James Duffy, M.D.
The University of Texas M. D. Anderson Cancer Center
Good morning, why don't we get started? It looks like we have a bit of an overflow crowd here. My name is Walter Baile and I am Director of I*Care the Program which is sponsoring this talk. I apologize for the lack of space for everyone. We had tried to get the Hickey Auditorium some time back but I think you have to book that about 5 years in advance from what I understand. In any case, we have a relatively new program at M. D. Anderson called Interpersonal Communication And Relationship Enhancement and some of you have participated in our workshops that we do on difficult communications and other aspects of communication with cancer patients.
This is the first lecture of our program which is called the ACE lecture series, Achieving Communication Excellence, and today, I'm happy to introduce Dr. Jim Duffy, who is professor of psychiatry here at M. D. Anderson to give our first lecture on the art and science of compassion. Jim is well-known in the M. D. Anderson community and is director actually for the Center for Health, Spirituality and Healthcare in the Texas Medical Center. Jim has a long interest in issues of spirituality, cancer and the relationship between clinician and doctor and nurse and other healthcare providers and recently has been focused on some of the psycho physiological and neuropsychiatric aspects of communicating with cancer patients and so without further adieu, I think I'll turn the lecture over to him and thank him for participating.
[ Applause ]
Okay, thank you. Okay, I've got a soft voice it's important that it works. I wanted to thank Dr. Baile for inviting me to come and share some of these ideas with you. Of course, I'm just so impressed by how many people are here and I would like to think that it was me, but I know it's the food. [ Laughter ] So I learned that a long time ago, but I also think it's the topic. The topic of compassion and compassion has become a really frequently used word in our society in the last 10 years in particular. But for us in healthcare, it has particular meaning and I think it's the topic and I look forward to many other conversations around issues relating to compassion and the nature of medicine and the goal of healing. As Walter mentioned, I'm a psychiatrist. My background's in neuropsychiatry, brain and behavior and also in palliative medicine. So in many ways, this talk brings together a lot of my different interests and different threads.
And I want start this conversation with a story, something that happened to me many, many years ago working in Africa and it's a story that's prompted me to ask myself a question. And hopefully in the next hour I will begin to address some of those answers to the questions that really have just manifested in the last 4 or 5 years as our neuroscience and our social science has become sophisticated enough to actually address some of these big questions that we have. Now the story is about a young physician working in a university hospital in South Africa and my first job was in the cardiothoracic unit. I was the intern there and I inherited a unit with about 24 patients with carcinoma of the esophagus.
Now unlike M. D. Anderson, if you have carcinoma of the esophagus in Africa, typically, you arrive very, very late in the progression of the disease and there really isn't any effective treatment that is available and so most of these patients were simply waiting to pass away and all we could offer them was some intravenous fluid and some pain relief. Well, I arrived to discover that none of my patients were receiving intravenous fluids and none of them were receiving pain relief and I felt pretty helpless in terms of what I could do to cure them. But I said, at least I can help their pain and give them some fluid. So I went around and I wrote the orders for the IV hydration and I wrote the orders for morphine. So while I accomplished something at least. I came back the next day and discovered that none of the patients had received the analgesia and every IV line which I put up myself had tissued overnight. We were back to where we started.
So I said, "Well, let's do it again," and I put all the IV lines up and spoke to the nurses and said "Make sure you follow my recommendations, my orders," and they said "yes doctor." And I came back the next day and all IV lines are tissued and nobody had gotten the analgesia. So I got a little frustrated and raised my voice and said "You need to do this nurse." You know, in those days nurses used to have 1-stripe, 2-stripes, 3-stripes, and the 1-stripes were called pinkies and so the little pinkie, 1-stripe, said "Yes, doctor. I'm sorry," and I came back the next day and still nothing had happened. And so I lost my temper which resulted in about 3 hours lost that left me being summoned to the matron's office.
Now in the Indus system, the matron is the most powerful person in the hospital and nobody wants to go to the matron's office. [Laughter] So she called me and then she said, "You sit down young doctor as you need to leave my nurses alone. You need to stop shouting at my nurses." And I said "But matron nobody is following any of my orders and my patients are suffering." And she said, "Doctor, you are very young but you need to understand that for my nurses these patients are invisible." And she said, "So you will not torment them and you will be polite to them and we will get along well." So I didn't quite know what to say to that, but I knew that she challenged me with some remarkable insight as to why it was that my patient's weren't receiving adequate analgesia. I just could not explain it, but I knew she was speaking a truth.
So, the question that she challenged me with was, "Why is it that sometimes people become invisible to us and we fail to respond to their suffering?" I think about what we've recently seen on television in Hartford, Connecticut. I used to work in Hartford and I know that street and that elderly man was hit down, knocked down by a car and just laid there and yet people seemed to be blind to him. So the question is, "Why does this happen? Why do nice people behave this way?" So this is a review of why people become invisible to each other. Now, one of the solutions to this, of course, is how invisible a thing is of not treating pain.
We all know that in this country it's very hard to get adequate pain relief. We did a study in Connecticut where we asked patients coming out of their primary care doctor's office with a primary complaint of pain how much their doctors have helped them with the pain. Less than 20 percent of patients going to see a doctor in Connecticut will come out and say, "My doctor helped me significantly with my pain." And we all know the data in most hospitals has been very poor when it comes to pain control. And so some very smart people came up with this good idea of creating a gold standard, an objective measure of pain experience and they created what we call the "One Smiley Face" and I believe people here at M. D. Anderson were very instrumental in creating this really interesting way of trying to address pain.
So the idea there is that if I was a doctor in Africa, if only I had a "One Smiley Face" scale that I could fill out and my nurses could fill out with their patients, everybody would get pain control. Well, the data is beginning to suggest that it isn't that simple. Well the JCAHO would report that we have a 98 per cent compliance with smiley face scales in our assessment of pain. If you actually begin to talk to nurses and other folks about how they use the smiley face scale, some rather concerning things begin to arise. In a study in Connecticut, we found that 78 per cent of our nurses in our hospital actually admitted anonymously that they actually changed the score that the patient gave them, frequently, all right? In other words, the patient says I'm a 10 out of 10 and the nurse would say, "Well you know, he's got a lot of tattoos on him, he's been a drug addict and you know he's kind of needy and he never stops complaining and you know all he's got is just like this fractured foot and we'll give him a 5."
Okay, that's what our data suggested. We've a, Marshall Overton at Methodist Hospital who did a similar study on ICU patients using the ESAS (Edmonton Symptom Assessment Scale) which Dr. Bruera helped to develop, the Symptom Assessment Scale. Only about 20 percent of cases of what the nurses write down in their report correlated with what the patient was telling us separately. So this is, although the smiley face should make a lot of sense, some of us are beginning to suggest maybe there's a problem here and that we need to be looking beyond this. And one of the solutions that comes up is that, basically, all of us are just nasty people or nerds, insensitive and the reason that we come to medical school in particular is because we're selected based on our capacity to be totally disconnected from our patients and focus on science and not on human beings.
In fact, I had an argument with Shep Nuland one day on television. He wrote "How We Die," that book "How We Die" and Shep said on television that the reason people are selected from medical school in the United States is because they are nerds not because they're nice people. And I said well, you know doctors seem like kind of nice people to me and medical students are typically kind of nice people. I think something happens to them. Now I didn't have this data which came about 4 years ago which suggests that people coming into medical school are actually kind of nice people, all right. Upon entry into medical school compared to your peers graduating from college, if you're chosen to go to medical school you are likely to be a very significantly 0.001 less depressed, less angry, less fatigued, less tense and more empathically concerned about other people than your peers coming out of the business school who major even in Liberal Arts and things like that. So they seem to be kind of nice people. However, something happens as we go through our medical training, all right? This study looks at interns, internal medicine interns 5 months into their residency and after 5 months of being an intern at a significance level of 0.0001 you're more likely to be angry, depressed, tense, fatigued, distressed and less likely to be actually empathically concerned about the welfare of other people.
A similar study came out 2 months ago in academic medicine. The paper was actually titled "Is There Hardening of the Heart during Medical School?" Is there hardening of the heart during medical school? Up in the top here you'll see the top 3 lines represent the scores by female medical students on empathy called the Jefferson Empathy Scale. The top line represents the first year women going into a clinical specialty school around 65 on the Jefferson Empathy Scale. However, as you see here, with 4 years it drops down into the mid 50s. The triangle, third line shows female students going into a non-clinical specialty such as radiology. They start off being less empathically concerned about other people and boy, by the time they finish medical school they're really disconnected. Now, the bottom 3 lines represent those poor male medical students who come in even worse than the women that go into radiology. The male medical students empathically are less attuned to other people's experiences and boy, the bottom line is it shows those of us who go into a non-clinical specialty, we hardly even score anything. It's kind of like the SAT. If you just show up, they give you 100 points. I mean, so something's happening to medical students as they go through their training and it also seems you'll--what area being steered towards will also influence your empathy.
So I have 4 hypotheses that I want to share with you today. I'm just going to go through them quickly. First of all, I'm going to suggest that the reason that we're failing to address pain in our hospital systems, in our healthcare system, is not because we're not nice people. I believe that all of us are genuinely at base altruistic, compassionate beings but we have constructed a social healthcare environment that makes it almost impossible for us to manifest this true nature about who we are. I'm also going to suggest that advances in neuroscience, and I'm going to be showing a lot of neuroscience with you in a very broad way today, that these recent advances give us insights into some very simple strategies that we can use as clinicians to really enhance our empathy and our ability to respond to the pain of our patients. I'm also going to suggest, and this is an important concept, that if we can learn to be more compassionate to our patients, we will actually be happier people ourselves. I honestly believe that the very high levels of burnout and job dissatisfaction that we are seeing in the healthcare profession is not a consequence of hard work or third party payers because the data suggest it is not. It is a consequence of us not being able to be our authentic souls and find meaning in our work as healers. And then finally, very briefly, I'm going to suggest that all of these findings that I'm going to share with you today are just what people have been talking about for thousands of years. It's just taken us thousands of years of science to prove that it's actually "true."
So before I start, it's really important to start off with some definitions and we use words like empathy and compassion and sympathy and altruism everyday but we don't really spend much time saying what does that mean, right? And if you go into Harrison's textbook of medicine and you look in the index for the word healing, 2 lines, healing by first intention and healing by second intention. Isn't that amazing? If I was from Mars and said I want to learn about your healers and this is a major textbook of 4,000 pages or whatever, you think well, three quarters would be what is healing and the rest would be how to do it. Well as a culture, we don't do a very good job about really examining the words that define who we are. Chomsky says our words become us. Words create our consciousness.
So we really need to understand what are these words, empathy and compassion and altruism. So here are some definitions that I think most people in the field would accept as being valid. Empathy describes the process that results in the subject, that's you the clinician, with the other person acquiring a cognitive and emotional appreciation of the other person, the object's experience. So what this is suggesting is that there are 2 components to empathy. There's a cognitive thinking part and there's also an emotional feeling part. And I'm going to come back to that because the science is beginning to show us that. So is empathy the same as sympathy? No. I get very upset with my poor medical students when we talk about feeling bad for a patient, having sympathy, because sympathy is our judgmental response to seeing that somebody else is suffering, okay? It's about feeling sorry, for some of them and focuses on their weaknesses rather than their strengths and also suggests, in fact, that we have some control over it. What is emotional contagion? Okay. Emotional contagion is not the same as empathy. Emotional contagion is where you actually take on the feeling of the other person. So we've all had that experience, one of the so called hateful patients, right? And I know when there's one of those on the unit because all of the nursing staff would go "Aah."
Okay, where is the patient? And it's true enough this patient, bed 3, and he or she is driving everybody crazy because almost by definition those people externalize their emotional state and other people become infected with it, then it is emotional contagion. Emotional contagion is not a good thing because it suggests that you don't have any control over your own emotional experience like a chameleon. So what about this word equanimity? When we go to medical school, they tell us that Sir William Osler said, of all attributes of a physician that of equanimitas is most important. Equanimitas. He should have known what he was talking about. He was a professor at Johns Hopkins. He's there at Johns Hopkins Department of Medicine. He was at Oxford, the father of modern medicine. What people told me at medical school was he was describing that you, as a clinician, need to be a scientist with detached, cold scientific objectivity, examining the patient as if they were in a Petri dish. Equanimitas is held up for us as the model that was given to us about the clinical scientist. Well I would suggest that Sir William Osler, God bless him, did not mean that and if you actually read what he said, he wasn't describing a cold-hearted scientist. He was describing the capacity of the physician or the nurse to be wise, to calmly accept whatever life brought to them with what he described as physical and emotional imperturbability. Try to say that backwards, imperturbability. It is not detached objectivity and in the 4 immeasurables from the Tibetan tradition they described equanimity as a capacity to experience another thinking being with clarity without any other motivation and to be compassionate.
Now, if we took equanimity as being the most important attribute, according to this definition, we would've changed our entire healthcare system. What about this word compassionate? Our president talks about compassion, right? All right? I hear it all the time. I'm actually getting a little frustrated with the way people are using this word, justifying it to mock things, political statements but justify ends that maybe have little to do with compassion. Compassion comes from the root to suffer with. It is a genuine heart felt concern for the welfare of others. It describes your intention to be of benefit to other beings. With altruism it describes the action. Altruism is a verb. Altruism decides the action towards helping other people and I love this image from the Tibetan teachings of the thousand-armed Chenrezig. The body suffers of compassion with a thousand arms reaching out to embrace the world with compassionate intent and altruistic action. So, does altruism even exist? Some of us would say, "Well you know this guy, he's a nice guy. He tries to be nice. He is just a naive idealist." And I've heard that many times in many different places. And that altruism, it doesn't exist.
Thomas Hobbes told us that human beings are really nasty creatures. In his book "Leviathan," he said that, "I put forth a general inclination for all mankind, a perpetual restless desire of power after power that only ceases when we die." According to Hobbes, there was no such thing as an altruistic person. We are all just beasts. We are controlled by societal rules. It doesn't feel very good, that description does it? So, of course in our more modern era of science we have this gentleman, Charles Darwin, who's held up as another example of why altruism is not real as people suggest. Well Darwin showed that the only reason people or organisms do things, is for the genetic pool. Well actually, Darwin wasn't saying that he was--actually in his writings he talked about the profound appreciation he had for the altruistic drive of all sentient beings across all species and most particularly he described beasts. The modern version of Thomas Hobbes is this gentleman, Richard Dawkins, from Oxford. He recently wrote the book called, "The God Delusion." Richard Dawkins in his book described the selfish gene. Dawkins would suggest that none of us do anything altruistically. We're only there because our genes determine that we have to behave in certain ways. So, how do we explain this then? This is a quotation from Arthur Schopenhauer. "We only see the true nature of the human spirit when we watch a man running into a burning building to save a stranger." How do we explain those powerful acts of altruism that we see whenever there's a great disaster or catastrophe?
Schopenhauer said that this was a true spirit of human beings is this capacity to help other people. So, up until recently we've been caught in 2 worlds, the idealists like myself who say that altruism is real. We need to find ways to tell our people to manifest that and the cynics who say, "No, we're all just nasty pieces of work and we need more laws and Attorney Gonzales can create more restrictions on us and force us to behave in certain ways." Until this gentleman came along about 10 years ago and said, gee--somebody asked him the question, is altruism real, and he said, "Well, absolutely," and they said but you know isn't altruism just about helping yourself and he said, "Yes." And he said, "That it is also about helping you. You help others and you help yourself. It doesn't have to be selfish or selfless it can be both." It sounded like an interesting idea but how do you prove that? Well, about 5 years ago this study came out. This is called The Prisoner's Dilemma. This is a board game which is being used a lot these days in functional neuroimaging studies. And in this board game which people can actually play while under the scanners and you have several people playing simultaneously on different scanners, people can make selfish or selfless choices, altruistic choices or selfish choices. And what they found was that when people make selfless or altruistic choices in this game to help another player even though they don't need to, the mesiofrontal area and most particularly the nucleus accumbens is activated.
That part of your brain intimately connected with pleasure experience and this is the part of your brain that lights up when you use cocaine for example. So, when you help other people, your brain actually experiences itself as though it was on cocaine. So, helping others makes you feel good, right? Some other data, are human beings the only species that can be altruistic to other people? Absolutely not. I'll just go through this real quickly. In studies from 60 years ago with rats and with pigeons what they found was that rats and pigeons not only will not do something to prevent one of their conspecifics another rat or pigeon, from being shocked with a probe, they will actually do things. They can actually learn to, for example, push their lever to stop the colleague, the other rat or the other bird from receiving shocks. That actually demonstrates not just passive behaviors but actually positive altruistic behaviors to help their colleagues. And in primates we see the same thing.
What's really interesting about some of this study in particular from Mason was they had a bunch of these Rhesus monkeys and what they did, was they learned that if they deprived themselves of food, their colleague, the other monkey would not receive a shock. They have to deprive themselves of eating. And 12 out of 15 Rhesus monkeys actually would starve themselves and go without food rather than see their colleague being shocked. And one little fellow actually starved himself for 12 days, he starved himself, rather than seeing his friend being shocked and who would rather take on the suffering of the world than see others suffering. What was interesting is the better the monkeys knew the other monkey being shocked the longer they would hold out without food. And I won't go through this, but here's an example where a gorilla actually showed an altruistic act towards another species.
So, Kuni actually took care and protected a little bird from other gorillas because she wanted to protect it until it was strong enough to fly away by itself. So, animals are telling us that in fact altruism and compassion is not just a uniquely human thing that all of us possess. This capacity in all of us, I think you've heard about that gorilla that recently saved that child in the zoo, was it in Japan where actually the child fell over the barrier and the gorilla actually nurtured the child and protected it until the child could be rescued. Okay, so now I'm going to move on to some neuroscience and we're going to cover a lot of stuff. For those of you who are neuroscientists, I give you an apology that I'm not going to go through all the methodologies and all these studies, because each of them, in itself, is worth several talks. But I'm going to try and give you a taste of what science is telling us about how the brain mediates compassion and also what this tells us about how we can become more compassionate, at least manifest our compassion in our clinical work.
Now, all of us know that our brains have gotten bigger as we have developed along the evolutionary scale, right? And all of us think that the reason our brains got bigger is because we have to invent Apple computers and we need to do math and we need to get jobs at M. D. Anderson. If our brain is really big, then maybe will get tenure somewhere and that's why we have big brains. Well, actually the reason that we have big brains is because we need to learn how to live in more complex communities. The larger the community that we live in the bigger our brain becomes, all right. And so if you look at the evolution of the human brain from little hedgehogs that live in little groups of 4 or 5 up into primates and up into humans, it really correlates the size, the explosion of our communities in which we live.
Now, as a behavior neurologist and neuropsychiatrist, I learned earlier on the studies that we always used to use before fMRIs came along was we would take patients that had a focal neurological disease and study them and see what it would tell us about how the brain functions and this tradition came from this gentleman up here who's Phineas Gage. That guy that got a tamping rod through his frontal lobe in about 1860 and he had a change in personality and became a foul mouthed reprobate alcoholic, left his family and died at Barnum's Circus about 15 years later. That was the model for how we, as behavior neurologists, would study how the brain functions. And so if we study several conditions, we can actually get an idea about how the brain mediates empathy.
The first of these are developmental disorders and here are 2 patients, one with Williams Syndrome and one with autism, Dustin Hoffman. Anybody know anyone with Williams Syndrome? Williams Syndrome is not that uncommon. Actually there was a thing on 60 Minutes a few years ago. I used to work a lot with developmentally disabled folks and I loved the Williams Syndrome kids, or young people, because they were so loving. They were so delightful to have to come into your office. Unlike being a psychiatrist, normally everybody comes so depressed. These folks would come in, they'd hug you, they say, "How are you doing?" They're musically often very gifted. It's a lot of fun. You're like gee, wish you could have just that whole program of Williams kids. These children seem to have enhanced capacity for empathy, and of course, outside of the spectrum are the people with autism who seem to be disconnected from other sentient beings. It's very hard to connect emotionally with somebody with autism. So, these are truly ends of the, which you might call the compassion spectrum and here's an example of how different they are.
This is a little picture of what we call the cookie jar test in neuropsychology. You can see in this picture, there's a lady there who's washing. There's water spilling and those kids are getting up to mischief. And what we do with patients who have certain kinds of lesions, most involving posterior sensory association areas, we ask them to describe what's in the picture and some people with lesions can't see the whole story. They can just see little bits, but if you show this picture to a child with Williams Syndrome, this is what they'll say with a very high voice and laughing, "The mommy left the tap on," she says pointing to the water, and, "The boy is trying to get a cookie but the chair is tipping over. Oh, no, no! Mom, won't you save the boy? Oh, gosh! She better save the boy quickly, the son and her daughter. Oh there's going to be a flood on the floor. The boys and the cookies, maybe it's after supper, maybe, or the mommy's drying it with the towel. Poor boy! He could get hurt and break his arm. Poor, oh poor, poor thing!" She says it. Now, if you show this to a child with autism, the autistic person will say, "Mom washes dishes. A bowl fell. Boy slips, boy push. Boy helps mom with dishes. Mom big mess in water," and shakes his head. This is a profoundly different experience of their relationship with the world andthe experience of other people.
And so, one of the other theories of autism when we come back to this is that people with autism lack the capacity to understand what is in somebody else's head, right? They'd lack the capacity to cognitively understand what you're going through, right? And this skill develops at about the age of 4. This is the little picture up in the right. There are 2 little girls, I think one's called Mary Jane Story and they were with a doll, and Mary puts the doll in the crib, and then she leaves the room, and then Jane, being mischievous, gets up, takes Mary's doll, puts it in the cabinet, and then when the other child comes back, she sees her crib is empty, and up until the age of 4, a child wouldn't be able to say why Mary looked surprised, right? After the age of 4, we can, and it seems as though this capacity to read other people's thoughts, so to speak, is connected with our frontal lobes, mesiofrontal lobes in particular. So, another example of people that have problems with empathy and compassion, of course are sociopaths, right? Cold blooded killers, all right? I had a chance to work with a paralegal who worked with Ted Bundy that infamous Ted Bundy, and I asked her what it was like to be in the room with him, and she said it was like being in the room with somebody that had no capacity for feeling. He was totally like a machine, very brilliant but had no affective component to his experience.
There is a book written by Captain Gilbert who was a psychologist. He was given the job of stopping the Nazis on trial in Nuremberg from committing suicide, and so, he would spend many hours a day with these individuals and he wrote in his book, "I told you once that I was searching for the nature of evil, and now, I think I have come close to defining it. Evil is a lack of empathy. It is the one characteristic that connects all the defendants, a genuine incapacity to feel with their fellow men. Evil is I think" said Captain Gilbert, "an absence of empathy." So, what we discovered in children with Williams Syndrome is that in fact, they have a decrease in the size of some of their visuospatial areas, but actually an increase in particularly the vermal area, the old part of the cerebellum. So, some interesting insights, I'm sorry, those 2 slides were out of sequence. But in sociopaths, it seems that the primary deficit in sociopaths--I have a colleague, Kent Kiehl, who just got a grant from New Mexico, Governor Richardson. He's bought a couple of mobile fMRIs and he goes around giving fMRIs to all the prisoners on death row in New Mexico, and the study is beginning to suggest that in fact the primary problem with the sociopath is a failure to develop the extended parts of their limbic system. Your limbic lobe, of course, is the emotional part of your brain. So, sociopaths have an inability to emotionally connect with you. Autistic people have an inability to cognitively connect with you empathically. Well, that's kind of interesting.
It goes back to our definition that we had earlier, right? And here's an interesting example from Mario Mendez from UCLA. Mario noticed that people with certain kinds of dementia seemed to be kind of more autistic, would like to draw as their disease progressed and so, he got these series of drawings from people with frontal type dementia. In the top there, you'll see a drawing of Ernest Hemingway by a patient and as his disease progressed, this person turns into a machine almost, right? He really begins to just lose connection and down at the bottom are some other examples. And once again, an example of Jackie Gleason drawn earlier on in the patient's illness and by the end of the illness, Jackie Gleason becomes an inanimate monster, and I just put up the slide over here because this is of course, Picasso, and most people would suggest that Picasso's major contribution was his radical new way of envisioning art. It's possible of course, that what we're seeing in Picasso is based on an empathic connection that is manifested in a way in which he could reproduce human beings. He was a very traditional, very gifted artist earlier in his life and then developed his kind of cuboid, inanimate species that were considered by experts to be brilliant. Okay, so nothing yet. How about you and Newton? What I'm going to talk about now for the next 10 or so minutes is what V.S. Ramachandran at San Diego and others have called the most important discovery in science since the apple dropped on Newton's head.
Anybody know what it is? So, I agree with Dr. Ramachandran. I do think that this experiment is probably the most important experiment since Newton and the apple, because not only will it revolutionize our concepts of empathy and compassion, it offers to revolutionize our concepts of consciousness, and even what it means to be a human being. And so, hopefully I'll make that argument in the next few minutes. What the study shows is this--so this is Giacomo Rizzolatti from Parma in Italy. Basic neuroscientist who's interest was in looking at the electrophysiological characteristics of the prefrontal motor system. Sounds kind of dry, right? Well, he would implant electrodes in these monkeys' heads and he'd have them do various experiments and then he would see what happens to the electrical characteristics of the monkeys' brain. Now, of course these electrodes, once they were implanted, needed to stay where they were because you couldn't keep putting them in and out. And one day, Rizzolatti was walking around doing stuff in his lab and the machine was--the EEG was still running and he heard this little buzz and being a very knowledgeable person about these things thought, "That's a strange frequency coming from that monkey's brain. I wonder what he's up to." And he kind of ignored it. But a number of years later, he and some of his colleagues in Parma went back and they said, "You know, we keep coming across this phenomena where the monkeys' brains sound as though they're active even though they're not doing anything." And so, they went back and they looked at the data, and what they discovered was when a monkey watches somebody pick up something, a piece of apple or a peanut, from his abode, the monkey's prefrontal cortex, F5 of the prefrontal cortex, would be activated as though the monkey was picking up the peanut himself or herself. What they were saying was when you watch somebody do something; your brain actually acts as though it's doing the same thing itself, right?
Rizzolatti also reported back 20 year ago, when all of this was first reported, was that when a monkey hears a peanut being opened by one of the experimenters elsewhere in the lab, the monkey's motor system that correlates with the motor activity of cracking open a peanut because they had that data, is activated, all right? By just hearing something, your brain begins to make associations and acts as though it's actually opening a peanut. So, this brings us back to when we were kids, right? Monkey see, monkey do. Human see, human do. And so, we'll get to that one now. So, unfortunately, this information is now widely known by people who would choose to use it to manipulate us into behaving the way they want through the use of mirror neurons. So for example, there's a book called "Neuropolitics" that just came out, "Neuroeconomics" after the Super Bowl last year. They actually had subjects who were on fMRI machines as they watched the advertisements afterwards, and what they discovered was that when people watched, the most popular advert was that FedEx commercial where there's that little man and a cavemen, and you're having a bad day and eventually the caveman ends up being squashed, remember that? Anyway it's a really funny commercial and we thought it was nice, but actually when people watched that, their brain actually mirrored out the experience of being squashed. It was not a good thing you want to associate with your product, right? And what people looked most comfortable and had the happiest mirroring experience with was going to Disney World and so I guarantee you that right now people within our political system on whatever side they are, are looking at ways in which they can modify our mirror response using various symbols and provocative visual stimuli.
Okay, so what relevance does this have for us as clinicians, as people that want to take care of patients with pain, who want to be compassionate? Well, the first major study in this regard came off from Tania Singer in London. This study was 3 years ago. What she reported was when you watch somebody in pain your brain lights up in areas of the brain that are the same as the patient who is experiencing the pain, most particularly in areas related to the emotional aspect of pain. This would be the anterior cingulate cortex, cerebellum, the insular cortex, the areas--and some areas of the somatosensory cortex. So when you watch one of your patients, you walk in to their room and they are in pain, your brain emotionally feels the same way as your patient, okay? Now, why isn't it that you don't--you're not consciously aware of that? That's because, what's it, 400 billion bits of information are processed by our brain every second and I think we allow ourselves to be consciously aware of maybe 2 million bits. There are the structures now called super neurons in the mesiofrontal area which actually help us decide which parts of our experience we're going to pay attention to. So even though you are not aware of the fact that your brain, that you are emotionally the same as your patient the moment you walk in a room, you are, you're just deciding to ignore that fact.
And that explains why, have you ever noticed that the more uncomfortable a patient is the quicker you want to get out of the room, right? Not because you're cold hearted, you don't care and whatever. You literally are feeling bad, right? You're just not aware of it. Here is an interesting study from 2 years ago where they looked at empathic accuracy, the ability of a person to actually identify cognitively and emotionally in another person's experience and they correlated it with fMRI studies. And what they found was you can actually use the fMRI as actually a correlate of someone's accuracy. What was particularly interesting is, I mentioned the cerebellum a little early on. The area of your brain that's most specific in correlating with your empathic accuracy is your cerebellum and we always think of the cerebellum as being kind of non-consequential, you know. I used to learn that the reason why our cerebellum was the biggest part of our brain was because it has to balance out the frontal lobe, right? It didn't really make sense, but I mean I would have patients coming to me with cerebella lesions. Their spouse would say you know they're not the same or something's changed and you know I read the text books, and textbooks say you know you may not be able to play tennis anymore, but you'll be the same guy.
Clearly, the cerebellum mediates all of these, what you might call metasocial behaviors and interesting if we go back 200 years to the phrenologists who studied lumps and bumps on people's heads. They actually localized things like friendship and collegiality and conjugality to the cerebellum. So isn't that interesting? The more things change, the more they stay the same. Here is an interesting study, all right, from "Nature, Neuroscience." These are all in great journals, "Science, Neuroscience," okay. What they showed was using transcranial magnetic stimulations is that when you watch an image of somebody experiencing a pain on a computer. Imagine giving your patient an injection. Your brain lights up in somatosensory areas that correlate with that part of the brain. They couldn't pick this up on fMRI because the changes are too subtle. But not only do you feel this pain emotionally, you actually feel this pain physically. You're just not consciously aware of it. Can you imagine what burden this takes on somebody working in a hospital like M. D. Anderson? I mean you are literally in a sea of distress. You're just not aware of it. And you wonder when you get home, "Gee, why is it I feel so burned out?" Because you're living this, you're just not aware of the fact.
Another interesting study, when you watch somebody in pain, it actually affects how you experience pain. This was a study in which they have people watch this young man tell 2 different stories. In one group the man was being a real jerk and saying, you know I duped this guy and I stole money from him and yadda, yadda, yadda. And the other story was he was talking about how he'd lost his girlfriend, how she passed away, how sad he was and while subjects watched these 2 different stories they had their hands in a noxious stimulus like hot water. And what's interesting was those people that felt empathically connected to the story actually reported a more distressing response to the hot water compared to those people who were watching the guy that had been a jerk, interesting. So when you really empathically connect with your patients, it also creates more distress for you, interesting challenge. A fascinating condition called synesthesia. Synesthesia is the capacity to actually feel physically, be consciously aware. You know just that we all feel this stuff lets you be consciously aware of what other people feel. When you touch the face, I'm actually feeling her. I have synesthesia I'm actually, when I've touched, synesthesia. I'm actually feeling it. It's like you're actually doing this. Can you imagine that? What is interesting of these folks are these are brilliant people when it comes to empathic accuracy. They are savants. They score--they are 100 percent accurate all the time. I heard somebody on the radio yesterday and she was--she said that she talks to animals and we all think, "Oh, those people are crazy," but what she said was on this program, "I don't talk to animals." She said, "I just know what animals feel. When I'm with a horse, I feel that the horse has pain in his right leg. I feel that the horse is sad." Then maybe people that talk to animals are just very gifted synesthetics, have a very enhanced empathic system.
Here's an interesting study where Marco Ilcoboni at UCLA actually showed that our brains look different depending on what the intention of the action is. And so we have a person who's both acted in pretty much the same action, right? They're both reaching for a cup, but there are differences in this picture. In the one cup, the cookies are on the plate, cup is full. In the other the cup is empty. The cookies have been eaten, all right. Your brain reacts differently based on how you interpret the action, all right. You actually have mirror neurons in your brain that correlate with what the other person intends to do. If they intend to hurt you, your brain looks different. You actually are mirroring their thoughts, their intentions, isn't that amazing? When you're with somebody who really has a wonderful intention for you, your brain experiences that this person really wants to help me, all right, as opposed to this person who doesn't give a shit about me and they're just here because they want to get out of this room as soon as possible. You experience that. What's interesting, as well, is that women are much better at being forgiving than men when it comes to empathy and forgiveness. When you--this board game, again, when men--people playing the game were told that somebody was cheating, the women continued to act altruistically, but their brains looked as if they were being altruistic and the men seem to get a lot of pleasure out of seeing that person being punished.
So what this tells us is that our empathic system is flexible and malleable to the way in which we categorize the other person. It's called stereotyping, right? So the Lucifer Effect is that study at Stanford and it's done where they took students and they had them act as just jail wardens for people in a jail in California. The students didn't know that the prisoners were actually other students, as well, and they wanted to just see how the students would behave towards these so called prisoners. They had to stop the study within 36 hours because these--the jail wardens, the student subjects were so cruel to the prisoners although they were just other students. They didn't know that. And this explains how we can do these awful things, because our brain modifies our experience of the other person and based on our stereotyping, we can actually shut down some of our empathic systems.
I just want to show you. This just came out 2 months ago. What this shows--the study is far too complicated to talk about in detail, but what it tells us is that women and men process empathy differently. Women are far more likely to experience emotional contagion. Women have a far more challenging time making a separation between the self and the other. Men are very good at that. Men light up their left temporoparietal cortex when they watch feeling in another person. That area of your brain is involved with the distinction between self and other, all right. This may be why it is that women in healthcare, particularly physicians, are experiencing tremendous mental health fallout. The suicide rate in woman is 2 to 5 times the general population, all right. I had hoped that woman coming into medicine would somehow create a more compassionate environment where science could be balanced with compassion. Unfortunately, it seems that for many female physicians, not all but for many, this experience is actually very damaging and this may begin to explain it. It is not a question of being strong or incompetent, just a question of being different and learning how to use these different capacities to the benefit of ourselves and our patients.
I love this study. This was a study of acupuncture in 2 groups of people. One group was acupuncturists and one was a controlled general population. They had them watch images of this patient getting acupuncture needles in different parts of the body. The acupuncturists actually demonstrate a less significant empathic response to the patient getting the needles. Now, that may just mean that acupuncturists know that needles don't hurt very much and regular--controlled don't. What was interesting about this study is the final part of that, the needle in the feet. The acupuncturists actually were more empathically entrained than the controlled general population group because acupuncturists know that that's the most painful part of the body to get a needle into.
What about empathy for other species? Are we only capable of caring for our same community? Well, actually this study shows that in fact when we see our dog for example, similar areas of our brain light up empathically as when we see another human being but certain parts of the anterior cingulate cortex are specific to recognizing our own species. But we do have an empathic experience of other species which suggests that maybe all sentient beings need to be treated with compassion.
This gentleman, I love this picture. This reminds me to talk about another area of research that's very interesting and hasn't been explored very much scientifically yet and that is the idea that not only are there these verbal and nonverbal ways of communicating empathy and compassion but there is a third channel, which is an energetic channel that happens across wavelengths or frequencies or course that we don't really understand, but there is significant data to show that when 2 human beings are engaged, even without the knowledge of the other, they change each other. Marilyn Schlitz has done a lot of work looking at people who are in a room and they do not know they just are sitting in the room and then another person is on a TV monitor watching them and after a while, both subjects will start synchronizing their physiology. That's why in the secret service when they train people to follow an individual. They are trained to always look 6 feet behind the person's feet, the experience of being stared at, all right.
Anybody had the experience of being--knowing someone was looking at you? It's a universal experience. This perhaps is the way in which large groups of different species can be like birds, geese. This may be a form of communication. I could spend more time about that but I want to give you this wonderful example, because this is really, this really makes you humble. This is about the third channel of communication called spontaneous communication. And I haven't got time to get through it in detail but I want to talk about these people. These are slime molds, all right, and all of us have heard about slime molds? Well, slime molds are like hanging--little single cell organisms. They like hanging out by themselves. There is enough food and enough moisture and it's warm. They are pretty happy hanging out as single cell organisms, but if the food starts becoming depleted or it gets too hot or it's unfavorable for maintaining homeostasis, these single cell organisms start looking for some friends and when they get enough friends together they become slime mold, right, and slime mold--How do they know how to get together? They don't have FedEx. They don't have e-mail. They don't speak a language. There is some energetic communication that seems to produce changes, maybe in mRNA, messenger RNA level.
We don't know, but when enough of them get together and become slime mold, they move through the soil until they find a food source or a nice environment and then part of them becomes the root and then part of them becomes the stalk and then part of them becomes spores to generate the next generation. It's pretty intelligent behavior, right. Now, this gentleman, Dr. Nakagaki reported in Nature magazine, so it's pretty reputable. I think most of us would like to have our stuff published in Nature. This study with slime molds and their capacity to learn their way through a maze test. This is a porteus maze test. We use this with patients who have frontal lobe deficits. What these little slime molds were able to do, they were able to find their way through this maze without a single mistake. How on earth do they get to do that? And he actually went on to report an even more difficult mathematical study. It has this like 9 distant cells and it's more difficult and they also managed to do that better than most human beings, certainly better than I could do it. So there is something going on. There is some wisdom in the communication that we don't understand yet, but hopefully we'll be hearing more about in the next few years.
But here is an example in clinical practice. It came out about 6 months ago, the Journal of Nervous and Mental Diseases. They asked patients and their therapists during the session to rate when they felt they were connecting with each other. The therapists and the patients would say I feel like I'm connecting now. And what they find on the polygraphs, there were polygraphs on the patients and the therapists, and what they found was, at those times when patients and therapists felt that they were connecting and in fact they were creating synchrony between their autonomic nervous systems. So, there is some energetic system that is going on that we don't understand. This is just to say that we can actually begin to understand all of these things if we look at how the brain evolved. We haven't got time for that. What I want to do is talk about this idea that maybe we are moving into all of this finding about mirror neurons and where do I begin, where do you begin, where do we connect. As I mentioned that may be the biggest discovery since Isaac Newton. Because not only is it important for empathy but it's beginning to shift our ideas of consciousness.
One of the big debates in philosophy is consciousness generated by the brain or does the brain simply filter consciousness. The idea... is the brain the center of the universe? Is my brain the center of my consciousness? Or is my brain just part of a bigger consciousness in which I have something to face. This is a profoundly important and very provocative area and most philosophers like Daniel Dennett. Now, there's a saying, of course, our brains generate consciousness and it's just an epiphenomena. This gentleman, Francisco Varela suggested in fact our brains are not really generating consciousness. They're just participating in a shared consciousness and he calls this autopoiesis and I haven't got time to go through this. Autopoiesis has a number of features, but basically what it says is that our brains consist of holarch using holons that are co-creating each other. That consciousness occurs at the space between us. It's a pretty profound idea and we could spend the whole, I guess a whole college course talking about that and so within this model there are cells and organs and people and families and communities and we're all co-creating consciousness together and if we have, can you imagine the world in which we had compassionate intent and performed altruistic action knowing that we are all connected to each other through these systems energetically and neurologically in our brains.
And I love this sculpture by M.C. Escher that I think describes the emergence of consciousness out of the shared energy field and created, supported and filtered by our brains and our energy systems. I came across this painting by, I keep forgetting another Spanish not Ruben, the Spanish, Goya and Goya was extremely ill and almost died and he made this portrait of his doctor caring for him during his illness and I think we have that same experience of them co-creating their relationship to suffering and that we as clinicians can join with our patients understanding that we are participating in a shared experience. We will do a lot to support their suffering. I often say, for me, the definition of suffering is experience of being alone. It's not pain. It's experience of being alone and that if we disconnect to each other empathically, we become alone and everything becomes unbearable.
So, to go back to the idea that we are not simply generated by our brains that we are not one brain but one consciousness in which we all participate. I'm going to show you these images from the New York Times. On one side is a reconstruction of the evolving cosmos by scientists at the Max Planck Institute and the other side is a mirror. Pretty similar, hard to tell one from the other, so where do we begin and where does the universe begin? Where does my mirror neuron reflect you and reflect me and we're all in this thing called Shiva's dance, right, closely knit where we co-create conscious and what happens to you happens to me. So, I want to just, finally just go through this, because this is really probably the most practical part of this talk in 5 minutes and it's what can we do about this in a very practical way? It's all very well for me to stand here and talk about mirror neurons, anterior cingulate cortex and Francisco Varela and autopoiesis. Well, we have to go back to the seventh floor, right. Well, some social scientists are beginning to give us some very interesting insights as to how this all kind of comes together when it comes to healthcare.
What my friend Ross Buck and others have shown is that there are determinants in our capacity to be empathically accurate about another person's emotional state and these are: first of all in order to be empathically attuned to another person, these should not be a hierarchical power difference between you and the other person. There shouldn't be any power differential. Think about healthcare. Who has the power? Yeah, the clinicians. Who has no power? The patient, right. What's the next? So that's not good for empathy. The next thing that they found was that there needed to be no physical hierarchical distinction.
In other words, one person was high and one person was low that shut down these connections. Think about patients in the hospital. How do they lie? Right. What happens if that person tries to stand up in a hospital? Get back in bed! And then we give them these little jammies that are open at the back, so God help them. No one's going to be walking around if they look like that. The next predictor is the expectation of a long term outcome. The better and more you think that this relationship is going to be a long term relationship; the better you are at being empathically attuned to the person. How long do we expect our relationships to last with our patients these days? Short as possible. Yeah. Right. Get them out of the hospital! Get them out of my office! Six minutes. The expectation of a positive outcome is critically important. The better you think this relationship's going to go, the better the outcome, the more likely you are to be empathically connected. Think about healthcare. Do we expect positive outcomes from most of our patients?
Hmm, not really. Okay. Nonverbal reinforcers. What they found was that you need to use nonverbal cues. It's not just enough to say things. You need to use your hands, your face to keep these channels open, okay. Think about the patient in the hospital. How many nonverbal facilitators do they use, all right? Motionless. It shuts us down whether we know it or not. It's shutting us down. And what's really interesting is that we, as individuals, are absolutely pathetic at evaluating our own capacity to be empathic. We think that we are doing a wonderful job. I was so empathic to that person. I'm really--I know exactly what he's feeling. I could cognitively like him. Oh, I'm just really empathic.
Studies have shown that we haven't got a freaking clue, all right. We are totally incapable of self reflection, and think about it, it is because we have what's it, 400 billion bits of information a minute going on in our brain. We have sifted out all of the stuff we don't want to deal with. And so therefore, we're only left with the stuff that makes us comfortable. So, if you were to describe a perfect social environment for empathic communication, empathic communion. It's called the first date with my wife. Long term expectation of positive outcome, no physical hierarchy, at that point I was still her equal. And also if you've noticed a lot of time we think a date went a lot better than it really did. So, that's a good environment and here's probably--here's an environment where empathic accuracy is pretty much set up to be a disaster, right.
So, that's, I'm not going to talk about this, but I think that there are ways in which we can be and Dr. Baile will be doing this in his program beginning to address ways in which we can educate ourselves knowing the science of how we can be more empathically connected with our patients. And I want to finish with this which is a statement by his Holiness which the science is now proving. "If you want others to be happy practice compassion and if you want to be happy, practice compassion." So, I want to thank you for your time and I don't think we have time left for questions.
[ Applause ]
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