"I'm sorry to have to tell you this...."

Empathy by The Shopping Sherpa

Another Sunday morning, another stimulating conversation about medical education on Twitter.

It started with a tweet from Dr. Jonathon Tomlinson “To say you cannot learn insight and empathy is like saying you cannot learn science or a new language. Possibly true, but very sad.”

So can we teach empathy? What do we mean by empathy? A good review of the complexities was published earlier this year by some researchers from the University of East Anglia. They suggest that we might be better to step away from the concept of empathy and instead just focus on etiquette. It's a provocative read.

I wonder if teaching empathy isn't like teaching clinical reasoning. We need to first think of empathy as a disposition before concentrating on the skills. The following quote comes from a just-published study on how physicians think about clinical reasoning in students, is it an ability or a disposition? : "The ability-disposition distinction highlights the difference between teaching knowledge and skills, referred to as teaching-as-transmission, versus teaching attitudes, modifying personality and changing behaviour, referred to as teaching-as-enculturation."

So how can we transmit what we think is important to others about empathy? A few years ago,  I blogged about a communication skills session that I was teaching. I was aware of how this session on "breaking bad news" had to some become formulaic. But an interesting discussion did occur and we all questioned our thoughts and approaches to the topic.

Just as Krupat et. al suggest that in order to develop clinical reasoning we need to focus on  "encouraging self-awareness and mindfulness, modelling open discussion and inquiry, accepting doubt and uncertainty", I'd suggest that the same is true of developing empathy.

What we do not want is for students to leave thinking that empathy is just a set of behaviours. As this doctor tweeted: ""Empathy by rote" is a ridiculous concept. It's like teaching somebody to be "happy". Faked empathy is insulting."

Another doctor replied that to his mind one of the worst examples of this was: “ to score on 'empathy' student said 'sorry it has to be me to tell you this'”. The doctor was shocked as he saw this as the student putting “professional discomfort before patient distress”. It’s this kind of situation that we exactly need to tease out when talking to students about empathy and communication.

In a comment on a blog post by a doctor about breaking bad news, a patient writes of her feeling when she was told she had a serious condition. She explains how the doctor “As he spoke, he began to sip little bits of air in between his lips. This suggested to me he was feeling emotions as well. It made him more human and incredibly compassionate. I loved him for that.”

For some patients showing that we are human and have emotions to will be right. For others it might be seen selfish. They might want us to have ‘professional distance’, to just get on with the job. How with someone that we don’t know well can we figure out how to be? Do we have to accept that sometimes we will just get it wrong and that etiquette is the best we can aim for?

I don’t expect to reach the answers to those questions through this blog. But they are the kind of issues we should discuss with students when we are in real-life situations, so that we can help them to start developing their sensitivity to communication and their inclination to becoming good communicators.

More tweets can be seen in the storify here.
Regina Holliday tells the powerful story of a doctor who seems to lack all empathy here.
Excellent post on empathy by oncologist, Robert Miller, here.
Previous posts on medical students' thoughts about teaching and learning about empathy:
A medical student's thoughts on empathy and #meded
A twitter conversation with UK medical students about empathy

Reflection and Portfolios

Do you agree with these medical students and young doctors?

What happens when you have a brilliant website but you don't have search and google doesn't seem to know about you?

Answer: your content can't be accessed and most people don't know about your website. EDIT Unless they search tripdatabase.

Behind the headlines is an excellent service. Here you can find the background to the latest health stories that you find reported in the UK press. The problem is that it is hard to find what is there. The NHS Choices website seems to exclude BtH from its search. Google doesn't seem to know about the content of the BtH website. Infact, the only way of getting to BtH content seems to be through Tripdatabase, the excellent metasearch.

But, BtH does have it's own twitter feed! Yes, you can follow @NHSNewsUk!

Maybe NHSChoices thinks that content in BtH is of no interest after a few days and that no-one will ever want to look past what is on their front page. They are wrong.

To me this is evidence why anyone who produces content should think about search first and social media later. Get the basics right.

New Post

I'm very pleased to announce that I have been offered a part-time secondment within Cardiff University School of Medicine to look at how we can make best use of technology to support learning throughout the undergraduate medical course.

I go into this post having learned so much from my personal learning network. In the next few years I hope to keep learning and sharing with you.

Thanks.

Storify: the story of a single tweet

Location and Learning

Image: SP Nurse on the Job by dharder9475
In the last few weeks I've been thinking about how we can support the learning that takes place when medical students are on placement. We know that entering wards can be a daunting experience for students. They don't feel part of a team. They don't know who everyone is. They don't understand what is happening. They don't want to interrupt nurses attending to patients or junior doctors catching up with paperwork at desks.They see other members of the team wandering in and out of the ward but they don't know what their role is. They don't recognose the social worker or the pharmacist or the OT.   They might not even know what their own role is. They miss out on opportunities to attend meetings and teaching sessions because they don't know they are happening. In fact they spend too long waiting around for someone else to turn up to teach them, and on activities that have little educational value. They generally have a haphazard learning experience.

But placements are very rich environments with many unique opportunities to learn.

So what can we do?

Imagine instead that before coming to the ward the students had access to a network which let them find the profiles of all the staff who worked on that ward. They could see the timetables for teaching. They could even see what the last students who had been on this placement had seen and learnt. They can select what they would they would particularly like to gain from the placement, and this will become part of their profile which will also be available to all the staff on the ward. The network will also contain links to information about initiatives that are happening in the ward to address patient safety and quality improvement. They students can see if there are opportunities for them to get involved in this work and learn about the input their colleagues have had in the past.

When they turn up on the ward the students check in. They can see the profiles of the staff who are working there and when they should be finishing, when they will be on call and what clinics or theatre sessions they will be doing that week. Their calendar updates with activities that are happening that day that they should know about.

The network that they are tapping into is the same one that all the staff in the hospital use to keep themselves up to date. The students can record their learning and their thoughts about how the ward works. Their input is valued by the staff on the ward and their fellow students from other disciplines.

Do you think this will happen soon? Why hasn't it happened already? And how could patients use this network?

Lies, damned lies and statistics: How do you turn 61% into 95%?

Image from "Working together for a stronger NHS" Crown Copyright

Edit: 13/05/11 An analysis of the BSA 2007 dataset by Siobhan Farmer, Mark Hawker and myself has been published today in the new publication Lancet UK Policy Matters. You can find it here. We conclude that it is not possible to conclude that 95% of respondents wished for more choice. Using the kind of suppositions given below it may be possible to infer that between 61% and 72% may have thought there should be more choice, but the survey was not designed to answer this question. 

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Edit: 17/4/11 I and a colleague have independently tried to verify Mark's analysis. We have reached similar conclusions but they don't corroborate Mark's results. Unfortunately he is currently outside the UK. We will update with our own results in the UK. We are in agreement that there is still no justification for claiming that "95% of people want more choice in healthcare". 

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Today many of you will have read Ben Goldacre's excellent  analysis of the leaflet which the Department of Health issued last week to help the public understand why they were pursuing reforms of the NHS which are facing widespread opposition. 

Page 11 of the leaflet contains the graphic above stating that 95% of those surveyed in the 25th British Social Attitudes Survey  wanted MORE choice in the NHS. When Ben looked at the published reports he found that 'Do you want more choice in the NHS?' was not a question in the survey. Instead respondents were asked 'How much choice do you think you should have?' and 'How much choice do you actually have?'  But if you could establish how many people thought they should have choice but who currently think that they don't have choice then you might be able to say how many people think that they should have more choice. As Ben points out to answer this you would need to have individual level data. When he asked the DOH for the dataset they unfortunately pointed him to a book chapter.

But fortunately the day this leaflet was published, April 6th, 2011, Mark Hawker  started wondering if he could find out more about this dataset. And he did find more. The individual level data is available to download. So Mark did that. Then he analysed it. And what did he find?  Well, you can read a lot more in the blog post that he published on April 7th but here is a summary.

13% thought they had more choice that they thought they should have.

46% thought they had just the right amount of choice.

41% thought they should have more choice that they had.

So how did the DOH manage to get this so wrong? How did they confuse 41% with 95%? Why weren't they able to direct Ben Goldacre to the correct data source? And why have they decided not to fund this survey in the future?

Hopefully someone can help make the correct data look just as pretty as the incorrect infographic in the leaflet. In the meantime I think I'd like to thank Mark for his work, and to agree with this tweet: