Monday, February 2, 2009

Compassion Inc.

Pauline Chen MD (from the NY Times) recently highlighted an article from Academic Medicine that promulgates the idea that compassion and empathy can be taught to physicians in whom such sentiments don't come naturally. Here's the gist of the study:
In the study, groups of established physician-teachers from five different academic medical centers met at least twice a month. During the meetings, the doctors either practiced skills designed to enhance compassion, or reflected on their own work through discussion and narrative writing.

After 18 months, residents and medical students at each of the medical centers evaluated the physician-teachers, as well as a “control group” of faculty, on such matters as listening carefully and connecting with others, teaching communication and relationship-building skills, and inspiring the adoption of caring attitudes toward patients.

I imagine the meeting where the participants met with the study designers to review their performances went something akin to the following:

Proctor: So Dr X, it seems that after undergoing the training, your compassion/empathy quotient (CEQ) scores went up substantially.
DrX: Why thank you.
Proctor: There were just a few areas you could work on. Do you mind if we run the tape and talk about some minor deficiencies?
DrX: Of course. Go right ahead.
Proctor: (Clicks the play button) Now here, I like how you've brought a bouquet of flowers with you in the room. The patient seems to really appreciate it.
DrX: They're orchids. Just lovely I thought.
Proctor: Agreed. You see the patient identifies with you as one who appreciates beauty, natural beauty, just like her.
DrX: Yes. That's what I was aiming for. Plus it'll make the room smell nicer.
Proctor: Nevertheless, also arranging for a singing get-well-soon telegram, performed by a scantily attired Chippendale dancer may have been going overboard.
DrX: Agreed. Next time maybe just a clown with balloons or something.
Proctor: Um, or maybe just not doing anything at all of that nature.
(The tape runs)
Proctor: Now here I like how you've invited the patient to join you on a yoga mat you've splayed out on the floor.
DrX: I thought if we sat cross legged, palms pressed together for 20 or 30 minutes it would allow us to connect on a deeper, more spiritual level.
Proctor: But the patient just had knee replacement surgery. She was in no condition for hatha yoga.
DrX: I see your point.
Proctor: Anyway you seemed not to get flustered by her reluctance. But then you crawled into bed under the covers with her.
DrX: I wanted to identify with her. To see what it was like to be in your shoes, literally in her hospital bed.
Proctor: Yes, but....don't you think it a bit weird for a doctor to join a patient in bed?
DrX: I let her have most of the sheets and covers and I basically was on a little sliver of mattress and I must say, those hospitals beds are exceedingly uncomfortable.
Proctor: I see. Anyway, as we learned during the training module, touch is always important in building a patient/physician relationship. We talked about holding a patient's hand, resting your hand on a patient's shoulder...
DrX: I utilized touch...
Proctor: You kept patting the patient's head like she were a puppy or something. Look at what you're doing there. The patient keeps trying to wave you away.
DrX: (Blank faced staring at TV screen)
Proctor: And we talked about the use of facial expressions.
DrX: Yes. I always remembered to stare deeply into the patient's eyes as I spoke, to let her know I was looking into the depths of her pain and suffering.
Proctor: Maybe that was your intention, but in reality you seem to have a lascivious, lustful look on your face, as if your looking into the eyes of a long lost lover.
DrX: Oh. I didn't realize. Is that why security showed up?

Is this really the road we want to travel down? Where compassion and empathy are "taught", packaged into an edifying lecture/power point format, to be "acquired" like any other commodity? Is this what we ought to be doing? In A Supposedly Fun Thing I'll Never Do Again, David Foster Wallace (I know, I know, yet another DFW reference) talks about the rise in American culture (especially in our service oriented economy) of the Professional Smile. We all know this smile. It's the one you get from the check out clerk at Target on a hectic saturday afternoon. Facial muscles visibly quivering from the strain to keep the corners of the lips upturned. The eyes aren't involved, a smile that stops below the nose, the disturbing juxtaposition of dead vacant eyes against strained cheeks and lips and bared teeth. We all know it's phony. We all know that clerk couldn't give a damn if we "had a good day" or not. We all know the clerk only does it because he/she has been instructed to smile and say have a nice day (forced and monotone) to every customer by the corporate honchos because it's good for business to present a friendly, approachable visage to the paying consumers so they feel good about themselves when they leave with merchandise in hand. And the absurd part of all this is that if a service employee doesn't flash you that phony smile, you get pissed off. Like if you are buying gum at the 7-11 and the clerk is chatting on his cell phone, barely acknowledges you as he slides your change through the slot in the glass window, you feel slighted. Where's my smile, you think? Where's my encouraging platitude?

I'd like to think that the doctor/patient relationship is so fundamentally different from the buyer/seller one that any attempt to impose the "rules of engagement" from the latter on the former is doomed to failure. Developing a compassionate bed side manner comes easy to some. For others, it is definitely a struggle, something that takes years to master. And then some docs will never "get it" no matter what they do. But it isn't a "technique". There's no recipe to follow. It's like trying to tell someone how much you love your spouse. Or why you cry when you drop your five year old off for his first day of Kindergarten. There's something inexpressible about it. And I submit that this is a good thing. I don't think we want to be able to break down "physician compassion" into a two week CME class with a syllabus and scientific literature to study and a quick little exam (pass/fail) at the end. We don't need to repackage our physicians in the slick, glossy veneer of used car salemen. What we do as physicans, this relationship is very simple. One human being who is ill presents herself to one who has knowledge of what may be wrong and the possible treatment remedies. The ill one is honest and open and completely vulnerable. The physician processes the data, the physical exam, her professional experience and must render a verdict. But before that verdict, the physician must pause and acknowledge that the data must be coalesced with the actual human being sitting across from her. It is in that pause, that brief sliver of time in a hospital room or an office when compassion will or will not crest to the surface. That's all it is. Some physicians genuinely have it, some don't. What we have to ask ourselves is whether increasing the number of docs who "appear" to have it (via the indoctrination of "compassion school") is necessarily for the best, or if it ends up corrupting the sanctity of the patient/physician relationship.


Anonymous said...

I have to agree, at my school we have to garble down buckets of tripe concocted by our resident James Joyce PhD/ Family Medicine MD (she has like 3 clinic hours a week). She spear headed the first "narrative medicine" course.

Our spring time, oh-so-mandatory enrichment consists of mini humanity courses. This is all so when we finally meet patients, we can talk to them about Foust, or their feelings; or something like that.

Tonight I have to read Japanese poetry because the yoga class filled up almost instantly. Honesty I'd rather be studying for my cardio exam next week, but the compassion police will have me learning haikus.

Jeffrey Parks MD FACS said...

That's hilarious.

Anonymous said...

Male surgeon sarcastically complaining about any element of medical education that attempts to develop interpersonal skills? Well, I for one am surprised by this.

Come on, Dr. Parks. Nobody is claiming that physician empathy and communication skills can be "packaged into an edifying lecture/power point format" that will obviate the need for years of experience and maturity. Is it really that outrageous, though, to suggest that students - and maybe even practitioners - can learn even a little bit about human interactions specific to their profession with skills practice and formative feedback?

Jeffrey Parks MD FACS said...

M Student-
No, I think they can. I do believe you can "teach" someone to be more "compassionate" in the sense that you can teach a recent MBA grad how to be a better salesman. I just think the end result, if successful, somehow devalues what we mean by "compassionate care" and "physician empathy".

rlbates said...

You and your commentors have already covered it all. Have to say, I agree.

p said...

I disagree -- I see these attempts as comparable to when couples or families go into therapy, for example, to learn how to better communicate with each other or express love to each other. For sure, that type of stuff does not come naturally to some people or to some combinations of people, and yet marriage and family counselors still are valued, I assume because of some successes. I also think that not every doctor can learn to be more empathetic, but I bet some can if they're willing to try, and will or desire to learn these things probably is the determining factor in how successful stuff like this can be.

No, we shouldn't have doctors that have the same effect as the fake-smiling Walmart guy, but I think training somebody to smile in a grocery store is different from regularly training doctors how to be more smooth with people.

Anonymous said...

Did ya' ever notice its the Shrinks and GPs who have the worst bedside manner, at least thats been my experience when I've been treated by Shrinks/GPs, Internists aren't much better, for my money, give me a General/Neuro/Orthopedic Surgeon at 4am, they might not ask you how that perforated appendix makes you feel, but at least they'll take care of your problem..

Victor Lazaron said...

The secret of caring for the patient is CARING for the patient. Can't be taught. Faking it can. Not every doc who cares is slick with the right buzzwords at the bedside. But, I think most patients can tell the difference.

Nice post.

Stephanie said...

i'm stephanie ..second year medical student..
i've a dream to be onco surgeon..
i've already usmle id and i wannna given next year..
do u have any advice for me?
many thanks..

Jeffrey Parks MD FACS said...

VLaz- Good points. What worries me is, what if this "teaching" becomes so successful and efficacious that patients can't tell the difference anymore between genuine compassion and a slick faker who sits on the edge of the bed holding everyone's hand? Will it matter? Will it be like the Wallmart situation where you know it's fake but you expect that smile and have a good day anyway, because that's just 'the way the doctor/patient visit is supposed to go'....

p said...

That's the difference-- I think you can teach people to care, whereas others think you can only teach people to seem like they care.

If people can't learn to care, then I think counselors, educators, and religious folk in lots of other disciplines would never have any successes at all. But I do think it's possible to teach people to feel things for other people, given the appropriate attitudes and methods.

Anonymous said...

Unfortunately, my school has a class that teaches empathy using this method. After four years, no one has changed his/her personality.