In The Arena: I Hear Ya, Brother

May 2010

By David F. Baehren, M.D.

You can't teach morality. At least, so I've heard. It's definitely hard to legislate.

What about empathy? Is this ability to understand the predicament and station in life of others without needing to experience it yourself a God-given talent, or can you learn it? If you can learn it, do you have to grow up learning it, or can you take a course like you can for speed reading?

To be empathetic, must you be like Bill Clinton, who is a master at feeling people's pain? Or can it be more of an "I hear ya, brother" or a "That's what I'm talkin' about" kind of a thing?

I've been pondering this because we have an orientation month in our residency. One of the scheduled activities in this jam-packed month is a patient encounter. The twist is that the resident meets the patient in triage and then accompanies him or her through the entire ED visit. I had the idea of giving the residents ipecac and ex-lax in their sandwiches at lunch and then waiting to see who shows up first for treatment. We thought better of it.

We don't make them stay the night if we happen to be boarding patients, but they are expected to stay with the patient until a disposition is made. They may not participate in the care, and they may not come out and socialize. They are stuck in the room with the patient and family. They get to experience the waiting, the poor communication, the uncertainty, and the frustration of being a patient.

After the experience, they write a 500-word essay about the experience. Can you guess who came up with that great idea? So far, the residents think that the experience is worthwhile.

Now, nobody at our place is thinking that a few hours stuck in a room with Toledo's version of the Osbournes is going to flip the switch for an unsympathetic soul. We do feel that this time with the patient and her family will prepare the soil for seeds of empathic behavior to be planted.

If you want to find empathy deep enough to swim in, spend some time with first- and second-year medical students. They would give a stinky homeless guy a ride to the shelter in their brand new Chevy. It's refreshing but at the same time sad, because I know that for many of them this will be lost by the end of the first clinical year.

So what causes this unwelcome transformation?

Is it the patients? I think not. The vast majority of patients are pleasant and honest. The few dishonest or manipulative ones often are not even recognized by these students for their unappealing traits. The first time these students are told that a patient has lied about an opiate prescription, they get that "What do you mean there's no Easter Bunny?" look.

Unfortunately, the bad influence comes from some of the residents and attendings who poison the well for these learners. By the time many students reach residency, bad habits of thinking the worst of people and saying demeaning things about them are commonplace. At many institutions, this is part of the resident culture. Cultures are hard to change.

I think the best we can do as individuals is to set the tone for empathetic encounters when we work. Our example of treating a cantankerous patient with respect or taking extra time with someone who is slow to understand sends a strong signal to others. When residents observe this over weeks and months, they will take on these behaviors as their own.

Unfortunately, we all have lapses and occasionally regress in haste to references such as "dirt bag." Chalk it up to blowing off steam, but call yourself on it and make sure the learner knows where your heart is.

Many of us find humor in our interactions with patients. Some of this can be shared with patients, and some of it is best kept quiet. The key is to make sure that learners interpret the humor in its proper context and that patients are unaware.

Not long ago, there was a patient parked in the hallway about 5 feet from me. Her decaying sneakers rested on the floor beneath her cart. The odor was so bad my eyes were watering. Paint would have peeled if I had not intervened.

I quietly asked the nurse to "hermetically seal" the shoes before I was overcome. He did so and assured the patient that he wanted to keep her belongings in order while she was in the hall. After she was given good discharge instructions and assisted from the department, we had a good laugh about it--but she never knew. The humor was more rooted in my reaction to the smell than to the shoes themselves; nevertheless, it was best to keep the patient out of it.

Empathy works in two directions. It helps the healer as much as it does the patient. Empathic behavior brings us closer to our patients and closer to the untainted enthusiasm we had during the first years of medical school. It reminds us of who we are--and who we are not.

On the empathy front, our job is not easy. We are in the empathy spelling bee. It's one tough one after another. Yes, I know you won't get every one right.

I hear ya, brother (and sister).

DR. BAEHREN lives in Ottawa Hills, Ohio. He practices emergency medicine and is an assistant professor at the University of Toledo (Ohio) Medical Center. Your feedback is welcome.
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