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.

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