Megan Kamerick interviews Dr. Rana Awdish, Henry Ford Health System, Detroit, and author of the book In Shock

RA: It didn’t feel that there was an emotional connection to my care team. If I didn’t feel that they were invested in my recovery or saw my suffering, there was a hollowness to it that, honestly, as a physician, I never anticipated.

MK: After you barely survived surgery, you hear the surgical resident presenting your case outside your room, which I’m sure you’ve done a number of times, say: “She’s trying to die on us. She’s circling the drain.” This was a real epiphany for you. Why?

RA: I had said that same thing; “He’s been trying to die on me.” I know as a physician I had said that, but I never thought about who might hear it. I never thought about the directionality of that statement. Not just that a patient was trying to die, but that they were trying to die “on me.” That created this idea of antagonism between the care team and the patient.

As a patient, I knew I was trying very hard not to die and yet, my team was attributing this intention to me that, in some ways, I felt was an easy out. It was a way of saying, “She’s trying to die, so even if we do everything we can, and she dies, it’s almost an unavoidable reality.”

I was horrified that I had said it and yet realized that the culture really created an [atmosphere] in which that was how we viewed the patient-physician relationship.

MK: How did that experience influence later when you were on rounds? It was a student or resident talking about a patient who was dying while in the room with her.

RA: There were a number of instances like that when I returned that I think prior, I wouldn’t have noticed. It was just so characteristic of our culture that my ear wasn’t attuned to it. It took time to integrate both halves of myself where I could really teach to the residents how hurtful those things can be as a patient when you overhear them.

Even if we don’t imagine that the patient can overhear them, there were times when I could hear my care team describe me in that way and they would have never thought that I would have known because I was either in a medically-induced coma or in the operating room in a state where they just weren’t anticipating that I would have those senses intact. Hearing is the last to go. So often our patients will tell us; “I heard everything that was happening around me.”

I just feel that we need to control those episodes of harm that are really preventable suffering. There is so much of suffering that is inherent to disease that you can’t avoid, but we have to identify when we are applying addition suffering to a situation. That’s our obligation.

MK: I confess, it was terrifying to read. At one point, you’re going into anaphylactic shock and you couldn’t get anyone to pay attention to that.

Another time, a line had fallen out so you didn’t get enough pain killers and you were in so much pain. Then they were asking you questions indicating that you might be an addict.

RA: For me, it was terrifying because not only did I realize that I didn’t have a voice, but when I did have a voice, it wasn’t necessarily believed. I was incredibly vulnerable. My life was in the hands of people who didn’t believe me.

As a physician, if I couldn’t advocate for myself in those situations, that spoke to me so strongly that I had to tell this story because I, at least in theory, had a voice and some knowledge of medicine. So many of our patients are disenfranchised and don’t have any of those things.

MK: I forgot to add the one instance of when you were going into sepsis and a doctor dismissed you as an anxious young woman.

RA: We do that. There’s good evidence that women get less pain control than men do. They’re believed less about their pain. This is true even more if you are Hispanic or African American. There are huge issues with implicit bias in medicine that we have not looked at.

MK: How did these experiences spark a realization about how you yourself had interacted with patients?

RA: As a patient, when I heard these things said to me, I felt so damaged by it and yet, I recognized myself in every failure. I saw how we as a culture didn’t view the emotional aspect of the care that we provided in the same way that we valued the medicine. We were so oriented to the disease that we sometimes even missed the person that was carrying the disease in their body.

MK: When you were training as a medical student, how were displays of emotion or empathy towards patients treated by senior doctors?

RA: I was in medical school about 20 years ago. At that time, we were told that our job was the medicine, the science and that if we wanted to care for patients, if we wanted to emote with patients or have feelings about it, medicine wasn’t the field. That was something else like nursing or social work.

Our first instincts as medical students who were naive was to feel things very strongly. I remember feeling very strongly when mothers would have a still-birth, or a patient would die. When we displayed that emotion, we were told that we were being reckless and careless, and we were putting our other patients in jeopardy.

I don’t think we saw any way out but to suppress those emotions and really keep them, not only to ourselves, but in some ways, even hidden from ourselves.

MK: What effect does that tamping down of emotions have on young doctors?

RA: I think it’s disastrous. What I recognize now is that we didn’t have a culture of resiliency where we could feel our feelings. There wasn’t a place for it because there was no venue for it. There was no safe space for disclosure. There weren’t the things that are being put into place now where we talk about the harder things. We have activities around sublimating those emotions into more productive means of expression like writing and art. We didn’t have any of that and I think, left to our own devices, we just tried to numb the feelings and numbing them often meant alcohol, drugs, avoidance behavior. We lost two residents to suicide during my training. Had we had those tools, I will always wonder if that would have been different.

MK: Your mentors argued while you were training that letting patients touch you emotionally would make it impossible for you to practice medicine. It would be too overwhelming. Isn’t there some truth to that?

RA: You know, I subscribed to that for a time because it was presented to me by people who I trusted. I believed that I couldn’t get attached to people and if I did, I would somehow be depleted by it.

When I saw the relationships that I had with physicians who bucked that trend, who decided that they were going to invest in their patients and show that they cared, that truly amplified their practice. It didn’t diminish it. That was when I really decided to try being different and what I’ve found is that it truly does open so many channels that are available to me, not just to the patient that fuel my resilience and my longevity I hope in medicine in a way that I never could have attained if I had kept myself closed off.

MK: How are you working with your hospital, the Henry Ford Health System, to foster a new culture and change some of this?

RA: One of the things that I noticed as a patient was how difficult it was for physicians to give me bad news. It was uncomfortable. They felt like they were failing me. They didn’t know how to do it well.

One of our first initiatives we call CLEAR Conversations which stands for Connect, Listen, Empathize, Align and Respect. Those are the overarching values that all of our communications initiatives have at their core.

We use improvisational actors to role play difficult conversations with physicians and they get to try out new skills in terms of not only noticing emotion, which we talked about is an issue, but responding to emotion with empathy and compassion.
We really [need to] explore with humility the values of the patient and align with those values before providing a discussion of recommendations for care.

It’s branched beautifully into so many other areas that really are more about physician resilience and wellness. [There are now] safe spaces to debrief after bad events like codes that we didn’t used to talk about. [There is] narrative medicine exercises where physicians might parallel chart. They will write about an experience in the chart the way we normally document, but then they will journal about their feelings and we share those sometimes at story slams, but we do it with an eye for resilience.

This isn’t an airing of grievances, this is truly examining our stories for that beautiful golden center that is universal for everyone and united around that.

Megan Kamerick interviews Dr. Marc J. Kahn, Associate Dean, Tulane University

MJK: The way that our brains are organized, appreciation of arts and humanities are considered a more open framework for attaining knowledge. We think that through exposure to humanities, our brains work a little bit differently and allow us to better understand the human condition in ourselves.

MK: What did you find about the kinds of humanities exposure that most closely correlates with more empathy?

MJK: They all correlated very well. What we did was we came up with a quantitative humanities score that considered the amount of time spent, either actively or passively, with these endeavors.

The other thing that was interesting is that we might have hypothesized from the onset that active participation was better than passive participation, but in our study, we really didn’t find that. There were really no differences between exposure, whether it was passive or active.

MK: Some of the qualities that you found were fostered by this and that you wanted to focus on included spatial skills and tolerance of ambiguity and a few others. Can you talk about the role that these play in promoting empathy in someone?

MJK: Yes, tolerance of ambiguity is an important characteristic for a physician. Medicine can be ambiguous. It’s not an exact science. It’s not like math or physics or even chemistry and when one sees a patient with a constellation of symptoms, one makes their best educated guess, uses their best detective skills to make a diagnosis. Tolerance of ambiguity is exceedingly important. We all have examples of physicians who are relatively intolerant of ambiguity, who got frustrated and perhaps even left the medical field.

The spatial test that we use in our study, because we thought that spatial ability may play a role in creativity and may also be important for some aspects of medical practice. Physician empathy really fosters the ability of physicians to modify behavior to create a population of more healthy patients.

MK: What do your conclusions mean for medical education?

MJK: I think our conclusions support the notion that there is an association between exposure to arts and humanities and positive physician qualities including reduced burnout. This is not a cause and effect study. I think that’s important. We’re able to statistically show a very robust and meaningful correlation between the two.

MK: How can the pretty crammed curriculum that medical students already have in med school fit in more materials such as humanities?

MJK: I don’t think it’s fitting in more material. I think it’s look at the way that you deliver a curriculum. For example, I’m a hematologist and when I show images of blood cells, I ask my students in the class to draw them. Drawing engages that part of the brain that makes it more open to new ideas. So rather than having a separate class, I incorporate arts and humanities into an existing class.

Another example that’s done around the United States is when we teach students physical diagnosis, we bring them to an art museum and teach and foster their skills and observation. I don’t think it’s adding more to the curriculum, I think it’s changing the pedagogy or the way we teach what we already teach medical students.

MK: What about people who are already doctors; does what you’ve found have implications for ways to help them be more empathetic?

MJK: A PhD scientist, Albert Einstein would frequently stop and pull out his violin and play for a while when he got stuck. He talked about doing that.

We know that Bill Roth, a famous surgeon would take time out to play orchestral music, which apparently, he did very well.
I think there have been examples of physicians who incorporate art into their lives to enrich their careers.

Perhaps an implication is we need to do more of these things for physicians in an effort to help prevent burnout. In fact, at our institution several weeks ago, we brought in an expert on cheese, invited faculty to a free tasting and seminar to help prevent burnout, to help people to use a different part of their brains and help people to think more creatively.

Megan Kamerick interviews Dr. David Rakel, Chair of Family and Community Medicine at the University of New Mexico author of the book The Compassionate Connection: The Healing Power of Empathy and Mindful Listening

DR: There’s was a classic study done in Italy where people just came out of surgery and in one group, they had a very kind, compassionate nurse say, “We’re going to give you pain medicine to help with your suffering” and they all got morphine. The other group got morphine at an unpredicted time from a computer behind a curtain without that human interaction.

Then they looked at the severity of pain and the severity of anxiety. That pain and anxiety when that morphine was given by a kind nurse, a kind human being, the amount of pain reduction went down significantly. They calculated the degree of that pain reduction when that medicine was given by a nurse versus a computer behind a screen and that equaled eight milligrams of morphine.

MK: Which is a lot I’m guessing.

DR: It’s a lot. We usually start with two milligrams. If you need eight milligrams of morphine, we worry about putting you into respiratory arrest.

Just that human connection has a tremendous effect.

MK: I think that’s really interesting because I know you’re doing research on the placebo effect. It’s a derogatory term, but you’re turn that around saying actually what you’re seeing is a placebo effect and it was a positive effect.

DR: Exactly. And we want to get rid of that word “placebo” because it suggests trickery. This isn’t trickery. This is strategic healing. We’re trying to activate internal healing mechanisms that allows that individual to get better whether we give a drug or not and if we do give a drug, hopefully it will work better.

MK: You write that it’s not just about communication. Better communication is always great, but it’s about connection. Why is that distinction so important?

DR: Well, I think it’s something you feel. When someone feels connected to another human being, they’re more likely to disclose or share sensitive information. In order for us to make an accurate diagnosis, often it’s the story beneath the symptom that gives us the true diagnosis. That connecting really allows authentic information to come out that allows us to be more accurate in judging what’s really going on in another human being. Otherwise, we just project our beliefs.

If I don’t take time to listen and you come in with epigastric pain in between your ribs, I can just shut that off with an Omeprazole proton pump inhibitor, but that doesn’t get at the root of what’s eating you up inside.

That’s that metaphor, the story of metaphor that only comes out if we’re trusted. If it comes out, that alone is therapeutic. If you’re holding something inside that’s tense and sad and angry, often that comes out in some sort of symptom. One of my favorite quotes is by Henry Maudsley, one of the father’s of psychology, he said, “The sorrow that hath no vent in tears may make other organs weep.”

MK: How does a doctor or care givers intention or emotion affect a patients’ well-being? You write about that.

DR: The first step in the process of passionate connection is to do your own work. If we’re stressed out, the patient is going to be stressed out. Emotion is contagious and if we’re not calm and trustworthy, they’re not going to feel calm and trustworthy. You get what you give.

How we are with people really matters in our ability to go in, find how those self-healing mechanisms need to be defined and then mobilize them.

MK: I wanted to reference part of your book. You shared a story from a colleague who watched an oncologist tell a patient that he was going to die. He was young. He was 31.

He actually asked her what happens when we die. I’m just going to read that real quick. “I don’t know what happens when we die. Some people believe there is a heaven, some people believe we get to come back to life in a new way. I honestly don’t know, but I do know this; look around this room, you can feel the love that’s here right now in this room. I believe you were conceived in loved, you were raised in love, love is here right now, and I believe with all my heart that when you pass from this [life], you will be received by love.”

She was actually telling him it was time to leave the hospital and go home and be with his family and die. You’re right that patients don’t remember what we tell them as much as how you made them feel. How do you suggest that doctors and caregivers find it in themselves to be as compassionate as this doctor was?

DR: Well, Katherine Bonus was the head of our Mindfulness program at the University of Wisconsin and she was there during that story. She actually went back and interviewed that physician and said, “How did you do that? It was beautiful! It was a beautiful example of artful connecting.” She said, “I don’t know. I just calmed my mind and those words came out.”

I think that’s so important that we clear our own clutter. You cannot treat suffering with facts. It’s impossible. It never works. If someone is suffering, we have to get out of our own clutter, we have to really drop into the present moment on purpose without judgement. That’s the definition of mindfulness.

Just be with them and often, in that beautiful special place, the beauty comes out. Sometimes “beauty” isn’t the right word. I would say authenticity comes out, the truth comes out about what’s really going on and what that person needs most.
That’s the practice; how do we first do this for ourselves in service of others. We can’t do it for anybody unless we explore it for ourselves.

MK: You write to encourage people to turn towards suffering. Is that difficult to tell?

DR: It is! Which would you rather do, go get a massage or turn towards suffering? Everyone wants to get a massage! If we’re really going to explore those root causes of disease or a symptom, at some point, we have to turn towards it. If we’re brave enough to do that together, some wonderful things happen, things that make the hair stand up on the back of your neck and things that energize us, both of us.

We like to say, “Caring goes one way, us to them, but healing goes both ways.” We get just as much out of this as the other person does.

MK: It’s interesting that you write that we’re all hardwired to be fixers rather than healers. What’s the difference?

DR: Well, there is a big difference. Both are beautiful. If you have a broken femur, you could go to UNM Hospital and be fixed by one of our great orthopedic surgeons, but if you have a fixer who is also a healer, ah, then you’ve got it!

Then you have the surgeon who comes and sits by your bedside before surgery and puts you at ease and creates positive expectation like “Hey, we’re going to get you better. You’ve got a great team around you to help you succeed. We’ll get you back to work and connected to your family.”

Fixing isn’t a bad thing but fixing and healing have completely different curriculums and they are synergistic, they build on each other and they help each other.

MK: I’m guessing that a lot of doctors do want to have a connection with their patients and authentic conversations, but there are a lot of structural constraints preventing it such as the amount of time doctors can spend with patients, the documentation they have to do. How do you suggest work-arounds for these?

DR: The challenges are, particularly when you’re paid by how many patients you see that encourages us to see more patients and that also creates a barrier between connecting to that person in front of you.

Now we have this Electronic Health Record and we are being asked to put more data in that medical record. The research shows we spend twice as much time looking at computers than we do at human beings in the practice of medicine. That’s an unsustainable medical process.

We are exploring ways that we can use that tool to allow more face to face time instead of face to computer time. That’s being strategic by using other health providers to do more data entry, so we can have time working at the top of our license to really give that human being what we know best after we listen to the story.

More than 50% of physicians in America report at least one symptom of burnout. I would argue that it’s these barriers that prevent human connection which feeds us most in this work, is at the root of that burnout.

MK: Can you teach empathy?

DR: That’s a big question. I believe yes, but there is also a difference between empathy and compassion. I’d like to just hit on that a little bit here. Empathy requires me to feel your pain and then do something about it. That’s different than sympathy. Sympathy means we cry together and go home. There is no action. Empathy requires action to what I feel from you. That leads to empathy fatigue because when we’re dealing with suffering, that’s assuming I can fix your suffering, which I can’t. I can’t do that.

Think about how many times you tried to change a loved one; a child, a spouse. How did that go for you? They will find their own way.

Compassion is different. That’s two people suffering together. The root essence of that word means “We are one.” When I help you, I help myself. When I have that mindset when I walk into that room, that makes it more fun because I’m going to connect to the story and once I hear that story, we’re going to try to figure out a better path towards your health and we’re going to do it together through dialogue where that word means “meaning running through.”

How do we open up that conversation? In helping you, I help myself. The beautiful thing about this work in medicine is sometimes if you have this relationship with your patients, they’ll come into my office and I’m suppose to be treating them, but they’ll say, “Dave, you don’t look so good! Are you getting enough sleep?” We start to treat each other.