Dr. Karl VanDevender: Empathy and the Doctor-Patient Relationship (Part 2)

 

Dr. Karl Vandevender

I’m Alan Alda, and this is Clear and Vivid, conversations about connecting and communicating.

Karl:                                           Here I am, a 70 year old physician. I’ve been in practice for all practical purposes 40 years, and so I think to myself, what have I learned and what can I pass on that might be useful? Many people will leave a doctor’s office feeling there’s been no connection and leave many relationships in life feeling there’s been no connection. But what I’ve learned is, if you make an honest attempt, not some phony attempt, but if you’re actually struggling, working to understand a person, it goes much better. You actually can help them.

Dr. Karl VanDevender is a physician in Nashville, Tennessee. And he’s one of the most empathic doctors I’ve every met. Actually, he’s one of the most empathic peopleI’ve ever known. Karl seemed like the perfect person to talk with on our second show in this special series on the role of empathy in medicine We got together in our studio in Manhattan.

Alan:                                          I wanted to talk to you about the way you talk to patients. It’s really unusual in this day in age. For one thing, the time you’re able to spend is different from what most doctors are able to do now. How long can a doctor spend with a patient usually?

Karl:                                           It depends on the field, but most people who do what I do, which is so-called primary care, I’m a general internal medicine doctor for adults, and I would say most [00:00:30] physicians in today’s climate are in the room with the patient for 12 to 15 minutes.

Alan:                                          12 to 15 minutes?

Karl:                                           Yes, and unfortunately much of that time is spent at a computer filling out a computer form to document a visit, or as they call it, an encounter, so that they can get paid.

Alan:                                          And I hear increasingly that when the doctor is at the computer, the computer is up against the wall, and the doctor’s back is to the patient. So the time they spend face-to-face is even less than 12 minutes.

Karl:                                           Yes. It’s very unfortunate, but let’s just think about why a person goes to see the [00:01:30] doctor. They go, first of all, because they might have a problem, but they want to have some sort of connection and some sort of connection that allows for someone to understand the bigger picture of what’s going on with them. For example, if a person has a headache, it’s usually not because they were just hit in the head. It’s usually because of something much larger than that. It might be some sort of stress, or some sort of other illness.

[00:02:00] If you are filling in a blank, person has headache, location occipital region, you really haven’t helped that person. You filled out a form, but you haven’t understood what’s going on with them. I tell the young doctors that most of our patients did not go to medical school, and so for the most part, they don’t know if we know what we’re doing. But they’re world class experts on whether or not we care, and through you Alan, and your improvisational technique, [00:02:30] I’ve had a chance to think about the word empathy. And I have to confess, and I think you implied this when I first met you, that when empathy sort of came into vogue, I wasn’t that impressed with the word empathy. I thought sympathy was a fine old word, and we didn’t need to give it up.

Alan:                                          Yeah. I had the same feeling. I was mistrustful of the word empathy for a long time.

Karl:                                           But I’ve come to see this. That sympathy is feeling for someone. Empathy is feeling with someone.

Alan:                                          Yeah, [00:03:00] but to be feeling … That’s the way it’s often described. That you are able to … and I think historically it came about through a picture of somebody understanding what the other person is going through.

Karl:                                           Right. So here I am, a 70 year old physician. I’ve been in practice for all practical purposes 40 years, and so I think to myself, what have I learned and what can I pass on that might be useful? And [00:03:30] I’ve had a hard time putting that into any concrete form until I had the good fortune of meeting you and learning about what you’re doing. And I’d like to share with you as I’ve done before, and if it’s okay, I’ll share it with you now again.

When I first came into practice, I had this wonderful, older mentor who said that it was easy to sort of make a diagnosis and give a treatment, but the challenge was to look at four factors that go into any [00:04:00] attempt to help another human being in their illness, shall we say. One is the idea of dignity. The second is the concept of suffering. The third is the patient’s independence. And the fourth is the patient’s feeling of being a burden to their family or to society. And so I struggled for a long time, who do you convey to someone that you honor their dignity?

Alan:                                          So let me hear those four again. Dignity.

Karl:                                           Suffering.

Alan:                                          [00:04:30] Suffering.

Karl:                                           Independence.

Alan:                                          Independence.

Karl:                                           And dependence.

Alan:                                          And dependence.

Karl:                                           Dependence. In other words, their dependence on those taking care of them, their family and society. Or to put it another way, their fear or feeling of burdensomeness.

Alan:                                          The doctor who was helping you with these concepts, trying to get you to be more in touch with the patients, why do you suppose he landed on those four factors?

Karl:                                           Well, it was at the end of his [00:05:00] career when he imparted this to me. He himself was in fact 72 years old. I was taking over his practice, and he was a remarkable man. Someone I really looked up to. I don’t know how he came to those during his life as a physician, but he had it boiled down to those four.

Alan:                                          So dignity meant expressing your understanding of the person’s dignity.

Karl:                                           Well let’s think about the word dignity [00:05:30] a little bit. You know, dignity and respect are quite different. Respect is something you earn. Dignity is something you have, and you know we hear abo humanism coming along during the age of enlightenment. You think well, that’s good, and then you start realizing that it was actually a very important transition in the psyche, if you will, of our civilization. Part of that, they were actual homo sapiens, people, [00:06:00] who are regarded as less than human. They were slaves or they were untouchables or whatever you want to call them. And so during the enlightenment, mankind started seeing us all as having inalienable qualities. One of which was dignity.

So in medicine, we’re often called upon to take care of normal citizens, shall we say, but also prisoners who’ve done pretty bad things. Murderers and so forth. So how do you convey that you recognize [00:06:30] their inherent human dignity, and recognize it as part of the care of the patient. And so, through your organization I learned about reading emotions. So most … part of that is someone said to me, “What’s the emotion I’m reading on this man’s face right now?” I had a very limited vocabulary. You know, sort of happy, sad, bored.

Alan:                                          You had … When I started trying to do it, that’s all I had. You suddenly [00:07:00] realize you don’t have a vocabulary. You can describe wine better than you can describe what’s on somebody’s face.

Karl:                                           So as I’ve shared with you before, I made a study of this and found various ways to increase my vocabulary. So I was giving a talk recently, and I was talking about your method. I was saying that in the act of attempting to understand through reading another person’s countenance what’s going on in their head trying to get [00:07:30] inside them, or to put it another way, to increase empathy for them or with them, people subconsciously recognize that you’re trying to do that. And they let down their guards. They all of a sudden want to be in that relationship with you.

Alan:                                          It’s an intimate look you give somebody when you’re trying to figure out what they’re feeling, and that look possibly triggers an openness on the person [00:08:00] that you’re looking at because it’s unguarded. And it might help them be unguarded too. Then suddenly you’re in a connection that’s powerful.

Karl:                                           Well that’s the whole key. The connection. Many people will leave a doctor’s office feeling there’s been no connection and leave many relationships in life feeling there’s been no connection. But what I’ve learned is, if you make an honest attempt, not some phony attempt, but if you’re actually struggling, working to understand a person, [00:08:30] it goes much better. You actually can help them.

So I was giving this talk, and after the talk two women came up to me. Both from southeast Asia. They had not been sitting together. One from Cambodia, and one I believe from Vietnam. And they told me that in their particular languages, the verb to understand and the verb to love, are the same. And so I like to think that in our interaction with those we’re trying to help, that there would be an element of affection. [00:09:00] Something akin to love.

I met an older physician in the grocery store recently, and he’d retired. I’d inherited some of his patients, and I said to him, “I always enjoy seeing your former patients, and you know they loved you very much.” And he looked at me, and he said, “Well, you know I love them too.” It was refreshing to hear that.

MUSIC BRIDGE

 

Alan:                                          I always have been amazed at the responsibility that doctors take for the well being for the life of a patient, and that willingness to take on that responsibility can be seen as a kind of love. Or it could be seen as, I’ve got this sack of potatoes I have to get off the floor and in the back of the truck.

Karl:                                           Well there’s no question that there’s that too. That it is a burden, but what in life isn’t.

Alan:                                          Yeah.

Karl:                                           That’s meaningful.

Alan:                                          So the suffering and the foursome. The suffering is be aware [00:10:00] of their suffering, or reduce it or what’s the significance of that?

Karl:                                           Well suffering is not pain. Suffering is quite distinct. It’s one’s response to a situation. People don’t just come in with … someone’s not just a kidney infection or pneumonia. They’re a person, and they have an illness within a context. In my opinion, becoming aware of the context and letting someone tell you about the context [00:10:30] is acknowledging their suffering. And I can tell you right now, I could take you. You could take me. We could take anyone we run into on the street. Sit down quietly, and you will not find anyone who doesn’t have some degree of suffering going on in their life at this very moment.

If you think about it, what is the Old Testament about? It is about the suffering of the people of Israel. What is Buddhism about? Buddhism is nothing more than learning how to bear up under suffering and to put it into perspective. Jesus the suffering servant. [00:11:00] So suffering is an inherent quality just like dignity in my opinion, and a part of our obligation to our patients is to help put that suffering in a perspective that is both palatable and to make it more understandable. And I think that’s where story telling comes in.

Alan:                                          Story telling, why? Why does it come in there?

Karl:                                           Well if you go in and tell someone, “You’ve got adenocarcinoma of the putamen.” It’s part of the brain.

Alan:                                          You have laid it on me really well.

Karl:                                           You haven’t told them anything, but if you can create a palatable, understandable story about their illness that will allow them to understand it, you will in large part, address their suffering. So much of suffering is dealing with the unknown.

Alan:                                          So the suffering is not so much the condition itself or the pain you get from the condition, but the burden it is to you psychically.

Karl:                                           And spiritually. Yes.

Alan:                                          And what independence? And what the difference between independence and dependence?

Karl:                                           Well, in the old days when I started out, a doctor might come and say, “Well Miss Smith, you’ve got cancer of the whatever, and we’re gonna give you three rounds of chemotherapy, followed by surgery and radiation therapy.” And the person might say, “Well doctor, I’m 90 years old, and I’m not prepared to [00:12:30] go through that.” In the old days, the doctor might say, “Well, look. I’m the doctor. You’re the patient. It’s my way or the highway.” But we’re now encouraging partnership. These are the things that we have to offer. How do you feel about it? What are you willing to bring to this? And studies now show that if a patient feels a partnership with the treating team, things go much better. Their ability to get better, whatever that means, physically or mentally, is greatly improved [00:13:00] by feeling a part of a partnership.

On dependence, if you’re say a 70 year old doctor, which I am, and you have a medical problem, which I did. And you’re taken to the coronary angiogram suite to have your heart looked at, which I did recently, I was not worried about dye going through my system, or the possibility that I would die from that. I was worried about the burden it was to my wife to have to stop her day, come over to the hospital, and see me. My friends who had a busy schedule. [00:13:30] The doctors having to stop what they were doing to fool around with me, and the impact it would have on my patients. I was worried about being a burden to others. I was not primarily worried about my condition.

And so now, on my rounds, if I go and sit down, and hold someone’s wrist or hand, and say, “Are you concerned about being a burden?” You’re just literally like puncturing a boil because what comes forth is yes. I’m so worried that my daughter who lives in California, and [00:14:00] we live in Tennessee, is gonna have to stop what she’s doing and come look after me now that my leg is broken or whatever. And we have not done a good job of allowing people to express the concern about burdensomeness in illness, and I think it’s very important.

Karl is able to relate to his patients at an unusually deep level – probably because he’s established a connection with them from their very first visit. It’s an unusual first visit – in fact, it’s almost unheard of. Karl tells me all about it, right after this:

MIDROLL

This is Clear + Vivid – and now back to my conversation with Dr. Karl VanDevander.

Alan:                                          This attention to the other person, attention to the patient as a person just seems something so much diminishing in our world [00:14:30] because the world is sweeping past us, and you talked before about the 12 to 15 minutes a doctor typically spends with a patient. When you have a new patient, how much time do you spend with the patient?

Karl:                                           Well, I’m an older doctor, and when I see a new patient, I set aside four hours. And I use a blackboard. And I use a timeline of their life starting at their moment of conception actually because I need to know a lot about the [00:15:00] pregnancy that their mother had. What I’ve found is, if we go, and I invite them to bring as many people as they can with them, their mother or their sister or their best friend, spouse, children, and we go through the whole timeline. Usually there’s a moment in their timeline where they became an unwell person, or they developed a problem that needs to be addressed. But I’ve also found that if you write down every word they’re saying in their presence, they get the idea that you’re actually listening. [00:15:30] It’s just you, the chalk, and the blackboard and the patient. And then you attempt to put it into a narrative form, and this is the old fashioned way of doing it. But there are certain, there’s Abraham Verghese who wrote the book Cutting for Stone. Have you met him?

Alan:                                          No. No.

Karl:                                           Well, he would be someone you might consider meeting. He’s the Head of Medicine at Stanford University. In other words, he’s not insignificant person in the medical world, [00:16:00] and he has something called The School of Narrative Medicine. In fact, it’s taught right here in New York. One of the branches at Columbia, and it’s taught in Philadelphia, and in California, and in Chicago. And I actually teach it in Nashville. It’s primarily for doctors who are willing to make the, you might say, financial, sacrifice ’cause you only charge the same you would charge for a 15 minute visit. I think older doctors can offer that as a service to younger doctors. Take a really comprehensive [00:16:30] history and do a comprehensive physical for their younger doctors who may not have the time. Often they’ll say, could you see this patient whose really complicated and needs more time than my schedule will allow? It’s a great honor, and it’s really a lot of fun.

Alan:                                          Is the idea of narrative medicine what you described before about getting the story, the life story, of the person?

Karl:                                           Well, what you do instead of filling in the blanks like headache. Yes. No. Arm ache. Yes. No. Foot ache. [00:17:00] Yes. No. You actually write it out in narrative story in paragraph form, whole sentences. They can be anywhere from 10 to 40 pages, and then you give it to the patient and their family if they choose. And they get a red pencil and mark it up because some of it may have come out not quite right. Or they can add to it, and they finally have, up to that point in their life, what I would call a pretty comprehensive history. They can carry it with them wherever they go from that point forward seeing [00:17:30] other physicians. If a patient of mine wants to be referred to a center such as the Mayo Clinic or Johns Hopkins, I will do a narrative for them to take with them so that another doctor can read a story about them.

Alan:                                          And they get to participate in the construction of that story. So they’ve really invested in their own story telling.

Karl:                                           In the beginning I say, “This is the story of this person’s medical life as told by.” It might be the patient, or the patient and [00:18:00] their mother and two sisters and grandmother all there.

Alan:                                          So the physician who you refer them to gets the benefit of a more three dimensional picture of the person than he or she would get if all they got was answers to the checkbox questions?

Karl:                                           Yes. That’s correct. Some of these check box questions have had an unintended consequence, and that is, physician burnout. A recent study by the American Medical Association [00:18:30] showed that fully two-thirds of primary care physicians regard themselves as burned out.

Alan:                                          Two-thirds?

Karl:                                           Two-thirds, and it’s because so much of the filling in the blanks seems meaningless. For example, I have a patient who was born with many birth defects. Was born blind and many other problems. I got a form from the insurance company, and it said, “When did this person last appear to be blue?”

Alan:                                          [00:19:00] Blue? What did they mean by that?

Karl:                                           As in slightly sad.

Alan:                                          Oh. I see.

Karl:                                           Document the date, and what you did about it. The very next question was, “When was the last time that this patient expressed that they might be depressed?” What was the date, and what’d you do about it? And the point of that is, it seems silly to be asking that question because who’s gonna do anything about that? Whose gonna read that? What is the sense of it?

Alan:                                          Yes. Yes.

Karl:                                           Or have you talked to the patient about lose rugs in their home? Have you talked about pointed corners to the tables where they might fall? Well that’s important, but is it what we do?

Alan:                                          It seems to take away any of the personhood of the person you’re talking about because everybody has a story. Everybody has a life experience that has texture and meaning to them.

Karl:                                           Yeah, and not just a story but a really important and interesting story. My wife, as you know, is a writer, and she writes about fictional people. But I can promise you on any given day, I see people with stories that are unbelievably interesting. Just this week I saw a new patient who, as a tiny baby, I think age one week, was diagnosed with TB and spent the first 18 years of his life in a TB sanatorium. And his family was poor, and could only come see him two or three times a year. He was in a full body cast for the first six years of his life. He had a little suitcase handle on the side of it. They would carry him around and prop him up here and prop him up there. Those are people who are alive today, and to have him tell his life story is extraordinary.

Alan:                                          You remind me that I was told by a historian of medicine that doctors pretty much only had [00:21:00] placebos and bedside manner until about 100 years ago with the exception of maybe aspirin and maybe one or two other actual medications. The attention to the patient as a person was probably hugely important, and we called it bedside manner. But it was probably medicine in action.

Karl:                                           We need to remember that the human organism has a great defense mechanism in it. [00:21:30] I mean, most viruses and infections will do just fine without all the interventions we do today. I think antibiotics are over used. I’d like to see less of that and more of the old fashioned bedside manner.

 

MUSIC BRIDGE

Alan:                                          Narrative medicine as you practice it, hearing the story of the person from birth until now, and that procedure you go through with a new patient, contacting the patient like that. Have you ever found that it’s actually changed the course of treatment you gave the person?

Karl:                                           Let me tell you at least one story. So a prominent citizen in our state, in fact it was one of the governors, called me and said that he had a colleague who appeared to be dying. She’d been to two medical facilities for diagnosis, and no diagnosis had been forth coming and would I see her and do one of these, what we call chalkboard interviews? So this lady who was 52 years old, came with her sister who was slightly older, her daughter who was in her twenties, her mother and her grandmother who happened to be in a wheel chair. Her main complaint was that she had intractable vomiting and was losing weight and just unable to function.

So I took this long history, and she’d been hospitalized for seven days at one place, ten days at other, had all these fancy tests, and had all the records. So we filled the blackboard with all the things she had to say, and then I decided it was time to examine her. So I asked my nurse to take her to an exam room so that I could examine her, and I came back into the room where we were taking the history. And the grandmother, who was in a wheelchair said, “Karl, I don’t mean to be presumptuous.” She said, “In fact, I never went to school, and I’m certainly not medically educated. But I need to ask you, that pregnancy test up there, was that a urine test or a blood test?” I said, “Well let me look and see.” It was a urine test. She said, “I think that girl’s pregnant.” Well guess what? She was pregnant.

Alan:                                          Oh.

Karl:                                           And so, she wasn’t dying. She was just pregnant late in life and having nausea and vomiting from pregnancy. So did it change the course? I think so.

And one more, if I may. Another woman came in, and she had everything in the book wrong with her. I mean, you name it. She had … Do you have headaches? Yes. Do you have chest pain? Yes. Do you have shortness of breath? Yes. Do you have change in bowel habit? Yes. Has your urinating changed? Have you had rashes? Yes. So I had gone through all of this and really couldn’t figure out what was wrong with this woman, but I asked her if she would come with her twin [00:25:00] sister the next time. Her identical twin sister.

So they sat there, and it was clear that they were having a spat. And so I said, “What’s the problem?” And my patient said, “Nothing.” And the sister said, “Well if you don’t tell him, I will.” And I said, “Please tell me.” And she said, “You have right up there on the blackboard the date that all this started. Is that correct?” And I said, “That’s the date she told me.” She said, “Do you know what else happened on that date?” And I said, “I do not.” And she said, “I won the lottery, and she didn’t.”

Alan:                                          So [00:25:30] how did that change the cure? You bought her a lottery ticket, or what?

Karl:                                           No, I think we had an opportunity to discuss how this had been very upsetting to this woman who was quite poor, and her sister who had also been quite poor was also very wealthy. I think it had affected her in ways that became physical manifestations of, I don’t know what. Jealousy? Or resentment? Or whatever.

Alan:                                          It’s so interesting. You wouldn’t find that on a checklist.

Karl:                                           It was not on the review [00:26:00] of systems checklist. Did sister win the lottery?

Alan:                                          Let me ask you our seven quick questions. If you have the nerve to go through with seven quick answers, it’d be just really fun. What do you wish you really understood?

Karl:                                           Lately I’ve been reading Nietzsche’s Zarathustra which is, talks about Zoroaster who lived around 3,000 BC [00:26:30] and is considered to be, if you look at it carefully, the father of virtually all religions on Earth. At any rate, I wish I understood why it appears that most human beings have a propensity to posit or make up a god. I wish I understood where that came from.

Alan:                                          Very interesting. What do you wish other people understood about you?

Karl:                                           [00:27:00] I wish people could perhaps understand that I care about them when often it doesn’t seem that they think I care about them.

Alan:                                          What’s the strangest question anyone has ever asked you?

Karl:                                           You know, we live in the bible belt, and at least once a week somebody asks me if I have personal, intimate relationship with Jesus. And I [00:27:30] really find that difficult. I want to say, “Well you’d have to … a relationship takes two to tango, and you’d have to ask Jesus first.” You know, you want to answer it in a very respectful way, and you also want to be honest. I find that hard.

Alan:                                          Yeah. Yeah. How do you stop a compulsive talker?

Karl:                                           I have a lot of compulsive talkers who are my patients, and from time to time [00:28:00] I will stop them and say, “You know, this is extremely interesting, and I’d be grateful if you would flesh this out a little bit more in the form of a letter so we could look at it together.”

Alan:                                          Oh, that’s … I never heard that one. That’s good.

Karl:                                           And rarely do I get that letter.

Alan:                                          Right. Right. Sure, they don’t want to listen to it. Is there anyone for whom you just can’t feel any empathy?

Karl:                                           No. [00:28:30] Even dreadful people, dreadful, highly-deranged people have in their essence some element of humanity, and I came to that realization working in a hospital called Whitfield For The Criminally Insane down in Mississippi. I met a mentally ill man who had murdered many, many people, but he was mentally ill. On [00:29:00] the one hand, he seemed to have left his humanity, but on the other hand, I don’t think he had left it completely. I don’t … I think he had a chemical imbalance in his brain that was perhaps correctable.

Alan:                                          It’s great that you seem to have an ability to find that shred of humanity in the other person that you can connect with.

Karl:                                           Well part of it is self-interest. I’m hoping others might someday find it in me.

Alan:                                          How [00:29:30] do you like to deliver bad news? In person, on the phone, or by carrier pigeon?

Karl:                                           Well, as a physician I give a lot of unwanted news for sure. You have something for which there’s no cure or something of that sort. I think of course the best, ideal way 99% of the time is in person, face-to-face, and to be completely transparent. I think you do a person more harm than good by trying [00:30:00] to hide the facts.

Alan:                                          Right. So what, if anything … Our last question. What, if anything, would make you end a friendship?

Karl:                                           I am absolutely incapable of ending a friendship.

Alan:                                          Oh, that’s so interesting.

Karl:                                           Some people find fault in that part of my personhood, but often I feel the thing that appears [00:30:30] to be the factor that would end a friendship is really just a misunderstanding or something that can be worked out. I think when you give up on that, you’re really flying in the face of some basic concepts such as atonement, which I think is a very important part of the fabric of our humanity.

Alan:                                          Well, you’re my friend, and it’s good to know that you’ll never give up on that. Thank you, Karl.

Karl:                                           I feel the same way, Alan. Thank you.

 

This has been Clear + Vivid, at least I hope so.

 

My thanks the sponsors of this episode. All the income from the ads you hear go to the Center for Communicating Science at Stony Brook University. Just by listening to this podcast, you’re contributing to the better communication of science. So, thank you.

 

 

Karl VanDevender’s admirable approach to medicine helps make him such a sought after surgeon in Nashville.

 

It’s interesting that Karl studied English literature and linguistic philosophy before becoming a surgeon. So I guess it’s not surprising that he’s so dedicated to reintroducing the hundanities into medicine.

 

He’s a much-loved doctor. In Karl’s honor, TriStar Centennial Medical Center in Nashville, center recently created the The Karl VanDevender Clinical Pearls Series – where lecture topics include the most cutting-edge advancements and new care-delivery methods in cardiovascular care.

 

This episode was produced by Graham Chedd with help from our associate producer, Sarah Chase. Our sound engineer is Dan Dzula, our Tech Guru is Allison Coston, our publicist is Sarah Hill.

 

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Thanks for listening. Bye bye!