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Monday, August 15, 2016

Empathy: as essential to effective health care as #HealthIT?

Interesting tweet from Dr. Topol yesterday.

We all want our doctors to be kind. But does kindness actually help us get well?
Michael Stein, MD

...It’s reasonable to expect a doctor to be kind at every visit. Kindness may be less important to us when the visit is urgent, when we are in terrible pain and barely listening as we wait for relief, when the problem is diagnosed and fixed quickly. But generally, most of us assume that it matters. In ancient Greece, medical texts advised physicians to “be solicitous in your approach to the patient, not with head thrown back [in arrogance] or hesitantly with lowered glance, but with head inclined slightly as the art demands.” Today, medical schools teach and evaluate kindness at patients’ bedsides and through role-playing. As Leslie Jamison, who acted as a patient, writes in “The Empathy Exams,” “Checklist item 31 is generally acknowledged as the most important category: ‘Voiced empathy for my situation/problem.’ ”

Yet doctors and patients alike have lamented that fully booked appointment schedules, the laptop’s intrusion during history-taking, billing pressures and edicts from insurance companies are squeezing kindness out of the exam room. So what exactly do we lose when we lose kindness? It may improve doctor-patient relations and patient satisfaction, but does kindness matter for patient outcomes? Can it lower the risk of hospitalization or death? Can kindness save lives?

It seems obvious: When doctors are kind, patients do better. But when the hard-nosed and unsentimental scientist demands proof, persuasive evidence is hard to find...
Part of the difficulty may lie in conflation.

"Empathy" is not a synonym for "sympathy," strictly speaking (notwithstanding that we sloppily tend to glom the two concepts together). The former goes to the cognitive ability to understand another's point of view ("putting yourself in someone else's shoes," as the saying goes).

Whether you sympathize with that point of view is quite another matter. Finally, I guess "kindness" is an attribute we're more likely to accord someone who is sympathetic to our suffering when we're in distress.

On the other hand, I know I will get pushback here. e.g., the Wiki:
The English word empathy is derived from the Ancient Greek word ἐμπάθεια (empatheia, meaning "physical affection or passion"). This, in turn, comes from ἐν (en, "in, at") and πάθος (pathos, "passion" or "suffering"). The term was adapted by Hermann Lotze and Robert Vischer to create the German word Einfühlung ("feeling into"), which was translated by Edward B. Titchener into the English term empathy.
But, then, the Wiki entry continues:
Empathy is distinct from sympathy, pity, and emotional contagion. Sympathy or empathic concern is the feeling of compassion or concern for another, the wish to see them better off or happier. Pity is feeling that another is in trouble and in need of help as they cannot fix their problems themselves, often described as "feeling sorry" for someone. Emotional contagion is when a person (especially an infant or a member of a mob) imitatively "catches" the emotions that others are showing without necessarily recognizing this is happening.
I've also seen "empathy" referred to in three flavors: [1] "cognitive empathy" (the sense in which I use the term), [2] "affective empathy" (closer to outright "sympathy"), and [3] "somatic empathy" (the proffered ability to to accurately -- albeit vicariously -- "feel another's pain." 
UPDATE: I just did a quick search on the term "empathy" over at the rapidly growing platform, where I sometimes post stuff. A quick results scan reveals widespread use of the word as a synonym for "sympathy" (though, there are some nice exceptions. See, e.g., "Design is Mainly About Empathy").
Beyond the nominal semantic liability of "conflation," we should also note that things rarely compartmentalize into mutually exclusive boxes. Damasio pointed out in "Descartes' Error" that one must care about reasoning accurately.
Since Descartes famously proclaimed, "I think, therefore I am," science has often overlooked emotions as the source of a person’s true being. Even modern neuroscience has tended, until recently, to concentrate on the cognitive aspects of brain function, disregarding emotions. This attitude began to change with the publication of Descartes’ Error in 1995. Antonio Damasio ... challenged traditional ideas about the connection between emotions and rationality...

And, yeah, I know Damasio has his detractors. Nonetheless, his observation regarding "caring" about empathically informed, POV-aware, rational, truth-seeking reasoning remains on point. (The factually-indifferent 2016 GOP Presidential candidate apparently didn't get the Memo.)
I forget at the moment which of my many recent "omics" reads contained the observation "nurture is our nature."
Interesting book cited (by way of a NEJM review link) in the Stein WaPo article:

The treatment of medical illness today depends much more on science and technology than on the physician's ability to listen, comfort, and prescribe. Medicine is not only increasingly technical but is also increasingly involved with legal, governmental, and insurance constraints on patient care, and this state of affairs has done much to distance physicians from their patients. This important book seeks to restore empathy to medical practice, to demonstrate how important it is for doctors to listen to their patients, to experience and understand what their patients are feeling. The book-a collection of essays by physicians, philosophers, and a nurse-is divided into three parts: one deals with how empathy is weakened or lost during the course of medical education and suggests how to remedy this; another describes the historical and philosophical origins of empathy and provides arguments for and against it; and a third section offers compelling accounts of how physicians' empathy for their patients has affected their own lives and the lives of those in their care. We hear, for example, from a physician working in a hospice who relates the ways that the staff tries to listen and respond to the needs of the dying; a scientist who interviews candidates for medical school and tells how qualities of empathy are undervalued by selection committees; a health professional who considers what her profession can teach physicians about empathy; another physician who ponders whether the desire to be empathic can hinder the detachment necessary for objective care; and several contributors who show how literature and art can help physicians to develop empathy. Medicine, asserts most of these authors, is both science and narrative, reason and intuition. Empathy underlies the qualities of the humanistic physician and must frame the skills of all professionals who care for patients.
"The treatment of medical illness today depends much more on science and technology than on the physician's ability to listen, comfort, and prescribe."

That book was published 22 years ago, in 1994. The more things change, the more they remain the same? What are we waiting for?

The NEJM review (also penned in 1994) is equally interesting.
...Empathy has been so neglected and misunderstood in the field of medicine that the adequacy of a new book on the subject can be tested in large part by its success in explaining and overcoming two fallacies. The no-transference fallacy holds that faculty members can treat students like scum and they will nevertheless grow up to be compassionate physicians. The idiot-with-the-stethoscope fallacy -- taken from Robert Coles's interview with William Carlos Williams, as recounted in Coles's The Call of Stories: Teaching and the Moral Imagination (Boston: Houghton Mifflin, 1989) -- holds that empathy and compassion automatically turn physicians into blobs of emotion incapable of taking effective or thoughtful action...

Halpern's insights show why the definition of empathy in the lead essay by Spiro is basically flawed: “Empathy is the feeling that persons ... arouse in us as projections of our feelings and thoughts. It is evident when `I and you' becomes `I am you.”' Spiro here seems to be inviting the sort of uncurious self-absorption that Halpern and others warn against. Similarly, George Bascom's moving recollections of his life as a surgeon blur the distinction between empathy and sympathy and ultimately reveal Bascom much more than his patients.

Another important conceptual theme recurring in these essays concerns the extent to which empathy is emotional or cognitive. Jeanne LeVasseur and David Vance tilt toward the cognitive, whereas Halpern insists on the importance of the emotional. Joanne Lynn's important essay reminds us that true empathy may often lead to anger at injustices in our health care and social-support systems...
Recall my post from more than two years ago, dx Machina?
I spend a lot of time studying the cognitive processes of "experts," most notably those in the professions of medicine and law (the only two disciplines traditionally accorded the characterization; nowadays we've defined the appellation down to the point where your garbage truck driver is touted as an "Environmental Management Professional").

So, I read everything I can concerning "how doctors think," "how to think like a lawyer," etc...

...Smack square in this debate over whether empathy is innate or learned is the consistent and depressing observation that medical students seem to lose prodigious amounts of empathy as they progress along the medical training route. Something in our medical training system serves to stamp out whatever empathy students bring with them on day one.

The research appears to conclude that it is the third year of the traditional medical curriculum that does the most damage. This is a dispiriting finding, as the third year of medical school is the one in which medical students take their first steps into actual patient care. For most students, the third year of medical school is eagerly awaited. After two long years sitting in classrooms, you get to actually do what it is that doctors do — be in hospitals, take care of patients. One would think that these first steps into real patient care would bring forth all the idealism that drove students to medical school in the first place — idealism that is sorely tested in the first two years of memorizing reams of arcane facts.

But the reverse seems to occur. After their seminal clinical experiences involving real contact with real patients, medical students emerge with their empathy battered. Their ideals of medicine as a profession are pummeled by their initiation into the real world of clinical medicine. And it is in this demoralized state that we send them into residency to accrue what are arguably the most influential and formative experiences of becoming practicing physicians...
Highly recommended reading.

See also my post from April 2016, The future of health care? "Flawlessly run by AI-enabled robots, and 'essentially' free?"

Will there be benevolent, empathic health care robots, and soothing "apps" where you can go get some empathy?

"There is no smartphone application for empathy and offering emotional care."

The medical futurist in me cannot wait to see how the traditional model of medicine can be improved upon by innovative and disruptive technologies. People usually think that technology and the human touch are incompatible. My mission is to prove them wrong. The examples and stories in this book attempt to show that the relationship is mutual. While we can successfully keep the doctor– patient personal relationship based on trust, it is also possible to employ increasingly safe technologies in medicine, and accept that their use is crucial to provide a good care for patients. This mutual relationship and well– designed balance between the art of medicine and the use of innovations will shape the future of medicine.

Bertalan Meskó (2014-08-27). The Guide to the Future of Medicine: Technology AND The Human Touch (Kindle Locations 100-104). Dr. Bertalan Meskó (Webicina Kft.). Kindle Edition.
I first cited this Wunderkind last September.

Back to Dr. Stein at WaPo:
...At the moment, the best answer to the kindness contrarian is: Even if the evidence in favor of the therapeutic benefits of empathy is weak, there is no evidence that refutes the idea that empathy improves care. And too many patients have stories of how unkindness or the sheer obliviousness of doctors can be devastating and indelible.

Kindness carries with it a commitment to a certain way of thinking and being rather than to a particular pre-defined endpoint. By showing that they are open to patients’ experiences, doctors are helping them feel better, or at least feel at ease during office visits. Many long-standing medical recommendations (an annual physical examination, a total-body skin cancer check) are being reevaluated, and the makers of guidelines often determine that “there is not enough evidence to recommend.” Such old-fashioned medical interventions, absolutists suggest, could lead to over-diagnosis or over-treatment. But kindness at every visit is never too much to ask. Sophia was right: There is no burden added to the work of doctors if we expect them to be kind. Sometimes doctors don’t need to wait for evidence to do what is right.
Yeah, but, consider my prior posts "The Health Care Productivity Treadmill" and "Clinician Burnout."

Notwithstanding those very real and difficult structural operational concerns, more broadly as it goes to "empathy," sympathy," and "kindness," it never hurts to recall Tomasello's research on the "adaptive" utility of "prosocial" attitudes and behaviors. e.g., "A Natural History of Human Morality."

An afterthought. I recently reviewed Ann Neumann's fine book "The Good Death" (here and here). The word "empathy" appears only once therein, but her book is all about the nuances and difficulties pertaining to empathy, sympathy, and kindness -- i.e., "compassion."
Compassion is a complicated thing. It’s an emotion, both abstract and concrete, shown both in our broad support for groups or issues and in the care that we give those around us. Compassion: sympathetic consciousness of others’ distress together with a desire to alleviate it. I can write for years about equality for minority groups, the disabled, the ill, the dying, the incarcerated. I can feel that compassion sincerely, but I also know that compassion in theory is not always compassion in practice. I know what it feels like, but it’s not universal. I don’t have it for everyone who is suffering. I don’t have the capacity. Compassion in practice, when I do feel it, is fickle, too. I’ve cared about some hospice patients more than others. I’ve taken care of some loved ones more than others. And I’ve wrung my hands in guilt for the disparities. It’s easier to care for people when you trust them, but also when you know you have power over them. When you know they need you...

Neumann, Ann (2016-02-16). The Good Death: An Exploration of Dying in America (pp. 185-186). Beacon Press. Kindle Edition.
'eh? She needs to do a TED Talk.


I may have to buy this book once it's released in December.

The Amazon blurb:
A controversial call to arms, Against Empathy argues that the natural impulse to share the feelings of others can lead to immoral choices in both public policy and in our intimate relationships with friends and family

Most people, including many policy makers, activists, scientists, and philosophers, have encouraged us to be more empathetic—to feel the pain and pleasure of others. Yale researcher and author Paul Bloom argues that this is a mistake. Far from leading us to improve the lives of others, empathy is a capricious and irrational emotion that appeals to our narrow prejudices. It muddles our judgment and often leads to cruelty. We are at our best when we are smart enough not to rely on it, and draw upon a more distanced compassion.

Based on groundbreaking scientific findings, Against Empathy makes the case that some of the worst decisions that individuals and nations make—from who to give money to, when to go to war, how to respond to climate change, and who to put in prison—are too often motivated by honest, yet misplaced, emotions. With clear and witty prose, Bloom demonstrates how empathy distorts our judgment in every aspect of our lives, from philanthropy and charity to the justice system; from culture and education to foreign policy and war. Without empathy, Bloom insists, our decisions would be clearer, fairer, and ultimately more moral.

Bound to be controversial, Against Empathy shows us that, when it comes to major policy decisions and the choices we make in our everyday lives, limiting our empathetic emotions is often the most compassionate choice we can make.
I'll have to withhold judgment until after I've read it, but the foregoing gives me outset "conflation" concerns: "be more empathetic—to feel the pain and pleasure of others."

He first addresses "empathy" in clinical settings at 7:21. Wafts of Straw Man follow thereafter to about 8:00.
@7:21: We often say to one another ‘doctors and therapists should be empathic.’ And, if what you mean by empathic is 'caring, kind, and understanding,' absolutely. But, if what you mean by empathic is they should 'put themselves into our shoes, they should feel what we feel,' definitely not. This sort of empathic engagement leads to burnout. It leads to suffering and pain. It also makes them bad at what they do. @7:44
One hardly knows where to begin. First of all: "caring, kind, and understanding." Per Damasio, you have to 'care' about 'understanding,' and to the extent that you exude 'kindness' in your patient encounters, you will be more likely to elicit clinically significant and useful dx and tx information.

Again, the exasperating, wooly-headed conflation problem.

I had the great good fortune to teach "critical thinking" for a number of years at my university. I invariably admonished my students early on that "many arguments founder on imprecise definitions of key terms, which often leads people to wind up just endlessly talking past each other." (Sort of characterizes our national politics these days' 'eh?) I also studied trial lawyering and courtroom processes during my time at UTK in the '80's (Senior Seminar in Psychology of Law). Opposing Counsel typically "stipulate" to the precise agreed-upon legal meanings of core terms. And, in 1994 my first grad school paper comprised a thorough analytic deconstruction and evaluation of the JAMA Single Payer proposal (pdf). It commenced with three sinple-spaced pages of keyword definitions.

So, I'm a bit of a pedantic hardass when it comes to precision in language and communication. Sloppy language begets sloppy thinking, and vice versa. 

Q: Where (if anywhere) does "empathy" fit into "the Art of Medicine?" (An equally problematic phrase.)


A priority daily web surfing destination for me is that of Science Based Medicine. Good review of this book there.

...You might not agree that all the subjects he covers deserve to be labeled quackery, but you can’t deny that they are problems that need to be addressed. This is an incisive, thought-provoking, well-written, thoroughly referenced book that is an important contribution to science-based medicine information and reasoning.
Only $4.67 Kindle edition.


Only 7 weeks 'til the 10th Annual Health 2.0 Conference in Santa Clara.

Be there. I will. Gonna be loaded for bear this year.

Taking Lean to the screen: Removing waste from the electronic health record
Many physicians and nurses are traveling across desolate EHR wastelands replete with digital detritus, pixel dust and other non-value-add items.
By David Butler, MD

...To strive to deliver more value, many traditional healthcare systems have turned to utilizing formal process improvement methodologies such as Lean and Six Sigma, tools derived from the manufacturing industry, to deliver care efficiently and effectively. This trend and its effects have been well-documented by industry leaders like Patricia Gabow, MD, and John Toussaint. Dramatic improvements in cost reduction, quality improvement and patient safety have been seen in health systems like Toussaint's ThedaCare, Seattle Children's, Park Nicollet, and Denver Health. Centers for Medicare and Medicaid Services decreased contract modification cycle time by more than 50 percent and achieved a 95 percent reduction in post-implementation information technology change requests in national quality programs by adopting Lean.

With these success stories and over 300 books about Lean management available on Amazon, Lean is definitely hot in healthcare and not just a fad destined for hospitals' basement boxes within a few years. Many experts describe Lean as "corporate common sense" or metaphorically refer to it as "a diet and exercise routine for companies in order to stay healthy." These process improvement strategies are critical in healthcare because unlike other business models, we cannot just "have a sale" or drive more business strictly through marketing. We must streamline our processes and remove the waste and non-value add steps from the clinical care process. The most successful organizations leverage Lean transformation efforts to drive all business and clinical processes throughout their organization...
Music to my ears.

More to come...

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