Also Human Page 7

  What this resident is describing here is a catastrophic erosion of empathy; in the end she changed specialty because she didn’t want to respond to her patients in this way. If this resident was a lone example it would be a personal problem for that doctor, and for her patients. But the situation is much more worrying than that. A recent systematic review concluded that nine out of eleven studies of medical students, and six out of seven studies of medical residents reported a consistent decline in empathy as training progressed11. Some of the reasons given for this finding include sleep deprivation, excessive workload, mistreatment by superiors and lack of positive role models. In other words, the environment in which doctors work has a significant impact on their capacity to respond empathically to patients. Unfortunately, Ellen’s response to Vartika, or Suzy’s unsympathetic treatment of some of the in-patients on the ward are far from unique.

  Yet as we’ll come to see in later chapters, it’s also possible to have too much empathy – to feel the patient’s pain too acutely. The doctor needs the capacity to imagine the physical or psychological pain that the patient is experiencing, but mustn’t be overwhelmed by the patient’s suffering. So how can this be achieved?

  Over a hundred years ago, the Canadian physician William Osler, in his essay Aequanimitas12, wrote that the doctor should aspire to a form of emotional detachment such that ‘his blood vessels don’t constrict and his heart remains steady when he sees terrible sights’. That was the gold standard at the turn of the century. More recently in the 1960s, sociologist Renée Fox and psychiatrist Harold Leif argued that students should view the cadaver in the dissecting lab as their ‘first patient’ and the detachment with which they approach the task of human dissection should form a model for future interactions with live patients13. According to these authors, the ideal was to develop an attitude of ‘detached concern’. And as recently as 1999, a statement produced by the Society for General Internal Medicine concluded that ‘empathy is the act of correctly acknowledging the emotional state of another without experiencing that state oneself’.14

  But does detachment from all human emotion really enhance the doctor’s effectiveness? Psychiatrist Jodi Halpern has researched this issue for a number of years and concluded that the rationale for ‘detached concern’ is no longer tenable15: emotionally attuned physicians have a better understanding of their patients, and their patients are more likely to disclose sensitive information and stick to the prescribed treatment plan.

  Even the notion that emotional connection with one’s patients inevitably leads to doctors becoming emotionally overwhelmed isn’t supported by the evidence. For example, a recent study of over 7,000 physicians found that those with greater empathic concern for their patients were more satisfied with their work than those who struggled to regulate their feelings and responded by becoming emotionally disengaged from their patients16; the latter were more likely to experience burnout. Thus it seems that it’s not having feelings that causes problems for doctors but not being able to regulate these feelings. (Unsurprisingly, the authors of this study also pointed out that working shifts of 36–48 hours without a break dramatically reduced doctors’ capacity for emotional regulation.)

  Another writer – the late Michael Crichton – gave a vivid account of this process of emotional regulation17. Crichton, author of Jurassic Park and creator of the television series ER, originally trained as a doctor. In ‘Medical Days’ he described his experience of human dissection at Harvard Medical School in the 1960s:

  Somewhere inside me there was a kind of click, a shutting-off, a refusal to acknowledge in ordinary human terms what I was doing. After that click, I was all right. I cut well. Mine was the best section in the class …

  I later learned that this shutting-off click was essential to becoming a doctor. You could not function if you were overwhelmed by what was happening … I had to find a way to guard against what I felt.

  And still later I learned that the best doctors found a middle position where they were neither overwhelmed by their feelings nor estranged from them. That was the most difficult position of all, and the precise balance – neither too detached nor too caring – was something few learned.

  *

  In the summer of 1995, thirty or so years after Michael Crichton left Harvard Medical School, a forty-year-old man with terminal lung cancer, Kenneth Schwartz, was admitted as a patient to the hospital attached to the medical school – Massachusetts General Hospital (MGH)18. Schwartz was a lawyer who specialised in healthcare law, and shortly before his death he wrote about his experience of being a patient for the Boston Globe Magazine:

  I realize that a high-volume, high-pressure setting tends to stifle a caregiver’s inherent compassion and humanity. But the briefest pause in the frenetic pace can bring out the best in a caregiver and do much for a terrified patient. It has been a harrowing experience for me and for my family. And yet, the ordeal has been punctuated by moments of exquisite compassion. I have been the recipient of an extraordinary array of human and humane responses to my plight. These acts of kindness – the simple human touch from my caregivers – have made the unbearable bearable.

  Aware of the cost-cutting pressures on healthcare delivery from his legal work, he knew how difficult it could be for staff to remain empathic:

  In such a cost-conscious world, can any hospital continue to nurture those precious moments of engagement between patient and caregiver that provide hope to the patient and vital support to the healing process?

  After his death, his family created a non-profit organisation dedicated to strengthening the patient–caregiver relationship. And one of the most successful initiatives devised by the organisation was the so-called ‘Schwartz Center Rounds’19. This started as a pilot programme at MGH in 1997, but twenty years later has been adopted by over four hundred hospitals across North America, the UK, Ireland and New Zealand20.

  So what is a Schwartz Center Round?

  Basically it’s an hour-long opportunity for staff from across the hospital – both clinical and non-clinical – to get together to discuss the difficult emotional and ethical issues that arise in their day-to-day work. Or put differently, Schwartz Rounds provide an opportunity for staff to discuss the human dimensions of care. Topics include working with a difficult patient or family; medical mistakes; breakdowns in communication; bigotry surrounding obesity; complementary and alternative therapy; spirituality. In effect – all and any of the real difficulties that hospital staff face at work.

  A number of things mark Schwartz Rounds as different from other hospital-based educational initiatives: they are multidisciplinary, spanning both clinical and non-clinical staff; the thoughts, feelings and dilemmas of participants are brought to the fore rather than concentrating on narrowly clinical aspects of care; and the meetings are led by an experienced facilitator who teases out emerging themes and also ensures that everybody who wants to gets the opportunity to speak.

  So do Schwartz Rounds work? Do they actually have an impact on the patient–clinician relationship, or on staff well-being?

  Admittedly much of the evidence on the impact of Schwartz Rounds is somewhat anecdotal; as a recent study in the BMJ argued, ‘we do not know what proportion of staff – or which staff – may need to attend Rounds (and over what period) in order to maximise the impact of this organisational innovation’21.

  Fair enough. But the ‘anecdotal’ evidence is certainly encouraging, with staff in a 2017 study making the following sort of comments22:

  ‘Very human emotional issues get discussed that perhaps we don’t voice that often … but what has been interesting is that being voiced in a wider public forum and everybody being able to relate to it.’

  ‘Actually seeing senior people being quite open about the impact of people whom they have worked with in the past is actually incredibly valuable.’

  ‘I think it is very healthy to be exposed to other networks, other disciplines, other people and go, oh they have the same kind
of stresses as we do …’

  Nobody has yet published a study showing a downside to Schwartz Rounds. (I suppose one downside might be if they became a ‘one size fits all’ simple solution. An hour a month isn’t going to solve the problem of burnout, or lack of empathy across a whole institution.) And the 2017 study also emphasised that successful implementation of the initiative requires ‘strong leadership’ from the top.

  *

  Schwartz Rounds aren’t the only way that staff can be supported in the emotional demands of their work. The best clinicians have done this quite instinctively in their one-to-one and group teaching sessions. Clinicians like Bernard Heller.

  The first time I met Bernard, it was to observe him teaching a lunchtime session for junior doctors in a hospital outside London. Lunchtime teaching sessions can be challenging; the speaker may not know who they are supposed to be teaching and it is perfectly possible that they have never previously met any of the medical students or junior doctors in the room. To make matters worse, they may also have little sense of what they should be teaching. Sometimes there is no curriculum that could be used as a reference point whilst at other times attendees could be at such divergent stages of training, it would be impossible to meet the educational needs of everybody present.

  Then there’s the issue of interruptions. Lunchtime teaching is supposed to be ‘protected’ time, with juniors handing over their bleeps for the duration of the session. But the protection often doesn’t amount to much. Both as a teacher and as an observer, I’ve been in sessions where there have been over twenty bleep interruptions during the course of an hour. It’s hard to keep focused on one’s teaching when one is interrupted every other minute.

  Juniors also finish their morning ward rounds at different times. Whilst some may be there at the start of the session, others wander in, often apologising profusely, throughout the hour. And there’s the question of lunch. Sometimes it is provided, and I have been amazed by how appreciative junior doctors are when this happens. Often they bring in lunch from elsewhere. But whatever the source, the teaching session may be the only time during a long day that the juniors get to sit down and eat. The sound of rattling crisp packets and unwrapping sandwich packs is a frequent accompaniment to the voice of the presenter.

  Bernard started off by introducing himself and explained that he was based at the local hospice. He then introduced me and mentioned that I was observing him and not them, and they didn’t have to worry about my presence. Over the years I have been surprised how often consultants forgot to tell students or trainees that I wasn’t there to judge them; taking the time to do so was often a sign that the consultant had the reflective ability to think about what was happening in the room from the learner’s point of view.

  Bernard put up the first slide, which showed his name and the title of the talk: ‘Managing Breathlessness in End of Life Care’. He was just about to move on to the second slide when one of the juniors interrupted:

  ‘Dr Heller, can I ask you a question, please?’

  ‘Of course, go ahead,’ Bernard answered.

  ‘Well it’s not specifically about breathlessness, but it is about end of life. Is that OK?’

  Bernard responded with a nod.

  ‘Last weekend we had this patient on Blue Ward who was dying of bowel cancer. What was really upsetting was that they were in terrible pain, and they kept on screaming and asking for help. Nobody I asked seemed to know what to do. I called the registrar, but she didn’t get up to the ward before the patient died. Afterwards I asked the nurses if this often happened, and they said that it definitely wasn’t a one-off.’

  Bernard made sure that the junior had finished before he spoke.

  ‘That must have been difficult for you to see. I’m glad that you brought this to my attention.

  ‘Which team was this patient admitted under?’ he asked.

  The junior told him, and Bernard noted it down without comment.

  ‘What about other wards in the hospital? Have others of you had to witness patients dying with poorly controlled pain?’

  There were perhaps twenty junior doctors in the room. At least a third indicated with their hands that they too had witnessed distressing deaths.

  ‘I want to make sure that everybody here has the opportunity, if they want, to tell me about their experience. Although these patients may be admitted through A & E, end-of-life pain relief is the responsibility of the palliative care team. I need to get a sense of what has been happening.’

  Different doctors round the room told their stories. Some spoke about end-of-life care in this hospital. Others talked about previous hospitals they had worked in, where the end-of-life care was better (or, in some cases, even worse). As each junior described what they had seen, Bernard took detailed notes. On occasion he asked the junior to repeat what they had just said, in order to make sure that he had noted it down accurately.

  ‘Anybody else like to add to the discussion?’ Bernard asked.

  Round the table, the juniors shook their heads.

  ‘Thanks for listening,’ one of the doctors said. ‘It was good to get it off my chest.’

  ‘This isn’t only about getting things off your chest,’ Bernard responded. ‘There are clearly improvements that need to be made. I’m going to talk to the Foundation Programme Director, to the person who organises the medical registrars’ teaching sessions, and to the Director of Nursing. I also want to go and organise some teaching for the medical on-call team. It might take some time, but I’m going to set these things up as a priority. We’d better get back to breathlessness now, as that is what we were supposed to be looking at this lunchtime.’

  ‘Dr Heller, lots of us are going to have to leave at two on the dot. Is it worth starting your talk?’

  It was now quarter to two. The look on Bernard’s face indicated that he had been so absorbed by listening to the juniors, taking accurate notes and making sure that everybody who wanted to had been given a turn, that he had completely lost track of the time. He paused.

  ‘Probably best not to start on a whole new topic at this point. Let’s just call it a day.’

  The juniors thanked him for listening to them and, still talking, in twos and threes left the teaching room.

  When everybody had gone, Bernard turned to me.

  ‘You’re probably going to fail me now, aren’t you? I didn’t deliver any of the talk.’

  ‘No you didn’t,’ I said. ‘But it would have been an educational failure if you had stuck to Plan A, and ploughed on with your talk. What I’ve just observed was a masterly example of clinical teaching. You had the flexibility to realise that something you weren’t intending to discuss with the group (pain control) took priority over what you had initially planned. You picked up on the level of distress in the room and you made sure that everybody in the group could share their experience, if they wanted to. You took their concerns seriously, rather than brushing them on one side. And you gave them a clear account of what steps you were going to take next.’

  Bernard looked relieved.

  Our post-session feedback was wide-ranging. We talked about the transition from medical school to foundation, how to help juniors manage their feelings about the death of patients, the stresses of being a medical registrar and the relative lack of exposure to palliative care in the undergraduate curriculum.

  ‘What would you like me to come and see next?’ I asked.

  ‘I teach undergraduate medical students,’ Bernard said. ‘Why don’t you come and see an undergraduate teaching session in the hospice?’

  *

  A couple of weeks later I arrived at the hospice. As I walked through the door I was struck once again by the differences between hospitals and hospices; the soft colours on the walls, the artwork, the tea trolley doing its rounds for patients and their visitors – and above all, the absence of the frenetic rush that pervades so much of hospital practice. Why do we have to wait for the patients to be at the end of their l
ives before we provide this kinder environment?

  But despite the fact that I had been so impressed by Bernard’s previous session, I wasn’t looking forward to the hospice observation. After Bernard had asked me to come and see him teach undergraduates, he had gone on to explain that in these sessions he used a ‘goldfish bowl’ technique with the twenty or so medical students forming a large circle around the edges of the room. He would sit in the middle of the circle with a day patient from the hospice. The students would then observe him as he had a conversation with the patient about their illness.

  Familiar with the goldfish bowl technique from my training as a psychologist, I knew that it could provide the observers in the outer circle with a unique opportunity to see a conversation in the inner circle unfold in front of them. Yet at first the idea of putting terminally ill patients at the centre of the circle, with large numbers of medical students sitting around them and peering in, seemed grotesque. I felt there was something of the freak show about it, with the dying patient as the central exhibit.

  With another consultant, I might have questioned this approach and encouraged them to consider a different way of teaching the medical students. But I had seen Bernard demonstrate an exceptional level of sensitivity to the junior doctors’ needs. On the basis of the lunchtime session, I was willing to give him the benefit of the doubt.