Empathy is key to healing…but is devalued in our healthcare system

No matter the technological advancements made, AI will never be able to fully imitate human connection. There is something unique about the trusting relationship between patient and provider, about person-to-person contact, that is innate to healing. A popular refrain states that the first evidence of civilization was a fractured femur that had healed, demonstrating that at some point, at least one human had taken care of another one until they had healed. Society is built around empathy and compassion for our fellow human beings.

“The art of medicine is a process for nurturing a special human relationship that champions a partnership for healing.”

– Dr. Bernard Lown

Most healthcare workers enter the field to care for those in need. But the system we have now makes it difficult to practice medicine in a way that fosters connection. As Jennifer Lycette, a rural community hematologist/oncologist from Oregon, notes in her STAT opinion piece, the pressure placed on physicians to get through as many patients as possible, as fast as possible, is not conducive to compassionate care. The pressure to be as “efficient” as possible has resulted in less time with patients and more time documenting. The burnout in some hospitals has gotten bad enough to push medical residents to unionize.

Time pressure pushes physicians to go-go-go. The lack of quality time with patients has documented negative impacts on physician well-being, empathy, and patient outcomes; could it be that AI performed better than doctors because of a systemic flaw and not an individual one? 

AI could support, not replace, human healthcare

It’s worth noting that the JAMA IM study is not completely comparable to real-life circumstances. Researchers could not ethically feed real electronic medical records into AI without violating HIPAA, so patient questions were chosen from a Reddit forum. This does not diminish the validity of the questions but could influence how human physicians answered them. Online culture, particularly Reddit, does not prioritize empathy and the humans responding may have followed online communication norms rather than professional communication norms. Human respondents were also not familiar with the entire medical history of the patients and may have had better results if they were seeing them in real life. 

This study suggests that AI at least has the potential to support quality, empathetic care. Already, AI is being used to streamline administrative tasks, answer patient questions, and for machine learning; its likely that in the near future there will be more AI scribes and virtual nursing assistants. As the technology continues developing, AI will be used to supplement care but it can’t replace doctors. The art of healing is a human one.

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Systems awareness and systems design are important for health professionals, but are not enough…..Ultimately, the secret of quality is love.

Last week, Lown president Dr. Vikas Saini was presented with the Donabedian International Award. 

Dr. Avedis Donabedian was a revolutionary physician who is credited with creating the field of healthcare quality and outcomes research. His model for measuring quality, the Donabedian model, has shaped the way healthcare quality is conceptualized. Like our founder Dr. Bernard Lown, Dr. Donabedian was a physician activist who advocated for compassion in healthcare. 

In his acceptance remarks, Dr. Saini shared his vision for a future of medicine that uses new technologies for socially responsible goals, while still keeping empathy and the human connection in medicine at the forefront.  View the video or read excerpts from the transcript of his speech below.

Dr. Saini on the art of healing: “Across the millennia a shaman accompanied us whenever we had an illness, whether serious or minor, reminding us of our frailty and transience in this world. Healers have always been honored–for healing if successful, but mostly for being present as a trusted companion on an unwelcome journey.”

Dr. Saini on AI: “Intelligent machines could unburden us of the tedious calculations of clinical effectiveness and cost utilities. More than that, they could democratize expertise and radically reduce the division of labor between knowledge workers and manual ones.  Most importantly, they offer the promise of democratizing healthcare policy itself by helping non-specialists understand complex issues, set priorities and make trade-offs. But the barriers are enormous. AI models trained on backward-looking datasets will reproduce biases and reinforce obsolete paradigms. The massive capital required increases the risk of monopolies of the few.  Critically, machines have no values; they do not care about people. It is therefore urgent that all of us engage in a debate on the role of AI in reshaping health care.”

Dr. Saini on the future: “There is a yearning worldwide…because people want to escape the cul-de-sac of a sterile modernity and return to a geography of connection and of solidarity–solidarity with each other and with the natural world. If we fail, we may become the tools of our tools and turn machine intelligence into the enemy of human freedom. If we succeed, we may create the space for all health workers to focus their energies on Right Care for their patients.  Freed from the burden of repetition, we could enjoy a future of radical fulfillment and a democracy of knowledge that enables a democracy of health. If we can imagine such a future we can create it–a world that allows us to return to our roles as shamans in a digital village, free to focus on the things that matter most: warmth, empathy, and profound human presence that can overcome the angst of the clinical moment.”

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Another potential consequence of social isolation is medication overload. Older adults who are lonely may report depression or pain to their doctors, which can result in a prescription for medications that have concerning side effects for older adults. Chronic health problems associated with multiple medication use can also make it difficult for older adults to be social, which can lead to loneliness.

In a recent study in JAMA Internal Medicine, researchers at the University of California, San Francisco School of Medicine examined the relationship between loneliness and use of medications that pose a high risk of adverse events for older adults.

Older adults who reported high levels of loneliness were more than twice as likely to be taking a benzodiazepine or sedative compared to those reporting no loneliness.

The researchers used data from the National Social Life, Health, and Aging Project (NSHAP), a nationally-representative survey of adults 65 and over living in the community (not in a nursing home or other institutional setting). The probability of medication was adjusted for age, sex, race/ethnicity, education, and multimorbidity (having more than one health condition).

They found that older adults who reported moderate or high levels of loneliness were more significantly more likely to be taking certain pain relievers, sedatives, and antidepressants. For some of these drugs, the difference was striking. Older adults who reported high levels of loneliness were more than twice as likely to be taking a benzodiazepine (11% vs 5%) or sedative (20% vs 9%) compared to those reporting no loneliness. Lonely older adults were about twice as likely to be prescribed an antidepressant compared to adults reporting no loneliness (27% vs 14%). High levels of loneliness was also associated with higher rates of polypharmacy; half of lonely older adults were taking five or more drugs, compared to 41% of adults not reporting loneliness.

The link between these medications and loneliness is concerning, because these medications have potentially dangerous side effects and are not recommended for older adults. Benzodiazepines and antidepressants increase the risk of falls, fracture, cognitive impairment, and other adverse events. And chronic use of NSAIDs (non-steroidal anti-inflammatory drugs, like high-dose aspirin or ibuprofen) increases the risk of kidney failure, cardiovascular events, and ulcers and bleeding, which can be life-threatening.

“It’s easier to prescribe a pill than to ask ‘Why are you lonely?’ and listen to the answer.”

Dr. Carla Perissinotto, geriatrician and Associate Professor of Medicine at the University of California, San Francisco

Further, there is little evidence that taking these medications reduces loneliness; these medications are used to treat the symptoms of loneliness while the underlying causes go unaddressed. “It’s easier to prescribe a pill than to ask ‘Why are you lonely?’ and listen to the answer,” said Dr. Carla Perissinotto, geriatrician and Associate Professor of Medicine at the University of California, San Francisco.

The study authors recommend “prescribing” social interventions for lonely older adults, by referring them to local community-based support programs. Not only would this help address the underlying causes of loneliness, but also would avoid prescription of high-risk medications. However, this requires clinicians to take the step of discussing such a personal topic with their patients, which requires time and a trusting relationship. “We see loneliness in our older patients every day, but we don’t have time to ask them about it, because we have to check off so many other boxes,” said Perissinotto.

In our current health system, clinicians have less time to spend with patients, and we expect to get a “pill for every ill.” Unfortunately these factors have led to the medicalization of loneliness, in which older adults are put at grave risk of harm from overmedication, while their underlying social isolation goes unaddressed. To tackle this problem, we need to give clinicians and patients the time and space to have difficult conversations, make “social prescribing” options more available to clinicians, and educate both clinicians and patients about the risks of certain medications for older adults.

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“If doctors don’t understand how likely — or unlikely — it is that a treatment will help, they can’t give patients the best advice for their care.”

Dr. Daniel Morgan

What is the difference between these two questions? The example of remdesivir can lend some insight. The antiviral drug recently approved to treat Covid-19 has had mixed evidence, but in one study was found to reduce the risk of death in hospitalized Covid-19 patients from 15.2% to 11.4% after 30 days. According to that study, the likelihood that it works for any one patient is small. This means that clinicians and patients or family members have to discuss the potential benefits in context of side effects and cost.

As Morgan writes, most medical treatments fall into this gray area of having a known but unlikely benefit for patients. This is especially true when it comes to preventive treatments for patients without symptoms.

For example, for patients without existing heart disease, taking a statin reduces the risk of having a heart attack or stroke, but only by 0.4%. On a population level, that adds up to a lot of heart attacks prevented over the years. But on an individual level — when patients want to know if this medication is “right for me”– the small benefit may not be seen as worth it, especially for people who are already taking many medications, or those who have experienced disruptive side effects from statins.

“Our job isn’t only to cure people; it’s also to help them make it through when there is no easy cure.”

Dr. Daniel Morgan

It might make sense that patients who aren’t trained in medicine may overestimate the benefits of medications. But surprisingly, doctors are also overly optimistic when it comes to the potential benefits of treatments — why? Morgan cites several potential reasons: There is very little training for doctors (if any) in statistics and probability, which are skills needed to evaluate benefits and harms of medications; promotion from drug and device companies may influence clinician thinking; clinicians may fear getting sued for not doing enough; and performance metrics often use “one size fits all” guidelines, even when a certain treatment doesn’t benefit all patients.

For better patient-centered care and less overuse, we have to reverse some of these trends. Providing better clinician training in basic probability, removing performance metrics that incentivize overuse, and prioritizing spending time with patients and having shared decision making conversations would go a long way, Morgan writes.

He also calls on doctors to embrace the gray area rather than avoiding tough conversations. Acknowledging the limits of medical treatments can be difficult for clinicians that view themselves as needing to be “invincible.” But doing this will help “foster a more holistic and meaningful sense of the doctor’s role,” Morgan writes. “Our job isn’t only to cure people; it’s also to help them make it through when there is no easy cure.”

Read Dr. Morgan’s full piece in the Washington Post!

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The authors argue that using the language of “risks vs benefits” gives the impression that treatment options have the potential to cause harm (risk) but that the benefits are guaranteed:

"Presenting treatment decisions as a comparison of risks vs benefits creates an inherent imbalance in which benefits simply exist, whereas harms are uncertain. This imbalance is widespread and is present in how physicians have discussions with patients, how physicians likely approach decisions, and even how studies are reported in the medical literature."

Research shows that the language we use has a strong effect on clinicians’ and patients’ perceptions of their health care options. For example, when family members of patients with advanced disease are told that their loved one “wanted everything done,” they were much less likely to recommend withdrawing life-sustaining treatment, even for patients with a poor survival prognosis. Using a different phrase to elicit patients’ goals of care would give family members a clearer picture of the treatments patients would be willing to undergo.

Morgan et al. suggest that instead of saying “risks vs benefits” we should use the language of “harms vs benefits,” to properly emphasize the potential harm of medical treatments.

For more, read the full piece on the JAMA website.

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