Near-Death Experience Leads Physician to Promote Empathy

Damian McNamara

January 09, 2017

When physicians learn how to be more empathetic and attuned to patients' emotions and needs, taking a more holistic approach to patient care, clinical encounters become more efficient and physicians experience more satisfying interactions, according to Rana L. A. Awdish, MD, from the Henry Ford Health System in Detroit, Michigan.

How does Dr Awdish know? She became critically ill on her last day of fellowship training in respiratory critical care medicine, and suddenly transformed from physician to patient.

An occult adenoma in her liver ruptured, triggering the loss of the entire volume of blood into her abdomen, an event so sudden and so extensive that she required 26 units of blood products that first night in 2008. Her blood was too cold and too acidic to clot properly, and she rapidly progressed to multisystem organ failure, required ventilator support, and experienced a stroke and hemodynamic collapse. As if that were not enough, the baby she was 7 months pregnant with did not survive.

Dr Rana L.A. Awdish

Five operations and relearning how to talk and walk were just part of her recovery, she explains in a perspective piece published in the January 5 issue of the New England Journal of Medicine.

"What surprised me most was how little I actually understood about what it felt like to be that sick," Dr Awdish told Medscape Medical News.

"In the process, as a patient, I learned things about us — physicians and other medical professionals — that I might not have wanted to know. I learned that though we do so many difficult, technical things so perfectly right, we fail our patients in many ways."

Expanding an Emphasis on Empathy

Miscommunication, inefficient coordination of care, and a lack of empathy emerged as serious shortcomings from her perspective on the patient side of the bed. Physicians are rarely taught how to listen and empathize with patients in medical school or during training, so this happens through no fault of their own, Dr Awdish said.

However, physicians who want to build better and more effective relationships with their patients can do so, she added. In fact, her experience inspired the administration at Henry Ford to expand their existing Culture of Caring program for nursing to all new employees who join the health system, including physicians.

The physician empathy training, which could be employed at other institutions, centers on these main strategies:

  • taking the position of the other person;

  • staying out of judgment;

  • recognizing the emotion a patient may be feeling; and

  • reflecting what the patient is saying back to them.

"We feel those are the four components that are critical to developing a relationship," Dr Awdish said. "Empathy allows you to transform these encounters into relationships, and that is truly what will impact the patient experience."

In fact, empathy is only one component. "We are teaching relationship building skills, which allow for empathy within that relationship. Part of it is making sure doctors recognize emotional cues and respond to them appropriately. But [it's also about] building compassion, dismantling those prejudgments that we're all prone to, and really listening — that is really what we're teaching," said Dr Awdish, who now serves as medical director of Care Experience, which directs the patient communications initiative across the health system. She is also director of the hospital's Pulmonary Hypertension Program.

Other institutions interested in implementing a similar empathy training curriculum could focus first on certain specialties, as they did at Henry Ford Health System. "There are certain groups of physicians who are more likely to have these high-risk, high-yield conversations on a daily basis," Dr Awdish said. Intensive care physicians, emergency room physicians, oncologists, surgeons, and hospice and palliative care clinicians are examples.

"There are some fields where almost every conversation involves serious news that is often life changing. So that is where we've chosen to focus our efforts."

During onboarding at Henry Ford Health System, physicians are taught some important nuances of effective conversations. They learn to recognize emotions in the room, a "looping type of discussion" that tends to be very ineffective, and the types of questions patients ask when they are actually making a request for connection.

For example, Dr Awdish recalls an incident that occurred before her own illness. After a cancer diagnosis, one patient asked her, "Why did this happen to me?" "I took that question as a request for data," she told Medscape Medical News. Genetic predisposition, environmental triggers, and certain behaviors can contribute to risk, she explained. In retrospect, she realizes the question was "a request for connection. A better response would have been, 'I can't imagine how shocking this is for you after living such a healthy lifestyle.' "

She continues, "To recognize some questions as a request for connection is probably what I took away most from my hospitalization."

Time Management and Patient Management

Sufficient time to empathize and hold difficult conversations with patients is a common concern among physicians, Dr Awdish acknowledges. She often hears, "My encounters have to be efficient because I have a lot of work to do."

However, "if you've ever tried to have a discussion about something concrete with someone who is angry with you, or who is sad or anxious, you know they don't hear you," Dr Awdish said. "The truth is, if you're building trust and addressing the emotions in the room, you can have a discussion about the diagnosis and treatment."

When asked by Medscape Medical News whether a growing workload and physician "burnout" can impede patient empathy, Dr Awdish replied that physicians are asked to do so many things that it creates "mission conflict." Documenting through electronic medical record systems, learning all the complexities of billing, and navigating health care reform, for example, all take precedence if you let them, she said.

"In a way, what physicians are at risk of is of giving away the thing that is most important to them. So if you don't prioritize the relationship building and empathy with patients, you won't have those amazing moments that feel like what you went into medicine for, when you feel like you're supporting somebody through the most difficult time in their lives, that you're an asset to them, that you're partnering with them," Dr Awdish said.

"Those are the things that prevent burnout and augment resilience."

Perspective Gained With Time

Amazingly, Dr Awdish said, she is "super grateful" to have had the patient experience. "It was the education that I needed, it turns out."

Her perspective enabled her to turn a frightening ordeal into a positive training experience for herself and other physicians, and she hopes others will learn from her experience. "I wouldn't want anyone else to have to go through it to learn it," Dr Awdish emphasizes. "It was one of those things that was horrible, and I wouldn't change it."

Dr Awdish has disclosed no relevant financial relationships.

N Engl J Med. 2017;376:7-9. Full text

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