Category: Clinical

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Clinical General Healthcare Costs Opinion Patient-Centered Care Reflection

Excellent, good, or fair? How accurately can patient satisfaction surveys measure quality of care?

Last week I had my semiannual dentist appointment. Right after I stepped out the door, I received an email: Dental Office – Patient Satisfaction Survey. Hi, thank you for visiting the dental office. Please take a minute to complete the survey…. Was it a déjà vu? Didn’t I just fill this out recently? Oh wait no. That was for the hygienist? Or was it for that new periodontist? Maybe it was my other specialists?

So besides rating my favorite restaurants and shops on Yelp and Google, now my clinics and insurance companies also want to know how I would rate my doctors– how splendid!

To my surprise, when I clicked the link, the questions were trickier than I expected. According to the email title, it seemed like the survey was about my dentist, but 75% of the questions were about the clinic itself: Waiting time in reception area, appointment phone call answering friendliness, waiting room neatness, office decoration….(Wait…my dentist is responsible for decoration? Great, let’s talk about changing the interior lighting and repainting the wall at the next appointment). As I was filling out the questionnaires, my head started to spin with my own questions: It was a normal checkup appointment, will “fair” be good enough? But I remembered I had given the hygienist an “excellent,” and honestly I couldn’t tell which one was better…oh boy! How are they going to use my answers? Who will be reading my survey responses? Who will be affected by my answers?

To me, it’s difficult to judge the doctors’ performance fairly. I can measure a finance manager by his portfolio performance, a designer by how many designs have been ordered, and a lawyer by how many lawsuits she has won. But judging a doctor is more like judging a piece of artwork: there’s a lot of subjectivity. How do I know Dr. ABC is better than Dr. XYZ? By my test result? Or by the number of medications they prescribe? Like with my dental visit, I couldn’t really tell the difference between that cleaning from the previous ones. Interestingly, some physician groups use patient satisfaction surveys to allocate bonuses [1]. That would make the weight of responsibility seem heavier; I would hate to find out that my dentist lost his Christmas bonus because of my thoughtless answers.

Needless to say, it’s difficult for management to evaluate every department and employee in a large organization. I truly hope that upper management does not blindly rely on this “big data” to determine a doctor’s career path. I would very much like my doctor to focus on my health, instead of for him or her to be driven by monetary incentives and to act as a salesperson. If the survey data is used for allocating the budget, perhaps the survey needs to be transparent about how the clinic is going to use the result: “This survey is for quality training purposes only” or “this survey is for determining the best doctor of the month and who gets the nearest parking spot.” I suspect that knowing the purpose of the survey helps the respondent think twice before jotting down comments or complaints. It might motivate patients to actually finish the survey (I would very much like to meet the saintly soul who is able to finish 30 ambiguous questions without losing their temper). Also, I would like to suggest that since we are giving patients such power, perhaps we can give some power to the physicians too and allow them to rate their patients (like how Airbnb and Uber lets hosts/drivers grade their guests/riders).

Surveys and ratings can be important sources of information. If I need to find a new doctor or specialist, the first thing I do is go on Yelp and sort the list by how many stars they have. Some industries routinely rely on survey systems to improve their customers’ experiences [2].

I understand that the idea behind patient satisfaction surveys is to encourage more communication. But at the end of the day, I believe that the doctor and the patient should have a strong mutual trust that enables them to communicate and give feedback freely and respectfully, without needing to rely on 30 ambiguous survey questions.

 

Reference:

  1. White, B. (1999, January 01). Measuring Patient Satisfaction: How to Do It and Why to Bother. Retrieved April 17, 2018, from https://www.aafp.org/fpm/1999/0100/p40.html
  2. Columbus, L. (2018, April 22). “The State of Digital Business Transformation, 2018.” Retrieved April 25, 2018, from https://www.forbes.com/sites/louiscolumbus/2018/04/22/the-state-of-digital-business-transformation-2018/#761f84535883

Edited by Shaun Webb

Photo credit: Steve Harris

Special thanks to Blog Associate Editor, Janie Cao, for some last-minute content revisions

To learn more about the author, please visit her website here

Categories
Clinical Emotion Empathy General Humanistic Psychology Narrative Palliative Care Poetry Psychiatry Psychology Reflection Spirituality

The Dying Man

The Dying Man
Written by Janie Cao
Edited by Mary Abramczuk
A few years ago, I spent half my day with a dying man. I remember these things about him: his name, his past profession, and that he was dying alone.

I never saw his résumé, the size of his house, or how much money was left in his bank account. I was not curious to know, either. But I bet they seemed significant once upon a time, at a dinner party, maybe. He worked as an engineer.

On that day—the day he died—no one who had cared about those things was there.
I was a stranger, yet I saw his last breaths. It was a curious day.

This world teaches us to do many things. To set goals (S.M.A.R.T ones, in fact) and to meet them. To maximize profit and minimize loss, and to use other people, to our advantage. We learn to build storage houses and efficiently fill them with glorified trash; to talk like we matter, and live like it, too.

Someday, we will all be that dying man. Not fully here, and not quite there; mere wisps of breath. When that day comes, will this world be at your bedside? 
Sometimes, I wonder.




-----
Dedicated to a friend: May you find what you are searching for.
Photo credit: Jörg Lange
Categories
Clinical General Healthcare Costs Law Opinion Patient-Centered Care Primary Care Public Health Reflection

Discontinuity in Care

My resident tries fairly hard to take care of his patients. When he is with them, I catch him paying attention to all sorts of details that he could have easily let slip past. So it made it all the more difficult when I saw him enraged. When he opened up his list of clinic appointments one morning, on the list was a patient he did not want to see. It was not just that she was a new patient to him. It was not just that her problem list went on like a run-on sentence. It was that both were true, and my resident was still expected to see her in only 15 minutes.

While chart reviewing, he learned that the only consistency in this patient’s medical care at our clinic had been a history of inconsistent providers—and based on their notes, none of them had the complete story. “Why am I even seeing her?!” my resident asked rhetorically, as he frantically searched for answers he knew he did not have the time to find. I wondered, too. This visit seemed to benefit no one except the Billing Department, and even that would depend on whether the Medicare reimbursements actually made it through.

That patient’s experience was hardly unique, though. While rotating through various specialties as a medical student, I have met several patients who were passed from one provider to another. Maybe the provider had to switch services. Maybe they left the institution for better opportunities elsewhere. The reasons were myriad. Stories like those suggest that continuity of care may still only be a priority in primary care literature.

I think one reason for this reality is a lack of incentives to keep doctors and patients together. In any field, including medicine, we see money driving people’s attention and vice versa. Since our country has historically kept primary care on the back burner, there is little evidence to believe that practical incentives for continuity of care will spontaneously appear in the near future.

So, for the primary care fans out there, it might be worth it to start speaking up.

 

Photo credit: Norbert von der Groeben/Stanford School of Medicine, posted by National Center for Advancing Translational Sciences

Categories
Clinical Patient-Centered Care Reflection

“Listen to understand” not “listen to reply”

A two-month stint at the oncology department in a Singapore government hospital has provided me with vivid examples of the importance of doctor-patient relationships and communication. Cancer, in many societies, is still widely regarded as medical taboo – a condition people closely associate with death. While I got to witness very sensitive and depressing conversations in relation to end-of-life care, the most impactful conversation I experienced had nothing to do with end-of-life care. Rather, it was a complaint from a patient about his team of allegedly negligent doctors.

It took place in a private ward room with just Mr. C and his wife. When I first entered the room, Mr. C gave me a hostile look and asked me who I was. Feeling awkward given the cold welcome, I persisted to introduce myself as a medical student who wanted to take his history. Although reluctant, he agreed to talk to me. What started as a cold introduction turned out to be an hour-long avenue for Mr. C to vent his anger and frustrations. It became etched in my mind for the important lesson that came with it.

I understood from Mr. C that it was not the diagnosis that brought about his unhappiness, but how the diagnosis came about.  Mr. C presented with a 6-month history of progressive dull epigastric pain and loss of weight with no co-morbidities. He had no associated fevers, nausea or vomiting. The conversation went well until I asked him the question, “Did you bring this to your doctor’s attention?”

Immediately, there was a change in his facial expression. I divined from his grim expression that the news was not good. He started shaking his head, somewhat in disappointment. His wife started tearing. I had inadvertently asked a sensitive question and was caught helplessly in that moment of grief and sorrow.

Mr. C then explained that he actually went to the Emergency Department (ED) thrice as his abdominal pain worsened. Unfortunately, on the first two occasions, they sent him home after establishing that his vitals were stable with no abnormalities in his test results. He was sent home with a stack of medications but without a diagnosis.

Interestingly, Mr. C actually suspected himself that he had gastric cancer given his strong family history; he expected that he would suffer from it one day. The doctors shook it off despite his persuasion. On the third visit, however, the doctors finally admitted him and performed an endoscopy. It was later confirmed to be Stage 3 gastric cancer. It was at this point in the conversation when emotions started running wild.

The atmosphere heated up. I was shot with questions and complaints by both Mr. C and his wife.

“I would not have been denied earlier detection and treatment if doctors listened to my history,” Mr. C said.

“That period of 6 months could have made a huge difference to his disease stage and prognosis!” Mr. C’s wife added.

“Do you think the doctors have done the right thing for me?” he asked.

“Doctors never bother to hear patients out!” he shouted.

It felt as if the blame was on me, and I felt angry for a moment. I was on the edge of questioning his accusations, and refuting his comments. I was conflicted inside. On the one hand, the manner in which he was treated at the ED seemed unjustified. But at the same time it did not seem fair for me to blame the doctors without understanding what their line of thought was.

I further understood that Mr. C had explained his case to a senior consultant, who was also the surgeon who performed his gastrectomy. The surgeon brushed Mr. C off, and told him rudely to switch to another hospital if he did not like it here. It was at this point that I stood in favor of Mr. C. I actually could not believe such an insolent comment would come from the mouth of a senior doctor, whom I thought was supposed to possess the maturity and authority to handle such a complex matter.

Mr. C and his wife were evidently distraught with how the diagnosis came about, compounded by the fact that he was still relatively young to suffer from stage 3 gastric cancer. He explained that gastric cancer is one of the most aggressive and treatment-resistant cancers with the highest mortality rate, as evident from the young deaths of his family members who succumbed to the illness. My heart immediately sank after coming to terms with his bleak prognosis.  I recalled what was taught in my clinical skills classes, and took on an empathetic coat to try and calm them down. I felt an ephemeral sense of shame for the apparent lack of professionalism Mr. C’s doctors had displayed. Furthermore, I was sunk in guilt for initially doubting his comments.

I continued with the rest of the history and thanked Mr. C and his wife for their time. I walked out of the room and told them, “Thank you for sharing with me. Both of you have taught me about the kind of doctor whom I do not want to emulate in the future”.

It was an eventful hospital experience for Mr. C, and a rather eventful conversation for me with him and his wife. Despite the awkwardness and negative emotions, it taught me a great deal about the nature of difficult situations, the qualities a doctor should possess, and the importance of communication.

It was no doubt a challenging conversation. It was unlike all the other conversations I have had with patients, that were full of praise for their doctors, which always reassured me of my choice to become one.  My limited exposure to issues that arise from the lack of proper doctor-patient communication caught me off guard during this particular conversation.

When I mentioned to Mr. C that I was a medical student, his facial expression and body language conveyed his bitterness and dissatisfaction. It was almost as if he had something against me. I was filled with self-doubt and hesitancy. I was unsure if I should persist with the conversation given his hostile appearance but I knew that he had a story that he was dying to tell. Mr. C’s experience at the ED has probably altered his perception of doctors, and it was worth it to hear him out.

In hindsight, I am consoled by the fact that I had that conversation with Mr. C because he gradually opened up to me, treated me as an avenue to vent his frustrations, and perhaps subconsciously, taught me a lesson or two about being a doctor. I have learned that patients are always keen for a listening ear, be it to share their joy, or to pour their sorrows. It is hence important for medical students like me to not be doubtful when approaching patients for the fear of intruding in their privacy or taking up their needful rest time. Never be afraid that you are just an unqualified medical student.

Communication is the crux of medicine. As Sir William Osler said, “The good physician treats the disease; the great physician treats the patient who has the disease.” History-taking is not just about the whims and fancies of signs, symptoms, investigations, and differentials. It is in fact a conversation, an opportunity to build rapport and trust with the patient. We are not community health surveyors ticking off boxes in our questionnaire; we are there to hear our patients out by expressing their problems and concerns. There is no better opportunity than in medical school, where you are not confined by the “rush hour” situation in hospitals, to hone these human skills.

Fortunately, patients tend to given you their trust, and willingly share their most personal information with you. This has shown me the power imbalance of the doctor-patient relationship, which arguably has been exploited in Mr. C’s case – i.e. doctors sometimes do not give patients enough attention.

Another issue that I struggled with was handling the complaints that were hurled my way. My lack of maturity was evident from my agitation, and the urge I had to refute Mr. C. Deep down, I was conflicted and defensive. Mr. C’s story contradicted my own impression that all doctors do their best for patients. It felt as if I was taking the blame on behalf of all doctors. However, I decided to stay quiet about it. I learnt that doctors aren’t  “super-humans” who will never make mistakes. It was only when I started consolidating my thoughts and weighing out the situation that I was eventually convinced that Mr. C’s care was indeed compromised by the negligence of his various doctors.

Admittedly, I handled the situation rather poorly. I reckon it was largely due to lack of exposure to such situations, especially given the sheltered, cozy environment we enjoy in medical school. Clinical interactions are based around simulated patients who, more often than not, have simple presentations that are short enough for us to take a history and perform a physical examination. Everything is staged for us to learn in a protected environment. Even in hospitals, the patients we see are recommended by interns as “cooperative enough” for us to take a history.

Medical students should be taught how to deal with complicated cases through the use of simulated patients. When I say complicated, I mean in a psychosocial sense rather than in a medical sense. The skills needed to deal with these situations are those that cannot be taught through textbooks, but through practice. These are human skills; skills that define the art of medicine. These non-scientific skills may not be as interesting as pathology, physiology or anatomy, but are equally, if not more important than the scientific aspects that students are often keener about.

Students are often enthusiastic to ask senior doctors about the scientific aspects of a patient’s presentation. Similarly, they should not be shy to ask them about approaches they should adopt when such situations arise. I am inclined to believe that most students underestimate the importance of communication, which often takes a backseat in their learning priorities.

Medical schools can no longer assume that their students are equipped with the necessary communication and social skills from just clinical skills examinations, which are often not representative of an actual hospital setting. Rather, explicit emphasis on the mastery of such complicated yet common social presentations, should be made an integral part of the curriculum.

I have learned the importance of giving patients the space to talk. For example, in my encounter, I was close to interrupting Mr. C when he was complaining about his experience. Having done so, however, would have prevented me from comprehending the entire situation in context. As medical students, we need to appreciate the difference between “listening to reply” and “listening to understand”. Practice the latter, not the former. Never be too quick to cut off your patients halfway through, and jump to conclusions. Let them tell their whole story, and you will be surprised to find that it contains most of the answers you need.

Photo Credit: Ky

Categories
Clinical Patient-Centered Care Psychiatry Public Health

If you don’t ask, you’ll never know

On the first day of my first rotation as a medical student, my preceptor shared this bit of wisdom: if you don’t ask, you’ll never know.  In the nearly 18 months that have followed, I think about those words on a daily basis. To my mind, asking questions does more than just help us gather data. Asking questions establishes the type of relationship we are going to have with our patients. There are so many questions I wish I would never have to ask, whose affirmative answers are often indicative of the cruelty of this world. But when I ask about things like whether a patient has been the victim of abuse, I hope it sends the message that the relationship we are about to embark upon is one that can withstand such unpleasantness.

Not only can it be excruciatingly frustrating when other practitioners don’t share this point of view, it potentially has grave consequences. Unfortunately, patients with mental illness often seem to be the victims of physician “brush-off.” As someone who plans to devote her life to working with the mentally ill, I can only hypothesize as to why the same patients I find so much joy in working with are often given sub-par medical care as compared to their non-mentally ill peers. Perhaps physicians feel uncomfortable providing care for patients who come across as different than the norm, or perhaps their medical problems are too frequently attributed to psychiatric causes.

I recently cared for a patient who was two weeks post-partum from the birth of her first child. Though she was being seen for psychiatric admission, multiple aspects of her health were addressed during our initial evaluation.  When asked about her post-partum health, she denied having been scheduled for a post-partum visit with her obstetrician. Casually, she mentioned that she was having some malodorous green discharge since giving birth. It doesn’t take a medical degree to know that green, foul-smelling discharge is not a good sign, let alone when it occurs in the immediate post-partum time period. We were able to secure a next-day appointment with our hospital’s obstetrical practice, and with the patient’s permission, called ahead to the clinic to alert them of her complaints.

The next day, the care team gathered around to read the note from the obstetrician who had seen our patient. The note comprised all of five lines.  There were no pending labs. There was no mention of a physical exam.

There was no mention of the discharge at all.

The American Congress of Obstetricians and Gynecologists (ACOG) states, “It is recommended that all women undergo a comprehensive postpartum visit within the first 6 weeks after birth. This visit should include a full assessment of physical, social, and psychological well-being.”[1] The issue here, though, isn’t really about post-partum care. The issue here is about how we as health care providers need to provide equal care for unequal bodies and minds, and how we need to protect and advocate for our patients.

Patients with mental illness undeniably have poorer overall health. The average lifespan for an American adult with mental illness is a striking 30% shorter than for a non-mentally ill individual.[2]  While it is known that mental illness itself creates difficulty in accessing the healthcare system, for mentally-ill patients who do access healthcare, their quality of care is demonstrably lower than it is for those without mental illness. Literature consistently demonstrates that patients with psychiatric diagnoses receive fewer preventative health measures and have overall poorer quality healthcare than patients without psychiatric diagnoses.[3],[4] No matter what field of medicine you are in, you will see patients with mental illness. For these patients who sometimes cannot speak for themselves, the role of the physician in patient advocacy becomes even more crucial.

I will never know exactly what transpired during that appointment between my patient and the obstetrician, but I do know that obstetrician did not ask the questions that needed to be asked, and therefore did not ascertain the information necessary to appropriately care for the patient. At our request, a different practitioner saw the patient again. This time, the appropriate questions were asked, the appropriate testing was completed, and ultimately the patient was diagnosed with a sexually transmitted infection. Left untreated by the first obstetrician, this infection could have caused my patient systemic symptoms and permanent infertility.

As future physicians, it’s important for us to keep asking questions. So often, I have been surprised by the information I find when I ask a question about which I almost kept silent. Equally as important as asking the questions, however, is doing something with the information that you receive. The good doctor isn’t necessarily the one that stops the green discharge; they’re the one the identifies the problem in the first place and advocates on behalf of the patient to get the best people for the job.

[1] https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Postpartum-Care

[2] http://europepmc.org/abstract/med/19570498

[3] http://journals.lww.com/lww-medicalcare/Abstract/2002/02000/Quality_of_Preventive_Medical_Care_for_Patients.7.aspx

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951586/

Photo credit: airpix

Categories
Clinical Lifestyle Patient-Centered Care

Running Low and No Longer Running

I recently completed a rotation in endocrinology, and I learned valuable lessons about diabetes management in both the inpatient and outpatient setting. Today, I wanted to share a clinical pearl generally not discussed in lectures: Diabetic patients often gain weight because of the fear of hypoglycemia.

That’s right. The fear of hypoglycemia drives patients to eat a little more at meals. Let’s backtrack. Patients who have persistently elevated sugars are often started on insulin in addition to oral agents. Depending on their insulin regimen, patients may not eat enough after an insulin dose to prevent a drop in blood sugar. Patients who experience a hypoglycemic event try their best to prevent it from occurring again. This is understandable—fainting is scary and should not be taken lightly (pun intended).

The problem is that patients counteract this fear of hypoglycemia by either eating more after an insulin injection, or by exercising less. This impedes diabetes management. In addition to advising our diabetic patients to monitor their carbohydrate intake, we urge them to start some form of physical activity. Physical activity enhances the body’s insulin sensitivity—it gets to the core of the problem (insulin resistance) and improves overall cardiovascular health as well. But how can we encourage these lifestyle modifications if our patients are getting lightheaded after injections?

The answer: carbohydrate counting and education.

Not the answer: increasing insulin.

My attending explained that “increasing insulin” is actually what happens in some cases. For example, let’s say a patient named Sara comes in for her follow-up appointment and unknown to us, has “fear of hypoglycemia.” Sara brings her glucose meter, and the sugars are poorly controlled. Part of the reason for this poor control is secondary to a) eating more after an injection to prevent fainting and b) decreased physical activity to prevent fainting. Now, if we just treat her numbers, we would increase her insulin.

The lesson here is that one can’t just treat the number in medicine. Talking to the patient, even for a few minutes, will provide the story. Increasing the insulin perpetuates a viscous cycle, and breaking the cycle comes from better regimen management. Validating patient concerns about hypoglycemia and educating them on injecting based on carbohydrate intake is invaluable.

Photo Credit: Melissa Johnson

Categories
Clinical Emotion Public Health

The Day I Took off my White Coat

The man in scrubs stands in the middle of the room. He has a blood-filled syringe in one hand and hand-written lab notes on the back of an envelope in another. He scans the room, looking for someone or something. I follow his gaze. A young man is curled up in a ball on the floor, rocking himself back and forth while groaning in pain (gangrenous wound on leg). A man is throwing all his weight on his wife and yelling in pain (renal colic). A woman is holding a piece of red, soaked gauze tightly on the hand of her screaming 7-year-old son (amputated finger). An older woman in a wheelchair is drooling from one side of her mouth and has a drooping shoulder (stroke). A young man, handcuffed to a police officer, has circular marks around his neck and blood dripping from his mouth (suicide attempt with hanging and ingesting barbed wire). A young woman sits limply in a wheelchair, eyes rolled back, and blood on her clothes between her legs (severe anemia – abortion days prior). In this room no bigger than my mother’s walk-in closet, the suffering is palpable and audible, but the man in scrubs does not find what he is looking for, and begins to walk out. Before he reaches the door, an unconscious man is carried in to the room (antifreeze ingestion). Without missing a step, he reaches over and gives the man a rough sternal rub to wake him up, to no avail. He exits the room.

The man in scrubs is the sole medical resident in charge of the stabilization and triage of incoming patients at this Emergency Department situated in a Low and Middle Income country. As a visiting medical student, I am wearing a white coat, and although I should fit in, my general ignorance about the majority of relevant things makes me feel like an imposter. I shouldn’t be here. I shouldn’t be wearing this white coat.

‘You! You can help me!’ exclaims a woman in a wheelchair as she reaches towards me. Her face is covered, but somehow I know that she is in pain. Reluctantly, and with as much grace as a fish on land, I walk towards her. I walk towards her knowing that the only care I can provide is a hug, a tear, or a smile; the only prescription I can write is a kind word, and the only order I can put in is a prayer to the heavens.

I came to medical school to gain the skills that I need to better care for my neighbors, to share moments of humanity, of suffering and healing with my neighbors, to be meaningfully curious – to ask and answer questions that benefit my neighbors and our community, and to use medicine as a platform to implement meaningful social change. The irony is, I see none of that now; all I can do is stand defeated as I watch my neighbors suffer. I watch because I don’t have the money to cover the 15 pounds admission fee for every patient that is turned away at the door of the ED. I watch because I don’t know whether that comatose child who was just intubated is in trouble because his stomach is inflating instead of his lungs. I watch because I don’t know if that medical student just injured that woman’s radial nerve while trying to get an arterial blood sample.

With tears in my eyes, I fumble out of my white coat and head for the exit. I’m done watching, I tell myself. I’m done watching and I’m ready to learn. I’m ready to learn how to care for the suffering. I’m ready to be a part of the change I want to see in the world. As the door of the ED closed behind me, I managed to catch a final peek of the chaotic scene, as if to tell myself, ‘I will return when I’m ready.’

Looking back, I wish I had kept my white coat on, even if just to care with a tear, heal with a kind word, and pray for the well-being of my neighbors.

Photo Credit: Alex Proimos

Categories
Clinical Emotion Empathy Humanistic Psychology Reflection

The Enigma of Empathy

“My mother says I’m a piece of shit.” My 18-year old patient sits at the head of a conference table, her face stony with resolve. The members of her care team are surrounding her. She asks, “Why do you all care about me when I don’t even care about myself? That’s just weird.” Her resolve crumbles and tears begin rolling down her cheeks.

The attending physician stares at her before responding. “We don’t know you,” she says. “But we do care about you. You’re right-it’s a weird concept.”

It took this exchange-during my final year of medical school-for me to fully grasp the unusual nature of the empathy that we have for our patients. As medical students, most of us have described ourselves as empathetic or compassionate at some point. But I’ll wager that most of what we know about empathy comes from close relationships, be they with friends, family members, or even repeat clinic patients. It’s not difficult to understand how these established relationships could be colored with empathy. After all, these are relationships that we usually choose to have, or at least, choose to continue having, and in many cases, they’re relationships of mutual benefit.

As medical students, much of our experience is gained on the inpatient units in the hospital, with patients who are thrust into our service. While it is possible that the relationships we have with those who are closest to us serve as templates for empathy, the relationships that we develop with our hospitalized patients are different in several ways. First, we do not choose these relationships. Generally, patients are assigned to us regardless of our desire to have them as patients. Part of being a physician in training implies consent to treat patients. Another reason why our relationships with patients are unique is that we rarely can choose to terminate a relationship with a patient who we are treating. Finally, the relationship between the hospitalized patient and the doctor is not mutual. Hospitalized patients cannot and should not offer any direct benefits to their treatment team. My relationship to this 18-year old patient fit all the aforementioned parameters: I did not choose her as my patient, I could not stop my service to her, and I enjoyed no direct benefit from her as my patient. And yet, even accepting the above as true, even recognizing that I had only known this person for 48 hours at the time of this discussion, my empathy for her was not any less genuine than my empathy for my best friend or closest family member.

Does being a physician mean that we are forced to have empathy for near-complete strangers? Or does it mean that the people who choose this profession are characterized by an ability to freely give empathy to those who cross our path?

Interestingly, the word “empathy” did not reach the English language until 1909. Derived from the German word “einfuhlung” (or “feeling into”), it has been a continually enigmatic concept that has eluded any simplistic definition. Philosophers have described empathy as a central emotive descriptor that characterizes the feeling one has when they recognize the human spirit in another.[1] Even neuroscientists have taken up the job of trying to define empathy, noting that mirror neurons, which are neurons that fire when one living creature acts and then observes the same action in another living creature, may play a role in the development of empathy.[2]

Reflecting on my patient’s remarks has given me serious cause to contemplate what empathy means to me as a soon-to-be physician. While I can speak only for myself, I think the thing that makes me different is not my capacity to give empathy, but my desire to foster relationships with my patients. Even though my relationship with that patient may have been only days old, the quality of that relationship and therefore my ability to feel empathetic towards her, is a direct reflection of my desire to have that relationship. While I did not choose the patient, I chose to get up that day and practice medicine, and empathetic medicine is the only kind of medicine I know how to practice.

[1] https://plato.stanford.edu/entries/empathy/

[2] https://www.ncbi.nlm.nih.gov/pubmed/18793090

Photo Credit: Sean MacEntee

Categories
Clinical General Public Health

Medical Residents: A Dream Career Can Be Yours If You “Choose Sleep”: Dr. Ilene Rosen, President of the American Academy of Sleep Medicine

Now is the time that many medical residents are considering future plans, and hopefully giving thought to a sleep medicine fellowship. The truth is, we need you. Millions of Americans suffer from chronic sleep disease, and now more than ever there is an increasing demand for sleep physicians. As awareness of sleep health increases, millions of new patients will be seeking evaluations from sleep physicians.

Sleep medicine is an intriguing field with long-term growth potential and the opportunity to have a positive effect on the health of a huge population of patients. By diagnosing and treating sleep disorders, you can directly improve patients’ health and quality of life. In addition, because sleep is still a relatively young field, many research questions still exist. These questions can lead to involvement in cutting-edge basic, translational, and clinical research.

As a new sleep medicine physician, you may have the opportunity to practice in diverse settings. Opportunities abound in teaching hospitals, community hospitals, and independent sleep centers, allowing you to cultivate a work schedule that best fits your lifestyle. In addition, you can expect a call schedule that is quite manageable, as trained technologists at an accredited sleep center monitor most overnight sleep studies, and patients often self-administer their own sleep studies at home.

Another great thing about sleep medicine is the constant collaboration. As a sleep specialist, you will work closely with physicians from other disciplines and lead sleep teams of other health care providers – including nurses, physician assistants, psychologists and technologists. You may find many opportunities to collaborate with multidisciplinary teams, treating patients in coordinated efforts using the latest technology. I think you will find these collaborations eye-opening and educational.

So, the choice is yours and the options are plentiful to pursue your dream career, just as I did. There are 83 sleep medicine fellowship training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Learn more at www.ChooseSleep.org.

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Clinical Emotion Empathy Narrative

Tears of a Child

I walked up to my dad and said, “Baba, there’s something wrong with me”. I was probably around 8 years old at the time. He looked concerned and prompted me to tell him more. I said, “I cry a lot. About everything. And my brother and friends make fun of me.” He then smiled and, through his smile, said words that will stay with me forever. “Don’t worry Mohammad. It’s a sign of a soft and warm heart. Your special mission is to travel through this life and keep your same soft heart.”

Fast forward 10 years to my second year of medical training. I remember entering a patient’s room as a part of our Introduction to Clinical Medicine course. Moon face. Truncal obesity. Buffalo hump. Abdominal striae. Hirtuism. I was like a child with a fulfilled Eid gift wish list! Here I was, celebrating my ability to recognize the quite obvious presentation of Cushing’s syndrome, oblivious to the very real and detrimental complications of Cushing’s syndrome and the emotional toll that these symptoms must be having on this young woman. She entered the room to receive care, and I entered the same room so focused on my ability to produce a differential diagnosis that I failed her and myself; I failed to show her the compassion that fuels my love for medicine. My inability to see past the mere facts of her presentation left me in a poor position to honor my mission. Fueled by the tears of a child, I cried.

 

Photo credit: Quinn Dombrowski