(Photography by Kevin Van Paassen)

How empathy retains the humanism in patient-doctor rapport

Dr. Matthew Cesari spends a lot of his time in a laboratory, peering at human tissue through a microscope. It’s rare that he will meet with an actual patient. Still, the director of surgical pathology at Sunnybrook believes that empathy is an essential component of his job.

“I try to humanize the specimen,” he explains. “We are dealing with tissues that have been removed from a person. I want to always remember there’s a human being at the other end, and that the work we do will have a tremendous impact on that patient.”

The job of a pathologist is to analyze tissue specimens – “mostly cancer, but not always,” he says – and then submit a diagnostic report that will, ultimately, influence the therapy a patient receives. Accuracy is crucial.

“When you’re not necessarily dealing with the [actual] patient, it’s much easier to fall into a routine mindset,” Dr. Cesari notes. “By reminding yourself that patients are not just case numbers, it keeps you sharper. It’s like having an interaction with the patient, even if the patient isn’t there. For me, it makes the work more valuable. It’s more than just issuing a report, it’s consulting on a human problem.”

At the other end of the patient spectrum is Dr. Debbie Selby, a physician in Sunnybrook’s Palliative Care Unit. Interacting daily with people who are nearing the end of their lives, Dr. Selby sees empathy as a given. “I don’t walk around thinking about being empathic,” she says. “To me, that’s inherent in what you’re doing, which is figuring out the best options for them.”

This is the skill she attempts to teach her students – the ability to be sensitive to the patient’s needs, beyond the obvious. “There’s a difference between listening and hearing,” she notes. “It’s the ability to hear, and not just look at the numbers, that really matters. And that can be really hard, particularly for trainee doctors, who are still working at learning a vast body of knowledge. They can become obsessed with the facts and figures.”

When caring for patients at the palliative stage, Dr. Selby says it’s important to focus on who the patient is. “Who is this person? What is important to this person? What does this person need from me to make their path easier?”

For Dr. Selby, it may be as simple as sitting on the edge of a patient’s bed during daily rounds, arranging for another patient to be taken outside to enjoy the sunshine, or discussing medical details in depth with a third patient.

“It’s about tailoring the treatment to the patient’s needs,” she points out. “Is that empathy or is that just sensible medicine?”

To that question, Dr. Ari Zaretsky, Sunnybrook’s chief of psychiatry and vice-president of education, would answer, “Both!” An ardent proponent of “narrative medicine” – the official term for the integration of empathy into medical practice – Dr. Zaretsky warns that as health care becomes ever more dependent on complex technology, something vital may be at risk.

“Medicine is becoming extremely technologically sophisticated and scientifically based, and that’s a good thing on many levels,” he says. “But there’s a danger of losing the humanism, both in medicine and in the doctor-patient relationship. It’s very important to retain the humanism.”

The narrative medicine movement emerged about two decades ago as an effort to encourage medical practitioners to pay close attention to their patients’ personal stories (their narratives) in order to maintain that human connection, even while remaining steeped in the necessary science.

“When you listen closely to a patient’s experience of illness, it’s not the same as just knowing the facts and figures of the illness,” Dr. Zaretsky explains.

The benefits of narrative medicine go both ways. “Generally, patients do better with empathic treatment,” he says. It can also be a way to reduce burnout among health-care professionals, especially in high-pressure places, like the intensive care unit. It helps them to “retain their hope and their sense of meaning,” he notes.

Dr. Zaretsky sees narrative medicine as the wave of the future. Already, major medical schools, like the University of Toronto (U of T), are integrating it into their programs. “It’s a way to counterbalance the head with the heart,” he says. “Otherwise, you’re probably going to have patients feeling that their doctors are robots.”

Ben Fung, a third-year medical student at U of T, understands the attraction to technology. “It’s immediate,” he says, “and it provides so much more information to work with than ever before.” But he believes it must be properly integrated into the narrative process.

“History-taking is the most important aspect of our medical decision-making,” he declares.

“In the past, the patient in front of you was all you had – their narrative and the physical examination. In the end, 90 per cent of [the medical information] comes from the patient interview. Only 10 per cent of the time do you need the extra tests to confirm diagnosis.”

According to Fung, the new generation of trainees is embracing narrative medicine, with its importance being heavily emphasized in the curriculum. “Perhaps there has been a cultural change,” he speculates. “Medical students are being taught to hold onto those idealistic feelings that motivated them to come into medical school.”

It’s a misconception, Fung notes, that narrative medicine takes a long time, that it’s arduous and low-yield. “It does not take a lot of effort. It could be one small question, a physical gesture, and one or two reassuring words. We must never forget that the patient is a person, not just a problem to be solved.”

The post The important role that empathy plays in medicine appeared first on Your Health Matters.

“We are trying to find ways of getting the truth out,” he says, “rather than the many misconceptions about suicide that have been perpetuated for a very long time. People want to understand suicide and what is to ‘blame,’ but we need to resist simplistic answers like the historical notion that suicide is the result of a single life stressor. Unfortunately, suicide is sometimes depicted as an inevitable outcome, with a de-emphasis on the role of treatable mental disorders. But none of this is the case at all.”

A staff psychiatrist with Sunnybrook’s Department of Psychiatry, Dr. Sinyor points out that people with mood disorders – depression and bipolar disorder – account for more than 50 per cent of all suicide deaths.

“There is no reason that anyone needs to die from suicide,” he says. “Suicidal crises are often fleeting and there are many ways in which we can intervene to help people through them. In virtually all cases, they are accompanied by a treatable mental disorder. Every suicide death is a tragic missed opportunity for someone to have gotten help.”

Timely care for the underlying disorder can be the key to preventing most of these tragedies.

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“There is no reason that anyone needs to die from suicide.”

– Dr. Mark Sinyor, psychiatrist

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Colin is one of Dr. Sinyor’s patients – and a case in point. For years, Colin’s bipolar condition remained undiagnosed. To all outward appearances, he appeared to be doing fine.

“Life is not only what happens on the outside,” says Colin, 29. “I was in pain all the time. I didn’t tell anyone at first that I was suicidal. I put on a good face, but I was crying when I was alone.”

After several suicide attempts, visits to multiple psychiatrists and a variety of medications, a friend’s intervention led Colin to Sunnybrook and a course of treatment under Dr. Sinyor’s supervision.

“I owe Sunnybrook my life,” says Colin.

That was over two years ago. Colin has since gotten married and now works at a job that he finds satisfying. He wants nothing more than to “stay like this – stable,” he says. “I know it’s going to be a struggle, but I’m surrounded by good people. I’m a lucky guy.”

His message to others like himself? “Reach out for help. Just do it.”

The stigma of mental illness continues to hinder treatment, which motivated philanthropists Glenn and Stacey Murphy of Toronto to donate $10-million to create the Murphy Family Centre for Mental Health at Sunnybrook. This new state-of-the-art inpatient facility will treat those with severe mental illness, including patients like Colin with mood and anxiety disorders. It will use a collaborative approach that frames mental illness as a disease like any other to reduce stigma and encourage treatment.

Colin’s case is the type of positive story Dr. Sinyor would like to see highlighted more often in the press. A scientist with the Hurvitz Brain Sciences Program at Sunnybrook, Dr. Sinyor cites research showing that the way the news media reports on the topic may significantly affect rates of suicide – and attempted suicide – in wider society.

“Suicide contagion” is a very real phenomenon. “When news reports are published emphasizing suicide methods or the inevitability of suicide, sadly, we see more suicide deaths,” Dr. Sinyor explains. “But the opposite is also true – resilience is also contagious. Research from Europe shows that when the media broadcasts stories like Colin’s, you see fewer suicide deaths afterwards.”

He notes that people are apt to identify with people depicted in the media they consume. “It is a fact that too many people still do die by suicide, but far more find ways to overcome it, and if you only publish stories about deaths, you’re sending a skewed picture to everybody – and a potentially dangerous picture. Our goal is to help shift things in a positive direction.”

Dr. Sinyor is currently creating a structure for collaboration between mental health professionals and journalists to better “inform the public in a way that sends accurate messages,” he says. “We’re not trying to censor journalists or tell them how to do their job,” notes Dr. Sinyor, who is the lead author on the Canadian Psychiatric Association’s updated media guidelines on suicide reporting. “Journalists need to be independent.”

Still, he believes more effort could be made to “create context” when reporting on suicide and to convey the key truths on the issue – that suicide is preventable, that there are other means of coping with life’s stresses, and that the vast majority of people who have suicidal thoughts never follow through. In short, suicide is not inevitable even when life appears hopeless.

“Journalists have a lot of power to influence the way people think and, to an extent, behave,” he says. “They need to exert that power in a way that’s safe and helpful. We are just trying to be a resource that they can call on for guidance.”

Ultimately, Dr. Sinyor would like his message to be a positive one. He points out that suicide rates in Toronto and in most westernized countries – the U.S. is the exception – have declined significantly in recent years.

“People are more willing to seek help,” he says, “and resources are increasing. It’s not all doom and gloom and people need to understand that. We’re making a dent. We need to decrease the stigma of these disorders, increase people’s ability to seek help, and send the message that there is hope.”

The post The media could have a role to play in suicide prevention. Here’s how appeared first on Your Health Matters.

For Sandra Mitchell, Sunnybrook’s Palliative Care Unit (PCU) became her second home in April of this year. She, her two sisters and a close cousin were taking turns keeping constant vigil at the bedside of their 85-year-old mother, Laurie James, who was in congestive heart failure and the final stages of a cancer that had spread from her kidneys to her pancreas and lungs.

“I would arrive at 8 p.m., spend the night on a cot next to Mom, help her with breakfast and lunch, then leave at 1 p.m. to pick up my granddaughter from school,” says Sandra, recounting her caregiver schedule at Sunnybrook. She would babysit until 6 p.m. and then go home to grab a shower.

Sandra’s family isn’t alone in their dedication. Given there are 56 beds at the PCU – one of the largest palliative care units in the GTA – the presence of devoted family members is a constant. This is why the extensive renovations taking place at the unit are so critical. “We wanted to have as many amenities as possible for the families that stay overnight,” says Sandra De Costa, the unit’s patient care manager. “We want to make it as home-like as we can, not so institutionalized.”

The first phase of the renovations, which began a year ago, are already bringing comfort and convenience to the unit’s families – welcoming open-concept lounges with gas fireplaces, comfy armchairs and flat-screen TVs; a private meeting room overlooking a lovely garden; and two sleek modern kitchens offering patients’ families ample space for storing and preparing food, as well as a place for them to gather at tables over coffee or tea.

“The reaction has been very positive, particularly for the kitchens,” notes De Costa. “Most families socialize and congregate in the kitchen. Comfort and convenience mean a lot during their time here.”

The second phase of renovations will be underway soon. It will see upgrades to the on-site workstations of Sunnybrook’s interprofessional health-care teams. The final phase will enhance and upgrade the patient rooms. The renovation work has been largely funded by McDermott House Canada, which has made a commitment of $3.6-million to the project.

When they were caring for Laurie, who passed away in July, Sandra and her family certainly appreciated the new amenities. “We used the kitchen all the time. We brought in our homemade Caribbean food,” says Sandra. “It’s also great that we were able to do laundry on the unit. And on Mother’s Day, we booked some private time in the Garden Room. We brought food, Mom opened her presents, all her grandchildren and great-grandchildren were around her. It meant a lot.”

Choosing palliative care at Sunnybrook for their mother – a strong, independent woman from Guyana who fought her first bout with kidney cancer five years ago – was “the best decision ever,” according to Sandra. “It maintained her dignity and gave her a greater sense of control.”

At Sunnybrook’s PCU, Laurie also had numerous activities she could participate in – pet therapy, music therapy and various social events, to name just a few – which Sandra also appreciated. “You’re not just lying there on a bed waiting to die,” she says. “You can still enjoy life a little. It’s not that you’re just hooked up to machines fighting for life. It’s more that you’re releasing life on your own terms, letting go gently.”

During her stay, Laurie forged personal bonds with the staff – Ruben Amando a Registered Practical Nurse (RPN), was her favourite. “She used to light up when he’d pass by,” says Sandra, laughing. “He could get her to do anything!”

This is precisely the rapport that the Sunnybrook palliative care team aims to build with all their patients.

From physicians and nurses to art, recreation and music therapists, dietitians, a chaplain, a social worker, pharmacist, physiotherapist, occupational therapist and other support services, the unit’s interprofessional team does everything possible to ease pain and other distressing symptoms while tending to the emotional, psychosocial and spiritual needs of the patients. Every effort is made to respect cultural differences, rituals and beliefs, to find out what is important to their diverse clientele and incorporate this into their care.

“People think the Palliative Care Unit must be a sad place,” says De Costa, herself a registered nurse who worked on the unit for many years before becoming patient care manager. “But our focus is on helping each patient enjoy each day to the fullest. If you were to ask anybody on the team why they do what they do, it’s because it’s such a rewarding job. It’s an honour to help patients at the end of life. You’re really making a difference to them and to their family. We’re here for the patient and we’re here for the family, whomever the patient considers their family to be.”

It is this kind and compassionate approach to palliative care that resonates strongly with the family members left behind, once their loved ones are gone. Some return to the unit to train as hospice volunteers, repaying the kindness they received during their own time of sadness.

“I’m certainly going to go back and volunteer,” declares Sandra. “We are all diverse, but [in the unit], I see only oneness. We’re all there for the same reasons – your loved one is dying and you’re just there. It’s all about love.”

Thoughts from the Dying About Living

It’s not easy to talk about dying. For many, the subject is almost taboo. But at Sunnybrook, patients in the Palliative Care Unit are being given the opportunity to be heard – that is, if they choose to.

Thoughts from the Dying About Living is a project that aims to open the lines of communication on this difficult topic. Patients volunteer to talk about their lives, their thoughts, their philosophies. Some appear on video, others prefer to share their thoughts in print. Edited for length and uploaded to the hospital’s website, these interviews are then made accessible for viewing by their families and the wider community.

The project – unscripted and open-ended – is a way for patients to deal with some of the emotions associated with dying, and to be able to share thoughts and feelings that might be difficult to express in person. Through Thoughts from the Dying About Living, Sunnybrook is helping patients create an emotional legacy for their families, as well as the community at large.

At once poetic and pragmatic, the patients say what’s on their minds, as depicted in these excerpts:

Barbara: Don’t be sad, it’s not worth it. It happens to people and you have to come to terms with it, and I did.

Guy: I’m ready for this. It’s okay. I don’t like it. Who would? Wiebke: You just take it as it comes. I’m at peace with myself.

Christl: I’m satisfied with what I had in life. I had 80 wonderful years.

Helmut: The most important thing is the people around you.

Joyce: Life is an adventure. Don’t sit back and be afraid to do anything. Go for it! Go do it, I tell my family. Come out and visit me and we’ll have this day together.

Judith: When I go out and hear the birds and smell the flowers, that’s good!

Visit Sunnybrook.ca/dying to watch the videos.

The post How Sunnybrook provides support for end-of-life patients appeared first on Your Health Matters.

She wanted, more than anything else, to have a baby, but trying to get pregnant was proving to be extremely difficult and frustrating. Unsuccessful in her attempts to conceive naturally, she turned to in vitro fertilization (IVF). Finally, in 2012, Adetoun, at age 36, became pregnant.

“I was overjoyed,” recalls Adetoun, a business analyst who lives in Oakville.

But then, 23 weeks into the pregnancy, she started feeling “strange.” She was diagnosed as having an “incompetent cervix,” a condition in which the lower portion of the uterus begins opening too soon in pregnancy.

Labour was induced and the baby – a boy born four months too soon – died shortly after birth, in her husband’s arms.

She remembers the experience as “quite traumatic.” It was last year, when Adetoun found the courage to begin again. There was a second attempt at IVF at a clinic, which was also unsuccessful, but the third try produced twin embryos.

Adetoun’s age and medical history made carrying twins a risk. The doctor at the IVF clinic recommended selective reduction – limiting the pregnancy to one child, who’d then have a better chance of survival. “I was in tears,” she says. “I had prayed for twins. I didn’t want to lose one of them.”

So Adetoun consulted with Dr. Jon Barrett, head of Sunnybrook’s specialized clinic for multiple births.

Instead of selective reduction, Dr. Barrett performed a cervical cerclage – stitching the cervix to hold it closed and prevent pregnancy loss or premature birth.

“He’s the guy to go to if you’re having twins or triplets,” she enthuses. “I felt like I had won the lottery!”

The doctor at the IVF clinic had warned Adetoun that mothers carrying twins are not good candidates for cervical cerclage, but according to Dr. Barrett, the procedure could work, with close monitoring.

“That’s why this is a miracle,” says Adetoun. “It was very risky, really scary, but I knew I had the best care.”

She had the surgical procedure done 16 weeks into her pregnancy. Overcoming a few ups and downs, her twins remained snugly in utero until the scheduled C-section, at 37 weeks, a healthy length of pregnancy.

Chinasa and Chidinma, who were born last August, are healthy and thriving, according to their mother.

Dr. Jon Barrett. (Photo by Kevin Van Paassen)

“Multiple pregnancies have a very high risk of preterm birth, compared to single basics and we’re working on more ways to prevent preterm birth when we can,” notes Dr. Barrett, who holds Sunnybrook’s Waks Family Chair in Maternal Fetal Medicine Research.

His work on cervical length as a predictor of premature labour offers the possibility of targeted intervention to reduce the numbers of babies born too early.

“Preterm babies lead to almost 80 per cent of adverse outcomes in our newborn population – death and disability, [such as] cerebral palsy, blindness, deafness, and learning disabilities. There’s also evidence of longer-term childhood diseases among these infants, respiratory or gastrointestinal.”

Not only is this difficult for both the children and their families; it’s also extremely costly to society, as a range of supports must be provided at every stage of the lives of these babies, who are at increased risk of developing cardiovascular disease and diabetes in later life.

High-risk obstetrics has engrossed Dr. Barrett since 1995. As director of Sunnybrook Research Institute’s Women and Babies Research Program, he leads a team that is exploring every aspect of preterm birth in Ontario, from pregnancy and delivery to support systems after hospital discharge. Prevention of early birth is his main priority.

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“That’s why this is a miracle. It was very risky, really scary, but I knew I had the best care,” says Adetoun Oyenubi, patient.

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“There’s the ability to predict who’s at risk for preterm birth and the ability to prevent it,” he explains. “But what we lack is the mechanism in the health-care system to get to that population and engage them in preventative measures early enough. We have proven ways to do it. It’s just going to take money and a system change.”

It is Dr. Barrett’s hope to create the Alliance for the Prevention of Preterm Birth and Stillbirth in Ontario. Families, maternal and newborn care providers, hospitals and researchers would come together to reduce preventable preterm births and stillbirths in Ontario, improving infant health outcomes and quality of care for families.

“It’s this kind of network that can improve system coordination in the future,” Dr. Barrett predicts. “For the first time, hospitals [in Ontario] would start to say, ‘Instead of working in isolation on research projects, let’s start working together.’”

Database integration would be a big part of the story. “Ontario already has a fantastic system that can connect data and reach patients,” he says. “But no one has closed the loop to make sure the best screening and treatments reach patients. That’s what this initiative could do.”

That’s very good news for families across the province. And it’s comforting for Adetoun to know her experience will help identify and treat women at higher risk for preterm birth, saving families from the immense stress of having a premature baby.

The post Experts working to reduce preventable preterm births in Ontario appeared first on Your Health Matters.