Friday, June 22, 2012

Doctor and Patient: Can Doctors Learn Empathy? -

My colleague loved performing surgery as much as anyone I had ever met. Every morning he bounded into the hospital, full of energy and cheerful anticipation of the day's surgical schedule, his prominent mouth stretched into a broad grin.
"Too bad his foot is always in it," another doctor whispered one day as our colleague passed by.
The sad truth was that despite his gusto, patients often complained about our colleague. He was brusque when the moment required sensitivity, flip when the conversation was grave, and heavy-handed when the situation called for a light touch. Just a few days earlier, we were shocked to learn he'd bluntly told an elderly war hero in the hospital for his diabetes, "I need to cut off your leg."
"He sure doesn't lack enthusiasm," the other doctor continued as our colleague rounded the corner, the bounce in his step unmistakable. "It's just too bad you can't learn empathy."
Empathy has always been considered an essential component of compassionate care, and recent research has shown that its benefits go far beyond the exam room. Greater physician empathy has been associated with fewer medical errors, better patient outcomes and more satisfied patients. It also results in fewer malpractice claims and happier doctors.
growing number of professional accrediting and licensing agencies have taken these findings to heart, developing requirements that make empathy a core value and an absolute "learning objective" for all doctors. But even for the most enthusiastic supporters of such initiatives, the vexing question remains: Can people learn to be empathetic?
new study reveals that they can.
Building on research over the last decade that has shown that empathetic observers have brain activity, heart rate and skin electrical conductance that mirror those of the person undergoing the emotional experience -- observing a friend's hand getting slammed in a car door, for example, causes us to flinch because an image of the accident gets mapped onto the pain and threat sensors in our own brain -- Dr. Helen Riess, director of the Empathy and Relational Science Program in the department of psychiatry at the Massachusetts General Hospital in Boston, created a series of empathy "training modules" for doctors. The tools are designed to teach methods for recognizing key nonverbal cues and facial expressions in patients as well as strategies for dealing with one's own physiologic responses to highly emotional encounters.
In one lesson, for example, doctors watch a video of a tense exam room interaction while a striking graphic sidebar records the electrical skin conductance of both patient and doctor, the mismatched spikes peaking as each person's frustration with the other escalates. Another lesson walks doctors through a series of pictures of a patient whose face expresses anger, contempt, happiness, fear, surprise, disgust or sadness.
To test the effectiveness of the lessons, Dr. Riess and several of her colleagues enrolled about 100 doctors-in-training and asked their patients to evaluate their empathy, based on the doctor's ability to make them feel at ease, show care and compassion and fully understand patient concerns. Half of the doctors then took part in three one-hour empathy training sessions.
Two months later, the researchers asked a second group of patients to evaluate all the doctors again. They found that the doctors who had taken the empathy classes showed significant improvements in their empathetic behavior, while those who had not actually got worse at empathizing with patients.
"People tend to believe that you are either born with empathy or not," said Dr. Helen Riess, lead author of the study. "But empathy can be taught, and you can improve."
Compared with their peers, doctors who went through the empathy course interrupted their patients less, maintained better eye contact and were better able to maintain their equanimity if patients became angry, frustrated or upset. They also appeared to develop resistance to the notorious "dehumanizing effects" of medical training. After the empathy classes, one physician who had complained about being burned out said, "I feel as though like I like my job again."
Responses to this study have so far been enthusiastic, in part because it is one of the first to rely on patient evaluations of empathy rather than physician self-assessment. "The holy grail of this kind of research is whether patients think doctors are empathic, not whether the doctors think they are," Dr. Riess said. She and her colleagues plan to expand their research and offer the training to more doctors, as well as to nurses, physician assistants and others.
"We are in a special place in the history of medicine," she said. "We have the neurophysiology data that validates and helps move medicine back to a real balance between the science and the art."
Curious to know whether the empathy course worked, I decided to try out what I had learned in researching this column. The next day at the hospital, I took extra care to sit down facing my patients and not a computer screen, to observe the changing expressions on their faces and to take note of the subtle gestures and voice modulations covered in the course. While I found it challenging at first to incorporate the additional information when my mind was already juggling possible diagnoses and treatment plans, eventually it became fun, a return to the kind of focused one-on-one interaction that drew me to medicine in the first place.
Just before leaving, one of the patients pulled me aside. "Thanks, Doc," he said. "I have never felt so listened to before."

Tuesday, June 19, 2012

End-of-Life Choices Shoud Be Clearly Mapped -

Robert H. Laws, a retired judge in San Francisco, and his wife, Beatrice, knew it was important to have health care directives in place to help their doctors and their two sons make wise medical decisions should they ever be unable to speak for themselves. With forms from their lawyer, they completed living wills and assigned each other as health care agents.
They dutifully checked off various boxes about not wanting artificial ventilation, tube feeding and the like. But what they did not know was how limiting and confusing those directions could be.
For example, Judge Laws said in an interview, he'd want to be ventilated temporarily if he had pneumonia and the procedure kept him alive until antibiotics kicked in and he could breathe well enough on his own.
What he would not want is to be on a ventilator indefinitely, or to have his heart restarted if he had a terminal illness or would end up mentally impaired.
Nuances like these, unfortunately, escape the attention of a vast majority of people who have completed advance directives, and may also discourage others from creating directives in the first place.
Enter two doctors and a nurse who are acutely aware of the limitations of most such directives. In 2008, they created a service to help people through the process, no matter what their end-of-life choices may be.
The San Francisco-based service, called Good Medicine Consult & Advocacy, is the brainchild of Dr. Jennifer Brokaw, 46, who was an emergency room physician for 14 years and saw firsthand that the needs and wishes of most patients were not being met by the doctors who cared for them in crisis situations.
"The communication gap was huge," she said in an interview. "The emergency room doctor has to advocate for patients. I felt I could do that and head things off at the pass by communicating both with patients and physicians."
Sara C. Stephens, a nurse, and Dr. Lael Conway Duncan, an internist, joined her in the project. Ms. Stephens flew to La Crosse, Wis., to be trained in health care advocacy at Gundersen Lutheran Health System. Through its trainees, tens of thousands of nurses, social workers and chaplains have been taught how to help patients plan for future care decisions.
"People often need help in thinking about these issues and creating a good plan, but most doctors don't have the time to provide this service," said Bernard Hammes, who runs the training program at Gundersen Lutheran. "Conversation is very important for an advance care plan to be successful. But it isn't just a conversation; it's at least three conversations."'
A Necessary Decision Process
Dr. Hammes, editor of a book, "Having Your Own Say: Getting the Right Care When It Means the Most," said that while he is especially concerned that people 60 and older make their wishes known to family members and develop a cohesive plan, this should be done by someone who develops a serious illness at any age.
"People need to sit down and decide what kind of care makes sense to them and what doesn't make sense, and who would be the best person to represent them if they became very ill and couldn't make medical decisions for themselves," Dr. Hammes said.
"If, for example, you had a sudden and permanent brain injury, how bad would that injury have to be for you to say that you would not want to be kept alive? What strongly held beliefs and values would influence your choice of medical treatment?"
Divisive family conflicts and unwanted medical interventions can be avoided when people specify their wishes, he said. His own mother "told us that if she had severe dementia, it would be a total waste of her life savings to keep her alive. She would rather that her children got the money."
"We help people work through the decision process and involve those close to them so that the family shares in their goals," Dr. Hammes said. "When patients have a care plan, the moral dilemmas doctors face can be prevented."
At Good Medicine in San Francisco, Dr. Brokaw and her colleagues have thus far helped about two dozen people explain their goals and preferences, at a cost of $1,500 for each person.
"In today's health care systems, families will be asked when patients can't speak for themselves and many families are very unprepared to make these decisions," she said.
Her colleague Ms. Stephens pointed out that only about a quarter of American adults have advance care directives of any kind, and only half of them have them in hand or know where they are should they be needed.
Furthermore, only 12 percent had any input from a physician when filling out the forms, which are often done alone or with a lawyer.
"Your lawyer shouldn't be writing a medical contract any more than you'd want your doctor to write a legal contract," Dr. Brokaw said.
The kinds of questions she said people should consider: What was your state of health at the start of the illness? What state are you likely to be in at the end of the illness? What, if anything, can provide a soft landing?
Proper Planning Helps Avoid Troubles
Judge Laws writes in the directive he is preparing, "After family, I value clarity of mind and the capacity to make decisions. To live well is to continue to possess the ability to converse, to read, to retain what I learn and to coherently reflect and understand. I do not want my life prolonged if I undergo a marked lessening of my cognitive powers."
Judge Laws also does not want "to live with severe, distracting pain."
His directive will request that any treatment he receive be compatible with those goals. He also writes that he expects his sons and his wife to support his decisions even if they disagree with them and not to let any quarrels over his care cause a rift in the family.
Studies have shown that advance care planning reduces stress on patients, their families and health care providers. It also results in 30 percent fewer malpractice suits, greater patient and family satisfaction, and a lower incidence of depression, drinking problems and other signs of complicated grief among survivors.
Ms. Stephens said that advance directives are "organic documents that can be changed at any time if circumstances or a person's wishes change." They should be reviewed at least once every 10 years, she added.

The Midwife Becomes a Status Symbol for the Hip -

BESIDES being impossibly gorgeous mothers, what else do Christy Turlington, Karolina Kurkova and Gisele Bündchen have in common?

Each could probably afford to buy her own private wing at a hospital, but instead of going to a top-notch obstetrician, all chose a midwife to deliver their babies.

"When I met my midwife, her whole approach felt closer to home," said Ms. Turlington, who delivered both her children — Grace, 9, and Finn, 6 — with a midwife at St. Luke's-Roosevelt Hospital in New York, one with the help of an obstetrician because of complications. A former model, she founded Every Mother Counts, a nonprofit organization devoted to maternal health. "I knew I wanted a natural childbirth."

Are midwives becoming trendy, like juice cleanses and Tom's shoes? It seems that way, at least among certain well-dressed pockets of New York society, where midwifery is no longer seen as a weird, fringe practice favored by crunchy types, but as an enlightened, more natural choice for the famous and fashionable. "The perception of midwives has completely shifted," said Dr. Jacques Moritz, director of the gynecology division at St. Luke's-Roosevelt and a consulting obstetrician for three midwife practices. "It used to be just the hippies who wanted to go to midwives. Now it's the women in the red-bottom shoes."

And like any status symbol, a pecking order has emerged. Just as getting your toddler into the right preschool requires social maneuvering, getting into a boutique midwifery clinic has become competitive.

"We constantly have to turn women away," said Sylvie Blaustein, the founder of Midwifery of Manhattan, a practice on West 58th Street that has its share of well-heeled clients. Opened in 2003, the practice now has six midwives on staff. "Because of the quality of care, we can only deliver about 20 babies a month."

"It sounds bizarre," Ms. Blaustein added, "but midwifery has become quote-unquote trendy."

Like obstetricians, midwives are medically trained and licensed to deliver babies. The main practical difference is that only obstetricians can perform surgeries, including Caesarean sections, and oversee high-risk pregnancies. On the other hand, midwives tend to approach childbirth holistically, and more of them provide emotional as well as physical care. This can involve staying by a laboring mother's side for 12 or more hours and making house calls.

Nevertheless, misconceptions remain. "There will always be people who have no idea what we do — they think we're witches who perform séances and burn candles," said Barbara Sellars, who runsCBS Midwifery, a small practice in Manhattan's financial district. "Sure, some women want a hippie-dippy spiritual birth and I can't guarantee that. I can guarantee the quality of care."

Ms. Sellars is considered one of the more respected midwives in New York, and her patients have included opera singers, actresses, bankers and models like Ms. Turlington. (Disclosure: of the more than 1,850 babies that Ms. Sellars has delivered, my daughter was No. 1,727 and my son was No. 1,798.)

It was that high degree of care that led Kate Young, a stylist in New York, to seek out CBS Midwifery when she became pregnant with her son, Stellan, in 2008.

"My friends who had the best birth experiences all went to midwives," said Ms. Young, whose clients have included Natalie Portman and Rachel Weisz. "When you go to a doctor, you're left alone a lot. You don't have someone sitting there, looking you in the eye, getting you through it. When I thought about what I wanted for my child and how I wanted to have my child, every sign pointed to going to a midwife."

The rising popularity of midwifery among cosmopolitan women also coincides with larger cultural shifts toward all things natural, whether it's organic foods, raw diets or homeopathic remedies.

"Pregnancy is not a disease, it's a condition," said Dr. Moritz, whose own children were delivered by midwives. "We need fewer OB's and more midwives."

For other women, midwives offer a sense of control. "This is a time when women are asking more questions, getting healthy, wanting to be more empowered," said Ms. Kurkova, the 28-year-old model, who gave birth to her son, Tobin, in 2009. "I didn't want a hospital to take away my power. I didn't want to risk someone cutting me open and taking the baby out that way."

While midwife deliveries typically take place in the hospital, Ms. Kurkova is among those who have given birth at home.

"A home birth is more relaxed," said Miriam Schwarzschild, a home midwife for 25 years who lives in Brooklyn. "I wash my hands, listen to the baby's heartbeat, take the mother's vital signs and that's it. There are no routines. You step outside the bureaucracy at home."

A big selling point for midwives — both at home and in the hospital — is that, barring medical complications, the baby is not separated from the mother after the birth.

Another at-home advocate is Ms. Bündchen, who gave birth in 2010 to her son, Benjamin, in her Boston penthouse.

"We say Gisele delivered her own baby but I was in attendance," said Deborah Allen, a midwife in Cambridge, Mass., who, along with Mayra Calvette, a Brazilian midwife, was present at the birth. "Obviously, privacy is of the utmost importance. You are completely exposed. You need to be in a place where you feel comfortable to do that. Gisele was extremely prepared."

But not everyone is ready to go that route.

When Esther Haynes, deputy editor at Lucky Magazine, decided to go to a midwife, she quickly rejected an at-home birth. "This is New York, and if there was an emergency, I didn't want my story being, 'I called 911 and the ambulance took 45 minutes because of traffic!' " Ms. Haynes said.

"Also my apartment is kind of cluttered," she added. "I hated the thought of going into labor thinking, I wish I'd thrown out more magazines."

U.S. Hospitals Adding Palliative Care Teams at a Feverish Pace | Healthland |

Fighting stage-four ovarian cancer, Carol Delzatto has had more doctor appointments than she cares to count. But this day, she is beaming as Dr. Pamela Sutton comes into sight, greeting her patient and calling her beautiful. Delzatto looks forward to her monthly meeting with the palliative care doctor, where she won't be pricked and won't be rushed, just listened to and offered help.

Hospitals across the country have been adding programs in palliative care — which focuses on treating pain, minimizing side effects, coordinating care among doctors and ensuring the concerns of patients and their families are addressed — at a feverish pace. The field has expanded so rapidly that a majority of American hospitals now have palliative programs, to the delight of patients who say they've finally found relief and a sympathetic ear.

Palliative care has its roots in the 1970s, but was slow to grow. Several pieces of research helped to advance the cause, though, showing widespread untreated pain in hospitals and nursing homes and the positive impact palliative programs had on such patients.

"She's not writing. She is just looking at me and listening and feeling," said Delzatto, 67, during her visit to Broward General Medical Center, where Sutton helped start the palliative care program more than a decade ago.

Dr. Diane Meier of Mount Sinai Medical Center in New York, who directs the Center to Advance Palliative Care, says one of the discipline's greatest benefits is that it looks at the patient as a whole.

"Patients see a different person for every single part of their body or every problem. The patient as a whole person gets lost," said Meier, who won a MacArthur fellowship for her palliative work. "The patient is a person, not a problem list, not a list of different organ systems with different problems, not a list of different diseases. So we end up serving in a quarterback role for the entire medical system."

In 2000, there were 658 palliative programs in hospitals, according to the Center to Advance Palliative Care, representing about one-quarter of American hospitals. By 2009, about 63 percent of hospitals had palliative teams, with a total of 1,568 programs recorded. The field is expected to continue growing as awareness and acceptance spreads, just in time to help baby boomers — the 78 million Americans born between 1946 and 1964 — as they move toward old age and begin developing more serious and life-threatening illnesses.

Though the programs and their scope vary widely, a common scenario might look like this: A patient is diagnosed with lung cancer, and a palliative care team's assistance is enlisted from the start, working alongside oncologists and other specialists. The palliative team may include doctors and nurses as well as a social worker and chaplain. Together, they coordinate care among the many medical professionals, have long consults with the patients and their families to answer questions, and may preventively prescribe medications for likely side effects of treatment, from pain to constipation to nausea.

The palliative team has a clear vision of the patients' goals and personal philosophies and, depending on these factors, might help steer them away from treatments that are determined to be more painful than they're worth. Though palliative doctors share some similarities with hospice doctors in this regard, their goal is still to cure, and their patients are not considered to be at the end of their lives, they are simply facing a serious illness.

Besides cancer, their help is commonly employed for treatment of heart and liver failure, HIV and AIDS, emphysema, sickle cell anemia, chronic obstructive pulmonary disease and a wide variety of other illnesses.

Palliative teams are sometimes met with doubt by both patients and their medical colleagues. Dr. Timothy Quill, a palliative care doctor at the University of Rochester Medical Center and president of the American Academy of Hospice and Palliative Medicine, concedes that patient recognition of what palliative care is remains relatively low and that resistance to the field remains among doctors untrained in the field.

Aside from misconceptions about palliative care being non-curative pain relief for patients destined to die, specialists may find a palliative team helps a patient reach a treatment decision that doesn't offer the most payment. Quill offers an example of a heart failure patient who may be considering getting a ventricular assist device.

"The economic incentives clearly favor doing aggressive medical interventions like this," Quill said. "Palliative care, it's all conversation. And conversation is not compensated in the same way that doing procedures is in our system right now."

Meier says resistance to palliative care tends to be generational, with many younger doctors embracing the field. Research on the subject has also helped prove its worth, particularly a 2010 study published in the New England Journal of Medicine.

That widely publicized report looked at terminal lung cancer patients and found patients who received palliative care as soon as they were diagnosed were in less pain, happier and more mobile than those who didn't receive such care, and the patients ultimately lived nearly three months longer.

Even with such scientific backing, and generally rave reviews from patients, even palliative care's most ardent backers admit it would not have spread as it has without showing cost savings to hospitals. Because a result of palliative care is shorter hospital stays, it can cut costs since many insurance plans pay a flat reimbursement for a treatment, not for the length of stay.

If a bed is freed up sooner, that means another paying customer can occupy it.

"By itself, better outcomes for patients would not be enough," Meier said. "In our society and current way of life, it is impossible to introduce any innovation whether it's surgery or drugs or any innovation if you can't show that it doesn't increase costs."

Broward General's adult and pediatric palliative teams saw more than 1,300 patients last year, but so far administrators have had trouble quantifying what the precise financial impact has been. Sutton and her colleagues have little doubt their work has resulted in fewer hospitalizations and shorter stays, but have found it hard to pinpoint the savings.

Sutton is focused this day on Delzatto, asking her about her sleep and bathroom patterns, and addressing her pain by writing prescriptions. Before seeing Sutton, the patient said she was suffering so greatly she was barely able to move. Now, she's able again to live fairly normally, browsing garage sales with a neighbor and walking the mall with her husband.

"The oncologists are focusing on chemo, the patients are focusing on cure and I think the conversations about comfort aren't happening," Sutton said.

Much of the appointment, Sutton just sits and listens, to Delzatto talking about her Mother's Day celebration, her new Kindle Fire and how she hopes to be able to go on a cruise later this year. And she hears Delzatto credit her with making her life livable again.

"They need more of you," she said.

Monday, June 18, 2012

The High Price of Loneliness -

Loneliness stings at any age. But in older people, it can have serious health consequences, raising the risks of an earlier-than-expected death and the loss of physical functioning, according to a study published on Monday.

The report, in the Archives of Internal Medicine, is the largest yet to tease out the impact of loneliness on people in their later years. Geriatricians at the University of California, San Francisco, asked 1,604 adults age 60 and older how often they felt isolated or left out, or lacked companionship. The researchers were attempting to quantify the feeling of loneliness — a sense of not having meaningful contact with others, accompanied by painful distress.

Answers were recorded in 2002 and every two years after through 2008. The number of older adults who reported feeling lonely — just over 43 percent — didn't change significantly over that period, according to Dr. Carla Perissinotto, an assistant clinical professor at U.C.S.F. and the study's lead author. About 13 percent of older adults said they were often lonely, while 30 percent said loneliness was sometimes an issue.

What did change over the six-year period was the health status of elderly men and women who felt isolated and unhappy. By 2008, 24.8 percent of seniors in this group reported declines in their ability to perform the so-called activities of daily living — to bathe, dress, eat, toilet and get up from a chair or a bed on their own. Among those free of loneliness, only 12.5 percent reported such declines.

Lonely older adults also were 45 percent more likely to die than seniors who felt meaningfully connected with others, even after results were adjusted for factors like depression, socioeconomic status and existing health conditions.

The emphasis on meaningful connections goes to the heart of what loneliness is and is not. It is not the same thing as being alone: 62.5 percent of older adults who reported being lonely in this new study were married. Nor is it simply a paucity of social contacts. As has been observed many times, people can feel lonely even when surrounded by others if their interactions lack emotional depth and resonance.

Loneliness is about the way people experience relationships subjectively, not the number of relationships they have, expert say.

That isn't to say that the number of relationships, or what's known in the scientific literature as "social supports," isn't important. In fact, a large body of research has demonstrated that social supports are critical to older adults' health and well-being, as well as to their longevity. Instead, both social supports and loneliness are important, each separately, each in its own way, even as these components of older people's lives interact, Dr. Perissinotto said.

Barbara Dane, an 85-year-old jazz and blues singer who lives in Oakland, Calif., has seen this play out in her relationship circles.

"As you get older, you see the world writing you off," she said, adding, "So you tend to become passive and think, 'I don't want to bother anybody.' You lose contact with your own kind, your tribe. And before you know it, you're feeling bad."

"It's kind of life a self-fulfilling prophecy. Your eyes start to fasten on the sunset, and you start walking toward it."

An unanswered question is what explains the physical impact of loneliness on older adults. Andrew Steptoe, director of the Institute of Epidemiology and Health Care at University College, London, has been studying this subject. "There is growing evidence that both loneliness and social isolation are related to biological processes that may increase health risk, including changes in immune and inflammatory processes and disruption of the stress-related hormones," he wrote in an e-mail.

"Practical aspects of human contact may also be important," Mr. Steptoe continued. "Someone who lives alone may not have anyone around to call for help if they suddenly experience acute symptoms, while a lonely older person may not have others about them to remind or encourage them to take their medications or follow the doctor's advice."

A small study published last year in Psychology and Aging offers another clue. In that report, Anthony Ong, associate professor of human development at Cornell University, showed that the blood pressure of older people rises in reaction to some kinds of stress and that loneliness accentuates this response.

"Loneliness may be something that is particularly salient in later life, and we should design interventions that help screen for it," Mr. Ong said.

Short of that, reaching out more consistently to elderly friends, neighbors or relatives may help, Dr. Perissinotto said. "Sometimes for older people, just realizing that someone is listening and they're not being ignored makes a difference."