- Email: [email protected]
Feigned feeling
Perspectives
The art of medicine Feigned feeling
Minneapolis Institute Of Arts, Mn, Usa/The Ethel Morrison Van Derlip Fund/Bridgeman Images
Laura was 35 years old and 9 weeks into her first pregnancy. She had come into the hospital after experiencing light bleeding for 24 hours. The ultrasound scan showed no fetal heartbeat. She had miscarried. Weary from a lack of sleep, I steeled myself and went into the room. I introduced myself, sat down, and asked her how she was feeling. I told her the ultrasound findings. I gave her a minute to take in what I had said. Then I told her how common miscarriages are. I paused again. I didn’t want to seem rushed, but I was. I only had 5 minutes. There was nothing she could have done to prevent the miscarriage, I said, and nothing she did to cause it. I went through the management options. I said there was no reason that she could not have a successful pregnancy in the future. I didn’t go into detail, knowing that little of what is said after conveying bad news is processed. Laura nodded vacantly. I asked her if she had any questions. She asked why this had happened. “‘We don’t know”, I replied. She looked so sad. But there was no time to invite more questions. A bell rang. I had to go.
Francisco de Goya, Self-Portrait with Dr Arrieta (1820)
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As I stood up her demeanour changed. No longer a patient, she started to write. Did my bedside manner impress her? Was the way I communicated with her convincing? She was an actor. I was a student. No time to dwell. Next station. Management of a uterine prolapse. Clinical proficiency has many implications for medical students; to be safe, thorough, knowledgeable, skilful, and, importantly, to care—to be compassionate, kind, and understanding. In short, empathetic. Students are taught that empathy is something to strive for and to demonstrate. Even, presumably, if they are pretending. In the USA it is also apparently good for business. Thomas Lee writes in An Epidemic of Empathy in Healthcare that “Creating an epidemic of empathy is not an act of charity. It is a strategic business imperative…driven by competition based on value.” The term empathy, as an attribute or a skill, has become commonplace in the literature on management and the caring professions, although not necessarily with a shared meaning. I thought, as a fresh medical student, that at its simplest—understanding and acknowledging a patient’s feelings—it was a given trait of physicians. Why else would doctors want to spend their days with the sick, dying, and fearful? But various studies suggest that even if medical students start with a passion for developing a therapeutic connection with their patients, it can be eroded as they progress through the clinical years. So now students are taught something called empathy. We learn a formula and practise it. We are tested on our proficiency. Perhaps authenticity is too much to hope for and we just have to persuade our patients that we understand and care, even if feigned. The pressures of clinical practice no doubt contribute to the tendency of doctors to objectify the patients who cycle daily through the wards, forgetting or ignoring their names, and referring to them as “the ectopic” or the “the IVDU”. These labels are applied with little thought and no malice. As often as not it is the more junior members of a team who resort to such terms, their brains replete with medical facts, whose job it is to complete paperwork, keep track of ward upon ward of patients, chase up test results and investigations, plead down the phone for a bed for a patient, or appeal to colleagues on another team for a consult. They are the exhausted, underpaid workers for whom the original motivation for a medical career can become dulled by long shifts and administrative tasks. But they are not alone. For all clinical staff caught up in the demands of the hospital or clinic the resort to shortcuts and labels is a rational stratagem. Is it really possible to take the time to connect with patients’ stories www.thelancet.com Vol 388 September 10, 2016
Perspectives
and understand their experiences of illness in such an environment? Surely it is the effects of the pressures of a burdensome workload on clinical encounters and the erosion of the relationship with our patients that should be discussed and addressed, rather than teaching students how to simulate compassion. One morning I was on rounds with the surgical team in the hospital. The public ward was crowded, with a dank smell of urine and disinfectant. As the surgeon tried to elicit a history from a confused 80-year-old patient, my gaze wandered to the patient opposite, an elderly man who had fallen asleep across his bed. He had one arm on his bedside wardrobe and his legs were hanging off the side of the bed. It appeared that he had fallen asleep halfway through dressing himself. He had several jumpers and jackets and his bowler’s cap on, with one sock and his underwear over his shorts which in turn were over some longer trousers. I asked the nurse what had happened to him. She explained that his dementia was severe, that he had become “disruptive” during the night and was threatening to leave, so they had sedated him. But his desire to leave seemed to me understandable. The ward was no place to be for someone old, anxious, confused, and alone. Pharmaceutical restraint seemed a poor, if perhaps unavoidable, proxy for caregiving. I wondered whether those on the night shift had the time or patience to calm him, to try to provide comfort and reassurance, and the acknowledgment of his distress that comes with a gentle tone of voice or the touch of a hand. And all present on rounds seemed oblivious to his loss of dignity, sprawled as he was half in and half out of bed. Much of medical students’ time is given to such watching and listening—flies on the walls of hospitals, clinics, and surgeries or observers at rounds. Witnesses to consultations from the routine to the complex. But as we progress we risk becoming immune to suffering, more protective of ourselves, and more cynical about the machinery and workings of the health-care system. This cynicism becomes a weapon of self-protection, of resistance, that we risk unleashing on our patients in the form of distance and apathy. We discover, perhaps with a tacit recognition of our failings, that empathy isn’t our highest priority. Why establish a connection, physical or otherwise? Why feel for someone’s spleen when you know they will have a CT anyway? Why stop and connect or ask about home and family? Every patient has a story, whether they are allowed to tell it or not. And when they are sick, dying, or in pain, telling that story can be central to their sense of being respected, reassured, and understood, of being cared for by the very profession tasked with caring. It also helps to inform the doctor whether the patient can be safely discharged, whether they have family or friends who will care for them while they recover, whether they have the means to eat and www.thelancet.com Vol 388 September 10, 2016
sleep safely. But for most doctors these concerns fall, of necessity or inclination, outside their remit. This is for the social worker or the chaplain, or perhaps a fellow patient. The pager, the list, the unfinished entries in the electronic record beckon. Much is said and written about the hallmarks of professionalism in medicine: quality, efficiency, risk management, productivity, value, and profitability. Much less attention seems to be given to the importance of caring, compassion, and kindness, or to the experiences, of trainee doctors themselves. We can role play being kind and thoughtful. But no amount of practice, of empty empathy, will prepare us for our own reactions to our patients and understanding of the array of illness experiences and fears we are likely to encounter. Most patients will recognise authenticity over artifice. Medical schools do their best to teach us communication skills and how to express caring, concern, and interest. But the question is not whether we can learn and enact it. Some hold that we can; that empathy, or perhaps empathetic responses, can be learned and even internalised. And no doubt some patients are reassured by even a token personal connection. But the causes of distance from our patients are much deeper and are masked by an implicit agreement that we are all in the same boat. Our senior colleagues experienced the trials of the rite of passage of clinical training and so should we. So pernicious is the convention that we are expected to just soldier on without complaint; perhaps this accounts for the high rate of depression among trainees which often remains unacknowledged and untreated. Burnout and depression are not the sole province of junior doctors but they can blight the formative years of their careers. We rarely get to talk about how we feel, what it is really like to see 15 patients, some of whom are aggressive or uncooperative, in 2 hours, shift after shift, and how best to cope. And yet, notwithstanding the unremitting demands of life on the wards or in the clinic, some of the most powerful lessons students learn are on those occasions when the senior clinicians teaching us have a personal presence and palpable connection with a patient or family, even in a consultation that is hurried and difficult. These experiences are hard to capture, the qualities hard to define, but they are important, because they represent the moral basis for a meaningful doctor–patient relationship. True kindness, honesty, interest, and caring once experienced, are not easily forgotten. At best they become what we seek to emulate, not as an actor with a rehearsed script but with sympathy and a willingness to connect with another human being, who just happens to be a patient.
Amelia Reid Royal College of Surgeons in Ireland, Dublin 2, Ireland [email protected]
Further reading Lee TH. An epidemic of empathy in healthcare: how to deliver compassionate, connected patient care that creates a competitive advantage. New York: McGraw-Hill, 2015 Mata D, Ramos M, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA 2015; 314: 2373–83 Neumann M, Edelhäuser F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med 2011; 86: 996–1009 Ofri D. What doctors feel: how emotions affect the practice of medicine. Boston: Beacon Press, 2014 Macnaughton J. The dangerous practice of empathy. Lancet 2009; 373: 1940–41 Riess H, Kelley JM, Bailey RW, Dunn EJ, Phillips M. Empathy training for resident physicians: a randomized controlled trial of a neuroscience-informed curriculum. J Gen Intern Med 2012; 27: 1280–86 Soler JK, Yaman H, Esteva M, et al. Burnout in European family doctors: the EGPRN study. Fam Pract 2008; 25: 245–65
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The art of medicine Feigned feeling
Minneapolis Institute Of Arts, Mn, Usa/The Ethel Morrison Van Derlip Fund/Bridgeman Images
Laura was 35 years old and 9 weeks into her first pregnancy. She had come into the hospital after experiencing light bleeding for 24 hours. The ultrasound scan showed no fetal heartbeat. She had miscarried. Weary from a lack of sleep, I steeled myself and went into the room. I introduced myself, sat down, and asked her how she was feeling. I told her the ultrasound findings. I gave her a minute to take in what I had said. Then I told her how common miscarriages are. I paused again. I didn’t want to seem rushed, but I was. I only had 5 minutes. There was nothing she could have done to prevent the miscarriage, I said, and nothing she did to cause it. I went through the management options. I said there was no reason that she could not have a successful pregnancy in the future. I didn’t go into detail, knowing that little of what is said after conveying bad news is processed. Laura nodded vacantly. I asked her if she had any questions. She asked why this had happened. “‘We don’t know”, I replied. She looked so sad. But there was no time to invite more questions. A bell rang. I had to go.
Francisco de Goya, Self-Portrait with Dr Arrieta (1820)
1048
As I stood up her demeanour changed. No longer a patient, she started to write. Did my bedside manner impress her? Was the way I communicated with her convincing? She was an actor. I was a student. No time to dwell. Next station. Management of a uterine prolapse. Clinical proficiency has many implications for medical students; to be safe, thorough, knowledgeable, skilful, and, importantly, to care—to be compassionate, kind, and understanding. In short, empathetic. Students are taught that empathy is something to strive for and to demonstrate. Even, presumably, if they are pretending. In the USA it is also apparently good for business. Thomas Lee writes in An Epidemic of Empathy in Healthcare that “Creating an epidemic of empathy is not an act of charity. It is a strategic business imperative…driven by competition based on value.” The term empathy, as an attribute or a skill, has become commonplace in the literature on management and the caring professions, although not necessarily with a shared meaning. I thought, as a fresh medical student, that at its simplest—understanding and acknowledging a patient’s feelings—it was a given trait of physicians. Why else would doctors want to spend their days with the sick, dying, and fearful? But various studies suggest that even if medical students start with a passion for developing a therapeutic connection with their patients, it can be eroded as they progress through the clinical years. So now students are taught something called empathy. We learn a formula and practise it. We are tested on our proficiency. Perhaps authenticity is too much to hope for and we just have to persuade our patients that we understand and care, even if feigned. The pressures of clinical practice no doubt contribute to the tendency of doctors to objectify the patients who cycle daily through the wards, forgetting or ignoring their names, and referring to them as “the ectopic” or the “the IVDU”. These labels are applied with little thought and no malice. As often as not it is the more junior members of a team who resort to such terms, their brains replete with medical facts, whose job it is to complete paperwork, keep track of ward upon ward of patients, chase up test results and investigations, plead down the phone for a bed for a patient, or appeal to colleagues on another team for a consult. They are the exhausted, underpaid workers for whom the original motivation for a medical career can become dulled by long shifts and administrative tasks. But they are not alone. For all clinical staff caught up in the demands of the hospital or clinic the resort to shortcuts and labels is a rational stratagem. Is it really possible to take the time to connect with patients’ stories www.thelancet.com Vol 388 September 10, 2016
Perspectives
and understand their experiences of illness in such an environment? Surely it is the effects of the pressures of a burdensome workload on clinical encounters and the erosion of the relationship with our patients that should be discussed and addressed, rather than teaching students how to simulate compassion. One morning I was on rounds with the surgical team in the hospital. The public ward was crowded, with a dank smell of urine and disinfectant. As the surgeon tried to elicit a history from a confused 80-year-old patient, my gaze wandered to the patient opposite, an elderly man who had fallen asleep across his bed. He had one arm on his bedside wardrobe and his legs were hanging off the side of the bed. It appeared that he had fallen asleep halfway through dressing himself. He had several jumpers and jackets and his bowler’s cap on, with one sock and his underwear over his shorts which in turn were over some longer trousers. I asked the nurse what had happened to him. She explained that his dementia was severe, that he had become “disruptive” during the night and was threatening to leave, so they had sedated him. But his desire to leave seemed to me understandable. The ward was no place to be for someone old, anxious, confused, and alone. Pharmaceutical restraint seemed a poor, if perhaps unavoidable, proxy for caregiving. I wondered whether those on the night shift had the time or patience to calm him, to try to provide comfort and reassurance, and the acknowledgment of his distress that comes with a gentle tone of voice or the touch of a hand. And all present on rounds seemed oblivious to his loss of dignity, sprawled as he was half in and half out of bed. Much of medical students’ time is given to such watching and listening—flies on the walls of hospitals, clinics, and surgeries or observers at rounds. Witnesses to consultations from the routine to the complex. But as we progress we risk becoming immune to suffering, more protective of ourselves, and more cynical about the machinery and workings of the health-care system. This cynicism becomes a weapon of self-protection, of resistance, that we risk unleashing on our patients in the form of distance and apathy. We discover, perhaps with a tacit recognition of our failings, that empathy isn’t our highest priority. Why establish a connection, physical or otherwise? Why feel for someone’s spleen when you know they will have a CT anyway? Why stop and connect or ask about home and family? Every patient has a story, whether they are allowed to tell it or not. And when they are sick, dying, or in pain, telling that story can be central to their sense of being respected, reassured, and understood, of being cared for by the very profession tasked with caring. It also helps to inform the doctor whether the patient can be safely discharged, whether they have family or friends who will care for them while they recover, whether they have the means to eat and www.thelancet.com Vol 388 September 10, 2016
sleep safely. But for most doctors these concerns fall, of necessity or inclination, outside their remit. This is for the social worker or the chaplain, or perhaps a fellow patient. The pager, the list, the unfinished entries in the electronic record beckon. Much is said and written about the hallmarks of professionalism in medicine: quality, efficiency, risk management, productivity, value, and profitability. Much less attention seems to be given to the importance of caring, compassion, and kindness, or to the experiences, of trainee doctors themselves. We can role play being kind and thoughtful. But no amount of practice, of empty empathy, will prepare us for our own reactions to our patients and understanding of the array of illness experiences and fears we are likely to encounter. Most patients will recognise authenticity over artifice. Medical schools do their best to teach us communication skills and how to express caring, concern, and interest. But the question is not whether we can learn and enact it. Some hold that we can; that empathy, or perhaps empathetic responses, can be learned and even internalised. And no doubt some patients are reassured by even a token personal connection. But the causes of distance from our patients are much deeper and are masked by an implicit agreement that we are all in the same boat. Our senior colleagues experienced the trials of the rite of passage of clinical training and so should we. So pernicious is the convention that we are expected to just soldier on without complaint; perhaps this accounts for the high rate of depression among trainees which often remains unacknowledged and untreated. Burnout and depression are not the sole province of junior doctors but they can blight the formative years of their careers. We rarely get to talk about how we feel, what it is really like to see 15 patients, some of whom are aggressive or uncooperative, in 2 hours, shift after shift, and how best to cope. And yet, notwithstanding the unremitting demands of life on the wards or in the clinic, some of the most powerful lessons students learn are on those occasions when the senior clinicians teaching us have a personal presence and palpable connection with a patient or family, even in a consultation that is hurried and difficult. These experiences are hard to capture, the qualities hard to define, but they are important, because they represent the moral basis for a meaningful doctor–patient relationship. True kindness, honesty, interest, and caring once experienced, are not easily forgotten. At best they become what we seek to emulate, not as an actor with a rehearsed script but with sympathy and a willingness to connect with another human being, who just happens to be a patient.
Amelia Reid Royal College of Surgeons in Ireland, Dublin 2, Ireland [email protected]
Further reading Lee TH. An epidemic of empathy in healthcare: how to deliver compassionate, connected patient care that creates a competitive advantage. New York: McGraw-Hill, 2015 Mata D, Ramos M, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: a systematic review and meta-analysis. JAMA 2015; 314: 2373–83 Neumann M, Edelhäuser F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med 2011; 86: 996–1009 Ofri D. What doctors feel: how emotions affect the practice of medicine. Boston: Beacon Press, 2014 Macnaughton J. The dangerous practice of empathy. Lancet 2009; 373: 1940–41 Riess H, Kelley JM, Bailey RW, Dunn EJ, Phillips M. Empathy training for resident physicians: a randomized controlled trial of a neuroscience-informed curriculum. J Gen Intern Med 2012; 27: 1280–86 Soler JK, Yaman H, Esteva M, et al. Burnout in European family doctors: the EGPRN study. Fam Pract 2008; 25: 245–65
1049