Interoception I: Practitioner perspective

All I can seem to think about lately is interoception. When I think about interoception, I think, critter brain.

In this series, I want to view interoception from different angles. 


The first angle is from the outside, from a practitioner perspective. I suppose you could say, the take here, in this first blogpost, is from an operator model perspective. 




INTEROCEPTION FROM THE PRACTITIONER PERSPECTIVE: EMPATHY


Recently, this was published in NYT: Can doctors learn empathy? 
It starts out with an illustration of non-empathy, describing a surgeon:  

"despite his gusto, patients often complained about our colleague. He was brusque when the moment required sensitivity, flip when the conversation was grave, and heavy-handed when the situation called for a light touch. Just a few days earlier, we were shocked to learn he’d bluntly told an elderly war hero in the hospital for his diabetes, “I need to cut off your leg.”

It goes on to discuss recent research suggesting that empathy can be taught to doctors: 
Empathy Training for Resident Physicians: A Randomized Controlled Trial of a Neuroscience-Informed Curriculum.  
(Available preview)

Background  Physician empathy is an essential attribute of the patient–physician relationship and is associated with better outcomes, greater patient safety and fewer malpractice claims.  

Objective  We tested whether an innovative empathy training protocol grounded in neuroscience could improve physician empathy as rated by patients.  

Design   

Randomized controlled trial. 

Intervention  We randomly assigned residents and fellows from surgery, medicine, anesthesiology, psychiatry, ophthalmology, and orthopedics (N = 99, 52% female, mean age 30.6 ± 3.6) to receive standard post-graduate medical education or education augmented with three 60-minute empathy training modules. 

Main Measure  Patient ratings of physician empathy were assessed within one-month pre-training and between 1–2 months post-training with the use of the Consultation and Relational Empathy (CARE) measure. Each physician was rated by multiple patients (pre-mean = 4.6 ± 3.1; post-mean 4.9 ± 2.5), who were blinded to physician randomization. The primary outcome was change score on the patient-rated CARE. 

Key Results  The empathy training group showed greater changes in patient-rated CARE scores than the control (difference 2.2; P = 0.04). Trained physicians also showed greater changes in knowledge of the neurobiology of empathy (difference 1.8; P < 0.001) and in ability to decode facial expressions of emotion (difference 1.9; P < 0.001). 

Conclusions  A brief intervention grounded in the neurobiology of empathy significantly improved physician empathy as rated by patients, suggesting that the quality of care in medicine could be improved by integrating the neuroscience of empathy into medical education.

From the introduction:

"Empathy has been defined as process with both cognitive and affective components which enables individuals to understand and respond to others' emotional states and contributes to compassionate behavior and moral agency. Neuroscience is elucidating the neural mechanisms of empathy and providing new theoretical frameworks."

It sure is. And it sure has: Empathy in Medicine - A Neurobiological Perspective, published 2010, by Helen Riess (who seems to be a driver in this field - "Associate Clinical Professor of Psychiatry at Harvard Medical School and Director of the Empathy and Relational Science Program in the Department of Psychiatry at Massachusetts General Hospital.  She conducts translational research utilizing the neuroscience of emotions in educational curricula to improve empathy and relational skills in physicians and other health care providers.")

Most of the time, she says, medical students learn/are taught to down-regulate their own "empathy response": 

"Empathy begins to decline in the third year of medical school for complex reasons, including an emphasis on emotional detachment and clinical neutrality, overreliance on technology that limits human interactions, lack of role models, and inappropriate treatment of medical students... physicians down-regulated their pain empathy response by inhibiting neural circuits involved in pain processing areas (somatosensory cortex, insula, anterior cingulate cortex, and periaqueductal gray). Down-regulation of the pain response dampened negative arousal in response to the pain of others. Without emotion regulation skills, constant exposure to others' pain and distress may be associated with personal distress and burnout, suggesting that down-regulation may have some beneficial consequences. 

"Although down-regulation of empathy may have important protective elements during medical training, the practical consequences of unempathic medical care may also have serious implications. Lack of empathy dehumanizes patients and shifts physicians' focus from the whole person to target organs and test results. This is not simply a moral or philosophical issue; empathy is an important component of clinical competence, without which there can be serious consequences. Empathic physicians can obtain critical information and insights that affect quality of care and, ultimately, medical outcomes. Evidence supports the physiological benefits of empathic relationships, including better immune function, shorter postsurgery hospital stays, fewer asthma attacks, stronger placebo response, and shorter duration of colds. Low physician empathy also affects physicians and trainees. An estimated 60% of practicing physicians experience symptoms of burnout, which is linked to lower job satisfaction, leaving the profession, increased substance abuse, and suicide. Low physician rapport is correlated with lack of trust in physicians by patients as well as increased patient complaints and more malpractice claims, which are linked to the costly practice of defensive medicine."

My bold. So, what is an empathy response? It's one's own critter brain responding directly to another's critter brain... I think. Physicians squash their own awareness of it or it would drive them off track. (I think PTs do too. I vividly recall the emotional upheaval I felt, at age 18, in my first days on the "wards", directly confronted by human physical and emotional suffering. I never felt I had succeeded in learning to suck it up very well, which is why I left hospital PT work altogether.  I admired the PTs I saw working, day after day, patiently, supportively, with the worst of the worst (in my young mind) - the head injured, the stroked, the paralyzed - but I "knew" I could never "be" them.)  

But anyway, back to physicians, there is hope: 

Helen Riess: “People tend to believe that you are either born with empathy or not. But empathy can be taught, and you can improve."

The blogpost author, Pauline W. Chen, MD: "Just before leaving, one of the patients pulled me aside. “Thanks, Doc,” he said. “I have never felt so listened to before.”

"It is possible that empathy can also be up-regulated through education. Medical educators can teach students about the neurobiological correlates of empathy, demonstrate behavioral skills that build an empathic connection, and scientifically validate the importance of empathy in the patient-physician relationship, while also teaching self-regulation strategies that may help prevent emotional distress during medical training and other challenging situations. Advancing physician empathy with deliberate, neurobiologically informed training and research may be a helpful approach to enhance the professionalism and compassion that are the hallmarks of medicine."

........

So, why should we (human primate social groomers of a non medical physician persuasion) care about any of this? I mean, aren't we the heart and soul of empathy? Is that not why we are drawn to manual therapy in the first place? Maybe, maybe not. We'll explore that question as we go possibly. 

I think knowing about interoception is important because:

We treat patients too. Nociception is a kind of interoception. Not the only kind, but an important kind. Besides pain, which is somewhat different, is interoception not what we treat most of the time?

We need to know, deeply deeply know, what's going on in:

a) the patient 

b) his/her brain/nervous system 

c) in the treatment dynamic itself, in that shared space 

d) so that we might pace the treatment itself accordingly 

e) to maximize outcomes. So the patient benefits, doesn't feel ripped off for his or her time or money. 

In short, we need to study interoception.

Next: Bud Craig.

Further reading:
1. Empathy decline and its reasons: A systematic review of studies with medical students and residents 2011 (open access)

2. The death of Mr. Lazarescu: Roger Ebert film review (hat tip to Carol Lynn Chevrier)

3. Neural systems supporting interoceptive awareness (Critchley et al 2004) open access

4. From affect to control: Functional specialization of the insula in motivation and regulation (Wager 2004) open access pdf

5. A unifying view of the basis of social cognition (Gallese, Keysers, Rizzolatti 2004) abstract

6. Putting the altruism back into altruism: The evolution of empathy (deWaal 2008) abstract

7. Somatosensation in social perception (Keysers, Kaas, Gazzola 2010) abstract

8. Interoceptive Awareness Enhances Neural Activity During Empathy (Ernst et al 2012) open access

9. How you feel what another body feels: Empathy's surprising roots in the sense of touch. (Scientific American)

10. The neuroscience of empathy: progress, pitfalls and promise (Zaki & Ochsner 2012)

11. Stigmatization of Patients with Chronic Pain: The Extinction of Empathy (Cohen M, Quintner J, Buchanan D, Nielsen M, Guy L 2012) full text pdf
12. Emotions promote social interaction by synchronizing brain activity across individuals 

(Nummenmaa, 

Glerean , 

Viinikainen , 

Jääskeläinen , 

Hari ,

Sams 2012) open access