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A Teachable Model for

Compassionate Care
David S. Burstein

Physicians who have difficulty regulating their negative arousal seem to be

more prone to emotional exhaustion, detachment, and a low sense of
accomplishment. Ezequiel Gleichgerrcht & Jean Decety, Institute of
Cognitive Neurology, Buenos Aires, Argentina. Plos One 2013
Because students educational exposure does not include sufficiently thorough
preparation to reflect on, be present with, and come to terms with their fear and
anxiety about being contaminated by patients confusion, loss, vulnerability,
helplessness, powerlessness, and suffering and their own these difficult
emotions become objects of dread, to be avoided at all costs. Attempts at empathy
in the face of such encultured psychological pressures tend to exacerbate rather
than diminish the students own anxiety, and raise the likelihood that students
actions will be motivated more by the need to reduce their own discomfort than by
the patients needs. -Joanna Shapiro, PhD Stanford, Director of Program in
Medical Humanities & Arts, Family Medicine at University of California,
Irvine. Philosophy, Ethics and Humanities in Medicine 2008.

ADSARPS in Practice
You are suffering.
Perhaps you feel anxious about what lies ahead.
We are here.
We are going to do all that we can.

As medical training intensifies, there is a nearly ubiquitous decline in empathy
amongst medical students and resident physicians19. A contributor to this phenomena is
the emotional demands of clinical practice9,19,21,25. Despite this, the Liaison Committee on
Medical Education has no certified standard for training medical students to navigate
emotional encounters18, leaving students to learn behaviors and coping strategies via
institution dependent formal and informal curricula14,22,23. As a result, patient-focused care
may be compromised. A formal approach to empathy is needed to protect physician wellbeing and promote compassionate care.
The following training module is believed to be the first of its kind15. Much like
the SPIKES method of sharing bad news, this model uses an acronym that trainees can
work through to establish a healthy connection with patients. Ideal for the current
landscape of medicine, it is intended to be efficient, sensitive, of high quality, repeatable,
moral and wholesome.
Assume that the patient is suffering
Determine the source of the patients suffering
Separate yourself from the patients condition
Affirm & Acknowledge the patients suffering
Reflect or Label the patients emotional state
Be Present
Explanations & Rationale
Assume that the patient is suffering
Inattentional blindness: When given a complex task, one may fail to recognize
obvious irrelevant stimuli unless their attention is explicitly directed towards it8,26
Complex task Obtaining clinical information in short time frame
Obvious irrelevant stimuli Patients emotional disposition
fMRI has demonstrated perception of physical pain is diminished when attention
is directed elsewhere11
Determine the source of the patients suffering
Hojat found that perspective taking is the most important component of
empathy according to experienced physicians12
Compared against compassionate care and standing in the patients
Separate yourself from the patients condition
A certain amount of clinical distance is proper and needed for selfpreservation -Dr. Daniel Lazar
Do not confuse the patients suffering with your own -Dr. Arthur
12 out of 24 internal medicine residents agreed that empathy favors burnout
because of compassion fatigue in qualitative study21

8/12 cited emotional overload, 2/12 cited lack of coping strategy

Rushton writes, When arousal in response to anothers suffering is not regulated,
it can give rise to personal distress*, thereby undermining the possibility for
expressing compassion*, leading to either avoidance or self-focused behaviors*24
* - Citations can be found in original publication
Two major forms of empathetic processing have been suggested13
Bottom-up processing involves emotional states and mirror neurons; Topdown processing is based on theory of mind by which emotions are
imagined and understood
Hypothesis: ADSARPS pushes empathetic processes toward Top-down
neural structures and should reduce the risk of emotional overload.
Affirm & Acknowledge patient suffering16
This is a moral act
Affirm: To state that something is true in a confident way
Acknowledge: To say that you accept the truth of something
Moral awareness is postulated to mediate empathetic responses24
Reflect or label the patients emotional state
Common tenant of empathy-skills training
Be Present Defined as Being in view or at hand
Identified as a form of compassion in qualitative study of burn patients2
The notion of being there for ones patient has changed in response to reliance
on computer technology and shift work in medical practice7
Only 12% of intern year is spent performing direct patient care4
Trainees should be prepared to endure with the patient17
Self One must be taken care of in order to take care of others
Physicians who display high levels of empathy are at higher risk of burnout
Resident physicians identified by senior colleagues as high functioning in
empathy and professionalism had higher observed levels of burnout3
Attending physicians identified by their peers as compassionateempathetic physicians had higher self-report levels of burnout5
High personal well-being may promote taking care of others based on in-group /
out-group psychology6,10
Proper expectations in clinical practice may promote well-being28
Medical student training heavily emphasizes cure as the goal endpoint,
which is often unmet in clinical practice
Self awareness has been shown to correlate with confidence in delivering calm,
comforting care20
Pursuing extracurricular activities of ones own initiative was identified by
physicians as a key factor positively associated with expression of empathy1
Approach to life most closely associated with physician well-being over
relationships, religion or spirituality, self-care and work (p<.01)27
Next Steps
-Characterize resident physician approach toward expressing empathy (qualitative).
-Understand changes in empathy that occur during MS3 (qualitative and/or longitudinal).

Key Publications
Neumann 2011 Meta-analysis on decline in empathy during medical training
Picard 2015 Qualitative study of empathy and burnout as a resident physician
Detsky 2013 Commentary on changes in medical practice during technology era
Kleinman, The Lancet, 2008-2014 Essays on moral caregiving and burnout
Shapiro 2008 Philosophical discussion of cognitive and emotional distancing that
occurs during medical training
1. Ahrweiler F, Neumann M, Goldblatt H, Hahn E G, Scheffer C. Determinants of
physician empathy during medical education: hypothetical conclusions from an
exploratory qualitative survey of practicing physicians. BMC Medical Education
2. Badger K, Royse D. Describing compassionate care: the burn survivor. Journal of burn
care & research 2012;33(6):772-80.
3. Beckman T J, Reed D A, Shanafelt T D, West C P. Resident physician well-being and
assessments of their knowledge and clinical performance. Journal of general
internal medicine 2012;27(3):325-30.
4. Block L, Habicht R, Wu A W, Desai S V, Wang K, Silva K N, Niessen T, Oliver N,
Feldman L. In the wake of the 2003 and 2011 duty hours regulations, how do
internal medicine interns spend their time?. Journal of general internal medicine
5. Carmel S, Glick S M. Compassionate-empathic physicians: personality traits and social
organizational factors that enhance or inhibit this behavior pattern. Social science
& medicine 1996;43(8):1253-61.
6. Colman AD. 1995. Up from Scapegoating: Awakening consciousness in groups.
Chiron publications. 162 p.
7. Detsky A S, Berwick D M. Teaching physicians to care amid chaos. JAMA: the
Journal of the American Medical Association 2013;309(10):987-8.
8. Drew T, V M L, Wolfe J M. The invisible gorilla strikes again: sustained inattentional
blindness in expert observers. Psychological science 2013;24(9):1848-53.
9. Gleichgerrcht E, Decety J. Empathy in clinical practice: how individual dispositions,
gender, and experience moderate empathic concern, burnout, and emotional
distress in physicians. PLoS ONE 2013;8(4):e61526.
10. Greene J. 2013. Moral Tribes: Emotion, reason and the gap between us and them.
New York (NY): Penguin Books. 422 p.
11. Gu X, Han S. Attention and reality constraints on the neural processes of empathy for
pain. NeuroImage 2007;36(1):256-67.
12. Hojat M, Gonnella J S, Nasca T J, Mangione S, Vergare M, Magee M. Physician
empathy: definition, components, measurement, and relationship to gender and
specialty. The American Journal of Psychiatry 2002;159(9):1563-9.
13. Jankowiak-Siuda K, Rymarczyk K, Grabowska A. How we empathize with others: a
neurobiological perspective. Medical Science Monitor 2011;17(1):RA18-24.
14. Kelly E, Nisker J. Medical students first clinical experiences of death. Medical
education 2010;44(4):421-8.

15. Kelm Z, Womer J, Walter J K, Feudtner C. Interventions to cultivate physician

empathy: a systematic review. BMC Medical Education 2014;14:219.
16. Kleinman A. Caregiving as moral experience. Lancet (London, England)
17. Kleinman A. How we endure. Lancet (London, England) 2014;383(9912):119-20.
18. Liaison Committee on Medical Education. Guide to the Institutional Self-Study for
Full Accreditation Surveys. Standard 7: Curricular content. 2016-2017:17. Accessed online Aug 8, 2015.
19. Neumann M, Edelhuser F, Tauschel D, Fischer M R, Wirtz M, Woopen C, Haramati
A, Scheffer C. Empathy decline and its reasons: a systematic review of studies
with medical students and residents. Academic medicine 2011;86(8):996-1009.
20. Olson K, Kemper K J. Factors associated with well-being and confidence in
providing compassionate care. Journal of evidence based complementary and
alternative medicine 2014;19(4):292-6.
21. Picard J, Catu-Pinault A, Boujut E, Botella M, Jaury P, Zenasni F. Burnout, empathy
and their relationships: a qualitative study with residents in General Medicine.
Psychology, health & medicine 2015;:1-8.
22. Ratanawongsa N, Teherani A, Hauer K E. Third-year medical students experiences
with dying patients during the internal medicine clerkship: A qualitative study of
the informal curriculum. Academic medicine 2005;80(7):641-7.20.
23. Rhodes-Kropf J, Carmody S S, Seltzer D, Redinbaugh E, Gadmer N, Block S D,
Arnold R M. "This is just too awful; I just cant believe I experienced that:
Medical Students Reactions to Their Most Memorable patient death. Academic
medicine 2005;80(7):634-40.
24. Rushton C H, Kaszniak A W, Halifax J S. A framework for understanding moral
distress among palliative care clinicians. Journal of palliative medicine
25. Shapiro J. Walking a mile in their patients shoes: empathy and othering in medical
students education. Philosophy, ethics, and humanities in medicine 2008;3:10.
26. Simons D J, Chabris C F. Gorillas in our midst: sustained inattentional blindness for
dynamic events. Perception 1999;28(9):1059-74.
27. Weiner E L, Swain G R, Wolf B, Gottlieb M. A qualitative study of physicians own
wellness-promotion practices. Western journal of medicine 2001;174(1):19-23.
28. Werner E R, Korsch B M. The vulnerability of the medical student: posthumous
presentation of L.L. Stephens ideas. Pediatrics 1976;57(3):321-8.
Credit to Drs. Arthur Kleinman, Larry Goodman, Daniel Lazar, David Rothenberg, Rudolf
Kumapley, and many of my peers who have influenced this model through published works,
presentations, conversations, mentorship and encouragement.

David S. Burstein
MS4, Rush Medical College
Chicago, IL