2 + a Checklist: The Formula for Compassion

by Khushboo Jhala 

With my cleanly pressed short white coat, a pen planted neatly in the top left pocket above my official “Medical Student” ID, and a fresh notepad firmly grasped between my hands, I knocked on the door. I heard the soft-spoken words, “come in,” and entered with the intention of seeing a 22-year-old female patient who, according to her chart, was hospitalized because of an anticoagulant medication overdose. She was a new admittant at the end of the day, right at 5 pm. My purpose as a third year medical student was to obtain a thorough medical history and formulate a plan of action to keep her stabilized after the overdose. As I pulled up a chair next to her hospital bed, I leaned forward and made a point to have good eye contact. I took note of her vitals and began to ask the standard questions of why she was on anticoagulant medications, what were her previous diagnoses, and why she took more than prescribed. It was already 5:45, and as I hurriedly began wrapping up the interview, I was reminded of one more thing on my mental checklist, “Oh, don’t forget to be culturally competent and verbally compassionate.” I awkwardly asked a few questions from the list of Kleinman questions that I was familiar with from my first two years of medical school.

Like many other medical schools, my institution emphasizes compassion. The theme is woven into all of our activities, from basic science courses to community volunteering. A class entitled “On Doctoring” focuses on the application of skills and tools necessary for fostering compassionate and competent physicians. One of the first tools in our toolbox was a script of questions called Kleinman Questions. Developed by Dr. Arthur Klienman, a psychiatrist and Professor of Medical Anthropology at Harvard University, the eight questions provide a framework in which the medical provider can better explore how a patient’s culture, thoughts, and beliefs affect their understanding of their illness. These questions empower patients as active participants in the medical decision making process. Examples of the questions include: “What do you fear most about your illness?” and “What are the biggest problems that your illness has caused for you?”

The Kleinman Questions script is not the only checklist that has been created for physicians to follow in order to be more compassionate. Interested in the idea of how best to teach compassion, I undertook a research endeavor as part of the Schwartz Fellowship sponsored by the Schwartz Center for Compassionate Healthcare. Upon researching the topic, my mentor and I came upon the work of Dr. Helen Reiss, a psychiatrist and Director of the Empathy and Relational Science Program at Harvard University, who developed the acronym “EMPATHY” based on scientific translational research. In the video, Introduction to E.M.P.A.T.H.Y, Reiss explains that, “how physicians choose to communicate can influence their patient’s neurological and physiological states.”1 The acronym EMPATHY helps providers with compassionate communication. In the model, E is for eye contact, M is for muscles of facial expression, P is for posture, A is for affect (expressed emotions), T is for tone of voice, H is for hearing the whole person without judging and Y is for your response, as people mirror each other’s feelings.

What, then, is the impact of teaching nonverbal and verbal compassionate gestures to a group of medical students? A survey asking how patient interactions have gone through implementation of these techniques to our first and second year class painted the picture of an awkwardly scripted patient interview, with robotic gestures and phrases, leading to segmented interactions. Simultaneously, a survey of patients’ opinions on the matter indicated that many disliked the idea that a standard template could be used to understand their individual and unique values, goals, ideas, and concerns.

While one would hope that being compassionate would come effortlessly to all physicians, the scenario at the beginning presented an example of how sometimes interactions may not go so smoothly. First, while I wanted very much to be present and empathetic with my patient, she was a new admittant at the tail end of a day in which I had skipped lunch to address other patients’ concerns; the churning of my empty stomach contributed to my distraction and hurriedness. Second, at a glance of her chart, I had close to no similarities that would allow me to connect with her, be it demographic, medical, personal, or any other. For many, it is difficult to pull empathy out of a hat when there is little common ground in the first place. I imagine that the initial interaction felt distant and uncomfortable to her, as she was already in a vulnerable position. Despite this rough beginning, we both went through the motions of asking and answering questions.

When I asked her what bothered her the most about her disease as part of my checklist, rather than telling me about medical issues, she described to me about how she felt like a burden to her already financially struggling parents. When she told me that she had never had a boyfriend, I “sustained eye contact” instead of looking at my notes. While looking at her, I could see the fear she felt of never being loved by anyone because of her disease. These were concerns that many of us have faced: the general distress of letting others down, the longing to be loved. Within a matter of minutes, I became more present and the interaction seemed to flow more naturally. When I left the room, I entered the information in her chart while eating a granola bar. I brought her back a glass of water and magazine before I left for the day since she had told me that the television in her room did not work.

In my view, there was absolutely nothing spectacularly compassionate about that interaction. So when I found out that she later said that the magazine was one of the most comforting and compassionate things anyone had done for her during her stay in the hospital, I was surprised. Her comment made me re-examine what compassion meant, and what it was that I saw in my own personal physician care that led me to think that doctors were compassionate individuals. Compassion does not come in magnificent gestures. It comes in little gestures, like bringing someone a magazine or a glass of water.

How, then, does a checklist translate to compassion in the way just described? I cannot speak for how the patient felt about the Kleinman questions or how my gestures were perceived. Perhaps she did not feel empowered at all by the questions, and was not particularly affected by my posture. What I do know, however, is that by understanding her narrative, I was reminded that we are both human; that while I was hungry, she was scared, and that we both needed each other’s support and cooperation to make this a meaningful interaction. I did not think twice about giving her the magazine because the natural extension of that interaction was walking out of the room and thinking, “what would comfort me if I were in her position?” and that while I could not change her financial situation or the reality of her disease, “what could I do right now?”

I have come to the conclusion that checklists do not foster compassion. Sitting with the right posture, making the right eye contact, and asking the right questions does not in and of itself make a physician sympathetic or empathetic. Rather, it is the absorption of what you observe while leaning forward and sustaining eye contact, and the listening of and responding to the answers of the questions on the checklists, that allow for meaningful relationships. While most often these things come naturally to physicians, in times of being rushed, tired, hungry, or wrapped up in the bustle of work, the checklists serve as solid reminders to be the type of doctor that each of us came into medicine to be: considerate and kind individuals. To patients, then: thank you for bearing with us through our occasional robotic routine. Sometimes, compassion takes 2 + a checklist.

 

PDF available: Khushboo Jhala, “2 + a Checklist,” Voices in Bioethics (2015).

Reference:

1 Helen Reiss, Introduction to E.M.P.A.T.H.Y. Retrieved from http://empathetics.com/wordpress/wp-content/uploads/2012/06/web_intro_r1.mp4

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