Attending

by Ronald Epstein

  13 I thank Kathryn Montgomery Hunter for this quote and the associated discussion in this paragraph from her blog exploring the nature of clinical practice, including decision making. See K. Montgomery, “Thinking about Thinking: Implications for Patient Safety,” Healthcare Quarterly (Toronto, Canada) 12 (2008): e191–e194. The William James quote can be found in W. James, William James: The Essential Writings (Albany: State University of New York Press, 1986); W. M. James, “Brute and Human Intellect,” Journal of Speculative Philosophy 12(3) (1878): 236–76; and W. James, “Brute and Human Intellect,” in William James: Writings, 1878–1899 (New York: Library of America, 1992), 11.

  14 In that context, here are some other dilemmas that I faced in one day in the office. Do I suggest that a patient agree to take another round of potentially toxic chemotherapy knowing that it only has a 10 percent chance of helping? How frequent or “typical” does chest pain need to be to warrant an invasive procedure to determine whether serious heart disease is present? When do I prescribe narcotics for patients with intractable low-back pain, knowing that a small percentage of patients will become addicted? When do I assume that I should choose the treatment I used the last time I saw a patient similar to the current one, and when does that represent availability bias or some other form of self-deception?

  15 Shared mind is when ideas, intuitions, and decisions emerge not only from individuals but from the interactions among them—an intersubjective experience. R. M. Epstein and R. L. Street Jr., “Shared Mind: Communication, Decision Making, and Autonomy in Serious Illness,” Annals of Family Medicine 9(5) (2011): 454–61; R. M. Epstein and R. E. Gramling, “What Is Shared in Shared Decision Making? Complex Decisions When the Evidence Is Unclear,” Medical Care Research and Review 70(1S) (2012): 94–112; R. M. Epstein, “Whole Mind and Shared Mind in Clinical Decision-Making,” Patient Education & Counseling 90(2) (2013): 200–206; and J. Zlatev et al., The Shared Mind: Perspectives on Intersubjectivity (Amsterdam and Philadelphia: John Benjamins, 2008.)

  16 A provocative study using hyperscanning (two people in MRI scanners communicating with one another) showed that people whose brain activity is coordinated also are socially more connected. E. Bilek et al., “Information Flow between Interacting Human Brains: Identification, Validation, and Relationship to Social Expertise,” Proceedings of the National Academy of Sciences 112(16) (2015): 5207–12.

  17 L. R. Mujica-Parodi et al., “Chemosensory Cues to Conspecific Emotional Stress Activate Amygdala in Humans,” PLoS ONE 4(7) (2009): e6415.

  18 This vignette was adapted from F. Borrell-Carrió and R. M. Epstein, “Preventing Errors in Clinical Practice: A Call for Self-Awareness,” Annals of Family Medicine 2(4) (2004): 310–16.

  19 R. Srivastava, “Speaking Up—When Doctors Navigate Medical Hierarchy,” New England Journal of Medicine 368(4) (2013): 302–5.

  20 This quote, attributed to Dr. Faith Fitzgerald, appeared in A. K. Smith, D. B. White, and R. M. Arnold, “Uncertainty—the Other Side of Prognosis,” New England Journal of Medicine 368(26) (2013): 2448–50.

  21 F. Ismail-Beigi et al., “Individualizing Glycemic Targets in Type 2 Diabetes Mellitus: Implications of Recent Clinical Trials,” Annals of Internal Medicine 154(8) (2011): 554–59.

  22 D. L. Sackett et al., Clinical Epidemiology: A Basic Science for Clinical Medicine, 2nd ed. (Boston: Little, Brown, 1991).

  23 G. Guyatt et al., “Patients at the Center: In Our Practice, and in Our Use of Language,” ACP Journal Club 140(1) (2004): A11–A12. The presence of multiple conditions also affects patients’ choices. See M. E. Tinetti, T. R. Fried, and C. M. Boyd, “Designing Health Care for the Most Common Chronic Condition—Multimorbidity,” JAMA 307(23) (2012): 2493–94.

  24 A. Tversky and D. Kahneman, “The Framing of Decisions and the Psychology of Choice,” Science 211(4481) (1981): 453–58.

  25 D. Kahneman, “A Perspective on Judgment and Choice: Mapping Bounded Rationality,” American Psychologist 58(9) (2003): 697–720.

  26 Croskerry suggests that enhancing metacognition would be a good thing for clinicians. If we could only understand our own biases during decision making, then we could have some hope of engaging in what Croskerry calls “de-biasing strategies” to make sounder and better-informed decisions by not only considering information and knowledge that we have, but how we select and use that knowledge and information. For Croskerry, who directs the Critical Thinking Program at Dalhousie University in Nova Scotia, de-biasing often involves switching from autopilot to “mindfulness of one’s own thinking.” See P. Croskerry, “From Mindless to Mindful Practice—Cognitive Bias and Clinical Decision Making,” New England Journal of Medicine 368(26) (2013): 2445–48.

  27 Few interventions have shown promise in reducing implicit bias, and reduction in implicit bias has implications far beyond medicine. See Y. Kang, J. R. Gray, and J. F. Dovidio, “The Nondiscriminating Heart: Lovingkindness Meditation Training Decreases Implicit Intergroup Bias,” Journal of Experimental Psychology: General 143(3) (2014): 1306; Y. Kang, J. Gruber, and J. R. Gray, “Mindfulness and De-automatization,” Emotion Review 5(2) (2013): 192–201; A. Lueke and B. Gibson, “Mindfulness Meditation Reduces Implicit Age and Race Bias: The Role of Reduced Automaticity of Responding,” Social Psychology and Personality Science (2014): 1–8; and A. C. Hafenbrack, Z. Kinias, and S. G. Barsade, “Debiasing the Mind through Meditation Mindfulness and the Sunk-Cost Bias,” Psychological Science 25(2) (2014): 369–76.

  28 G. Norman, M. Young, and L. Brooks, “Non-analytical Models of Clinical Reasoning: The Role of Experience,” Medical Education 41(12) (2007): 1140–45.

  29 See P. Croskerry, “A Universal Model of Diagnostic Reasoning,” Academic Medicine 84(8) (2009): 1022–28.

  30 J. M. Harlow, “Recovery after Severe Injury to the Head,” History of Psychiatry (1993): 274–81 (originally published 1868 in the Bulletin of the Massachusetts Medical Society).

  31 Epstein and Gramling, “What Is Shared in Shared Decision Making?”

  32 S. Farber, “Living Every Minute,” Journal of Pain and Symptom Management 49(4) (2015): 796–800.

  33 K. Murray, “How Doctors Die—It’s Not Like the Rest of Us, but It Should Be,” Zócalo Public Square, November 30, 2011, 1775–77.

  7. RESPONDING TO SUFFERING

  1 The ideas in this chapter germinated with and expand on an article I coauthored with Tony Back, whom I acknowledge with gratitude, as part of a larger project on suffering and compassion in health care. See R. M. Epstein and A. L. Back, “Responding to Suffering,” JAMA 314(24) (2015): 2623–24.

  2 R. B. Haynes et al., “Increased Absenteeism from Work after Detection and Labeling of Hypertensive Patients,” New England Journal of Medicine 299(14) (1978): 741–44; and J. E. Dimsdale, “Reflections on the Impact of Antihypertensive Medications on Mood, Sedation, and Neuropsychologic Functioning,” Archives of Internal Medicine 152(1) (1992): 35–39.

  3 A. W. Frank, “Can We Research Suffering?,” Qualitative Health Research 11(3) (2001): 353–62.

  4 E. J. Cassell, “The Nature of Suffering and the Goals of Medicine,” New England Journal of Medicine 306(11) (1982): 639–45; E. J. Cassell, “Diagnosing Suffering: A Perspective,” Annals of Internal Medicine 131(7) (1999): 531–34; and E. J. Cassell, “The Phenomenon of Suffering and Its Relationship to Pain,” in Handbook of Phenomenology and Medicine, ed. S. K. Toombs (Dordrecht, Netherlands: Kluewer Academic Publishers, 2001), 371–90.

  5 A slight misquote of Eldridge Cleaver, who said, “There is no more neutrality in the world. You either have to be part of the solution, or you’re going to be part of the problem.” But he was not the first or the last to say this.

  6 For further elaboration of this theme, see T. H. Lee, “The Word That Shall Not Be Spoken,” New England Journal of Medicine 369(19) (2013): 1777–79.

  7 There is a rich literature on the relationships among unexplained somatic symptoms, traumatic life events, mental illness, and functioning. See P. Salmon, “Patie
nts Who Present Physical Symptoms in the Absence of Physical Pathology: A Challenge to Existing Models of Doctor-Patient Interaction,” Patient Education & Counseling 39(1) (2000): 105–13; and W. Katon, M. Sullivan, and E. Walker, “Medical Symptoms without Identified Pathology: Relationship to Psychiatric Disorders, Childhood and Adult Trauma, and Personality Traits,” Annals of Internal Medicine 134(9, pt. 2) (2001): 917–25. For a reference about how physicians respond to such patients, see E. A. Walker et al., “Predictors of Physician Frustration in the Care of Patients with Rheumatological Complaints,” General Hospital Psychiatry 19(5) (1997): 315–23.

  8 Clinicians reading this case report undoubtedly each have a theory of what else could have been done, an additional blood test or scan that would reveal the body’s secrets and provide a clear path. Some may assert that the diagnosis is not recognized by mainstream medicine—due to an infectious agent, an environmental toxin, or a psychological process—nor is a humoral diagnosis according to traditional Chinese or ayurvedic medicine. Karen did explore many of these options. The point here is that the possibilities are endless, but investigating further always has a cost. Sometimes that cost is a side effect of a medication; other times it is in energy (seeing lots of doctors can be exhausting) or in finances or is existential (seeing oneself as diminished and fragmented rather than complete and whole).

  9 Here are a few sources about the perils of labeling people “somatizers”: R. M. Epstein, T. E. Quill, and I. R. McWhinney, “Somatization Reconsidered: Incorporating the Patient’s Experience of Illness,” Archives of Internal Medicine 159(3) (1999): 215–22; I. R. McWhinney, R. M. Epstein, and T. R. Freeman, “Rethinking Somatization,” Advances in Mind-Body Medicine 17(4) (2001): 232–39; R. M. Epstein et al., “Physicians’ Responses to Patients’ Medically Unexplained Symptoms,” Psychosomatic Medicine 68(2) (2006): 269–76; P. Salmon et al., “Doctors’ Responses to Patients with Medically Unexplained Symptoms Who Seek Emotional Support: Criticism or Confrontation?,” General Hospital Psychiatry 29(5) (2007): 454–60; and H. Waitzkin and H. Magana, “The Black Box in Somatization: Unexplained Physical Symptoms, Culture, and Narratives of Trauma,” Social Science & Medicine 45(6) (1997): 811–25.

  10 In her case, methotrexate, several TNF inhibitors, and a selective T-cell costimulation blocker.

  11 I am grateful to Tony Back, who picked those words out when I was first recounting Karen’s situation as part of an article we’ve coauthored for JAMA. See Epstein and Back, “Responding to Suffering.”

  12 Tony is also the founder of a new venture called VitalTalk, which offers training to physicians to help improve communication with patients during the most difficult moments.

  13 A. L. Back et al., “ ‘Why Are We Doing This?’: Clinician Helplessness in the Face of Suffering,” Journal of Palliative Medicine 18(1) (2015): 26–30.

  14 S. E. Thorne et al., “ ‘Being Known’: Patients’ Perspectives of the Dynamics of Human Connection in Cancer Care,” Psycho-Oncology 14(10) (2005): 887–98.

  15 Reference to Henry James noted in R. Charon, Narrative Medicine: Honoring the Stories of Illness (London: Oxford University Press, 2006).

  16 J. Coulehan, “Compassionate Solidarity: Suffering, Poetry, and Medicine,” Perspectives in Biology and Medicine 52(4) (2009): 585–603.

  17 M. L. Johansen et al., “ ‘I Deal with the Small Things’: The Doctor-Patient Relationship and Professional Identity in GPs’ Stories of Cancer Care,” Health 16(6) (2012): 569–84.

  18 A. L. Back et al., “Compassionate Silence in the Patient-Clinician Encounter: A Contemplative Approach,” Journal of Palliative Medicine 12(12) (2009): 1113–17.

  19 A. M. Kleinman, The Illness Narratives: Suffering, Healing, and the Human Condition (New York: Basic Books, 1988).

  20 Kübler-Ross’s five stages of dying—denial, anger, bargaining, depression, acceptance—are described in E. Kübler-Ross, S. Wessler, and L. V. Avioli, “On Death and Dying,” JAMA 221(1972): 174–79.

  21 From “Do Not Go Gentle into the Night,” in The Poems of Dylan Thomas (New York: New Directions, 1938).

  22 L. M. Candib, “Working with Suffering,” Patient Education & Counseling 48(1) (2002): 43–50.

  8. THE SHAKY STATE OF COMPASSION

  1 G. L. Engel, “The Need for a New Medical Model: A Challenge for Biomedicine,” Science 196(4286) (1977): 129–36.

  2 G. L. Engel, “From Biomedical to Biopsychosocial: Being Scientific in the Human Domain,” Psychosomatics 38(6) (1997): 521–28.

  3 D. L. Berry et al., “Clinicians Communicating with Patients Experiencing Cancer Pain,” Cancer Investigation 21(3) (2003): 374–81.

  4 G. E. Pence, “Can Compassion Be Taught?,” Journal of Medical Ethics 9(4) (1983): 189–91.

  5 B. A. Lown, J. Rosen, and J. Marttila, “An Agenda for Improving Compassionate Care: A Survey Shows About Half of Patients Say Such Care Is Missing,” Health Affairs 30(9) (2011): 1772–78.

  6 The Milgram experiments were conducted in the early 1960s, shortly after the trial of Nazi war criminal Adolf Eichmann, with the intention of proving that most citizens were vulnerable to ethical compromise. See S. Milgram, “Behavioral Study of Obedience,” Journal of Abnormal Psychology (1963): 67371–78.

  7 It remains controversial whether long-term psychological harm was inflicted on some of the participants and whether the research protocol violated ethical norms at the time. Yet, this study prompted strict rules about informed consent for and the ethical review of all behavioral research.

  8 J. M. Darley and C. D. Batson, “ ‘From Jerusalem to Jericho’: A Study of Situation and Dispositional Variables in Helping Behavior,” Journal of Personality and Social Psychology 27(1) (1973): 100–108.

  9 For one recent example, see A. Schattner, “My Most Informative Error,” JAMA Internal Medicine 175(5) (2015): 681.

  10 J. Halifax, “A Heuristic Model of Enactive Compassion,” Current Opinion in Supportive and Palliative Care 6(2) (2012): 228–35. Also, see her book Being with Dying (Boulder, CO: Shambhala Publications, 2008). For an understanding of how one can empathize with someone whom we perceive as different, see C. Lamm, A. N. Meltzoff, and J. Decety, “How Do We Empathize with Someone Who Is Not Like Us? A Functional Magnetic Resonance Imaging Study,” Journal of Cognitive Neuroscience 22(2) (2010): 362–76.

  11 H. Fukushima, Y. Terasawa, and S. Umeda, “Association between Interoception and Empathy: Evidence from Heartbeat-Evoked Brain Potential,” International Journal of Psychophysiology 79(2) (2011): 259–65; and T. Singer, H. D. Critchley, and K. Preuschoff, “A Common Role of Insula in Feelings, Empathy and Uncertainty,” Trends in Cognitive Sciences 13(8) (2009): 334–40.

  12 C. Lamm, C. D. Batson, and J. Decety, “The Neural Substrate of Human Empathy: Effects of Perspective-Taking and Cognitive Appraisal,” Journal of Cognitive Neuroscience 19(1) (2007): 42–58.

  13 H. De Jaegher and E. Di Paolo, “Participatory Sense-Making: An Enactive Approach to Social Cognition,” Phenomenology and the Cognitive Sciences 6(4) (2007): 485–507.

  14 For some illustrative examples of physician self-disclosure gone awry, see S. H. McDaniel et al., “ ‘Enough about Me, Let’s Get Back to You’: Physician Self-Disclosure during Primary Care Encounters,” Annals of Internal Medicine 149(11) (2008): 835–37.

  15 A concise summary of these pathways linking the ventral striatum and the medial orbitofrontal cortex can be found in O. M. Klimecki et al., “Differential Pattern of Functional Brain Plasticity after Compassion and Empathy Training,” Social Cognitive and Affective Neuroscience 9(6) (2014): 873–79.

  16 See M. Hojat et al., “The Devil Is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School,” Academic Medicine 84(9) (2009): 1182–91.

  17 D. C. Batson, “These Things Called Empathy: Eight Related but Distinct Phenomena,” in The Social Neuroscience of Empathy, eds. J. Decety and W. Ickes (Denver, CO: Bradford, 2009), chap. 1, 13–15; Lamm, Batson, and Decety, “Neural Substrate of Hu
man Empathy”; and N. Eisenberg and N. D. Eggum, “Empathic Responding: Sympathy and Personal Distress,” in Social Neuroscience of Empathy, eds. Decety and Ickes, chap. 6, 71–83.

  18 For recommendations on how clinicians can use self-disclosure more effectively, see McDaniel et al., “ ‘Enough about Me.’ ”

  19 J. Halpern, “What Is Clinical Empathy?,” Journal of General Internal Medicine 18(8) (2003): 670–74.

  20 M. K. Kearney et al., “Self-Care of Physicians Caring for Patients at the End of Life: ‘Being Connected . . . a Key to My Survival,’ ” JAMA 301(11) (2009): 1155–64.

  21 J. Decety and C. Lamm, “Empathy versus Personal Distress: Recent Evidence from Social Neuroscience,” in Social Neuroscience of Empathy, eds. Decety and Ickes, chap. 15, 199–213.

  22 S. Salzberg, Lovingkindness: The Revolutionary Art of Happiness (Boston: Shambhala, 1997).

  23 These areas would be the anterior insula and anterior midcingulate cortex.

  24 The dopamine, opioid, and oxytocin centers.

  25 F. de Vignemont and T. Singer, “The Empathic Brain: How, When and Why?,” Trends in Cognitive Sciences 10(10) (2006): 435–41.

  26 Salzberg, Lovingkindness.

  27 Aristotle, The Nicomachean Ethics, trans. David Ross, revised with an introduction and notes by Lesley Brown (New York: Oxford University Press, 2009); and T. J. Oord, Defining Love: A Philosophical, Scientific, and Theological Engagement (Grand Rapids, MI: Brazos Press, 2010).

  28 Here, the work of psychologist Tania Singer at the Max Planck Institute in Leipzig, Germany, is particularly relevant. Singer reported results of an experiment in which people who had never done any kind of meditation agreed to participate in a nine-month program. For three months they practiced focused attention training, alone at home and in group sessions. Then for another three months they practiced a form of dyadic attention training—“attentive listening” to others through structured dialogues conducted in person or by phone. For the final three months they engaged in traditional compassion practice. Singer and her team found that the effects of each contemplative practice built a particular set of skills. Focused attention training enhanced attentional networks and reduced distractibility. Compassion practice had greater effects on pro-social attitudes such as caring and concern for others and desire to ameliorate others’ suffering. Singer’s study was done with ordinary people from a variety of walks of life, yet could easily apply to those who work in medical settings. See T. Singer and M. Bolz, Compassion: Bridging Practice and Science (Munich, Germany: Max Planck Society, 2013).