Living better through empathy

PFSP PERSPECTIVES

March 31, 2014

Physician and Family Support Program
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I have to admit, I often overlook empathy at the dinner table – sometimes, too, in my clinical encounters. And while I’m okay with leaving this virtue undeveloped in regard to my food, I could really benefit from improving it in other aspects of personal and professional life.

Thanksgiving dinner’s sad and thankless. Christmas dinner’s dark and blue. When you stop and try to see it from the turkey’s point of view. - Point of View, Shel Silverstein

Empathy is an important tool in any medical toolbox. It’s the band-aid of a good first aid kit. Any parent knows the value of a cute bandage with a picture of a cartoon character for any bleeding wound and even for those ones that didn’t quite break the skin but hurt a lot. Somehow it eases the pain.

That somehow is empathy. In addition to easing the pain of a superficial skin wound, empathy has also been shown to improve outcomes in diabetic patients, improve medication compliance, decrease the duration of the common cold, improve patient satisfaction and decrease lawsuits.

Research, not to mention intuition, contradicts the oxymoron of “a good doctor with a horrible bedside manner.” A review on the so-called “soft skills” of medicine suggested that a “consistent finding is that physicians who adopt a warm, friendly and reassuring manner are more effective than those who keep consultations formal and do not offer reassurance.”

There are courses, articles, chapters, books, even careers based on techniques and tools to develop this virtue. I’ll offer just a few phrases to cultivate empathy: “a space to be,” “the third alternative” and “just listening.”

A space to be

Humanistic psychologist Carl Rogers described a way of seeing other people, not for their accomplishments, not for what they could do for others, but for their own inherent value as fellow human beings. This “unconditional positive regard” is a foundation for conflict resolution, negotiations, family life and maybe for any interaction with another person.

Dr. Gabor Maté, author and physician in downtown Vancouver, has more than the average amount of experience dealing with people who aren’t used to being appreciated for their inherent worth. In his book In the Realm of Hungry Ghosts, he talks of his experiences in treating people with addictions. Most of his patients would be considered “difficult patients” to many of us.

But like anyone, they need to feel valued or even valuable. He quotes a nurse colleague: “People just need a space to be. They need a space to exist without being judged and hounded and harassed.” (Liz Evans, nurse, director of Portland Hotel Society.)

We make mistakes when we make assumptions. I learned this when I treated a patient in the middle of the night with a simple scalp laceration.

“What happened,” I asked.

“I just tripped on the stair,” he replied sheepishly.

Taking his embarrassment for avoidance, I assumed alcohol was involved. Luckily, I didn’t say so. I did inquire about his social situation. I usually do with people showing up drunk in the night at my downtown emergency department. It probably came out something like,

“So, do you have a job?”

He did have a job. He was a drug counsellor in a downtown clinic that had many of the city’s underserved residents as patients, many of the same people I saw as patients.

We did end up talking about alcohol, but in a very different way than my original assumptions would have led.

The third alternative

We get stuck in dichotomies. In manufacturing (quantity or quality), politics (increase taxes or decrease social funding), even family life (permissiveness or discipline), we often limit ourselves to narrow choices. Sometimes we can only see “my way or the highway.”

The influential philosopher Immanuel Kant introduced the idea that valuable perspectives sometimes lie outside the range of our usual responses:

“I do not approach reasonable objections with the intention merely of refuting them, but that in thinking them over, I always weave them into my judgments, and afford them the opportunity of overturning all my most cherished beliefs. I entertain the hope that by thus viewing my judgments impartially from the standpoint of others some third view that will improve upon my previous insight may be obtainable.”

Have you ever been sure of a diagnosis or treatment only to have the patient himself suggest something you hadn’t thought of? And then to realize that he was right. If you haven’t, maybe you’re really smart and always think of all possibilities. Or maybe you’ve just missed some diagnoses because you were “refuting reasonable objections.”

Empathy often means seeing things from a different viewpoint. (Photo provided by David Bly)Another scalp laceration in the night. This on a man in his 40s, assaulted at a bar. In fact, he had more than just a scalp laceration; his face, too, was slashed in four or five places. Nothing serious, but more than a little suturing was indicated.

“Can you put me out?” he asked. General anesthesia didn’t seem to be a reasonable objection, and I refuted it with little thought.

As I began to inject local anesthetic, his response was dramatic, to say the least. Not that he wasn’t co-operating; the tiny needle seemed to inflict immense pain. Even once an area was anesthetized, he still seemed to require great effort just to remain on the stretcher.

“I have a thing with needles,” he explained apologetically, as I paused to wonder why this seemed so difficult for him. He described his phobia a little, but was willing to do what he needed to have his gaping wounds repaired.

I reconsidered the idea of “putting him out” in this new light. His objection didn’t seem so unreasonable now. The rest of the procedure was facilitated by a little sedation.

Just listening

A 30-something woman was brought by EMS, accompanied by police, to my emergency department during the night. She had been acting violently, even “pulled a knife” on someone, and spit on a paramedic. She was unclothed, had a mask applied to prevent further bodily fluid exposure to health care workers, and restrained to the bed for the next few hours until seen by a physician.

When I did see her I said something about how I thought it didn’t look like much fun to be in her current situation. She swore at me. But we talked and I tried to see things from her point of view. And she told me her story, which was little more than a night of excessive drinking.

Pulling a knife? The police officer on scene told me she pulled everything out of her purse, including a knife, looking for her identification.

C.S. Lewis said, “What you see and hear depends a good deal on where you are standing.”

In my first month of medical school before I was taught how to palpate an abdomen or listen for whispering pectoriloquy, I was taught where to place myself in relation to a patient. Sitting attentively, not standing impatiently, hand on doorknob. At eye level, not looming above them. Close enough, not too close. You know, all those things I forgot when I became more concerned about heart sounds (was that a pathologically split S2?) and neurological findings (is this sharp or dull? sharp or dull? sharp or dull?). Dull.

C.S. Lewis was right.

“… it also depends on what sort of person you are,” he continued. How we are with others is maybe determined by how much we can be with others during times of need. Not so much in terms of quantity of time, but in quantity and quality of our being present.

“When we honestly ask ourselves which person in our lives means the most to us, we often find that it is those who, instead of giving advice, solutions, or cures, have chosen rather to share our pain and touch our wounds with a warm and tender hand. The friend who can be silent with us in a moment of despair or confusion, who can stay with us in an hour of grief and bereavement, who can tolerate not knowing, not curing, not healing and face with us the reality of our powerlessness, that is a friend who cares.” - Henri J.M. Nouwen, Out of Solitude: Three Meditations on the Christian Life

Empathy is an important ingredient if we would be an influence for good at home or at work. People flourish when they are appreciated simply for who they are (“a space to be”), when their viewpoint is considered important (“the third alternative”) and when they feel heard (“just listen”). And who knows, maybe dinner would even taste better if we considered its origins. At least the turkey might feel better about it.

References available upon request.

 

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