There’s Something About Osteopaths
Is a DO more inclined to touch a patient than an MD? In this episode, Leonard Calabrese, DO discusses empathy as a measurable and reproducible science. Drawing on his experiences as a physician, researcher, professor, and human being, Calabrese also recounts his personal journey in empathy.
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There’s Something About Osteopaths
Podcast Transcript
Adrienne Boissy:
Welcome to another episode of Studies in Empathy, a Cleveland Clinic podcast, exploring empathy in patient experience. I'm your host, Adrienne Boissy, Chief Experience Officer here at the Cleveland Clinic in Cleveland, Ohio. And I'm very pleased to have Dr. LeonardCalabrese, rheumatologist, researcher, medical professor at the Cleveland Clinic Lerner College of Medicine and director of Clinical Immunology here. Len, welcome to Studies in Empathy.
Leonard Calabrese, DO:
Thanks, Adrienne. I'm really excited to be here because I've listened to this show, love it and I want to throw my pebbles on the pile.
Adrienne Boissy:
Well I was wondering what you don't do because this list is long and lengthy about all of your different titles and hats. Is there anything you don't do?
Leonard Calabrese, DO:
No, but I am the Platte River of all of them. I don't know much about anything but I know a moderate amount about a lot of things.
Adrienne Boissy:
Well I think as people listen to you they'll find that's not quite true. You are an immunologist by training. And tell me a little bit about how that led you to empathy.
Leonard Calabrese, DO:
That's a really good question.
Adrienne Boissy:
I try to ask those.
Leonard Calabrese, DO:
Right. My card carrying membership is I'm an immunologist. I run the Fasenmyer Immunology Center here and we do all kinds of interesting things in terms of patients with autoimmune and immunodeficiency diseases and rare and unusual and complex disorders. And that's kind of a day job. And my travels into empathy occurred about 15 years ago when we opened our medical school. Somehow I was asked if I would be interested in taking a leadership role in a track or a thread in the curriculum that they called Human Values. And I said, "What's that?" and kind of described it, and I said, "Aside from being human and having values, I really had no qualifications in this area," and I wasn't interested. And then they were very persistent, kind of came back and said, "Well, it's kind of like humanities, and we think that you have something to offer in this area." And I said, "Well, let me do a little due diligence first." I said, "I don't know anything about this. I'm not pedagogic." And I said, "Let me make some calls."
Leonard Calabrese, DO:
I called some friends at famous medical schools who I said, "What do you do in medical humanities and professionalism and values?" And each one described something that was totally different from the other one. I said, "Well, I can do that." I said, "Let's think of something." Bud Isaacson, who's now the Dean, and I started putting a track down while the train is right behind us. And we started exploring topics that I knew nothing about.
Leonard Calabrese, DO:
And so I took a scientific tack with it. Empathy is a hot topic, obviously has face validity that we're all for it. I didn't understand it so I started to say, "Well, who are the leading scientists in empathy around the country or the world?" I said, "Let's get some here." And one of the first people that I invited was Dr. Hojat from Jefferson, the architect of the Jefferson Empathy Scale. And we hit it off in grand fashion. And that's how we kind of started. And I must have written a dozen papers with him since that time and we've become forthrightly interested in this as a science, as a craft, and been exploring it ever since.
Adrienne Boissy:
Appreciate you mentioning him because he wrote an early article about the, I believe it was called the Death of Empathy, the third year of medical school.
Leonard Calabrese, DO:
The devil in the third year.
Adrienne Boissy:
The devil, not death, the devil. That's exactly right. And have you seen that play out? What is it about that time? And is there something different that we've tried to do to impact that devil in the third year?
Leonard Calabrese, DO:
Let's put the quantification issues about empathy to side and not everybody agrees on how to measure it, but it's measurable and reproducible. And most studies, not all, but most studies have shown that when we come into medicine, we're as empathic as we can be. We want to do good and be good and listen.
Adrienne Boissy:
Be human with values.
Leonard Calabrese, DO:
Yeah, right. Be human with values. If we track this longitudinally, it endures, but classically, medical school curriculum, we're codified. First two years, were kind of your basic science. And then the last two years were clinical and in your third year, you get much more clinical exposure than you do in the first two years. There is a palpable erosion. And that has been reproduced in multiple settings both by looking cross-sectionally and longitudinally, and so we're interested in, what is that all about?
Leonard Calabrese, DO:
And so I'll tell you two interesting things about it. One, qualitative sciences has taken some shots at this and the effects of the hidden curriculum loom large. We know what we're supposed to think and we know what we aspire to, but when we're cut loose and in uncontrolled circumstances where people are situationally challenged, we often see things that are not ideal and that takes a toll. And not only in empathy, but a lot of other values that we have. That's probably one of the leading factors. And then multiply that by stresses and fatigue and things that wear you down so you're not your best person coming to work.
Leonard Calabrese, DO:
The other interesting thing is, is that all the studies have shown, even in the studies that have shown the greatest erosion of empathy, about one in three students don't lose empathy. What's up with that? That's what I'm interested in. It's like, let's start looking at them, and what is, how can we describe that? Somehow, people have buffers for that. And then, all the usual things that women have more empathy than men. It's totally reproducible. And empathic people are more likely to follow paths in cognitive disciplines versus procedural ones. And that has some face validity as well, that empathy correlates with evaluations on services, on clinical services, but it doesn't correlate with your board scores. That, I love that too.
Adrienne Boissy:
I can attest to that.
Leonard Calabrese, DO:
Well, I hear you. There's a lot there. When we started our program at the Lerner College of Medicine, a number of years ago, Marty Cohen, who just retired, who was leader of our humanities and taught me so much and was a PhD, he said, "Our job is to keep the pilot light of humanity going." I had no idea what he was actually talking about at that time, but he was totally present in that. The evolving story is that, well, if we can measure it and we can look for all these correlations, we need to understand the science of it. We need to know whether, can we only lose our empathy? Can we get it back? Can we teach it? Can we, that's where all the cool stuff is going on now.
Adrienne Boissy:
I would take argument with something you said, which is, it was only when you became asked to work in the medical school that you tapped into empathy because earlier in your career, you had significant involvement in caring for early HIV patients. And so I have to presume that it was a part of who you were and how you practiced much earlier. Talk to me about that time in your life and what that taught you about caring for others.
Leonard Calabrese, DO:
Well, that's absolutely true. Empathy is a term that we have excellent working definitions and quantitative metrics and qualitative metrics for, and if you don't know any of that, you still can have empathy internally. I have to say that HIV, which I've been doing for almost 40 years now, influenced every aspect of my professional and personal life permanently. And that nothing has taught me more about science, people, suffering, discrimination, social injustice, hope and beyond. Incredible teacher. And I find that the people who did HIV in the early days of the epidemic, this is not to say HIV is a very different disease now, it's not mysterious or scary, it's just hard.
Leonard Calabrese, DO:
But those people had broken down all professional barriers. There was no competition, no academic competition. Everybody is there to try to find answers to important questions and to defend the downtrodden. It was something that if I could just try to think of my little hat is a rheumatologist, not there was anything un-humanizing about it, these large questions weren't facing you each and every day. I think it's helped me so, so much and that's a very special breed of people that have done that and I still am extraordinary friends with a lot of those people from that time.
Adrienne Boissy:
Is there a story you'd be willing to share about that time? Something that has a lasting impression on you and who you are?
Leonard Calabrese, DO:
There are stories of every minute of that time. I think of going to rural Ohio to talk to a town meeting over a young child who had HIV from hemophilia that was being barred from school and barred from everything. It's pre-Ryan White, and facing a wrath of people who are genuinely frightened. Genuinely frightened. Now with coronavirus, I've been tweeting that out, that the fear of a disease will always move faster initially than the disease. And being given this privilege to be able to talk to people and try to bring them back into the fold, and then working with our own patients who were my age, who were dying without any treatment.
Leonard Calabrese, DO:
Charles Bryan, who's a great medical humanist and author and Booz Larian, he's an ID guy, emeritus. He said, "In the early days of HIV, the whole field was driven by empathy because that's all you had to comfort.” It was like you weren't curing anybody. You're comforting all if you could. And now today it's all molecular, we have all these PharmDs that can pull out therapies. And sometimes that initial sense of empathic care and concern can get lost with all of that. It's nice to reflect on that journey.
Adrienne Boissy:
You recently said that empathy should be a vital sign for the osteopathic profession. I'm curious about how you see that profession is grounded, perhaps differently or not differently. What brought you to thinking about how do we measure how we're upholding the promises of a profession?
Leonard Calabrese, DO:
All right, now you're going to get me in trouble. I'm an osteopath and my father is an osteopath and my daughter's an osteopath, so we have something in our genome or something about it.
Leonard Calabrese, DO:
Early on after I met Dr. Hojat, he said, "What do you think are important questions?" And I said, "Well, there's this thing that's bugging me." I said, "I work in this allopathic institution for my entire career, never been anywhere else than here. I'm an osteopath and we have some residents and stuff like that." And I said, Dr. Young, who was former Dean at the school and head of our academic program, he came up to me and he said, he goes, "You osteopaths, you're different." He goes, "I can pick you out." I said, "What the hell do you mean by that?" And he said, "I don't know, there's just something personable and just, this." And I said, "Is that?"
Adrienne Boissy:
Oh, it was a compliment?
Leonard Calabrese, DO:
It was a compliment. And I heard him say this publicly. I said, "Well, I wonder if that means anything? I wonder, is there anything there? And could there be a scientific rationale?" DO-granting medical schools, which are now prolific, 41 colleges, one out of every five physicians who graduates in this country is a DO, have grown leaps and bounds and oriented to primary care. I said to Hojat, I said, "Let's look at this." I said, "Osteopaths, I would say that, they are holistic with their patients and is that just smoke or is there science there?" And treat it as a problem. We actually have done a series of studies and bringing this up, I think because I had fed you a paper that came out in academic medicine, which is the largest biorepository of empathy data on 10,000 medical students looking at the trajectory of empathy in osteopathic schools.
Leonard Calabrese, DO:
And it appears that the devil's not so big. Maybe that there is a buffering of this. And so we've explored this and I have no axe to grind to say being different is better and if there's things to be learned they should be shared with everyone. The things that we're interested in, it appears that students who have a greater belief, and we have studied this with validated measures in complementary and integrative medicine, tend to have a higher empathy quotient. You kind of think of that, somebody who believes in that. I also believe, this is unproven hypothesis, is the only thing different between an osteopathic school and an allopathic school is that osteopathic students within one week have their hands all over each other and you're learning.
Adrienne Boissy:
In a good way.
Leonard Calabrese, DO:
In a good way. And this osteopathic manual medicine laboratory is very intimate and over the course of the year, people are doing soft tissue massage and you're just comfortable. And when I watch people in clinic, I believe that the distance is less, that you're more inclined to touch someone. And touch is powerful. And I'm not talking healing touch, I was just talking about, as the world of medicine has progressed with EMR and echocardiograms, it's come a long way from putting your head on somebody's chest, and I'm holding my stethoscope up right now, to going to the echo lab to find out what's going in somebody's heart. That's one of the hypotheses I really want to test, is physical distance. One of those things that can bring us together in a more empathic, healing relationship.
Adrienne Boissy:
I always even reference the stethoscope. It used to be your ear to skin.
Leonard Calabrese, DO:
Ear, and then Laennec.
Adrienne Boissy:
And then a little tube.
Leonard Calabrese, DO:
With a tube. And now this.
Adrienne Boissy:
And now it's two feet of distance.
Leonard Calabrese, DO:
Echocardiogram or with your smartphone you can do it. Those are just some hypotheses. And as I say, those are things that we want to keep continuing to explore, to try to learn how can we buffer and how can we build this? And then lastly, how can we use that empathic communication not only to comfort patients and make them feel at ease, but to harness that in terms of placebo response. And that's, we've had some visitors here recently to talk about placebo science and empathic communication. Placebo is not a trick and it's not something that we use in an unethical way. It's something we want to learn and harness.
Adrienne Boissy:
There's a couple different roads that could go down here. One of them that I want to go down and be sure to cover is the discussion of how immunology and stress relates to ability to heal and be healing. It actually never dawned on me until I heard a professor come from NIH and talk about all of this stress. This environment does create physiologic changes and immunologic changes in us and to you, of course, you're nodding your head going, yes, Adrienne, of course it does. But for the audience to really appreciate that it's not just, you feel down or you're tired or your empathy is less, but we are being changed and transformed by the environment within which we live. And we can do something about that if we choose. Can you comment?
Leonard Calabrese, DO:
Well, talking to you as a neuroscientist is easy but let me break this down a bit. I believe that a brain and immune system are one, they are not separate organs and that this epidemic that we are living in of noncommunicable diseases where 60% of the planet dies from everything from neurocognitive decline to cardiovascular disease, the fatty liver and type II diabetes and beyond, is driven by this chronic systemic inflammation. And what is driving our immune system is something that we have a new one called the exposome of all these external factors which include our environment and pollution and global warming, important. How we eat, how we sleep, how we exercise, and then this kind of psychosocial stress variable, which is probably the most potent. As many people are aware that, acute stress is good, chronic stress is bad.
Leonard Calabrese, DO:
We live in this era of this chasm of evolution. Three centuries ago before the industrial revolution, we wouldn't recognize what we ate, our physical activity, our sleep patterns and the stresses were totally different. We know that social isolation, poorly buffered stress, PTSD, any dysfunctional stressors actually change the way our genes function. And we now call that the CTRA, conserved transcriptional response to adversity. And when we look at those genes, it's all inflammation. And we need to hack into that. And that's where our research is going. And we've just completed a study of very low dose meditation in 60 stressed out Cleveland Clinic nurses. And the primary endpoint of that study is gene transcription. And I can't tell you what we found yet.
Adrienne Boissy:
Come on.
Leonard Calabrese, DO:
Can't.
Adrienne Boissy:
Come on, exclusive.
Leonard Calabrese, DO:
You can't. It lowered their stress, I'll tell you that.
Adrienne Boissy:
There you go. I'm sure.
Leonard Calabrese, DO:
We're still actually waiting for the final readouts. But I am very much for a dual target of therapy, whatever their disease is, whether it's multiple sclerosis or rheumatoid arthritis, got to stop that disease in its tracks with all our high power drugs, et cetera. And then we have to look at the patient and ask them what are their goals? What is their quality of life? And then use everything that we have, behavioral education, the power of our empathic connection. TNF inhibitors might not do that. But we have the capacity to do that. And our next horizon route with Dr. Elaine Husni here, we're creating a working group for this behavioral research within our center. I'm so excited about this. I can't even tell you, because it links molecular medicine with holistic medicine and anybody that thinks it's one or the other is wrong.
Adrienne Boissy:
I tried meditation recently with my children.
Leonard Calabrese, DO:
Oh that's so great.
Adrienne Boissy:
Well, wait till you hear the rest of the story. They're in their beds, they share a room. One's on one side, the other is on the other side and I'm on the floor in the middle. And invariably what happens of course, is it's guided meditation. And within about five to 10 minutes, maybe two minutes, I am completely zonked, and by the end of the meditation, the kids are still jumping up and down, I'm just wondering, do you have something for that because I'm not sure I'm achieving the full therapeutic potential.
Leonard Calabrese, DO:
Jon Kabat-Zinn said that lying down meditation is great if you don't fall asleep. But if you do fall asleep it's usually great sleep.
Adrienne Boissy:
That's it.
Leonard Calabrese, DO:
What I am very interested in, and I follow along online, a lot of Twitter feeds on mindfulness of mindfulness for children and I think that you ought to invent your own meditation for your kids. Give them their own images.
Adrienne Boissy:
It's funny you say that, one of them has anxiety around sports, soccer. Really we have like these extensive talks in the car ride. And just the other day I was looking around for what's available that he could listen to and there seemed to be a paucity of resources to support him and navigate.
Leonard Calabrese, DO:
Adrienne, that's our next project.
Adrienne Boissy:
Let's do it. How do you stay one of the four? You're not a med student anymore, but what tools of the trade have you picked up and adopted and applied to your own life as a means to maintain your zenness? If people could see you now, they would agree. You have a zenness about you that I think many of us would like to have in our own lives. What can you teach others?
Leonard Calabrese, DO:
You're being kind.
Adrienne Boissy:
You know I'm not that kind.
Leonard Calabrese, DO:
I've learned a lot from this journey and if you can't learn from what you're doing then you're just treating it like an object. My nurse practitioner and I, Betsy Kirschner, who is now getting her doctorate, we've invested ourselves in trying to work with our patients in all of these behavioral domains before we ever were invested in the science. And so we've taken the things that we teach and we religiously do it ourselves. I'll give you several small examples.
Leonard Calabrese, DO:
My diet, if I think of 20 or 30 years ago here, going to the cafeteria every day and probably, I don't know, eating a hamburger and french fries or whatever you did at that time. And just everybody, well, when I was an intern, everybody smoked. We try to get our patients to eat real food and eat the rainbow like Roxanne Sukol tells us. I do a VB6 diet. I eat no meat before 6:00 o'clock at night ever. Two thirds of the eating time is plant based for me. At night I eat rationally. It's very simple and patients love that. How can I give that up? Well, go meatless Monday or don't have it at breakfast or don't have it at lunch and then, treat yourself and know when you're entertaining yourself, number one.
Leonard Calabrese, DO:
Number two, we believe in instant recess.
Adrienne Boissy:
It sounds amazing.
Leonard Calabrese, DO:
Instant recess is our answer to exercise training. It's not like go get a subscription to the gym and start pounding the pavement, et cetera. It is first encouraging us all not to be sedentary. And literally not being sedentary. That if you're at your desk for too long, you got to get up and move. And there is a wonderful physician who has passed on, named Antronette Yancey, who did beautiful community health work in Southern California. It took community groups, instead of having the breaks where you had donuts and coffee, you'd get up and do calisthenics for five minutes. At my immunology meetings for the past five years, I bring my own yoga instructor and first time that I ever did this, at an immunology meeting, I brought her out on stage. And I know that people are saying, "Calabrese is totally losing it here. What is he doing?" Now, where's the yoga instructor? When are we going to do yoga on the beach with T reg cells?
Leonard Calabrese, DO:
Those are two things. And then thirdly, we're all in for the mindfulness meditation. We've developed our own program, Stress Free Now for Healers, and we're doing research in that space and trying to find out what the dose and what the right type is. And lastly, the sleep thing. I don't have any problem in that area. I'm a world champion sleeper, but I do believe that sleep is the new frontier in wellness and immunology.
Leonard Calabrese, DO:
With this lovely interview talking about empathy and wellness, I would like to bring these things all together and I am sure that you agree with me that the empathic healer brings the best version of themselves to work every single day. When you're good, when you have an incredible day and you wake up and you see the clouds and taste your toothpaste, you can be one with the universe with the most horrendous situations. At the other end, when you're stressed out and you're not taking care of yourself and you're sleeping poorly and you're not eating right, that is not the best version of yourself. And it is hard to be naturally and empathically engaged with other people who have their own stresses to share. I think they go hand in hand.
Adrienne Boissy:
Well, I think as a anchoring sentiment for probably both of us, we've lost a lot of good colleagues this year in our own organization and certainly I'm sure beyond in your personal life perhaps. And as crazy as some mornings are, when I'm thinking about getting the dog to daycare, getting my kids to stop just eating Fruit Loops for breakfast, racing them to school and making sure my socks match, I often just take some perspective as I'm climbing the stairs from the parking garage into the organization on the way in and on the way out that I get to do that.
Leonard Calabrese, DO:
That's so lovely and so simple. It's just emblematic of doing what you can to be your best self. And I think that most people as we come into this world of healing, our inclinations of the vast majority of people are good. And that somehow in the fog of war, you can get distracted from it. And these are just great opportunities for us to kind of reel it back in. I always tell the medical students, I said, "There's two ways of doing this." I said, "The easy way of a patient saying you're an empathic doctor is merely being polite and if that's all you can do, it's a great start." We say fake it till you make it.
Leonard Calabrese, DO:
And the other is this more complex route of actually cultivating your own being. And when you are comfortable with yourself mentally, spiritually, and physically, you can't get burned out. You are resilient in the good sense of the word and all that good stuff just flows naturally. Now, tall task and we're not all good at it all the time, but that's the way I think about it.
Adrienne Boissy:
How many choose the latter path?
Leonard Calabrese, DO:
Well, I think everybody aspires to that. And life is a journey. If I think back on my career, there are probably large swatches of time that were not great for me. I was not self-aware. No one was giving me guidance. Now we talk about it and I think this self-awareness component is huge.
Adrienne Boissy:
Well Len, thank you so much. I can't tell you how much I appreciated having you here today.
Leonard Calabrese, DO:
Thanks, Adrienne.
Adrienne Boissy:
This concludes Studies in Empathy podcast. You can find additional podcast episodes on our website, my.clevelandclinic.org/podcasts. Subscribe to Studies in Empathy podcast on iTunes, Google Play, SoundCloud, Stitcher, or wherever you get your podcasts. Thank you for listening. Please join us again soon.