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

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.

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

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.

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.

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.