"There's no billing code for empathy" - Graphic narratives in medical education

Dr. Catherine Yu, Associate Scientist, Li Ka Shing Knowledge Institute

Thursday February 9, 2017

Posted by Nadine Abdullah, MD, MEd, FRCPC

(Photo source: annals.org)

This week we talked about empathy. Can it be taught? Can it be learned?

Dr. Catherine Yu shared with us a surprising finding that sparked her interest in this area: Empathy loss in medical students occurs as early as second year, before they even engage in patient care, possibly due to the stress of rigorous medical training. Dr. Yu and her colleagues embarked on research to see if this trajectory can be altered using medical narratives early in medical training to humanize the patient experience as they learn the medical science of disease.

They created graphic comics depicting a patient’s relationship with his doctor, learning about his new diabetes diagnosis, lifestyle modification, and insulin administration. Watching these graphics, you get a real sense of how exhausting his life is, and how he changes over the course of a year, failing to keep up with the required changes. In their study showing these graphic narratives to medical students, they showed that they had impact on their perception of the patient experience, and helped them understand the challenges of chronic disease management. Through critical discussion of the graphics, they see the changing posture of the physician becoming looming and ominous; the patients deteriorating diet, thrown away prescriptions and missed medications, and change in affect toward despondence, gloom and abject failure in managing his disease, the students felt a sense of what it is like to be in his shoes. They felt empathy. They described a sense of renewal, and felt that periodic reminders of empathy are required to reflect on why they came into medicine in the first place. It was an antidote to empathy loss that comes with exhaustion.

For those who doubted, it seemed like maybe we can teach empathy. Whereas most felt that the lecture format to traditionally teach empathy has no impact, some felt that a formal curriculum using creative Narrative Medicine methods such as the graphic comics we viewed can be an efficient and fun way to teach empathy, and can easily be interspersed throughout the formal curriculum as reminders. Time was not a barrier.

Many in the audience felt that the hidden curriculum had the greatest potential for teaching empathy. Students learn empathy both explicitly and implicitly from the clinical environment. This can either lead to empathy loss where empathic behaviours are discouraged, or promote empathy growth when educators and coworkers model and positively reinforce empathic behaviours. One student in Dr. Yu’s study cited being mocked on a surgical rotation for taking time out to bring water to a thirsty patient. The student internalized this as a lesson how not to behave, and a message that there is no place for empathic behaviours. Where these messages exist, students feel empathy loss. However, the positive reinforcement of empathic behaviours gives them permission to feel and behave empathically.

Is it sufficient to teach empathy passively through role modeling, or does it require active labeling and explicit reinforcement? When I take time to listen to a patient’s story on morning rounds and recognize how complicated it is for them to live with chronic disease, I do not label it as “This is empathy.” When I hear from my students that I demonstrate compassionate care, and that this has affected their learning experience and they want to emulate this, I am implicitly teaching empathy. I have a colleague who takes a different approach. On morning rounds in the ED he would open patient’s juice containers, butter their toast, and then explicitly tell his team “This is patient-centred care.” He points out how impossible it is for a frail patient connected to wires and tubes, with arthritic hands and weakness even to prepare to eat the tightly sealed food. He is teaching empathy. Is the explicit labeling necessary?

In contrast, a few residents expressed that we cannot teach empathy at all, but that students can fake it. One went as far as saying that most of being a doctor is acting, and that you have to be able to fake it. The attending physicians I later polled shared my shock at this remark, but the trainees did not. In times of long hours and exhaustion, they feel they sometimes do have to “fake it ‘til you make it”. They relayed a sense of frequently feeling burnout and emptiness, and having nothing left to give. One of the students in Dr. Yu’s study precisely echoed this sentiment. While they feel genuine in their empathy most times, when particularly stressed, they choose to fake it rather than the alternative, to disengage and not even try, and in their minds, provide worse care. I do not think they are wrong. All of us experience stress and burnout. It requires a mature ability to self-monitor, and if the need to fake it persists, we need to address the burnout and re-calibrate.

This reminds me of the children’s book “How Full is Your Bucket?” The concept is in being kind to others, we fill their bucket with empathy and in so doing we fill our own. Surrounded by a clinical environment with interdisciplinary health professionals who embody empathic care, seeing how each contributes to the care of the patient with the goal of improving their experience and clinical outcome, you cannot help but feel refueled and ready to join in to do the same with renewed energy. Setting an empathic clinical learning environment with professional behaviours when interacting with one another is a large part of the hidden curriculum that teaches empathy, and helps prevent empathy drain.

But empathy is beyond being kind. In fact, some argue we should not even be teaching empathy at all. It may make you and your patient feel good, and improve the likelihood of adherence to a treatment plan and success, but what really makes a difference in patient care is using our understanding to effect change. Emotions can get in the way of acting. Humanistic medicine utilizes our empathy and compassion as agency to effect change in individual patients and beyond to the greater population. I would disagree that we should not teach empathy, but on its own, it does not suffice. It is a starting point from which to care enough to act as an agent of change through advocacy. One senior physician in the audience included this in the definition he offered for empathy, and it is this view that is most consistent with humanistic care. It may be semantics, but as educators, we should be mindful that whichever way we might teach empathy, it is not just for the sake of improving patient satisfaction and adherence. It is ultimately to advocate for change to improve the health of our patients.

In answer to the question, can we truly teach empathy, in so much as we can articulate what professional behaviours demonstrate compassion and understanding of the patient experience, and make change to improve patient care, I think the answer is yes. For those who firmly believe we cannot teach empathy, I wonder if what they mean is we cannot make students empathic if they are not empathic to begin with. If a doctor is putting on an act and not authentic, patients will sense it. For those who begin empathic, we may be able to reinforce characteristics that already exist naturally in preselected students who have chosen a career path based on their inherent empathy. If this is the case, I think we are merely channeling their humanistic characteristics, providing context and re-enforcing what is already there. It requires attention to the formal and hidden curriculum, the clinical environment, implicit and explicit role modeling, and it needs periodic reinforcement.

Resources:

“There’s no billing code for empathy” - Animated comics remind medical students of empathy: a qualitative study

Annals Graphic Medicine - The Daily Grind: A Day in the Life of Someone Living With Diabetes

Annals Graphic Medicine - Not the Needle! A Day in the Life of Someone Living With Diabetes

Multimedia Learning -- Back to the Drawing Board?

Bio – Catherine Yu, MD

Dr. Catherine Yu is a Staff Endocrinologist at St. Michael’s Hospital, Associate Professor of Faculty of Medicine and Dalla Lhana School of Public Health, and Associate Scientist in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital. After completing her undergraduate and postgraduate training in Internal Medicine and Endocrinology at the University of Toronto, she then completed an MHSc in Public Health, focusing on the role of education and behavior change in knowledge translation.

Specifically, her research focus is on the care of the patient with diabetes in the context of a health care team, revolving around the role of integrative health informatics tools, patient and clinician education and behaviour change in improving quality of care. In this regard, she has been Principal Investigator and Co-Investigator on several CIHR-funded projects.  In addition, she is the Chair of the Clinical Practice Guidelines Dissemination and Implementation Committee of the Canadian Diabetes Association, in which role she has developed evidence-based and innovative strategies to put guidelines into practice across Canada.