Published on February 15, 2017 

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Empathy in Medicine

by Hannah Simon at Rutgers Robert Wood Johnson Medical School

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When I enter the examining room, Mr. Jones is visibly distressed. His chest heaves as he struggles to catch his breath. I glance at his charts and make note of his chief complaint: chest pain. After a brief introduction, I fire off a barrage of well-rehearsed questions: When did the chest pain first begin? Does it radiate outwards or stay localized in one spot? Is there anything that makes the pain better or worse?

At one point during the interview, Mr. Jones grows teary-eyed as he recalls his father’s death from a sudden heart attack. “I’m really scared, doc. Do you think what happened to my Dad could happen to me, too?” Placing my hand delicately on his knee, I assure him that I will do everything I can to make sure his heart is working fine. For the first time during our brief encounter, Mr. Jones looks relieved.

But despite my warm promises, I don’t return with an EKG machine. I’m not really a doctor, and Mr. Jones is not suffering a likely heart attack. He is a perfectly healthy medical librarian who happens to moonlight as a standardized patient. The scene I have just portrayed is the third-year summative OSCE (Objective Structured Clinical Examination), a familiar milestone along students’ journey to become physicians. The OSCE assesses students’ abilities to clinically examine patients, diagnose medical illness, and demonstrate strong communication skills. For first-timers, the OSCE may feel like a bizarre, yet clinically sacred ritual, an act of “faking doctor” that has become an integral part of most American school medical curricula.

In addition to the more technical aspects of a physical exam-things like generating a differential diagnosis or correctly manipulating the chest and lung, students also receive points for how well they “praise patient for taking steps to improve health,” “use encouraging and supportive gestures,” and “show empathy.”

In other words, students are graded on how good they are at being humans.

And given the widespread concern regarding a loss of empathy in medicine it’s no wonder that so much emphasis has been placed on medical students’ convincing capability for “humanism.”

In recent years, health care reform restrictions favoring shorter, less personal visits and an admissions process that traditionally favors excellent scores over interpersonal skills have largely eroded away at physician empathy. And consequently, patient satisfaction has plummeted. A 2011 survey by the Schwartz Center for Compassionate Care found that only about half of the 800 recently hospitalized patients felt that their physicians were empathic and caring. In a study of videotaped doctor-patient encounters with oncologists and cancer patients, researchers only provide empathic responses 22 percent of the time.

Some health care educators questions blame an admissions process that traditionally favors excellent scores over interpersonal skills, others believe the strenuous nature of training and the uncompromising hours result in dehumanized physicians. Whatever the reason, it’s clear that empathy is a vital part of a physician’s training and when it comes to our education, it’s a part that we’re getting shortchanged on.

During the preclinical years of their training, medical students spend hundreds of hours memorizing biochemical pathways and learning disease etiologies. Yet during these first two years, there is significantly less curriculum time devoted to the softer skills of medicine, attributes like empathy, active listening, reflection and introspection. This disparity translates into a cohort of newly-minted physicians with strong technical skills and a mental encyclopedia of factual knowledge, but deficits in equally important interpersonal skills.

Anecdotally speaking, I can’t tell you how many times a friend or relative has complained to me about their doctor: “They just didn’t listen” or “They don’t really care.” I’d like to think these are exceptions and not the norm. But as a third-year medical student on the floors, I’m beginning to have doubts. I’ve seen residents or attendings dismissed a patient’s pain complaints knowing those complaints could possibly lead to a longer hospital stay. I’ve been in the operating room while an attending compared an overweight patient’s body (sedated on the operating table) to a Thanksgiving turkey. I have heard residents crack jokes about a patient’s mental illness, not take her complaints seriously because she was “crazy.” I won’t pretend to stand on some moral pedestal, even as a naïve and idealistic third-year student, I’ve had my own moments of weakness. There are times when I’ve interrupted patients or cut them off, when I was more concerned with presenting at rounds for my attending than listening to my patient’s needs.

Beyond anecdotal observations, this erosion of empathy has been shown in scientific studies. At Jefferson Medical College, researchers used an “empathy scale” to show the most significant and rapid decline in empathy in medical students occurred during the third year of training. Puzzlingly, this phenomenon occurs during a time when students should be most empathetic, as they have finally ditched the endless P and textbooks for real human interaction. Researchers also point out that these decline in empathy is not transient; it persists through graduation and beyond.

When I leave my OSCE, and my last exam of medical school, I can rest assured that I was convincing enough to pass the empathy litmus test. I surely passed as a human. But, as I near the end of my medical training, I have to wonder, is this enough?

Hannah Simon (2 Posts)

Contributing Writer

Rutgers- Robert Wood Johnson Medical School

Hannah Simon is a fourth year medical student at Rutgers- Robert Wood Johnson Medical School. She has a bachelors degree in neuroscience from Dartmouth College and a masters in science education from the City University of New York. Before medical school, she was a high school biology and psychology teacher.

The Conversation Placebo

DANIELLE OFRI, JAN. 19, 2017

The New York Times Opinion  https://nyti.ms/2k3nfYu

In my daily work as a primary care internist, I see no letup from pain. Every single patient, it seems, has an aching shoulder or a bum knee or a painful back. “Our bodies evolved to live about 40 years,” I always explain, “and then be finished off by a mammoth or a microbe.” Thanks to a century of staggering medical progress, we now live past 80, but evolution hasn’t caught up; the cartilage in our joints still wears down in our 40s, and we are more obese and more sedentary than we used to be, which doesn’t help.

So it’s no surprise that chronic arthritis and back pain are the second and third most common non-acute reasons that people go to the doctor and that pain costs America up to $635 billion annually. The pain remedies developed by the pharmaceutical industry are only modestly effective, and they have side effects that range from nausea and constipation to addiction and death.

What’s often overlooked is that the simple conversation between doctor and patient can be as potent an analgesic as many treatments we prescribe.

In 2014, researchers in Canada did an interesting study about the role of communication in the treatment of chronic back pain. Half the patients in the study received mild electrical stimulation from physical therapists, and half received sham stimulation (all the equipment is set up, but the electrical current is never activated). Sham treatment — placebo — worked reasonably well: These patients experienced a 25 percent reduction in their levels of pain. The patients who got the real stimulation did even better, though; their pain levels decreased by 46 percent. So the treatment itself does work.

Each of these groups was further divided in half. One half experienced only limited conversation from the physical therapist. With the other half, the therapists asked open-ended questions and listened attentively to the answers. They expressed empathy about the patients’ situation and offered words of encouragement about getting better.

Patients who underwent sham treatment but had therapists who actively communicated reported a 55 percent decrease in their pain. This is a finding that should give all medical professionals pause: Communication alone was more effective than treatment alone. The patients who got electrical stimulation from engaged physical therapists were the clear winners, with a 77 percent reduction in pain.

This type of study provides hard evidence for what shamans, witch doctors and assorted mystics have known for millenniums: A substantial portion of “healing” comes from the communication and connection with the patient.

Before we had treatments that could actually counteract the pathology of disease — antibiotics, chemotherapy, stents, organ transplants, transfusions — placebo was the mainstay of medical care, and in many cases it was remarkably effective. 

A good example is patients suffering from vague diffuse pains with no discernible cause. Frequently my patients ask if a multivitamin will give them more energy. In the past I would say no, because there are no significant scientific studies to demonstrate this, and also because in the absence of a vitamin deficiency there’s not much for a basic multivitamin pill to do. Now I take a different approach. I say something along the lines of “Many of my patients find that they have more energy when they take a multivitamin.” I’m not lying, because many have indeed said so. Without fail, there are always a few patients who come back at the next visit and swear they feel much better.

There are some who argue that it is unethical to promote placebos to patients. But increasingly, many say it would be unethical not to give placebos a try in situations where patients are not getting relief from traditional means (and where it would not cause harm or replace a necessary treatment).

It’s clear that how doctors and nurses communicate their treatment can have profound effects on how patients experience the results of that treatment. Yet the conversation between doctors and patients is one of the least valued aspects of medical care. Insurance reimbursements for tests and medical procedures dwarf reimbursements for talking to patients or spending time thinking about what ails them. And the pharmaceutical industry, with its direct-to-consumer advertising, has promulgated the fallacy that every ailment must be met with a pill — brand name, of course.

As health care faces its latest overhaul, it’s crucial for the medical profession, as well as insurance companies and decision makers in government, to recognize the power of the doctor-patient conversation. It’s the most valuable diagnostic tool we have and can be remarkably effective as a treatment tool as well. Training for doctors and other medical professionals should emphasize communication skills with the same rigor that it does for other clinical skills.

Call conversation a placebo if you like, but if it helps without causing harm, then it’s legitimate medicine. Relieving suffering, after all, is what the Hippocratic oath is all about.

Danielle Ofri is an associate professor of medicine at N.Y.U., the editor in chief of the Bellevue Literary Review and the author of the forthcoming “What Patients Say; What Doctors Hear,” from which this essay was adapted.

 

What does a 'focused' history taking and physical mean?

I received the following email from an OSCE candidate and would like to share it with you:

Dear Dr Al lmari,

I am still confused regarding Focused physical examination.

I need your guidance for 5 min, 8 min stations.

I read it from your notes that it is not a head to toe examination.

But still not getting it, Could you please guide me.

Is it

1.        .   To focus on Only the system asked to exam as per chief complaint e.g CVS, Respiratory etc.  OR
2.       .    Do physical as per differential + focused examination of system asked as per Chief complaint.

For example

1.        .   in case of patient with cough, Face, Neck, LN & Respiratory System + Upper Abd ( GERD) or Only Respiratory ( Chest Only)   or only Chest
2.       .    In case of Fluid Assessment CHF pt- BP, JVP, Kausalmaul, hepatojuglar reflux, CVS( Ins, Pal, Ausculation) +  Vessels-Radial, + Carotid, Aorta, Renal & Illac for Bruit, + Popletial, Post Tibial and Dorsalis pedis,  Edema over leg, crepts on base of lungs and Abdominat Girth, Ascites

Am I right ? Sir please guide me. Thanks for your time.

With Best Regards

-------------------------

Hello Dr ....,

Sorry for the delay of my reply.

You are right its somehow confusing what a focused approach is.

Basically, the shorter available time is, the more focused you should be.

But focused on what? You should be focused on the differential diagnosis (DDx) of the chief complaint, not the system.

Your focus is on developing a differential diagnosis specific for this patient with your first guess is the best match followed by less matching DDx.

If you noticed, OSCEhome flow charts’ questions box for each system does cover all the required differentials for any chief complaint from other systems.

For example, the first few system specific questions box for chest pain are similar in cardiology and respiratology and even GI.

Meaning after asking these few questions you will know that you are dealing with a cardiac, respiratory, GI, or MSK case and proceed with questions of that system specific questions/examination box.

Similarly, questions for each symptom, e.g cough, are identical in any system specific questions box.

However, if you thoroughly practice our flow charts, you will be fast to ask and do more than needed if you are not sure.

This will assure checking all the required check marks to be on the save side.

The main logic of the OSCEhome Systematic Approach to the OSCE and clinical patient encounters is to eliminate burden of focusing on WHAT to ask or do, HOW to ask or do, and WHEN to ask or do and redirect your attention and thinking to focus on developing a specific DDx for this patient, to build rapport with the patient and a plan to proceed,

In answering your questions:

Is it

1.         .  To focus on Only the system asked to exam as per chief complaint e.g CVS, Respiratory etc.  OR
2.         .  Do physical as per differential + focused examination of system asked as per Chief complaint.

By using the OSCEhome flowchart for history taking, you do have now a DDx.

Next, for examination select the system specific box that match your first DDx.

Similar to questions boxes, OSCEhome examination flow charts do cover related symptom/sign DDx.

Meaning your above #2 answer is the way to go.

1.         .  in case of patient with cough: Face, Neck, LN & Respiratory System + Upper Abd ( GERD) or Only Respiratory ( Chest Only)   or only Chest
2.        .    In case of Fluid Assessment CHF pt- BP, JVP, Kausalmaul, hepatojuglar reflux, CVS( Ins, Pal, Auscultation) +  Vessels-Radial, + Carotid, Aorta, Renal & Illiac for Bruit, + Popletial, Post Tibial and Dorsalis pedis,  Edema over leg, crepitus on base of lungs and Abdominal Girth, Ascites

1- If you look at the OSCEhome questions set for cough in all system specific questions boxes you will find them identical and by asking them you will know which system specific examination box to follow.

(Note: Face and neck in cough cases are for upper respiratory causes which is already covered in chest examination box).

2- For CHF, the cardiac specific examination box cover all these.

Hope this answers your questions.

All the best for your OSCE preparation.

Have a nice day.

Al
www.oscehome.com

The Last Hours of Living: Practical Advice for Clinicians

How did OSCEhome.com created the Systematic Approach to the OSCEs and clinical patients encounters.

Physicians' Top Ethical Dilemmas

Physicians' Top Ethical Dilemmas:

Would you fight with a family that wanted to withdraw care from a viable patient? Would you follow the family's directive to continue treatment if you thought it was futile? Would you date a patient? More than 24,000 physicians told us how they feel about this and other ethical dilemmas.

Check this interesting Medscape survey..

www.oscehome.com

'via Blog this'

Are The OSCEhome Systematic Approach Flowcharts The Answer To Today’s Short Patient-Physician Encounters?

Recently, I received an email from one of OSCEhome.com newsletter subscribers concerning a valuable article in Newsweek Magazine titled “The Doctor Will See You- If You’re Quick”. In that article, the Author, Shannon Brownlee, points out that ‘they are signs that something in the world of medicine is seriously amiss’. She said patients ‘tell tales of being rushed out of the office by harried doctors who miss crucial diagnoses, never look up from their computers during an exam, make errors in prescriptions, and just plain don’t listen to their patients. Studies show a steep decline over the last three decades in patients’ sense of satisfaction and the feeling their doctors are providing high-quality care. And things don’t seem much better from the other side of the stethoscope. In a recent survey by Consumer Reports, 70 percent of doctors reported that since they began practicing medicine, the bond with their patients has eroded’.

The main issue she stated is that ‘Today visits are still short… The number of required tests and conditions primary-care doctors are supposed to screen for has skyrocketed’. One physician in the article said: ‘When you have only 15 minutes per patient, then there are home visits and hospital visits, you feel like you’re on a hamster wheel’.


Then, she reported studies that concluded that ‘This is not a recipe for optimal care. One Canadian and U.S. study found that doctors interrupt their patients on average within 23 seconds from the time the patient begins explaining his symptoms. In 25 percent of visits, the doctor never even asked the patient what was bothering him. In another study that taped 34 physicians during more than 300 visits with patients, the doctors spent on average 1.3 minutes conveying crucial information about the patient’s condition and treatment, and most of the information they provided was far too technical for the average patient to grasp; disconcertingly, those same doctors thought they had spent more than eight minutes’.


On the patient clinical management side, she said ‘At the same time, doctors often prescribe too much of the wrong kind of care. Between 2000 and 2005, the number of CT scans performed annually nearly doubled to more than 75 million a year, many of them given, say experts, out of habit or fear of litigation, not because they were likely to help the doctor make a diagnosis’.


Concerning patient-physician relationship, she emphasized that ‘Numerous studies have found a link between how well the doctor and patient communicate and the patient’s sense of well-being, his number of symptoms, and his overall health.’


Bottom line reality is; 1) physicians have limited time allocated to each patient visit. There are more patients than physicians and training more physicians with these economical circumstances is not possible, 2) have a wide list of differentials to cover in order to be a good physician and to protect themselves. Obviously, the focused history and physical approach became so focused that failed frequently, 3) have no time for establishing an effective patient-physician relationship, and 4) have limited time to explore patient management options.

Currently, physicians have to adopt a focused approach. It is kind of the third world out-patient approach for treating patients’ symptoms. In order to protect themselves, they instruct patients to come back if things don’t improve! It is kind of an initial screening process during which physicians omitted several important issues concerning clinical and patient-physician communication. This may work initially. The problem is that when the patient comes back for a second visit, will he be allocated more visit time and addressed differently? What if the patient will see another physician who will re-initiate this focused approach?


So, how to solve this?


Since 2004, OSCEhome.com introduced the Systematic Approach to focused history taking, physical examination, and counseling in which a set of grouped carefully phrased questions and actions sets are arranged based on patient complaints, not body systems or physician specialty. It has the same rationale of ATLS APLS, ALSO, and ACLS approaches. After memorizing and practicing all the flowcharts, physicians can pick specific sets of history taking questions and physical exam actions to perform during the patient encounter based on the presenting patient complaint.


Verbal and non-verbal communication skills are embedded within this system. By practicing these flowcharts over and over until it become a second habit, physicians can be confident that they accomplished a professional conduct. This focused approach puts the physician on an autopilot mode to cover all relevant differentials without thinking about them as they have no time in today’s short patients’ visit.


This approach ensures that the physician won’t forget to ask or examine crucial things. In stead, they’ll have relatively more time for clinical decision making, establishing rapport, and discussing the patients’ options, attitude, and compliance.


Read more about the OSCEhome Systematic Approach at http://www.oscehome.com/.

Read the full Newsweek article at The Doctor Will See You- If You’re Quick.


Have a nice day.

Dr Al Imari.

http://www.oscehome.com/