– 12 --
Caring for People on the Edge:
Emergency Medicine, Negotiation and the Science of Compassion
Editors’ Note: The author, a physician specializing in emergency medicine, finds his work replete with negotiations of all kinds, many of them demanding compassion. Finding similarities to police hostage negotiation work, O’Shea reviews the neuroscience involved, and concludes that professionals of any kind who must demonstrate compassion at work can pay a price in their own peace of mind, or at an extreme, even in their ability to continue to do the job at all, when the demands exceed their time and ability to recharge their batteries of compassion. Most insidiously, the author finds hidden curricula in the training of his profession, and of others, which militate against the professional ever adopting a compassionate enough attitude to really suffer stress—or to do the job properly.
Negotiation’s starting point is often one of distrust and opposition, partly because each side associates the other with a history of suffering, caused (which makes one defensive) as well as experienced. Yet the act of negotiation requires that we “process” our own suffering, as well as that of others. Typical training in both my own field—emergency medicine—and negotiation lacks this element. I began to realize that there were other parallels when I had the privilege first of encountering, and later doing a small amount of experimental training with, Jack Cambria, the longtime (2001-2015) chief hostage negotiator of the New York Police Department (and contributor to multiple chapters in this volume, noted below.) This chapter is the result of those discussions’ impact on my longstanding interest in compassion, as a working quality not sufficiently developed or even discussed. An example may help.
During my medical school education, I received knowledge and procedural skills, but I did not have one single lecture on how to actually handle my job. As a first-year resident, I encountered a 28-year-old woman who came in with symptoms not unlike a common cold. She was unwell, but did not appear critical based on her vital signs and history; she had a slight fever, and she was tired.
She was accompanied by her largely unconcerned husband. He had other things to think about; he had their three beautiful kids running around the little emergency department examination room. Two hours later that same man pushed me out of the way after his wife was declared dead, so that he could get to the bed to “wake her up”. He turned to me in shock, with a face in the most indescribable agony, and asked me to help to wake her up. My attention was torn between him, the children and the blood on her body from what we had had to do to her to try to save her. She had a rare emergency condition with a high mortality rate, and she deteriorated and died without warning.
Practicing medicine requires one to process a significant amount of suffering, that of others and also our own. A knowledge of how humans are biologically designed to handle exposure to suffering can be a powerful tool, both in negotiating well and in the practice of medicine. In this article I will use medical settings, and their often unrecognized negotiations, to illustrate the value of such knowledge for negotiation more generally. This choice is partly dictated by the settings I know; but also, medical practice and biological research throw some of the issues into a sharp light, and I join at least two other authors in this work in finding these settings useful for illustrative purposes. [See NDR: Morash, Non-Events, and NDR: Jendresen, Creativity]
I believe that medicine involves more negotiation than is commonly recognized, and an emergency department physician in particular—my personal specialty—is in one of the occupations others in this volume have argued as needing some of the skills of a police hostage negotiator. [NDR: Volpe et al., The Unknown]. In the real and tragic case of Sarah outlined above, there was a need to negotiate with other doctors in order to get specialists down to the emergency department quickly, and a need to negotiate with Sarah’s husband to consent to an invasive and painful procedure for his wife in the midst of his own shock and fear. There was also the need to negotiate the reality of the situation as it unfolded, which played out in trying to explain to Sarah’s bereaved husband what had...
For full contents please purchase The Negotiator’s Desk Reference.
Batson, C. D. 2011. Altruism in Humans. New York, NY: Oxford University Press.
Batson, C. D. and D. A. Lishner. 2005. Similarity and Nurturance: Two Possible Sources of Empathy for Strangers. Basic and Applied Social Psychology 27: 15–25.
Batson, C. D., J. Fultz and P. A. Schoenrade. 1987. Distress and Empathy: Two Qualitatively Distinct Vicarious Emotions with Different Motivational Consequences. Journal of Personality 55(1): 19–39.
Bellini, L. M. and J. A. Shea. 2005. Mood Changes and Empathy Decline Persist During Internal Medicine Residency Training. Academic Medicine 80(2): 164–167.
Berge, K. H., M. D. Seppala and A. M. Schipper. 2009. Chemical Dependency and the Physician. Mayo Clinic Proceedings 84(7): 625-631.
Brennan, T. A., L .L. Leape and N. M. Laird. 1991. Incidence of Adverse Events and Negligence in Hospitalized Patients: Results of the Harvard Medical Practice Study I. New England Journal of Medicine 324: 370–376.
Carson, J. W., F. J. Keefe, T. R. Lynch, K. M. Carson, V. Goli, A. M. Fras and S. R. Thorp. 2005. Loving-Kindness Meditation for Chronic Low Back Pain: Results from a Pilot Trial. Journal of Holistic Nursing 23(3): 287–304.
Condon, P. and L. F. Barrett. 2013. Conceptualizing and Experiencing Compassion. Emotion 13(5): 817-821.
Decety, J., C. Yang and Y. Chen. 2010. Physicians Down-Regulate Their Pain Empathy Response: An Event-Related Brain Potential Study. Neuroimage 50: 1676–1682.
Dunn, E. W., L. B. Aknin and M. I. Norton. 2008. Spending Money on Others Promotes Happiness. Science 319(5870): 1687–1688.
Eisenberg, N., R. Fabes and P. Miller. 1989. Relation of Sympathy and Personal Distress to Prosocial Behavior: A Multimethod Study. Journal of Personality 57(1): 55–66.
Goetz J. L., D. Keltner and E. Simon-Thomas. 2010. Compassion: An Evolutionary Analysis and Empirical Review. Psychological Bulletin 136: 351-374.
Halpern, J. 2010. From Detached Concern to Empathy: Humanizing Medical Practice. New York, NY: Oxford University Press.
Hertenstein, M. J. and D. Keltner. 2011. Gender and the Communication of Emotion Via Touch. Sex Roles 64(1-2): 70-80.
Hickson, G. B., C. F. Federspiel, J. W. Pichert, C. S. Miller, J. Gauld-Jaeger and P. Bost. 2002. Patient Complaints and Malpractice Risk. Journal of the American Medical Association 287: 2951–2957.
Hill R. G. Jr., L. M. Sears and S. W. Melanson. 2013. 4000 Clicks: A Productivity Analysis of Electronic Medical Records in a Community Hospital ED. American Journal of Emergency Medicine 31:1591-1594.
Hojat, M., M. J. Vergare, K. Maxwell, G. Brainard, S. K. Herrine, G. A. Isenberg, J. Veloshi and J. S. Gonnella. 2009. The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School. Academic Medicine 84(9): 1182–1191.
Honeyman, C. and J. Coben. 2013. Epilogue: The Biz. In Educating Negotiators for a Connected World, edited by C. Honeyman, J. Coben and A. W-M. Lee. St. Paul, MN: DRI Press.
Hutchison W. D., K. Davis, A. Lozano, R. Tasker and J. Dostrovsky. 1999. Pain-Related Neurons in the Human Cingulate Cortex. Nature Neuroscience 2: 403–405.
Jackson P., A. Meltzoff and J. Decety. 2006. Neural Circuits Involved in Imitation and Perspective-Taking. Neuroimage 31: 429–439.
Klimecki, O. and T. Singer. 2012. Empathic Distress Fatigue Rather Than Compassion Fatigue? Integrating Findings from Empathy Research in Psychology and Social Neuroscience. In Pathological Altruism edited by B. Oakley, A. Knafo, G. Madhaven, and D. S. Wilson. New York, NY: Oxford University Press.
Krasner, M.S., R. M. Epstein, H. Beckman, A. L. Suchman, B. Chapman and C. J. Mooney. 2009. Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians. Journal of the American Medical Association 302: 1284–1293.
Lamm C., J. Decety and T. Singer. 2010. Meta-Analytic Evidence for Common and Distinct Neural Networks Associated with Directly Experienced Pain and Empathy for Pain. Neuroimage 54: 2492–2502.
Maslen, H. 2013. Is Compassion a Necessary Component of Healthcare? Practical Ethics. September. Available online at http://blog.practicalethics.ox.ac.uk/2013/09/is-compassion-a-necessary-component-of-healthcare/ (last visited February 23, 2017).
Miles, S. H. 2004. The Hippocratic Oath and the Ethics of Medicine. Oxford, UK: Oxford University Press.
Miller, J. G., S. Kahle, M. Lopez and P. D. Hastings. 2015. Compassionate Love Buffers Stress-Reactive Mothers From Fight-or-Flight Parenting. Developmental Psychology 51(1): 36-43.
Neumann, M., F. Edelhäuser, D. Tauschel, M R. Fisher, M. Wirtz, C. Soopen, A. Hasamati and C. Scheffer. 2011. Empathy Decline and Its Reasons: A Systematic Review of Studies with Medical Students and Residents. Academic Medicine 86(8): 996–1009.
Nunes, P., S. Williams and K. Stevenson. 2011. A Study of Empathy Decline in Students from Five Health Disciplines During Their First Year of Training. International Journal of Medical Education 2: 12–7.
OED. “Compassion.” Accessed May 19, 2016, http://www.oed.com/view/Entry/37475?rskey=aTnbzq&result=1&isAdvanced=false#eid.
Pace, T. W. W., L. T. Negi, T. I. Sivilli, M. J. Issa, S. P. Cole, D. D. Adame and C. L. Raison. 2010. Innate Immune, Neuroendocrine and Behavioral Responses to Psychosocial Stress Do Not Predict Subsequent Compassion Meditation Practice Time. Psychoneuroendocrinology 35(2): 310–315.
Parish, R. and J. Cambria. 2018, in press. The Other Side of the Door: The Art of Compassion in Policing. St. Paul, MN: DRI Press.
Peckham, C. 2016. Medscape Lifestyle Report 2016: Bias and Burnout. Available online at http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview (last visited February 23, 2017).
Pinker, S. 2011. The Better Angels of our Nature. New York, NY: Viking.
Preston S. D. and F. B. M. De Waal. 2002. Empathy: Its Ultimate and Proximate Bases. Behavioral and Brain Sciences 25: 1–20.
Riess H., J. M. Kelley, R. W. Bailey, E. J. Dunn and M. Phillips. 2012. Empathy Training for Resident Physicians: A Randomized Controlled Trial of a Neuroscience-Informed Curriculum. Journal of General Internal Medicine 27: 1280-1286.
Roche, W. P., A. P. Scheetz, F. C. Dane, D. C. Parish and J. T. O'Shea. 2003. Medical Students' Attitudes in a PBL Curriculum: Trust, Altruism, and Cynicism. Academic Medicine 78(4): 398-402.
Roy, M., D. Shohamy and T. D. Wager. 2012. Ventromedial Prefrontal-Subcortical Systems and the Generation of Affective Meaning. Trends in Cognitive Sciences 16: 147–56.
Rudolph, U., S. Roesch, T. Greitemeyer and B. Weiner. 2004. A Meta-Analytic Review of Help Giving and Aggression From an Attributional Perspective: Contributions to a General Theory of Motivation. Cognition & Emotion 18: 815–848.
Saarela M., Y. Hlushchuk, A. Williams, M. Schurmann, E. Kalso and R. Hari. 2007. The Compassionate Brain: Humans Detect Intensity of Pain from Another's Face. Cerebral Cortex 17: 230–237.
Sargeant, A. and S. Lee. 2004. Donor Trust and Relationship Commitment in the U.K. Charity Sector: The Impact on Behavior. Nonprofit And Voluntary Sector Quarterly 33: 185–202.
Saxe R. and N. Kanwisher. 2003. People Thinking About Thinking People: The Role of the Temporo-Parietal Junction in ‘Theory of Mind’. Neuroimage 19: 1835–1842.
Shanafelt, T. D. C. M. Balch, G. Bechamps, T. Russell, L. Dyrbye, D. Satele, P. Collicott, P. J. Novotny, J. Sloan and J. Freischlag. 2010. Burnout and Medical Errors Among American Surgeons. Annals of Surgery 251(6): 995-1000.
Singer, T. and C. Lamm. 2009. The Social Neuroscience of Empathy. Annals of the New York Academy of Sciences. 1156: 81-96.
Smajdor, A. 2013. Reification and Compassion in Medicine: A Tale of Two Systems. Clinical Ethics 8(4): 111-118.
Van’t Wout, M. and A. G. Sanfey. 2008. Friend or Foe: The Effect of Implicit Trustworthiness Judgments in Social Decision-Making. Cognition 108: 796–803.
Vollhardt, J. R. and E. Staub. 2011. Inclusive Altruism Born of Suffering: The Relationship Between Adversity and Prosocial Attitudes and Behavior Toward Disadvantaged Outgroups. American Journal of Orthopsychiatry 81: 307–315.
Young L., F. Cushman, M. Hauser and R. Saxe. 2007. The Neural Basis of the Interaction Between Theory of Mind and Moral Judgment. Proceedings of the National Academy of Sciences 104: 8235–8240.
Young L. and R. Saxe. 2008. The Neural Basis of Belief Encoding and Integration in Moral Judgment. Neuroimage 40: 1912–1920.