Postcard — August 28, 2019, 11:00 am

Alternative Medicine

In Russia, doctors master a new clinical skill: listening and talking with empathy

The patient, a petite woman in her late forties with short dark hair, was visibly tense as she sat in front of the doctor, clutching her purse and sighing deeply. Lyudmila had made the appointment because she was feeling tired and worn-out. But as the doctor encouraged her to say more, worrying details emerged. Hers was no ordinary fatigue: She felt tired waking up. She felt tired walking her dog. She felt so tired that when she climbed the stairs in her apartment building, she had to stop between the first and second floors just to catch her breath. Had anything else been on her mind? the doctor asked. Yes, come to think of it, there had been: Lyudmila had lost a lot of weight recently without even exercising or going on a diet, and could now slip into her old clothes that had hung in the closet for years. After more delicate prompts from the doctor, Lyudmila reluctantly dropped one more detail: she had blood in her stool.

The picture was clear to Lidiya, a middle-aged physician with long blond hair and glasses: the symptoms were consistent with cancer, and the patient needed urgent testing and treatment. Yet when Lidiya carefully broached the topic of a colonoscopy, Lyudmila balked.

“But I still need to perform that colonoscopy,” Lidiya said impatiently.

An awkward pause hung in the room.

Lidiya was an actual doctor, a proctologist from Perm, a city in the Urals, but Lyudmila’s real name was Yulia Kaul, and she was an actor trained to portray patients with various illnesses. Their exchange was part of a two-day course held in Moscow where physicians master a new clinical tool: talking and listening to patients with empathy and understanding.

The idea is both a medical and cultural shift in Russia. While clinical communication skills are part of a doctor’s training in the United States and in much of Europe, the subject, until recently, received little attention in Russian medical schools, which still largely operate according to the Soviet model. This new approach also transforms the doctor from the ultimate decision-maker and expert who should be obeyed to a sympathetic listener and the patient’s partner.

Anna Sonkina-Dorman, a Moscow pediatrician and palliative care doctor, has set out to popularize the concept in Russia through her company, SoObscheniye, which in Russian is a play upon the words “shared,” “communication,” and “information.” Today, SoObscheniye teaches roughly thirty doctors a month through intensive two-day courses that are popular with doctors from outside Moscow, and a five-week module mainly for doctors in the capital. The training with Lidiya took place in a small, brightly lit room that Sonkina-Dorman had rented out from a market research company in central Moscow. She asked me to observe the seminar from a nearby room with a one-way mirror, the kind used to study focus groups, so as not to disturb the participants.

Back inside the classroom, Lyudmila kept resisting a colonoscopy. She had read online that someone’s mother-in-law died as a result of the exam. “Thank you very much, I don’t want that!” she said combatively.

Lidiya looked around the room, puzzled. Should she explain the diagnostic benefits of a colonoscopy? Should she warn Lyudmila of the risks of forgoing the procedure?

Yes, answered Sonkina-Dorman, but first she recommended that Lidiya show the patient empathy and acceptance. “I understand, Lyudmila, that you are frightened by stories of perforation that you have read,” Sonkina-Dorman said in a soothing voice. “Yes, indeed, I can understand how frightening it can be. Can I now share with you some data that I have? Perhaps it will influence your decision.”

“You heard her out. Now she will be more likely to hear you,” Sonkina-Dorman told the group.

Sonkina-Dorman (photographed from the back) gestures as she discusses patient communication with a doctor during her course.

Sonkina-Dorman (photographed from the back) gestures as she discusses patient communication with a doctor during her course.

Doctors occupy a peculiar place in Russian society: they are respected and idealized, yet severely underpaid and neglected by the state. (While the number of private clinics in Russia is growing rapidly, most doctors and nurses are paid by the state.) The great writers Anton Chekhov and Mikhail Bulgakov praised the Russian doctor as a humanist, an altruist and an enlightener. Soviet state-run health care was based on a paternalistic model of doctor–patient interaction in which the doctor in a white coat was a benevolent master who knew what was best for the patient. The patient was respectfully obedient and submissive, and often little-involved in decisions about their health. It was common practice to keep terminal cancer patients in the dark about their diagnoses so as not to shock them, and the real state of things was often shared only with the relatives.

The paternalistic model was also dominant in the West until the late 1970s, when the philosophy slowly began to shift toward patient-centered care, in which the patient’s ideas and expectations mattered, and where the patient was empowered to make decisions together with the doctor. The doctor relies on empathy to communicate support and interest in what the patient has to say. While the doctor remains an expert in the medical aspects of a disease, the patient is seen as an expert in how he or she experiences it. Research has shown that this approach leads to greater satisfaction for patients and doctors, improved patient outcomes, and increased compliance with treatment.

When the Soviet Union ceased to exist in 1991, the health care system, like much of everything else, crumbled. Hospitals were starved for equipment, medicine, and other supplies, like gauze, and struggled to heat themselves in winter. Doctors, waiting for months for overdue paychecks, were busy trying to keep patients alive and at least semi-healthy. Talking and listening were unattainable luxuries left for better days.

But as the economy grew and Russia opened up to the world, people’s expectations began to change. Private clinics sprang up across the country, which offered better customer experience to those who could afford it. That doctors’ communication skills had fallen through the cracks was brought to the fore two years ago in Look at Him, a memoir by internationally acclaimed author Anna Starobinets. In the book, Starobinets recounts her traumatic experience of terminating her pregnancy because the fetus had a fatal kidney defect, and how her pain was amplified by the heartless treatment she encountered along the way.

In one of the most dramatic scenes, Starobinets describes undergoing an ultrasound exam, naked from the waist down, a probe inserted into her vagina. She held her breath in anticipation and fear, waiting for the diagnosis. But the doctor, a renowned gynecologist and perinatologist, only mumbled some medical terms and did not engage with his patient. Instead, he whispered something to his assistant, and soon about a dozen medical students and junior physicians filed in. The following dialogue comes from Starobinets’s account.

“Take a look,” the physician said to the students as he pointed at the monitor. “This is a typical case. Here are the cysts. Do you see them?”

As the doctor continued his lecture, the diagnosis became clear to Starobinets. Her child had polycystic kidney disease, a rare genetic disorder.

“See, how interesting,” the doctor said. “Children with such defects don’t survive.”

Starobinets realized that such treatment was just one way in which the country’s health care system siloes and victimizes women with pathological pregnancies. The author spent all of her family’s savings to travel to a clinic in Germany to terminate her pregnancy there. At the clinic, she was amazed to discover that psychological support was an integral part of medical care in Germany. While the comparison between nominally free, state-provided health care in Russia and an elite clinic in Germany may not be entirely fair, Starobinets said that money was not the point: some basic ethical standards, some respect, and a simple “I am sorry” from the doctor would not have alleviated her pain, but it would have certainly helped her cope with the devastating news.

“When you are dealing with situations of life and death, you become helpless. And when you are helpless, it is very important for you to maintain your sense of dignity,” Starobinets told me inside the small studio apartment in central Moscow that she uses as her office. “So it is the job of medical professionals to treat you in such a way that it would be less traumatic for you.”

Author Anna Starobinets poses for a photo in her writing studio in central Moscow.

Author Anna Starobinets poses for a photo in her writing studio in central Moscow.

Last year, Look at Him, was short-listed for National Bestseller, a prestigious Russian literary award. But the readers’ reaction was mixed. Starobinets told me that she received a lot of messages of support from women who faced similar treatment, but also a hail of criticism on social media.

Aleksei Kascheev, a neurosurgeon in Moscow and a popular medical blogger, has agreed that Starobinets’s book is truthful and timely, but also said that his colleagues’ difficulty with empathizing may be rooted in the fact that they themselves need compassion. According to government data, an average physician working in a state clinic earns about 77,000 rubles (or about $1,200) a month—a figure that experts believe might be inflated. Many physicians have to work overtime, or work several jobs, in order to support themselves and their families. Many cannot afford a car or travel.

Kascheev also runs a medical translation company where most of his freelancers are doctors who speak a foreign language. He said that for most of them, the majority of their income comes from translations, not from seeing patients. Kascheev recalled meeting a friend from medical school several years ago who worked as a physician in a Moscow hospital and moonlighted as a vacuum-cleaner salesman at a housewares store.

“It is not healthy situation,” Kashcheyev told me with a sigh.

Doctors are saddled with heaps of frequently useless paperwork and aimless bureaucratic directives. They’re also squeezed by ambiguous legislation where a medical mistake, whether real or perceived, can mean jail time. In recent years, a number of doctors have faced criminal charges for negligence and malpractice. In June, a neonatologist in Kaliningrad was detained for failing to rescue an infant born at twenty-three weeks weighing one and a half pounds. She was charged with murder and is now under house arrest.

As a result, the number of doctors is dwindling.

Yelena, a pediatric orthopedist in the class I observed, said she was feeling so burned out at work that she was on the verge of quitting medicine. The pay was low, the hours long, and she felt like she was toiling in vain when some mothers ignored her recommendations or didn’t care much for their children’s health. In the end, Yelena decided to stay in the profession and learn to communicate with them more effectively.

“I realized that patients may want more than just effective medical treatment, they want a rapport with the doctor,” Yelena, told me on the first day of the seminar.

Like most others in the course, she had paid her own money to fly to Moscow from the Siberian city of Irkutsk, stay at a hostel here, and pay 23,000 rubles ($360) for the training. It was her entire month’s salary.

Sonkina-Dorman, thirty-five, comes across as gentle and soft-spoken, but also exudes the resolve and enthusiasm of a person a mission. Many Moscow mothers know Sonkina-Dorman as a pediatrician who in her articles and public lectures debunks Soviet-era medical myths that are still popular with old-school doctors and zealous Russian grandmothers, advising that children won’t get sick from drinking cold milk straight from the refrigerator, and that taking medicine for the common cold is unnecessary.

Sonkina-Dorman began her medical career in a hospice in Moscow, which was one of the first such institutions in the country. There, she began appreciating how relatively simple adjustments in patient care can transform their lives: they would breathe better, sleep more, feel less pain. The same, she realized, was true about talking to patients: sometimes words could have a profound effect. She decided to specialize in palliative care and, after graduating from medical school in Moscow, enrolled in a postgraduate program at Cardiff University in Britain.

When Sonkina-Dorman completed the studies, her colleagues noticed that she was doing something differently, and that it was working, so they asked her to teach them. She did additional training in Europe and learned how to teach others clinical communication skills. She also wrote on Facebook that she was looking for people who would study to become simulated patients—something that was largely unheard-of in Russia at that time. The post was shared widely. Kaul, a philologist by training, turned out to be the best of the many who turned up, Sonkina-Dorman said.

The idea that communication is an essential part of medical care has been catching on: the Moscow city government says that since 2018, it has trained more than sixteen thousand doctors and nurses in clinical communication skills, and Russia’s Health Ministry is working on incorporating those skills into medical school curricula and doctor certification.

During the class I observed, Sonkina-Dorman had the group practice empathetic listening with an exercise that involved the story of a man who had been convicted of murder and sentenced to fifteen years in jail. After serving ten years, the man escaped from prison and was caught five years later, when his sentence had expired. Should he be put back behind bars and serve out his time? Or has he been punished enough? The two sides with opposing views had to listen to each other—without expressing disagreement or interrupting—and then repeat their opponents’ arguments back to them.

Yulia Kaul, left, and Anna Sonkina-Dorman, second from left, share a laugh with the participants of the course

Yulia Kaul, left, and Anna Sonkina-Dorman, second from left, share a laugh with the participants of the course

But it wasn’t all serious. Kaul also played Galina, a forty-six-year-old storeowner who was suffering from pain in her right foot. Before the doctor had a chance to ask more questions, Galina volunteered her own diagnosis: she had heard on a popular medical TV talk show of parasites that live in the brain, and can travel down the body through blood vessels and end up in the feet. The parasites are hard to detect with the usual tests, so Galina was asking for an MRI.

After the group had a laugh, Sonkina-Dorman urged them to resist what would be a typical reaction in this case: shaming Galina for watching trashy TV shows and telling her to stop repeating nonsense. Instead, Sonkina-Dorman carefully listened to the horror stories of mysterious parasites and demonstrated to the patient that she understood her worry. She then told Galina that scientists have been unable to detect any such parasites in the human body, and that medical advice dispensed on talk shows should be taken with a grain of salt. Galina walked away relieved that there were no worms in her head.

On the second day of the course, I grabbed lunch with Emin, an emergency-room doctor in his early thirties in a crowded Moscow government hospital. He often had to juggle dozens of patients during a shift and could get frustrated when some of them refused his orders, taking away his time and energy from others in the waiting room. He had come to the course to learn to talk to patients more persuasively. Athletic, beefy, with short-cropped hair, Emin could seem like a tough guy at first. But, as he interviewed Lyudmila, the patient with suspected colon cancer, a gentler side of him emerged: he thanked her for sharing her story, and told her that he could relate to her fatigue, as he often felt tired himself.

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