Teaching students the empathy piece

It’s a lecture hall without fancy features, except for the model of a human skeleton occupying one corner. Typically outfitted first-year students file in—backpacks, laptops, water bottles. They’re wearing white coats, which prove useful for accommodating the accessory of a clipped-on DukeCard. The white coats mark the start of the journey to become a physician; they were awarded in a formal ceremony a couple of days earlier.

Anthony Galanos, a professor at the School of Medicine, introduces a woman in her mid-twenties whom he identifies just as Jessica, an intimate witness to the human dimensions of health care; he’ll be “gently interviewing” her. The lecture-hall conversation is one element of “LEAD,” an acronym (creative wordplay being an emblem of the academy) standing for “Leadership Education And Development.” LEAD is largely about “being able to effectively listen, communicate, and conduct oneself with an understanding of one’s own and others’ motivations and feelings in a meaningful way.” And Galanos is modeling patient-centeredness.

When I’ve thought of professional-school education, I’ve imagined mastery of a standard toolkit. Hey, medical students, welcome to gross anatomy. Nursing students, here’s your dose of pharmacology. Business students, you’re ready to figure out financial accounting, right? Law students, it’s time to amend your understanding of constitutional principles.

Watching Galanos, I see a more expansive vision. Then I run into a commentary by Brewer Eberly, a newly minted doctor whose Duke connection is with the divinity school. Writing for STAT, a life-sciences website, Eberly wrestles with professionalism in medicine, which he defines as “something enduring and sacred.” He’s no fan of PowerPoint slides with words like “autonomy,” “beneficence,” “non-maleficence,” and “justice.” He celebrates, rather, “friendship,” “practical mentorship,” and “community” as helping to nourish “living traditions, authentic habits, and robust practices.”

The question driving Eberly’s musings is: Can professionalism, broadly conceived as a humane pursuit, be taught? The answer from Duke’s professional schools is: Yes, right from the beginning.

The Eberly essay invites a deeper exploration, so we arrange to meet on campus, right after he takes in a lecture on faith and science. We sit down in the library’s von der Heyden Pavilion, a glass cube that offers a ready-made metaphor for looking out and looking within. He’s a recent fellow of the Theology, Medicine, and Culture program at Duke Divinity, through which, in 2017, he earned a master of arts in Christian studies. He took courses on medicine and storytelling; theological bioethics; and the theology of illness, suffering, and death. He also volunteered with Reality Ministries in Durham, which applies the power of friendship in working with adolescents and young adults who have profound disabilities.

What a humbling thing it is, he says, to be sitting with a young woman with cerebral palsy who tells you she wants to pray for your success as a physician.

In our conversation, Eberly veers effortlessly from Aristotle to Aquinas to the divinity school’s Stanley Hauerwas. Aristotle would say we do our work as professionals because it matters for large purposes. Eberly would add that formation and habituation begin at moments of transition—like the transition to professional school.

At the medical school, the large purpose of medicine drives the lecture-hall dialogue: Galanos ’75, the doctor; and Jessica, now seasoned in the patterns of physician communication. “We wish we could dictate how the story ends,” he says to the students. “But nature always wins.” It was just over a year ago that Jessica lost Oz, her new husband, to a raging cancer. Jessica is—and Oz was— about the same age as the students. “I wish every single patient we cared for got better and went home. But that’s not reality. Some never make it home.”

One day at home in South Carolina, Jessica’s then-boyfriend, Oz, got down on the floor to fix a TV and complained that his back was hurting. From that discomfort, as Jessica recounts with remarkable poise, followed multiple medical consultations and a series of diagnoses—muscle strain, a slipped disk, a lesion on the spine, lymphoma, and finally sarcoma. A local doctor said if this was indeed sarcoma, Oz would want someone else to be treating it. That was after ten days of testing. “You’re hoping for solid information,” Galanos says. “But it comes out in drips, not gushes.”

Jessica did a lot of Web-based searching and ended up at Duke, close to where both had gone to school and close, as well, to family members.

The students listen intently; they’re remarkably resistant to the lure of their electronic devices. Galanos asks Jessica about interactions with doctors: What was helpful? What was not helpful? He tells the students that patients and families remember everything that was said, and everything that was not said, in the course of treatment.

I have a chat with Cecily Peterson, assistant professor of medicine and associate director of LEAD. She tells me medical students have long argued that it’s not enough to be steeped in a science-heavy curriculum. Being a good doctor means not just familiarity with the traditional medical toolkit, she says. She’s big on “emotional intelligence”; and she sees medical education, in part, as “a process of self-awareness and self-management.”

It’s advice that’s stuck with Dalton Hughes, now in his fifth year in Duke’s joint M.D./Ph.D. program. His aim is to specialize in neurobiology, go on to a psychiatry residency, and complete a fellowship in palliative care. As he was starting out, he listened to an exchange similar to the one I witnessed. “You’re reminded of the fact that you’re not only walking into an interesting medical case. You’re walking into a whole life. How do I make sure the care I provide is in line with that?”

Talking with Hughes, I think back to the medical and divinity student-turned-essayist, Brewer Eberly; in his recipe for professionalism, he refers to “practical mentorship.” That’s exactly what Hughes finds with Galanos, a palliative-care specialist whom he calls “an inspiration.”

A few buildings away on the medical campus, students assemble for the first meeting of the formidably titled “Health Assessment and Foundations for Nursing Practice Across the Lifespan.” These are students in the Accelerated Bachelor of Science in Nursing program, a second degree program for undergraduate degree-holders.

Their course is coordinated by Kathleen Ashton M.S.N. ’09, an assistant clinical professor. On the big screen of the lecture hall, Ashton is showing an image from her personal scrapbook, a lake scene along the Blue Ridge Parkway. She soon wades into the school’s statement of philosophy; among other things, it celebrates relationships with patients that “reflect respect for dignity, diversity, integrity, self-determination, empathy, and a capacity for grace and empowerment.”

As nurses, Ashton says, we take care of human beings. Kind of obvious. But what comes to mind when we think of human beings? Lots of ideas come up in the lecture hall. A moral compass. Growth and change through different stages of life. The desire for a meaningful life. Relationships. Biases. Advocacy, someone mentions, and Ashton rides with that: Advocacy is a “cherished value” in nursing. Well, as human beings, we look to growth and change through different stages of life, another student suggests. Ashton’s co-instructor for the course, associate clinical professor Beth Phillips, takes an opportunity to make a point: You will be changed in this profession. Caring for others in such an intimate way will force you to think about your own life choices.

The next day, Ashton offers another picture. It’s taken from the American Journal of Nursing, and it shows a patient being supported by a nurse as they navigate a hospital hallway. That sparks another class discussion. How do patient-nurse relationships compare to other relationships? Students talk about the complications that arise from the nurse knowing a lot about the patient’s health status, even as the patient knows little about the nurse. It’s a power differential worth pondering. They talk about conveying respect through body language, tone of voice, and gentle physical touch. And they talk about trust.

A colleague in an adjoining office teaches another course for the newest nursing students, “Wellness and Health Promotions Across the Lifespan.” That’s Jacqui McMillian-Bohler, an assistant professor. At the beginning of the semester, the course involves students in a “motivational interview” simulation with a “standardized patient.” The standardized patient is, in essence, an actor playing the role of a patient—in this case, someone who was told by his main health-care provider that he’s overweight and his blood pressure is too high.

In the simulated encounter that I observe, the student nurse introduces herself to “Wyatt.” He explains that he’s a long-haul trucker; typically he’s on the road for eleven hours every day. The truck-stop offerings pretty much consist of burgers, hot dogs, and pizza. He regularly walks all around the truck for a safety inspection, and at home there’s always yardwork. That’s about it for exercise: “I can’t be a gym rat two hours every day.” Wyatt mentions that his wife occasionally prepares trail mix, chicken wraps, and salads as on-the-road supplements.

The student encourages Wyatt to look on that as a good start. She asks if he’s interested in a suggestion or two. What about combining exercise with family time—say, going together for a walk? And yes, even a ten- or fifteen-minute walk counts.

Eberly, in the STAT essay, calls out authentic habits and robust practices among the markers of professionalism. And McMillian-Bohler echoes that thinking. The point of the exercise isn’t to show off early expertise in giving medical advice, she explains to me. Rather, she wants students to be finding good avenues for interaction—looking that patient in the eye, catching that smile when he mentions a spouse, affirming that he is already making smart decisions, having a conversation rather than operating off a check-list.

Nurses, in Ashton’s view, have to be operating with empathy along with knowledge. “There is an expectation that a nurse will admit a mistake, like a medication error,” she tells me. “That takes maturity, honesty, integrity, courage, and a commitment to put someone else’s well-being ahead of a need to preserve oneself. I think it would be hard to be a nurse if one wasn’t willing to get into messy, unpleasant, and hard stuff—assisting someone with basic bodily needs or dealing with messy societal stuff such as the consequences of racism or poverty.”

Imagine speaking for someone who doesn’t know how to advocate for himself or herself—maybe even someone who, because of a stroke, has no voice at all. “All of that requires a selfless willingness to take on another’s experience.”

There’s plenty of willing noisemaking among the newest students at the Fuqua School of Business. I watch them get down to business at the Triangle Training Center, a wooded enclave about twenty-five miles west of campus in Pittsboro. On this hot August afternoon, they’re negotiating a forty-foot climbing wall and a high-ropes course. One challenge has them walking in pairs along two divergent wires. Another has them spinning a metal ring until it buzzes; they then pass that still-buzzing ring to their colleagues without interrupting its spin.

They shout advice as their (sometimes roped-together) peers struggle to scale up the wall or to keep their balance: “Kick off!” “Lean back a little bit!” “Watch the purple line!” “Go right, then left!” “Do like Michael Jackson!” And along with advice, encouragement: “You can do it!” “Just five more steps!” “You’re a natural up there!”

Staffers later have them reflect on what, in business lingo, might be called the takeaways: The individual perhaps looks on a particular task as impossible, but it becomes doable from a team perspective. And as collective energy goes into making it happen, the team becomes, in essence, more of a team. All of that suggests a focus on the process—not so much on the task alone.

It’s a different set of tasks a few days later. The neighborhood is pretty much a baseball’s throw from the downtown Durham Bulls stadium, and the student teams are at work on several Habitat for Humanity sites. They’re wearing “Duke Fuqua” work gloves and somewhat wordier T-shirts—“Building Community/ Habitat for Humanity Durham-Duke.”

There are quick lessons in how to use a circular saw. Soon the students are measuring and cutting planks, making connection points for drywall, framing doors and windows, applying insulation, sheathing exteriors. It’s another (noisy) exercise in collaboration.

This is all part of what Fuqua—which, of course, also likes references to leadership—calls its “Consequential Leadership,” or C-LEAD 1 program. The faculty lead for these experience-based activities is Gráinne Fitzsimons, a Fuqua professor of management and organizations. She says the modern organization is a collaborative environment. Sure, business students need a lot of hard skills, a lot of quantitative exposure. But Fuqua’s students, from the start, will be assigned to teams. Their first-year courses—accounting, economics, strategy—all have at least one team-oriented assignment or project.

Their cohort, in a larger sense, is meant to function as a support network. “It’s no longer the case that you can be a brilliant numbers cruncher or IT person, and that’s your only contribution,” Fitzsimons tells me. “You really need to know how to work with people.”

As their formative years at Fuqua kick off with such active endeavors, the students slip easily into “team” talk; they’re quick to pick up on Fuqua’s well-established credo around collaboration. But all that team-spiritedness can sound purely instrumental. Can a focus on working collaboratively help create a better person, and not just a better executive? To answer that, I engage, naturally, with Duke’s own Empathy Development Lab, whose principal investigator is Rita Svetlova. “Working in teams is a great way to increase all kinds of cooperative behaviors,” she tells me.

Beginning around age three, children behave with others in ways that reflect whether or not they collaborate with them. Svetlova points to studies that have looked at what happens when children work together to get common resources—say, if they collaborate on grabbing four toys. What happens, then, when the resources are “accidentally” distributed unequally—three toys for one, one toy for the others? If they’re seasoned collaborators, the three-toy child happily shares her extra toy with her somewhat deprived peer. But if children don’t have the experience of working together, they’re much less likely to share.

“Collaboration promotes a sense of fairness and also a sense of care for the others,” Svetlova says.

Another Duke school, another bit of wordplay around “leading,” and for these students, a series of early encounters meant to impress them with—to borrow a phrase from the Eberly essay—“living traditions.” Students start out as first-year law students, or Duke 1Ls, with “LEAD Week”; here the acronym points to “Lawyer Education And Development.”

The 1Ls meet Kerry Abrams, the dean of the law school; she’s new to Duke, just like them. Abrams talks about the social-justice aspects of the law and her own specialties, immigration law and family law. And she brings up her early pro bono work: It had her handling eviction cases on behalf of low-income residents in New York’s Chinatown and standing up for mentally disabled men who, in a Medicaid kickback scheme, had been forced to endure unnecessary surgeries.

One of the lead-in events to LEAD Week is a “Professionalism Luncheon” at the Washington Duke Inn—complete with guidance for professional-luncheon etiquette. Caryn Coppedge McNeill J.D. ’91, president of the North Carolina Bar Association, talks about legal practice as a grand calling, including the grand ambition—so basic to justice, and so often unrealized— of providing access to legal services.

The students stand and recite the Duke Law School Pledge, which commits them to the Duke Law Blueprint. Basic to the blueprint: the assertion that “the student experience at Duke Law will be transformative of the whole person, and not merely a means to obtain a formal credential.”

Other LEAD Week activities build on that blueprint. One is a screening of the documentary The Trials of Darryl Hunt. In 1984, Hunt, an African American, was convicted of the rape and murder of a white newspaper editor near Winston-Salem, North Carolina. DNA results proved his innocence in 1994; it took another ten years of legal appeals to exonerate him. Some tears flow in the audience, and there are sounds of sniffling, and then some questions for the lawyer for Hunt, who’s attending the screening.

The co-director of the Wrongful Convictions Clinic, Theresa Newman, tells me: “Many first-year law students arrive at Duke with only a passing understanding of the power of the law, especially in the criminal-justice system. And many imagine that, in the end, fact and truth will win out in nearly every case.” The documentary demonstrates how fragile that promise is, she adds, and how “heartbreakingly slow the path to justice” can be.

As for the enduring impact of that story, for lawyers-to-be—well, I go back to Rita Svetlova at the Empathy Development Lab. She talks about the “identifiable victim effect.” It’s well known that people are more likely to donate disaster-relief money if they see a picture of one hurt child than if they are told about thousands of victims, she says. “Part of the reaction to that child’s picture—or to a powerful story—is the thought that it could have been me, or my child, or someone I care about.”

So any kind of a personal connection is important for eliciting empathy—which is a big part of the law-school journey for Patrick Butler. Last year’s president of the Duke Federalist Society and now a 3L, he tells me he “vividly” remembers learning over LEAD Week about Darryl Hunt, and learning more broadly that the law has a real impact on people’s lives.

Butler seems to have remained faithful to that lesson: His favorite activity at Duke Law has been volunteering with the Durham County Youth Home. The children are in juvenile detention, either transitioning out of serious incarceration or awaiting a formal hearing. Among his projects there: a class on “How to Talk to the Police,” teaching the children about their constitutional rights and about the importance of treating officers with respect. Volunteering has reminded him of “the reason that I attended law school in the first place: to help serve the public good,” Butler says.

As he talks about the profession, he embeds the greater purpose of legal work in justice, and even in empathy: “I put aside my worries over readings or assignments, and focus on putting myself in the shoes of those children.”

Most states have either an “aspirational” or an ironclad expectation that lawyers will do pro bono work, explains Stella Boswell ’90, assistant dean of public interest and pro bono. According to Boswell, the most recent graduating class contributed 45,326 hours of public service over their three years, including clinics, externships, and pro bono work. From Day One, she says, the school tries to impress on students that they’re now members of the profession.

Early in their path through law school, some beginning students research cases for the Innocence Project. They work closely with the Wrongful Convictions Clinic, among the oldest of the school’s eleven clinics. (Geared to more advanced students, the clinics involve a teaching component and closely supervised legal work.) Other 1Ls work with the Duke Cancer Center; among other tasks, they help with the preparation of power- of-attorney forms and advance directives.

Butler, for his part, will follow Duke Law with a two-year judicial clerkship. Then he’ll return to the Washington law firm where he interned this past summer. While there, he sought a pro bono project involving Social Security benefits for a young boy. His embrace of that project was, he says, “inspired by my experience at the youth home”; he likes to think his legal path will always have him “serving the common good.”

A vivid cancer story continues to unfold back in the medical school’s lecture hall. For Oz, the patient at the center of the story, there would be periods of chemotherapy and immunotherapy, none of which, it turned out, stymied the spread of aggressive tumors. Galanos, the doctor, takes these doctors-in-training back to Oz’s final night. Oz, sedated, appeared comfortable. That changed, with increasingly severe brain swelling. When he took his last breath, it was almost a relief, says Jessica, Oz’s widow. After his death, friends would ask her about adjusting to “the new normal” in her life. “The new normal. I’m not sure I like that phrase.”

The students have lots of questions: How do you distinguish between delivering bad news to the patient and to the patient’s family? At what point should you bring up the possibility of counseling? How do you improve conversations around hospice care—the sort of topic most doctors shy away from?

In the lecture hall, Galanos’ repeated message is that these doctors-in-the-making would need to step outside themselves: Their command of science, all the tech they have at their disposal, is great. But it’s about the patients and their families. Avoid the sort of “doctor prose” that just blurts out medical facts. Ask something like, “Is there anything else we can do to make it better for you?” And ask the family member, “How are you doing today?”

Above all, be respectful. “It’s their moment, not yours,” he says.

“Everything you do is measured, quantified, codified. It’s up to you to retain what is the soul of medicine. You don’t want a twenty-six-year-old widow to say no doctor spent more than five minutes with her.” Sometimes you won’t know what to do, he adds. Crying along with the patient or the family member is okay. Or maybe just sitting silently with them.

Just a few hours later, a first-year medical student, Monica Bodd, e-mails Galanos. “Thank you,” she writes, “for reminding us of the limited power of biomedicine in favor of honesty, humility, and a listening ear with patients—especially at the end of life.” She expresses hope that she can cling to the idea of common humanity “throughout my own journey as healer.”