Tuesday, April 19, 2016

Is Empathy Dead, or Just on Life-Support

A physician recently took to the Internet in a blog featured on Fox, titled In the war on illness, the real Victim is Empathy

There has been ample discussion of the "great divides" in America, rich versus not, fat and thin, academic, racial, political, gender; the list goes on and on. Dr. Jame Abraham explains to us in this post that we must also accept that "doctors and patients exist in two distinct worlds: the world of the healthy and the world of the sick."

He likens this to a culture divide. The two groups simply do not understand each other. Like the theme in some Coke commercial, Dr. Abraham says "the only language that connects these two worlds is kindness and compassion." It is this commonality that can overcome the disconnect and communication barrier. He says we need physicians that are "fluent in" compassion. 

Dr. Abraham's analysis resorts to the age-old dispute of nature v. nurture. He contends that physicians are naturally good people, and that the decline in medical empathy is a product of nurture. Our educational process, he explains, is training empathy out of medical professionals. He claims that "studies have shown a sharp decline in empathy by the time students finish medical school."

If that is not alarming enough, he continues, explaining that physician "compassion continues to drop during residency and fellowship." So, by the time the professional "is a physician with patients depending on them," empathy and compassion are at an all time low. Those we look to for guidance and expertise in our times of need are trained not to have empathy for our complaints or situation?

I ran into a physician recently. He lamented his income and complained that his brethren were seeing twice as many patients daily, compared to his practice. He asked me "if you could double your income tomorrow, would you?" I was surprised that his focus seemed to be money and his envy of his brethren was a bit disconcerting. A great many commentators lament that professions like law and medicine have turned into businesses; some degree of the professional motivation lost in the daily grind to meet overhead, and produce profit. 

Dr. Abraham explains that empathy is not the victim of neglect. The medical education process is intentionally eradicating this troublesome emotion from those who will provide us medical care. His contention is significantly in line with the lament of the business of medicine. He says that medical students begin the process with "dreams and aspirations of being a healer of sick." But they are then confronted with "the crucial task of mastering technology." The "good" physician is the one who can best master the data and the equipment that produces it. 

The news is full of intriguing stories of medical technology. It seems a day does not pass without news of a new device, test, or treatment. There really is a great deal going on in the world of science and medicine. They are discovering treatments, perfecting devices, and so many promise great things for our future. Recently this has included new drug approaches to melanoma, electronic skin for measuring oxygen, and a variety of tech tools for management of diabetes. Every day seemingly brings an interesting medical technology breakthrough story. 

But Dr. Abraham says that our medical education now is to "teach students to be, among other things, technicians who treat the human body as a collection of data, and we train them to be proficient in collecting and analyzing that data." Ours has become a data-driven society generally as computers have made collecting and summarizing data increasingly inexpensive. Dr. Abraham concedes that to an extent, "focusing on this type of training makes sense." He cautions, however, that this focus can harm the doctor's relationship with the patient. 

I have written about Watson, and the amazing innovation that is occurring in artificial intelligence. A computer named Deep Blue beat the best humans in chess, and a computer named Watson beat us on Jeopardy. (cue Weird Al, I Lost on Jeopardy). Computers have evolved from performing repetitive and rote tasks. They have begun to think, and while we have not reached 2001 A Space Odysee (in which the computer locks Dave out of the space ship), computers are involving into thinking, learning devices. 

Dr. Abraham says that "if being a doctor was only about having a razor-sharp memory and delivering the right diagnosis, then IBM’s Watson would be the epitome of the 'perfect' doctor." We have seen Hollywood glorify the role of physician, finding the elusive clue or symptom, a la House and others. What if a computer could be engaged in the pursuit of appropriate diagnosis?

It turns out that IBM's Watson is currently attending medical school Dr. Abraham says Watson is "better than any physician at computing, connecting and analyzing data." Watson has "read and memorized thousands of medical books and journals and is much faster than a human brain at conjuring up the right answer." It may be the epitome of the data analyzing, data-driven doctor. 

Despite Watson's great success, speed, and efficiency, Dr. Abraham points out "there are some things Watson simply can’t master." More aptly, perhaps "can't master" yet. But the point he is making is that computers cannot yet form true relationships. And thus, we return to the real theme today, empathy.

To illustrate, Dr. Abraham describes his relationship with one patient who ignored a mass until ultimately presenting with stage-4 breast cancer. This is a serious diagnosis, and the patient "was so unhappy with the doctor who diagnosed her, that she was considering not pursuing treatment." She had multiple complaints about the diagnosing physician. This is not as uncommon as one might expect. I have run into a fair number of patients over the years who eschew regular medical care because of their perceptions of the provider. 

This patient complained to Dr. Abraham that the diagnosing physician “was in my room for less than ten minutes;" that "he didn’t answer any of my questions;” that "he said he cannot cure this." and little more. Dr. Abraham says that she "didn’t feel like she could rely on or connect with" the diagnosing physician. She later presented for care with Dr. Abraham, and described her familial experience with cancer (anyone who has seen a loved one go through chemo will have thoughts on this), and her reluctance for the chemotherapy journey. She expressed only one desire, to live to see a granddaughter's high school graduation. 

Thus began a doctor/patient relationship, with a simple goal, sustaining toward a particular future event. As Dr. Abraham puts it, together they found "the only thing that mattered to" the patient. He feels that despite its incredible access to knowledge and speed, Watson would fail in this setting because it is "emotionally unintelligent." 

Dr. Abraham contends that Watson cannot connect because it cannot (yet) "smile, touch, hug and connect." Though this is an indictment of a computer, the point is clearly directed at humans. As young students strive to amass information, to perfect their data collection and analytics, strive for the right answer, they are emulating Watson. Dr. Abraham suggests that Watson should be striving for more human traits, and the irony is that those who already possess them are instead striving to be more like the computer. 

He asks "is it possible to teach students and young doctors to connect with patients?" He contends that compassion is not easily learned. This seems at odds with his original premise that suggests we all have compassion, but the medical education system is currently training it out of doctors. Perhaps a good start, rather than teaching compassion, would be to stop suppressing or devaluing the compassion and empathy already there? He concludes that "there are key aspects of health care that can’t be reduced to numbers." They require listening to the symptoms, but beyond that to the patient's fears and motivations. 

Dr. Abraham has some suggestions for physicians. They bear reiterating. He says it is not about the amount of time a physician spends with the patient, but about the quality. He says "whether a doctor spends five minutes or 60 minutes with someone, each patient should be treated as the most important person to the doctor during that time." That seems simple enough. Be present when you are there. That is good advice for any relationship. 

He says that "every patient is truly unique and we must do our best to understand each one as a whole person." Understanding concerns and motivations is a critical element in helping people with their medical conditions. Why do they feel as they do about their situation, what experiences, fears and concerns are influencing their understanding and expectations?

Dr. Abraham says that the physician has to engage. He claims that success is dependent upon the formation of a partnership between patient and physician. This, he explains, forms trust and confidence. Through that, patients will "open up and truly get on board with their treatment plan." Once again, this element of partnership and trust is valuable to any human relationship. 

In the end, there remains a great deal about medicine that is not science. There is a great deal that is art, and much of that appears to be the art of human relations. Will we strive to make the automatons like Watson more human, or should we find a way to have our human doctors retain more of their humanity and emotions? While we are at it, perhaps attorneys, adjusters, risk managers, and more could benefit with the same advice for their relationships?

Food for thought. 

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