SAN FRANCISCO — Rose Gutierrez has a big decision to make.

Gutierrez, who was diagnosed with breast cancer last spring, had surgery and 10 weeks of chemotherapy. But the cancer is still there. Now Dr. Jasmine Wong, a surgeon at UC San Francisco, is explaining the choices – Gutierrez can either have another lumpectomy followed by radiation, or she can get a total mastectomy.

“I think both options are reasonable,” Wong said. “It’s just a matter of how you feel personally about preserving your breast, how you feel about having radiation therapy.”

“I’m kind of scared about that,” said Gutierrez, 52, sitting on an exam table with her daughter on a chair beside her.

“Well if you made it through chemo, radiation is going to be a lot easier,” Wong told Gutierrez, who is from Merced, Calif.

In many hospitals and clinics around the country, oncologists and surgeons simply tell cancer patients what treatments they should have, or at least give them strong recommendations.  But here, under a formal process called “shared decision making,” doctors and patients are working together to make choices about care.

It might seem like common sense:  Each patient has different priorities and preferences; what’s right for one patient may be wrong for another.  Of course patients should weigh in. But many aren’t accustomed to speaking up. Even the most engaged or educated patients may defer to their doctors because they are scared, they don’t want to be seen as difficult or they think the doctor knows best.

For their part, not all doctors want to cede control to patients who have far less medical knowledge or who may be relying on information they got from friends and the Internet. Also, many physicians don’t have the time for long discussions and the health care system isn’t set up to pay for them.

Even so, hospitals and clinics in several other states, including Massachusetts, Minnesota and Washington, have created collaborative programs to ensure that information and concerns flow back and forth between patient and doctor. UCSF’s approach, in particular, has been a model for other programs around the nation.

The concept of shared decision making has been around for years, but it is gaining new traction with the nation’s health law, which specifically encourages its use.

“Patients and families need to be in the driver’s seat with their doctors, making decisions that are the right choice for them for their unique circumstances,” said UCSF associate professor Jeff Belkora, who runs the shared decision-making program also known as the Patient Support Corps.

That way, he said, patients avoid “a rocky, bumpy ride” of either too much or too little treatment.

At UC San Francisco, patients receive DVDs, pamphlets or links approved by the physicians that explain available options for treatment. During appointments, the doctors not only explain carefully the benefits and the risks of those options but also ask about patients’ priorities and goals.

Patients are paired with college students or recent graduates who help them make a list of questions for the doctor beforehand. These young people also record the visit and type notes for the patients, who then leave with a definitive account of what was said.

That’s important because patients are nervous and emotional after a cancer diagnosis and often freeze up, said premed student Edward Wang. Wang said his presence helps put them at ease. “You’re just making a question list and you’re just taking notes,” he said. “But these simple things really do matter to the patient and to the doctor as well.”

Shared decision making has been used for patients with breast and prostate cancer, heart disease, back pain and other conditions for which there are multiple treatment options that offer similar results.

“It’s a massive cultural change,” said Glyn Elwyn, who researches shared decision making at The Dartmouth Institute for Health Policy and Clinical Practice. “It’s going from ‘I’m the expert, take my recommendation’ to ‘I am going to inform you and respect your wishes.’”

Elwyn and other researchers have found that patients are more satisfied with their care when they have a say in it. Also, it may save money. Some research shows that patients who are involved in their treatment decisions are more likely to be conservative, opting against costly procedures or surgeries.

That doesn’t mean the decisions are easy – even for knowledgeable patients.

Ilene Katz, a UCSF nurse who often works with cancer patients, was recently diagnosed with breast cancer and became a patient herself.

At first, she wanted a mastectomy. “My knee jerk reaction, which probably a lot of women have … is there is cancer in my body, cut it out, cut all of it out,” she said.

But on this February day, she came out of the exam room feeling different. A long conversation with the surgeon and the oncologist helped her decide that, for her, there was no real benefit to having a mastectomy over a lumpectomy.

Katz said she was relieved someone was there taking notes so she could go over it later. “I don’t remember everything,” Katz said, her eyes red from crying. “It’s all a black cloud.”

Katz’s doctor, Laura Esserman, said some patients want her to make choices for them. But Esserman, head of the UCSF breast care center, sees herself more as a coach, often asking questions to make sure patients don’t act out of fear or lack of knowledge: What’s the most important thing to you? How do you feel about your body image? What complications are you worried about?

Typically, Esserman said, she tells patients, “I need to know more about your thought process … and how you are going to feel a year from now.”

Candace Walls, 41, appreciates having some control over her care. Diagnosed with cancer six years ago in Stockton, Walls said the doctor recommended a mastectomy and then did the surgery.

“I didn’t have lots to choose from,” Walls said. “It was just kind of like, ‘This is what I think you should do.’”

Since coming to UCSF a year ago, however, she has been very involved with her decisions about breast reconstruction, even asking the doctor to redo part of the surgery when she didn’t like how it turned out. At a February appointment, Dr. Wong answered her questions one by one. “It is a very good feeling to know you can say what you want to your doctor,” Walls said afterward.

That same day, Gutierrez, the patient from Merced, sat nervously in Wong’s exam room as the doctor explained more about her surgery choices.

“With the partial mastectomy we just need to take a little bit more tissue out … and then we would have to do radiation,” Wong said, as a note taker sat typing quickly. “With the [total] mastectomy, you probably wouldn’t need radiation but obviously it’s a bigger operation.”

Gutierrez said that as a single woman in her 50s, she wasn’t too concerned about keeping her breast. But she was worried about how her body would react to radiation.  Most important, she wanted to be sure doctors got rid of the cancer.

“I have 12 grandbabies,” she said. “I want to be here for them.”

Still, Gutierrez told the doctors she was leaning toward the lumpectomy, saying she felt nervous about the pain. “I’m a big sissy,” she said.

“No, you are doing great,” Wong said. She encouraged Gutierrez to take the time she needed to talk over the choices with her family and to call if she needed to talk more. “I don’t want you to feel like you are pressured to make a decision.”

A few days later, Gutierrez decided on a mastectomy, mostly to avoid the radiation and the worry about cancer’s return. She had surgery in early March.

Reached by telephone the next day, Gutierrez said she felt good about her decision – and how she made it with her doctors. “It makes us seem like we are a team,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

With a deadline fast approaching, bipartisan negotiations are heating up in the House to find a permanent replacement for Medicare’s physician payment formula. But the tentative package being hammered out behind closed doors contains some key provisions that are likely to raise objections from both Republicans and Democrats.

Unless Congress takes action by the end of this month, doctors who treat Medicare patients will see a 21 percent payment cut.

For doctors, the nail-biter has become a familiar but frustrating rite. Lawmakers invariably defer the cuts prescribed by the 1997 reimbursement formula, which everyone agrees is broken beyond repair. But the deferrals have always been temporary because Congress has not agreed to offsetting cuts to pay for a permanent fix. In 2010, Congress delayed scheduled cuts five times.

The current proposal for a permanent fix may not include full financing for repealing the payment formula, according to congressional aides and industry lobbyists who have been briefed on the talks but spoke on the condition of not being named because of the sensitivity of the discussions. That provision could run into concerns from many Republicans and some Democrats. 

In addition, Senate Democrats are leery of another provision reportedly part of the negotiations – charging wealthier Medicare beneficiaries more for their coverage, according to top Senate aides who briefed reporters Sunday. They also noted that although Democrats are eager to attach to a deal an unrelated measure to extend the Children’s Health Insurance Program, they would like it to cover four years, not the two years that the House is reportedly considering.

Still, they said, with some changes in the package, Senate Democrats might be able to support the developing House package.

“Our members would like to get there,” one of the aides said.

Here are some answers to frequently asked questions about the congressional ritual known as the doc fix. 

Q: How did this become an issue?

Today’s problem is a result of efforts years ago to control federal spending – a 1997 deficit reduction law that called for setting Medicare physician payment rates through a formula based on economic growth, known as the “sustainable growth rate” (SGR). For the first few years, Medicare expenditures did not exceed the target and doctors received modest pay increases. But in 2002, doctors were furious when they came in for a 4.8 percent pay cut. Every year since, Congress has staved off the scheduled cuts. But each deferral just increased the size of the fix needed the next time.

The Medicare Payment Advisory Commission (MedPAC), which advises Congress, says the SGR is “fundamentally flawed” and has called for its repeal. The SGR provides “no incentive for providers to restrain volume,” the agency said.

Q. Why don’t lawmakers simply eliminate the formula?

Money is the biggest problem. An earlier bipartisan, bicameral SGR overhaul plan produced jointly by three key congressional committees would cost $175 billion over the next decade, according to the Congressional Budget Office. While that’s far less than previous estimates for an SGR repeal, it is difficult to find consensus on how to finance a fix.

For physicians, the prospect of facing big payment cuts is a source of mounting frustration. Some say the uncertainty has led them to quit the program, while others are threatening to do so. Still, defections have not been significant to date, according to MedPAC.

In a March 2014 report, the panel stated that beneficiaries’ access to physician services is “stable and similar to (or better than) access among privately insured individuals ages 50 to 64.” Those findings could change, however, if the full force of SGR cuts were ever implemented.

Q: What are the options that Congress is looking at?

A: The bipartisan negotiations among key House leadership and staff from committees with jurisdiction over the SGR have been behind closed doors, and the offices of both House Speaker John Boehner, D-Ohio, and House Minority Leader Nancy Pelosi, D-Calif., declined to comment on the negotiations. But some details are emerging.

Late Friday, the bipartisan leadership of the House Ways and Means and Energy and Commerce committees – the two House panels with jurisdiction over the SGR – said in a statement that “we are now engaging in active discussions on a bipartisan basis – following up on the work done by leadership – to try to achieve an effective permanent resolution to the SGR problem, strengthen Medicare for our seniors, and extend the popular Children’s Health Insurance Program.”

Last year’s proposal from the House Energy and Commerce and Ways and Means committees and the Senate Finance Committee is reportedly the basis of the current SGR talks, according to the lobbyists and aides, in part because it enjoyed bipartisan support and would encourage better care coordination and chronic care management, ideas that experts have said are needed in the Medicare program.

That proposal would have scrapped the SGR and given doctors an 0.5 percent bump for each of the next five years as Medicare transitions to a payment system designed to reward physicians based on the quality of care provided, rather than the quantity of procedures performed, as the current payment formula does.

Tacking on a package of other health measures – known as extenders – that Congress renews each year during the SGR debate would push the cost even higher. They include additional funding for therapy services, ambulance services and rural hospitals, as well as continuing a program that allows low-income people to keep their Medicaid coverage as they transition into employment and earn more money.

As part of the proposal, the House members are also talking about adding two years of funding for the Children’s Health Insurance Program, a federal-state program that provides insurance for low-income children whose families earned too much money to qualify for Medicaid, according to the lobbyists. While the health law continues CHIP authorization through 2019, funding for the program has not been extended beyond the end of September.

The length of the extension could cause strains with Senate Democrats. Last month, the Senate Democratic caucus signed on to legislation from Sen. Sherrod Brown, D-Ohio, calling for a four-year extension of the current CHIP program, according to senior Senate Democratic aides. Democrats want that CHIP language in the SGR deal because “this may be the only health care vehicle moving,” said one of the Senate aides. 

Just two years of additional CHIP funding is non-starter for Democrats. “We need to make sure that Children’s Health Insurance Program is on a sustainable path,” the aide said.

Q: How would Congress pay for all of that?

A: It might not. That would be a major departure from the GOP’s mantra that all legislation must be financed. Tired of the yearly SGR battle, veteran members in both chambers may be willing to repeal the SGR on the basis that it’s a budget gimmick – the cuts are never made – and therefore financing is unnecessary.

But that strategy could run into stiff opposition from Republican lawmakers and some Democrats. Most lawmakers are expected to feel the need to find financing for the Medicare extenders, the CHIP extension and any increase in physician payments over the current pay schedule. Those items would account for about $60 billion of financing in an approximately $200 billion package.

Conservative groups are urging Republicans to fully pay for any SGR repeal.

“Americans didn’t hand Republicans a historic House majority to engage in more deficit spending and budget gimmickry,” Dan Holler, communications director for Heritage Action for America, said in a statement. “Any deal that offsets a fraction of the cost, like the one currently being discussed behind closed doors and leaked to the press, is a non-starter for conservatives.”

But physicians and other analysts make the point that Congress has already paid out billions on temporary patches that don’t fix the problem.

“Congress has spent a staggering $170 billion on 17 patches in a 12-year period, the cost of which has far exceeded the cost of eliminating the SGR altogether,” American Medical Association President Robert M. Wah wrote last month. “This continuous cycle of putting a Band-Aid on the real problem, creates an unpredictable environment that makes it difficult for physicians to budget and plan for practice innovations that could improve quality and reduce costs.”

Q. Will seniors and Medicare providers have to help pay for the plan?

According to the lobbyists and aides, the potential financing options being looked at by House negotiators include charging wealthier Medicare beneficiaries – who already pay a higher premium – even more and introducing a surcharge on the popular “first-dollar” supplemental Medicare insurance known as “Medigap.” Experts contend that the “first-dollar” plans, which cover nearly all deductibles and co-payments, keep beneficiaries from being judicious when making medical decisions. The change could convince them to reduce opt against treatment they don’t need, thus saving Medicare money. President Barack Obama’s fiscal 2016 budget plan includes similar provisions.

Congress could also extend the automatic 2 percent Medicare cuts in place as part of budget sequestration, but those cuts would face stiff opposition from Medicare providers and the groups they serve.

Senate aides said Democrats there are likely to take issue with the provisions to reduce reimbursements to Medicare providers and to require seniors to pay more.

Medicare beneficiaries already pay 25 percent of all Part B costs (physician services are included in Medicare Part B), so an increase in Medicare reimbursements to physicians would increase what seniors in the traditional Medicare program pay for premiums, deductibles and co-insurance, according to an analysis from the Kaiser Family Foundation. According to the report, half of all people on Medicare live on incomes of about $23,500 or less, and seniors spend three times more than younger households on health care as a share of their household budgets. (KHN is an editorially independent program of the foundation.)

Asking seniors to pay more for their Medicare in exchange for higher Medicare payments to physicians “doesn’t seem like a very fair thing to do for seniors,” a senior Senate Democratic aide said.  Using payment cuts to other Medicare providers, like hospitals, may be problematic as well because such steps “always sort of generate opposition and heartburn for both sides of the aisle,” the aide said.

Q. How quickly could Congress act?

Legislation to repeal the SGR could move in the House as early as the week of March 16, the lobbyists said.

The Senate Democratic aides said that they expected Democrats and Republicans in that chamber will want to offer amendments to the emerging House package, making it extremely difficult to pass any overhaul before the Senate’s two-week break scheduled to begin starting March 30.

If the SGR issue can’t be resolved by March 31, expect Congress to pass a temporary patch as negotiations continue.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

With millions of Californians gaining coverage under the health care law, counties need to strengthen their health programs to serve the remaining 3 million uninsured people, nearly half of whom are living in the state illegally, according to a report by a statewide advocacy coalition.

Under state law, each county is responsible for providing care to low-income Californians who are uninsured. But eligibility restrictions in county programs vary dramatically, leaving the uninsured with uneven access to care across the state, according to the report by Health Access California.

The coalition, which surveyed all 58 counties last fall, found that 48 of them preclude residents who are in the country illegally from enrolling  in county programs, and 43 exclude any resident earning more than twice the federal poverty level. (The poverty level is $11,770 per year for an individual and $24,250 per year for a family of four.)

In 2014, counties worked hard to enroll as many of their residents as possible into new coverage options through the Affordable Care Act, said Anthony Wright, executive director of Health Access.  Because millions were enrolled either through the insurance exchange, Covered California, or through Medi-Cal, the government program for the poor, the counties experienced a significant decline in the number of people enrolled in their programs.

But significant pockets of uninsured people remain – especially immigrants living here illegally, who are mostly ineligible for state and federal programs.

In counties with strict eligibility criteria for their programs, such as Merced, Placer and Tulare counties, no residents are enrolled. But counties with expansive programs that cover the undocumented and higher-income residents are still seeing high levels of enrollment. In Los Angeles, for example, 81,000 people were signed up with My Health LA, the county program.

The widely varying levels of enrollment among counties suggest that local governments “need to re-adjust their programs,” said Wright in a press release. “We need counties and the state to reorient their safety-net programs to serve the need that continues to this day.”

Few counties have adjusted eligibility requirements for their programs in the past two years, Wright said. Instead, they have taken a “wait-and-see” approach until the effects of the ACA and the state’s reallocation of safety-net funds were clear.  Many are reconsidering how to manage their safety-net health programs as of 2016, and advocacy groups such as Health Access are hoping the counties will expand their eligibility requirements, particularly to allow immigrants here illegally to enroll.

“These county efforts should ultimately be a bridge to a statewide solution, where all Californians can be covered regardless of immigration status,” said Wright. “Immigrants are part of our economy and society, they should be fully included in our health system as well.”

But some in the state say that expanding health coverage to additional residents would be too costly. A bill currently moving through the state legislature, for example, would expand insurance options to immigrants living in the state illegally. That bill, called the Health for All Act, would cost the state between $424 million and $436 million in 2019, according an analysis from UC Berkeley’s Center for Labor Research and Education and the UCLA Center for Health Policy Research.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Too many consumers have learned the hard way that their credit rating can be tarnished by medical bills they may not owe or when disputes delay insurer payment. That should change under a new policy agreed to this week by the three major credit reporting agencies.

The agencies say they will establish a 180-day waiting period before medical debt is added to someone’s credit report. In addition, the agencies agreed that when an insurer pays a bill, the debt will be promptly removed from the consumer’s credit report, unlike certain debts that remain for years.

The changes are part of a settlement between the credit rating agencies — Equifax, Experian and TransUnion – and the New York Attorney General’s office that aims to improve accuracy and enhance procedures for disputing credit report errors. The agreement covers consumers across the country.

The three agencies gather information from banks and collection agencies about consumers’ credit — such as payment history and how much someone owes — to create a credit score for about 200 million individuals throughout the country. A person’s credit score is used as a measure of credit-worthiness, and it can influence people’s ability to get loans and the interest rates they’re charged, among other things.

“This is going to help millions of people access more affordable loans,” says Mark Rukavina, a principal at Community Health Advisors in Chestnut Hill, Mass. “People will no longer be penalized for having a medical bill slip past them and get on their credit report even though the bill gets paid.”

Insurers sometimes wrangle with patients and providers for months before paying a bill. The new six-month waiting period will give consumers time to resolve such disputes, Rukavina noted.

Medical debt accounts for more than half of the collection items on credit reports, according to a report by the Consumer Financial Protection Bureau. Among people facing collection for only medical debt, about half have otherwise clean credit reports with no sign of past debt collection problems.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The patient was dying and she knew it. In her mid-50s, she had been battling breast cancer for years, but it had spread to her bones, causing unrelenting pain that required hospitalization. Jeremy Force, a first-year oncology fellow at Duke University Medical Center who had never met the woman, was assigned to stop by her room last November to discuss her decision to enter hospice.

Employing the skills he had just learned in a day-long course, Force sat at the end of her bed and listened intently. The woman wept, telling him she was exhausted and worried about the impact her death would have on her two daughters.

“I acknowledged how hard what she was going through was,” Force said of their 15-minute conversation, “and told her I had two children, too” and that hospice was designed to provide her additional support.

A few days later, he ran into the woman in the hall. “You’re the best physician I’ve ever worked with,” Force remembers her telling him. “I was blown away,” he says. “It was such an honor.”

Force credits “Oncotalk,” a course required of Duke’s oncology fellows, for the unexpected accolade. Developed by medical faculty at Duke, the University of Pittsburgh and several other medical schools, “Oncotalk” is part of a burgeoning effort to teach doctors an essential but often overlooked skill: clinical empathy. Unlike sympathy, which is defined as feeling sorry for another person, clinical empathy is the ability to stand in a patient’s shoes and to convey an understanding of the patient’s situation as well as the desire to help.

Clinical empathy was once dismissively known as “good bedside manner” and traditionally regarded as far less important than technical acumen. But a spate of studies in the past decade has found that it is no mere frill. Increasingly, empathy is considered essential to establishing trust, the foundation of a good doctor-patient relationship.

Studies have linked empathy to greater patient satisfaction, better outcomes, decreased physician burnout and a lower risk of malpractice suits and errors. Beginning this year, the Medical College Admission Test will contain questions involving human behavior and psychology, a recognition that being a good doctor “requires an understanding of people,” not just science, according to the American Association of Medical Colleges. Patient satisfaction scores are now being used to calculate Medicare reimbursement under the Affordable Care Act. And more than 70 percent of hospitals and health networks are using patient satisfaction scores in physician compensation decisions.

While some people are naturally better at being empathic, said Mohammadreza Hojat, a research professor of psychiatry at Jefferson Medical College in Philadelphia, empathy can be taught. “Empathy is a cognitive attribute, not a personality trait,” said Hojat, who developed the Jefferson Scale of Empathy, a tool used by researchers to measure it.

“The pressure is really on,” said psychiatrist Helen Riess. The director of the empathy and relational science program at Massachusetts General Hospital, she designed “Empathetics,” a series of online courses for physicians. “The ACA and accountability for health improvement is really heightening the importance of a relationship” between patients and their doctors when it comes to boosting adherence to treatment and improving health outcomes.

“Demographics and economics are driving this,” said James A. Tulsky, one of the developers of “Oncotalk.” (The original course for oncologists has been adapted for other specialties under the aegis of Vital Talk.) “Baby boomers have higher expectations” and are less willing to tolerate doctors they consider arrogant or unapproachable, added Tulsky, director of the Duke Center for Palliative Care. A 2011 study he headed found that doctors who took the course inspired greater trust in their patients than those who did not.

While empathy courses are rarely required in medical training, interest in them is growing, experts say, and programs are underway at Jefferson Medical College and at Columbia University School of Medicine. Columbia has pioneered a program in narrative medicine, which emphasizes the importance of understanding patients’ life stories in providing compassionate care.

While the curricula differ, most focus on self-monitoring by doctors to reduce defensiveness, improve listening skills (one study found that, on average, doctors interrupt patients within 18 seconds) and decode facial expressions and body language. Some programs use actors as simulated patients and provide feedback to individual doctors.

Too Busy For Empathy

“In the 1980s, when I trained, the emphasis was on medical knowledge and technical skills,” said Debra Weinstein, vice president for graduate medical education at Partners HealthCare, the largest provider of medical services in Massachusetts. But in the past decade, “the profession has been more attuned to patient satisfaction and the connection between satisfaction and outcomes and incentives.”

Partners, which includes Mass General and other Harvard teaching hospitals, is requiring that its 2,000 residents take “Empathetics.” In a 2012 study involving 100 residents, researchers found that doctors randomly assigned to take the course were judged by patients as significantly better at understanding their concerns and making them feel at ease than residents who had not undergone the training.

Riess said that while some doctors have told her they don’t have the time to be empathic, the skill has proved to be a timesaver rather than a time sink. It can help doctors zero in on the real source of a patient’s concern, short-circuiting repeated visits or those “doorknob moments” doctors dread, when the patient says “Oh, by the way . . . ” and raises the primary concern as the doctor is headed out of the room.

Because a lack of empathy and poor communication drive many malpractice cases, a large malpractice insurer, MMIC, is urging doctors it insures to take the “Empathetics” course. Another benefit: Empathy training appears to combat physician burnout.

“Empathy training is naturally self-rewarding,” said Laurie Drill-Mellum, a former emergency room doctor who is chief medical officer of the Minneapolis-based insurer. “It gives [doctors] the love back,” she said, referring to the positive feedback empathic doctors receive from their patients.

‘Doctors Are Explainaholics’

Both Riess and Tulsky say their interest in empathy was sparked by personal experience. In Riess’ case, it was the flood of patients in her psychiatric practice a decade ago who spent their time in therapy discussing devastating interactions with doctors. “These are not just innocuous effects,” she said, “but often experiences that were profound and deeply affected people’s lives.”

Tulsky said that his father, an obstetrician-gynecologist in a solo practice, routinely talked about his patients at dinner. “His stories were about their lives, so I got this idea that medicine was about more than the illness,” he recalled. In medical school, Tulsky said, “I was very drawn to challenging moments in patients’ lives and volunteered to give bad news,” particularly when he believed other doctors would botch it.

“I saw a lot that disturbed me,” Tulsky said. One memorable incident involved his chief resident loudly berating a frightened, impoverished and very sick old man, saying, “If you don’t have this operation, you’ll die. Don’t you understand?”

Tulsky said that researchers have found that some doctors don’t respond with empathy because they are clueless when it comes to reading other people. Many others, he said, do recognize distress but fear unleashing a flood of emotion in the patient, and sometimes in themselves.

“Doctors are explainaholics,” Tulsky said. “Our answer to distress is more information, that if a patient just understood it better, they would come around.” In reality, bombarding a patient with information does little to alleviate the underlying worry.

The “Empathetics” program teaches doctors “how to show up, not what to say,” said Riess. “We do a lot of training in emotional recognition and self-monitoring.” That includes learning to identify seven universal facial expressions — using research pioneered by psychologist Paul Ekman — and to take stock of one’s own emotional responses to patients or situations.

Some of the course is explicitly prescriptive: Make eye contact with the patient, not the computer. Don’t stand over a hospitalized patient, pull up a chair. Don’t conduct a monologue in off-putting medicalese. Pay attention to tone of voice, which can be more important than what is said. When delivering bad news, schedule the patient for the end of the day and do not allow interruptions. Find out what the patient is most concerned about and figure out how best to address that.

One Doctor’s Experience

Andy Lipman has taken the Duke course twice: first as an oncology fellow in 2004 and last year as a practicing oncologist in Naples, Fla., when he felt in need of a “booster shot.” Oncology, he said, “is a full-contact” specialty with a high burnout rate.

Among the most important lessons Lipman said he learned during both sessions was to let go of “my own medical agenda, the desire to fix something or make something happen in that visit.” He learned to pace himself, monitor his reactions and talk less.

Every day, he said, he thinks about what he was told in 2004: “Never answer a feeling with a fact.” That means responding to a patient in a six-month remission from cancer who reports having a sore elbow by saying, “Tell me more about your elbow. This is probably scary stuff” and not “Your scans show no evidence of disease.”

One technique Lipman routinely employs is taking 15 seconds before entering an exam room to ask himself, “What is needed here?”

On the day he was interviewed, Lipman said, he used what he has learned with a patient with end-stage cancer. She was scheduled for a brief appointment but began weeping loudly as she told Lipman how alone she felt.

“I engaged, I expected the emotional response and I hung in there,” he said of the meeting, which lasted 45 minutes. “It felt good to me,” Lipman said, and he hoped it gave his patient some comfort.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.