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

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!

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.

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.

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?

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.

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

Fear + Avoidance + Reflection + Courage = Compassion

My colleague, Anna Reisman, a practicing internist and talented writer,  published a touching,  revealing and instructive New York Times blog post that demonstrates the value of reflective practice. See: The Death House

Anna writes movingly about her angst and ambivlance about visiting one of her patients at an inpatient hospice. Her ambivalence is rooted in her fears and anxieties about what she might experience during her visit, imagining suffering, sadness, hopelessness and a heavy dose of death (.."a steady line of hearses idling in the parking lot like taxis at a train station"..). Her avoidance is also linked, she reveals, to concerns that her patient will be suffering or too ill to acknowledge her presence, and she shares her worries that she will not know what to say to family members who may be present at his bedside. I would guess that most, if not all,  caring and compassionate clinicians harbor similar feelings....I know I have had these fears and anxieties when I was clinically active and had patients who were dying. However, Anna also feels a strong desire to visit her patient to pay her respects and provide some measure of comfort to the patient or his family. So, she wills herself to visit the hospice, where she is pleasantly suprised to find a homey, supportive and even healing environment, and, most importantly, a patient who is grateful for her presence. I was deeply moved by her prose.

Anna's courage to share her inner thoughts and feelings in her blog is remarkable, and courageous. As you might expect, her post has stimulated many comments, and though most commend her for her compassion, there are also several posts that judge her harshly for having and sharing negative thoughts and feelings about the hospice. This is unfortuante, as I believe these critics are missing the point. The fears and worries that Anna reveals are ubiquitous among clinicians. These feelings often lead to avoidance of patients during the last stages of life, which is unfortunate for both patients and clinicians. Taking the time to reflect and acknowledge  the feelings, in a non-self punitive way, is a step towards challenging them and summoning the courage to confront them. The result is often highly rewarding, and, hopefully,  reinforcing.

I hope Anna's post will stimulate others to be mindful and perhaps help them free up their inner capacities for empathy and compassion.

New Research Suggests Empathy and Analytic Thinking are Mutually Exclusive

Recent research utilizing functional MRI suggests that the circuits of the brain that are activated during analytic tasks are actually inhibited when people are engaged in social tasks,  and vice versa.

So, for example, when people are engaged in tasks that stimulate the centers of the brain associated with analytic problem solving, pathways activated during tasks that evoke empathic understanding are inhibited. The results, published online in the neuroimaging journal, NeuroImage, in October, 2012, were  summarized in an artilce that appeared on Medical News Today  - http://www.medicalnewstoday.com/articles/252241.php

These interesting findings shed light on the neural processes invovled in analytic and social tasks and suggest that empathic thinking and analytic thinking may be mutually exclusive. No wonder it is hard for us to consider the experience and feelings of others when we are deeply engaged in analytic problem solving. This also may explain why many health care providers miss opportunities to respond to patients' emotions when they are "conducting a history" and engaging in diagnostic reasoning and treatment planning.

From a healthcare professional training perspective, these research findings suggest that clinicians need to learn how to compensate for the inhibition of the social circuitry that occurs when they enage in analytic tasks. Helping clinicians to actively "tune in" to patients' emotional state may help "turn down" their analytic thinking and allow them to respond more effectively to patients' psychosocial needs.

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

Barbara Ficarra on the Value of Empathy

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

Graphic on Mind the Gap Emphasizes Impact of Clinician-Patient Communication

A new posting on the blog, Mind the Gap, by Stephen Wilkins, graphically shows the value of good clinician-patient communication. See: Mind the Gap Graphic.

I really like the quote he included from George Bernard Shaw, "The problem with communication is the illusion that it has occurred".

Shaw's quote reflects a key finding from research on clinician-patient communication: clinicians who have lover levels of skill are least likely to be aware of their skill deficit. For example, a review on the effectiveness of self-assessment of learner needs by I. Colthart and colleages (Medical Teacher, 30(2):124-45, 2008) found evidence that that the least competent are also the least able to self-assess accurately. This is why we can't count on clinician self-report and need to assess the competency of clinicians using methods that provide direct evidence of clinician communication skills, such as audio or videos of actual encounters,  evaluations of simulated encounters, assessment of patient experience. (See: Levinson et al.,  Health Aff (Millwood) 29(7): 1310-8.)

The good news is that the accuracy of self-assessment can be enhanced by feedback, particularly video and verbal feedback.