EMPATHY AND PATIENT CARE

 

                                     EMPATHY AND PATIENT CARE

 

 

 

 

 

 

 

Recently,I came across an article in the health section of The New York
Times.It was headed-REFFERAL SYSTEM TURNS PATIENTS INTO COMMODITIES.The
article, candidly written by a cardiologist,takes a critical look at the
inter-referral practices amongst community practitioners and specialists in the
USA.At one point,the article reveals that a New Jersey hospital was
investigated for giving sham salaries to community doctors to increase the
number of referrals in its cardiac surgery programmes.
The above mentioned Referral System is,however,not the subject of discussion here.
.And I mentioned the cardiac surgery programmes for a reason I shall
elaborate later.

 

 

Which direction contemporary health system is heading for?One can notice - the more the advancement in
Medicine in various fields,the broader the gap
between the doctor and the patient.A patient is being looked upon more
and more as a Vehicle for a clinical anomaly.We,health care professionals,are
definitely to be accounted for this to a large extent.Our
focus,predominantly,the sole focus is on the management of the clinical anomaly
itself,as we comfortably tend to forget the fact that the Vehicle is a human
being with a sensitive mind,in a state of apprehension and uncertain
fear.Modern health care is taking this aspect of the patient farther and farther
away.

 

 

A patient with heart disease had come to me for consultation.He was a diagnosed
case of coronary artery disease with heart failure.He had been admitted in a
city hospital with sudden onset acute chest pain,breathlessness,severe
perspiration and vomitting.As I glanced through his case papers,I knew that he
had an acute myocardial infarction.He had been admitted in the ICCU,an
immediate thrombolysis had been done.Following a series of ECGs,a 2D-Echo had
revealed an ejection fraction of 15-20%.The doctors having stabilized the
cardiac failure status,had set him up for a coronary angiography.

The angiography had revealed a 3-vessel block with a 80%lesion in the RCA,and
an atherosclerotic plaque blocking the entire bore of the LAD-100%.Subsequently
a balloon angioplasty had been done with medicated stents in the RCA and the
left circumflex,the doctors having not dabbled with the plaque in the
LAD,presumably finding that the collateral circulation to the left ventricle
was satisfactory at that stage.The patient had been discharged with medications
with an advice for regular follow-ups.

 

I found an uncertain gaze of apprehension in his eyes,almost amounting to
fear.I wondered why he had not followed up with the hospital and chosen to
consult a new cardiologist.I found nothing wrong in the treatment protocol he
had been subjected to,the choice of medicines being exemplary.I asked him as
soothingly as possible about how he was feeling with his present medications.
"I had a heart attack!"he said.I nodded agreeingly,waiting for him to
disclose further.
"I have heart failure..",he blurted out immediately,and I did not
miss the change in his expression as he said that.I had just begun to tell him
that I appreciated the fact that he knew what he was suffering from,when he
interrupted me with a trembling voice,"How long shall I live?" I was
surprised by this question.His face had turned pale,and he was desperately
trying to hold back his tears.
I reached across the table and held his trembling hands,saying,"You
shouldn't be thinking of that at all..if you follow the medications properly
and have regular follow-ups.."-my attempted speech was interrupted by his
completely breaking down.He sobbed inconsolably,his shoulders jerking in
spasms.I waited facing him,puzzled,my mind trying to figure out why this man
was in such a mental state.
I am not going into the details of the dialogue that followed.But after he went
out of the door an hour later,I began to meditate upon What he had gone through
while he was in the hospital.I tried to picturise myself in his position,going
through all the experiences he had gone through and at the end of it,I almost
revolted inside.

 

After his first ECG,he was told by a cardiac resident that he was having a
Heart Attack.He was rushed to the ICCU for an immediate thrombolysis.He was
being monitored closely,being frequently visited by intensivists and nurses who
were doing their job by the book.But all along,the only fact that overpowered
his mind was that he had a Heart Attack-a term that creates in the mind of the
common man.

A 2D-Echo was performed,after which he was told that he was in Heart
Failure.Period.Again nothing was explained to him regarding what "heart
failure"means clinically.Now he knew that he'd had a heart attack and he
was in heart failure.I could well imagine what he must have had in his mind
during that agonising time he spent in the ICCU.
The coronary angiography that followed told him that he had 'severe blocks' in
his heart vessels and a PTCA was needed.He was informed in detail about how the
procedure would be done and what were the risks involved.He was told to sign a
consent form.

 

Now I could understand why he had not gone back to the hospital for a primary
follow-up.Despite being successfully treated for the myocardial infarction,the
heart failure having been well taken care of,and the angioplasty ensuring a much
improved circulation in the coronary arteries,he had walked out of the hospital
knowing three things about himself-he had a heart attack,he had heart failure
and his heart circulation had severe blocks.
And he continued live in fear till he hesitantly decided to approach another
cardiologist for reassurance.I explained to him,drawing simple pictures on a
sheet of paper,what a heart attack means,that his heart was not really failing
that it would stop pumping suddenly,and showed to him what the blocks meant.
I had a taken a little over an hour.I sensed the relief inside him looking at
his face,his eyes asking a confident question-"Is that
all?".
I told him just that-what he Needed to know-"That's all".

 

Are we really looking upon a patient as a "commodity"?I had mentioned
the New Jersey hospital episode
earlier because it was connected to cardiac surgery programmes.
I have no doubt in the hospital had not looked upon the patient as a
Commodity.Nor do I believe that there is a rat to smell in its cardiac
procedure programmes.But,ironically,I feel worse.

 

No one had tried to empathise with this patient.No one had even tried to feel
what the patient might have feeling when official data were being presented
before him at various stages of his treatment.Nobody had told him what he
Needed to know.He was just a Vehicle for clinical anomalies,and those had been
looked after well..Yet he walked out of the hospital,a frightened human being,with
a deeply traumatized mind.

 

Modern health care has got serious flaws in almost every level.Is the way
medics and paramedics are being taught and trained in their formative years,the
correct way?Able health professionals could not even Feel the mind of a patient,let
alone trying to allay his fears.Is the way treatment protocols are being
executed,the correct way?Despite a near-perfect treatment being given, a
patient went home broken,scarred and frightened to death.Is health care being
guided by the correct moral values?A patient did not recieve any empathy from
health professionals,and his psyche had to surrender in front of the treatment
protocol,to be deeply wounded.

 

 

 
The origin of the word "empathy" dates back to 1883,when Theodore
Lipps,a German psychologist coined the term "ein fuhlung",literally
meaning-"in feeling".He used this term to mean "emotional
appreciation of another's feelings".

Objectively,Empathy has been variously defined,right from "the process of
understanding a person's subjective experience by vicariously sharing that
experience while maintaining an observant stance",to "a balanced
curiosity leading to a deeper understanding of another person's experience
within that person's frame of reference".

Pin-point analysis of a simple word leads to complicated definitions which tend
to put the word in an objective frame of reference.We may Understand the
concept better,but not necessarily Feel the same.And empathy is all about
Feeling.I am specifically putting a stress here because empathy cannot be
taught.Physicians,in the contemporary infra-structure of health care,are
trained in the world of "FIND IT AND FIX IT"medicine,a world where
empathy is a mere afterthought.Empathy has been known to be a bed-side manner
considered innate and impossible to acquire.Either you have it or you don't.
But experiences like those of the patient narrated here,having heart
attack,heart failure and severe heart blocks,and the subsequent train of events
that followed have been perceived by physicians in millions,worldwide,in day
to day practice.And it Can produce remarkable results-within a little over an
hour,a man who was unsuccessfully battling a fear of death,was transformed into
a satisfied man,happily accepting the realities concerning his health,and
confident enough to confront them positively.Only after this stage,his
treatment can be qualified as Successful.

 

 

Empathy does have a role to play in treating a patient.The Approach of the
health-care model has to change.

Students of medicine and paramedicine can be taught the same
volume of information with a different approach,an approach which will instill
the 'feeling of Feeling' in a student's psyche,as he advances towards completion
of studies.Yes,Empathy cannot be taught,but it can be gradually inculcated in a
human mind.The "FIND IT AND FIX IT" can be done away with after
debatable deliberations.

Many experts have begun to agree that empathy and empathetic communication are
"learnable skills".

The PERMANENTE MEDICAL GROUP'S Terry Stein with
Richard Frankel developed a communication model-the "Four Habits
Model"(Invest in the beginning,Elicit the patient's
perspective,Demonstrate Empathy,Invest in the end).

 

The BAYER INSTITUTE FOR HEALTH CARE COMMUNICATION developed the "4 E's"model(Engage,Empathise,Educate,Enlist).

 

The AMERICAN ACADEMY ON PHYSICIAN AND PATIENT has invented the PEARLS
model(Partnership,Empathy,Apology,Respect,Legitimisation,Support).

Having mentioned the novelty and success of these models,it has to be kept in
mind that these models are training programmes which aim to drill the concept
of Empathy in a Trained Physician's mind.And a trained physician might choose
to "not to be drilled"in the first place.So shouldn't the process
begin in the formative years when a trained physician was a student?

Many medical schools have recently developed curricula with a strong focus on
the physician-patient communication and empathy.Delivery of these curricula
begins early in the students' training.This 'Beginning Early' is the most
important(and of course,debatable)aspect.

 

The UNIVERSITY OF COLORADO HEALTH SCIENCES CENTER has taken up a curriculum known as the "Foundations of Doctoring Programme",where the teaching staff consists of senior
physicians and trainees from the CPMG(Colorado Permante Medical Group).
Making practical use of an esoteric concept requires 'division of the concept
into its simplest elements' as Carl Jung said.

But for that a health care professional does not need to be a psychiatrist or a
mental health expert,obviously! Willingness and Spontaneity can more than
suffice.The only requirement is an "awareness"(again a spontaneous
emotion)of oppurtunities for empathy during a consultation of a patient.The clue
Always comes from the patient's emotion,either directly expressed,or
implied.Clues oftenly get hidden in the fabric of discussion of a clinical
anomaly,and physicians very often tend to miss them,the "brain"
sincerely engaged in the biomedical details of management of the disease.The
"mind"should be equally involved.

 

Ideally,when a patient perceives the physician's empathetic attention,he
expresses an agreement or confirmation-"You got it,doc!" In the case
of the patient discussed in this chapter,the confirmation was in his eyes,which
had the question,"Is that it?".But it required merely an hour to
bring in this psychological change.He was openly invited to participate in the
understanding of his own problems and their solution.Simple words re-assuringly
explaining "fearful"concepts,aided by simple diagrams of lines,curves
and circles on a piece of paper did the trick.The mode of explaining may
vary,but the notable fact is the patient did Participate without any
inhibitions,when he sensed empathy.This is the reason Empathy can be an
integral part of user-driven health care,and narrative medicine.And here lies a
vast scope of improvement ahead along with Evolution of Awareness.

A recent informal survey has revealed serious
misgivings and misconceptions about empathetic communication.Physicians have
declared to "not having enough time during consultation",to be
"too busy focusing on the acute medical problem",and some have even found
it "mentally exhausting".Unfortunately,this group of physicians have
mistaken empathy for Sympathy.Unlike sympathy,empathy does not require
emotional "effort"on the part of the physician.An appropriate gesture
of empathy takes less than a second,can go huge distances ahead in building
relationships,enhancing rapport,all of which can only result in the Success of
a treatment protocol.But as I said,Evolution of Consciousness has to be in
process.

 

 

Referrances:
1.M A Stewart-A Study of interactions and outcomes.Soc Sci Med 1984.

2)P J Moore,N E Adler,P A Robertson-Medical Malpractice. West J Med,Oct 2000.

3)A L Suchman,D Roter,M Green-Collaborative Study Group of the American Academy on Physician and Patient. Med Care,Dec1993.

4)R M Frankel,T Stein-the four habits model, Perm J-Fall 1999.

5)P A Barrier,N M Jensen-Mayo Clin Prog,Feb 2003.