It takes more than empathy to truly understand.
[Harmonie der Geschöpfe via wikimedia]

My first post on Setting the Standard began: "If I could teach medical students only one thing as an SP, it would be to provide empathy first." I'm a big proponent of empathy as a way to reduce the power differential and enhance connection & communication between doctors and patients.

So after I posted "Empathy is the highest form of respect," a friend sent a link titled "Empathy Won’t Save Us In the Fight Against Oppression." I was intrigued. I became even more intrigued when that article referenced "The Baby and The Well: The Case Against Empathy."

In it, Paul Bloom argues, "Empathy has some unfortunate features—it is parochial, narrow-minded, and innumerate. We’re often at our best when we’re smart enough not to rely on it."

Recognizing the limitations of empathy helps me give better feedback to learners. I still believe empathy should be a starting point for patient encounters. But empathy alone is not enough, which is why I also pay close attention to the other values in my feedback hierarchy like respect & autonomy.

In scenarios, a major limitation of empathy is a lack of imagination from the person using it. Frequently, empathy is employed in a fashion similar to the Golden Rule: How would I feel in that situation? But empathy should be more complex and nuanced than that. SP scenarios are a good way to increase learners' exposure to a wider variety of situations than they might otherwise find themselves. But there are situations and lives it is almost impossible for us to truly understand if we haven't lived them. This is especially true for vulnerable & marginalized patient populations.

So when empathy fails, respect and unconditional positive regard can fill the gap. Bloom writes, “Our best hope for the future [lies] in an appreciation of the fact that, even if we don’t empathize with distant strangers, their lives have the same value as the lives of those we love.” That's always good feedback to give learners.

Quote of the Day

[The assumption of Mary via wikimedia]

"Empathy is the highest form of respect."

Lisa B. Marshall

I have yet to write a separate post about evaluating respect, but in the Feedback Hierachy post I wrote:

"Respect indicates an awareness of the patient as an individual worthy of consideration and dignity. For instance, respect includes things like validation, normalization, accommodation, reflective language and transparency. Respectful student doctors are non-judgmental, honest, don't interrupt, admit uncertainty, apologize when necessary, take responsibility, keep commitments, and don't make assumptions based on class, gender, sexuality or race."

But since empathy is one of my core values, I find Lisa B. Marshall's quote fascinating. What do you think?

Alphabet soup

Embellishing a standard student mnemonic.
[16th Century Ornamental Alphabet via wikimedia]

One of the essential mnemonics for medical students asking about HPI is LMNOPQRST:

L: Location (where is the pain exactly? Can you point to it?)
M: Mechanism (how did this pain occur, if known? -- for instance, with trauma)
N: New (prior history of this pain or similar?)
O: Onset (when did this pain occur?)
P: Palliative/Provocative (what makes the pain better or worse? Not asked as a stacked question, hopefully!)
Q: Quality (describe the pain)
R: Radiation (does the pain move?)
S: Severity (how bad is the pain? often rated on a 1-10 pain scale)
T: Timing (how does the pain change over time? e.g. duration, contant/intermittent, sudden/gradual)

So brilliant! Because the alphabet is strongly ingrained in anyone who speaks fluent English, it's actually difficult to forget this one. The questions don't neccessarily need to be asked in this order during the interview, but if a student hits all of these points, the student has done a thorough job of asking the right questions to understand the patient's chief complaint.

Using the core value of "Empathy first", I propose a new mnemonic:

K: Kindness (empathetic statement, validation or reassurance)
L: Location
M: Mechanism
N: New
O: Onset
P: Palliative/Provocative
Q: Quality
R: Radiation
S: Severity
T: Timing

I love that including Kindness in the traditional HPI mnemonic creates a logical sequential addition and places empathy as the first element.

Extra credit:
I also use this mnemonic when memorizing my cases and checklists to verify I have all the info I need to answer a student's questions, even if that information isn't in the case. In which case, I also add:

U: Unusual/associated symptoms
V: actiVities of daily liVing (aka ADL: how does this affect your life/work?)
W: What do you hope to get out of this visit?

Bonus points:
An advanced student will begin a patient encounter with an open-ended question like, "So tell me what brings you in today." After they allow me to tell my story in my own words, the advanced student will then go back and ask the alphabet questions I didn't talk about to fill in the blanks naturally. This enhances rapport with the patient, speeds the interview process, and makes the student-doctor look gracious and competent.

Core value: Consent

Drink this. You don't need to know what it is.
[Self-Portrait with Dr Arrieta via wikimedia]

I have written about physical autonomy as a core value before. As an SP, feedback about treating patients with physical respect seems like the very least I can do. But full autonomy is about respecting the whole patient. Either way, consent is a requirement.

Consent is only consent if it is informed consent. But informed consent is not a ham-handed attempt to shock and awe. No, informed consent is a delicate and nuanced thing. Rather than an intimidating stack of papers as thick as a brick, informed consent is a beautiful waltz of informer and informed. Rather than a mad chaos of anxiety and pressure, informed consent can be a quiet and deliberate Sunday morning. Informed consent invites inquiry and empathy rather than blame and scrutiny. Informed consent should relieve ambiguity and bolster confidence. Informed consent should ideally take as long as it damn well needs to. That's why asking "Do you have any questions?" or "Is that OK?" isn't enough.

Of course, all of that's often not possible in the constraints of an SP encounter, even the long-form scenarios. But when a student genuinely tries to include consent in an encounter, I am relieved and delighted.

A student who excels in consent:

• Identifies procedures before they happen
• Asks permission
• Waits for recognition/response
• Uses simple language to describe complex topics (e.g. AGUS, screening vs. diagnostic)
• Keeps inviting questions until I don't have any more. Consent without comprehension isn't consent. 
• Asks questions that have more than one possible answer: how can I say truly say yes if i don't know what no will mean? As a patient I will say "yes" because I assume the consequences of saying "no" are worse.
• Does not ask leading questions (e.g.: "You don’t mind if I’m touching you like this, do you?")
• Tells me the range of options, not just the worst or best one
• Confirms my understanding using "teach back" or other concrete methods

Extra credit!
I was recently asked to sign things in a hospital. I was asked to sign them without having read them first or know what I was signing for. One was for HIPAA. When I asked to read it, I was told, "It's the same thing you sign everywhere. You've been signing it since 1996 or something." In other words, "You give me permission to do everything on this piece of paper that I’m not going to let you read, right?" This is a poor, but appallingly common, example of respecting patient autonomy.

Discussion question: 
Consent can lean towards coercion when a power differential is involved. Why is that?

Core value: Physical Autonomy

How I feel after a particularly disappointing physical exam.
[La Autopsia via wikimedia]

My first core value as an SP is "Empathy First." Many years of SP encounters have also led me to claim physical autonomy as a second core value. I firmly believe that autonomy is the key to respect. It is one of the things that is critical in reducing the power differential between doctors and patients.

Autonomy manifests most directly in an SP encounter during the physical exam. When a student doctor doesn't respect my physical autonomy, I feel vulnerable, helpless and insignificant.

When autonomy is not a core value for the student, my body feels like an object for the student to manipulate. Autonomy hinges on consent. There are several different levels of autonomy a student doctor can observe:

1. Move the object without explanation
2. Move the object with an explanation
3. Asking while moving the object
4. Asking before moving the object
5. Asking before moving the object and waiting for consent
6. Asking the object to move itself

Here's the thing: even if the student doctor is nice about 1-4, only numbers 5 and 6 are true autonomy. A student can be nice and still not respect my personal autonomy. Let's look at this more closely:

1. Move the object without explanation: the student doctor moves my arm out of the way and continues the exam without explanation. This makes me feel as if I am no longer a person to the student doctor, just in the way. This makes me feel resentful and cautious.
2. Move the object with an explanation: the student doctor moves my arm out of the way and explains why s/he is doing so. This makes me feel powerless.
3. Asking while moving the object: the student doctor asks "May I move your arm?" as the student doctor is moving my arm out of the way. Lots of students know they should ask a patient's permission, but many of them perform the action as they are asking for permission -- which makes me feel as if my consent doesn't matter.
4. Asking before moving the object: the student doctor asks "May I move your arm?" and waits for a beat. If I don't respond immediately in the affirmative, many students will move my arm anyway as if I had answered affirmatively! As a woman, I have been trained to be agreeable to implied consent, so it is difficult for me to offer any resistance to the student doctor's expectation when asked (especially if the student doctor is friendly). However, I don't immediately answer because I want to see what happens: when student doctors assume consent when there is none, this trains them badly for real patient encounters.
5. Asking before moving the object and waiting for consent: the student doctor asks "May I move your arm?" and waits for me to agree. This is an terrific way to reduce the power differential. I feel relieved, validated and grateful.
6. Asking the object to move itself: when the student doctor is conscientious enough to ask "Could you move your arm overhead, please?" I feel like cheering. Allowing patients the chance to move themselves into position allows them to feel in control in a vulnerable situation. I want medical education to rest on a strong foundation of patient control and consent.

Homework assignment:

Notice this week how many times you agree to something before the person has even finished making the request. Try not to agree in anticipation. How did that feel? How did the other person respond? Conversely, notice how many times you make a request and begin an action without waiting for a response.

Setting the standard:
An adequate standard would be one where student doctors ask permission before moving the patient and wait for the patient to respond. The student doctor would then continue to watch for verbal or non-verbal cues which indicate the patient feels more comfortable with assistance or does not need to provide continuous consent.

A better standard would be to find ways to allow patients to move themselves whenever possible. The student doctor would then watch for verbal or non-verbal cues to indicate the patient is having trouble understanding the instructions or unable to move themselves without assistance, at which point the student doctor would ask permission, as above.

Empathy first

Show me yours and I'll show you mine.
[Maria mit flammendem Herz, via wikimedia]

If I could teach medical students only one thing as an SP, it would be to provide empathy first. Nothing makes me feel more heard and understood than empathy right at the beginning of the encounter.

What usually happens:

student: "What brings you in today?"

SP: "I have chest pain/this weird rash/trouble sleeping."

student: "When did that start?"

What would make me feel ten times better:

student: "What brings you in today?" 

SP: "I have chest pain/this weird rash/trouble sleeping." 

student: "I'm sorry to hear that. So when did that start?"

Extra credit! Add validation:

student: "What brings you in today?" 

SP: "I have chest pain/this weird rash/trouble sleeping." 

student: "I'm sorry to hear that. I'm glad you came in. So when did that start?"

Doctors have the most ability to influence patient trust within the first few minutes of the encounter. As soon as the doctor has offered me empathy for my current pain and validation for coming in, I feel like the doctor has heard my concern and is taking it seriously. At that point, I can feel myself relax.

Setting the standard:
If a checklist item asks the SP to evaluate empathy, that empathy should be some sort of verbal statement about the pain the patient is currently experiencing within the first minute of the encounter.