An Epidemic of Empathy in Healthcare Page 7

  Ten Tactics for Acquiring Empathy

  Acting isn’t the only way to acquire empathy; a number of other approaches have been developed by psychologists, counselors, and educators. In his book, Hojat describes a fairly comprehensive set of 10 tactics that are specific to healthcare, all of which are consistent with the goal of understanding patients’ concerns and experiences. Here are brief summaries of and comments on his 10 approaches:

  1. Improving interpersonal skills

  Training programs can help clinicians improve their ability to recognize patients’ negative emotions, concerns, and inner experiences so that they can explore those issues with the patient.5 The key skills correspond to Hojat’s focus on cognition, understanding, and communicating. Training gives caregivers practice in recognizing when patients are offering an opportunity for an empathic interaction by expressing emotions or worries. The caregiver can then respond empathetically, explore the issues, and convey understanding.

  A key focus of such training is recognizing the windows of opportunity in conversations with patients and not letting them pass. Developing more subtle skills such as nodding to give patients the sense that they are understood and giving appropriate verbal cues (“I see what you are worried about”) is also highlighted. The importance of nonverbal communication such as tone of voice, touching, physical distance, and body posture (sitting at the same level as the patient, keeping the arms uncrossed) is stressed. Some programs even instruct clinicians to mirror patients’ postures, gestures, breathing rates, and speech patterns.

  Several studies have shown that such training can lead to more empathic relationships and better patient experience, but exactly how it achieves these improvements remains something of a mystery. Is the benefit a result of the impact of individual acts such as touching the patient’s arm? Or does the improvement result from conveying a general message: “I understand you, and it’s my job to make things better for you”? The answer is probably somewhere in between.

  2. Audio recording, videotaping, or actual observation of encounters with patients

  Researchers studying empathy have long used audio recording and videotaping of encounters between clinicians and patients. An increasing number of healthcare delivery organizations are doing the same thing or having trained observers sit in on clinician-patient interactions. Of course, when clinicians know that they are being observed, they behave differently. What is surprising is that even when under observation, so many clinicians show a great deal of room for improvement.

  In one study,6 oncologists either missed or prematurely terminated conversations about patients’ concerns 73 percent of the time. Other findings show similarly low rates of detecting or seizing opportunities for conveying empathy. How low? Let’s just say that if baseball players had a similar batting average, they’d have a poor chance of making it to the major leagues. Physicians seem to be connecting emotionally with patients less reliably than baseball players are connecting a bat with a small, round, fast-moving sphere.

  Data show that recorded or live observation can lead to improvement. Organizations that have used these approaches are convinced that many—but not all—clinicians sustain that improvement.

  3. Exposure to role models

  Role models are often discussed in the context of physicians at academic medical centers, but in fact they exist in all settings, among all types of clinicians and other medical personnel, and at every level of the healthcare system. Many (not all) of these role models demonstrate empathic skills as a core feature of their skill sets, but those role models are not systematically identified, and the nature of their skills is not widely shared. The pace of modern medicine and the number of clinicians involved in care at many medical centers work against identifying role models and developing their best practices into social norms.

  4. Role playing

  The Aging Game is an example of how role playing can enhance clinicians’ ability to empathize. It was developed in 1989 to help medical students prepare to provide empathic care to the elderly.7 The game has three stages. In the first, students are told to imagine that they are elderly and use earplugs to simulate hearing loss. In the second, students make a transition from independent living in one area to semidependent living in another and then transition to dependent living in which they are confined to wheelchairs and stretchers. The third stage of the game is a group discussion of the participants’ experiences.

  There are a variety of other forms of structured role playing in which devices such as goggles with film over the lenses simulate cataracts or heavy stockings simulate leg edema. Studies consistently show that students who go through such programs become more sensitive to patients’ concerns.

  5. Shadowing a patient

  Many medical curricula routinely include shadowing of patients over prolonged periods. Such experiences help trainees understand that patients are not just an admission or a case but are human beings who are undergoing something important, often life-changing. An extreme—and extremely effective—version of patient shadowing is the longitudinal experience model for medical students pioneered at Cambridge Health Alliance in Massachusetts.

  In this model, medical students do not rotate through traditional blocks of time defined by specialties (e.g., surgery, pediatrics, obstetrics, and gynecology). Instead, they follow a large group of patients through every type of care: primary care, hospitalizations, nursing homes, and care at home. The focus is on what patients need rather than what doctors do. The assumption is that students will learn what doctors do as they help meet their patients’ needs.

  When students who went through this track were compared with students who had traditional training, the longitudinal approach was associated with better academic performance on standardized tests as well as greater satisfaction and idealism. These data are based on a small number of students, of course, and research to evaluate this concept on a broader scale is under way. However, the results offer hope that more exposure to patients over time can lead to greater empathy rather than greater burnout for clinicians.

  6. Hospitalization and illness experiences

  When clinicians or trainees pretend to be patients, that is, persons being admitted to the hospital, they increase their insight into what patients are going through. Some organizations have personnel go through such exercises with or without the knowledge of the caregivers.

  A variant on this theme is to disseminate commentary from clinicians and other colleagues who themselves have become ill. For obvious reasons, their comments resonate with their colleagues in a way that the same words from a patient might not.

  7. Studying of literature and the arts

  Many medical schools and healthcare delivery organizations promote appreciation of the arts—novels, nonfiction literature, plays, films, paintings, photography, and the like—as an approach to deepening appreciation for and insight into the perspectives of other human beings. Several studies have shown that such programs (e.g., intensive reading of Tolstoy’s The Death of Ivan Ilyich) can enhance students’ empathy. Whether such programs lead to durable increases in empathy and whether they appeal only to clinicians who already have strong empathic skills is uncertain. Nevertheless, they clearly seem to enrich the lives of both teachers and students.

  8. Improving narrative skills

  Everyone listens more attentively to a story than to a recitation of facts. Accordingly, one approach to enhancing empathy skills entails getting clinicians to understand patients’ experiences as stories as opposed to simply collecting clinical data. As one of my clinical mentors would say, “Don’t just tell me a patient’s age, race, and gender. Tell me about him. Don’t say a seventy-six-year-old white male. Tell me he is a seventy-six-year-old former piano teacher so I can begin to understand what it means for him to lose his ability to use his left arm.”

  To think in terms of stories, it is critical to listen for them and then write or tell them. Patients can tell when clinicians are listening to the
m in this way. Conversely, patients can tell when clinicians are not attentive to the overall arc of their stories. Some programs train clinicians and students in “narrative competence” through reflective reading, writing, and discussions.

  9. Theatrical performances

  Beyond reading, writing, and telling stories is portraying them. Dramatic performances by real or simulated patients have been memorable interventions in many medical communities. By observing or acting in plays that capture the experiences of patients with serious conditions (e.g., AIDS and cancer), clinicians can enhance their readiness to understand patients’ issues in real life.

  10. The Balint method

  The Balint training program was developed by the Hungarian psychoanalyst Michael Balint at the Tavistock Institute in London. It is based on the assumption that many clinicians have spent so much time training for their medical work that they may not have had an opportunity to develop skills in the interpersonal aspects of patient care. In regular small group meetings over one to three years, clinicians discuss behavioral and emotional issues related to interactions with their patients. The groups are often moderated by a psychoanalyst or another mental health professional.

  The Empathy Short Course

  Learning the basics of empathy doesn’t require a huge investment of time. Helen Riess and her colleagues at Massachusetts General Hospital have demonstrated that a month of training can increase physicians’ empathy enough to get them significantly higher ratings by patients.8 She recruited 99 residents and fellows in six specialties—anesthesiology, internal medicine, orthopedics, ophthalmology, psychiatry, and surgery—more than half of whom reported that they had less empathy for patients than they did when they began their residencies.

  Riess and colleagues randomized the trainees into two groups. One group participated in three hourlong sessions of empathy and relationship training spread over four weeks; the other group continued with standard medical training. Not surprisingly, by the end of the study, the intervention group had a better understanding of the neurobiology of empathy and an improved ability to decode subtle facial expressions.

  However, what mattered more was what their patients experienced. At the beginning and end of the study, the patients rated their doctors by the Consultation and Relational Empathy (CARE) Measure,9 a 10-item survey in which patients used a 5-point scale to evaluate their doctors’ demeanor on their last visit. At the end of the study, the control group had lost ground, with their patients scoring them an average of 1.5 points lower on the CARE scale than they had at the beginning. In contrast, the intervention group had gained an average of 0.7 point.

  What Does Empathy Look Like?

  The challenging reality is that empathic care is not a simple, straightforward action that clinicians can perform as reliably as washing their hands. It cannot be boiled down to a checklist of behaviors or an etiquette manual.

  Empathic care is something that happens between clinicians and patients and often with patients’ families as well. If it is more like dancing than running for clinicians, it is dancing with new partners every 15 minutes. Patients and clinicians vary in their temperaments, and the fact is that we all vary as individuals from day to day and even from hour to hour. The result is that empathic care can seem like snowflakes: when you look at relationships between clinicians and patients, no two are exactly the same.

  When I talk to doctors and patients about their relationships, I am often startled at the descriptions of their interactions. “My doctor has empathy in spades,” one woman said. We’ll call her Gloria. She was referring to her primary care doctor, an internist who is well known among her colleagues for her directness, which sometimes comes off as bluntness. We’ll call her Dr. Smith. Here is the example Gloria provided:

  “Several years ago, Dr. Smith found what seemed to be a large fibroid during my annual pelvic exam. She didn’t seem too concerned but suggested I have an ultrasound. I had the test on a Friday morning a few weeks later and left that afternoon for a long weekend in New York. When I came home the following Tuesday, there was a voice mail from Dr. Smith’s office asking me to come in that afternoon. I knew immediately that the ultrasound had found something serious.

  “When I got to her office I expected the usual 15-minute wait, but Dr. Smith was at the reception desk to meet me. ‘When I saw your ultrasound results, I almost threw up,’ she said as soon as we were alone. ‘It’s ovarian.’”

  “And that was empathy?” I asked.

  “Exactly,” Gloria said. “Because I felt like I was going to vomit, too.”

  I have never told a patient that one of his or her lab tests made me want to throw up. Indeed, reserved as I am, the very idea of saying that unsettles me. But somehow Dr. Smith sensed that this was just the thing to say to Gloria at that moment. Gloria loved Dr. Smith for saying it; she took that comment to mean that Dr. Smith completely understood what she was feeling and was going to be on and at her side every step of the difficult path ahead.

  Blunt though she can be, Dr. Smith knows what empathy is: understanding what another person is feeling and conveying that understanding. Dr. Smith’s reciprocal expression of nausea was a visceral statement that she understood what Gloria was feeling. Dr. Smith also sensed how this particular patient wanted to be treated. She knew that Gloria would rather be given a direct bolus of bad news than have it spoon-fed to her in bits and pieces.

  Dr. Smith has a large and diverse practice. I can’t imagine that all her patients would like hearing that their test results made her sick to her stomach. What do Dr. Smith’s other patients think of her? In fact, her ratings are superb, pretty much the equivalent of perfect SAT scores. Perhaps she attracts patients who all want care of a certain style, but it is more likely that she knows how to deliver empathic care differently for different patients.

  Dr. Smith is constantly adjusting what she does for and says to her patients. What stays the same is her reliability in making the effort to tune in to the needs of the person in front of her. It’s work—draining work, in fact—to do that. It’s art as well. And when it goes well, it is part of what makes medicine such a fabulous field in which to work.

  Barriers to Empathy

  Empathy is innate, but it can also be learned. However, certain circumstances can make it difficult to learn how to be empathic or to maintain empathy.

  History abounds with examples of what happens on a large scale in the absence of empathy, the most extreme of which include genocide, slavery, terrorism, and economic exploitation. The concept of moral disengagement describes how people might focus on something good that they are doing and wall themselves off from considering the negative impact on others who are outside their self-imposed field of vision. The result can be extreme empathy within a group but the opposite for everyone else.

  Yet these periods of moral disengagement—though dramatic—are sporadic episodes in history. There is a societal advantage to sustaining empathy, as suggested by the political scientist Robert Axelrod.10 Axelrod is a game theory expert who was well aware of how logic suggests that human beings are selfish and how they do what it takes to survive, with the net result often being a failure to cooperate in ways that would have enhanced the fortunes of all. However, Axelrod was struck by the fact that society does not devolve into chaos, or at least not as often as it might. Instead, people find a way to cooperate, often at the most unexpected moments.

  One of those moments was in the winter of 1914 in the trenches of the Western front during World War I. This was the scene of the famous Christmas Eve soccer game between British and German forces, but as Axelrod described it, the actual extent of the cooperation was much greater. Once the two armies realized that they were stuck together and that neither was likely to be victorious any time soon, they developed cooperative behaviors in which injuries were minimized on both sides. German snipers would demonstrate their prowess by firing at the walls of cottages in a tight target area until they had cut a hole in a wall, but the
y would not fire at British soldiers. That encouraged and rewarded British soldiers for also doing what they could to avoid harming the Germans. Artillery from both sides deliberately overshot their targets.

  This live-and-let-live approach was obviously not the major story of World War I, and commanding officers behind the front lines tried to eliminate it whenever possible. But the lesson that emerges from these and other examples of the evolution of cooperation is that when two parties are brought face-to-face and become invested in a future that they will be sharing, the ability to understand the needs of the other side naturally emerges.

  With this insight, it becomes obvious why so many wars begin with the effort to dehumanize the other side and eliminate empathy for the enemy. The implication for healthcare is that anything that dehumanizes patients also destroys our ability to meet their need for empathic care.

  Distraction: The Enemy of Empathy

  Patients want empathy and clinicians see themselves as empathic, so what’s the problem? One primary care physician at Cambridge Health Alliance, an articulate young woman, summarized it for me this way:

  “I want to be empathic, I really do. But it is so hard to focus on anyone or anything these days,” she said. “I try to listen. I try to look at them. But in the back of my mind, I am aware of e-mails arriving in my in-box. I hear little pings and feel little vibrations. I’m aware of the three patients who are waiting because I’m running late, and the telephone calls I have to answer, and the worrisome lab results I have to run to the ground. That’s not to mention the issues from my life at home that also need to be addressed by five o’clock today, and the reality is that I don’t have any time before seven o’clock.”

  Distractions are the destroyers of focus. Such distractions seem almost inherent to modern life, but arguably, they pose bigger problems in healthcare than they do anywhere else. It’s one thing for people to cast glances at their smartphones at the dinner table or during other types of business interactions, but if patients realize that a physician is not taking in what they are saying because the physician’s mind is somewhere else, they’re not going to feel that they are getting good healthcare.