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by Kayla Sheehan (@kksheehan)

October TW, Dizon ZB, Arnold RM, Rosenberg AR. Characteristics of Physician Empathetic Statements During Pediatric Intensive Care Conferences With Family Members: A Qualitative Study. JAMA Network Open. 2018;1(3):e180351. doi:10.1001/jamanetworkopen.2018.0351

Ask any patient what qualities they desire in a physician, and empathy will almost always make the list. A physician’s ability to demonstrate empathy has been shown to significantly impact patient outcomes¹, increase patient satisfaction², and raise physician “compassion satisfaction,” which may hinder burnout (3). Though much debate surrounds empathy’s teachability, learning how and when to make empathetic statements is a crucial aspect of physician training. Many of us struggle with finding the right thing to say, but a recent open access study published in JAMA Network Open shows there may be more power in pauses made after empathetic statements than in the words themselves.

The study recorded 68 pediatric intensive care unit conferences over four years. Transcripts of every meeting were made, and empathetic statements were noted using the infamous NURSE criteria (naming, understanding, respecting, supporting, exploring). “Missed opportunities” to express empathy were noted as well. Empathetic statements were placed into two categories, “buried” and “unburied.” A buried statement was one in which the physician expressed empathy, but did not allow time for the family to respond. This most commonly occurred with the physician immediately segueing into clinical jargon, but was also counted as buried if another member of the team interrupted, or if the physician finished the statement with a closed-ended question.



Transcript analysis showed that physicians are fairly good at identifying when to express empathy, taking advantage of 74% of the opportunities analyzers identified. However, almost 40% of these statements were buried, and “medical talk” accounted for the vast majority of buried statements (95%). Interestingly, non-physician team members (typically a social worker or nurse) spoke only 5% of the time, but when they offered empathy, they did so unburied 87% of the time, further demonstrating the importance of a multi-disciplinary team in fully supporting patients and their families.



Physicians have a wealth of medical knowledge to share, but timing is paramount, and tacking jargon onto the end of a well-intentioned empathetic statement may prevent patients and families from even recognizing the empathetic effort at all. In October’s study, when physicians made unburied empathetic statements, families were 18 times more likely to respond with additional information, to express their fears, and to discuss their goals. Clear communication is an obvious cornerstone of the physician-family relationship, and while buried empathetic statements may be better than no expressions of empathy at all, they may leave families with a feeling of being unheard and ignored.



Though a busy clinician may not feel they have the time to open the Pandora’s box of family concerns and fears, investing time in “a pause” may pay dividends for all parties involved. For physicians, better communication skills have been shown to decrease instances of burnout, lower rates malpractice suits, and raise patient satisfaction scores⁴. Meanwhile, the family leaves these conversations feeling heard and understood, and the patient receives care tailored to them, with every fear, concern, and hope kept in mind.

If, as cellist Yo-Yo Ma would assert, “music happens between the notes,” perhaps the heart of medicine lives in the pause.

More Pallimed posts from Kayla Sheehan can be found here. More journal article reviews can be found here. More posts on communication can be found here.


Kayla Sheehan is a third-year medical student at California Northstate University. She enjoys singing, sharp cheddar, and long walks with her Australian Shepherd, Posey.

References:

1) Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient satisfaction and compliance. Eval Health Prof. 2004 Sep;27(3):237-51. PubMed PMID: 15312283.

2) Pollak KI, Alexander SC, Tulsky JA, Lyna P, Coffman CJ, Dolor RJ, Gulbrandsen P, Ostbye T. Physician empathy and listening: associations with patient satisfaction and autonomy. J Am Board Fam Med. 2011 Nov-Dec;24(6):665-72. doi:10.3122/jabfm.2011.06.110025. PubMed PMID: 22086809;

3) Gleichgerrcht E, Decety J (2013) Empathy in Clinical Practice: How Individual Dispositions, Gender, and Experience Moderate Empathic Concern, Burnout, and Emotional Distress in Physicians. PLoS ONE 8(4): e61526. https://doi.org/10.1371/journal.pone.0061526

4) Boissy, A., Windover, A.K., Bokar, D. et al. Communication Skills Training for Physicians Improves Patient Satisfaction. J Gen Intern Med (2016) 31: 755. https://doi.org/10.1007/s11606-016-3597-2

Altmetric for this study: October TW, Dizon ZB, Arnold RM, Rosenberg AR. Characteristics of Physician Empathetic Statements During Pediatric Intensive Care Conferences With Family Members: A Qualitative Study. JAMA Network Open. 2018;1(3):e180351. doi:10.1001/jamanetworkopen.2018.0351

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by Kayla Sheehan (@kksheehan)

My first day of medical school, I asked the Dean how to start a Hospice and Palliative Medicine Student Interest Group (SIG). Before I became a medical student, I began volunteering for hospice. It changed my life. I learned invaluable lessons about life, death, and healing throughout my nearly five years as a hospice volunteer and I realized these lessons would not be taught in a classroom. Three years into medical school, we are one of the most active groups on campus, and we continue to grow.

Assembling the group was not as difficult as one might think. The biggest hurdle is many students simply don’t realize this is something they should know about, and because HPM is a blind spot for faculty as well, it gets left out of an impacted curriculum. How and when are students supposed to learn about these things if there is no time or place for them? In our case, it came down to a spark of initiative, which caught on with persistence. As a medical student with hospice experience, I understood the anxieties my peers might have when it came to caring for people who are very sick or terminally ill. Clearly, the majority of my classmates were not aiming for careers in hospice or palliative medicine, but there are many specialties which can be enhanced with early exposure to HPM.

At least once a month, our group meets to discuss topics such as grief and loss, advance care planning, and death with dignity. We’ve teamed up with other interest groups to broaden our audience, and have held “cross-talks” with our emergency medicine, internal medicine, and oncology interest groups. Our next meeting is a triple cross-talk with surgery and oncology. When we meet, it not only introduces the topic of palliative medicine to a group of students who have likely never heard of it, but also allows them to discover for themselves why this is something they should know about, and something they will likely use in some capacity in their specialty of choice.

Though these talks are invaluable, I know from firsthand experience that some of HPMs most powerful lessons are learned at the bedside. I have been working with local hospices to find a way to get students trained as hospice volunteers. Though it is difficult to motivate the majority of medical students to do anything other than study, many of us crave interaction with the human side of medicine, and jump at the chance. When I was a volunteer, we had to commit to four hours a week minimum. Because this is not possible for medical students, flexibility from the hospice is key.

Almost 50 1st and 2nd year medical students attended our #hpm sig triple cross talk today, where we learned about how #surgery #oncology and #palliative medicine intersect. Such a big turnout, we had move to a bigger room! pic.twitter.com/7VqBoiZ5ko

— Kayla Sheehan (@kksheehan) August 31, 2018

The HPM SIG also serves as a springboard for research, which is another opportunity for students to directly engage with the field, and maybe meet a mentor along the way. Our University does not have an affiliated hospital, but we have been involved with research projects done by our neighbor UC Davis’ fellows, and a few from other local physicians as well.

Importantly, this group costs nothing, only time, effort, and lots of e-mails. It is a passion project that would not exist without nurses, social workers, and physicians volunteering their time to come speak to us. Despite the minimal cost of running such a group, very few exist in medical schools. It is no secret that there is a scarcity of hospice and palliative physicians, and that dearth will only become more apparent as our population ages. Student interest groups have the potential to not only recruit future hospice and palliative physicians, but also to educate their colleagues in training on what hospice and palliative medicine is, and when to use it.

Thank you @JudyThomasJD for coming to speak to our #hpm student interest group about the #EoLOA. One hour doesn’t do it justice. Thank you for providing us with information we won’t get elsewhere in our medical education! pic.twitter.com/YFDt1lm4c9

— Kayla Sheehan (@kksheehan) April 24, 2018

At the end of our M2 year, a lecturer said something along the lines of “palliative medicine is only for the terminally ill,” after which dozens of my classmates’ heads snapped back in my direction, recognizing the error. I could have burst with pride. When we graduate, I may be the only one headed for HPM, but 90 physicians will be going into the world with at least some knowledge of what hospice is, what palliative medicine is, how they overlap and differ. It may not singlehandedly solve the HPM physician shortage, but it is a step in the right direction. Does your local medical school have an HPM SIG? If yes, add it to the comments, and share what you have been doing with it. If no, what are you waiting for?

Kayla Sheehan is a third-year medical student at California Northstate University. She enjoys singing, sharp cheddar, and long walks with her Australian Shepherd, Posey.

A few members of cnucom’s #hpm interest group. Future specialities range from em to obgyn to surgery, but every member recognizes the importance of integrating palliative competencies into their practice. We currently have about 60 members, one of the most active groups on campus pic.twitter.com/rfVcyQv38R

— Kayla Sheehan (@kksheehan) April 17, 2018