American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, September 11, 2015

The Pied Piper of empathy

I was sitting at a lunch counter the other day chatting with one of my former small group advisees about his career interests. Gunan, who is now an intern, was rotating on the oncology service. During our conversation he told me about how much he was enjoying his experience.

“That's right in line with your chosen field of radiation oncology, right?”


“Good stuff,” I replied.

“I think I just … I don't know. I just like taking care of people with cancer.”

Wait, huh?

I wasn't sure what to say to that. I mean, can a person technically like cancer? Is it even okay to say that? I wasn't so sure.

Gunan saw my wheels turning and clarified, “I've figured out what it is about cancer that makes me like it.”

Like. Cancer. Uh, okay.

I raised my eyebrows. “Oh yeah? What's that?”

Gunan paused for a moment to find his words. I think he wanted to be sure that it didn't come out wrong. After a few seconds he finished chewing his bite of sandwich and spoke. “You know what it is? Peoplerespect the cancer diagnosis. No matter who they are, they do.”

I squinted my eyes at this concept which pushed him to go on. From there he fleshed out the idea pointing out that there aren't too many other things that every person old or young fully respects like a cancer diagnosis. He described how even the most difficult patients straighten up the moment it gets uttered. Family members step in to help, even estranged ones come from the woodworks, because it's cancer. Almost like having a U.S. president walk into a room. Essentially, it's kind of like the universal last word of diagnoses.

Now this? This was a pretty thought provoking idea. And especially so since I'd never thought of diagnoses as rungs on some sort of ladder of respect.


“That's deep, man.”

Lame reply, I know. But that's all I could say because this was such an interesting perspective, and one that I believe was extremely accurate.


Gunan gave me something to really chew on that day. This idea of diseases being hierarchal and having one that is the President Obama of them all, cancer.

Heart disease is exponentially more likely to take out any person than cancer. It also has a much, much greater chance of disabling or redefining a life than cancer. And, though a lot about cancer is terrifyingly mysterious, when it comes to heart disease? Meh. Not so much. High blood pressure, obesity, inactivity, elevated cholesterol, and family history are just a few things that greatly increase the chance of a person getting heart disease. And you know? Society has done a pretty darn good job of getting that memo out.


And sure, if someone doesn't seem so stressed about potentially getting something like heart disease, surely they'd feel the wake up call if they actually had it, right? In my experience, I'd say that answer isn't in the affirmative. While some folks definitely straighten up and fly right after a heart attack or some other cardiac event, many, many people don't. Nor do the people around them.

But cancer? That's a whole different story.

The other diagnosis that doesn't get it's full respect is HIV. All of the aforementioned things about heart disease ring true for HIV. This virus? We know about it. Like, all about it. There are ways to prevent and treat it, too. But perhaps even more than heart disease, it gets treated like an annoying tick on a dog's butt, something to ignore or not even look for until your forced.

I've told people that they were HIV positive. I've held their hand and walked them through the process of getting into care, too. But unlike cancer, it doesn't arrive with the same amount of boundless empathy. And worse, many times it prompts people to run in the other direction.

The patients are usually somewhere between really, really adherent to all that you suggest or totally in denial. And you know? That doesn't happen so much with cancer.


Compared to cancer, HIV, as the late comedian Rodney Dangerfield would say, gets ”no respect at all.”


It's true. AIDS and heart disease just don't get the respect that they absolutely deserve, man. And don't even get me started on mental illness which really gets disrespected.

But cancer? For some reason it's on a lonely list of diseases that somehow escapes all that. Even the most ill-equipped, contentious, poorly resourced and opinionated patients and families respond swiftly to that 6-letter word. They become more pleasant, cooperative and agreeable. They try what you suggest and listen when you speak. It's pretty damn remarkable.

Yeah. My former advisee was totally right. And it's a fascinatingobservation, isn't it?

So what is it about cancer? Is it the terminal nature of many of its forms? Is it the ruthlessness of it in how it strikes or the triumph of those who overcome its prickly grasp? Is it our universal fear of it that makes us all feel some need to show strong empathy lest we awaken the cancer-gods and find ourselves stricken out of some punitive wrath? Maybe it's all of this. Or none of it. Whatever it is, there's just something about malignancy that makes everybody listen just a little bit closer, follow up a little more carefully, and immediately get onto our best behavior.

And you know? It's not just the patients and their families, either. Doctors are also in this same camp. Our empathy heightens for patients carrying a cancer diagnosis. I know for sure that this is so because I've felt it inside of me and witnessed it time and time again at Grady Hospital.

Let me give you an example.

I took care of this super-cantankerous gent named Mr. Kelly with a longstanding stronghold of alcohol abuse on my service recently. He'd been admitted several times over the years for withdrawal and complications of his alcoholism. That man had a very sick liver and never once got hospitalized on a “soft call.”


But even though he didn't walk the line on illness severity, that didn't make him nicer or uniquely appreciative of his healthcare providers. He was difficult. Due to his illness and unstable housing, Mr. Kelly's hygiene was poor and frankly, that made it unpleasant to care for him. And, if I man be frank, downright noxious. He also argued with staff and, due to fear and frustration, wasn't so nice most days. The team and nursing staff lost empathy for him. People went in only when absolutely imperative. And even though people held their eye rolls, you could feel them whenever his name came up in a discussion.


But then he had that MRI that showed a mass on his liver. A mass with features pathognomonic for hepatocellular carcinoma, that is, liver cancer. A blood test and additional studies confirmed what we thought. Not only did Mr. Kelly have this bad diagnosis--he wasn't really a candidate for any interventions that could lead to a meaningful recovery.


And that moment? That second when we scrolled through the MRI images and hit that big oval mass on his liver? It was a turning point. Suddenly we all began rooting for him in a different way. And I'm embarrassed to admit it but something about knowing this about him made me want to see him more and spend time in his room. The heavy cloak of foul dank odor that hit you when walking through the threshold somehow seemed insignificant now. And his “difficulties” suddenly seemed like “quirks” instead.


But you know? Mr. Kelly changed, too. The minute we sat in that room at eye level and shared that information, a switch turned on in him. Or off. Or whatever it was, he changed. He asked questions and listened. His family members took his calls and he took theirs. There were cards on his window sill and balloons tied to his bed rail. And the nurses, like me, in unspoken solidarity rallied around him to make sure he was comfortable and that all was well.


One could argue that his advanced liver disease, cirrhosis and alcoholism were already equally as life threatening if not more than this new diagnosis. His life expectancy, chance for recovery from his liver damage, all of it already portended a very poor prognosis. And we, the physicians and nurse, knew that. Yet somehow when someone threw hepacellular carcinoma into the mix, we lined our ducks up and offered this man a new dignity. It's true.

And you know? I'm not sure how I feel about that. I'm not.

I talked to my friend Wendy A. about this whole concept. This idea of disease hierarchy and how some illnesses we throw our shoulders back to salute and how others get a head nod and that's it. I asked her thoughts on how cancer especially wins when it comes to that and why that was. And her take on it is that no person is exempt from the potential cancer diagnosis. She said, for this reason, perhaps, we all revere it.


And I still don't know how even the ones that some cancer patientsseduced into their lives through tobacco use or other finger-wag worthy habits garners the same empathy. But they do. Like, not these attitudes that the man who has sex with men got what what he had coming to him when he found out he had AIDS or how the lady who had a stroke after using crack cocaine got what she deserved. Again, regardless of the etiology, cancer escapes all that. Somehow it justdoes.


So the Pollyanna positive girl in me has decided that this speaks to some innate thread of good in all of human kind. And how, as awful as cancer can be, it's amazing that there exists something that stands out as a pied piper for humanism and care for human suffering made palpable.

Yes. That.

You know? I don't even know why I wrote about all of this. But I do know this: The complexity of what we do is mind-blowing, man.


Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

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William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

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David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

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Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

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Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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PLoS Blog
The Public Library of Science's open access materials include a blog.

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One of the most popular anonymous blogs written by an emergency room physician.

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