Dennis H. Novack, M.D., F.A.C.P.
Drexel University School of Medicine
Associate Dean of Medical Education
Director, Clinical Skills Teaching and Assessment
Division of Medical Education
Dr. Baile: So, today I'm really pleased to introduce Dr. Dennis Novack as our guest speaker. Dennis is not only a very old very friend from way back when we began communication skills studies, training, research together, but also has now really moved the field of communication skills forward in his position as Associate Dean of Medical Education at Drexel University College of Medicine in Philadelphia. So, Dennis trained originally as an internist and then completed a two-year fellowship with a very well-known psychosomatic medicine program headed by George Engel in Rochester, New York. He's worked in academic medicine for most of his career heading up programs in communication skills, teaching, and currently at Drexel, he is in-charge of the clinical skills teaching and assessment and directs the first year medical student course on medical interviewing as well as the doctoring curriculum in the medicine residency. Dennis is really a designer of an online communication skills training program based on video--interactive video called Doc.com, which is a joint project with the American Association of Communication in Healthcare. He's been involved with a number of organizations of promoting communication skills training and is published extensively in the field. And, in the past year, his educational efforts won him an Alpha Omega Alpha Robert J. Glaser Distinguished Teacher Award from the American Association of Medical Colleges and a Career Achievement Award in medical education at the national meeting of the Society of General Internal Medicine. Today, his talk is entitled Therapeutic Aspects of Clinician-Patient Relationships. So Dennis, thank you so much for coming down, so let's--
[ Applause ]
Dr. Novack: Thank you. Yeah, Dr. Baile and I go back so many years, back to 1979 and it's always a pleasure to come down here Walter. I don't know how to get out of this screensaver. Let's see. Escape?
» Escape and then your slideshow.
Oh, okay, cool.
I'm getting there. Just keep eating everybody and--there we go. Thank you. So, Dr. Baile asked me to talk about therapeutics. And he remembered a paper that I wrote, I don't know, almost 30 years ago. Shortly after I finished my fellowship, I was really interested in why some of my patients got better when I didn't really do much for them except talk to them. Sometimes they actually came back even after symptoms for a long time that were accompanied by some emotional issues. I tended to get a lot of patients because I was in the psychosomatic medicine fellowship, I tended to get a lot of patients who had conversion disorder and other psychosomatic conditions, and some of them got better just from talking and I thought, well, what's that all about? So, I started doing research. I researched the world's literature at that time and I wrote an article about that. I had something like a 150 references that was--I was able to find, and it really looked at the question of sort of what's eternal about healing relationships? You know, it's only been in very recent years, less than a half century or a little bit more, that physician have actually been able to do much, right, in terms of the kinds of therapeutic drugs and innovations and radiation therapy and so on. 150 years ago, there wasn't much around, and yet the practice of medicine and all the healing disciplines have survived for many thousands of years. So, what is it that's sort of eternal about healing relationships, and can we break that down and understand it better? And so, I wrote this article and I'll go through some of what I--I was able to find out but I also want to bring you up to date on some research in physician-patient communication that shows which aspects of communication are helpful and therapeutic, and especially some research on empathy because there's been a lot of research in empathy in the last 20, 30 years including neuroimaging studies, and psychophysiologic studies. So, the understanding of what's therapeutic about clinician-patient relationships has really advanced and it's not--I'm not just talking about physician-patient relationships, it's all healing relationships. So, you know, allied health professionals, nurses and so on, they all can do a lot of the aspects and do a lot of the aspects of what I'm going to talk about. So, the goals of this talk--I'm going to have to periodically go back so I can actually, I don't have to look up each time--describe the foundations of a therapeutic relationship, history of therapeutic relationships in healing. Just a few words on that. Talk about some fundamental concepts by a psychosocial model, transference and countertransference, meaning of illness and so on, talk to you about some research findings. And then I'd like you--while you're looking at this talk, to look at and think about some of the issues and concepts that you may not have thought deeply about before or some of the skills and try it out with your patients. So at the end, I'd like you to all commit. Yes, well, you don't have to raise your hands and say what you're going to commit to, but think about actually committing to trying out one of these new behaviors or techniques with your patients just to see how it works. All right, you're all enrolled in that? Can I--yeah, okay, good, thank you. All right, so what--just a little bit about the history. You know, physicians, the healing professions really started out as sort of priests and shamans, you know thousands of years ago, and in a lot of primitive cultures they're still that way. I had the privilege of--after my residency program, my wife and I took a year off and I went around the world and I practiced medicine in a variety of countries, volunteered here and there in Kenya and India, Taiwan and I got to see native healers and learn something about what--how they work. And, you know, even though much of what they have to do and what they offer is either ineffective or even harmful yet people tend to get better and still trust them with their lives. You know, a good example was Benjamin Rush, you know, you all know Benjamin Rush? No? He signed the Declaration of Independence. He was a prominent Philadelphia physician. To really [inaudible] I'm from Philadelphia--you know he's well-known there and he was really someone who was ahead of his time in many respects with thoughts about public health and professionalism, altruism and so on. But he had this firm belief in a practice that was done very often back then, which was bleeding and purging, right? So, he believed, you know you get rid of the bad humors in your blood by bleeding and purging, he believed that if some bleeding and purging was good then more bleeding and purging was better, you know? And, he's still remembered for his courage. He stayed in Philadelphia during the Yellow Fever Epidemic and ministered to the sick including his own sister who died in that epidemic. I'm sure taking off a couple units of her blood didn't help, you know, her healing process but that's what Benjamin Rush did and he was actually criticized by others in the field for that, but a lot of physicians also believed in that. Oliver Wendell Holmes, a famous physician, you probably know his son who was Chief Justice of the Supreme Court, but Holmes Sr. was a physician, poet, literary, man of letters, and he said at the end of the 19th Century, "If we threw the entire Pharmacopoeia into the ocean, it would be better for mankind and worse for the fishes," you know.
So he recognized that what physicians were doing was a lot of snake oil and "hocus pocus" and so on, but yet physicians were a respected profession and they minister to the sick and they help patients. So, what is it about what physicians were able to do way back when--that's similar to what other healers do at that work? And, if we know what the components of that goodness is, you know, Hippocrates said, "Often patients will get better just because of the goodness of the physician," you know. Well, what is that goodness? You know, what are the components of that goodness? So that's what I tried to do in my reviews so many years ago and I'll just talk about a few foundational concepts to that goodness. I mean one is mind-body unity. You know, we've grown up with sort of this dialectic of mind and body are separate, and that's been sort of entrained in us, sort of by Descartes onward. And, the fact is, mind and body are one and I appreciate that most of you understand that. And just as an example of that, I right now, I'm changing your biology and anatomy, right, right? I mean right now, mRNA is happening in your brains, a new neurologic, you know, connections are being made. I mean it could be that, you know, six months from now, someone will say "Hey did you go to that talk by Novack” and you’ll go “Novack?”
All right, so maybe I'm not, maybe I'm not. But, you know, stuff's happening, you are affecting me, I'm affecting you, and to the effect--to the extent that I might arouse emotions, laughter or remind you of something sad or something, your neurobiologic processes are happening in your brain that may affect your feelings, your emotions, your behaviors, your subsequent behaviors and so on. So, just to remember that that is a foundation of what clinicians, all clinicians can do. Transference and countertransference, you all have experienced this with patients, patients when they are sick or vulnerable and often will look to you as mother and father figures. Even though you're younger than they are, still you have knowledge, your authority figures and they will look up to you and may even act as they did when they were children and so on in their relationships with you. And there's countertransference, you'll have similar feelings towards them, right? Meaning--I don't want to say just a couple of words about meaning. You know I've done landmark education, I don't know if you all know about it but it's a kind of sort of a community self-awareness and personal growth organization, and I've done some of their courses and it's actually quite useful. And, they talk about human beings as meaning making machines, right? And, that's the truth. We are creating meaning all the time, right? You know, it's a little bit of an existentialist, you know, philosophy 101, but there is no objective world out there, right? We all experience the world in different ways and we all create the world in different ways. Yeah, you don't know what I'm talking about? You meet somebody new, within 30 seconds you're going "Well I like this person" and you react. That changes how you act with them. If after 30 seconds you're going "Jerk" [laughter] you know, that person is now a jerk and you go "Oh, you know I got a really important meeting to go to, I'm a--" you know. And so, that's what I mean, you're--you know, that same person is just who he or she is but you've created him or her in a different way depending on your--you know, your past and personality and a whole variety of factors. So, we are always creating our world, we're creating meaning and one thing that physicians and all clinicians do is we manipulate, or we could help change the meaning and that, you know in an oncology center, you know, you can see if somebody has cancer and they think "This means that I'm going to die and probably die very soon," that's a very different meaning than "Well, I have this terminal disease but, you know, I have to leave a legacy for my family. I'm going to fight this thing to the end, I'm going to"--you know, one person can give up you know because "I'm going to die anyway, what's the use?" and the other person will go "No, no, no, no, no, I'm going to fight forever. I'm going to be around. I've got to see my daughter's graduation." So, people create meaning and we help them, we co-construct meaning with them, and that's part of what's valuable about what we do. Anxiety and depression, just to be aware that there's so much anxiety and depression out there, you know, and there are good treatments for anxiety and depression. Depressive illness is actually missed by about 50 percent of primary care docs. And many other specialists will miss depression as well. But, you know, depression creates meaning, right? It creates more dire meanings, and then also there's rumination and there's somatization and so on. So, to the extent that we recognize anxiety and depression, we can help people with their illnesses. I'll say something about empathy, I'll say something about trust because its trust that helps people move on with their illnesses, follow directions, adhere to medications and so on. High levels of patient trust, they're associated with much higher levels of adherence than low levels of trust in the clinician. And I'll say something about the biopsychosocial model, so there's George Engel. I like putting pictures of George Engel in my presentations. He is my mentor, he's a brilliant guy. He's the guy that first really articulated the biopsychosocial model. And Engel, you know, basically said "Medical science, biomedical science that is being taught at medical schools, and the care that's being delivered is basically unscientific" you know because it's just looking--biomedicine just looks for causes of disease and treatments for disease but it systematically takes--excludes consideration of patient's social supports, their emotions, their psychological background, their personality styles and so on, all of that needs to be understood to help patients and, you know, we're not doing it. And so, after he wrote an article in science in 1978 or 79, that article has been cited thousands of times and now most schools say "Yes, we teach according to a biopsychosocial model of medical care." Although, in truth a lot of schools don't, maybe most schools don't but they say "At least, we've got lip service so it's a good thing. And, despite this a psychosocial model leads to a couple of definitions, I just want to go over them with you, so disease versus illness. You all know what--have you heard those distinctions, disease, yeah? So, what's disease? Disease, somebody tell me, disease.
Yeah, it's--comes from outside well, it often feels like it does, yeah but not necessarily. Other ideas about disease? Yeah?
» Absence of being easy.
» Absence of being easy.
» You feel the pain.
» You feel the pain, yeah.
» Dis-ease, that's very good.
» Body changes.
» Dis-ease, body changes, yeah. So, let me just--in the interest of time, I'll just say that disease is objective. Right, you could see it under a microscope, you can see it on an abnormal lab tests, CAT scans. You can--it's what's happening. Illness is what patients come in with. It's a subjective sense of dis-ease, so thank you for that. Yeah, so that's illness, you know, and one of the problems of course with medical care is that patients come in with illness. You know, I've never had a patient come in and say "Well, the reason I'm here today is I have metastatic cancer from my-as yet undiagnosed breast lesion".
No, you know, they come in and they go "I don't know, I got a lump. I'm little worried about it, right? And it hurts a little bit." So, illness--they're coming with illness but of course as clinicians, you know, as physicians we often search for disease and not necessarily the illness. So, you know, you can cure disease with surgery or drugs you know, Penicillin, you know, can cure pneumonia. But, you heal illness with your words, right? So, healing has to do with making somebody whole again, it comes from the Greek "holos". You make somebody whole again, body and soul. And, I'll just say a word about science versus art, because we all spend most of our time learning the science of medicine. But, the art of medicine is using ourselves as instruments of diagnosis and therapy, we use ourselves. And so, you know, if we're artists, if we practice the art of medicine or the art nursing care and so on we can become more skillful artists, you know, by learning techniques, by honing our techniques. We don't have to be amateurs at this. So, you know, I talked about therapeutic strategies. It seem that strategies that I saw in the literature in a wide variety of literature and healing disciplines fell out into a variety of categories of strategies, cognitive, affective, behavioral and social. And of course they overlap a great deal. But, for our purposes, you know, we can classify them. And, I'll just say--I don't want to spend the huge amount of time on this, but all of them, all of them have therapeutic effects. So, priorities and expectations, you know, if patients come to a physician and their expectations and priorities aren't met they go away unhappy, you know. So, you know, a lot of people who are really into communication, recommend that at the beginning of every encounter so you say "So, what you hope to achieve today?" You know, I have a one pager that I give out to my patients, I'm a primary care doc, and all my patients fill out, you know. So the first five lines or so is "You know, what do you hope to achieve today?" You know, and they write them all down and then you know, then I have to sometimes say "Gosh, we only have 20 minutes today and you've got eight things which are the most important and then we'll deal with others the next time we see you. You know, we have to negotiate that." Giving an explanation is something that all healing cultures do. So, you know, when I was in Kenya, you know, some of the shamans that work with people would say "Well, I know what's the matter. You've insulted ancestors. Here is what you have to do to make it right." Well, if it you know, if you have a belief in that culture, if you have a belief that insulting ancestors makes it different in your--difference in your current life, you know, then you have a path forward. You know, the explanation helps focus and helps people understand what’s the matter with them . You know, in this culture people believe in biomedicine except this is a multicultural society and people come from variety of cultures where they have alternate beliefs too. We have to respect those and work with them. Bring patient to a crossroads, you know, sometimes we have to do that, often we have to do that, whose patients are, you know, they're upset, they're conflicted and they--and often don't know they're at a crossroads, you know? And we say, "So look! This is what I understand about where you are" and you have two clear choices right now. You know, this is, you know, what do you want to do. It's that you know, I've worked with a number of women who are victims of domestic abuse and that's you know, a lot of these women think "Well, this is my life. Life is for suffering. You know, I'm just such a worthless person; this is what I deserve out of life." You know, when we say "No, no, this is not what you deserve out of life. No one deserves to be hit like this. This is wrong. You don't have to live this way." You know, sometimes that opens their eyes, they go "I don't?" They didn't know that they didn't have to feel that way. You know, and we can help bring them to a decision point. In fact, when patients--when people realize they have a choice, that's the first step in adaptive behavioral change. It's like what happens in psychotherapy too, people--you know, most people feel like--47 percent of the country feel like they're victims, Mitt Romney said that [laughs]--I don't know where he got that figure. But, the truth is a lot of people do feel like they're victims, like this is my life, you know, this is what I was born for. And, you know, when a physician or health care--other health care professional says "No, no, you have a choice. You don't have live this way." There's other things you can do, why not try this? You know, people go "Oh, [inaudible] yeah.” You know, they have never thought of it. So, you know, we can bring them to a crossroads . I'll say just another word about suggestion, it's, you know, it's a hypnotic technique but suggestion really works, and it's really associated with the placebo response. And, you know, the placebo response is quite powerful. When I was young physicians were still giving out placebos as obecalp. My--I remember talking to my friend's dad who was a family physician back when I was college and I ask them about, you know, how he would have prescribe for this or that. And, he said "Oh, you know, he’s worried [phonetic] well, I just give him obecalp", what's that? Well, its placebo spelled backwards, you know, and you know, the black placebo is stronger than the red placebo. It's very interesting, yeah. People are--and there's a lot of, you know, neural imaging these days that show who, you know, who are placebo responders, certain people are really placebo responders, some people aren't and respond to suggestion. But, if we make positive suggestions to people, you know, it changes the way they react. I mean, if I say to a patient, I'm going to try this new medication you know, it's only out--oh gosh! It's only out a few months and, you know, a drug rep gave me samples of it. I mean--you know, she said that it was really good. And so--I mean, we'll give it a try maybe it'll work, you know? Suppose I say with the same pill "You know, I just got these new pills and I've read some articles on it, and it looks really great. You know, I think this is going to help a lot better than the previous medications we've had you on." You know, you're invoking and encouraging the placebo response and people will start--you know, part of the hypnotic--you know, positive hypnotic technique is, you know, you look for something positive and then when it happens it reinforces that something good is happening and that sets up a positive feedback loop. So, suggestion can be very, very important. Patient education, giving a prognosis, so I'll just say "Well, patient education is very important, it's very poorly done in many areas of the country in certain circumstances as well as discharge planning is not well done despite the fact, you know, that people really try hard to do it. But, you know, if you ask the patients what they remember as many studies have done, after they walk out of the hospital, you know, they forget quite a bit of what they've just learned and are confused about quite a bit. So, you know, even though patients might shake their heads and say "Yeah, yeah I understand" they don't, very often. So, you know, a patient education technique that's being, you know, suggested is, you know, saying something like "You know, sometimes I'm not clear, I wonder if you could just say back to me in your own words what you understanding is just to make sure that I've explained it correctly you know." And, I've done and been surprised of how much--you know, here I thought I was being crystal clear, you know, but am surprised at how much people did not understand.
And, giving a prognosis just to say that one of the most noxious emo--you know, mental states is uncertainty, right? If you don't know what's going on and you don't know what to expect that is associated with a lot of dysphoria. So, to the extent that clinicians of all stripes create a certain amount certainty, you know, that's quite helpful for people. For instance, I had a patient who I was told had an anxiety disorder and this patient was sent to me. And, you know, he'll come in once a month, you'll just calm him down, he has one symptom after another but he seems to get along once you calm him down, okay. So, he calls me up and goes "I'm seeing double but I know it's my anxiety" and I said "Well, come on in, let me take a look at it" you know, and it ended up ophthalmoplegia, you know, like one eye went straight ahead and the other eye, you know, went this way. I said "This is not conversion disorder, it's not anxiety" and we worked him up and he had multiple sclerosis. And, the first thing he said was "I'm so happy, I have multiple sclerosis [laughter] thank God I have multiple sclerosis. You know, everybody thought I was crazy, but now you know what to do." It's like, yeah, not so fast. So--but nevertheless, that gave him comfort to know what he had and the same thing about prognosis, it gives people a certain level of comfort. So, affective strategy. So I'm going to talk about empathy in some detail, encouragement of emotional expression, you know, you all know what's like to have a good cry, right, you feel better after it. Well, more women than man, I suppose men. I mean, there is a cultural, you know, gender difference in men’s ability to talk to each other and cry in front of other men but it is helpful. And, to the extent that patients are comfortable enough to cry in your presence it means they have a trusting relationship with you. And sometimes when they're crying they're telling you their most and their, you know, scary deepest concerns. They're telling you something they wouldn't even tell their priests, you know? And that can be quite helpful because part of what happens is, you know, acceptance, facilitation of self-forgiveness--you know, there's a lot of people out there that feel guilty about all sorts of things especially about loved ones who've died and they didn't do enough for them, you know, and for the extent that we can say "You know, I admire what you did for your wife." I had this discussion with one of my basic science colleagues two weeks ago on the shuttle. You know, I'm going from the medical school to one of the hospitals and I sit down next to him and I say "Oh, you don't look good what's the matter?" "My wife died." "Oh my God, I'm so sorry! What happened?" And then, you know, he told me this story about how--he was Bangladeshi and he and his wife were back in Bangladesh for his son's wedding and they all had great time, and then she had some shortness of breath and he called an ambulance, and in the hour ride that it took to get from the hotel to the hospital she died. And he was really quite bereft, you know, and went over with me in detail what was going on, what happened, what he did with the EMTs did. And, he was blaming himself, perhaps I should’ve noticed earlier, I should have brought her to the doctor, I should have, I should have, you know. He just kept talking and I kept saying it sounds like you did the best you could. You know, you have to forgive yourself for this. You can't--this is not going to be helpful. It's not going to bring your wife back, and it's going to just--you know, just going to overwhelm you, you know? And actually--so that was no. It was about three or four weeks ago and then I got on the shuttle again last week and, you know, we talked some more and he was doing better you know. And, after of the shuttle ride, you know, everybody was looking at him because he was hugging me, you know, it's not the usual thing for, you know, men to hug right after a shuttle ride. But--you know, but yeah. But, I think I helped him come to some level of self-forgiveness, and we can do that. And, you know, letting go of resentments. So many people hold resentment for years. Landmark education they also have another one. Resentment is like taking poison and hoping the other person dies, you know. Well, that is resentment, you know. I mean, let go of it, you know, and we can help people with that, touch, there are whole therapies based on touch, offering hope--you know, hopelessness is the most noxious of mental states and it has negative physiological consequences, right? I mean we know that hopelessness is associated with decreased immune function. We know that. So, to the extent that physicians and other health care professionals can engender and encourage hope, you know, that promotes a positive physiologic state and also positive behaviors. So, behavioral strategies, you know, make sure patients have an active role in their own care. We know that activated patients do better lots of studies on that. Sheldon Greenberg and others, you know, have done lots of research on activating patients. And patients who are more active in their care do better. They have better adherence rates but they also have better health outcomes. And, we can do that. I mean, I care for a lot patients who have depressive disorders and, you know, I'm constantly having this conversation like "Are you going to church this Sunday? No, I'm not going to church. I don't like those women anymore all they do is gossip. They are your friends. You used to do church suppers. What happened to that? I'm just I'm not into it anymore. I prefer just sitting home. Sitting home on a Sunday morning. No, it's not good for you, you know, its part of the therapy for your depressive illness is for you to get back engaged in the community of people who care about you. So, I want you to promise me that you're going to church this Sunday. Do it for me. Okay, Dr. Novack. I'm going to ask you about it next week. Okay, okay, I'll go. And then I ask about it, you know, you get them motivated and activated, doing stuff, getting out to a community center, just don't sit in your home watching television if you're depressed you know, go out and get cognitive behavioral therapy and so on and they'll tell you other behaviors to do. So, yeah, I don't have time to really talk about motivational interviewing but of course it's very big these days and it encourages adaptive behaviors. And, it's a good way of encouraging behavioral change. And--you know, and praising desired behaviors that's what we do. You know, I talked about transference, the fact is that people do see us often as parental figures. And, if we go "Hey, that's just so great. You quit smoking for three weeks, okay, you went back to it. Next time you'll be six weeks and the time after maybe you'll quit for good. You know, that's great." You know, you turn things into positive reinforcement opportunities. You know don't get disappointed, you quit--you went back to smoking. What a failure. You know, you can't do that. Suggesting alternative behaviors, people have limited behavioral options in their own minds and I mentioned this a little earlier we can cleverly think of alternative behaviors that are more adaptive for them. And sometimes they listen to us, not always but sometimes. Attending to adhere--just by attending to adherence and making sure, you know, that you're over--you know, you can help them overcome barriers to adherence and so on. That can really be helpful. So, social strategies, I don't have to tell you much about this, I think you know there's plenty of community agencies, social support, family, reinvolve family and so on, these can all be helpful. So, I want to talk just for a little bit about the concept of empathy, research and empathy, teaching empathy, and I probably won't have time to do all of this. But, just to say that there's, you know, there's--empathy is one of the most important strategies in therapeutic relationships. And there's some discussion in the literature, disagreement about what empathy truly is and I don't think we have to be too bothered with it. And I won't say too much about it except to say that it's also a neurobiologic process, and if you go--if you type empathy into a search field in your library database, maybe half of the papers that come up are now neurobiologic, neuroimaging studies, conductance, skin conductance studies. Very interesting.
And people are looking at, you know, empathy concordance with physician and patient, in their skin conductance and so on. And, the work is extremely interesting, the kinds of papers that come out, I'll just say one fascinating finding has to do with mirror neurons. Do you know about mirror neurons? People know about that? Some are shaking their head, yes. So, some don't know. So, mirror neurons, we all have mirror neurons in our brains. So, like see I'm raising my hand. So, right now in the motor cortexes of all of your brains, some mirror neurons that would--are in the section that controls raising your right hand, they're being activated right now. Well, now I've lowered my hand, but a moment ago they were. And it's thought that, you know, evolutionary biology tells us that they were put there to help with imitative behavior because that's how we learn, we imitate. But it turns out that people who are very empathic have a lot of mirror neurons especially in certain areas, anterior cingulate and so on. And, you know, some clever researchers did a study that looked at mirror neuron activation, people with high levels of empathy as measured on a paper and pencil test and low levels of empathy when these people--when these students looked at faces that showed negative emotions. Right? So, if you're looking at someone who seems sad, and you have high levels of empathy according to the IRI, a certain test, a paper and pencil test of empathy, you light up like a Christmas tree. And if you have low levels of empathy, you barely light up at all which made me feel better about some of the students I've been trying to teach empathy too. You know, it's like, oh okay, they're hardwired, it's not my fault. But, yeah, so there's a lot about the neurobiology of empathy and it's very interesting. And people are trying to now teach neurobiology and teach skin conductance and show how Helen Riess, we talked about her last night. You know, I did a study of a--and she's had a couple of studies published recently, you know, of teaching people to recognize patient's expressions of empathy and what the physiologic processes are with patient and physician so that they can become more sensitive. And these students who learn it that way become much more empathic. So, you know, a common explanation of empathy is the ability to understand what a patient must be going through, an objective understanding of that and communicate that understanding. People have called it a component of moral decision making and professionalism and there's a distinction between empathy and sympathy. And that distinction has relevance in care, I can say a little bit about that. But, there's another aspect of empathy that my colleagues and I have discovered. And that is making sure and it's what Helen Riess is talking about, you know, it's making sure that the patient got it. So, we did this very interesting study, Swaley Grossman [phonetic] had the idea to do it and did it in our learning center. And, we developed--you know, we gave--I can't--maybe close to 200 residents an empathy scale, Jefferson Scale of Physician Empathy. And then we asked them after they did a ten station, [inaudible], you know with standardized patients and five of their stations had a number of issues that you could be empathic about. So we looked at those five stations and we asked the residents to say "Well, how empathic was your communication during that?" And then we asked the patients, the standardized patients to say, well how empathic was the physician? So, what do you think the association was between resident's evaluation of their own empathy and the standardized patient's evaluation of the resident's empathy? Well, I'll just tell you. There was no relationship. It's a slightly negative relationship actually. So, the residents were not very good at assessing their own empathy. They thought, "Well, I'm feeling a lot of empathy." A patient must be getting this. Well, they weren't. You know, so part of empathic communication is making sure that the patient got it and there's plenty of ways to do that. So, I just, you know, people tend to fall out on being empathic or sympathetic. And, the deal with sympathy is, you know, you feel the same thing with the patient, sympatico, you know. So, it leads to over involvement, Nightingale did a couple of studies that were really classic showing that residents who are more sympathetic, you know, according to their answers on, you know, scenarios. Actually in practice, you know, did CPR longer, they ordered more tests, and so on. You know, they had less comfort with uncertainty, you know. They wanted to make sure they were so concerned about the patient's welfare. You know, so, they lost a certain objectivity that empathy affords. You don't have to feel the same thing that the patient is feeling, you can understand where they're coming from, but you don't have to get lost in the emotions of it which you can on sympathy. So, there's a lot of research on empathy in communication. Philadelphia is a hot bed of empathy research for some reason, it's the city of brotherly love, so, I guess that that translates into research. And there's a lot of studies that look at--so Bellini [phonetic] did a study on empathy in residents with, you know, whether--where they're burnt out and unhappy, how much empathy did they offer, well, not much. You know, they make--and--yeah, so Hojat is actually--who is sort of the dean of empathy research has now done an outcome study that shows--that physicians who score high on his scale, you know, actually had better health outcomes with cholesterol and diabetes than patients with low empathy scores. You know, so empathy translates into more effective care. You know, a study done by Zeke Emanuel, showed that 20 percent of oncologists attending a national meeting rated themselves as not being so good in their empathic and communication confidence in general--in transitions. So, transitions of care from, “Oh gee, you have metastatic disease. Now, this is what we have to do or I think we have to talk about palliative care now” and so on. So, there's 20 percent of physicians, who wound up using chemotherapy longer, fewer pain meds, referred less to hospice care, found this the least satisfying part of their work and less likely to have had training in this which is why oncologist--oncology fellowships really need training in communication and empathy and so on, at the--you know, especially at transition times because this is when you can be most helpful to patients. Just want to say, you know, time and empathy, it doesn't take very much time to be empathic. You know, a kind word, "I see how much you're suffering here." It's the opposite of humiliation in a way, you know, if you say one thing in a 40 minute interview that happened to inadvertently humiliate the patient, the entire interview was humiliating. They will never come back to you again. If you say one thing that's empathic and concerning and shows you understand where people are coming from, the entire interview is empathic. You know, I have so many examples of that and even some of you who have been to physicians know what that experience is when you have a physician who is empathic and says a few words about what you've just gone through and understands. It's kind of amazing. So, you know, a study done by Maguire who really was a pioneer in communication research in oncology, you know, he looked at how many patients actually communicated their concerns and on an oncology ward less than half of patient concerns were actually elicited. And if the patients don't get their concerns met, they're unsatisfied, they're unhappy, they don't necessarily trust the physician, so--and so, just eliciting the concerns, even though you don't have any solution for it. Just eliciting the concerns increases satisfaction, adherence and reduced emotional distress in his sample. So, can empathy be taught? I'll just say there's a lot of studies, and Satterfield reviewed the studies that show--yes, you can teach empathy.
You know, you can teach people skills, you can help people grow so that they understand their own personal barriers to empathy, they can change their attitudes, they can learn to say the words, and then they say the words and their patients respond. Then they go, "Oh well maybe, maybe this is okay. Maybe I should keep doing this." And, Roter did an RCT, Randomized Controlled Trial, where she trained one group in certain empathic communication techniques, and found that those people trained, both with simulated patients, but with real patients showed decreased emotional distress that patients of--the actual patients of--these were family docs who were trained for two, three hour workshops. Six months later, their patients had decreased emotional distress when compared to a control group. So, yes, you can teach empathy and yes it has an effect. So, I'm going to stop in a moment. So, there are many components of empathy, active listening, silence--most trainees don't do silence very well. They don't, you know--so the 18 seconds is--was a classic study that's, you know, when do residents interrupt a patient when they first come in and tell what's going on, well, the mean was 18 seconds. And, that study was done like 30 years ago, it was repeated about ten years ago and a significant increase had, you know, been--because of all these training was now 23 seconds. But, you know, we make our students--if a patient stops talking, we make our students stay quiet for at least three seconds. And then there are skills, you know, support, you can make statements of support, legitimation, "Oh I can--you know, anybody would feel that way. Oh, I can clearly see how you feel that way." Respectful comment, "Oh, you're great at managing your diabetes." A reflective comment, "You seem sad. You're okay?" A statement of partnership, "We'll work together on this." It has the unfortunate acronym that my students realized was SLRRP. I overheard my students say one day, "Oh, my landlord was really pissed at me last night but I slurped them and it was fine." [laughter] You know, and--because somebody was walking by going, "What the hell?" You know, but just interest in the patient's life, who they are, what their perspectives and feelings are, the Bonnie and Clyde. There was a great moment in Bonnie and Clyde, where Bonnie--do you remember that movie, you might have seen that movie, there's a great moment they're having a picnic. And--but, one of Bonnie's poems gets published in the paper and she says, "Oh, Clyde, listen to this, they published my poem about you, The Story of Clyde." And, you know, at the end of reading that he goes, "Bonnie, you've told my story." And, they make love, you know. And he was sort of sexually ambiguous and so on. So, they make love and it's this great moment. He realizes that another human being completely understands him, and, he's free now. You know, if a patient really gets that you understand them. You know, it's freeing--it's a freeing kind of thing. Corresponding, Clyde got massacred about 30 seconds later. But nevertheless, the moment was a touching one and revealing. So, you know, I think I better--there's lots of more research that--you know, but I think you have the handouts and the references are there because I want to stop for questions. I'll just say--oh I'll show you these, because you can't just do it right? [laughter] You know, the boss is red. You know, the boss is red that saying certain things, doing certain things.
[ Laughter ]
Yeah. You know, but he doesn't quite get it, you know, and he hasn't changed his attitudes about things. He's just doing, you know--Willie Nelson--somebody asked Willie Nelson, "How do you--your songs are so moving. How do you do that?" He says, "Well the trick is to mean it," you know. And, I think that's true. You have to look within yourself, and don't just say the words but mean it. So, I think, let me just stop there and take some comments or questions.
[ Applause ]
» So, Dr. Novack, thank you for that wonderful presentation. I have a lot of questions and I'd like to tell you what I learned today but I'm just going to ask you one question.
» For the sake of time. You mentioned about the powerful, the therapeutic effect of hope.
» And I wonder, if in your experience, if a patient asks the question, "Doctor is there any hope?" Is that something that we answer with an answer or do we answer with a question? And is that something we help them create or do we let them create their own hope?
» Yeah. Well, obviously, it's complicated. You know, when I was young, doctors, I saw--you know, I saw doctors lie to patients about their cancers, you know. In the 50s and early 60s, 90 percent of physicians were lying to doctors about--physicians were lying to their patients about the diagnosis of cancer, you know. Well, it changed quite a bit. But now, you know, maybe many physicians are being unrealistically optimistic about their prognosis. And, you know, there are ways of talking about prognosis that helps people do what they need to do at the end of their lives while still hoping, you know. And, I think you're right, you can ask questions too like, "What are you hoping for?" One of my close colleagues died of metastatic ovarian cancer, but she was hoping that she would make it through her daughter's graduation from college. And she lived way longer than anybody thought she was going to. Until her daughter graduated from college. And so that was, you know, an organi--that she put all her energy and behaviors and everything else into that hope even though she knew she was going to die. So, people can know they're going to die, but hope for something aside from being cured. And, we can support those hopes. Yeah?
» What else?
» Other comments?
» Anything else on your little minds?
» Lack of empathy. Okay. Well, thank you very much for coming.
» Thank you.
[ Applause ]
Therapeutic Aspects of Clinician - Patient Relationships (57:54)
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