Bill Miller's Book, "Listening Well" is Worth a Post, and Read

It's been about a year and a half since I last posted here. I can't tell you why I have lapsed, though I have been preoccupied with work, my family and current events. All have contributed to the challenge of staying "posted" on developments in the world of empathy.

Plus, Ed Rutsch and his sites, Center for Building a Culture for Empathy, and Empathy and HealthCare are both awesome and comprehensive sources for posts and developments.

It was actually a post by Ed on Culture for Empathy that featured Bill Miller and his new book, Listening Well: The Art of Empathic Understanding that stimulated me to resume blogging and write this post.

Bill Miller is the primary force behind Motivational Interviewing, a highly effective motivational counseling method that features an empathic patient-centered style. I highly recommend Bill's little new book, which serves as a primer on the core empathic listening skills that are central elements of MI. There is so much wisdom in this little book, as well as great examples of empathic listening and valuable suggestions for skill practice.

Enjoy!

Empathy and Compassion Matters.

Marina Sampanes Peed, a friend and fellow person with a MPN, shared her reactions to the recent US election on her website. Marina's comments are compassionate and inspiring.

I shared her post on Facebook - see my embedded post below.

Why We Train & Coach Clinicians in Communication Skills and Motivational Interviewing

This video was developed by the Veteran Health Administration (VHA)'s National Center for Health Promotion and Disease Prevention (NCP) to help VHA clinicians and leaders recognize the value of participating in NCP's patient-centered communication training. NCP developed two training programs to meet clinicians' needs: 1) TEACH for Success (TEACH), which features basic communication skills in health education and health coaching: and 2) Motivational Interviewing (MI), a clinical method for identifying and building patients' motivation to actively engage in self-care and health behavior change. VHA's TEACH and MI programs were specifically designed for VHA primary care clinicians providing care in Patient Aligned Care Teams (PACT), VHA's version of the patient centered medical home.

The patient-centered communication skills featured in TEACH and MI training enhance clinicians' capacity to provide personalized, proactive, patient-driven care (PPPDC). These skills include relationship-building skills (e.g., open-ended questions to explore patient needs, values and concerns; reflections, empathy, respect); health education skills (e.g., sharing information, teach-back), shared decision making skills, and health behavior counseling skills (e.g., evoking change talk, goal setting, problem-solving).

In addition to participating in face-face, experiential TEACH and MI courses, clinicians are offered opportunities to participate in follow-up clinician coaching to help them apply TEACH and MI skills in clinical encounters with Veterans. To disseminate TEACH and MI training and follow-up clinician coaching, NCP trains and supports over 300 active TEACH and MI Facilitators, who are also extensively trained to provide learner-centered clinician coaching. TEACH and MI facilitators/coaches also serve as VHA facility-based Veterans Health Education Coordinators (VHECs), Health Behavior Coordinators (HBCs) and Health Promotion Disease Prevention Program Managers (HPDP PMs), and work collaboratively with PACT teams to integrate TEACH and MI skills with other tools, resources and programs that support PPPDC. These tools and resources include: an online health risk assessment tool, goal-setting and decision-making tools, an online Veterans Health Library; and access to VHA and community-based programs in tobacco cessation, weight management, self-management and other health behavior change areas.Training and clinician coaching in TEACH and MI is a key component of PACT's "roadmap" for operationalizing PPPDC in primary care.

In the "Why Train" video, PACT leaders, PACT clinicians and Veterans share reflections about the value and impact of TEACH and MI training on Veteran experience, the quality of care and health outcomes. Clinicians also share how training and coaching has enhanced their skills, their  morale and even their overall satisfaction with their work!

EmpathyWorks Reaches 25,000 Views!

Since my First Post on EmpathyWorks on July 11, 2009, the blog has now reached 25,000 views!

My 79 posts on EmpathyWorks have covered a range of topics that reflect my interest in the role of relationship-building in health care and the impacts of empathy, compassion and patient engagement on patient experience and health outcomes.

Some posts have shared new research findings on the value of clinician empathy or have featured the wisdom of  Carl Rogers, Jodi Halpern, Brené Brown, Bernie Lown, Jessie Gruman, and many others who have made empathy, compassion or patient engagement a focus of their professional careers. 

Other EmpathyWorks posts have featured the experience of people, like myself, who are coping with the challenges of living with a chronic condition. When I first started blogging, several posts were linked to a column I wrote for MPNforum, an online magazine for people, or loved ones of people, with myeloproliferative neoplasms (MPNs). 

My heart goes out to my fellow "MPNers", who regularly demonstrate empathy and compassion for others in their posts on support sites on Facebook, such as Polycythemia Supportive Friends, and MPN Foum.

Since I have started blogging, I have found many inspiring and helpful blogs, websites and social media sites that address the topics of empathy, compassion and patient engagement. Links to these sites are available in the right column of the EmpathyWorks blog page. I particularly recommend Edwin Rutsch's Culture of Empathy website, a treasure trove of links, resources and commentary on empathy and its application to a wide range of topics, from health care to education to international relations.

You will also find links to organizations that focus on training clinicians in patient-centered communication skills, such as the American Academy on Communication in Healthcare (AACH) and the Institute for Healthcare Communication (IHC). IHC and AACH have played critical roles in my personal and professional development as an educator and advocate for patient-centered communication training.

Other organizations, such as Center for Advancing Health and the Institute for Patient and Family-Centered Care offer approaches and resources for advancing patient and family engagement at all levels of health care, from patient involvement in self-care and self-management to patient and family engagement in health care policy and health system redesign.

I hope you will continue to visit EmpathyWorks and that you will also share your reactions, insights and resources.

Enjoy!

Michael

When Empathy Doesn't Work:The Paris Attacks

The recent bombings in Paris are maddening, sickening, disturbing and deeply troubling. The attacks targeted innocent unsuspecting people attending a concert, a soccer game, dining or simply enjoying a warm fall Paris evening at a local cafe or bistro.

And or course, it is natural to respond to these brutal senseless killings with fury, hate and a desire to inflict revenge upon those responsible. 

ISIS has taken responsibility for the carnage, so our anger and calls for retribution are directed at them...whoever and wherever they are.

I understand this....I too, feel pain and anger as well as disgust and worry, though of course, my pain and anger is only a fraction of what is experienced by those who have been directly impacted by the losses, or by the threats of further loss. 

My visit to Paris last month, my first visit to France, to the very hospital that is across the street from one of the cafes that was hit by the terrorists, has heightened these feelings,

I feel a connection to Paris that seems to grow stronger with each passing hour and each story that I hear or read about the tragedy. 

Yesterday, I sent an email to the physician and his assistant who generously consulted with me during my visit to Paris, letting them know my thoughts were with them.

I imagined what they might be feeling, and I was moved to reach out to them to let them know that I support them. 

This, I believe, is an attempt to express empathy. Hopefully, my attempt to express empathy was received and was experienced as helpful, as emphatic. If so, it's an example of how empathy can "work".

However, I am having difficulty understanding how humans, the terrorists who both planned and executed these acts of violence, could act so ruthlessly, with such blatant disregard for human life.

I can't even imagine this...how a human brain, a human heart, a human soul could allow someone, anyone, to act in this way. 

In this instance, empathy fails me. It's missing. It doesn't work. Perhaps, I am missing something?

For Empathy!

As a follow-up to a previous blog post, Against Empathy? , I would like to share a column by Denise Cummins, PhD, a cognitive scientist and author. Dr. Cummins is an elected Fellow of the Association for Psychological Science and her research specialty is decision-making and thinking.

In her column, which appeared in Psychology Today in 2013, Cummins argues that Bloom is wrong when he concludes "empathy is prone to biases that render moral judgment potentially harmful.” 

 As Cummins points out in her column, Bloom errs when he posits that empathy for the suffering of individual victims that we can identify with because they are "like us" produces biased and faulty moral reasoning that can lead to mass retribution and violence.

Cummins argues that Bloom places too much value on reasoning, which is certainly not immune from faulty  moral judgements. Cummins suggests that it is the pairing of empathy with "good" reasoning that leads to humanitarian actions.

"The answer is to expand our empathy to include those who are not like us. That is what drove so many white Americans to argue for the abolition of slavery, the end of Jim Crow laws, and the institution of civil rights.......It is precisely our ability to imagine the plight of the nameless and faceless that elicits our empathy and our desire to act."

Dr. Cummins ends her column with the following call for embracing both our capacity for empathy and our ability to reason when engaging in moral reasoning.

"Instead, it is the marriage of empathy to principle that has always been and will continue to be our salvation. It is our ability to generalize and to direct our empathy through the use of reason that is our saving grace. Without that, it is easy to create a holocaust, a crusade, or a jihad.

More on Dr. Cummins' illuminating views on the value of empathy can be found  on the Culture of Empathy website.

Dr. Cummins wrote Good Thinking: Seven Powerful Ideas that Influence the Way We Think (Cambridge University Press, 2012).

Hawking Identifies Empathy as Key to Civilization's Survival

See this AOL feature on Stephen Hawking's views about the importance of empathy as an antidote to aggression and a key to civilization's survival. Clearly, Hawking's brilliance extends beyond "hard science". Thanks to Vaughn Keller for sharing this piece on Facebook.

Keeping up with Empathy in Health Care

Want to keep up with the latest article or blog post that addresses Empathy in Health Care? Click here: http://www.scoop.it/t/empathy-and-healthcare

Edwin Rutsch is, as far as I can tell, the world's greatest purveyor, or "scooper" of empathy-related news. 

Edwin is a master at utilizing online resources to collect and link up with the those who conduct research, develop curricula or write about empathy, compassion and related topics. He uses "Scoop it!", a service for "scooping", organizing and sharing news and resources. See his page on Scoop it! - http://www.scoop.it/u/edwin-rutsch'

You can also get a eyeful by visiting his Culture of Empathy webpage: at: http://cultureofempathy.com/Projects/Conference/
or by visiting Edwin' facebook page: https://www.facebook.com/edwin.rutsch?fref=ts

Warning....if you visit on of Edwin's pages, plan to spend a big chunk of time exploring, reading and learning!

Happy Holidays!

Michael

Against Empathy?

Paul Bloom, Professor of Psychology and Cognitive Science at Yale University, recently wrote a thought provoking (and emotion provoking) post on Boston Review, entitled, Against Empathy?. He writes about the downside of relying on empathy, particularly "emotional empathy", as a guide to action. Emotional empathy, he argues, is biased, clouds our thinking, and promotes moral errors, which may have dire consequences. He writes:

"Empathy is biased; we are more prone to feel empathy for attractive people and for those who look like us or share our ethnic or national background. And empathy is narrow; it connects us to particular individuals, real or imagined, but is insensitive to numerical differences and statistical data." 

"Our policies are improved when we appreciate that a hundred deaths are worse than one, even if we know the name of the one, and when we acknowledge that the life of someone in a faraway country is worth as much as the life a neighbor, even if our emotions pull us in a different direction."

Too much emotional empathy, he notes, can also produce "empathetic exhaustion", particularly among those who try to apply empathy as a clinician or aid worker. Some may also experience "pathological altruism" and seek to heal or soothe others at their own expense.

Bloom concedes that it is appropriate for clinicians to respond to a patient's pain or angst, though he argues that too much clinician empathy will generate burnout and promote ineffective and even unwanted clinician behavior. 

Bloom contrasts emotional empathy with compassion, which he describes as "concern and love ....., and the desire and motivation to help" which need not involve mirroring or experiencing the anguish of others. Compassion, he argues, is a more effective, and more sustainable response.

Personally, as I read his blog, I found myself arguing against Bloom and for empathy. When I think about the application of empathy in clinical settings, I have trouble seeing the cognitive and emotional components of empathy as separate processes. 

Though there may be distinct neural pathways for these 2 aspects of empathy, clinical empathy is a therapeutic interactive process that integrates eliciting, exploring, listening, observing, perceiving, imagining AND responding to others' expressed emotions, values and needs. 

As I noted in a previous EmpathyWorks blog post, Brene Brown has described empathy as having 4 critical elements:

1. perspective taking
2. staying out of judgement
3. recognizing emotion; and
4. communicating what you notice

In another EmpathyWorks post, I cite others' conceptualization of clinical empathy as a relational process that includes both cognitive and emotional elements. See: Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA: 1997;277(8):678-682.

Jodi Halpern, another clinical educator, emphasizes the relational process of "emotional attunement"  that comes from perspective taking (the cognitive aspect) together with exploring and responding to the "meaning" of the feeling. 

For those interested in learning more about clinical empathy, I also recommend the book, Empathy Reconsidered, New Directions in Psychotherapy (Eds: Arthur Bohart & Leslie Greenberg. American Psychological Association, Washington, 1997) which provides further perspectives on the role of empathy in clinical encounters, particularly in psychotherapy. 

In my own experience, empathy happens when I:

• allow myself to be fully present,

• listen generously,

• seek to fully understand the meaning of the patient's feelings,

• respond with genuine reflections about what I am hearing and experiencing, and

• allow the patient to correct, refine or elaborate upon my attempts to understand.  

This process may continue for a bit, as the patient elaborates about the meaning of their situation or feeling. More often than not, the patient eventually responds by saying, "Yes, that's it, exactly".  Afterwards, some will indicate that they felt better being heard and responded to.

In previous posts on EmpathyWorks, I have shared the evidence for clinicians' use of empathy and a wide variety of positive outcomes, including enhanced patient satisfaction, increased patient follow through, positive health behavior change and even improved illness outcomes. For just 1 example, see: Hojat, M., D. Z. Louis, et al. (2011). "Physicians' empathy and clinical outcomes for diabetic patients." Acad Med 86(3): 359-64.

Whether or not you agree with Bloom's arguments, the post is worth reading, as are the many insightful and often brilliant responses written by a broad spectrum of commentators, including: Marco Iacoboni,  neuroscientist; Peter Singer, ethicist; Barbara Fried, law professor and public policy expert; Maryanne LaFrance, psychologist and women's studies expert; Nomy Arpaly, philosophy professor; Christine Montross, physician/poet; and Leslie Jamison and Simon Baron-Cohen, writers/commentators with  strong interests in empathy.

Learning and Practicing Spiritual Empathy

Follow the link below to a moving post is by an Israeli rabbinical student intern who is completing an internship as a hospital chaplain. He shares his struggles to comprehend, connect with and ease the suffering of patients, a challenge that is even more difficult in the setting of the current Israeli-Palestinian conflict.

http://www.huffingtonpost.com/avram-mlotek/spiritual-empathy_b_5619383.html

More Strategies for Expressing and Teaching Empathy

In a previous EmpathyWorks blog post, I addressed the question, "Can you actually teach empathy?".  As i noted in the column, the answer is a resounding, "Yes!" , at least for medical students and health care professionals.

Research has demonstrated that courses like, "The Healer's Art", (see: The Healer's Art webpage),  developed by Rachel Remen at the University of California San Francisco, profiled in EmpathyWorks, and also in a New York Time feature article, are effective in promoting humanistic attitudes and practices among medical students.  

Rachel Remen

And  there is strong evidence that skill training and practice can promote patient-centered skills, including empathy, among practicing clinicians. (See:.http://www.ncbi.nlm.nih.gov/pubmed/23235595)

Motivational Interviewing skills were featured in my previous post on strategies for teaching empathy. 

Another strategy for helping students and clinicians learn how to respond with empathy has been disseminated by Robert C. Smith, MD and colleagues at Michigan State University. The approach, NURS,  is a mnemonic that stands for Name, Understand, Respect and Support. This approach is described in detail in Dr. Smith's textbook, Patient-Centered Interviewing. You can also read an recent article on this approach in the medical journal, Patient Education and Counseling: 

See below for a modified version of the NURS approach, NURSE. The E is for Empower

• Name the emotion - reflect what you heard or noticed non-verbally. 

          Examples include:

• "You feel frustrated..."
• "You're angry....".
• "You seem pretty sad..." 

•  Understand  - express understanding, or normalize, without trying to fix

           Examples include:

• "It's understandable that you are frustrated, considering all you have been through."
• "I  can understand you why you would be angry about...."
• "Many of my patients have experienced deep sadness for a long time after losing a loved one."
• "I think I can understand how distressing this has been for you."

• Respect - affirm and express respect for the patient's efforts to cope 

          Examples include:

• "I'm impressed with your efforts to manage your diabetes, despite the challenges"
• "It's remarkable that you were able to.....".
• "I appreciate how hard this has been for you..." 
• "Thanks for letting me know"

• Support - let the patient know that you are willing to help 

          Examples include:

• "I want to help in any way I can."
• "I am here for you."
• "I am willing to help you get through this".
• "I will work with you to figure out a way to help." (Some educators call this "Partnership")
• "Let's work together to address your concerns" (Some educators call this "Partnership")
• "What can i do to help?"  (Asking this question reflects your willingness to explore how you might be helpful)

• Empower - identify and support strengths and capabilities

          Examples include:

• "What are you currently doing that is helping?"
• "What have you done in the past that has been helpful?"
• "What success have you had?" 
• When strategies are mentioned: "It's good that you have been able to xx"
• "How can you build on previous success?"
• "What else can you do?"
• "Who can help you?"
• "What can i do to support you?
• When resources are identified: "You have been able to identify some helpful resources and sources of support."

As always, i am interested in hearing about your feedback and in learning about your favorite strategies for teaching empathy.

Strategies for Expressing Empathy

"So you think you can actually teach empathy to doctors?"

This is a question I have been asked scores of times during my 30+ years as a a medical educator.

And my answer is:

"Yes, it is possible to teach empathy to clinicians, even doctors."

Though many students, and practicing clinicians, are naturally empathic, and express empathy consistently during encounters with patients, others need help identifying how to respond to patients' expressed emotions, values and concerns, both verbally and non-verbally. And many others, though fully capable of responding effectively, have learned to suppress their natural empathic responses, both consciously and unconsciously, during training. Researchers have shown that the rigors of training and its intense focus on acquiring biomedical knowledge and skills can erode humanistic attitudes and practices. (See Rabin MW, Remen RN, Parmaelee DX and Inui TS. Professional Formation: Extending Medicine's Lineage of Service into the Next Century. Academic Medicine: 2010; 85:310 - 317. http://www.ncbi.nlm.nih.gov/pubmed/20107361)

For those who need help in learning how to express empathy, research has shown that skill training and practice (with feedback) can help, even among "seasoned" practicing clinicians. (See Dwamena, FM, Holmes-Rovner, et al. (2012). "Interventions for providers to promote a patient-centred approach in clinical consultations." Cochrane Database Syst Rev 12: CD003267. http://www.ncbi.nlm.nih.gov/pubmed/23235595)

Though a single communications skills workshop is not a sufficient "dose" of training for most learners, providing opportunities for repeated learning and practice can help many clinicians to adopt and regularly employ empathic skills in their interactions with patients, especially if personalized feedback is offered in the context of a supportive learning environment.

So,how do you teach empathy?

In my teaching, I have found the following strategies to be particularly valuable. They can help clinicians "find the words" to use when opportunities arise in encounters with patients.

Open-ended questions help the clinician explore and elicit the patients feelings, concerns, values or beliefs. Here are some examples:

• How are you holding up?
• What has this been like for you?
• Tell me more about how you are feeling.
• What else have you been experiencing?
• How has this impacted your…..(relationships, condition, work, school, life)
• Tell me more about what this means to you.

When a patient expresses an emotion, value or belief, (either spontaneously, or in response to a query),  the clinician may respond with a "reflection" that reiterates what the patient has said, either in the patient's own words, or with an approximation. 

Reflections (with "stems" to help form the reflections)

• I can see you are ..…(upset, sad, frustrated, worried, anxious, distressed, angry, etc.)
• You seem ..…(upset, sad, frustrated, worried, anxious, distressed, angry, etc.
• I hear you saying that you feel.(upset, sad, frustrated, worried, anxious, angry, etc.)
• Sounds like it’s been ….(.upsetting, depressing, frustrating, worrisome, nerve- wracking,  distressing, maddening, awful, etc.)

Reflections (without stems)

• You are…(upset, sad, frustrated, worried, anxious, distressed, angry, etc.)
• It’s been…(upsetting, depressing, frustrating, worrisome, maddening, awful, etc.)
• This is important to you…

After a reflection, WAIT to allow the person to correct, confirm, elaborate, continue. (This is challenging for many clinicians who want to follow a reflection with a question)

Affirmations (with genuineness) are a type of reflection that also recognizes the patient's efforts or achievements. Patients generally appreciate this. 

• You put a lot of effort into this….
• You have worked so hard on this….· 

“Non-verbal” responses·

• Eye contact
• Sitting down, leaning in, moving closer,
• Nodding, verbal facilitation (“oh”, “hmm”, “uhh”, “gosh”)
• Matching (reflecting non-verbal gestures, without mimicking)
• Touch, when appropriate

These strategies are featured in Motivational Interviewing (MI), an evidence-based clinical method that promotes partnership, acceptance, compassion and an evoking (as opposed to directing style). See my favorite links or go directly to: http://www.motivationalinterview.org/ for more information, tools and resources on using MI.

What are your favorite strategies for helping others to express empathy?

More on the Brene Brown Empathy Video

My last post was about a brief video on expressing empathy that featured Brene Brown, PhD. You can find the video at:https://www.youtube.com/watch?v=1Evwgu369Jw

Many liked the video, though some colleagues who are experts in clinician-patient communication felt that Dr. Brown was off target in her conceptualization of sympathy. Dr. Dennis Novack, Professor of Medicine and Associate Dean of Medical Education at Drexel University College of Medicine, wrote:

"I like what she says about empathy, but disagree completely with her definition of sympathy, which really undermines the value of the video for me. Sympathy is derived from the Greek sympatheia which means "feeling with." In one sense it might be empathy on steroids. We send a sympathy card to someone because we feel the loss as well. We feel sorrow for and with another, though maybe not as deeply, and in some ways identify with the other. 

The classic studies of Nightengale et al show that physicians who adopt a more sympathetic stance toward patients’ emotional situations do too many tests and perform CPR longer – they lose their objectivity (Nightengale, S.D., et al. JGIM:1991; 6:420-23.)
Empathy is conceived as a more objective process. All the actions you listed are components of the empathic process, that allow the physician to feel for patients and communicate that understanding, while still being able to make good decisions about their medical care free of the effects of the emotions elicited.By the way, a recent study Suely Grosseman and I and others recently did suggests that another component of the empathic process is checking to ensure that the patient got the empathic communication. We found that residents’ self-assessment of their empathic communication to standardized patients in 5 OSCE stations had zero correlation with SP assessments of their empathic communication."

Richard Frankel, Professor of Medicine, Indiana University School of Medicine noted the value of focusing on the interactional dynamics of empathy and referred interested folks to Jodi Halpern's use of the concept of "attunement" in her 2003 Journal of General Internal Medicine article (Halpern J. What is clinical empathy? Journal of general internal medicine. Aug 2003;18(8):670-674.) He added:

"Our group in Rochester also published a paper in 1997 in which we described the interactional dynamics of empathy, (Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA: the journal of the American Medical Association.1997;277(8):678-682.).
The model was later validated by Hilde Eide (Eide H, Frankel R, Haaversen AC, Vaupel KA, Graugaard PK, Finset A. Listening for feelings: identifying and coding empathic and potential empathic opportunities in medical dialogues. Patient education and counseling. Sep 2004;54(3):291-297)

Rich also endorsed the empathy video created by the Cleveland Clinic, featured in my March 23 2013 post:

http://empathyworks.blogspot.com/2013/03/watch-this-wonderful-video-empathy.html

I agree with both Dennis and Rich about the importance of both the cognitive and interactional aspects of emapthy and I, too, have found Jodi Halpern's conceptualization of clinical empathy quite helpful. Her thoughtful and erudite book, From Detached Concern to Empathy: Humanizing Medical Practice (Oxford University Press, New York, 2001) is highly recommended for all those interested in promoting and studying clinical empathy.

For those interested in learning more about clinical empathy, I also recommend the book, Empathy Reconsidered, New Directions in Psychotherapy (Eds: Arthur Bohart & Leslie Greenberg. American Psychological Association, Washington, 1997) which provides further perspectives on the role of empathy in clinical encounters, particularly in psychotherapy. I especially recommend the introductory chapter by the editors, in which they describe 3 different types of therapeutic empathy:

1. "empathic rapport" - the clinician expresses understanding and acceptance of the client's feelings (this is closest to what Brene Brown was describing in the video);
2. "experience - near understanding of the client's world" - a deeper understanding of the client's experience or "world". This usually results from exploration of the client's perceptions and reactions, including how the client's past experiences may have shaped their current emotional response; and
3. "communicative attunement" - characterized by moment-moment attunement based on reflections or other attempts to understand what the client is trying to communicate.The therapist is actively trying to, not only understand what the client is saying, but also trying to "help the client make sense of their ever-emerging experience."

In a future post, I will share some simple strategies and approaches clinicians might use to enhance their capacity to develop empathic rapport.

A Short Video on Empathy Featuring Brené Brown

Sue Raffa, PhD, a colleague at Alpert Medical School, Brown University,  recently shared a wonderful animated video on empathy with me. The brief video was created by the Royal Society of the Arts (RSA) and features Brene Brown, PhD, LMSW, a research professor at the University of Houston Graduate Colleage of Social Work.

You can find the video at: https://www.youtube.com/watch?v=1Evwgu369Jw

The video offers a wonderful, quick,and amusing lesson on empathy and how if differs from sympathy. 

I particularly like Dr. Brown's  reference to the 4 key qualities of empathy:

1. perspective taking
2. staying out of judgement
3. recognizing emotion; and
4. communicating what you notice

I also like her idea that empathy "fuels connection", contrasted with sympathy, which "drives disconnection". Empathy, she states, can be operationalized as "feeling with" other and requires a "vulnerable choice". She adds, "To connect with you, I have to connect with something in myself that knows that feeling", which can be painful. Empathy, she notes, is not about trying to make things better, it's about being present and expressing understanding to a person who is struggling>

"Rarely can a response make something better....what makes something better is connection."

Awesome! 

Rachel Remen, The Healer's Art, and Healing Healers

Two recent columns in the New York Times by David Bornstein highlight the work of Rachel Remen, MD, a physician, healer, educator and writer whom I deeply admire and respect.

David Bornstein is a journalist who has chronicled the impact of social entrepreneurs (I love his book, How to Change the World).  David writes a blog for NYT called "Fixes". In his September 18, 2013 column, Medicine's Search for Meaning, he writes about burnout among physicians that results from the challenges of practicing medicine in the current environment, one that focuses on productivity and treatment outcomes, rather than on meeting the emotional and functional needs of patients. To paraphrase:

"....healing involves far more than knowledge and skill. The process by which a doctor helps a patient accept, recover from, adapt to, or endure a serious illness is full of nuance and mystery......Great doctors don’t just diagnose diseases, prescribe medications and treat patients; they bring the full spectrum of their human capabilities to the compassionate care of others....."

Bornstein also writes:

"As administrative and documentation burdens have exploded in the past three decades, doctors find themselves under pressures to work as quickly as possible. Many have found that what is sacrificed is the very thing that gives meaning to the whole undertaking: the patient-doctor relationship."

Bornstein quotes medical educators who note that these burdens produce high levels of distress, depression, loss of satisfaction, fatigue, and burnout, producing "medical errors, substance abuse, and doctors quitting" and asks,  "How could we help medicine overcome its own illness?"

Bornstein answers his own question by describing work of Rachel Remen, who, as I noted in my introduction, has been a source of inspiration and healing for me for many years. Rachel is a wonderful clinician, educator and writer who has dedicated her career to meeting the broad biopsychosocial and spiritual needs of her patients. Through her writings and trainings, she has also helped practicing clinicians, as well as clinicians in training, to recapture the core values...the "meaning" ... that often led them to choose medicine or nursing as a career.

The Healer’s Art course was developed by Rachel over 2 decades ago at the University of California, San Francisco medical school. As David writes, The Healer's Art:

"is predicated on the idea that medicine is an ancient lineage that draws its strength from its core values: compassion, service, reverence for life and harmlessness. When students  derive meaning and strength .....[from these values, they] can 'immunize' themselves against the assaults of the medical curriculum and even the health care system itself."

The Healer's Art has now spread to dozen's of medical and nursing schools in the US and to a growing list of professional schools around the globe.

A similar program for practicing clinicians,  Finding Meaning in Medicine (FMM), provides a supportive forum for exploring core values and sharing positive experiences related to working with patients. I was a member of a FMM group for a few years and found it highly enlightening, rewarding and satisfying. Though I left the group when I changed jobs, I am still longing for participating in a group years later.

There were so many poignant and heartfelt responses by clinicians to the Sept 18th column that David wrote a follow-up column, Who Will Heal the Doctors?. This produced even more responses, reflecting the need for more programs like The Healer's Art and FMM.

As I noted in my comment, my heart goes out to all my colleagues who continue to make daily sacrifices to care for their patients, providing every ounce of compassion they can in the few minutes they have with patients.

I have been planning to attend the Healer's Art training program at Commonweal for several years now so I might serve as a facilitator of the program at Brown University's medical school. Just yesterday, I made a commitment to apply to attend the 2014 course, with Rachel, at The Institute for the Study of Health & Illness (ISHI). I am already excited about attending and experiencing some healing myself.

See more on Rachel, The Healer's Art, FMM and ISHI at:

www.rachelremen.com 

www.ishiprograms.org

www.theheartofmedicine.org

Danielle Ofri's Reflections on Fear Triggered by Illness

Danielle Ofri's recent column on Slate, the online magazine, addresses the topic of fear that results from uncertainty and the risks associated with medical illnesses and procedures, even minor ones. Danielle shares the distress and acute fear she experienced as a mom when her young son required minor ear surgery. Even though, as a physician, she understood that the risk of the procedure was low, she nonetheless imagined the worst and became gripped with raw fear that  didn't abate till her son was fully recovered from his surgery.

Dr. Ofri's distress during that minor ordeal increased her awareness of the needs of her patients and their family for her  support, empathy and compassion during episodes of illness, especially when tough medical decisions need to be made. As Danielle points out, the process of shared decision making requires more than information sharing and collaboration. It also requires eliciting and responding to the emotions that are aroused by uncertainnty and risk. As she she beautifully writes, 

"When I sit with a patient now, deciding on a treatment, I still lay out the risks and benefits as systematically as I can. But then I take a moment to acknowledge the raw fear that cannot be assuaged by even the most convincing clinical data. This conversation can’t eliminate the necessary leap of faith. But at least there is some recognition of the stomach-plummeting sensation that occurs" when a decision has to be made.

Thank, Danielle for your enlightening column! I also highly recommend Dr. Ofri's well written memoirs, including her latest book, What Doctors Feel: How Emotions Affect the Practice of Medicine .

EmpathyWorks Has Had 10,000 Views!

On July 11, 2009, I wrote My First Post on EmpathyWorks (click on text to view).

In the 57 posts that have followed, I have shared links and comments about articles, books and research studies on empathy and related aspects of relationship building. Many of my EmpathyWorks posts were links to a column I wrote for MPNforum, an online magazine for people who, like myself, are self-managing, or helping a loved one manage a myeloproliferative neoplasm.

I have enjoyed writing and sharing these tidbits and hope they have provided readers with opportunities to become more aware of the ways in which empathy can be a tool for enhancing understanding and promoting compassion and caring, particularly in health care settings.

I look forward to continuing to continuing to write and reflect on the impact and value of empathy here.

It would be great to have more comments and dialogue with readers, so please feel free to share your thoughts or ideas, either in the comment section on the blog, or via e-mail at goldsteinm52@gmail.com.

Enjoy!

Michael

Don Berwick Urges UK's NHS to Emphasize Empathy

In a report commissioned by the British National Health Service (NHS) to address  concerns about recent slippage in NHS's patient safety and quality ratings, Dr. Donald Berwick  encouraged NHS leaders to focus on empathy, compassion and support for both patients and health care teams.

Helen Riess provides her perspective on the report in her blog post for The Huffington Post- http://m.huffpost.com/us/entry/3757483

Bernie Lown is My Hero

Bernie Lown is my hero and a exemplary role model for physician healers, scientists, and social activists.

As co-founder of International Physicians for the Prevention of Nuclear War, Bernie Lown accepted the Nobel Peace Prize for this organization in 1985. Before that, we was one of the founders of Physicians for Social Responsibility. An accomplished academic cardiologist, he actually has an arrhythmia named after him, the Lown-Ganong-Levine Syndrome. (Please don't ask me to describe it). Bernie is a medical inventor as well. He developed the first direct current defibrillator and still holds an academic position as Professor of Cardiology Emeritus at the Harvard School of Public Health.

For decades, Bernie has been an outspoken critic of the growing medical industrial complex and the business of medicine. He writes eloquently about how these developments contribute to infatuation with and overuse of technology, overtreatment, waste of health care resources, escalating health care expenditures and, most importantly, unnecessary harms to patients.

Now in his 90s, Bernie is still voicing his concerns, as well as encouraging medical practitioners to return to the core values and behaviors that characterized medicine before it became a business. These principles include:

• listen to your patients and to their "stories";
• put patients and their needs, values and preferences at the center of your attention;
• build and nurture healing relationships with patients, using empathy and compassion;  
• evaluate new and emerging technologies carefully and choose wisely;
• engage patients and caregivers in informed and shared decision-making; and
• focus on enabling and empowering patients to help them stay healthy and engage in self-care and self-management.

These principles were the bedrock of good medical care when Bernie, and my dad, completed medical school in the 1940's. I dare say they were core elements of medical training in the days of Flexner and Francis Peabody, when my grandfather trained in the early 20th century. As Francis Peabody remarked in 1927, "One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is the caring for the patient."

Recently, a wonderful interview with Bernie was published on a blog created by Melanie Lown, a communication specialist and Bernie's granddaughter. See: The Lown Conversation.

Melanie is the daughter of Beth Lown, Bernie's daughter, a friend and colleague and a wonderful physician and educator. (See the photo on The Lown Conversation blog of Bernie and 6 year old daughter Beth, taken when Bernie arrived in Boston after accepting the Nobel Peace Prize.)

See also the following sources for more vintage Bernie:

• Lown lecture on Avoidable Harms - 2012
• Bernard Lown's Blog

The Empathic Appreciative Closer

Tonight, after pitching a perfect 8th inning for the American League in Major League Baseball's All Star Game, Mariano Rivera told TV reporter Ken Rosenthal that he appreciated the standing ovation he received from fans, fellow players and even opposing players and coaches from the National League. Choked  up with emotion, Mariano, who is retiring at the end of the season at age 43 after an amazing record setting career that all consider to be the best ever as a closer, told Rosenthal that the experience walking off the mound was "priceless" and "up there" with his experience closing World Series victories.

This show of emotion and sincere appreciation for the adulation he received from fans and peers  is not an unusual response for this great athlete with a huge heart. See the article that appeared in The New York Times today to learn how Mariano has chosen to spend his last day in each of the cities he is visiting this year: http://www.nytimes.com/2013/07/16/sports/baseball/yankees-rivera-spends-his-goodbye-tour-saying-hello.html