Attending

by Ronald Epstein

  These are experiments in a laboratory and present crude models of how the brain—and the mind—works in the real world. But they are revealing in terms of how we train doctors.25 I finally understood why training physicians to be more sensitive and to resonate with patients’ emotional distress—a good thing—can lead to emotional exhaustion and burnout. In fact, when I’ve surveyed students and residents, some of those who score highest on empathy are sometimes the most burned out. They experience secondary—or vicarious—trauma from having assimilated the suffering of others. For years, I had been training medical students, residents, and practicing physicians to name and acknowledge the patient’s feelings, by saying things like “Now I have a better understanding of how much pain you’re in.” Was this approach all wrong? Could it be that too much empathy was toxic? We had been training our students to share emotions and take the patient’s perspective, but had failed to help them be aware of and manage their own strong feelings. Feeling traumatized, they disconnected, assumed a stance of cool objectivity, avoided getting involved. Which is to say that training in empathy is a good thing, but it goes only so far. It’s now clear that we also need to train physicians to be compassionate, not only for the sake of their patients, but because compassionate action seems to relieve the emotional tension that is inevitable when we try to imagine the experience of another. It’s an antidote to burnout.

  We know now that it is possible to train clinicians to be more compassionate, an idea that would have been considered radical just a few years ago. Yet, the emotional “climate” of the health care institutions within which doctors work is typically unsupportive, hardly providing a model of compassion that clinicians can emulate with their patients. To provide compassionate care, we have to address institutional climate and values. Consider the alternative. Empathy—and compassion—are doomed to decline if we continue to neglect the emotional lives of physicians, if we fail to provide the conditions under which they can learn to regulate their emotions, develop mental stability, and have the right kind of equanimity—an engaged equanimity in which clinicians are present with—but not consumed by—patients’ emotional needs. And it’s not just physicians; “compassion fatigue” is as much of a problem among nurses and other health professionals.

  TRAINING IN COMPASSION

  But how?

  When I learned about metta meditation—sometimes called loving-kindness meditation or compassion practice—it initially struck me as insufferably New Age. I couldn’t imagine how dreamy voices, pictures of lotuses, and invitations to a “revolutionary art of happiness”26 could possibly appeal to hard-edged physicians.

  Metta is a Pali word that translates as “friendship” and “kindness,” a sincere wish for the welfare and genuine happiness of others. Metta is an attitude that the practitioner aspires to bring to all beings, without exception—so-called nonreferential or unconditional compassion—akin to Aristotle’s concept of philia, or “brotherly love.”27 If you take the view that humans have the capacity for compassion but are hindered by a distorted view of the world, then it is possible to remove those hindrances through practice.

  The first time I experienced it, I was at a workshop. During the guided meditation, the teacher instructed us to imagine ourselves and our positive attributes, then to extend kindness to ourselves, then a “benefactor,” a friend, a “neutral person,” a “difficult person,” and finally “all beings.” We were asked to enact silently, in our minds, a series of phrases, first directed toward ourselves: “May I be free from danger, may I be happy, may I be healthy, may I live with ease.” Then, to others, in turn: “May they be free from danger, may they be happy, may they be healthy, may they live with ease.” And so on.

  I took some solace when I learned that compassion practice has been part of meditation traditions for over twenty-five hundred years. But could you really train people to be kind, to befriend, to care? Or was this exercise an indulgence, helping well-educated, privileged healthy people feel good about themselves? Somewhat skeptical, I went along with the exercise, trying to keep an open mind. I noticed that it was more difficult to wish myself well than to direct kindness toward a friend. This certainly was revealing in how difficult it is for clinicians to care for themselves. I wondered what a “benefactor” meant to me, and how I had expressed my gratitude for my benefactors’ selfless actions. It helped me appreciate how many people had helped me to get where I am. When I was asked to imagine standing beside a “difficult person” and wishing him well, I became more curious about my interactions with people whom I regarded as difficult and began to recognize that their presence was teaching me something helpful too. I found myself feeling deeply grateful—to others and to myself. Being in a room with others, all of whom were working on cultivating something positive, was powerful—it created a sense of community and shared purpose. What had seemed to be a rather odd and forced exercise began to make sense.28

  Since then, at least one research study has distinguished the neural fingerprint of compassion practice from other forms of contemplative practice. Studying a group of novice meditators for nine months, psychologist Tania Singer’s research group at the Max Planck Institute found that compassion practice led to activation of the inferior parietal cortex, the dorsolateral prefrontal cortex, and the nucleus accumbens—demonstrating links between the “reward circuit” in the brain and the parts of the brain that have to do with understanding and resonating with the feelings of others, and the ability to regulate our own emotions (what is commonly called emotional intelligence).29 While you don’t need a functional MRI scan to “prove” that bestowing kindness on yourself and other human beings is a good thing, this line of research30 is tantalizing now that evidence suggests that through practice people can act more altruistically and expand their emotional compass.

  9

  When Bad Things Happen

  Angela Bradowski had over three hundred pounds on her five-foot-three-inch frame. For the first two years after I diagnosed her with diabetes, she controlled her disease with oral medications. Then her blood sugars started climbing from the 100s to the 200s, then the 300s. I didn’t see her for a few months, and when she came back, her blood sugar was nearly 500. When it gets above 600 or so, people are at risk for coma and even death.

  Angela had all of the classic signs of poorly controlled diabetes—insatiable thirst, frequent and copious urination, weakness, and blurry vision. I started her on a long-acting insulin (glargine), otherwise known as Lantus. Normally insulin doses range between thirty and eighty units per day, and patients with insulin resistance may need doses in excess of one hundred units. But Angela didn’t seem to respond, and with each visit I increased her insulin even further.

  I started to feel out of my element when her Lantus dose exceeded one hundred units twice daily. I consulted the medical literature and called a diabetologist. He had had a couple of patients who had needed doses of over four hundred units a day, and some cases in the literature documented patients receiving close to a thousand units. Emboldened, I kept increasing the dose, and eventually Angela was giving herself four hundred units twice a day, and still her sugar was out of control.

  I asked Angela about her diet, medications, and physical activity—the usual questions—yet I was baffled. Nothing seemed to explain the situation. She didn’t eat all that much. She didn’t exercise, but that wouldn’t explain her extraordinary resistance to insulin. The most common explanation—not taking her insulin—didn’t seem to apply. She had the skin marks to prove it, and she had been refilling her vials of insulin on schedule.

  Occasionally people are more sensitive to one formulation of insulin than another. With that in mind and on the advice of the diabetologist, I switched her insulin from long-acting to intermediate-acting (NPH) insulin. Not knowing what would happen, I started her on eighty units twice a day, one-fifth of her previous dose. I was hoping that the more rapid onset might control her blood sugar more effectively. It seemed to be worth a tr
y.

  The next day she was hospitalized with a stroke. She was found unconscious at home and her blood sugar was zero when the ambulance arrived. By the time I got to the hospital, she was beginning to wake up; she was drowsy, but couldn’t move her left side. In the emergency room, George, her husband, was waiting for news about Angela’s condition. He told me that he had been worrying about her because, unbeknownst to me, she had been slaking her unquenchable thirst with three two-liter bottles of sweetened iced tea every day. My heart sank. Now it all made sense. I did a quick calculation—at least two thousand calories in addition to whatever else she was eating.

  When diabetes is out of control, glucose doesn’t get into the cells and stays in the blood, making people urinate copiously and frequently to try to get rid of the sugar. As a result, they get dehydrated and thirsty. Insulin also makes you hungry and gain weight. Angela’s craving for liquids and sweets was insatiable—the more she took in, the worse it got. I had asked what she ate every day, and I had asked about soft drinks, but I hadn’t thought to ask about iced tea—and she didn’t volunteer it. Because Lantus acts slowly, she could take in enough sugar to keep up with the insulin, and then some. In essence, I was prescribing what for most of us would be a lethal dose of insulin, and she was rescuing herself from hypoglycemia with her own form of resuscitation, which then would send her blood sugar skyrocketing. But, with the switch to NPH insulin, this could no longer work. NPH has a more rapid onset and she couldn’t keep up, no matter how fast she might drink—even though the dose was lower. She almost died—at least in part from following my instructions.

  I vacillated between being furious with her for not telling me an important piece of information and being furious at myself for not having done a more thorough nutritional assessment. She certainly had the opportunity to tell me, but perhaps she felt she needed to hide it, or perhaps it never occurred to her. While I didn’t bear sole responsibility for the situation, neither did she. It was somewhere in the middle. She had seen other physicians and the nurse-practitioner on our primary care team. None of them asked either. In that sense, our health care team failed her. One could even say that the larger health care system failed her. She had many life stressors and a long list of physical and psychological conditions, and the fifteen-minute visits that were allotted to her didn’t allow enough time to address them all—or even come close. Her insurance covered only a one-time visit to a dietitian, and she had used that up. Perhaps with more time for each visit, or a more sustained relationship with a nutritionist, her iced tea consumption might have been disclosed.

  Angela was fortunate. Over the next two days she improved, with seemingly little residual damage. It’s remarkable that she survived at all. She went home a few days later on low doses of NPH insulin—and no iced tea. She was scared and never wanted to have something like that happen again. She controlled her diabetes effectively from that point on. She lost weight. I told her that I felt bad about having prescribed a dose of insulin that resulted in a major scare. It’s remarkable how forgiving some patients can be. She was grateful to be alive.

  After the dust settled, I mentioned the event to a trusted colleague. In an attempt to be supportive, he was all too eager to absolve me of any responsibility before having assimilated the details of the situation, saying that I had done nothing wrong and that the responsibility was the patient’s. Strikingly, for him it didn’t even register as an error, yet I felt traumatized. In fact, if you ask most physicians whether they have made a significant error during their medical careers, they will more likely than not say no, they haven’t. Yet over one hundred thousand patients die each year as a result of medical errors, mostly preventable, and hundreds of thousands more experience nonfatal errors and near misses.1 Experts on medical errors would define Angela’s as a “potentially preventable” error—a near miss.

  FATAL MISTAKES

  Other errors don’t have such positive outcomes. Most dramatic are medication errors and surgical errors. Several years ago I discharged Kathryn Wolk from the hospital with a prescription for methotrexate—a powerful immunosuppressive medication to help control her symptoms of lupus. She was transferred from the hospital to a nursing home under the care of the nursing home physician. Somewhere in the transition to the nursing home, someone—it’s not clear who—wrote that Kathryn should be receiving three pills daily. The correct dose—the dose she was receiving in the hospital—was three pills once a week. The incorrect prescription wasn’t noticed for months until I received a report from the nursing home. I was furious and incredulous. How could this happen? By that time she had developed pulmonary fibrosis, irreversible scarring of the lungs caused by methotrexate toxicity. She died several weeks later.

  Kathryn’s daughter was also a patient of mine. I had to explain. “Everyone feels very badly that this happened, myself included. Kathryn clearly got the wrong dose. It was a terrible miscommunication.” This explanation didn’t sit well with Kathryn’s daughter. “Why didn’t anyone notice?” she inquired. I was honest: “I scoured the records—at least the ones I have access to—and I can’t figure it out. The discharge medication list said three pills weekly rather than three pills daily.” She asked, “You mean to tell me that she might have lived longer—maybe a couple of years? Do you think that I should talk to a lawyer?” If there’s anything to make a doctor feel on the defensive, to feel judged and inadequate, it is the threat of litigation.

  Here, a grief-stricken family member is trying to make sense of a complex series of events. She was puzzled, not only by how the events could have occurred, but also by my response. I felt devastated, but I had been counseled not to say anything that might implicate myself or anyone else. Kathryn’s daughter, like most people in these kinds of situations, wanted to know the answers to several simple questions: Did I or didn’t I personally make a mistake? Am I really sorry? Shouldn’t I apologize? Will this kind of mistake happen again?2 Even though I knew that I had written the correct order on Kathryn’s discharge paperwork, I was questioning myself—did I really communicate clearly? Was I really at fault? I was so preoccupied with my own conflicted sense of responsibility that I couldn’t be fully present with Kathryn’s daughter. I just wanted to hide.

  In 2000 the Institute of Medicine published a game-changing report on medical error in which they suggested that most errors in hospitals were problems of institutions, not of individuals.3 The revelation for most clinicians was that institutions were set up in such a way that errors were inevitable. This radical shift in consciousness impelled health care institutions to enact procedures to reduce errors—especially medication errors and surgical mishaps—through checklists, handoff protocols when patients were transferred to a new unit, team training, and time-outs prior to surgical procedures to assure that important details weren’t missed.

  The methotrexate disaster occurred a number of years ago, and perhaps tragedies like this are less likely now. But they still happen, and in some cases the solutions designed to prevent future errors, such as electronic health records, create the conditions for a whole new set of errors—for example, those that result from patients being transferred among institutions that have incompatible electronic record systems. Here, the error was a systems failure. It was a demonstration of the “Swiss cheese” model of medical error in which bad things happen when all the holes in the system happen to line up.4 My intention, though, is not to assign blame or guilt or to propose how these situations could have been avoided or changed. I’ve already explored how errors happen through inattention, not seeing, not being curious, not having an open mind, not being present—and how the solutions, often unique to each situation, depend on local factors. Here, I am exploring how physicians might approach bad outcomes more mindfully, regardless of their own responsibility.

  Physicians generally endorse the approach I took when meeting with Kathryn’s family—a measured disclosure and an expression of regret, without falling to pieces emotionally or assuming guil
t. Yet when patients sense a lack of heartfelt regret, it only fans the flames of their anger and feelings of abandonment.

  Physicians don’t apologize because they feel afraid. Lawsuits are just the tip of the iceberg. “Morbidity and mortality” rounds in surgical specialties can be a sadistic ritual in which the guilty party is thrown to the lions; there’s no sympathy or support. Even when lawsuits aren’t an issue, doctors are afraid to confront their fallibility. When we’re afraid, we clam up, which only makes matters worse because patients interpret lack of communication as lack of caring. Most malpractice suits start with a real or perceived error but are carried forward only if patients feel abandoned, if they feel that the doctor hasn’t listened or hasn’t expressed regret.5 Research by psychologists, physicians, and attorneys consistently shows that patients want an apology—it improves communication and diffuses anger.6 One research study even created mock trials; settlements were lower when physicians apologized.7 By trying to protect themselves, physicians may paradoxically increase their risk of being sued.

  With that in mind, most states have enacted “apology laws.” These laws, which offer some degree of protection to physicians if they are more fully disclosing about medical errors, have been associated with fewer and smaller malpractice settlements.8 Yet, physicians still hide, and apologies still don’t happen as often and in the way that they should.

  THE SECOND VICTIM

  With all of the current attention to errors, no one seemed to be paying attention to the inner lives of physicians when things go wrong—the emotional and interpersonal fallout of a bad outcome. In 2007, Amy Waterman, a researcher at Washington University in St. Louis, surveyed 3,171 physicians in the United States and Canada about the aftermath of medical errors and near misses. Of those who reported that they had made errors, most felt traumatized; 61 percent reported that they were more anxious about future errors, and over 40 percent reported loss of confidence, sleeping difficulties, and lower job satisfaction. Even near misses increased stress. I was not surprised that only 10 percent of the physicians surveyed said that their health care organizations were supportive after they or a colleague had made an error; I doubt it’s much better now.9 The emotional climate remains hostile; in general, physicians don’t want to hear about one another’s errors, and only now are health care institutions recognizing clinicians’ psychological trauma.