Reflection and Refraction

I have spent much of the last year or two thinking about empathy. An etymological breakdown of the word is ‘in – feeling’; from the online etymological dictionary we get the definition of ‘A term from a theory of art appreciation that maintains appreciation depends on the viewer's ability to project his personality into the viewed object.’ Similarly, empathy was once described to me as a way of ‘feeling your way in’ to a person. When we empathize with patients effectively, we are feeling our way into their state of emotional, physical, and social wellbeing. In medical school, our Art & Science of Clinical Medicine (ASCM) course intends to teach us patient-centered interviewing techniques, encouraging us to be non-judgmental, cultivate empathy, engage in active-listening, and connect with our patients. But does this truly teach us how to understand our patients? Four years later, I can see that there are clearly individuals to whom this comes more easily or those who have learned to be better at this Art than others. In my previous post, I alluded to changes in medical education that are focused more on encouraging these non-medical expert components of physician competencies, but today I would like to discuss it in more depth.

What is it that makes some of us better at connecting with our patients?
How can we learn to be better at it?
hat are some of the barriers to developing this skill?

I think at the root of this ability to empathize with our patients is awareness. This awareness is not only of others, but also of ourselves, and of how we interact with others. Medical Education has done a much better job in recent years of addressing diversity in our patients, not only in terms of race and gender, but also varied cultural groups, sexual orientation, and socio-economic status. This intrinsic curriculum does a good job of increasing knowledge of others (often described as Cultural Competency) but often falls short of true understanding, and, it does little to address knowledge of our self, our personal prejudices, biases, and privilege that influence how we interact with the world.

Beyond Cultural Competence: Critical Consciousness, Social Justice, and Multicultural Education, by Kumagi & Lypson, addresses this particular issue very succinctly. They comment on the very nature of the term ‘Cultural Competency’ as a “knowledge of characteristics, cultural beliefs, and practices of different non-majority groups, and skills and attitudes of empathy and compassion in interviewing and communicating with non-majority groups”; as such it is often thought of as a static outcome, as opposed to a way of being. They argue that it is far more important to cultivate a Critical Consciousness: “the continuous critical refinement and fostering of a type of thinking and knowing of self, others, and the world.”

This idea, whose conceptual roots were developed by Paulo Freire, requires a deep awareness, not only of others, but of ones’ self and the disparities and differences that exist subsequent to power and privilege imbalances; Friere describes this as “reading the world”. Further however, it involves reflection on our own emotional and intellectual response to knowledge of this inequity. By employing self-reflection, we can increase self-awareness of our own implicit biases, beliefs, and values that may affect how we respond to others that may be similar or ‘other’ to ourselves. By understanding and being able to predict our responses, we can therefore adjust our interactions on an individual basis to best empathize and connect in a therapeutic manner.

If developing critical consciousness it the goal, I would argue that current strategies in place at this medical school at least are not adequate. There are individuals certainly that have learned to be self-aware independent of being explicitly taught, but should we not encourage all medical graduates to achieve this ability? The challenge however, is determining how this ability can even be taught or incorporated in medical education curricula.

Enhancing Self-Awareness in Medical Students: An Overview of Teaching Approaches by Benbassat & Baumal provides an excellent review of several studies published at a variety of medical schools that have attempted to address this in their curriculum. Of note, Henderson & Johnson discuss a course in Cambridge that has been developed that consists of 16 full or half-day workshops where small groups meet to have an encounter that is designed to foster self-reflection and personal development and then must subsequently write a reflective evaluation of the session via e-mail to their preceptor. While many of these studies are very interesting, Benbassat & Baumal highlight the lack of depth and controlled studies in this field, cite many of the challenges or potential pitfalls of these approaches, and conclude that: “before we recommend the use of direct small-group programs for enhancing self-awareness, medical educators must be more certain than they are today that the benefit of such programs exceeds their cost.”

At our own school, we have the Portfolio course which has us meet in facilitated small groups to discuss and reflect on experiences we have had throughout clerkship and to subsequently submit a written reflection. While I have found this course valuable as an opportunity to see friends and discuss challenging experiences, I have often found it limiting as it requires you to select and write about stories centered each time on a particular CanMEDs role. The reflections I have created were useful when it came time for my CaRMS interviews, but in retrospect, I think there is the potential for so much more in these small groups.

Imagine the opportunity for discussing specific lived experiences: As an example, we have the chance in second year to practice a palliative care end-of-life discussion in an ASCM group. While useful practice, there is so much more that could be gleaned from that discussion beyond the practical skills. A portfolio group meeting immediately after a workshop surrounding end of life care could allow individuals to explore their feelings surrounding death, what it brings up in terms of their own emotional responses, what they believe, their own particular religious beliefs and how that might affect how they respond to other individuals’ beliefs prior to death… the list goes on. I regret not having had that opportunity to explore my feelings and emotions with my colleagues in situations such as these and to have helped others to develop to become better physicians.

Noon rounds today were particularly inspirational, focusing on the art of Narrative Medicine. I was reminded again of Dr HPK and the story I told in my previous post about how being there to listen to patients’ stories and bear witness can be equally as or more effective than a physical treatment. Dr Abdullah used the term ‘refractive listening’ in describing one of her narrative exercises. It particularly captured the idea that a story is changed by being told and by being heard. By listening and absorbing and responding to the story, not only are we reflecting it back towards others but we are in fact refracting the story, or changing it into something more, and giving it deeper meaning.

As physicians we are incredibly privileged to encounter so many individuals in our lives with amazing stories, just waiting to be told, heard, and given deeper meaning. We all know how to listen, but for a patient to be truly heard and for us to feel fulfilled, we must cultivate our empathy, our self-awareness, and a deeply critical consciousness. We are truly doing our future patients a disservice by not incorporating formal teaching in these areas to our current standards of medical education.

~LG