Jessie Gruman: A True Champion for Patient Engagement

Jessie Gruman has been a outspoken and articulate advocate for people's engagement in health care for several decades. Actually, Jessie is more than an advocate. She is a visionary, a beacon, a once in a lifetime voice for millions of patients and caregivers who struggle with serious health care conditions.

Jessie is the founder and president of the Center for Advancing Health which, since 1992, has has focused people’s engagement in their health care from the patient perspective. Prior to founding CFAH, Jessie addressed health engagement, as well as the effects of behavior on health for the public sector (National Institutes of Health),  the voluntary health sector (American Cancer Society) and the private sector (AT&T).

In April, I had the opportunity to chat briefly with Jessie at the Society of Behavioral Medicine (SBM) Annual Meeting in Philadelphia. During this year's meeting, the SBM Board acknowledged and celebrated Jessie's lifetime contributions to health engagement by awarding her the inaugural Jessie Gruman Health Engagement Award.

In a moving brief ceremony, Jessie was acknowledged for her passionate and highly effective advocacy as well as for her wisdom, guidance  and contributions to the fields of both behavioral medicine and health engagement.

The Center for Advancing Health website is a great place to find research reviews, policy briefs, news, blogs and fabulous resources on patient and caregiver engagement, as well as other topical health care issues. If you visit, you will have a hard time leaving and you won't be able to avoid bookmarking at least 1 of the resources you will find there.

Be sure to sample Jessie's Prepared Patient Blog. Jessie makes frequent entries, often sharing stories about her own experiences coping with 5 life-threatening conditions. The Prepared Patient Blog also features guest bloggers, including leaders in the fields of health engagement, health policy, patient advocacy and health behavior change.

I also recommend Jessie's books, written from the patient perspective, chronically her journey as a patient and her insights as a 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 will share more about Jessie, CFAH and The Prepared Patient Blog in upcoming posts.

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?

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 .

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

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 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."

Barbara Ficarra on the Value of Empathy

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

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.

My First Post

With much trepidation, I write this first post to my own blog. I have to admit that, though I have been hesitant to create a blog, I have secretly wanted to have a public space to share my views.

For a long time, I have been been a passionate advocate for patient and family-centered health care and have spent the last 25 years trying to learn, and teach, skills that foster strong clinician-patient relationships. I have been very fortunate to have had many wonderful teachers, mentors, colleagues and patients who have helped me along the way. Though I believe I have become a pretty decent communicator, and some might say a very good teacher, I am humble enough to realize that I still have a lot to learn

In my efforts to enhance my own skills as a clinician and educator, I have hungrily sought out training, scoured the clinician-patient communication research literature, conducted some research myself and experimented with a variety of teaching techniques and formats. Relatively early on in my personal journey as a clinician-educator, I realized that the most basic skills were also the most important. If we can't communicate well, can't connect with patients on a personal level, can't understand the patient's concerns, how can we hope to help them heal, cope and recover?

The most basic skills are linked to what my colleagues and friends Steven Cole and Julian Bird have call the 3 functions, or tasks, of the clinician-patient encounter (which I have adapted a bit):

1. Eliciting the patient's story/problems/concerns/needs
2. Building a strong clinician-patient relationship
3. Developing a shared understanding of the problem/condition and collaborating on a plan for treatment and self-management

Each of these tasks can be accomplished though the use of specific skills....a long list of skills i might add, though some are more basic than others.

Empathy, in my humble opinion, is THE most important and powerful skill that clinicians can employ to enhance communication and forge strong healing relationships with patients and families. Empathy helps us to truly understand the experience of patients so we can ultimately help them. Through empathy, we strive to "stand in another's shoes" and see the world through their eyes. To be truly empathic this requires us to maintain an open heart and an open mind. This is not easy....and requires clinicians to be willing to spend the time it takes to understand, remain relentlessly curious and suspend all judgement. However, the payoff is immense....shared understanding, stronger relationships, and even better diagnosis and treatment outcomes.

So, I continue striving...and learning...and sharing...now here as well.

Michael