Empathy (conclusion)

—- Empathy in Medicine —-

As I alluded to in the beginning of this post, we as clinicians are given this incredible privilege of trust from the patient. Trust that you will, with this intimate information, do everything in your power to alleviate their condition and suffering. I am trying to think of another profession or situation in which such trust is given before meeting the other party, but I simply cannot. Thus as clinicians it is our duty to do whatever we can to fulfill the potential of this relationship. Empathy is a major tool needed to achieve this, and it would be a shame not to at least try and develop it.

There is school of thought in medicine that developing this empathy would be more emotionally draining (resulting in higher burnout rates) and also detract from the objectiveness of a clinician, a tool that is needed in critical times.[4] My thought is this: I cannot deny that burnout rates and objectivity may be affected by the practice of empathy. But if the ultimate goal is optimal patient care, and numerous studies have shown that displaying empathy results in better outcomes for the patient, then there is no question: it must be taught and developed as a part of training.

Now, whether a skill such as this one can be taught is a separate issue. I am not so sure empathy can be taught. But while I do believe that in most cases empathetic instincts are inborn, to a certain degree it can be developed. I liken this to the idea that while someone like LeBron James may be born with talents that make him great, there is no doubt that it took hours upon hours of practice and development to make him the player he is today. Empathy, like shooting a basketball, is a skill that needs to be developed. And while it may not result in a multi-million dollar contract with Nike, it could result in something more precious: better care of the patient.

Word chart imploring physicians to show empathy
Word chart imploring physicians to show empathy

I consider Amy Romain an expert in the field of empathy. As I mentioned in an earlier post, Amy is a dear friend that serves as our office social worker. I consider her such an expert on the subject that I consulted her when writing this piece. She responded by saying, “Empathy is the heart of medicine. It is an essential medium to the art of healing.”

—- My Fear —-

A friend of mine confided in me earlier this year that she had suffered a miscarriage. When she told me, my heart sank and I was devastated. I immediately thought of the time my wife and I thought she had miscarried; it was a horrible experience, one filled with grief and loss. But even though inwardly I was devastated by this news, outwardly all I could muster was, “That’s terrible, I’m sorry.” I knew that while this was a sympathetic response, it was only 1/100th of what I actually felt. Even though I knew at the time that I wasn’t accurately showing her how this news made me feel, I could not change it, it was almost like I could hear the words come out of my mouth, and part of me yelled to myself, you idiot! “That’s terrible, I’m sorry” is all you can say? Say what you’re feeling! But as much as I wanted to, “That’s terrible, I’m sorry” is all that came out. Did this tumor take away my ability to portray empathy ?

image

I am currently in the process of a return to residency going through what seems like an endless stack of paperwork and red tape. I must say that my greatest fear about coming back isn’t the titubation or my delayed speech. My fear is an unknown: have I lost my greatest strength as a clinician—have I lost my ability to show empathy? After this meeting with my friend who miscarried, I sent Amy an e-mail telling her of my fears of returning. She agreed that this was a legitimate concern and that I could work with her in developing strategies to circumvent this possible short-coming. But I knew, even before sending her the email, that the empathy I showed to patients would either be there or not, and I would only know the answer of whether or not I could portray it when I actually saw a patient. I  guess part of my irrational side hoped that some of her abundance of empathy would rub off on me.

I can be comforted by the fact that even though it may not show on the outside, inside my mind immediately tries to put myself in your shoes and ultimately show empathy. Maybe  with this tumor, and the experience I’ve been through I now have more of a leg to stand on. Only time will tell if I can learn to convey these feelings outwardly.

 

[1] It is for this reason I like my wife to give a ‘heads up’ to whomever I am to encounter. This way, I figure, the initial element of surprise is at least dulled.

[2] I’m lucky to have a friend who cried when dropping off my family a meal. The ‘luck’ for me is having someone like that in my life. For her, the thought of my situation and ordeal brought her to tears.

[3] Perhaps they were always there, I’m just picking up on them more now. It’s like the consumer in the market for a new car who says, “I didn’t realize how many car commercials there were until I needed a car.” For me, I didn’t realize the signals their body language was giving me until I looked.

[4] For a great article on the topic check out http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1466742/pdf/0020576.pdf

Empathy (part 1 of 2)

One of the greatest tools a clinician can have is the ability to ‘connect’ with a patient. As a physician you’re given an amazing honor; another human being tells you very intimate details that no one else is privy to: it could be something as an innocuous as a nagging cough to information as grave as thoughts of suicide. Whatever you’re being told, the privilege of having such information, of being able to aid this person with their ailments, is not to be taken lightly and clinicians should strive to realize the full potential of this relationship. Empathy, true empathy, is a tool that can help in achieving this. While I strongly believe in the value of empathy in any patient-physician relationship, unfortunately I feel torn on the debate whether or not it can be taught.

—- Empathy vs. Sympathy —-

image

These two terms are often incorrectly interchanged. Sympathy is defined by the acknowledgement of someone else’s suffering, while a person displaying empathy portrays a true understanding of this suffering, sometimes actually experiencing this suffering him/herself. In writing this I realize that the difference is harder to delineate than at first glance; perhaps an example would illuminate my point better. If someone were to tell you they are upset over the recent passing of a loved one—a sympathetic person acknowledges the loss and this person’s grief. “I’m sorry your grandma died,” this person may say, “I’m sorry you’re having such a rough time with it, but at least you had the time with her that you did.” This is in stark contrast to an empathetic person who maybe thinks back to when a loved one has passed away in his/her life. This person not only understands their grief, but feels the sorrow as well. “I’m truly sorry for your loss,” this person would say, “I remember when my grandma died, I was devastated by it. Is there any way I can help you get through this?”

Even though I was taught this in medical school and residency, I did not truly appreciate this delineation until after my surgery. The most common reaction I receive when someone realizes I am a hobbled young adult is one of surprise.[1] No matter the person or situation, surprise is always the first reaction. This surprise can be as overt as someone saying, “Oh” aloud, to something as subtle as an awkward glance that may only last for a millisecond. The next reaction is where people diverge: some obviously do not care or even acknowledge my disability; others respond sympathetically, giving my wife a look that says I’m sorry you’re going through this; then there are those who have an empathetic response as I can almost sense the emotions being conjured in this person.[2] I am not sure if this ability to detect subtle body language is innate or acquired during my medical training, but regardless of its origins, the messages I receive through body language seem magnified after my surgery[3] and the division between sympathy, empathy, and no reaction at all has become painfully clear.

For a great YouTube video on Empathy vs. Sympathy check this out

[1] It is for this reason I like my wife to give a ‘heads up’ to whomever I am to encounter. This way, I figure, the initial element of surprise is at least dulled.

[2] I’m lucky to have a friend who cried when dropping off my family a meal. The ‘luck’ for me is having someone like that in my life. For her, the thought of my situation and ordeal brought her to tears.

[3] Perhaps they were always there, I’m just picking up on them more now. It’s like the consumer in the market for a new car who says, “I didn’t realize how many car commercials there were until I needed a car.” For me, I didn’t realize the signals their body language was giving me until I looked.

Average (part 2)

—- Better or Worse? —-

Before this tumor struck me, I was once a professional athlete. Thus I’d like to think my attributes like agility, speed, and strength were above average. Playing tennis also requires much hand-eye coordination. Because of this, if I were asked to rate my hand-eye coordination (before the tumor) it’d be above average (I hope I’m not falling into the trap of the thinking ‘the older I get the better I was’).   I also like to think that my mind was sharp, that I was quick to learn and spot things. When it came to patient care, I was lucky to have the ability to connect with any patient. Because patient care is the name of the game, I would think I was on my way to becoming an above-average clinician. If I were asked to list some qualities in which I were below average, the first athletic attribute that comes to mind would be my balance. I would often tell my wife that if I were to have better balance on the court, I could have achieved much more in the sport (the older I get, the better I was). In fact, my speed, strength, and agility were good enough to mask my poor balance. I’ll admit that when I was away from the hospital I was a bad listener. I would often ‘tune out’ during conversations when not with a patient. I also think I was a below average husband and father prior to this ordeal. I would spend long hours in the hospital devoting much of my life to medicine. My rationale was that this devotion was to provide for my family and because of that, any time away from them was justified. Since the surgery this has all flipped: anything that involves motor skills or athletic ability I am now well below average. In terms of speed and agility, the only running I do now is for therapy on a treadmill and I can only run with the assistance of handlebars. Actually, even walking from point A to B is slowed, as I’m often passed on sidewalks by slow walkers. My hand-eye coordination is diminished, as I struggle to hit a balloon with a mini-tennis racquet to my son Cormac. I hate to dwell on deficits though, as I know that through this I have become well above average when it comes to being a husband and father. I am now home almost too much for the taste of my older son; he sometimes asks me when I will return to the hospital. For my wife, not only do I make sure dinner is prepared for her every day, but I also put a lot of effort into listening to every word she says. I have said it before in previous posts, but this ordeal has brought us closer than ever. The one attribute in which the effects are unknown is with respects to patient care. I am currently in the process of attempting to return to residency, and have not yet been involved in patient care, thus I do not know how my medical skills have been affected.

From an instructional guide to parenting
From an instructional guide to parenting

—- What’s Your Average? —-

Hopefully this makes you think, like it did for me, about the term ‘average’ and what you’re above or below average at. Maybe you’re in peak physical condition and a fantastic parent and spouse, and a skilled Nascar-like driver—maybe there is nothing you are below average at. But I bet if you think long and hard about it, you’ll come up with a list with both sides filled in. It is okay to be below average at some things. Remember, rating yourself as below average does not mean you are bad at it, it simply means that half of the people in the world are better at it. But the question you have to then ask yourself is, “What can I do to make myself above-average at this?” For me, it took a brain tumor to improve in these categories; hopefully for you it only takes some pondering and some minor changes.

Average (part 1)

In my readings I came across an interesting study that made me think and dig for more: In his book “Thinking, Fast and Slow” Daniel Kahneman references a study in which the subjects were asked two questions: “Are you a good driver? Are you better than average as a driver?”[1] The respondents typically answered ‘yes’ to both, rating themselves as good, above average drivers. Here’s the dilemma: by definition ‘average’ is a place with 50% above it and 50% below it. When I dug some more, a similar study performed in 1981 completed in Sweden and the U.S. asked respondents to compare their driving safety and skills to others partaking in the experiment. The numbers are surprising: for driving skill 93% of U.S. subjects rated themselves as above average, while 69% of the Swedish group claimed their driving skills to be above average. When it came to safety, 88% of U.S. and 77% of Swedish respondents thought they were above average.[2] This effect is not only limited to driving skills. As humans we tend to ‘overrate’ many of our skills—there’s actually a term for it: it’s called ‘illusory superiority’.[3]

image

In one of my appointments with my Physical Medicine and Rehabilitation physician the topic of my return to residency came up. It was clear that I would have to see less patients throughout a day than average.[4] He made the statement, “So what? You’ll see fewer patients; you’ll be below average. I do too, who cares?” This made me think about being considered average, and what that meant.

In the English language there are some words that have an inherent positive or negative connotation to them: words like relaxed and cripple to name a couple. The term average is one of these terms. “How was the movie?” someone may ask you; if you respond by saying, “average,” you don’t mean of all the movies you’ve seen, ½ were better and ½ were worse than this movie. Because of the negative connotation of the word, you mean the movie was pretty bad (I’m guessing you would not recommend an ‘average’ movie to a friend). That notion made me think about what this tumor has done to some of my abilities. I’ve always thought of myself as an honest self-assessor, but like everyone else I must suffer from this ‘illusory superiority’ complex. Regardless of my bias, I thought it was an important exercise to complete…

[1]Kahneman, Daniel. Thinking, Fast and Slow. 2011, New York, p.260

[2] Svenson, O. (February 1981). “Are we all less risky and more skillful than our fellow drivers?”. Acta Psychologica 47 (2): 143–148.

[3] Colvin, C. Randall; Jack Block; David C. Funder (1995). “Overly Positive Self-Evaluations and Personality: Negative Implications for Mental Health”. Journal of Personality and Social Psychology (American Psychological Association) 68 (6): 1152–1162.

[4] In medicine, many times your proficiency is based on your efficiency (i.e. the number of patients you can see in a day). There is a local Family Physician that sees about 60 patients a day! Not only is this an almost obscene figure, but apparently he is loved by his patients.

Falls (part 2 of 2)

This brings me to the issue of my falls. You may be wondering, if you fell, then wasn’t their decision to discharge you incorrect? Normally I’d agree, but in my case these falls took place 3-4 months after discharge; a prolonged hospital stay would not have prevented them. The first incident actually took place in the front yard, witnessed by Christian and his neighbor friends. It was the middle of the day, and Fleur was in clinic. I was holding Cormac in my hands. I went outside to tell Christian to come in for lunch. Our porch has two small steps leading to the front door. I normally descend these steps without issue, but for some reason got tripped up on this occasion. After the second step I stumbled forward, forcing me to take several awkward lunging steps. I remember that Christian’s playmates all stopped what they were doing to witness my stumble. Fortunately I did not fall, but recall being extremely embarrassed; all I could think to say was, “Whoa, that was fun.” Once I went inside and gathered my composure, I became incredibly frustrated with my condition that had caused me to almost fall in front of my neighbors.

My front porch- fall #1
My front porch- fall #1

The second incident took place only a few weeks ago. I was in the kitchen getting dinner ready and waiting for a friend to arrive. He sent me a text telling me that he was going to be late. I went to read the text and my legs buckled. I fell backwards onto my behind, not hitting my head. This fall created quite a loud sound, prompting my wife and older son to run into the room, asking if I was okay. Again, my initial feeling was embarrassment for creating such a racket. Then the embarrassment became frustration over my inability to traverse even my own kitchen. To this day, I’m not sure if the slight distraction of reading the text, a slippery floor, or perhaps my particularly tough leg workout contributed to this fall.[1]

Site of fall #2- my phone was on this counter
Site of fall #2- my phone was on this counter

The last ‘fall’ I want to discuss occurred only this past week. It was nearing the middle of the night and my parents were in the adjacent (guest) room. Unfortunately for them, this  was also the room that housed Cormac’s crib. We had all decided to let him cry for five minutes when he awoke. If at that point he did not console himself and was still crying, Fleur would retrieve him. The only hitch to this plan was that Fleur had left to go Black Friday shopping. His crying woke me, at which time I waited for five minutes to see if he consoled himself. After five minutes passed with his persistent crying, I arose from my bed to get him. I’m not sure if I got up too quickly or if I was distracted by his crying, but I fell onto our neighboring night stand, knocking over a cup and lamp in the process. Nobody witnessed this fall, the only people that could have heard the fall was my parents; otherwise it was dark in the middle of the night, and my wife was away. Even in this solitude my emotional reaction was the same: I was embarrassed at first for making so much noise, but this embarrassment turned into frustration over having to deal with both a crying baby and being an unsteady adult.

Fall#3- there was also a glass of water on it
Fall#3- there was also a glass of water on it

—- Get Up —-

This is where the clichés come in. I was always taught from a young age that if you fall get up. When I was a boy this was more metaphorical as any ‘fall,’ whether it be a rejection, loss, or bad grade had to be met with persistence. I had no idea these falls would become literal ones, but I’ve come to realize that they are a microcosm for this whole ordeal: no matter what life throws at you, you cannot control your initial reaction to it (for me this was embarrassment and frustration) but what you can control is your later reaction to this ‘fall’. You could stay on the ground and rue your situation and how you were treated, or you could get up, brush yourself off, and hope for more challenges.   For me this tumor is yet another challenge that life has thrown at me, stripping my ability to walk and talk normally. What it did not take from me is my ability to listen or write. As long as I have tools to fight I will.

 

[1] Most likelyall these factors contributed in their own way to my fall—in medicine this is called a ‘multifactorial’ cause, meaning many factors led to the event.

 

Falls (part 1 of 2)…

In this post, I have a warning for my readers: this piece contains many clichés. In writing there are a few steadfast rules: for example, always write to your audience; if you’re composing a book on how to make paper airplanes, write for people making paper airplanes, don’t write about the physics of flight. Another such rule is to avoid clichés, not only are readers probably tired of hearing them, but they can impede the flow of your writing, making it almost unreadable. But in thinking of today’s topic of falls, I could not help but keep returning to the same clichéd themes; so for that I apologize and warn you, if you hate clichés then do not read this post. I will first briefly describe each of the falls.

image

—- Fall Risk? —-

When arranging my discharge from the hospital, the concern was for my physical safety, with the main risk being a fall. At that time, I was reliant on a wheelchair for transport and had difficulty with my day-to-day activities. On the other hand, I was desperate to get home, as I could not wait to return to life with my wife, elder son, and newborn child. Luckily for me, all the clinicians remained objective when assessing my readiness to go home and did not factor my preference into their decision. A fall could result in some superficial bruising; but there is also a small chance it could result in brain hemorrhage and death. In medicine, the onus of any bad outcomes falls on the shoulders of the last physician to see the patient.[1] It is for this reason that discharging any patient is the result of much contemplation. I understood the risks of my discharge, but I felt torn. My rational, physician side acknowledged that my discharge might be premature; but my emotional side that wanted to be with my family won out—I let everyone know that I wanted to leave…

image

[1] This is why fields such as Emergency Medicine are such litigious ones. Even if the physician advises the patient to immediately see their primary care physician, many do not, and even if a negative health-related event were to occur years later, if the Emergency doc was the last to see the patient, then he/she is on the hook.

Community

Before this ordeal I gave little to no thought about where I lived: my only criteria for a locale was that 1. It was safe for my family and 2. It had a good school system for my children. Residency is interesting in that many people do not have a choice regarding where the training is located, for many you simply accept where you get in: one addresses details like a place to live and community later. It also happens to be the case that many of the more prestigious places to train are located in less than desirable cities: places like The Cleveland Clinic and Mayo come to mind. But even though I gave little thought to the locale when choosing to complete residency here, I was lucky in that the community here has been incredible and integral to my recovery .

—– Chicago —-

We live in a little suburb of Lansing (the home town of Sparrow Hospital) called Okemos. It’s a small, quaint town with a population of about 21,000[1]; many of those living here either work for or attend the local university, Michigan State University (MSU). To put the population of Okemos in perspective approximately 48,000 students attend the university.[2] You may be thinking now, you titled this section “Chicago” and you’re telling me about Okemos. The reason I want to discuss Okemos first is that my wife recently asked me an interesting question as we were in Chicago, walking home.[3] She asked me, “Do you notice any difference between here and home, in terms of the initial reaction you receive?” Her thought process was that because Chicago was a larger city, perhaps the people there would be less surprised to see an obviously hobbled young adult. I did not have to think long about this as my response was, “No, they are caught off guard like everyone else.” The only reason I bring this up is that it doesn’t matter where you’re from or what you’ve been exposed to, we are all human beings who at the core are very similar—it’s very minute changes that make us who we are, that differentiates us from each other. These minute changes can create people as different as Charles Manson and Mother Teresa. Heck, we share 98% of our DNA with chimpanzees. This is also true of communities; what separates a ‘good’ community from a ‘bad’ one is first a question of fit (ie do your beliefs match those of the community?) and boils down to very small differences. Luckily for me these small, almost unperceivable differences result in a community that I would deem a perfect fit for my family and me.

Walking down the street
Walking down the street

—- Okemos —-

Every “Good morning! How are you?” Every open door, even a small gesture like letting a car in when you are driving all adds up. I suppose I am a very superficial person in that I appreciate these (albeit small) kind acts. Now, you could undoubtedly find this in other communities, but the size and people that live here gives it an ideal mix (for me) of a small town with a gentle heart while enjoying the benefits of a larger city (ie a plethora of businesses, great food, and diverse community). There are people who prefer the hustle and bustle of a big city, and people who grow up in and need a town with the population in the hundreds; there is no ‘#1 community’[4], but I can say for me and my family, this community of Okemos perfectly fits our ideals and beliefs. And while these qualities and attributes can be barely noticeable, it is people who perform these acts.

image

In  thinking of Okemos three names come to mind (even though in reality this list could contain 21,000 names): Melissa Cochrane, a mother of one of my son’s best friends at school has shown me kindness I did not think was humanly possible. Even though she is no doubt busy raising her family, she often goes out of her way to check in with me to see if I’m doing okay.   I also cannot separate the community of Okemos in my mind without thinking of another one of my son’s best schoolmate, Wendy Gladhill. Wendy has been a godsend to our family doing thoughtful acts like making us a quilt.[5] She has also helped us out of many jams, as we often call her when a last minute meeting is scheduled at which point we scramble for child care; she never hesitates in imploring us to leave our children with her. I would also be doing Okemos a disservice if I didn’t mention my son’s 1st grade teacher Cathy Staudt. Besides serving her community as a wonderful teacher, she also was an amazing role model for Christian. We would often trade emails as she would update me on my son’s status. Her marvelous teaching not only helped to advance Christian as a person, but it also made my job as a parent infinitely easier as I knew he was getting great guidance at school.

I recently heard a program on NPR where guests give a monologue about their life. This gentleman’s story struck me; he had been through many less-than-ideal situations including: a mugging, a business deal gone awry, and a divorce. He ended his story by saying, “even though I’ve been through so much I never once wanted to move because I knew this city saved my life.” This was touching because for me I cannot imagine living and recovering anywhere else. This community of Okemos has not only given my family and me fantastic things like safety, great food, a great school system, and access to countless numbers of resources, but more importantly to one-of-a kind people. Even though communities are made up of physical things like land, trees, and parks, ultimately it is the people that make or break a locale. Luckily for me, this community of Okemos has amazing people in it.

 

[1] http://quickfacts.census.gov/qfd/states/26/2660340.html

[2] http://colleges.findthebest.com/q/2088/22/How-many-students-go-to-Michigan-State-University-MSU

[3] My parents live in Chicago, thus we often travel there to visit as it is only a 4 hour drive away.

[4] The ‘Top 10 Places to Live’ articles makes me laugh, a ‘good’ place to live is different for everyone based on fit.

[5] A quilt that has helped with these cold Michigan winters.