Dix Coups de Pinceau
To all of my friends:
I will be present at the show:
October 14, 6-8 PM
October 17 2-4
October 18 1-5
October 21 6-8 PM
October 24, 2-5 PM
October 25 2-4 PM
Saturday, September 26, 2009
Empathy, service at the Unitarian Church, 2009
Unitarian Church of Montreal
Order of Service
July 5, 2009
Gathering music
Welcome
Script
Lighting of the Chalice
453
May the light we now kindle
Inspire us to use our powers
To heal and not to harm
To help and not to hinder
To bless and not to curse
To serve you, Spirit of freedom
Passover Haggadah
Music
Rolling Home Eric Anderson
Opening Words
440
From the fragmented world of our everyday lives we gather together in search of wholeness.
By many cares and preoccupations, by diverse and selfish aims are we separated from one another and divided within ourselves.
Yet we know that no branch is utterly severed from the Tree of life that sustains us all.
We cherish our oneness with those around us and the countless generations that have gone before us.
Opening Song 80 Wild Waves of Storm
Candles of Joy and Concern
Gifts of Thanks
?
Song 192 Nay, Do Not Grieve
Meditation
In words
The prophet, Kalil Gibran, p. 47
And a woman spoke, saying, Tell us of Pain
And he said:
Your pain is the breaking of the shell that encloses your understanding.
Even as the stone of the fruit must break, that its heart may stand in the sun, so must you know pain.
And could you keep your heart in wonder at the daily miracles of your life, your pain would not seem less wondrous than your joy;
And you would accept the seasons of your heart, even as you have always accepted the seasons that pass over your fields.
And you would watch with serenity through the winters of your grief.
Much of your pain is self-chosen.
It is the bitter potion by which the physician within you heals your sick self.
Therefore trust the physician, and drink his remedy in silence and tranquility:
For his hand, though heavy and hard, is guided by the tender hand of the Unseen,
And the cup he brings, though it burn your lips, has been fashioned of the clay which the Potter has moistened with
His won sacred tears.
In Silence
In music
Debussy
Or choice of musician
Address/Reflection
The four stages of Empathy:
As I prepare for the 35th anniversary of my graduation from medical school, I have been invited to reflect on what it takes to be a good doctor.
Is it a good bedside manner? But a doctor with good bedside manner but without knowledge is a charlatan.
Is it a good up to date knowledge base? Certainly this is necessary, but if you cannot relate to the patient, your advice will not be followed.
Is it the ability to recognize your limitations? Without this, any doctor is dangerous. But obviously this is not enough.
Is it empathy? Empathy is currently heavily discussed in medical education circles.
What is empathy? The best definition I have found is that of Simon Baron-Cohen. "Empathy is about spontaneously and naturally tuning into the other person's thoughts and feelings, whatever these might be. (…) There are two major elements to empathy. The first is the cognitive component: Understanding the others feelings and the ability to take their perspective (….) the second element to empathy is the affective component. This is an observers appropriate emotional response to another's emotional state."
Empathy is the new by-word. Scales of empathy have been developed, and used to decide who among the hundreds of applicants with 4.2 grade point average should be selected for admission to medical, dental, and nursing schools. These scales are also used to test whether it is possible to teach empathy. And they are used to assess the changes in empathy in health care trainees as they progress through their training.
The experience of empathy involves a putting of oneself in the place of the other. In fact brain imaging shows that persons experiencing empathy have activation of the same parts of the brain as the person experiencing the pain. Individuals who are unable to experience empathy fail to show this activation.
Is it possible to teach empathy? How would we do that? By making sure our students have experienced a pain similar to that of the patient, so that they can understand it?
If this were the case, one would expect that an increase in life experience would result in an increase in the empathy of the medical trainee. However, the opposite seems to be the case. As trainees progress through their training their empathy, as judged by the empathy scales, decreases. Various techniques have been used counter this decrease empathy. These include mindfulness training, group sensitivity training, and courses in literature to help the students reflect on others' experience in life. But none of these strategies has been shown result in a increase in empathy as training progresses.
It is unlikely that these trainees are forgetting that their patients are experiencing physical and emotional pain. So what is happening?
I take a clue from my own reaction to the complaint of a journalist about a lack of empathy in her mother's doctors during her terminal illness.
The doctors had told her mother all about her mother's cancer in spite of her mother's express wishes. The doctors insisted that the family appoint a spokesperson so that information could be given in an efficient way, instead of responding to calls from each member of the family. The journalist accused the doctors of robbing her mother of her will to live by telling her the truth about her disease. She stated that only one junior trainee was felt to have expressed concern about the loss the family was facing.
My response to this letter was strong and defensive. In 1992 I wrote:
I read with sympathy the article by Ms. Davis-Barron about the death of her mother. However I feel the need to comment on two issues: physician empathy and informing the patient of his or her prognosis.
When I was a medical student and trainee I felt guilty that I did not feel what the
relatives of my patients felt. But in 1983 my younger brother killed himself, and at that point I learned what grief is. I also learned that one cannot possibly feel what one's patients and patients' families feel and continue to function: as physicians we learn to distance ourselves from such feelings.
Our job as physicians is to cure disease and to alleviate suffering. When cure is impossible one of the means of alleviating suffering is to help the patient and the patient's family to accept the inevitable and to say good-bye. The good-bye cannot take place until the patient and the patient's family acknowledge to themselves and to each other that the end is near. This allows them to thank each other for their lives and to say how much they will miss each other, and that they will get along somehow. The grieving process cannot properly begin if the patient and the family conspire to keep the coming death a secret.
I admit that physicians are not always as patient, kind, and sympathetic as we could be and that we could well learn to deliver bad news in a better way. But there is no way of making bad news good.
My writing from this time provides me with an important clue: "we learn to distance ourselves from the feelings of grief". This is an active process, an act of self-preservation. And a protection from the overwhelming feeling we have when it is our job to make the patient better and we are not doing it. The more the trainee feels he is failing when the patient dies, the greater the need for defence. Not to distance oneself from these feelings would lead inevitability to burnout. It is not a failure of learning, but a coping mechanism.
Is it possible to get past the need for this coping mechanism and gain a more mature level of empathy?
I think that it is. However it involves an acceptance of the fact that the doctor is not god, is not all-powerful in the face of disease, and should not expect to be so. After all, the outcome is always the same. I have never seen a one hundred and fifty year old patients. We must accept that we will all ultimately degenerate and die. That is part of life.
Having looked illness and the inevitability of degeneration and death in the face, I have experienced the feeling of a new kind of empathy. We are all in the soup together, and we just humanly do our best. And I try to accept that for myself and for my patient, while doing my best to make the present as good as possible.
Based on this experience, I have developed a model of the development of empathy, loosely based on M. Scott Peck's stages of spiritual growth.
Stage I. Pre-empathy. This is the newborn that is unaware of the other or the other's pain. He only knows his own primitive needs, and since he is not aware of the other or his pain he has no empathy.
Stage II. Natural empathy. This follows at a very young age. Even a small child will recognize the pain of another in tears and attempt to provide comfort. This child does not defend itself from empathy, there is no need. The child has the security of his family to back himself up, and can naturally empathize when empathy is called for.
Stage III. Withdrawal of empathy in response to overwhelming demand. This is seen in the medical trainee, who was selected in the first place for medical training because of a high degree of empathy, but is overwhelmed by apparently unrealistic expectations of himself or of others on himself, and needs to defend himself against these to avoid burnout.
Stage IV. True empathy. This is the response to the distress of others,which acknowledges our humanity, brokenness, and mortality, and which is able to provide a still quiet place at the bedside to listen, hear, reassure, and acknowledge the joys and the tragedies of life even if nothing can be changed. To quote Scott Peck talking of the fourth stage of spiritual growth, "They feel deeply connected to "an unseen order of things," although they cannot fully define it. They are comfortable with the mystery of the sacred."
With the drawing of this Love and the voice of this Calling
We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.
Through the unknown, remembered gate
When the last of earth left to discover
Is that which was the beginning;
At the source of the longest river
The voice of the hidden waterfall
And the children in the apple-tree
Not known, because not looked for
But heard, half heard, in the stillness
Between two waves of the sea.
Quick now, here, now, and always-
A condition of complete simplicity
(Costing not less than everything)
And all shall be well and
All manner of thing shall be well
When the tongues of flame are in-folded
Into the crowned knot to fire
And the fire and the rose are one.
Closing Song 16 'Tis a Gift to be Simple
Closing Words
The golden rule and others
As we leave this friendly place (song)
Go now in peace, Go now in peace
May the love of God Surround you
Everywhere, everywhere, you may go
(French)
Order of Service
July 5, 2009
Gathering music
Welcome
Script
Lighting of the Chalice
453
May the light we now kindle
Inspire us to use our powers
To heal and not to harm
To help and not to hinder
To bless and not to curse
To serve you, Spirit of freedom
Passover Haggadah
Music
Rolling Home Eric Anderson
Opening Words
440
From the fragmented world of our everyday lives we gather together in search of wholeness.
By many cares and preoccupations, by diverse and selfish aims are we separated from one another and divided within ourselves.
Yet we know that no branch is utterly severed from the Tree of life that sustains us all.
We cherish our oneness with those around us and the countless generations that have gone before us.
Opening Song 80 Wild Waves of Storm
Candles of Joy and Concern
Gifts of Thanks
?
Song 192 Nay, Do Not Grieve
Meditation
In words
The prophet, Kalil Gibran, p. 47
And a woman spoke, saying, Tell us of Pain
And he said:
Your pain is the breaking of the shell that encloses your understanding.
Even as the stone of the fruit must break, that its heart may stand in the sun, so must you know pain.
And could you keep your heart in wonder at the daily miracles of your life, your pain would not seem less wondrous than your joy;
And you would accept the seasons of your heart, even as you have always accepted the seasons that pass over your fields.
And you would watch with serenity through the winters of your grief.
Much of your pain is self-chosen.
It is the bitter potion by which the physician within you heals your sick self.
Therefore trust the physician, and drink his remedy in silence and tranquility:
For his hand, though heavy and hard, is guided by the tender hand of the Unseen,
And the cup he brings, though it burn your lips, has been fashioned of the clay which the Potter has moistened with
His won sacred tears.
In Silence
In music
Debussy
Or choice of musician
Address/Reflection
The four stages of Empathy:
As I prepare for the 35th anniversary of my graduation from medical school, I have been invited to reflect on what it takes to be a good doctor.
Is it a good bedside manner? But a doctor with good bedside manner but without knowledge is a charlatan.
Is it a good up to date knowledge base? Certainly this is necessary, but if you cannot relate to the patient, your advice will not be followed.
Is it the ability to recognize your limitations? Without this, any doctor is dangerous. But obviously this is not enough.
Is it empathy? Empathy is currently heavily discussed in medical education circles.
What is empathy? The best definition I have found is that of Simon Baron-Cohen. "Empathy is about spontaneously and naturally tuning into the other person's thoughts and feelings, whatever these might be. (…) There are two major elements to empathy. The first is the cognitive component: Understanding the others feelings and the ability to take their perspective (….) the second element to empathy is the affective component. This is an observers appropriate emotional response to another's emotional state."
Empathy is the new by-word. Scales of empathy have been developed, and used to decide who among the hundreds of applicants with 4.2 grade point average should be selected for admission to medical, dental, and nursing schools. These scales are also used to test whether it is possible to teach empathy. And they are used to assess the changes in empathy in health care trainees as they progress through their training.
The experience of empathy involves a putting of oneself in the place of the other. In fact brain imaging shows that persons experiencing empathy have activation of the same parts of the brain as the person experiencing the pain. Individuals who are unable to experience empathy fail to show this activation.
Is it possible to teach empathy? How would we do that? By making sure our students have experienced a pain similar to that of the patient, so that they can understand it?
If this were the case, one would expect that an increase in life experience would result in an increase in the empathy of the medical trainee. However, the opposite seems to be the case. As trainees progress through their training their empathy, as judged by the empathy scales, decreases. Various techniques have been used counter this decrease empathy. These include mindfulness training, group sensitivity training, and courses in literature to help the students reflect on others' experience in life. But none of these strategies has been shown result in a increase in empathy as training progresses.
It is unlikely that these trainees are forgetting that their patients are experiencing physical and emotional pain. So what is happening?
I take a clue from my own reaction to the complaint of a journalist about a lack of empathy in her mother's doctors during her terminal illness.
The doctors had told her mother all about her mother's cancer in spite of her mother's express wishes. The doctors insisted that the family appoint a spokesperson so that information could be given in an efficient way, instead of responding to calls from each member of the family. The journalist accused the doctors of robbing her mother of her will to live by telling her the truth about her disease. She stated that only one junior trainee was felt to have expressed concern about the loss the family was facing.
My response to this letter was strong and defensive. In 1992 I wrote:
I read with sympathy the article by Ms. Davis-Barron about the death of her mother. However I feel the need to comment on two issues: physician empathy and informing the patient of his or her prognosis.
When I was a medical student and trainee I felt guilty that I did not feel what the
relatives of my patients felt. But in 1983 my younger brother killed himself, and at that point I learned what grief is. I also learned that one cannot possibly feel what one's patients and patients' families feel and continue to function: as physicians we learn to distance ourselves from such feelings.
Our job as physicians is to cure disease and to alleviate suffering. When cure is impossible one of the means of alleviating suffering is to help the patient and the patient's family to accept the inevitable and to say good-bye. The good-bye cannot take place until the patient and the patient's family acknowledge to themselves and to each other that the end is near. This allows them to thank each other for their lives and to say how much they will miss each other, and that they will get along somehow. The grieving process cannot properly begin if the patient and the family conspire to keep the coming death a secret.
I admit that physicians are not always as patient, kind, and sympathetic as we could be and that we could well learn to deliver bad news in a better way. But there is no way of making bad news good.
My writing from this time provides me with an important clue: "we learn to distance ourselves from the feelings of grief". This is an active process, an act of self-preservation. And a protection from the overwhelming feeling we have when it is our job to make the patient better and we are not doing it. The more the trainee feels he is failing when the patient dies, the greater the need for defence. Not to distance oneself from these feelings would lead inevitability to burnout. It is not a failure of learning, but a coping mechanism.
Is it possible to get past the need for this coping mechanism and gain a more mature level of empathy?
I think that it is. However it involves an acceptance of the fact that the doctor is not god, is not all-powerful in the face of disease, and should not expect to be so. After all, the outcome is always the same. I have never seen a one hundred and fifty year old patients. We must accept that we will all ultimately degenerate and die. That is part of life.
Having looked illness and the inevitability of degeneration and death in the face, I have experienced the feeling of a new kind of empathy. We are all in the soup together, and we just humanly do our best. And I try to accept that for myself and for my patient, while doing my best to make the present as good as possible.
Based on this experience, I have developed a model of the development of empathy, loosely based on M. Scott Peck's stages of spiritual growth.
Stage I. Pre-empathy. This is the newborn that is unaware of the other or the other's pain. He only knows his own primitive needs, and since he is not aware of the other or his pain he has no empathy.
Stage II. Natural empathy. This follows at a very young age. Even a small child will recognize the pain of another in tears and attempt to provide comfort. This child does not defend itself from empathy, there is no need. The child has the security of his family to back himself up, and can naturally empathize when empathy is called for.
Stage III. Withdrawal of empathy in response to overwhelming demand. This is seen in the medical trainee, who was selected in the first place for medical training because of a high degree of empathy, but is overwhelmed by apparently unrealistic expectations of himself or of others on himself, and needs to defend himself against these to avoid burnout.
Stage IV. True empathy. This is the response to the distress of others,which acknowledges our humanity, brokenness, and mortality, and which is able to provide a still quiet place at the bedside to listen, hear, reassure, and acknowledge the joys and the tragedies of life even if nothing can be changed. To quote Scott Peck talking of the fourth stage of spiritual growth, "They feel deeply connected to "an unseen order of things," although they cannot fully define it. They are comfortable with the mystery of the sacred."
With the drawing of this Love and the voice of this Calling
We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.
Through the unknown, remembered gate
When the last of earth left to discover
Is that which was the beginning;
At the source of the longest river
The voice of the hidden waterfall
And the children in the apple-tree
Not known, because not looked for
But heard, half heard, in the stillness
Between two waves of the sea.
Quick now, here, now, and always-
A condition of complete simplicity
(Costing not less than everything)
And all shall be well and
All manner of thing shall be well
When the tongues of flame are in-folded
Into the crowned knot to fire
And the fire and the rose are one.
Closing Song 16 'Tis a Gift to be Simple
Closing Words
The golden rule and others
As we leave this friendly place (song)
Go now in peace, Go now in peace
May the love of God Surround you
Everywhere, everywhere, you may go
(French)
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