Sunday, April 29, 2018
I Was Compassionate Today ........
I attended the Minnesota Psychiatric Society (MPS) Spring Scientific Meeting today entitled "Reclaiming Our Joy and Wonder as Healers." The full program of that venue is available online at this site. In the registration process I noted that a lot of the content seemed to be experiential and that is my least favorite kind of conference. To make sure I did not miss anything I compared notes with a long time colleague and she agreed and had the same selection process - try to avoid the experiential components of the program. I was generally successful, but more about that later.
The program did begin with three lectures and ample audience participation. The presentations on happiness and burnout seemed to be an uncritical look at happiness and gratitude science. The lead off speaker talked about his personal experience in a health care system that sustained 2 physician suicides in less than a year and how he led the effort to reduce physician burnout. He discussed some straightforward exercises in gratitude and happiness as well as the importance of human relationships. He encouraged psychiatrists at one point to help out their nonpsychiatric colleagues in this area. He provided extensive resources for physicians to use through a web site.
I worked with the second physician for over a decade in my previous position. He discussed the clash of professional values and expectations with what happened in the family and intrapsychically and how he negotiated some of those transitions including going to a clinical track from an academic- research track. He read part of this piece by Jamie Riches, DO - an Internal Medicine resident at Sloan Kettering and the impact of resident suicides. It contained the familiar refrain: "The work does not stop!" No matter what catastrophe you encounter as a physician (and there are many) you are expected to take a deep breath and get back to it - immediately. A resident I worked with completed his shift and the final admission note on 15 patients he had seen that night despite an upper GI bleed. He did not seek medical attention until he had signed out at 8AM the next day. Any bystander can look at these occurrences and other problems listed by Dr. Riches and see how physicians are shooting themselves in the foot. You can't provide good care to patients if you can't take care of yourself.
The third morning lecturer was on the state hospital association and he discussed their attempts to address physician burnout. They had graphed the degree of burnout in various medical organizations and concluded that interventions could be useful for decreasing burnout in general and burnout specifically due to the EHR. I have seen first hand how survey data can be manipulated by health care organizations and I am skeptical that this data means much - especially when there was acknowledgement that the EHR itself has either not changed or the organization implemented the usual unhelpful EHR teams as the primary intervention.
I was able to propose a thought experiment in an afternoon session on Compassion Training. I am no stranger to Buddhism, meditation, or mindfulness techniques. As a psychiatrist trained in the theory and maintenance of therapeutic neutrality, I was skeptical of emotionally loaded terms like "happiness" and "compassion" being used in the context of a therapeutic relationship. Just about every definition of compassion includes terms like sympathy, pity, concern, and or sorrow for the plight of another person. That seems a lot less precise than empathy. The definition of empathy that I use is the technical version from Sims (1) : ".....empathy is a clinical instrument that needs to be used with skill to measure another person's internal subjective state using the observer's own capacity for emotional and cognitive experience as a yardstick. Empathy is achieved by precise, insightful, persistent, and knowledgeable questioning until the doctor is able to give an account of the patent's subjective experience that the patient recognizes as his own." Some definitions confuse empathy with passive understanding of another person's emotional state and compassion with understanding and a willingness to take action to help that person. Psychiatrists trained like me use empathy to explore the person's subjective state for the purpose of understanding it and trying to help them. It is anything but passive. In the course, the various stages of meditations were also focused on developing a baseline compassion toward oneself.
I asked the instructor to consider the following thought experiment:
1. In Room 1: I am interviewing a patient with borderline personality disorder and proceeding by using the guiding concepts of therapeutic neutrality and empathy.
2. In Room 2: A psychiatrist with compassion training is interviewing a patient with similar problems.
Question: How would an observer compare the psychiatrists in Room 1 and Room 2? Would there be any discernible differences between the two?
The response I got was quite interesting. She suggested that the main difference would be after the interview was terminated - the compassion trained clinician would be less distressed after the interview than I would. The problem with that response is that I am not distressed at all interviewing patients. I have plenty of experience across a wide array of scenarios. At some level, I am much more comfortable talking to people in my office than just about anywhere else. The expectations are clear. I know what I have to do and have done it tens of thousands of times in the past. I can talk about anything a person wants to talk about including how they perceive me in that situation. In the interest of time and not wanting to appear argumentative, I did not bring that up. It does raise the issue of whether the new interventions for burnout have much to add over appropriate training from the past. I have practiced mindfulness techniques and meditation and like a lot of the patients I see - they don't seem to add much.
In the summary session I requested the microphone. I don't come across well in a potentially contentious environment. When I speak people think that I am irritated or angry and that probably affects my message. I consider myself to be passionate - but I am not really angry about anything. It would be foolish to be angry about various things that haven't changed in 20 years.
At the micro level my emphasis was on direct connections. I described a scene from my internship, where another intern and I were responsible for a patient on a balloon pump in an ICU setting. At one point we looked at one another and realized there was nothing more we could do. I knew from the look on his face at 4AM that he was as distressed about the situation as I was. We did not know enough at the time to realize that there was nothing anyone could do - but it would have been very useful to have somebody tell us that. In those days, there was an implicit rule that attending physicians should probably not be called at night and that everything in the hospital could be resolved by you and your Internal Medicine PGY3. I only heard one attending ever give us explicit instructions and that was "I don't want to be surprised in the morning." My resident had to translate it for me: "We need to call him if somebody is going down the tubes." As an attending physician myself, I wanted to make sure that never happened. I got called by a resident who had a very confusing patient presentation and went in and made the diagnosis of serotonin syndrome and had the patient transferred to the ICU. My emphasis at the micro level was that there has to be clear communication that you don't mind discussions and consultations about cases even when you are out in practice. I am consulted by and consult many psychiatrists by phone and email on an ongoing basis and any time of the day and it has been a great source of professional development and peer support.
At the macro level, my message was politics. The speaker touched on the EHR as a burnout factor and what they might need to do about it. Nobody mentioned maintenance of certification. Some people seemed irritated that I mentioned either politics or MOC in this course that was supposed to be about preventing burnout and creating a more resilient workplace. I don't know what a more resilient workplace is. The workplace is resilient simply because it is out of physician control and completely resistant to change. There are more ways to get the EHR and MOC changed than hope that a hospital association will do it with survey data. I proposed that physicians consider political activism at the level of the practice environment and the government level and that they consider defeating MOC.
At the end one of my colleagues told me she appreciated the approach to providing residents support and wished she had it in her training program. I was glad I got that message out. No takers on the EHR or MOC.
I will keep going and adding my two cents - even though my anxiety seems to be getting higher and higher every time. At some level I probably realize that there are very few people who see the psychiatric world the way I do - and I know my time is limited. I also know that I don't see anybody coming along who is prepared to challenge the status quo that seems to keep dictating our deteriorated practice environment.
George Dawson, MD, DFAPA
1: Sims A. Symptoms in the Mind, 3rd Edition. Elsevier Limited, London (2003): p 3.
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