Her Near-death Experience Opened Physician's Eyes to Empathy

Medical doctors don't need to undergo a near-death experience to better engage with patients. What they need is empathy, says a pulmonary disease specialist who learned first-hand.

It took her own near-death experience in 2008 for Rana L.A. Awdish, MD, to comprehend the gulf in empathy that exist between hospital staff and the patients in their charge.

Awdish, who specializes in pulmonary disease, critical care medicine, and internal medicine at Henry Ford Health System in Detroit, MI, details her experience in a recent essay in the New England Journal of Medicine.

She spoke with HealthLeaders Media about the need for understanding the patient perspective. The following is a lightly edited transcript.

HLM: What is needed to understand the patient perspective?

Awdish: You don't need a near-death experience. What you need is empathy. Physicians have many things that they have to tend to every day. We cut back on those conversations that connect us with our patients. That is a mistake.

All of that is reciprocal and it's why we went into medicine in the first place. But we are at risk of demoting that on the list of things that are important in the day, just because of the many demands placed on us.

In every encounter, center yourself with your patient and try to understand from their perspective what they are going through, because that is the first step of empathy, taking the perspective of another person.

HLM: What happened in your experience as a patient that allowed you to see the lack of empathy that you had not seen as a physician?

Awdish: My position changed from being the physician to being the patient, being in the patient's bed.

The things I thought my patients needed from me, the highly technical expert care we deliver so proficiently, I took that as a given. I knew that would happen.

I didn't know that as a patient I would have needs beyond that. That sounds naïve, that I perceived that all my patients wanted was to get well, but I truly saw suffering as an extension of the disease. I thought my role was to cure the disease, or at least treat it, and the suffering would be alleviated. There was no reason to tend to it in the moment because it would just delay solving the problem.

HLM: How do you walk the line between empathy and being overcome by patients' suffering?

Awdish: There is this idea that we are all taught in medical school about the necessity of partition, maintaining composure regardless of the circumstances so that your emotions are not the ones in the room that matter.

We were taught that both as a means of preservation, but also of protecting our patients from our emotions. I would argue that that [guidance] is antiquated and misguided. To foster resilience in physicians there have to be moments of connection and shared purpose and attention to suffering because that is what fulfills us in the end.

It is not prescribing the right anti-hypertensive. It's connecting with our patients as people, feeling their suffering and feeling that you have alleviated it somewhat.

We don't get depleted by that. There is reciprocity in that. That is the frameshift that has to happen. The fear of connection is misguided.

HLM: Can empathy that be taught?

Awdish: If it's not, I should retire because I am fully convinced that it is where we need to go. Yes, there is good evidence that perspective taking can be taught, that having a sense of your own implicit bias can be taught, and that it can be improved upon. We use situational learning to do that, but there are many avenues by which we can affect change.

HLM: What have you done at Henry Ford to address empathy?

Awdish: The first thing was to start a discussion. We developed programs that are professional development tools.

We spend all of our time in medical school and residency and fellowship learning clinical skills and content and we don't spend a lot of time developing our emotional intelligence, our narrative competence, our ability to get a history from someone that is authentic to who that person is, but not just trying to corral them into 'yes' and 'no' answers.

Everyone goes into medicine because they want to do right by their patients, and they don't want to harm them. We in medicine have a history of unintentionally harming our patients through our behaviors, and so we are all focused on changing that.

HLM: What metrics do you use to know you are succeeding?

Awdish: The measure of success that I care about most is this sense of relationship between physicians and their patients. One of the tools to measure that is physician engagement. When physicians have relationships that are nurturing and fulfilling and their patients are co-creating a care plan with them, those physicians have longevity.

CMS has a measure called CAHPS, which looks at provider communication, which measures how effectively we are communicating as rated by our patients. It's under the umbrella of patient satisfaction, and all of those intangibles that go into someone wanting to recommend your practice or wanting to come back to you.

There are issues with the survey, as there are with every tool, but we have to embrace it and note that physician communication drives those scores.

HLM: How do you avoid making this 'one more thing' that frazzled physicians have to contend with?

Awdish: There are very few interventions that you can make in healthcare that not only engage the patient in their own care, that also improve adherence to medication, but also improves provider engagement and longevity and resilience.

That is the Holy Grail. How do we make patients happy at the same time as we are engaging providers and enhancing their professional fulfillment? This to me is so tangible.

We were medical students who were thrown into family meetings with no skills, no road map, no plan for how to get from A to B, no sign posts to watch for.

Until I found those tools, I would find ways to avoid those situations because I wasn't skilled. Being shown what to do gave me the courage to enter those conversations knowing they would turn out OK and I could help people and not wreck myself in the process.

There are very few things that can do that, that can engage both sides. It's team building, so when nurses are drawn into this, the whole team functions better. I don't think there is a downside to communication training.

HLM: There are thousands of employees at hospitals. How do you get everyone on the same page?

Awdish: No one has the resources to assign one-on-one care coordinators. When you orient people to a mission, when as an institution you let people know what their value is and not just their jobs, and you engage them in patient care in whatever position they are in, that they understand they are part of the care team, it translates across the culture.

These are not things that are specific to physicians and nurses. If you are in healthcare you need these skills because you have points of contact and you cannot imagine the impact you have on patients.

That is part of what we do at the new employee orientation. It is transporters, and billing clerks, and radiology techs, and everyone engaged in the process. To show them what it means to work here and the lives that you can impact, when maybe you don't think that that is what you signed up for when you signed up for the job. It changes the conversation.

HLM: Can what you're recommending be done at hospitals with few resources?

Awdish: You can start with a simple focus on empathy, which is taking the perspective of the other person, identifying what you see that they are feeling, whether it is sadness or anxiety or being overwhelmed, and reflecting it back to them so they know they are being seen. In many ways that is what is missing in healthcare.

Our patients feel they are seen as diseases rather than as people who are bearers of disease. By reinserting empathy in every interaction you can overcome much of that.