An elderly patient patiently waits for her appointment.
[Portrait of an Old Woman via wikimedia]

Some people still say you can't practice empathy, that people either have this as a skill or they don't.  I disagree, which is why I like these elderly simulations in Poland:

Medical student Ludwika Wodyk fumbles her way slowly down the stairs, her movements encumbered by heavy strapping around her limbs and body, her vision distorted by special goggles. She is one of a group of medical students in Poland being given the chance to experience first-hand how it can feel to be an aging patient.

Empathy is something that can be taught, or at the very least, experienced. For many people, empathy is highly contextual, so direct experience with a problem can often give them insight into the barriers or complications of a particular population. This brings benefits like understanding, tolerance, and more creative problem-solving when the same circumstances arise again.

Elderly simulations can also be found in Britain and at MIT.

Extra credit:
When I roleplay older patients, I usually focus on the visual aspects. In future scenarios I want to pay more attention to the physical aspects and give feedback from the perspective of a person who might also have mobility, sight and hearing challenges as well.

When learners cry

"When doves cry..."
[L'enfant à la colombe via wikimedia]

Only a handful of students have cried while working with me, but they have all been memorable. But I don't take it personally, because they always happen during high-stress scenarios, like when the event is required to pass or when my character has been terrifying. Sometimes the learner is suffering from something happening in their life which magnifies any bump in our encounter into an insurmountable challenge.

Usually these encounters are unsatisfying, but the learner generally holds it together during the scenario. When feedback begins, though, so do the tears. In those situations, I've learned that feedback about the encounter in those cases is almost entirely wasted. What is more helpful is to explore what triggered the student and what's going on for them. Empathy first works for learners, too! If there's time, I may also give feedback about compartmentalization, stress management and how to manage negative thoughts.

In general, feedback should role model the kind of interaction you want with providers. So if I stay with my traditional feedback agenda in those cases, I am training learners to stick to their agendas despite the emotional and nonverbal cues a patient is exhibiting.

New inspirations

Calliope, the muse of epic poetry, approves this post.
[La Muse Calliope via wikimedia]

This post original began as simply a grateful reference to Empathy 101 (how to sound like you give a damn), because I give similar feedback to learners. I nodded deeply in agreement when I read:

• "Reassurance often fails if the physician does not also communicate an awareness of the patient’s deepest fears or concerns." 
• "This model of doctor-patient communication begins with empathic listening and responding, requires reflectivity and self-understanding, and is in itself a healing act."
• The list of "Statements That Facilitate Empathy," which is a particularly useful tool.

But then I realized these quotes and tools are all by the same person, which is how I discovered Dr. Jack Coulehan. Coulehan has written both "Let Me See If I Have This Right… – Words That Help Build Empathy" for the Annals of  Internal Medicine as well as the textbook Metaphor and Medicine: Narrative In Clinical Practice.

Sadly, neither of those references appear to be available via my normal channels, but some of his other books are, and that's how I learned Coulehan is both a doctor and a poet!

For instance, in addition to his own poetry, Coulehan edited Chekhov's Doctors: A Collection of Chekohov's Medical Tales as part of the Literature and Medicine series. Perfect for actors, eh? The Kindle edition has a much more interesting description of it: "In his brief but distinguished life, Anton Chekhov was a doctor, a documentary essayist, an admired dramatist, and a humanitarian. He remains a nineteenth-century Russian literary giant whose prose continues to offer moral insight and to resonate with readers across the world. Chekhov experienced no conflict between art and science or art and medicine. He believed that knowledge of one complemented the other. Chekhov brought medical knowledge and sensitivity to his creative writing—he had an intimate knowledge of the world of medicine and the skills of doctoring, and he utilized this information in his approach to his characters. His sensibility as a medical insider gave special poignancy to his physician characters. The doctors in his engaging tales demonstrate a wide spectrum of behavior, personality, and character. At their best, they demonstrate courage, altruism, and tenderness, qualities that lie at the heart of good medical practice. At their worst, they display insensitivity and incompetency. The stories in Chekhov's Doctors are powerful portraits of doctors in their everyday lives, struggling with their own personal problems as well as trying to serve their patients. The fifth volume in the acclaimed Literature and Medicine Series, Chekhov's Doctors will serve as a rich text for professional health care educators as well as for general readers."

The intersection of art & science is one of my very favorite things. Looking forward to reading more work by Jack Coulehan.

Empathy is a choice

So many choices.
[Landscape painting in water-colours via wikimedia]

Another followup to my post The Case Against Empathy, where I examined Paul Bloom's argument that empathy was less useful than simple respect.

The NY Times disagrees:

"While we concede that the exercise of empathy is, in practice, often far too limited in scope, we dispute the idea that this shortcoming is inherent, a permanent flaw in the emotion itself. Inspired by a competing body of recent research, we believe that empathy is a choice that we make whether to extend ourselves to others. The 'limits' to our empathy are merely apparent, and can change, sometimes drastically, depending on what we want to feel."

Of particular note for those of us who work in scenarios:

"Karina Schumann, Jamil Zaki and Carol S. Dweck found that when people learned that empathy was a skill that could be improved — as opposed to a fixed personality trait — they engaged in more effort to experience empathy for racial groups other than their own. Empathy for people unlike us can be expanded, it seems, just by modifying our views about empathy."

And once empathy can be a choice rather than a character trait, empathy can be practiced. Even if a learner already exhibits empathy, it is as important to reinforce good habits as it is to instill new ones. As I wrote in The Value of SPs, empathy remains a choice by rewarding the use of it.

The case against empathy

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?

Feedback models: When you did X, I felt Y

Let X=X.
[De divina proportione via wikimedia]

Another classic SP feedback technique is offering your comments in this format: "When you did X, I felt Y." For example: "When you moved my arm out of your way without saying anything, I felt vulnerable and helpless."

This is the only SP technique I've ever attended a (brief) training on. I know a lot of people hate it because it seems forced and routinized. I resisted it at the beginning, too. But with practice, it's become very natural to me, and now I find it to be one of my most important feedback tools. Here's why:

• I value it for the way it really forces me to truly examine what I felt and why I felt it. It's an excellent tool for self-awareness. The more I know about what makes me comfortable or anxious, the better feedback I can give students.

• Because it focuses on my emotions and observable behavior, rather than the student's motive, it's much harder for a student to argue or dismiss my feedback. This reason alone makes it worth becoming comfortable with the X/Y technique. It keeps the discussion patient-centered.

• I love how it expands my range of expression and allows for more nuanced feedback. Otherwise a lot of feedback is often binary: either good or bad.

• It works for positive and negative feedback equally well. When I tell a student something s/he did made me feel safe and supported, I can visibly see the relief on the student's face. A concrete expression of something that worked well for a patient is as valuable as a comment about something that could be improved.

• It's individual to the SP: different SPs often interpret the same behavior different ways, but express it the same way: "I liked it" or "I didn't like it." Using the X/Y format gives students more information about how their actions are being perceived, which makes the full range of patient reactions more visible.

Though I didn't learn it this way, I also often add: "If you had done A, I would have felt B" like so: "If you had asked me to move my arm, I would have felt like I had some control in a vulnerable situation." This gives students a concrete way to adjust their behavior in response, which I think is critical for good feedback.

However, it can be easy to slip into blame or projection, twisting the format into "When you did X, I felt you were being Y." For instance: "When you asked me the same question again, I felt you weren't listening to me." Assigning motive to a student often leads to a more defensive reaction. Better: "When you asked me the same question again, I felt unheard." When I want to comment on motive, I find it more effective to ask about it directly: "Why did you ask me the same question again?" After the student answers, I can almost always use the agreement technique to redirect and align our goals together without defensiveness.

Homework:
To help me practice this technique in the beginning, I created my own list of Y emotions. I also added a Z category when I needed to shape the conversation around my general values as a patient. I don't use it much anymore, but whenever I work at a new school/event I review it since something unexpected is likely to come up.

Extra credit:
Discovering the concept of non-violent communication a couple of years ago really went a long way towards helping develop the X/Y feedback skill and giving better feedback in general. I really like how it centers itself around empathy. I'm not 100% sold on the whole system, but as a feedback lens I have found it to be very useful.

Rejection

An SP flees after an unsatisfactory experience with a student-doctor.
[Sita Bhumi Pravesh via wikimedia]

This Atlantic article is written from the perspective of marriage, but it helps crystalize a particular (dis)connection dynamic I experience with some students:

"Throughout the day, partners would make requests for connection, what Gottman calls "bids." For example, say that the husband is a bird enthusiast and notices a goldfinch fly across the yard. He might say to his wife, "Look at that beautiful bird outside!" He's not just commenting on the bird here: he's requesting a response from his wife -- a sign of interest or support -- hoping they’ll connect, however momentarily, over the bird. 

The wife now has a choice. She can respond by either "turning toward" or "turning away" from her husband, as Gottman puts it. Though the bird-bid might seem minor and silly, it can actually reveal a lot about the health of the relationship. The husband thought the bird was important enough to bring it up in conversation and the question is whether his wife recognizes and respects that. 

People who turned toward their partners in the study responded by engaging the bidder, showing interest and support in the bid. Those who didn’t—those who turned away—would not respond or respond minimally and continue doing whatever they were doing, like watching TV or reading the paper. Sometimes they would respond with overt hostility, saying something like, "Stop interrupting me, I’m reading.""

Students rarely respond with hostility, of course. But when they don't engage when I make a "bid," that makes me feel as if the student-doctor doesn't care about me as a patient. For instance, if I talk about my pain and the the student moves onto the next question without acknowledging it, s/he has rejected my bid. If I talk about my kids, my job, or a funny thing that happened to me but the student doesn't engage with it, s/he has rejected my bid.

Ignoring my request for connection (or responding insincerely) is very likely to affect the student's empathy and/or rapport scores.

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.

Communicating sincerity

A student-doctor demonstrating sincerity during an encounter.
[Sterne and Grisette via wikimedia]

I feel strongly that feedback is most effective when it rests on a foundation of observable behavior and offers a concrete way for the student to attempt to fix it.

This can be especially difficult for vague skills like empathy, rapport and respect. Because even if a student doctor knows to say the right thing -- "I'm sorry to hear that" to express empathy, for example -- sometimes it doesn't sound sincere.

So what does that mean? Without concrete observations and recommendations, it's not very helpful to say to a student, "When you said 'I'm sorry to hear that,' it didn't seem sincere" and leave it at that. But it's taken me a long time to really feel like I can describe what sincerity looks like in a helpful way.

So for me, sincerity is when verbal and nonverbal cues match. There are several cues I look for when gaging sincerity:

Eye contact: Does the student maintain or engage eye contact when speaking? If the student is looking away while speaking, or abruptly looks down right after or even while speaking, I will feel as if the student doctor is not sincere. However, if the student looks up and engages eye contact with me while speaking, I am more likely to feel they are sincere. 

Tone: When speaking, did the student's tone change? If the student offers an empathetic statement with the same tone as they use to ask about past medical history, I will feel as if the student doctor is not sincere. 

Expression: Did the student's expression change? Did they raise/lower their eyebrows, blink, tilt their head? Are they smiling or frowning? If the student's expression doesn't change when delivering bad news, expressing empathy, or attempting rapport, I will feel the student doctor is not sincere. For instance, if the student-doctor smiles widely while saying "That's terrible!" I will not feel s/he is sincere.

Rate: Does the student doctor pause for a moment after expressing empathy, or barrel right onto the next question without a breath? Does s/he rattle off "I'm-sorry-to-hear-that" all as one word? If so, that will feel less sincere.

Non-verbal vocal expression: Does the student add a non-verbal vocal expression like "ohhhh", a tongue ticking against teeth, or a sharp inhalation when offering empathy? Do they say "mmm-hmmmm" when attempting rapport or engaging in active listening skills? Those are signals that indicate sincerity.

Posture & Movements: Does the student's posture & movements match what they are trying to communicate? For instance, if we are having a personal discussion, is s/he all the way across the room? Checking their watch? Did they shake their head or nod appropriately? If the student is trying to communicate something serious but is slouching on the stool or leaning against the wall, I will feel the student doctor is not sincere. 

Energy: Is the student matching the patient's level of concern? Are they using a similar rate, volume, emphasis as I am? If the student seems much more upset than I am at a parent's passing, for instance, I will feel the student doctor is not sincere.

Setting the standard:
If the checklist asks me to grade a student on skills like empathy, rapport or respect, I prefer to give them full credit only when they seem sincere.

Empathy vs. sympathy: an animation

I loved this animation about empathy (one of my core values!). Student doctors are often so uncomfortable with my emotional discomfort that they want to fix or minimize those feelings. As a patient that often makes me feel worse, as if I am not allowed to be emotionally honest with my doctor. Then I feel like I have to take care of the doctor rather than the other way around.

According to the video, empathy includes:

• perspective taking
• staying out of judgment
• recognizing emotion in other people
• communicating that emotion

I like how this expands my view of empathy and gives me more ways to talk about it with students. I especially love when the video points out the use of "At least..." as an empathic terminator.

Homework:

Listen for ways your emotions are being received or deflected over the course of a week, even (especially?) by people you are close to. How does that make you feel? What would make you feel better?

The power of the power differential

Everything looks so... small from up here.
[Jupiter Weighing the Fate of Man via wikimedia]

When we go to the doctor we are at our most vulnerable. We are vulnerable because we are sick and we are vulnerable because we are at a loss for medical domain knowledge. This gap between knowledge and helplessness is the power differential between doctors and patients. The more pain a patient is in, the larger the gap.

The emotional heart of power differential is fear. As a patient, I have a huge incentive to say things which make the doctor think well of me for fear I might jeopardize the care I need otherwise. If I worry about being judged, I won't feel safe. Some patients will respond to the power differential with deference, while others will be defensive. Either way, doctors who are willing to examine their own power dynamics will enhance security, honesty and shared understanding with their patients. So when I give feedback to students about communication skills, I frequently focus on things that reduce power differential.

This is a living list. Last updated June 29, 2014.

What increases power differential:

• Technical language: As a patient, if I can't understand the student, I will feel ashamed and stupid. In response I can attempt a reasonable guess, let it slide, or ask a question. Because patients often see doctors as authority figures, asking a question can feel confrontational. Comprehension (and the desire for confrontation) fails at a rate directly proportional to pain.
• Body language: Formal body language and sitting far away enhances the power differential between us. A clipboard can sometimes feel like a shield if the student has a death grip on it or spends more time looking at the notes than at me. Some students, in order to demonstrate active listening skills, lean forward too aggressively, making me feel scrutinized instead of supported.
• Taboo topics: when students assume they can ask sensitive questions without appropriate framing, they are taking advantage of the power differential. Topics include sex (cheating, STIs, abortion), alcoholism, depression, etc. For some patients, this can even include topics like urine and bowel movements. The more taboo the topic, the more important it is that the student doctor communicates safety and acceptance.
• Physical exam: The power differential is at its most obvious during the physical exam, especially if any part of my body is ungowned. Bodily autonomy is, in my opinion, a primary and absolute right. When students move me without asking me, or when they don't tell me what they are going to do before they do it, or when they give me unclear instructions (and then show surprise when I don't do what they expect), that makes me feel violated and frustrated. Compassion should not end when the physical exam begins.
• Command language: When students ask if I have been "compliant" with prior instructions during an encounter, I immediately feel judged and unworthy. Even in feedback, when I hear that my character was "non-compliant," I flinch. Compliance has power differential built into the word itself: the doctor gives orders, the patient obeys. Similarly, when a student doctor refers to my "complaint," the word implies a value judgement and I worry the student doctor isn't taking my concern seriously. The same is true if the student doctor at some point mentions "denies [pain, loss of consciousness, past medical history]." To hear that I have "denied" something sounds as if the student doctor doesn't believe me.
• Unbalanced speaking ratio: when the provider speaks much more than the patient does, that's a reflection of the power differential.
  
  
  

What decreases power differential:

• Empathy: When a student offers empathy at the pain I am currently experiencing, I can stop worrying about whether the student thinks my issue is serious enough to merit attention.
• Validation: When a student validates my choice to come in, I feel recognized and empowered.
• Normalization: When a student normalizes my concerns, I feel less alone and more accepted. Without empathy first, though, it can feel dismissive.
• Body language: open and relaxed postures help decrease the power differential, but being too familiar can have the opposite effect. A good rule of thumb is to sit close enough so that if we both reached out an arm we could touch.
• Rapport: when a student wants to know something about me that isn't medically necessary, that makes me feel like more of a person. When a student remarks on something we have in common, then I feel more connected. Being too familiar with a patient too quickly it can have the opposite effect, but a good rule of thumb is 1-2 remarks per case in which the patient is a new patient.
• Autonomy: When a student gives me a choice, I feel respected. Whenever a student specifically acknowledges that I am a person who might have her own needs, expectations and feelings, I am relieved and feel more in control.
• Manners: using "please" and "thank you," especially during the physical exam, makes me feel respected.
• Reflective language: When a student uses the same words and terms I use, I feel we are sharing the same reality.
• Summarization: When a student summarizes what s/he has heard at the end of the history and asks me to verify it, I feels as if my opinion about my own history matters. This sounds obvious, but as a patient it can too often feel as if my words fall into a black box and I have no idea if what I'm saying is actually what's being heard. Being specifically invited to correct the doctor is a very simple and elegant way for a doctor to redistribute power. Transparency also helps even the power dynamic, and summarization is one of the best ways to demonstrate it within the context of the encounter.
• Accommodation: whether the student doctor asks my preferred name or whether I want the lights dimmed when I have a headache, accommodation demonstrates a willingness to adapt to the patient's needs. Accommodation also means physical self-awareness: if it hurts to turn my neck, the student doctor should sit where I can see him or her comfortably. If I have to adjust myself to accommodate the doctor, that reinforces the power differential.
• Ownership: when I am allowed or expected to contribute to the treatment plan, I am able to more fully integrate it to fit my actual life, making it more likely I will follow the recommendations.
• Asking permission: when I am asked permission to be touched, especially in painful, vulnerable or private areas, I feel more respected and safe.

Basically, reducing power differential is a way to reduce vulnerability, fear and shame in patients. Reducing power differential enhances trust, confidence and respect.

Extra credit! 
Power is different than authority: discuss.

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.