Category Archives: Empathy

It Takes a Village in Health Care, Too

Posted on July 18, 2013 | Leave a comment

It Takes a Village in Health Care, Too

David W. Stepansky, M.D.**

A few weeks ago, while rounding on patients at Phoenixville Hospital, I began to experience a vague tightness in my upper chest as I walked from one nurses’ station to the next.  The pain was fairly mild, but I also became a little sweaty with it.  The symptoms did not cause me to stop and rest, but when I did sit down to write on a chart, the discomfort would subside, only to recur when I began walking again.

As a physician, I well knew what my symptoms might have represented, but being just as susceptible to denial as any other human, I chose to ignore things for a little while, not wanting to believe that I might be experiencing angina.  I knew what would take place as soon as I said anything to anyone and only wanted to forget that it was happening.  I actually went out to my car to drive to the office to start my outpatient hours, again experiencing that same mild but gnawing pressure in my chest.  I sat in my car for a minute or two, just trying to think it all through, when I finally came to the realization that if I was indeed ignoring cardiac symptoms, than I was being very foolish.

Even then, I did not go directly to the emergency room.  Instead, I wandered through the hospital until I found one of my cardiologist partners and told him my story. Of course, from that moment on, I ceased to be a doctor and somewhat begrudgingly became a patient.  I knew from that moment that I would have to  completely relinquish my regular identity and become wholly reliant not only on the judgment and skill, but also on the compassion of the many who then began to care for me.

What happened after that was at once extraordinary and commonplace. Following my evaluation in the emergency room, I was taken directly to the cath lab where a 95% occlusion of my circumflex artery was discovered and uneventfully stented.  I recuperated in the post-op area, was transferred briefly to an inpatient room, and was ultimately discharged at 6:00 PM.  In the aftermath of this whirlwind, surreal day, I found myself at home safe, healed, and marveling with my wife at how I had had my heart fixed from a tiny hole in my wrist.  All that remained was for me to take it easy for a few days, contemplate how my life had changed, and reflect on this stark and jolting recognition of my own frailty.

The care that I received while a patient at the hospital was wonderful – efficient, accurate, and at the same time compassionate and reassuring.  As an attending physician at Phoenixville Hospital for over 30 years, as well as the organization’s CMO and Patient Safety Officer, I have spent countless hours in countless meetings overseeing the hospital’s quality and safety.  Yet experiencing the care provided from this new (and hopefully not oft repeated) vantage point was eye-opening in some unexpected ways.

In particular, I was repeatedly struck by the realization that exemplary health care is truly the sum total of the well-intended, expert actions of a multitude of people.  With due gratitude to, and respect for, the talented physicians who cared for me, their actions would not have been possible without the support of a highly competent and reliable team that comprised both people and machines.  I was repeatedly impressed and comforted by the confident attitudes of nearly everyone I encountered.  Some of these people I knew well and some I had never seen before.  The people who participated in my care, aside from my doctors, included ER nurses, x-ray technicians, laboratory technicians, cath lab personnel, post-op nurses, and telemetry nurses.  But this barely scratches the surface when one considers that the technology brought to bear on me was developed and refined by scores of dedicated individuals whose ultimate purpose was to provide accurate and safe healing to individuals like me.  In many ways, this was a humbling experience, as I must be thankful to a multitude of people, most of whom are actually behind the scenes and will never be known to me.

Many individuals who are involved in the front line of health care, including me, worry about the dehumanizing effect that high technology and specialization has had on patient care.  Doctors and the systems in which they work are so often criticized for being aloof and insensitive to the emotional needs of patients. Health care has become highly business-oriented, often at the expense of the human needs of those for whom the system ostensibly came into being.  Unfortunately, there is much truth to this concern.

However, the realization that I had during my brief hospital stay was that the human aspects of health care can be maintained even in the face of “dehumanizing” technology.  Doctors do less “hand holding” than in the past, but this is at least in part because there is so much more they can do.  Patients expect, and are entitled to, the high technology that modern medicine brings to them,  but they are also  entitled to  the warmth and  caring of the people who deploy that technology on their behalf.  I can happily report that I received both when I was ill.  It was, once again, an eye-opening experience.

The reality is that high-quality health care can only be the result of painstaking design.  The care that I received could never happen were it not for the coordinated actions of hundreds of dedicated individuals.  And so I would like to acknowledge the many people and machines that brought me back to good health.  To my doctors, nurses, technicians and others who provided efficient and compassionate care; to the many people behind the scenes whom I will never know who also contributed to my well-being; and finally to Community Health Systems for providing the structure necessary for all of this to happen – my heartfelt thanks.

Copyright © 2013 by David W. Stepansky.  All rights reserved.

________________________________________

**Internist David Stepansky is Chief Medical Officer and Patient Safety Officer at Phoenixville Hospital, Phoenixville, PA, and Chair of the Patient Safety Committee of Community Health Systems, Inc., Franklin, TN.

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My Father’s Empathy

Posted on June 16, 2012 | Leave a comment

My late father, William Stepansky, was the most empathic caregiver I have ever known.  Until recently, however, I never thought of him that way.  Indeed, I never had the sense that he “practiced” medicine one way or another, simply that he lived out his medical calling.  I thought nothing of having a father who taped the Hippocratic Oath to his dresser and read it every morning.

My father’s “empathy” did not grow out of medical training; it was the stuff of life experience. His family’s emigration from Russia followed the Hitler-like savagery of the Ukrainian Pogroms that followed World War I.  Anti-Semite thugs murdered his grandfather on his own doorstep several years before his father, Pincus, mother, Vittie (then pregnant with him), and older sister, Enta began their uncertain journey to America in 1921.  Pincus, a highly decorated Russian war veteran, a member of the 118th (Shuiskii) Infantry Regiment of the 30th Infantry Division, was the recipient of what my father termed the Russian equivalent of our own Congressional Medal of Honor.  “He was a sergeant,” he would tell me, “but a colonel had to salute him first.” On the battlefield he was wounded three times in the chest and once left for dead.  Stripped of his decorations by the bandits who raided his native village of Stavishche, he arrived in the new world penurious and crippled with chest pain.

My father, who was born in Kishinev, Rumania during the first leg of his family’s 1,900-mile journey across continental Europe, was six-months old when they arrived in Boston Harbor.  A year later, they left Boston and made their home in the densely Jewish enclave in South Philadelphia.  Throughout my life, my father shared two memories of his own father; they attest, respectively, to the positive and negative poles of the wounded soldier-tailor’s dedication to high culture. The first is of Pincus gamely limping across long city blocks with his young son in tow; he was taking his young son, my father, to his weekly violin lesson with his first teacher, the local postman.  Pincus never left the music room, and when the lesson was over, he took his son’s violin and lovingly wiped it down with a special cloth brought solely for that purpose.

The second memory is of Pincus imperiously ordering his son to bring his violin and perform whenever neighbors, friends, or relations gathered in the family’s small apartment.  A shy, retiring child, my father urgently wanted not to play. But his father’s directives were issued from on high with military-like peremptoriness that brooked neither contradiction nor delay.  And so my father got his violin and he played, perhaps through tears, perhaps through rage.

My father, at age 15, watched his father die of heart disease. In February, 1943, having completed his third-year of pharmacy training, he was called up by the army and served as a surgical technician in a medical battalion attached to the 80th Infantry Division of Patton’s Third Army.  In France, Belgium, and Germany, he worked alongside battlefield surgeons who fought to keep wounded GIs alive in a surgical clearing company only a short remove from the front line.  I learned a bit about the visceral reality of wound management in the European Theatre during his final years, when I interviewed him and several of his surviving comrades for The Last Family Doctor.  The prosaic summary of his duties in his army  discharge of January, 1946 – “Removed uncomplicated cases of shrapnel wounds, administered oxygen and plasma, sterilized instruments, bandages, clothing, etc.  Gave hypodermic injections and performed general first aid duties” – only hints at this reality.

My father, so I learned, held down wounded GIs for anesthesia-less suturing, assisted with frontline battlefield surgery, much of which involved amputation, and then, after the day’s work, went outside to bury severed arms and legs. He experienced close fighting in the woods of Bastogne during the freezing winter of 1945, when the techs worked 20-hour shifts to keep up with the inflow of casualties.  One can only wonder at the impact of such things on the constitution of a gentle and soft-spoken 22-year-old pharmacy student whose passion, before and after the war, was the violin, and who carried Tolstoy’s War and Peace in his backpack throughout his European tour.

A different man might have emerged from my father’s childhood and wartime experience emotionally constricted, withdrawn, intimidated by authority figures or, obversely (or concurrently) enraged by them.  In my father’s case, a lifelong performance anxiety – the legacy of a militaristic father repeatedly ordering him to play violin before visitors — was vastly counterbalanced by an enlarged empathic sensibility that enabled him to understand and contain his patients’ anxieties about their health, their relationships, their ability to love and to work.  Wrestling as he did with his own anxieties and memories of the war, which included the liberation of Dachau and Buchenwald, he became a physician who accepted utterly his patients’ prerogative to share their anxieties with him, even to project their anxieties into him.  He was, after all, their doctor.

My father was not only an astute diagnostician but also a gifted psychotherapist, and the amalgam of these twin talents was an ability to titrate his disclosures, to tell patients what they needed to know, certainly, but in a manner he thought they could bear.  His psychologically attuned approach to patient care is now associated with the paternalism of a different era.  But it was also an aspect of his ability, rare among physicians, to diagnose suffering and to discern the limits of this or that patient’s ability to cope with it.[1]  This style of practice was wonderfully appreciated by his patients, some of whom, after leaving the area, travelled a distance for yearly appointments with him.  No doubt they wanted to experience the “holding environment” of his person.

Premed students who grind away at biology and chemistry have no idea what my father and his cohort of war-tested physicians, many first- and second-generation immigrants, overcame for the privilege of studying medicine.  I would not wish his life story – of which I relate only a few particulars here – on any of them.  And yet, we might ponder the desirability of subjecting premed students to some muted version of his experience in order to nurture whatever elements of empathic temperament they possess.  Specifically, medical educators can take steps to ensure that premeds are not subverted by medicine’s  “hidden curriculum” – its institutional pull away from patient-centered values and practices – while they are still in college, especially when they complete their med school applications and present for their interviews.  And they can work harder to find clinical teachers who do not endorse shame, humiliation, and intimidation as credible educational strategies for acculturating young doctors into the profession.[2]

If we wish to steer contemporary medical students toward compassionate, or at least adequately sensitive, care-giving – and here I echo what others have said[3] – then we need to provide them with clinical teachers who are dissatisfied with a passive conception of role modeling and actually model discrete and specifiable behaviors in their interactions with patients.[4]  Sadly, the literature continues to provide examples of clinical training during medical school and residency that is denigrating, demoralizing, and ultimately desensitizing.  We end up with clinical teachers (not all, by any means, but no doubt a good many) who long ago capitulated to the hidden curriculum and devote themselves to readying the next generation of trainees for a like-minded (or better, a survival-minded) capitulation.  With this intergenerational dynamic in place, we are at the point of Marshall Marinker’s devastating “Myth, Paradox and the Hidden Curriculum” (1997), which begins:  “The ultimate indignity teachers inflict upon students is that, in time, they become us.”[5]

My father and his cohort of med students who trained during and shortly after WWII were resistant to shaming and intimidation.  They had experienced too much to be diverted from a calling to practice medicine.  But then their teachers too had experienced a great deal, many working alongside their future students – the pharmacists, medics, techs, and GIs – in casualty clearing stations, field hospitals, VA hospitals, and rehab facilities in Europe and America.  Teachers emerging from the war years encountered a generation of mature students whose wartime experience primed them to embrace medicine as patient care.  And the students, for their part, encountered teachers whose own wartime experience and nascent cold war anxieties tempered budding Napoleonic complexes.  High tech medicine, bioethics, and patient rights all lay in the future. Generalists like my father were trained to provide care that was caring; their ministrations were largely “medicinal, manual, and mentalistic, which is to say, psychological.”[6]  In the kind of training they received, the notion of  castigating as “unprofessional” med students whose patient-centered concerns and queries slowed down the breakneck pace of team rounds – a documented reality these days[7] – would literally have been non-sensical.

But that was then and this is now.  Today medical culture has in key respects become subversive of the ideals that drew my father and his cohort to medicine.  And this culture, which revolves around the sacrosanctity of an academic hierarchy that, inter alia, insists on perfection, denigrates uncertainty, privileges outcome over process, and, in the clinical years, engages students adversarially, is far too entrenched to be dislodged with manifestos, position papers, and curricular reforms.  What educators can do is seek out medical students whose empowerment derives less from high grades and artfully constructed admissions essays and more from life experience in the trenches – in any trenches. We don’t need to send premeds off to war to make them resistant to the hidden curriculum, but we should encourage premed experience robust enough to deflect its pull and let those of caring temperament develop into caring physicians.

Perhaps we need students who are drawn less to biochemistry than to the vagaries of human chemistry, students who have already undertaken experiential journeys that bring into focus the humanistic skyline of their medical horizons.  What Coulehan[8] terms “socially relevant service-oriented learning” should not be confined to residency training.  We need more students who come to medicine after doing volunteer work in developing nations; fighting for medical civil rights; staffing rural and urban health clinics; and serving public health internships.[9]  And if this suggestion is quixotic, let’s at least have premed students spend the summer before senior year in the trenches, as I proposed in “The Hunt for Caring Med Students.”  Such strategies will not create empathic caregivers de novo, but they will nurture the empathic temperament of those so endowed and, one hopes, fortify them a little better against the careerist blandishments of the hidden curriculum.  It would be nice if, a generation hence, other sons (and daughters) could write about their fathers’ (and mothers’) special kind of therapeutic empathy.

[1] E. J. Cassell, “Diagnosing suffering: a perspective,” Ann. Intern. Med., 131:531-534, 1999.

[2] J. White, et al., “’What do they want me To say?’: the hidden curriculum at work in the medical school selection process: a qualitative study,” BMC Med. Educ., 12:1-9, 2012; U. H. Lindström, et al., “Medical students’ experiences of shame in professional enculturation,” Med. Educ., 45:1016-1024, 2011; A. H. Brainard & H. C. Brislen, “Learning professionalism: a view from the trenches,” Acad. Med., 82:1010-1014, 2007; P. Haidet & H. F. Stein, “The role of the student-teacher relationship in the formation of physicians,” J. Gen. Intern. Med., 21:S16-20, 2006; Mary Seabrook, “Intimidation in medical education: students’ and teachers’ perspectives,” Stud. Higher Educ., 29:59-74, 2004.

[3] Haidet & Stein, “Role of the student-teacher relationship”; N. Ratanawongsa, et al., “Residents’ perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements,” J. Gen Intern. Med., 21:758-763, 2006; J. Coulehan, “Today’s professionalism: engaging the mind but not the heart,” Acad. Med., 80:892-898, 2005; B. Maheux, et al., “Medical faculty as humanistic physicians and teachers: the perceptions of students at innovative and traditional medical schools, Med. Educ., 34:630-634, 2000; J. H. Burack, et al., Teaching compassion and respect: attending physicians’ responses to problematic behaviors,” J. Gen. Intern. Med., 14:49-55, 1999.

[4] See further Burack, “Teaching compassion and respect,” p. 54.

[5] M. Marinker, “Myth, paradox and the hidden curriculum,” Med. Educ., 31:293-298, 1997, quoted at p. 293; cf. Haidet & Stein, “Role of student-teacher relationship,” p. 3: “The relational processes of the hidden curriculum assure the perpetuation of its content” (authors’ emphasis).

[6] P. E. Stepansky, The Last Family Doctor: Remembering My Father’s Medicine (Keynote, 2011), p. 114.

[7] Brainard & Brislen, “Learning professionalism,” p. 1011.

[8] Coulehan, “Today’s professionalism,” p. 896.

[9] For examples of such physicians and their role in the revitalization of primary care medicine in the 1970s, see Stepansky, Last Family Doctor, pp. 130-133.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.

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Posted in Empathy, General Practice, Medical Education, Medicine in WWII, Premed Education

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Humanitas, History, Empathy

Posted on June 1, 2012 | Leave a comment

In the nineteenth century, no one was devising courses, workshops, or coding schemes to foster empathic care-giving.  In both Europe and America, students were expected to learn medicine’s existential lessons in the manner they long had:  through mastery of Latin and immersion in ancient writings.  This fact should not surprise us:  knowledge of Latin was the great nineteenth-century signpost of general knowledge.  It was less an index of education achieved than testimony to educability per se.  As such, it was an aspect of cultural endowment essential to anyone aspiring to a learned profession.

I have written elsewhere about the relationship of training in the classics to medical literacy throughout the century.[1]  Here I focus on the “felt” aspect of this cultural endowment: the relationship of classical training to the kind of Humanitas (humanity) that was foundational to empathic caregiving.

The conventional argument has it that the role of Latin in medicine progressively diminished throughout the second half of the nineteenth century, as experimental medicine and laboratory science took hold, first in Germany and Austria, then in France, and finally in Britain and the United States, and transformed the nature of medical training.  During this time, physicians who valued classical learning, so the argument goes, were the older men who clung to what Christopher Lawrence terms “an epistemology of individual experience.”  In Britain, aficionados of the classics were the older, hospital-based people who sought to circumscribe the role of science in clinical practice.  Like their younger colleagues, they used the rhetoric of science to bolster their authority but, unlike the younger men, they “resisted the wholesale conversion of bedside practice into a science – any science.”  For these men, clinical medicine might well be based on science, but its actual practice was “an art which necessitated that its practitioners be the most cultured of men and the most experienced reflectors on the human condition.”[2]

For Lawrence, classical learning signified the gentleman-physician’s association of bedside practice with the breadth of wisdom associated with general medicine; as such, it left them “immune from sins begotten by the narrowness of specialization.”  In America, I believe, the situation was different.  Here the classics did not (or did not only) sustain an older generation intent on dissociating scientific advance from clinical practice.  Rather, in the final decades of the century, the classics sustained the most progressive of our medical educators in their efforts to resist the dehumanization of sick people inherent in specialization and procedural medicine.  Medical educators embraced experimental medicine and laboratory science, to be sure, but they were also intent on molding physicians whose sense of professional self transcended the scientific rendering of the clinical art.  Seen thusly, the classics were more than a pathway to the literacy associated with professional understanding and communication; they were also a humanizing strategy for revivifying the Hippocratic Oath in the face of malfunctioning physiological systems and diseased organs.

Consider the case of Johns Hopkins Medical College, which imported the continental, experimental model to theUnited States and thereby became the country’s first modern medical school in 1892.   In the medical value assigned to the classics, three of Hopkins’ four founding fathers were second to none.  William Welch, the pathologist who headed the founding group of professors (subsequently known as “The Big Four”), only reluctantly began medical training in 1872, since it meant abandoning his first ambition:  to become a Greek tutor and ultimately a professor of classics at his alma mater, Yale University.  Welch’s love of the classics, especially Greek literature and history, spanned his lifetime.  “Everything that moves in the modern world has its roots in Greece,” he opined in 1907.

William Osler, the eminent Professor of Medicine who hailed from the Canadian woodlands north of Toronto, began his education as a rambunctious student at the Barrie Grammar School, where he and two friends earned the appellation “Barrie’s Bad Boys.”  On occasion, the little band would give way to “a zeal for study” that led them after lights-out to “jump out of our dormitory window some six feet above the ground and study our Xenophon, Virgil or Caesar by the light of the full moon.”  Osler moved on to the Trinity College School where, in a curriculum overripe with Latin and the classics, he finished first in his class and received the Chancellor’s Prize of 1866.  Two years later, he capped his premedical education at Trinity College with examination papers on Euclid, Greek (Medea and Hippolytus), Latin Prose, Roman History, Pass Latin (Terence), and Classics (Honours).[3]  Ever mindful of his classical training, Osler not only urged his Hopkins students “to read widely outside of medicine,” but admonished them to “Start at once a bed-side library and spend the last half hour of the day in communion with the saints of humanity,”  among whom he listed Plutarch, Marcus Aurelius, Plato, and Epictetus.[4]

When Howard Kelly, the first Hopkins Professor of Gynecology and arguably the foremost abdominal surgeon of his time, began college in 1873, he was awarded the Universityof Pennsylvania’s matriculate Latin Prize for his thesis, “The Elements of Latin Prose Composition.”  Kelly, like Welch and Osler, was a lifetime lover of the classics, and he relished summer vacations, when he could “catch up on his Virgil and other classics.[5]

Of the fourth Hopkins founding father, the reclusive, morphine-addicted surgeon William Stewart Halsted, there is no evidence of a life-long passion for the ancients, though his grounding in Latin and Greek at Phillips Academy, which he attended from 1863 to 1869, was typically rigorous.  Far more impressive bona fides belong to one of  Halsted’s early trainees, Harvey Cushing, who came to Hopkins in 1897 and became the hospital’s resident surgeon in 1898.  Cushing, the founder of modern neurosurgery, entered Yale in 1887, where he began his college career “walking familiarly in the classics” with courses that included “geometry, Livy, Homer, Cicero, German, Algebra, and Greek prose.”  In February, 1888, he wrote his father that Yale was giving him and his friends “our fill of Cicero.  We have read the Senectute and Amicitia and are reading his letter to Atticus, which are about the hardest Latin prose, and now we have to start in on the orations.”[6]

In the early twentieth century, Latin, no less than high culture in general, fell by the wayside in the effort to create modern “scientific” doctors.  By the 1920s, medical schools had assumed their modern “corporate” form, providing an education that was standardized and mechanized in the manner of factory production.  “The result of specialization,” Kenneth Ludmerer has observed, “was a crowded, highly structured curriculum in which subjects were taught as a series of isolated disciplines rather than as integrated branches of medicine.”[7]  Absent such integration, the very possibility of a holistic grasp of sick people, enriched by study of the classics, was relinquished.

The elimination of Latin from the premed curriculum made eminently good sense to twentieth-century medical educators.  But it was not only the language that went by the wayside.  Gone as well was familiarity with the broader body of myth, literature, and history to which the language opened up.  Gone, that is, was the kind of training that sustained holistic, perhaps even empathic, doctoring.

When in the fall of 1890 – a year after the opening of Johns Hopkins Hospital – Osler and Welch founded the Johns Hopkins Hospital Historical Club, it was with the explicit understanding that medical history, beginning with the Hippocratic and Galenic writings, was a humanizing building block in the formation of a medical identity.  The first year of monthly meetings was devoted exclusively to Greek medicine, with over half of 15 presentations dealing with Hippocrates.  Osler’s two talks dealt, respectively, with “The Aphorisms of Hippocrates” and “Physic and Physicians as Depicted in Plato.”  Over the next three years, the Club’s focus broadened to biography, with Osler himself presenting essays on seven different American physicians, John Morgan, Thomas Bond, Nathan Smith, and William Beaumont, among them.  His colleagues introduced the club to other medical notables, European and American, and explored topics in the history of the specialties, including the history of trephining, the history of lithotomy in women, and the ancient history of rhinoscopy.[8]

The collective delving into history of medicine that took place within the Hopkins Medical History Club not only broadened the horizons of the participates, residents among them.  It also promoted a comfortable fellowship conducive to patient-centered medicine.  The Hopkins professors and their occasional guests were not only leading lights in their respective specialties, but Compleat Physicians deeply immersed in the humanities. Residents and students who attended the meetings of the Club saw their teachers as engaged scholars; they beheld professors who, during the first several years of meetings, introduced them, inter alia, to “The Royal Touch for Scrofula in England,” “The Medicine of Shakespeare,” “The Plagues and Pestilences of the Old Testament,” and “An Old English Medical Poem by Abraham Cowley.”   Professors familiar with doctor-patient relationships throughout history were the very type of positive role models that contemporary medical educators search for in their efforts to counter a “hidden curriculum” that pulls students away from patient-centered values and into a culture of academic hierarchies, cynical mixed-messages, and commercialism.[9]

Medical history clubs were not uncommon in the early decades of the twentieth century.  The Hopkins Club, along with the New York-based Charaka Club founded in 1899, had staying power.  In 1939, the third meeting of the Hopkins Club, which presented a play adapted by Hopkins’ medical librarian Sanford Larkey from William Bullein’s “A Dialogue Against the Fever Pestilence” (1564), drew a crowd of 460.  The following year, when the Hopkins Club celebrated its fiftieth anniversary, Baltimore alone boasted two other medical history clubs: the Osler Society of the Medical and Chirurgical Faculty of the State of Maryland and the Cordell Society of the University of Maryland.[10]

Although medical history clubs are a thing of the past, we see faint echoes of their milieu in contemporary medical student and resident support groups, some modeled on the Balint groups developed by Michael and Enid Balint at London’s Tavistock Clinic in the 1950s.[11]  All such groups seek to provide a safe space for shared reflection and self-examination in relation to physician-patient relationships.  In the late-nineteenth and early-twentieth centuries, history clubs filled this space with topics in medical history.  Their meetings broadened the care-giving sensibility of young physicians by exposing them to pain and suffering, to plagues and pestilences, far beyond the misery of everyday rounds.  Medical history and the broadened “medical self” it evokes and nurtures – now there’s a pathway to empathy.

[1] P. E. Stepansky, “Humanitas: Nineteenth-Century Physicians and the Classics,” presented to the Richardson History of Psychiatry Research Seminar, Weill Cornell Medical College, New York, NY, October 3, 2007.

[2] C. Lawrence, “Incommunicable knowledge: science, technology and the clinical art in Britain, 1850-1914,” J. Contemp. Hist., 20:503-520, 1985, quoted at pp. 504-505, 507.

[3] S. Flexner & J. T. Flexner, William Henry Welch and the Heroic Age of American Medicine (Baltimore:  Johns Hopkins University Press, 1968 [1941]), pp. 63-65, 419-420; H. Cushing, The Life of Sir William Osler (London: Oxford University Press, 1940), pp. 25, 39, 52.

[4] W. Osler, Aequanimitas, with other Addresses to Medical Students, Nurses and Practitioners of Medicine, 3rd edition (New York: McGraw-Hill, 1906), pp. 367, 463; L. F. Barker, Time and the Physician (New York: Putnam, 1942), p. 86.

[5] A. W. Davis, Dr. Kelly of Hopkins: Surgeon, Scientist, Christian (Baltimore: Johns Hopkins University Press, 1959),  pp. 17, 21.

[6] David Linn Edsall, who, as Dean of Harvard Medical School and of the Harvard School of Public Health during the 1920s, engineered Harvard’s progressive transformation, entered Princeton the same year (1887) Cushing entered Yale.  Edsall came to Princeton “a serious-minded young classicist” intent on a career in the classics. See  J. C. Aub & R. K. Hapgood, Pioneer in Modern Medicine: David Linn Edsall of Harvard (Cambridge: Harvard Medical Alumni Association, 1970), p. 7.  On Cushing and the classics, see  E. H. Thomson, Harvey Cushing: Surgeon, Author, Artist (New York: Schuman, 1950), p. 20.

[7] K. M. Ludmerer, Learning to Heal: The Development of American Medical Education (New York:  Basic Books, 1985), pp. 256-57, 262.

[8] V. A. McKusick, “The minutes of the Johns Hopkins medical history club, 1890 to 1894,” Bull. Hist. Med., 27:177-181, 1953.

[9] F. W. Hafferty, “Beyond curriculum reform: confronting medicine’s hidden curriculum,” Acad. Med., 73:403-407, 1998;  J. Coulehan, “Today’s professionalism: engaging the mind but not the heart,” Acad. Med., 80:892-898, 2005; P. Haldet & H. F. Stein, “The role of the student-teacher relationship in the formation of physicians: the hidden curriculum as process,” J. Gen. Int. Med., 21(suppl):S16-S20, 2005; S. Weissman, “Faculty empathy and the hidden curriculum” [letter to the editor], Acad. Med., 87:389, 2012.

[10] O. Temkin, “The Johns Hopkins medical history club,” Bull. Hist. Med., 7:809, 1939; W.R.B., “Johns Hopkins medical history club,” BMJ, 1:1036, 1939.

[11] K. M. Markakis, et al., “The path to professionalism: cultivating humanistic values and attitudes in residency training,” Acad. Med., 75:141-150, 2000; M. Hojat, “Ten approaches for enhancing empathy in health and human services cultures,” J. Health Hum. Serv. Adm., 31:412-450, 2009;  K. Treadway & N. Chatterjee, “Into the water – the clinical clerkships,” NEJM, 364:1190-1193, 2011.  On contemporary Balint groups, see A. L. Turner & P. L. Malm, “A preliminary investigation of Balint and non-Balint behavioral medicine training,” Fam. Med., 36:114-117,2004; D. Kjeldmand, et al., “Balint training makes GPs thrive better in their job,” Pat. Educ. Couns., 55:230-235, 2004; K. P. Cataldo, et al., “Association between Balint training and physician empathy and work satisfaction,” Fam. Med., 37:328–31, 2005.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.

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Posted in Classics and Medicine, Empathy, Medical Education, Medical Humanities, Nineteenth-Century Medicine

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Pathways to Empathy?

Posted on May 18, 2012 | 2 comments

Dipping into the vast[1] literature on clinical empathy, one quickly discerns the dominant storyline.  Everyone agrees that empathy, while hard to define,  hovers around a kind of physicianly caring that incorporates emotional connection with patients.  The connection conveys sensitivity to the patient’s life circumstances and personal psychology, and gains expression in the physician’s ability to encourage the patient to express emotion, especially as it pertains to his medical condition.  Then the physician draws on her own experience of similar emotions in communicating an “accurate” empathic understanding of how the patient feels and why he should feel that way.

Almost all commentators agree that empathy, whatever it is, is a good thing indeed.  They cite empirical research linking it to more efficient and effective care, to patients who are more trusting of their doctors, more compliant in following instructions, and more satisfied with the outcome of treatment. Patients want doctors who give them not only the appointment time but the time of day, and when they feel better understood, they simply feel better.  Furthermore, doctors who are empathic doctor better.  They learn more about their patients and, as a result, are better able to fulfill  core medical tasks such as history-taking, diagnosis, and treatment.  Given this medley of benefits, commentators can’t help but lament the well-documented decline of empathy, viz., of humanistic, patient-centered care-giving, among medical students and residents, and to proffer new strategies for reviving it.  So they present readers with a host of training exercises, coding schemes, and curricular innovations to help medical students retain the empathy with which they began their medical studies, and also to help overworked, often jaded, residents refind the ability to empathize that has succumbed to medical school and the dehumanizing rigors of specialty training.[2]

It is at this point that empathy narratives fork off in different directions.  Empathy researchers typically opt for a cognitive-behavioral approach to teaching empathy, arguing that if medical educators cannot teach students and residents to feel with their patients, they can at least train them to discern what their patients feel, to encourage the expression of these feelings, and then to respond in ways that affirm and legitimize the feelings.  This interactional approach leads to the creation of various models, step-wise approaches, rating scales, language games (per Wittgenstein), and coding systems, all aimed at cultivating a cognitive skill set that, from the patient’s perspective, gives the impression of a caring and emotionally attuned provider.  Duly trained in the art of eliciting and affirming emotions, the physician becomes capable of what one theorist terms “skilled interpersonal performances” with patients.  Seen thusly, empathic connection becomes a “clinical procedure” that takes the patient’s improved psychobiological functioning as its outcome.[3]

The cognitive-behavioral approach is an exercise in what researchers term “communication skills training.”  It typically parses doctor-patient communication into micro-interactions that can be identified and coded as “empathic opportunities.”  Teaching students and residents the art of “accurate empathy” amounts to alerting them to these opportunities and showing how their responses (or nonresponses) either exploit or miss them.  One research team, in a fit of linguistic inventiveness, tagged the physician’s failure to invite the patient to elaborate an emotional state (often followed by a physician-initiated change of subject), an “empathic opportunity terminator.”  Learning to pick up on subtle, often nonverbal, clues of underlying feeling states and gently prodding patients to own up to emotions is integral to the process. Thus, when patients don’t actually express emotion but instead provide a clue that may point to an emotion, the physician’s failure to travel down the yellow brick road of masked emotion becomes, more creatively still, a “potential empathic opportunity terminator.”  Whether protocol-driven questioning about feeling states leads patients to feel truly understood or simply the object of artificial, even artifactual, behaviors has yet to be systematically addressed.  Medical researchers ignore the fact that empathy, however “accurate,” is not effective unless it is perceived as such by patients.[4]

Medical educators of a humanistic bent take a different fork in the road to empathic care giving.  Shying away from protocols, models, scales, and coding schemes, they embrace a more holistic vision of empathy as growing out of medical training leavened by character-broadening exposure to the humanities. The foremost early proponent of this viewpoint was Howard Spiro, whose article of 1992, “What is Empathy and Can It Be Taught?” set the tone and tenor for an emerging literature on the role of the humanities in medical training.  William Zinn echoed his message a year later: “The humanities deserve to be a part of medical education because they not only provide ethical guidance and improve cognitive skills, but also enrich life experiences in the otherwise cloistered environment of medical school.”  The epitome of this viewpoint, also published in 1993, was the volume edited by Spiro and his colleagues, Empathy and the Practice of Medicine.  Over the past 15 years, writers in this tradition have added to the list of nonmedical activities conducive to clinical empathy.  According to Halpern, they include “meditation, sharing stories with colleagues, writing about doctoring, reading books, and watching films conveying emotional complexity.”  Shapiro and her colleagues single out courses in medicine and literature, attendance at theatrical performances, and assignments in “reflective writing” as specific empathy-enhancers.[5]

Spiro practiced and taught gastroenterology in New Haven, home of Yale University School of Medicine and the prestigious Western New England Psychoanalytic Institute. One quickly discerns the psychoanalytic influence on his approach.  The humanistic grounding he sought for students and residents partakes of this influence, whether in the kind of literature he wanted students to read (i.e., “the new genus of pathography”) or in his approach to history taking (“The clues that make the physician aware at the first meeting that a patient is depressed require free-floating attention, as psychoanalysts call it.”).

A variant of the “humanist” approach accepts the cognitivist assumption that empathy is a teachable skill but veers away from communications theory and cognitive psychology to delineate it.  Instead, it looks to the world of psychotherapy, especially the psychoanalytic self psychology of Heinz Kohut.  These articles, most of which were published in the 90s, are replete with psychoanalytic conceptualizations and phraseology; they occasionally reference Kohut himself but more frequently cite work by psychoanalytic self psychologists  Michael Basch and Dan Buie, the psychiatrist Leston Havens, and the psychiatrist-anthropologist Arthur Kleinman.

Authors following a psychoanalytic path to empathy assign specific tasks to students, residents, and clinicians, but the tasks are more typically associated with the opening phase of long-term psychotherapy.  Clinicians are enjoined to begin in a patiently receptive mode, avoiding the “pitfalls of premature empathy” and realizing that patients “seldom verbalize their emotions directly and spontaneously,” instead offering up clues that must be probed and unraveled.  Empathic receptiveness helps render more understandable and tolerable “the motivation behind patient behavior that would otherwise seem alien or inappropriate.”  Through “self-monitoring and self-analyzing,” the empathic clinician learns to rule out endogenous causes for heightened emotional states and can “begin to understand its source in the patient.”  In difficult confrontations with angry or upset patients, physicians, no less than psychoanalysts, must cultivate “an ongoing practice of engaged curiosity” that includes systematic self-reflection.  Like analysts, that is, they must learn to analyze the countertransference for clues about their patients’ feelings.[6]

There is a mildly overwrought quality to the medical appropriation of psychoanalysis, as if an analytic sensibility per se – absent lengthy analytic training – can be superadded to the mindset of task-oriented, often harried, clinicians and thereupon imbue them with heightened “empathic accuracy.” Given the tensions among the gently analytic vision of empathic care, the claims of patient autonomy, and the managerial, data-oriented, and evidence-based structure of contemporary practice, one welcomes as a breath of fresh air the recent demurrer of Anna Smajdor and her colleagues.  Patients, they suggest, really don’t want empathic doctors who enter their worlds and feel their pain, only doctors who communicate clearly and treat them with courtesy and a modicum of respect.[7]

And so the empathy narratives move on.  Over the past decade, neuroscientists have invoked empathy as an example of what they term “interpersonal neurobiology,” i.e., a neurobiological response to social interaction that activates specific neural networks, probably those involving the mirror neuronal system.  It may be that empathy derives from an “embodied simulation mechanism” that is neurally grounded and operates outside of consciousness.[8]  In all, this growing body of research may alter the framework within which empathy training exercises are understood. Rather than pressing forward, however, I want to pause and look backward.  Long before the term “empathy” was used, much less operationalized for educational purposes, there were deeply caring, patient-centered physicians.  Was there anything in their training that pushed them in the direction of empathic caregiving?   I propose that nineteenth-century medicine had its own pathway to empathy, and I will turn to it in the next posting.

[1] R. Pedersen’s review article, “Empirical research on empathy in medicine – a critical review,” Pat. Educ Counseling, 76:307-322, 2009 covers 237 research articles.

[2] F. W. Platt & V. F. Keller, “Empathic communication: a teachable and learnable skill,” J. Gen Int. Med., 9:222-226, 1994; A. L. Suchmann, et al., “A model of empathic communication in the medical interview,” JAMA, 277:678-682, 1997; J. L. Coulehan, et al., “’Let me see if I have this right . . .’: words that help build empathy,”  Ann. Intern. Med., 136:221-227, 2001; H. M. Adler, “Toward a biopsychosocial understanding of the patient-physician relationship: an emerging dialogue,” J. Gen. Intern. Med., 22:280-285, 2007; M. Neumann et al., “Analyzing the ‘nature’ and ‘specific effectiveness’ of clinical empathy: a theoretical overview and contribution towards a theory-based research agenda,” Pat. Educ. Counseling, 74:339-346, 2009; K. Treadway & N. Chatterjee, “Into the water – the clinical clerkships,” NEJM, 364:1190-1193, 2011.

[3] Adler, “Biopsychosocial understanding,” p. 282.

[4] Suchmann, et al., “Model of empathic communication”; Neumann, “Analyzing ‘nature’ and ‘specific effectiveness’,” 343; K. A. Stepien & A. Baernstein, “Educating for empathy: a review,” J. Gen. Int. Med., 21:524-530, 2006; R. W. Squier, “A Model of empathic understanding and adherence to treatment regimens in practitioner-patient relationships,” Soc. Sci. Med., 30:325-339, 1990.

[5] H. Spiro, “What is empathy and can it be taught?”, Ann. Int. Med., 116:843-846, 1992; W. Zinn, “The empathic physician,” Arch. Int. Med., 153:306-312, 1993; H. Spiro, et al., Empathy and the Practice of Medicine (New Haven: Yale University Press, 1993); J. Shapiro & L. Hunt, “All the world’s a stage: the use of theatrical performance in medical education,” Med. Educ., 37:922-927, 2003; J. Shapiro, et al., “Teaching empathy to first year medical students: evaluation of an elective literature and medicine course,” Educ. Health, 17:73-84, 2004; S. DasGupta & R. Charon, “Personal illness narratives: using reflective writing to teach empathy,” Acad. Med., 79:351-356, 2004; J. Shapiro, et al., “Words and wards: a model of reflective writing and its uses in medical education,” J. Med. Humanities, 27:231-244, 2006; J. Halpern, Empathy and patient-physician conflicts,” J. Gen. Int. Med., 22:696-700, 2007.

[6] Suchmann et al., “Model of empathic communication,” 681; Zinn, “Empathic physician,” 308; Halpern, “Empathy and conflicts,” 697.

[7] Halpern, “Empathy and conflicts,” 697; A. Smajdor, et al., “The limits of empathy: problems in medical education and practice,” J. Med. Ethics., 37:380-383, 2011.

[8] V. Gallese, “The roots of empathy: the shared manifold hypothesis and the neural basis of intersubjectivity,” Psychopathology, 36:171-180, 2003; L. Carr, et al., “Neural mechanisms of empathy in humans: a relay from neural systems for imitation to limbic area,” Proc. Natl. Acad. Sci., 100:5497-5502, 2003; G. Rizzolatti & L. Craighero, “The mirror-neuron system,” Ann. Rev. Neurosci., 27:169-192, 2004; V. Gallese, et al., “Intentional attunement: mirror neurons and the neural underpinnings of interpersonal relations,” J. Amer. Psychoanal. Assn., 55:131-176, 2007.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.

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Posted in Doctor-Patient Communication, Empathy, Medical Education, Psychoanalysis

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The Hunt For Caring Med Students

Posted on April 27, 2012 | 3 comments

The MCATs, new and improved, will save us!  The overhauled medical school admissions test, which was approved by the American Association of Medical Colleges last February and will take effect in 2015, will devote almost half its questions to the social sciences and critical reasoning, with the latter including reading passages addressing cross-cultural issues and medical ethics.  According to Darrell G. Kirch, President of the AAMC, the new version of the test will aid medical schools in finding students “who you and I would want as our doctors.  Being good doctors isn’t just about understanding science, it’s about understanding people.”[1]

To which I reply:  Will wonders never cease?  We’re going to help medical schools make humanistic doctors with better people skills by making sure premed students are exposed to humanistic medicine as it filters through introductory psychology and sociology courses.  Had AACP personnel perused a sampling of introductory psychology and sociology syllabi, they might have paused before deciding to cultivate this new skill set through introductory social science courses, which, in this day and age, devote little time to theories of personality, family structure and dynamics, psychosocial development, and psychodynamics – the very topics that engaged me when I studied introductory psychology in the fall of 1969.  Still less do today’s introductory social science courses permit psychosocial and ethical consideration of health-related issues; for the latter, one seeks out upper-class courses in medical sociology, medical anthropology, and, of course, medical ethics.

If it’s a matter of choosing general nonscience courses that frame some of the ethical and cross-cultural (and racial and gender-related) issues tomorrow’s physicians will face, introductory philosophy courses in moral philosophy and/or ethics would be far more to the point.  But I am a historian and my own bias is clear:   At the top of horizon-broadening and humanizing courses would be surveys of nineteenth- and twentieth-century medicine in its cultural, political, and institutional aspects.  I offer two such seminars to upper-class history majors at my university under the titles “Medicine and Society: From Antebellum America to the Present”  and “Women, Their Bodies, Their Health, and Their Doctors: America, 1850 to the Present.”  Both seminars address doctor-patient relationships over the past two centuries, a topic at the heart of the social history of medicine.

But let’s face it.  Requiring premed students to take a few additional courses is a gesture – something more than an empty gesture but still a weak gesture.  There is every reason to believe that students who spend their undergraduate years stuffing their brains with biology, organic chemistry, and physics will  approach the social science component of premed studies in the same task-oriented way.  The nonscience courses will simply be another hurdle to overcome.  Premed students will take introductory psychology and sociology to learn what they need to know to do credibly well on the MCATs.  And, for most of them, that will be that.  Premed education will continue to be an intellectual variant of survivor TV:  making the grade(s), surviving the cut, and moving on to the next round of competition.

The overhaul of the MCAT is premised on the same fallacy that persuades medical educators they can “teach” empathy to medical students through dramatizations, workshops, and the like.  The fallacy is that physicianly caring, especially caring heightened by empathy, is a cognitive skill that can be instilled through one-time events or curricular innovations.  But empathy cannot be taught, not really.  It is an inborn sensibility associated with personality and temperament.   It is not an emotion (like rage, anger, joy) but an emotional aptitude that derives from the commensurability of one’s own feeling states with the feeling states of others.  The aptitude is two-fold:  It signifies (1) that one has lived a sufficiently rich emotional life to have a range of emotions available for identificatory purposes; and (2) that one is sufficiently disinhibited to access one’s own emotions, duly modulated, to feel what the patient or client is feeling in the here and now of the clinical encounter.  Empathy does not occur in a vacuum; it always falls back on the range, intensity, and retrievability of one’s own emotional experiences.  For this reason, Heinz Kohut, who believed empathy was foundational to the psychoanalytic method, characterized it as “vicarious introspection,” the extension of one’s own introspection (and associated feelings) to encompass the introspection (and associated feelings) of another.

Everyone possesses this ability to one small degree or another; extreme situations elicit empathy even in those who otherwise live self-absorbed, relationally parched lives.  This is why psychologists who present medical students with skits or film clips of the elderly in distressing situations find the students score higher on empathy scales administered immediately after viewing such dramatizations.  But the “improvement” is short-lived.[2]  An ongoing (read: characterological) predisposition to engage others in caring and comprehending ways cannot result from what one team of researchers breezily terms “empathy interventions.”[3]

If one seeks to mobilize a preexisting aptitude for empathic care giving, there are much better ways of doing it than adding introductory psychology and sociology courses to the premed curriculum.  Why not give premed students sustained contact with patients and their families in settings conducive to an emotional connection.  Let’s introduce them to messy and distressing “illness narratives” in a way that is more than didactic.  Let’s place them in situations in which these narratives intersect with their own lived experience.  To wit, let’s have all premed students spend the summer following  their junior year as premed volunteers in one of three settings:  pediatric cancer wards; recovery and rehab units in VA hospitals; and public geriatric facilities, especially the Alzheimer’s units of such facilities.

I recommend eight weeks of full-time work before the beginning of senior year. Routine volunteer duties would be supplemented by time set aside for communication – with doctors, nurses, and aids, but especially with patients and their families.  Students would be required to keep journals with daily entries that recorded their experience – especially how it affected (or didn’t affect) them personally and changed (or didn’t change) their vision of medicine and medical practice.  These journals, in turn, would be included with their senior-year applications to medical school.  Alternatively, the journals would be the basis for an essay on doctor-patient relationships informed by their summer field work.

I mean, if medical educators want to jumpstart the humane sensibility of young doctors-to-be, why not go the full nine yards and expose these scientifically minded young people to aspects of the human condition that will stretch them emotionally.  Emotional stretching will not make them empathic; indeed, it may engender the same defenses that medical students, especially in the third year, develop to ward off emotional flooding when they encounter seriously ill patients.[4]  But apart from the emotions spurred or warded off by daily exposure to children with cancer, veterans without limbs, and elderly people with dementias, the experience will have a psychoeducational yield:  It will provide incoming med students  with a broadened range of feeling states that will be available to them in the years ahead.  As such, their summer in the trenches will lay a foundation for clinical people skills far more durable that what they can glean from introductory psychology and sociology texts.

Those premed students of caring temperament will be pulled in an “empathic” direction; they will have an enlarged reservoir of life experiences to draw on when they try to connect with their patients during medical school and beyond.  Those budding scientists who are drawn to medicine in its research or data-centric “managerial” dimension[5] will at least have broadened awareness of the suffering humanity that others must tend to.  Rather than reaching for the grand prize (viz., a generation of empathic caregivers), the AAMC might lower its sights and help medical schools create physicians who, even in technologically driven specialties and subspecialties, evince a little more sensitivity.  In their case, this might simply mean understanding that many patients need doctors who are not like them.  A small victory is better than a Pyrrhic victory.

[1] Elisabeth Rosenthal, “Molding a New Med Student,” Education/Life Supplement, New York Times, April 15, 2012, pp. 20-22.

 [2] Lon J. Van Winkle, Nancy Fjortoft, & Mohammadreza Hojat, “Impact of a Workshop About Aging on the Empathy Scores of Pharmacy and Medical Students,” Amer. J. Pharmaceut. Ed., 76:1-5, 2012.

 [3] Sarah E. Wilson, Julie Prescott, & Gordon Becket, “Empathy Levels in First- and Third-Year Students in Health and Non-Health Disciplines,” Amer. J. Pharmaceut. Ed., 76:1-4, 2012.

 [4] Eric R. Marcus, “Empathy, Humanism, and the Professionalization Process of Medical Education,” Acad. Med., 74:1211-1215, 1999;  Mohammadreza Hojat, et al., “The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School,” Acad. Med., 84:1182-1191, 2009.

 [5] Beverly Woodward, “Confidentiality, Consent and Autonomy in the Physician-Patient Relationship,” Health Care Analysis, 9:337-351, 2001.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.

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Posted in Empathy, Medical Education, Narrative Medicine, Premed Education

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