"Boosting" Empathy through Continuing Medical Education

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Have you had your empathy booster shot?

Interpersonal relationships are considered essential to the practice of medicine. Empathy, in turn, forms the basis of strong interpersonal relationships. However, empathy is often lacking in our medical system. A great deal of attention has been focused on redesigning medical education to address declines in empathy among medical students. However, I believe our efforts to boost empathy should also be targeted at practicing clinicians through continuing medical education. Dr. Beth Lown, Medical Director at the Kenneth B. Schwartz Center, agrees.

Beth recently published research (co-authored by Colleen Manning, Goodman Research) which found that participants in the Schwartz Center Rounds reported a positive impact on patient interactions. (The Rounds are interdisciplinary sessions where clinicians discuss psychosocial and emotional aspects of patient care.) Even more importantly, the study found that the frequency of Rounds participation had a statistically significant impact on the following dimensions of patient interaction:

• Having more compassion for patients and families
• Feeling more comfortable discussing sensitive issues with patients and families
• Having new strategies for handling difficult patient situations

I believe the lessons of this study extend well beyond evaluation of the Schwartz Center Rounds:

• Results support previous research that empathy can be systematically enhanced and measured.
• Findings underscore the fact that empathy education should not be limited to medical students.
• An ongoing commitment is essential to maintain high levels of empathy among clinicians.
• Continuing medical education programs can provide the basis for sustaining this commitment.

The Schwartz Center Rounds is just one of many programs which can promote empathy across the continuum of medical education. How are you “boosting” empathy?

Making Communication a Priority

What is your hospital doing to preserve compassionate care after recent passage of health care reform?

It was a hazy morning in Boston but the response was crystal clear: enhance communication.

At a breakfast gathering of current and former fundraising chairs for the Kenneth B. Schwartz Center, Ellen Zane, President and CEO of Tufts Medical Center, and Peter Slavin MD, President of Massachusetts

General Hospital (MGH) spoke about specific programs they have implemented to increase patient engagement and improve coordination as a means of improving communication.

In 2008, Tufts Medical Center created a medical home for patients with diabetes. The program has been able to improve coordination by making a single physician, with the support of a clinical team, responsible for managing all aspects of patient care.

Tufts Medical has also implemented several programs on the inpatient side:

Ticket to Safe Travel improves the process of handing off a patient from one clinical team to another;

Daily Goal Sheet specifically defines clinical objectives for each patient.

Ellen closed by noting that as we embrace health care reform we can't forget the importance of communication.

MGH, like Tufts Medical, is exploring variants of the medical home concept. The Medicare Demonstration Program, targeted at the sickest Medicare patients, has successfully reduced hospitalizations and costs. The Ambulatory Practice of the Future, opening later this month, seeks to engage patients by creating an individualized website where they can interact with clinicians.

Peter summed things up nicely when he pointed out that the goal of all these efforts is to free health care providers so they can focus their time on meaningful patient interactions.

What is your hospital doing to preserve compassionate care after recent passage of health care reform?

Listening to the Sounds of Silence

Originally uploaded by Brittany G

Diagnosis day, or D-Day in the words of Vicki Kennedy, is that pivotal moment when a patient learns the extent of his or her illness. This week’s post, written by medical oncologist Robin Schoenthaler, explores the lessons of D-day from a physician’s perspective. What lessons have you learned from D-Day?

"As a young doctor, training to become an oncologist, I quickly learned that many diseases don’t follow a “textbook” presentation – and neither do patients. Being able to recognize and respect a patient’s changing needs has been a crucial part of my practice ever since.

One of my first “teaching patients” was an insurance salesman. He’d begun seizing while meeting with a new client. After a harrowing ambulance trip, a long ER stay, and many scans, it turned out that a suspicious mass was lodged in his lung and an even more ominous mass sat in his brain. Within a few hours of his sales meeting we were telling him we wanted to get a brain biopsy and lung sample.

He stayed in the hospital for four days. During that time he told me over and over that he wanted "all the facts," that he was an insurance guy who was used to numbers, that I should tell him “the whole truth and nothing but the truth.”

Three days after his biopsy, I went to the lab, looked under the microscope, and saw a sickening sight. He had cancer in both the brain and the lung. The brain mass was, as we feared, a metastasis from the lung tumor. In those days, most patients with this diagnosis didn’t live six months.

I spent a hectic morning with other patients. Although I ran into his room a couple of times to check on labs and meds, I didn’t have time to sit down with him until late afternoon. As I stood in his room that morning, checking his IVs and trying to look him in the eye, I felt like I was choking.

Around five o’clock, armed with facts and figures, I returned to his bedside. "We've got the results back. I wonder if we can talk for a few minutes?" We walked together to the side room down the hall.

That ten minute conversation taught me an important first lesson in compassionate care: share the truth the moment you know it. And it was there, in the sanctuary of that starkly lit room in a busy inner city hospital, that I also learned to listen to a patient’s silence.

I watched this man -- to all appearances a classic "information seeker,” an insurance guy who had solicited statistics for days – take in the information, take a breath, and then completely reverse his course. He held up his hand and said, “Just the facts, doc, and just the facts that I ask for.” He then proceeded to ask questions about treatments and transportation, and about side effects and symptoms. He listened to my answers in silence and never asked about numbers, statistics or the likelihood of survival or cure

He only asked about logistics and he stuck with logistics for his remaining six months.

The next day, as he was discharged to his known but uncertain fate, he said, "I will always remember the sound of your shoes as they clicked against the linoleum as we walked into that room." And I will always remember the sounds of his silence."

Dr Robin Schoenthaler, a radiation oncologist practices at the MGH Department of Radiation Oncology at Emerson Hospital in Concord, MA. She also writes about her experiences as an oncologist. Her last essay, about men who hold their wives’ purses in cancer clinics, appeared in the Boston Globe Magazine last fall.

Palliative Care Grand Rounds

I'm very excited to be hosting the June 2010 installment of Palliative Care Grand Rounds, a monthly roundup of the most interesting palliative care and hospice blogs. (I've used a little creative discretion in defining palliative care and hospice blogs).

If you're not familiar with Bedside Manner, it's a two-and-a-half year old blog that focuses on compassionate health care. I write about special patient-caregiver relationships; programs that try to inject more humanity into medicine; interesting and relevant studies and much more. As you can imagine, issues of end-of-life and palliative care often figure into the conversation.

It was great discovering some new blogs and catching up on old favorites. I started out thinking I would stick to a theme or two this month, then quickly discarded that idea and simply collected posts that caught my fancy for any number of reasons. The topics are:

Reflections on Patient-Caregiver Relationships
21st Century Connecting
The Art of Listening
Making Art from Illness and Grief

Reflections on Patient-Caregiver Relationships:

Danielle Ofri, MD writes a beautiful piece in the New York Times about a patient of hers who died with few, if any human connections. The essay is her way of honoring the memory of a man who is buried in a "potter's field on Hart Island, a tiny sliver of land in Long Island Sound where unclaimed New Yorkers have been interred since the Civil War."

On GeriPal, Brad Stuart offers a moving definition of love - being willing to suffer along with a patient in pain - examining the difficult questions together, like when is it time to say "no" to further treatment.

Buddhist physician Alex Lickerman, MD lays out the Caregiver's Manifesto, a list of seven ways to make caring for loved ones who are chronically ill a better experience for everyone. Much of the advice is also relevant to people who aren't caregivers.

21st Century Connecting:

The Hospice and Caregiving Blog gives readers a primer on the different ways that Facebook can help with the grieving process.

On the heels of the flap about Facebook's confusing new privacy settings, I was intrigued by an item on Patients Like Me about a recent violation of the company's user agreement. The "user" was actually a computer program that was extractng data from a mood conditions forum. Company President Ben Heywood writes about the balance between openness and privacy in online patient communities. By the way, Ben is the brother of Stephen Heywood, a young man who died of ALS in 2006 and was the subject of a terrific documentary So Much So Fast.

Using a slightly older media - yearbooks - Hospice and Caregiving Blog links to a story from the Kansas City Star about how high schools do or don't memorialize students who have died during the year.

The Art of Listening:

On Better Health, Alan Dappen, MD saves a patent's life through the simple, yet powerful act of listening.

Beth Israel Deaconess Medical Center CEO Paul Levy, on his popular blog Running a Hospital, shares how compassion comes in many forms, including designing systems that minimize discomfort for cancer patients undergoing CAT scans, The idea of the new system came from listening to the feedback of a patient.

Making Art from Illness and Grief

Paradoxically, reading Debra Ruder's Goodbyes, a blog about death, is often very life-affirming. In the most recent post, she writes about a teenager's last visit with her grandmother at a nursing home in Greece and shares the poem the teen wrote about her beloved Yia Yia.

Zoe Fitzgerald Carter, author of a recent memoir about her late mother's wish to engineer her own suicide, writes a mother's day essay about her unsentimental mother's change of heart about a tender gesture - sending flowers. Check out her book Imperfect Endings - a fascinating journey down a difficult road with a thoughtful and amusing guide.

NY Times editor and writer Dana Jennings, who has been blogging about his prostate cancer for the past year, writes a terrific post about his new post-cancer hair style and its powerful symbolism.

At Pallimed Arts and Humanities, listen to actress-singer Charlotte Gainsbourg's sone about an MRI (the song's title is the procedure's' French acronym IRM), based on her experience with the machine after a skiing accident. Can you hear the machine in the background?

And for the finale, here a couple I couldn't shoe-horn into any category:

On Pallimed, Lyle Fettig writes about a study in Melbourne, Australia investigating the impact of advance care planning intervention on end-of-life-care in older patients. Of the 29 patients who died in the intervention group, 25 patients had their end-of-life wishes followed. That compares to the 8 out of 27 in the control group.

Finally in the "Shout out to Nancy Reagan" category, Mayo Clinic obstetrician and medical editor-in-chief Roger W. Harms, MD writes about how sometimes the most courageous things a patient can do is just say no (to medical tests with dubious utility.)

GeriPal.org is the host for the July edition of PCGR. Check them out for submission instructions.

PCGR now has subscription options; you can follow by email or RSS feed. An aggregated feed of credible, rotating health and medicine blog carnivals is also available.

Vicki Kennedy Talks about Compassionate Care

It was a beautiful May morning two years ago - bright skies and lots of sunshine. Senator Ted Kennedy was drinking coffee with his wife Vicki and reading the papers. The senator had taken the dogs for a walk earlier. And suddenly their lives changed forever. Senator Kennedy suffered a seizure that would eventually lead to the diagnosis of the brain tumor that took his life.

Mrs. Kennedy headlined the Kenneth B. Schwartz Center’s recent woman’s event, attended by 650 women from every segment of the health care industry. We knew when we invited her to talk at the gathering that she would have a tremendous story to tell about compassionate health care and she certainly did. What I didn’t realize is that she knew Ken Schwartz, our organization’s namesake, from Democratic political circles, and how much our mission resonated with her. Call it kismet.

She talked about the difficulty of what she calls “D-Day” – diagnosis day. The doctor was accomplished and outstanding in his field, but he delivered the grave prognosis in a way that left no room for hope. He basically assumed the worst outcome -- and soon. What the doctor didn’t realize was that he was dealing with a man who was a fighter and a questioner, someone who would want to take a large role in his own health care. He could never just accept those words of defeat and go home, according to Mrs. Kennedy. “Know your audience when delivering bad news” was her first message of the evening to clinicians.


She went on to talk about the “magnificent” group of nurses and doctors who subsequently became Senator Kennedy’s care team. “They listened to us. We weren’t Pollyannas. We knew how grave the situation was, but we also had hope,” she said. Senator Kennedy went on to live 15 months more months and they were “high quality months of high achievement,” said Mrs. Kennedy. “He saved Medicare, spoke at the Democratic convention and wrote a book, “she said. (And I might add: threw out the first pitch at Fenway Park!). And it was a precious time on a personal level as well, she said. She described how her husband loved to sing, and that last summer every visitor would have to sing a solo at the dinner table.

Mrs. Kennedy concluded her remarks with the following thoughts:

"Lovingly introducing the topic of end-of-life care. Don’t leave it to the families to broach this difficult topic," she said. "Just ask: do you want to be home or at the hospital? How can we help with the details to make things easier and comfortable and to give you the best quality of life possible? Let your patient know you're there for them. "

Not surprisingly, Mrs. Kennedy’s remarks brought down the house.