Empathy: Real Stories to Inspire and Enlighten Busy Clinicians

Contents

Introduction: A Case for Empathy

The introduction begins with a story of a young mother whose cancer has become resistant to treatment. The story leads to her impossible question to her physicians, “I cant die, who will take care of my children?” This narrative stimulates the reader to reflecton the benefits of responding with empathy and the hazards of instead offering a factual response in an attempt to fix the unfixable.

Section 1: Weaving Empathy into the Fabric of Every Clinic Encounter

Section 1 outlines the philosophy of the text: empathy is not just something you do when things go wrong, but rather something we do every day no matter the circumstances.

Chapter1: A history of empathy in patient care.

Chapter 1 considers the changes that have occurred in medicine after the Flexner Report was published in 1910. Prior to the Flexner Report, empathy was the most powerful tool available to the clinician. Similarly, in the modern world when we reach a point when focusing on a specific disease, like end-stage cancer or cystic fibrosis, is no longer helpful, empathy is the most powerful medicine. Unfortunately, under such circumstances we all too often continue to focus on disease to the detriment of the patient.

Chapter 2: Learning any skill takes practice, like playing tennis

Its easy to grasp what empathy is on a conceptual level: standing in the other persons shoes or imagining how another person is feeling or thinking. However, practicing empathy in the clinic takes much more than conceptual understanding. Just as winning the Wimbledon tennis tournament takes much more than viewing an instructional video about forehands, backhands, and overhead serves, empathy requires coaching and practice. Mirroring the coaches modelling of an effective forehand, all the way from backswing to follow-through, the extensive dialogue in the Clinicians Guide to Empathy provides a model of empathy that every student can embrace and refine.

Chapter 3: Speaking to people like people rather than as patients: How empathy looks and sounds.

Chapter 3 illustrates that empathy is not only a concept meant to be understood on the conceptual, physiological, or neuroanatomic level, but should also be embraced on the practical and operational level. Empathy is something that great clinicians weave into every conversation, not just classically difficult ones. We present an assortment of case vignettes written by expert clinicians depicting “typical” patient encounters that would not ordinarily be considered challenging, and demonstrate how to weave empathy into such conversations by speaking to patients like people rather than as patients. People enjoy knitting, bull riding, painting, and riding pontoon boats with friends and family. Brief discussions about human topics like these builds strong bonds between clinicians and their patients.

Chapter 4: Empathy as Collaboration

Daniel Epner, M.D., Laura Meyer, and others TBD

Chapter 4 addresses the Parallel process of empathy: treating coworkers with empathy involves the same skills as empathy during clinical encounters. The chapter illustrates how team members can utilize empathy to collaborate to the betterment of their patients and themselves.

Chapter 5: Difficult Conversations in Cancer Care

Previous chapters offered areal-life, operational definition of clinical empathy. Beginning with section 2, The Guide discusses how to apply the same empathic skills to emotionally charged and challenging conversations that commonly arise in clinical practice.

Section2: Common Challenging Conversations: What to say and not to say when the patient or family throws a curve ball.

In section 2, each chapter will begin with a narrative that epitomizes the role of empathy in responding to a particular conversational challenge in medical practice. The text will then offer specific responses and strategies that facilitate connection between providers and patients under such circumstances. These same responses are summarized in the pocket empathy-reference booklet.

Chapter 6: “Denial:” what we see on the surface that covers strong negative emotions, such as fear, sadness, and grief. Under such circumstances, patients and family members often cling desperately to unrealistic expectations.

Daniel Epner, M.D., and co-author TBD.

• We want mother to be alert and talk to us like she did just the other day.

• Youre just going to let me die?

• “I know he is brain dead and theres nothing more you can do for him. Stop telling me that.”

• I have faith God has a plan for me. I am sure I will be completely healed.

Chapter 7: Prognosis

Daniel Epner M.D., andco-author TBD.

• “How long do I have?”

• “Why cant you cure him?”

• “Will I ever be normal again?”

• “I cant believe that I have cancer. I take good care of myself.”

Chapter 8: Existential Concerns: “What comes later, and can you help me get there sooner?”

Marcia Brennan, PhD, Medical Humanities Professor at Rice University, and

Daniel Epner M.D.

• “Where am I going after this?”

• Im not sure what there is to look forward to. Whats the point of trying anymore?

• “Doc, Im ready for this to be over. Help me end this now. I want you to help me die.”

• “Why are you taking away my hope?”

Chapter 9: Family Impact: “But my family needs me…”

Authors TBD

• What if Im not there for my daughters sixth birthday?

• I dont want to talk to my kids about this. I need to be strong for them

• “Who will raise my family if I die?”

• “Will my children remember me?”

Chapter 10: Empathy and Pediatric Care

Kevin Madden, M.D., pediatric palliative specialist and Professor at M.D. Anderson.

This chapter addresses the lopsided triangle of pediatric care: supporting ill children and their parents with great finesse.

• I cant stop life support. This is my daughter. I cant give up on her.

Chapter11: Difficult Family Dynamics

Authors TBD

• “Please dont tell my mother she has cancer or any other bad news.”

• “Oh, it doesnt matter what he thinks. He may be the sick one, but we make his decisions for him.”

• “I know my daughter is suffering greatly, but she said, ‘Never give up on me. I have to honor her wishes, so I cant make her DNR.”

Chapter 12: Dealing with Anger and Blame

Laura Meyer and co-author TBD

• “Of course, Im depressed! Wouldnt you be if you were told you are going to die?”

• “This place has failed me miserably.”

• “You cant possibly understand how I feel. Im dying, and Im only 36! You are perfectly healthy. Dont try to convince me to feel better with your psychological mumbo jumbo.”

Chapter 13: The question of opiates and uncontrolled pain.

Joseph Arthur M.D., Assistant Professor at M.D. Anderson and Daniel Epner, M.D.

• “Doc, I know where youre going with this. I hate to be asked all these questions all the time. Youre talking to me like Im a criminal and you think Im taking these meds and trying to sell them.”

• Ive been giving my son some of my pain medication.

• “Ive been coming to this clinic for 2 years, and every doctor has given me the meds I need. You are the first doctor who has denied me.”

• You dont know how I feel. I may not look like Im hurting, but I have a high pain tolerance. I need meds.

Chapter 14: Empathy and Culture

Laura Meyer and Daniel Epner, M.D.

Using a case to exemplify person-centered care, the authors demonstrate how to engage with and respect patients of all cultures and backgrounds. This chapter outlines universal truths about empathic practice with patients and coworkers from all over the world: we all want the same things, and we are all deserving of empathy.

Chapter 15: Empathy and Spirituality

Marvin Delgado, M.D., Associate Professor at M.D. Anderson and

Alejandro Chaoul PhD, Assistant Professor at M.D. Anderson

In chapter 15, the authors demonstrate how a clinician can hold respectful space for the patients spiritual needs or practices. The authors reflect on how empathy can be expressed effectively in encounters where spirituality (or a lack there of)emerges.

• “Do you believe in miracles?”

• “I cant believe God would abandon me like this.”

Chapter 16: Empathy and Technology

Ali Haider, M.D., Assistant Professor at M.D. Anderson and

Kimberson Tanco, M.D., Assistant Professor at M.D. Anderson

Chapter 16 illustrates how empathy is adapted to overcome the modern realities where there are computers in every exam room and the electronic medical record sometimes pulls the clinicians attention away from the patient.

Chapter 17: Focus on process rather than rainbows

Author TBD & Laura Meyer

Describes unresolved predicaments, such as those involving patients with personality disorders, who sometimes do not respond to empathy, or those who have no spiritual foundation in their lives and therefore are never able to process the various stages of grief. Sometimes it is impossible to connect with patients or families despite our best efforts. This chapter reinforces the premise that learners should continue to shape and refine their own “art of medicine” through all encounters, positive or negative.

Section 3: Compact Empathic Responding Summary

An abbreviated version of Chapters 6-17.