tech­ni­cal skills,” said De­bra We­in­stein, vice pres­i­dent for grad­u­ate med­i­cal ed­u­ca­tion at Part­ners Health­Care, the largest provider of med­i­cal ser­vices in Mas­sachusetts. But in the past decade, “the pro­fes­sion has been more at­tuned to pa­tient sat­is­fac­tion and the con­nec­tion be­tween sat­is­fac­tion and out­comes and in­cen­tives.”

Part­ners, which in­cludes Mass Gen­eral and other Har­vard teach­ing hos­pi­tals, is re­quir­ing that its 2,000 res­i­dents take “Em­pa­thet­ics.” In a 2012 study in­volv­ing 100 res­i­dents, re­searchers found that doc­tors ran­domly as­signed to take the course were judged by pa­tients as sig­nif­i­cantly bet­ter at un­der­stand­ing their con­cerns and mak­ing them feel at ease than res­i­dents who had not un­der­gone the train­ing.

Riess said that while some doc­tors have told her they don’t have the time to be em­pathic, the skill has proved to be a time­saver rather than a time sink. It can help doc­tors zero in on the real source of a pa­tient’s con­cern, short-cir­cuit­ing re­peated vis­its or those “door­knob mo­ments” doc­tors dread, when the pa­tient says “Oh, by the way . . . ” and raises the pri­mary con­cern as the doc­tor is headed out of the room.

Be­cause a lack of em­pa­thy and poor com­mu­ni­ca­tion drive many mal­prac­tice cases, a large mal­prac­tice in­surer, MMIC, is urg­ing doc­tors it in­sures to take the “Em­pa­thet­ics” course. An­other ben­e­fit: Em­pa­thy train­ing ap­pears to com­bat physi­cian burnout.

“Em­pa­thy train­ing is nat­u­rally sel­f­re­ward­ing,” said Lau­rie Drill-Mel­lum, a for­mer emer­gency room doc­tor who is chief med­i­cal of­fi­cer of the Min­neapo­lis-based in­surer. “It gives [doc­tors] the love back,” she said, re­fer­ring to the pos­i­tive feed­back em­pathic doc­tors re­ceive from their pa­tients.

‘Doc­tors are ex­plaina­holics’

Both Riess and Tul­sky say their in­ter­est in em­pa­thy was sparked by per­sonal ex­pe­ri­ence. In Riess’s case, it was the flood of pa­tients in her psy­chi­atric prac­tice a decade ago who spent their time in ther­apy dis­cussing dev­as­tat­ing in­ter­ac­tions with doc­tors. “Th­ese are not just in­nocu­ous ef­fects,” she said, “but of­ten ex­pe­ri­ences that were pro­found and deeply af­fected peo­ple’s lives.”

Tul­sky said that his fa­ther, an ob­ste­tri­cian-gy­ne­col­o­gist in a solo prac­tice, rou­tinely talked about his pa­tients at din­ner. “His sto­ries were about their lives, so I got this idea that medicine was about more than the ill­ness,” he re­called. In med­i­cal school, Tul­sky said, “I was very drawn to chal­leng­ing mo­ments in pa­tients’ lives and vol­un­teered to give bad news,” par­tic­u­larly when he be­lieved other doc­tors would botch it.

“I saw a lot that dis­turbed me,” Tul­sky said. One mem­o­rable in­ci­dent in­volved his chief res­i­dent loudly be­rat­ing a fright­ened, im­pov­er­ished and very sick old man, say­ing, “If you don’t have this op­er­a­tion, you’ll die. Don’t you un­der­stand?”

Tul­sky said that re­searchers have found that some doc­tors don’t re­spond with em­pa­thy be­cause they are clue­less when it comes to read­ing other peo­ple. Many oth­ers, he said, do rec­og­nize dis­tress but fear un­leash­ing a flood of emo­tion in the pa­tient, and some­times in them­selves.

“Doc­tors are ex­plaina­holics,” Tul­sky said. “Our an­swer to dis­tress is more in­for­ma­tion, that if a pa­tient just un­der­stood it bet­ter, they would come around.” In re­al­ity, bom­bard­ing a pa­tient with in­for­ma­tion does lit­tle to al­le­vi­ate the un­der­ly­ing worry.

The “Em­pa­thet­ics” pro­gram teaches doc­tors “how to show up, not what to say,” said Riess. “We do a lot of train­ing in emo­tional recog­ni­tion and self-mon­i­tor­ing.” That in­cludes learn­ing to iden­tify seven uni­ver­sal fa­cial ex­pres­sions — us­ing re­search pi­o­neered by psy­chol­o­gist Paul Ek­man — and to take stock of one’s own emo­tional re­sponses to pa­tients or sit­u­a­tions.

Some of the course is ex­plic­itly pre­scrip­tive: Make eye con­tact with the pa­tient, not the com­puter. Don’t stand over a hos­pi­tal­ized pa­tient, pull up a chair. Don’t con­duct a mono­logue in off-putting med­i­calese. Pay at­ten­tion to tone of voice, which can be more im­por­tant than what is said. When de­liv­er­ing bad news, sched­ule the pa­tient for the end of the day and do not al­low in­ter­rup­tions. Find out what the pa­tient is most con­cerned about and fig­ure out how best to ad­dress that.

One doc­tor’s ex­pe­ri­ence

Andy Lip­man has taken the Duke course twice: first as an on­col­ogy fel­low in 2004 and last year as a prac­tic­ing on­col­o­gist in Naples, Fla., when he felt in need of a “booster shot.” On­col­ogy, he said, “is a full-con­tact” spe­cialty with a high burnout rate.

Among the most im­por­tant lessons Lip­man said he learned dur­ing both ses­sions was to let go of “my own med­i­cal agenda, the de­sire to fix some­thing or make some­thing hap­pen in that visit.” He learned to pace him­self, mon­i­tor his re­ac­tions and talk less.

Ev­ery day, he said, he thinks about what he was told in 2004: “Never an­swer a feel­ing with a fact.” That means re­spond­ing to a pa­tient in a six-month re­mis­sion from can­cer who re­ports hav­ing a sore el­bow by say­ing, “Tell me more about your el­bow. This is prob­a­bly scary stuff ” and not “Your scans show no ev­i­dence of dis­ease.”

One tech­nique Lip­man rou­tinely em­ploys is tak­ing 15 sec­onds be­fore en­ter­ing an exam room to ask him­self, “What is needed here?”

On the day he was in­ter­viewed, Lip­man said, he used what he has learned with a pa­tient with end-stage can­cer. She was sched­uled for a brief ap­point­ment but be­gan weep­ing loudly as she told Lip­man how alone she felt.

“I en­gaged, I ex­pected the emo­tional re­sponse and I hung in there,” he said of the meet­ing, which lasted 45 min­utes. “It felt good to me,” Lip­man said, and he hoped it gave his pa­tient some com­fort.

ANNA PARINI FOR THE WASH­ING­TON POST

ANNA PARINI FOR THE WASH­ING­TON POST

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