Empowered or Powerful? My Mini-Lesson from Jessie Gruman.

In a post on this blog over 3 years ago, Can Clinicians Empower Patients?, I noted that many who work in the area of patient engagement, including Jessie Gruman, the founder of the Center for Advancing Health, believe that clinicians can't empower patients, only patients can empower patients.

Though I understand the argument that patients already have substantial power and ultimately are already in control over whether to follow through with treatment and self-care, I believe that clinicians can take proactive steps to encourage patients to be more engaged in decision and care.

Why ask clinicians to "empower patients"? Though it is desirable for patients to take an active, and even the lead role in health care decisions and plans, many are reluctant to take charge or feel unprepared or unsure about how to play a more active role in self-care and self-management of chronic conditions. (See an article by Wendy Levinson and colleagues for data on patient preferences for involvement in decision making.)

Clinicians can help their patients understand the benefits of active involvement in decisions and self-care. Engaging patients in decisions and care is even more valuable when patients have serious life-threatening illnesses or chronic conditions that require ongoing self-management. Self-management can be quite challenging for any person with a single chronic condition and most people, particularly older adults, have multiple chronic conditions that they must manage simultaneously.

Self-management requires considerable expertise, effort, energy, expertise, coping, problem-solving and juggling. I have only 2 chronic conditions, yet I have spent a lot of time and energy on learning and actively managing my conditions.

Moreover, when clinicians actively include patients in the decision making and care, they are also "supporting autonomy", which has been recognized as an important determinant of motivation and subsequent behavior change. (Patrick & Williams, 2012) Supporting autonomy and building partnerships with patients are key elements of  Self-Determination Theory, Motivational Interviewing and models of Shared Decision Making.

In my teaching and writing, I have used the term, "empowering patients" as a way of helping clinicians consider inviting patients to participate in decisions and learn strategies that will increase their capacity to manage their conditions and stay well.

Last April, however, my views about using the term, empowering patients, changed forever. In April, I had the opportunity to chat briefly with Jessie Gruman just after she was awarded the inaugural Jessie Gruman Health Engagement Award at the Society of Behavioral Medicine (SBM) Annual Meeting in Philadelphia.  During the award ceremony, the SBM Board acknowledged and celebrated Jessie's  wisdom, guidance and lifetime contributions to the fields of both behavioral medicine and health engagement. See my previous EmpathyWorks post for more on Jessie's legacy.

Jessie's death in July, 2014 was a huge loss for all those who advocate for greater patient engagement in care, though her legacy lives on through the Center for AdvancingHealth.

Jessie has written passionately about the importance of understanding what it is like for patients to live with a chronic condition and what they need to be successful in coping with illness. In a blog post written at about the same time she received the SBM Health Engagement award, Jessie wrote:

"The idea that I should "manage" my chronic disease has always struck me as optimistic daffiness on the part of those who want me to do this...My image of having a serious chronic disease is of a cowboy riding a rodeo bull.....You call that management? No. But it gives you a pretty good idea of what it feels like to have a serious chronic disease. Most of us are just trying not to fall off the damn bull."

During our brief conversation at SBM, Jessie reminded me of the importance of viewing patients as the source of power for promoting health. She understood that, from the patient's perspective, the clinician can't empower a patient. Offering education, sharing decisions, and teaching self-management skills only go so far. Power comes not from the clinician, or a caregiver; it comes from within. Patients are already powerful, though they can become more prepared and skilled when they seek information, participate in decisions, prepare for visits, and learn and practice self-care skills.

Clinicians can empower health, not patients.  Patients are already powerful!

Jessie Gruman's Legacy

Last May, I wrote a post, Jessie Gruman, A True Champion for Patient Engagement, highlighting the extraordinary contributions that Jessie has made as a tireless advocate for this cause.

This week, after a long illness, Jessie died, generating both great sadness and wonderful tributes from those who had the good fortune to know her, work with her or benefit from her myriad contributions to the fields of patient engagement, health policy, behavioral medicine and public health.

I, too, am deeply saddened by this news. All those who knew her will all miss her wisdom, perspective, advocacy, and passion. 

I, personally, have been forever changed as a result of my interactions with Jessie. Jessie had a unique capacity to connect with others on a personal and emotional level, while also offering her input, feedback and perspective in a way that was precise and powerful.

One might say that Jessie's "way of being" epitomized effective engagement! 

As I noted in my post in May, the Jessie is the founder of the Center for Advancing Health, an organization which has developed, collected and disseminated fabulous resources and tools on patient engagement, health behavior, health policy and other related topics. See also Jessie's Prepared Patient Blog, where an In Memoriam statement has been posted from M. Chris Gibbons, MD, MPH, Chair of CFAH's Board of Trustees. You will also find many wonderful tributes from colleagues and respected leaders from the many fields that have been touched by Jessie's work.

Jessie's has also left us several several books, written from the patient perspective, in which she shares her insights as a patient, researcher, advocate, consultant and policy expert. Her books include:

Aftershock: When the Doctor Gives you - or Someone You Love - a Devastating Diagnosis(2007),
Cancer Survivorship: What I Wish I'd Known Earlier (2013)
Slow Leaks: Missed Opportunities to Encourage Our Engagement in Health Care (2013)A Year of Living Sickishly: A Patient Reflects (2013)

I am fortunate to have known and been impacted by Jessie. Her clear, articulate voice and pearls of wisdom will be with me forever. As a result, I am more committed than ever to furthering her vision of patient and health engagement.

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?

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

Does Empathy Produce Poor Moral Decisions? I Think Not!

In the May 20th issue of the New Yorker, Paul Bloom argues that empathy can lead to irrational decisions that are "parochial" and "narrow-minded". He concludes that, "a reasoned, even counter-empathetic analysis of moral obligation and likely consequences is a better guide to planning for the future than the gut wrench of empathy."

However, I agree with the point of view expressed by Michael Zakaras in his blog post, The Case Against the Case Against Empathy, which appeared on the Huff Post World on May 16th. Zakaras reminds us that empathy is more than just a gut reaction; empathy involves cognitive processes similar to imagining and perspective taking.  As Zakaras notes, empathy "requires careful thought, self-awareness, and real listening."

Zakaras continues, "But to truly empathize is not easy. In this sense Bloom is right: we're more likely to do so with those who look and think like we do. So rather than dismiss empathy, why not commit ourselves to practicing it more deliberately and more often, and expanding our spheres of empathy to those who are not just different but who challenge some of our very own moral foundations?"

I agree strongly with Zakaras. We need to practice and deepen our capacity for empathy. And, we must also use the understanding gained from empathy to choose and act wisely. As my colleague Vaughn Keller taught me, compassion is empathy in action.

I Love This Story: College Commencement Speaker Emphasizes Empathy

I love this story!  Empathy can fuel motivation. When combined with passion and persistence, wonderful things can happen! College Commencement Speaker Emphasizes Empathy - The Hoya

Obama Makes Empathic Appeal for Empathy in Israel

M
See the blog from CNN for an excellent article on President Obama's empathic appeal for empathy for Palestinians.
CNN empathy-president-gives-an-empathy-speech

Watch this Wonderful Video: "Empathy: The Human Connection to Patient Care"

Empathy is an essential element of quality health care. This video (Empathy: The Human Connection to Patient Care) simply, and beautifully, illustrates the value of seeking to understand others' experience. Listening, noticing, exploring and responding helps us to build healing connections with patients, family members and  caregivers. Empathy also helps those of us who are privileged to work in health care settings to know and support each other.

The video was published on YouTube on February 27, 2013 with the following information:

Patient care is more than just healing -- it's building a connection that encompasses mind, body and soul.

If you could stand in someone else's shoes . . . hear what they hear. See what they see. Feel what they feel. Would you treat them differently?

CEO Toby Cosgrove, MD, shared this video, titled "Empathy," with the Cleveland Clinic staff during his 2012 State of the Clinic address on Feb. 27, 2013.

 

The Empowered Patient - Shared Decision Making: Should I Have a Stem Cell Transplant?

In my The Empowered Patient column in the January 15th issue of  MPNforum, I provide some thoughts about the difficult decision that people with myelofibrosis face regarding having a hematopoietic stem cell transplant. See: The Empowered Patient - Stem Cell Transplant

Empathy Works for Business Too!

See the link below for an article on the value of empathy in the workplace that appeared in the online magazine Smart Business.

The importance of empathy in the workplace | Smart Business

The Great American Smokeout - An Empathic Opportunity

Though any time is a good time to quit smoking,  November 15, 2012 is the 37th annual Great American Smokeout, or GASO, a day when hundreds of thousands of smokers will try to stay cigarette free.

Tobacco use remains the single largest preventable cause of death and disease in the United States, with approximately 443,000 U.S. adults dying from smoking-related illnesses each year!

 

The good news is that stopping smoking will provide some immediate health benefits. For example, your risk for having a stroke, heart attack or other cardiovascular event are reduced dramatically as soon as you quit smoking. Moreover, the risks of developing a smoking-associated cancer or other tobacco use-related condition also diminish over time.

 

Even if you don't smoke, someone you love may be a smoker and might benefit from quitting smoking during the GASO, or as a New Year's resolution, or any time!

 

So, what does this have to do with empathy and why am I writing about the Great American Smokeout here? 

 

Well, I can't help myself. As a physician, I have seen the ravaging effects that smoking has had on my patients and those who love them. As an educator, I have spent a good part of my career trying to help caring clinicians feel more prepared and confident about assisting their patients who smoke. And as a researcher,  I know that even a small dose of clinician empathy and a little advice and support improves smoking cessation outcomes.

 

So, if you are a smoker, take this opportunity to think about quitting. If you love a smoker, tell them you care about them and want to support them in their efforts to stay healthy. If you are a clinician, ask your patients who smoke if you can help them address their smoking.

 

The good news is that many forms of effective smoking cessation treatment, including medication, counseling and support, are now readily available:

• Medications reduce symptoms of nicotine withdrawal and improve rates of quitting. Some nicotine replacement therapies (e.g., patch, gum, lozenge) are available over-the-counter while others (i.e., nicotine inhaler and spray; bupropion; varenicline) are available by prescription;
• Behavioral counseling, alone or when provided with medication, improves quit rates. Counseling is provided in individual and group formats and also via free state-supported telephone quit lines; and
• Online quit programs and mobile aps also show great promise.

For quitting resources and more on the Great American Smokeout, go to the American Cancer Society page at: http://www.cancer.org/healthy/stayawayfromtobacco/greatamericansmokeout/index

For a wonderful Youtube video by Dr. Mike Evans on how to quit smoking see: http://www.youtube.com/watch?v=I0zvG2vSjrA&feature=share&list=PL9FF73EC555CB6855

And for addition quitting resources see the National Cancer Institute site at: http://www.cancer.gov/cancertopics/tobacco/smoking

Health Coaching: A Road to Empowerment

See my latest The Empowered Patient column in the October 15th issue of MPNforum. MPNforum October 15, 2012 - The Empowered Patient.

In the column, I share my personal experience with health coaching as well as my reflections about the qualities to look for in a coach. In sum, "Great coaches empower us by helping us to build the self-monitoring, self-assessment and problem-solving skills that we need to achieve long term success."

More on the Empathy Gap in the Race for the White House

This article in Salon covering Michele Obama's speech at the Democratic National Convention provides another take on the emapthy gap between the major US political Parties:

Republicans’ empathy gap

Barbara Ficarra on the Value of Empathy

See Barbara Ficarra's post on her Huntington Post blog on the value of empathy.

The Joy of Throwing - New Post on MPNforum

See my latest column in the Summer Supplement to MPNforum. It's entitled the Joy of Throwing and chronicles my recent efforts to qualify for the National Senior Games in 2013. Go to: MPNforum

Too much talking | QReview

Follow this link Too much talking | QReview to a blog post about the importance of  eliciting understanding, concerns and beliefs and listening, rather than just telling.

The author, Dr. Susan Shaw, is Chair, Health Quality Council and Department Head, Adult Critical Care, for the Saskatoon Health Region in Canada.

The post originally appeared on Q Review, a blog published by theThe Health Quality Council (HQC). HQC is an independent agency that measures and reports on quality of care in Saskatchewan, promotes improvement, and engages its partners in building a better health system.

The Empowered Patient: Hearing is Empowering

My column in the June, 2012 issue of MPNforum, The Empowered Patient: Hearing is Empowering, (http://mpnforum.com/michael-june/ ) is about my long journey to improved hearing. Why did it take me so long to order hearing aids? I hope my story will lower the barriers to obtaining hearing aids among the millions who suffer from age related hearing loss.

Several Recent Articles Stress the Value of Empathy in Medical Care.

The importance of empathy in medical care is the focus of several articles recently published in the medical literature. See below for a brief comment on each and a link or reference to the article.

In an article that appeared in the March, 2012 issue of Perspectives on Psychological Science, Hacque and Waytz include empathy reduction in clinicians as one of the "causes of dehumanization" in medicine. They suggest that clinicians have difficulty being empathic when actively engaged in demanding cognitive processes, such as diagnostic reasoning and problem solving. Empathy reduction can be countered, however, by strategies which promote clinician awareness of the human and emotional aspects of patient care, such as learning about the whole patient (e.g., interests, roles, values, preferences) and recognizing the dehumanizing aspects of medical settings, technology and the procedural elements of care. The article citation is: Hacque, OS, Waytz A. Dehumanization in Medicine: Causes, Solutions, and Functions. Perspectives on Psychological Science March 2012 vol. 7 no. 2 176-186. doi: 10.1177/1745691611429706                                 

In the May, 2012 issue of the Journal of General Internal Medicine, Helen Reiss and colleagues reported that training in empathy improves physician use of empathic skills. Reiss reports that providing three 60-minute empathy training modules to residents and fellows (physicians undergoing specialty training post medical school) produced significantly greater changes in a patient-rated measure of empathy than residents undergoing standard training. Trained physicians also showed greater changes in their ability to decode facial expressions of emotion. An abstract of the article can be found at: http://www.ncbi.nlm.nih.gov/pubmed/22549298

And, the most inspiring article of the recent articles was written by Bernie Lown, MD's on his personal blog. See: http://bernardlown.wordpress.com/2012/04/29/social-responsibility-of-physicians/ . Bernie is a renowned cardiologist, educator and researcher who has been a proponent of patient-centered care for 60 + years! Dr. Lown is a leading voice in medical ethics and social responsibility and was a recipient of the Nobel Peace Prize for his leadership of the Physicians for Social Responsibility during this organization's campaign to educate the public about the medical consequences of a nuclear catastrophe. He has also been an outspoken critic of overtreatment and
unnecessary use of medical technology, especially in advancing cardiovascular health,  and has emphasized the value of addressing health behaviors and promoting patient engagement and empowerment in his publications. The current article is a transcript of his address to the April, 2012 Avoiding Avoidable Care Conference held in Cambridge, MA. (See http://avoidablecare.org/ for more on the conference). Here is my favorite section:

Sixty years of doctoring has taught me that taking a history, namely listening, is the quintessential part of doctoring. Proper listening is a skill, an art and a core element of medical professionalism. History taking is far more than providing key elements for a diagnosis. It is the basis for nurturing trust. I am persuaded that nothing of science taught to medical students is as difficult to master as is the fine art of listening.

Strategy #6 for Empowerment - Connect with Others

See the 1 year anniversary issue of MPNforum for my latest The Empowered Patient column: http://mpnforum.com/the-empowered-patient-connect-with-others/

MPNforum is an online magazine that features news, interviews and stories on topics of interest to people with Myeloproliferative Neoplasms. My contribution to the May, 2012 issue focuses on the benefits of connecting with others through online magazines, support pages and listserves. Experiencing and expressing empathy are among the most valuable aspects of contributing to and participating in these online resources and sites.