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

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.

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.

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 .