Step 1 Complete, Step 2 on the Horizon

Making a weak joke/pun here — Step 1, as mentioned in my last post, is the long and vexing exam all medical students must take covering 1.5 – 2 years worth of preclinical material. Step 2 is specific to the clinical years and tests diagnosis and treatment determining skills. I only had 4 days to recover from the skull numbing experience that was Step 1 before leaping into Clinical Skills Week, during which I realized how few clinical skills I indeed possess. However, I remain excited about the prospect of beginning this, my third year of medical school, since it means a) seeing more patients, b) developing some actual, might-help-people-in-the-real-world skills, and c) possibly figuring out exactly what kind of doctor I want to be!

My first rotation is OB-GYN. I haven’t spent all that much time near pregnant women or babies so far in medical school, so I’m looking forward to hearing new kinds of stories and building new kinds of relationships. I also hope to delve a bit into gynecologic oncology, or, cancers specific to the gynecologic tract, given my interest in cancer and cancer patients and the kinds relationships they build with their doctors.

There’s room for empathy, of course, in every field of medicine, but I believe the intimacies of each field are different, and those in a way, steer the narrative conversation. That is to say, the most personal details are the ones that decide the manner in which empathy can be displayed. For instance, I hope to be the kind of doctor who remembers to put patient comfort first, perhaps by warming the lips of the speculum, or draping appropriately. Small gestures can have huge impacts!

Til next time,
PC

 

Defining Empathy

One question I asked each and every participant in the radio documentary was “how do you define empathy?” or “what does empathy mean to you?”

Most people said, “being able to put myself in another’s shoes.” This is pretty close to how I define empathy myself, however I think this video (link below) nicely portrays some of the nuances of empathy vs. sympathy and also the kind of language that makes the speaker feel listened to vs. just heard.

I’m studying now for part 1 of a series of licensing exams, the infamous ‘Step 1′ which is pretty much every medical student’s nightmare. Remembering that at the end of this experience will be third year and caring for real-life patients is what’s getting me through. Well that and awesome videos like this one :)

 

Physicians Need Empathy Too!

“It’s hard for anyone outside the profession to understand just how rotten the job has become—and what bad news that is for America’s health care system. Perhaps that’s why author Malcolm Gladwell recently implied that to fix the healthcare crisis, the public needs to understand what it’s like to be a physician. Imagine, for things to get better for patients, they need to empathize with physicians—that’s a tall order in our noxious and decidedly un-empathetic times.”

Iterations of this very popular article have been around for some time around, but an important idea is emphasized here that I think does need to “go viral” — the importance of having empathy for doctors. 9 out of 10 doctors state they would discourage others from pursuing their field. This is important. If we truly desire better health outcomes, we need to start appreciating the difficult task physicians (and physicians-to-be) take on, and consider the sacrifices they are asked to make. It’s not surprising that many future physicians are disenchanted by the primary care field. What the article doesn’t address is how we can change the prevailing attitudes against doctors. They’re not to blame, and shouldn’t bear the brunt of public scorn for rising costs.

Don’t Sit There.

A few years ago, I submitted a short story to a fiction-writing workshop entitled, “The Angels of Watermark.” I have to admit, I was kind of proud of it. It was large and ambitious, dipping in and out of timelines, generous with its lyrical language — all in all a workshop leader’s worst nightmare. “Interesting read,” he wrote in his comments, “but could use more clarity.”

I quickly learned that was one of my professor’s favorite words — a story was useless, he declared, unless it had perfect clarity. Unless it had a beginning, middle and end that made sense. That didn’t confuse.

“You need to give your readers something to hold on to. You can’t trust that they’ll understand, that they’ll go where you want them to go.” He suggested I spend my time on a different work instead of experimenting with something new.

Now, I fundamentally disagree with this philosophy. But to get to how this story relates to the ‘theme’ of this blog, we need to rewind about a week or so. I was again at the hospital when I was assigned an interesting case. As with my last patient, I encountered a slight language barrier with this patient, whom we’ll call SG.

Almost immediately, I could sense this patient was scared. His voice shook as he spoke, as did his hands; I felt like his whole torso would also probably shake if it weren’t so well supported by the bed. It was difficult to make out the first part of his story, in which he was either describing a knife fight or a train accident. I didn’t interrupt him once while he was telling the story. The look of relief on his face as he told it was incredible. It was as though he’d just been waiting for someone to walk through the door so he could tell it, and afterwards he took a couple of deep breaths and lay silent.

The story was fairly implausible. I asked him to repeat it a couple of times, to see if any details changed in his telling, and indeed they did. In every version of the story, however, he was surrounded by folks drinking on the train. He would then gesticulate furiously, trying to paint a picture of the train demolishing a building as it was thrown off its tracks, and then in a different telling, assert that the people around him on the train were out to get him. I sensed the theme of drinking might be a good subject to tackle, and took a seat at the foot of his bed so that, even if we could not understand each other perfectly, at least I could maintain eye contact. A supervising physician sat in a chair a few feet away, interjecting a helpful question here and there to keep the interview going. SG explained that he’d quit drinking years ago, but the shaking of his hands and tongue, the sharp nystagmus we found in both eyes and the pin-pricking sensation he felt all over his body relayed the truth, that in fact he was probably in the midst of alcohol withdrawal.

“I feel safe here,” SG said several times, which served to ramify just how unsafe he felt out there. There was very little I could do for this patient, of course; there’s little I can do for any patient at this stage. But I thought listening to the story, no matter how wild it might be, providing the comfort of the routine physical exam, and being present in the moment by sitting there, at the foot of his bed, might be small and helpful things.

To my surprise, when we exited the room after the interview, the first thing the supervising physician said to me was, “Don’t sit there. On the patient’s bed. If you get permission, it’s all right, but still not preferred. They don’t want you there, and you might be giving them ideas.”

I was taken aback by this statement. After some thinking, I realized he was correct that I probably should have asked the patient for permission. But SG seemed pleased that I was there, and smiled every time I attempted to re-phrase a question in my rusty Spanish. As for “giving [the patient] ideas” — I was immediately reminded of the professor who told me I shouldn’t write complicated stories because my readers might not be able to follow along.

My philosophy is this: I trust my readers, and I believe we should trust our patients, too.

I submitted the complicated, possibly overwrought story to the workshop over my professor’s protestations, and I was rewarded with numerous peer critiques that desired more of the story; more background and details to flesh out the things they didn’t understand, instead of suggestions to cut back or guillotine the story altogether for the sake of clarity.

Next time I see a patient, I might sit in a chair close to them instead of on their bed, but I know I’ll never be comfortable towering over them while asking about the intimate inner-workings of their lives. I trust they’ll know I mean well.

Why Empathy?

In the radio doc, I mention that empathy leads to better communication between physicians and patients, and therefore better outcomes — last week, however, I realized for the first time how that might play in practice.

Bear with me. This story is kind of a long one.

Every Wednesday afternoon, we second year medical students act like mini-doctors for a day, complete with mini-white coats. We get to see one patient, and practice our history-taking and and physical exam skills. My patient was a petite older woman, who had come in with a swollen, red, and painful left hand. The doctor supervising me warned that she was “a poor historian.” Upon introducing myself, I noted quickly that she was hard of hearing, and did not speak much English. I also noted that her hand, while less swollen than first described, was still swollen and that there was a large crusty and blackened cut on the third digit of that same hand.

We quickly got into the nitty gritty of what had happened, and she casually explained the cut was from a knife wound two weeks prior; she had already taken antibiotics for it. Dutifully, I wrote all this down. We established a bond pretty quickly, Anabelle* and I. I was sorry to leave, and grateful for her kind words of wisdom – study hard! good luck! I went on to present the case to her attending physician, and when I got to the bit about the cut, the attending stopped me cold.

“Wait…she told you that? That she got a cut from a knife?”

“Yes…” I looked over my notes again nervously, wondering if I’d missed anything important or screwed up somehow.

“She’s seen so many doctors. So many teams. We all knew she’d gotten cut somehow, she didn’t tell any of us!”

I think the attending meant that as a compliment. Oddly, it made me feel embarrassed. Elated, of course, that I’d done something apparently right, but embarrassed too, because I hadn’t done it intentionally. I hadn’t wrestled anything out of the patient, or pursued a unique line of questioning. There was nothing I could look back at to say “ah yes, it was this-and-this that allowed me to get to the bottom of the mystery!” I didn’t know there was a  mystery to begin with.

I chose to accept the congrats, from that attending and the other two doctors she introduced me to as “the medical student who found out about the cut” – I felt like that title was hyphenated, comparable to “he-who-must-not-be-named.” Except, I didn’t feel all-powerful, nor did I want to feel that way. My “power” came a little from luck. But mostly, I think it just came from listening to a kind woman who was willing to share her story .

I needed to get all that down before I forgot how it happened. And also because it reminded me of this very powerful TEDx talk on narrative humility. One I hope you enjoy as much as I did!

Do you have a story about empathy or a moment in time that made you realize what empathy really means to you? If so, please e-mail prapti.chatterjee@mssm.edu, and it could end up on this very site. Empathy has an impact in so many different fields, and can affect us in profound, life-changing ways.

Expect more on empathy in medicine every week!

Cheers,

PC

P.S. The radio doc is at 100+ listens! Thank you to each and every one of you who listened to the radio doc. I welcome your questions and comments!

*name changed

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Welcome.

‘The Empathy Switch’ is a radio documentary about the difficult transition students make in the third year of medical school as they shift their focus from preclinical, textbook-oriented learning to the more hands-on kind of learning required in their clinical years. This radio documentary features interviews with students and medical education experts at the Icahn School of Medicine at Mount Sinai. It explores whether the less traditional path to medical school, exemplified by Sinai’s HuMed (now FlexMed) program, can reverse the much-talked-about trend of declining empathy and increasing burn-out in America’s medical school graduates. ‘The Empathy Switch’ also highlights the fresh and objective voice of lauded author and physician Dr. Danielle Ofri, author of What Doctors Feel: How Emotions Affect the Practice of Medicine. 

Narrator/producer Prapti Chatterjee is a second year medical student. She can be reached via email at prapti.chatterjee@mssm.edu.