Thursday, June 21, 2018

The kindest doctor knows how it feels to be a patient

By Louise Kinross

Two experiences helped Dr. Brian Goldman understand how it felt to be on the receiving end of care, and led to his “journey to find kindness around the world, and to see if I could rediscover it within myself.”

The emergency room doctor was speaking to developmental pediatricians at Holland Bloorview today about his new book The Power of Kindness: Why Empathy Is Essential in Everyday Life.

Brian recalled a time in the ER when he snapped at a family. The family wanted their 68-year-old mother with an end-stage disease admitted, and repeatedly asked in the ER if he’d made the referral, which he had.

Weeks later, after the woman died, her husband wrote Brian a letter “accusing me of being unkind to the patient, family and him,” he said. The husband asked to meet Brian “so we can find out if there’s still a human being lurking under all that brusqueness.” He met with the family and learned about who the woman was “as a mother, partner and worker. At the end, we all had a good cry.”

The other experience that prompted a greater understanding of patients was caring for his own father, who developed congestive heart failure after caring for his mother with Alzheimer’s.

After working a night shift, Brian learned that his father was having bad chest pains. By the time he got to his dad, had him admitted to hospital and got him settled that night, Brian had been up for 40 hours. He kissed his father on the forehead, told him he loved him for the first time, and went home to collapse.

His father died that night. It was back at the hospital, when an internist began to awkwardly explain his death, sensing that Brian might attack him, that Brian said “I understood what the other family was feeling. Health-care providers who have the greatest grasp on what it’s like to be patients have been patients.” What Brian said to the internist was “Thank you very much for looking after Dad.”

Brian noted the difference between sympathy—a somewhat detached gesture of concern when you don’t understand what someone’s feeling—and empathy, which “is the ability to imagine what it would be like to be the other person.”

Affective empathy happens when you feel what the other person is feeling—kind of like catching a contagious emotion, he said. For example, an orthopedic surgeon might feel exactly what a patient who has just undergone a knee replacement would feel. This is not helpful, he said.

Cognitive empathy, which is the ability to imagine someone’s perspective, is “what we want in abundance in health professionals.” Emotional concern is what drives us to take action to help.

Brian referenced a study that showed that empathy drops in medical students year over year, from their first to their fourth year.

He talked about the definition of kindness—“the quality of being friendly, generous and considerate,” and how it’s rooted in the old English word “cynde,” meaning kinship.

“We tend to ascribe kinder qualities to people who we identify as being us,” he said. But this tendency “can change on a dime,” he said, describing a simulation where an adult wears a motion capture suit and sees an avatar of him or herself as a child on a screen. The avatar appears as you “in another cultural group,” he said. If a second character that belongs to the same cultural group is introduced, “you will identify with them.” And if a third character belonging to your own cultural group appears, “you will say 'that is not me.' It’s that superficial,” he said, noting that humans and orangutans share 97.5 per cent of the same genome.

Brian said some medical cultures devalue empathy as a skill. “You’re either compassionate or you’re an excellent provider,” is the message, he said, “but it’s a false dichotomy.” He said medical students enter their program full of compassion “and it gets drummed out of them.”

Contributing factors include “a lack of focus on empathy as something to be prized and appreciated,” he said. He noted that’s while technology is wonderful when it allows clinicians to focus more on the patient, too often, staring at a screen while talking to a patient interferes with rapport. Specialization is a big impediment to kindness and empathy, he said, because people fall through the cracks when a doctor can say “That’s not my part of the body. I don’t deal in that.”

In the ER, time pressures work against kindness. Brian spoke of “the debilitating feeling of apologizing to everyone you’ve seen, eight or nine people in a row.” He noted that with a complex situation, a 10-minute interaction could balloon to 45 minutes.

Brian said adult health care is increasingly managing chronic disease, whereas many med students picture themselves treating acute disease. Burnout—exhaustion, alienation, withdrawal and apathy, “not caring”—is higher in medical students and residents than it used to be. “The higher the burnout, the lower the empathy.”

Brian said humans are hard-wired to be empathetic: newborns cry when their mother cries, and when a baby and mother interact, “the same parts of their brain light up.”

But in a complicated world of competing priorities “empathy is a choice. We’re not compelled to be empathetic,” he said.

Brian shared some personal stories of people with extraordinary empathy. One was Mark Wafer, who bought six Toronto Tim Horton’s stores. The first person Mark hired was a young man with Down syndrome who walked into a store looking for a job. What led Mark to take a chance on the young man was his own experience growing up deaf. “It wasn’t being deaf, it was being discounted, that was his engine of empathy,” Brian said.

We also heard the story of a Jewish girl whose family escaped Nazi Germany. Her father ran a home for the aged and the girl grew up there with its residents. She later became a psychologist and developed a method of validating the behaviours of people with late-stage dementia “as meaningful symbols of unfinished core personal issues,” Brian said.

“Long-buried feelings that are expressed verbally or in behaviour can be resolved when caregivers validate them.
” he said. These are meaningful gestures.” For example, when a patient speaks of their deceased grandfather, “don’t yank them back into the present,” he said, “or lie, or redirect them. Ask ‘What would you say to your grandfather?’” The agitation we often see in people with dementia is how they “work on deep trauma.”

Brian said that people who become health-care providers are “often burdened by more shame than others.”

Brian said we can use our own emotional despair to help others in distress, or embrace errors we’ve made to help those who have made terrible mistakes. “Share openly what you are ashamed of. Be mindful and live in the moment.”

Before sharing bad news, such as a patient’s death, Brian talked about his own practice of centring himself. Because he tends to ruminate on the negative, he said he takes a minute to picture himself watching a parade of floats going by. “This absurd idea of a parade of bad things going by” allows him to release them and “not take ownership of others’ distress.” That means he can be fully present for family members “and acknowledge what they feel. We need to give them permission to feel the way they do.”