How to preserve empathy in medicine [PODCAST]

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“No matter how extensive or well-developed your capacity for empathy may be, you cannot feel empathy for everyone all the time. Whether we’re talking about doctors who have never been patients, or clinicians who have never faced discrimination, we know that people’s ideas can change, when properly educated and supported.

In a randomized, controlled trial, one of the most exciting findings within my own research into the malleability of empathy looked at physicians of six different medical and surgical specialties. Using the E.M.P.A.T.H.Y.(R) acronym and other techniques, physicians learned how to accurately “read” their patients’ states of emotion and respond more empathically. Post-intervention, the training group received significantly higher patient satisfaction scores than the control group.

The good news about our research is that it showed that we can be hopeful about changing the culture of medicine. We now have evidence-based tools to accomplish this. There is hope for a brighter future in health care and all relationships when empathic principles are learned and practiced at the local, regional, and societal levels.”

Helen Riess is a psychiatrist and author of The Empathy Effect: Seven Neuroscience-Based Keys for Transforming the Way We Live, Love, Work, and Connect Across Differences.

She shares her story and discusses her KevinMD article, “How to preserve empathy in medicine.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Helen Riess. She’s a psychiatrist, and she’s the founder of Empathetics, which is a company providing empathy education to health care professionals and other industries. She’s also the author of the book The Empathy Effect: Seven Neuroscience-Based Keys for Transforming the Way We Live, Love, Work, and Connect Across Differences. We’ll get into your book and article a little bit, but first off, can you share your story and journey to where you are today?

Helen Riess: I grew up in a family that was very traumatized in World War II and came to the United States and really had to start over. Because of growing up in that family, which was very supportive, I couldn’t get away from the fact that when trauma affects people, it affects them deeply. So I always had a desire to work in health care, in a healing profession, and that led me to become a psychiatrist.

By listening to my patients, I realized over the last almost two decades that there’s been a resounding cry for more empathic care, more listening, more curiosity, and more continuity of their care. As I was doing neuroscience of empathy research at Harvard Medical School, I really wanted to answer the question: Can we teach empathy, or is it really something you’re just born with or not? My research led me to the very profound conclusion that it is definitely something that can be taught, and that led me to where I am today with providing empathy education.

Kevin Pho: Why do you think there could be improvement in the amount of empathy that clinicians can demonstrate to patients?

Helen Riess: Well, I’ve witnessed it firsthand. At Mass General, where I’ve been working for many, many years, I was initially called to shadow some people who were having some challenges, and I realized that with implementing a few basic behaviors and tips, people could connect better: when they were more mindful of how they were entering the room, how they were resetting their curiosity and expectations, and how they could be prepared to really meet that patient where they were.

That led to doing a randomized controlled trial of the training that I developed, and so we actually really have proof that we can move patients’ perceptions of their physicians’ empathy significantly higher. So it’s not my opinion anymore. We have the studies to show it.

Kevin Pho: What are some of the ways where physicians can increase patients’ perception of the clinician’s empathy?

Helen Riess: Well, Kevin, our most authentic communication is actually nonverbal. In medical school we’re taught a lot of terminology. We learn a whole new vocabulary, and we learn all these new systems and treatments and recommendations, but we don’t really learn a whole lot about nonverbal communication.

It takes a bit of mindfulness to realize that an encounter is quite different if you look someone eye to eye, so that you’re at eye level. If they’re seated when you’re seated, you create better rapport. Many of us were trained to stand up over patients and talk down to them, and we emulate what we see our mentors doing. That very active, equal eye level already opens up channels of oxytocin release that start as early as infant-mother bonding. But if we’re not looking at patients, and we’re staring at computer screens and so busy typing that we never meet their gaze in a meaningful way, we’ve lost a huge opportunity for genuine connection.

Kevin Pho: All right, let’s transition into your article and book. The article is titled “How to preserve empathy in medicine,” and it’s an excerpt from her book, The Empathy Effect: Seven Neuroscience-Based Keys for Transforming the Way We Live, Love, Work, and Connect Across Differences. Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Helen Riess: Well, we are living through, and I’m sure many of us wish we could say we have been through, a pandemic that hasn’t happened to this degree in a century, and everyone is getting really burned out. We’ve had more patients, sicker patients, patients who can’t see their relatives. I mean, we’ve just been through what some people describe as a war zone. When we get this depleted in taking care of others, we often just neglect ourselves, and the idea of self-empathy is very foreign to most medical professionals. Self-denial is something that comes much more naturally, because just to become a physician there’s a lot of self-denial involved. So the idea of self-empathy can often be confused with selfishness, but it’s actually self-preservation.

You mentioned the seven keys for connecting with others. That’s the tagline of my book. Those keys actually apply just as well to ourselves. The seven keys are spelled out in the book in great detail, but the first one is eye contact. Many of us stand in front of the mirror combing our hair and brushing our teeth in the morning, but what do we see when we actually make eye contact with ourselves? Are we seeing somebody who’s looking forward to the day, who’s well rested, or who’s looking exhausted? What’s coming back? Because many of us never think to check in with ourselves, almost like an outsider looking in, to say, “How are you doing?”

I have this EMPATHY acronym, which is what the book is kind of based on. The M is for muscles of facial expression, and that’s because there’s no F in empathy, so I had to use the M. But what’s our face saying beyond what we’re seeing in our eyes? These are the very skills we need to be paying attention to in ourselves, so that we have the energy to pay attention to these signals when we’re talking to other people. The P is for posture. Are we slumped over, looking like, “How am I going to slog through another day?” Or are we feeling like, “I’m ready to go to work and do what I love to do”? And do we remind ourselves that we once really loved what we do and we still can’t? But if we don’t replenish ourselves, we’re showing up kind of half empty.

So these are the keys that prompted me to write the article about why we need empathy in medicine, because this is what our patients need and want. If we show up half empty or worse, we’re giving that person a bad experience. When people are sick, lonely, and wondering, “Am I going to make it? Am I ever going to recover? Will I be able to get that operation, because everything’s on hold, and I’m really worried that I’m not getting the care I need,” are we showing up in a way that actually calms our patients, gives them reassurance, and reminds them that they are not falling through the cracks? Or are we making mistakes?

I think it’s so important, Kevin, not to put this all on the clinicians, because in order to provide really good care, the institutions need to be taking care of them. Treating health care professionals like cogs in a wheel that don’t need grease and don’t need a checkup now and then is just missing the fact that you can only get so much good care out of good people when you support them. So my biggest message is: Leaders, wake up. You’ve got precious people taking care of the people that are coming to your organization, and we have to figure out how to support them financially and emotionally, to have mental health resources available in a non-shaming way, and to create some community cohesion around some group activities.

One of the things that we at Empathetics are now providing is some healing and recovery groups for self-care, because a lot of institutions recognize that they need to do something, but they don’t know what to do and they don’t know how to do it. Through all this research I’ve done, I’ve been able to realize that empathy and empathic care is not just to give out toward patients, but actually to give to each other, and for institutions to provide it for their workers.

Kevin Pho: When you say that institutions have to provide behavioral health resources in a non-shaming way, tell me more about what you mean by that.

Helen Riess: A few organizations that I’ve come across have done some really creative things. Instead of having a hotline, they call it a warm line, or they’ll have a line where there’s someone there if you just need to vent or you need support. It’s not like I have to go to the EAP, the employee assistance program, to say I need to start professional therapy. Some people need easily accessible help that they can just call, and it can be anonymous, and there’s someone there. And it means making sure that organizations are providing insurance plans that cover mental health if it gets serious enough.

During the pandemic, the rates of anxiety and depression have skyrocketed, and the number of people with suicidal ideation and completed suicides is higher than ever. So this is not a nice-to-have. This is a must-have. It’s so important to find language and find resources that people will find acceptable. Some people want to see a psychiatrist, or they want to see a psychologist or social worker. Other people might benefit from seeing a chaplain, or from going to a community clinic with a group. There’s no one-size-fits-all, so organizations should really have a full menu of mental health support resources that their employees are notified about and encouraged to access.

Kevin Pho: From your experience working with various organizations, what’s the current state of behavioral health support for health care professionals?

Helen Riess: I would say there’s a lot of work to do. What I’m happy to see is that more and more notices are coming out in many organizations about getting the support you need, that mental health resources are available. Just the fact that they’re saying “mental health” is an improvement. It used to be the dark secret that no one would want to talk about. I think the more that hospital leaders talk about mental health and acknowledge it, hopefully someday it will be in the same category as every other type of health that people need. So I’m seeing progress.

Another interesting thing is that when we apply for our license renewal, there used to be a few questions at the end that said, “Have you ever been incarcerated, have you taken illegal drugs, and have you ever had a mental illness?” These things are all grouped together into categories where you just are wanting to say no to everything. I think that some medical societies are re-looking at these questions to be less shaming and less punitive, and if they’re not, that’s something they could do to not make getting mental health help akin to just committing some kind of crime.

Kevin Pho: If I’m a health care professional, and let’s say I’ve read your book and I’ve gone through the EMPATHY acronym and realized that there’s a problem, I may be burnt out, what’s my next step after that?

Helen Riess: Well, there are many degrees of burnout, and it’s kind of an umbrella term. Many people are starting to realize this: There are many layers to burnout. It could mean I need a day off. It could mean I need to get someone to help me around the house. So people have to really check in with themselves and ascertain, “What’s going on with me?”

One really important distinction is: Am I burned out, meaning I am exhausted and I need rest? Or am I losing a sense that I’m even good at my job? Do I feel every day that I haven’t lived up to the top of my license, and am I experiencing what’s called moral injury, that I’m not able to provide the care that I want to? That’s much more serious, because it means that the institution isn’t able right now, perhaps, to support people to do their jobs as well as they want to do them.

Another check is: Am I starting to treat patients like objects, like, “Oh, there’s one more, only four more to go”? Am I starting to feel like I’m just getting through a list? If those things are happening, it’s time to talk to somebody and to figure out how you are going to take care of yourself. There’s no one-size-fits-all, Kevin, but some people need to cut back on their work. Some people need to say, “If I’m going to do this job, I need a medical assistant, I need a physician, I need support.”

I think one of the hardest things is for health professionals to ask for help. We also have to be awake to recognizing when our peers and our colleagues are starting to suffer, and to lend a hand and help nudge them. Is it serious enough that they really should make an appointment and think about not just talking to somebody but maybe needing some antidepressants? Or is this somebody that you want to say to, “Let’s get together after work and just have a download about how it’s going”? So we have to be watching out for one.

Kevin Pho: We’re talking to Helen Riess. She’s a psychiatrist, and she’s the author of the book The Empathy Effect: Seven Neuroscience-Based Keys for Transforming the Way We Live, Love, Work, and Connect Across Differences. Helen, what are some of your take-home messages that you want to leave with the KevinMD audience?

Helen Riess: Well, first and foremost, empathy can be taught. So if you think, “I just don’t have it,” or “I lost it,” you can get it back, and you can improve. What we’ve mostly been talking about today is self-empathy, and remember, you are the most valuable person in the world, and you’re not going to be helpful to anybody else if you don’t take care of yourself.

And third, if you feel like you’re running low, or feeling like you’re ready to quit your job, or that you just can’t wait to retire, find someone to talk this through with, to understand whether you’re responding to a moment in time where you maybe feel like throwing in the towel because it’s been so hard, or whether this is really the next step in your career. But be mindful, and talk to people and connect, because that’s the best way to get to know yourself.

Kevin Pho: Helen, thank you so much for sharing your time and insight, and thanks again for being on the show.

Helen Riess: Thanks for having me, Kevin.

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