2: Empathy

The concept of empathy dates from the early years of this century, when discussions of the topic were restricted to psychotherapists’ analyses of their interactions with patients. More recently, the concept has received renewed attention from a wide spectrum of health practitioners and educators. They believe that empathy can positively affect communication with patients and thus lead to improved therapeutic outcomes. Many of the lay public regard empathy as an avenue to the restoration of compassion and humanism to the doctor–patient relationship, which has been increasingly impersonal and threatened by technology and financial pressures. Indeed recent studies have demonstrated that physician empathy increases patient satisfaction and improves clinical outcomes.

The Neurobiology of Empathy

Novel research tools, such as functional MRI scanning, which permit real-time investigation of the brain under experimental conditions, have revealed new insights into the functional neuroanatomy of empathy. The discovery of sensorimotor neurons in the cortex has suggested a mechanism whereby behaviors can trigger an unconscious reciprocal response in an observer. These mirror neurons fire when the subject performs a particular task or when the subject simply observes another individual performing the same task. Most of us have had the experience of reflexively smiling when a stranger walking down the street smiles at us. Our motor response often precedes a conscious reflection of what transpired.

This research is preliminary and some of the conclusions speculative. Nevertheless, a model of empathy is emerging in which connections between mirror neurons and other brain structures could facilitate the observed components of empathy. For example, in our example of the stranger-triggered smile, the mirror neuron projections that are downward to the facial muscles and limbic system could provoke the feeling of happiness concomitant with the motor expression of a smile. These responses are rapid and unconscious. Secondary projections to the more newly evolved cortex provoke awareness of the feeling, thoughts about the social context of the transaction, and decisions about further actions. These are slower, more conscious elements of a complex response.

Empathy as a Clinical Tool

In medical practice, the power of empathy lies in its ability to help us cross, if only for a moment, the divide between clinicians and patients created by their very different circumstances. To briefly bridge that divide and to become simply two humans sharing an experience can help in accomplishing professional diagnostic and therapeutic tasks. We have all experienced the gratitude of patients, isolated by depression or family loss, for our expression of understanding of their sadness.

Succeeding at the greater challenge of putting aside our disagreement with a patient requesting chronic narcotics or perhaps our negative judgment of a patient unable to quit smoking can have proportionally greater rewards. Being willing to imagine what it must be like for these more challenging patients can provide us with insights into what motivates them or what might help them. That is diagnostic information. Communicating that insight may encourage patients to change their behavior, and that is therapeutic. Our disclosure also allows us to check the accuracy of what we think we know about the patient’s state. We relinquish nothing of ourselves or our role in that moment; we simply expand our perspective.

Empathy can be defined as an intellectual identification with, or vicarious experiencing of, the feelings, thoughts, or attitudes of another. Thus, there are both cognitive and affective dimensions of empathy. Despite having found neurobiological correlates of both, there remains disagreement about their functional relationship and relative importance. Some have described empathy as a momentary identification with another person in which our human capacity to feel what another feels erodes the boundaries of self. If we, in fact, temporarily lose awareness of self, the process might better be termed “sympathy for” or “feeling with” someone else. Remaining aware that we are experiencing empathy prevents total dissolution of ego boundaries and permits a more salutary stance. Empathy skills are behaviors that demonstrate empathy. They are among the clinician’s most powerful therapeutic tools.

Research suggests that empathy skills can be taught. This chapter will describe how to develop and improve these skills. Research has recently shed light on the frequency of empathic opportunities in clinical practice, on how physicians respond to or neglect these opportunities, and the implications of such choices. Empathic opportunities occur in more than half of surgical and primary care visits, although on average there are more opportunities per visit in primary care than in surgical care. Patients initiate most of the opportunities. Contrary to common belief, surgeons respond empathically at least as frequently as primary care physicians, but both miss opportunities to respond more frequently. Empathic behaviors enhance the effectiveness of care as well as patient satisfaction, and their absence may predispose patients to initiate malpractice suits.

There are numerous barriers to discussing emotions with patients (see Table 2-1), from the impersonal office setting to the disinclination of both physician and patient to address particularly sensitive topics. Nonetheless, appropriate skilled communication can break through these barriers.

Understanding the feelings, attitudes, and experiences of the patient is the first step toward a more potent therapeutic alliance. Many patients, however, may not be skilled in revealing their feelings to their providers. They need to be made aware that their doctor is interested in their feelings and values them, and that feelings are a legitimate topic for discussion in a medical interview.

Emotions can be difficult for both doctors and patients, and doctors, in particular, may prefer the certainty of science. From the patient’s point of view, if difficult emotional issues are manifested as a somatic complaint, denial might be the first reaction to a psychological interpretation of the symptoms. The physician must appreciate and mirror the terms in which a patient will speak about illness. In many cultures, emotions are simply not discussed. In the United States, where the biomedical model of disease predominates over the biopsychosocial model, patients may feel that it is more acceptable to have physical rather than emotional complaints. Because this expectation is often reinforced by their physicians, it is important for physicians to establish a climate conducive to the expression of emotional material and a language useful to that end. Physicians often mention the following barriers to discussing emotions with patients.

1. It takes too much time. In a busy practice, concerns about time are legitimate. Given an organized framework, however, it takes only a few minutes to deal effectively with emotion, and the strategies discussed later in this chapter can prove time efficient for the physician. Recent studies suggest that interviews in which physicians respond to emotions may actually be shorter than those in which they do not. An explanation of this finding is that it may be more time consuming to deal with the indirect effects of unaddressed emotions during the rest of the interview. Moreover, it may be useful to distinguish between “acute efficiency” and “chronic efficiency.” “Efficiency” should take into consideration not only the duration of a particular visit but also the total amount of time required to address the patient’s concerns. Even if it were to take a few extra minutes to address emotions, that time is more than compensated by fewer phone calls and fewer unscheduled visits.

2. It is too draining. It is unrealistic to expect all providers to be emotionally available at all times to all their patients. A physician who has been awake all night or is emotionally needy may be justified in putting off a discussion of emotions that should otherwise occur. If the physician chooses to defer, it would be wise to return to the topic at another time. Primary care providers sometimes exert a tremendous amount of energy avoiding emotions in the belief that dealing directly with them will be draining. However, it can be far more efficient to make an emotional connection than to expend so much energy in resisting it.

   At times, patients may inadvertently raise issues that are emotionally difficult for their providers. Sometimes the clinician can discuss the difficulty with friends, family, or colleagues; at other times it may be most fruitfully addressed in the physician’s own therapy. (A longer discussion of this area is beyond the scope of this chapter, but difficult encounters with patients offer physicians an opportunity for personal growth; see Chapter 4.)

3. The interview will get out of control. Although many doctors worry that addressing emotions will cause feelings to escalate, the opposite is often true. Addressing emotions helps diffuse them. Learning a language to handle emotions creates a comfortable distance from the emotions themselves, so that neither the doctor nor the patient becomes overwhelmed.

4. I cannot fix it for the patient. Primary care providers are used to “fixing” things. Feelings, however, simply exist, and cannot be “fixed.” Patients do not expect their feelings to be eliminated; they just want them to be understood.

5. It is not my job. Some doctors believe that their job is to address disease and the psychotherapist’s job is to address mental illness. There are several problems with this attitude. Although it is certainly true that collaboration with mental health practitioners is important, at least two-thirds of patients with mental and behavioral problems are cared for mainly by primary care physicians. Physicians who insist on interpreting the physical symptoms of psychiatric disease, such as panic disorder or depression, in purely biomedical terms miss the point—and their patients will not get better. Telling a patient who develops chest pain on the anniversary of his father’s death (see “The Therapeutic Language of Empathy”) that there is nothing wrong with him will help the patient only briefly. Moreover, many physical illnesses have psychosocial sequelae that must also be addressed.

   When a patient keeps returning with the same complaint, unimproved by a physician’s interventions, the patient is trying to communicate a message. Physicians are often frustrated by these patients; this frustration can be alleviated and the doctor’s satisfaction improved by the progress that comes with addressing the underlying problem.

6. Perceived conflicts of interest. Although the more apparent financial conflicts of interest presented by managed care may have diminished in recent years, it is likely that new potential conflicts of interest will continue to arise even as the field upon which these play out changes. Physicians have always needed to balance the needs of the patients in front of them with those of society at large. Research has now demonstrated that patients prefer having their concerns acknowledged and validated rather than the physician blaming an external party for shared constraints. Physicians who feel challenged by patients’ questioning their motives are likely to act defensively. The empathy skills offer an alternative that makes the physician a partner again.

Feelings that arise in the provider during an encounter may be useful in forming a diagnostic hypothesis about the patient. For example, a doctor who feels burdened, heavy, or “down” during an interview might consider the possibility that the patient is depressed.

All clinicians have had the experience of trying to help a patient with a behavior change, such as weight loss, only to have each suggestion rejected: “I’ve already tried that, Doc; it doesn’t work.” The physician’s own feelings of frustration and powerlessness in trying to motivate the patient are often mirrored by the patient’s sense of frustration and powerlessness in attempting to accomplish the change in behavior. The physician can confirm the hypothesis that the patient is frustrated, as with any other diagnosis, by testing: “I’m feeling frustrated with this problem, and I’m wondering if you’re feeling the same way.”

Some patients consistently elicit dislike and rejection from their providers. It may seem that the patient is intentionally trying to manipulate the provider into becoming angry. This may in fact be true. When providers become aware of these feelings, they should consider the possibility that their own impulses to punish the patient may be playing into the patient’s self-image as deserving of punishment. This pattern may be consistent with a borderline personality disorder (see Chapter 29).

The physician’s experience does not invariably reflect the patient’s experience. Rather, physicians should notice their own feelings and ask, “Does the way I feel tell me something about the patient or something about myself?” For example, a physician who has recently seen a number of patients seeking drugs begins to feel angry and defensive on noticing that the nurse has recorded “low back pain” as the next patient’s chief complaint; these negative feelings indicate more about the physician’s recent experiences than they do about the next patient. Feelings are primary data about the person in whom they arise and indirect data about others. The next section clarifies how to test the hypothesis that a patient is feeling a particular emotion and outlines how to respond.

Although empathy is not generally considered a therapeutic tool, discussion of emotional issues can be therapeutic. An empathic relationship is crucial in psychotherapy and enhances the power of all therapeutic relationships. The following sections show how to talk about emotions using specific skills. A premise of this discussion is that biomedical aspects of disease cannot be effectively addressed without considering their emotional consequences. Emotions, whether related to physiologic dysfunction or psychosocial issues, color the discussion in the examining room, and may be so distracting that the patient cannot fully concentrate on other issues until the emotions are addressed.

A clinical scenario helps to illustrate the usefulness of the emotion-handling skills described in this section.

Despite a diagnosis of non-cardiac chest pain, providing good information, and attempts to reassure the patient, something goes awry in this interaction. The patient still does not seem satisfied. Let us look at the effect empathic skills might have.

The techniques discussed in the following sections are adapted from a three-function model of the medical interview. The goals of the interview are described as gathering medical data, building a relationship with the patient, and educating and motivating the patient (see Chapter 1). The following emotion-handling skills are related to the second function, building relationships with patients (Table 2-2).

Reflection

The term reflection refers to naming the emotion the doctor sees and reflecting it back to the patient. Reflection communicates the physician’s understanding of the patient’s experience. It also has the effect of making the feelings behind the patient’s behavior or words explicit, so that they can be dealt with directly.

For example, when a patient greets a doctor who is 20 minutes late with, “My time is as valuable as yours,” the doctor might say, “I’m sorry I’m late. You seem pretty angry with me.” The patient might then ventilate about the doctor’s lateness or his treatment at the hands of doctors. He might even deny his anger, since many patients might view an expression of anger at their physicians as unacceptable. In any case, the doctor has a chance to deal with the emotion directly and then proceed with the interview, rather than trying to work with a patient who is angry and has not had a chance to express his anger.

After reflecting an emotion, the doctor should stop talking and see how the patient responds. Although the patient will usually elaborate, if the physician keeps talking the exploration may be prematurely ended.

Sometimes it is clear that a patient is feeling a strong emotion, but it is not clear what that emotion is. It is perfectly acceptable (and perhaps preferable) to treat the emotion as having a differential diagnosis and test a hypothesis as one would for any other medical entity: “I’m wondering if you’re upset,” or, more tentatively, “It seems that you’re feeling something strongly, but I’m not sure what it is. Can you help me out?”

Validation

Validation informs the patient that you understand the reason for the emotion. This has the effect of normalizing the emotion and making the patient feel less isolated. For example, to a somatizing patient who has been to several doctors to find a cause for her abdominal pain, you might say, “I can understand how frustrating it’s been to be no better after seeking so much help.” Some physicians are reluctant to validate emotions in difficult patients for fear of adding fuel to the fire. If reflection is the empathy skill that opens Pandora’s Box, then validation is the skill that closes it—it is difficult to remain upset with a person who understands how you feel. You do not have to agree with patients to express an understanding of their feelings. For example, to a patient with chronic low back pain who has responded angrily when informed that you will not prescribe narcotics, you might say, “Even though I see it differently, I can understand why you would be angry with me.” Although disagreeing with the patient, such a statement allows you to offer support and enhances your chances of continuing a therapeutic relationship. Validation of feelings emphasizes that the patient and doctor are equals in the human condition, although they have different roles in the therapeutic relationship.

Support

An expression of support tells patients that the physician cares about them and is willing to be present to their emotion. The expression can be verbal or nonverbal. Examples of nonverbal expression are handing the tearful patient a tissue or touching the patient. In judging whether touching a patient will be perceived as supportive, invasive, or inappropriate, the physician should consider such factors as culture, age, gender, sexual orientation, previous experience of abuse, and the presence or absence of psychiatric symptoms, such as paranoia. In general, putting a hand on the patient’s hand or arm will not be misinterpreted. Many physicians prefer taking the lead from the patient by matching the patient’s non-verbal behavior.

Some verbal expressions of support are “It’s pretty normal to get angry with children when they act out” and “A spouse’s death is one of the most difficult life transitions.” Again, these responses are not an attempt to suppress, eliminate, or fix the emotion, but rather an offer to help patients, to reassure them that they are not alone with an uncomfortable emotion. These three skills—reflection, validation, and support—are the most important of the emotion-handling skills and will be involved in most of the work physicians do in this area.

Partnership

Partnership implies a team approach, in which the patient and doctor work together toward the same goal. Doctors support and are partners with patients in many ways, but in the context of this chapter the word partnership makes it explicit that you would like to help the patient with the troubling emotion. An advantage of partnership is that it may help motivate patients to take an active role in their improvement and may lay the foundation for a contract for behavior change. This is consistent with the notion, especially important when illness results from patient behaviors, that physicians facilitate the patient’s healing rather than curing disease in the passive patient. The physician’s use of the pronouns we and us expresses partnership, as in “Perhaps we can make a plan to help you feel better” or “Let’s figure out a way to help you deal with this difficult diagnosis.”

Respect

This skill honors the emotional resources within a patient. The doctor might say “You’ve been through a lot” or “I’m impressed with how well you’re holding up under the circumstances.”

Physicians may not always know what it would be like to be the patient, but they can acknowledge the patient’s experience nonetheless: “I’m not a parent, so I can only imagine what it would be like to lose a child. I can see you’re feeling the loss quite deeply.” On a happier occasion, she might say “What a joy it must be for you to see your grandchild’s birth!”

Although it often makes sense to use reflection or validation first when addressing emotion, these skills can be used in any order, and it may be best to go through the sequence several times at different points in an interview.

Patient satisfaction, as indicated by the patient’s responses toward the end of the interview, seems much greater than in the first scenario. Although this scenario is longer than the first, using empathic skills added only approximately 1 minute to the interview, and if that additional minute prevents unnecessary visits by allaying the patient’s concerns, the time is well spent. Early in the interview the doctor does very little talking, and what he does say primarily addresses the patient’s charged emotional state. He initially resists the patient’s invitation to confirm conclusively that this is all in his head, and, instead, allows the patient to continue to explore his feeling state. There is uncertainty at the end of the medical interview, but it seems to be an uncertainty that both the doctor and patient can accept comfortably, with a sense of partnership.

Suppose the content of what the patient reveals is upsetting, distasteful, or even abhorrent to the physician. In the previous example of the patient with chest pain, suppose that the doctor’s mother has just died and his father is scheduled for triple-bypass surgery. The mere contemplation of losing his father is so threatening that the physician withdraws into himself. Psychological defense mechanisms may cause the physician to become distracted from the patient’s visit and think about his own concerns.

However, suppose that the patient describes a situation that is emotionally charged, but is so alien to the physician’s experience that he cannot empathize. If, for example, a homosexual patient reveals that his partner has become HIV positive, the heterosexual physician may pity (feel sorry for) the patient but may be unable to relate to the patient’s grief and fears. Or suppose the physician must present certain treatments to a patient that he considers disgusting or repulsive. His own obvious feeling may prevent the patient from making a truly informed decision.

Finding just the right therapeutic stance is essential; it may be partly intuitive and partly learned, and it may vary from patient to patient—or even with the same patient over time—depending on the patient’s needs. Opportunities may be lost when the physician is unable to empathize with the patient, or when the loss of ego boundaries makes a therapeutic stance impossible. The most effective physicians are those whose repertoire permits a rapid interplay of objectivity and emotion.

Calibrating responses to patients requires noticing and understanding when clinicians’ own emotional issues prevent them from being maximally effective with patients. The first clue may be that a specific patient or type of patient particularly irks a physician. These “irksome patients” are our teachers. They teach us about ourselves. Personal barriers to effectiveness with patients usually originate in the physician’s own family of origin. Numerous tools are available to help physicians overcome these barriers: speaking with a trusted colleague, Balint or other support groups, courses that focus specifically on personal awareness, and personal psychotherapy.

On Authenticity

When the language of empathy is new, it can feel foreign and, therefore, phony. Some have likened empathy skills to acting. All new skills, whether in sports, cooking, or the performance arts, are awkward and effortful at first. As one gains experience and tailors these concepts to one’s own personal style, empathy skills become part of who we are. If a clinician says something he does not believe, with the goal of manipulating the patient, it is likely to be detected and to backfire. We all have had the feeling of being patronized by service workers trained in customer satisfaction. However, if we express what we imagine the patient is feeling with the goal of strengthening a connection, the patient is likely to detect the authentic intent and forgive any awkwardness in the expression. Returning to the “acting” metaphor, there is a distinction in the performance arts between “surface acting” (acting unconnected to emotions) and “deep acting” (grounded in one’s own life experiences or imagination of another’s experience). There are both ethical and pragmatic arguments against “faking” empathy. Only the most skilled actors are likely to possess the capacity to match subconscious nonverbal cues with inauthentic verbal expressions.

Non-verbal Expression of Empathy

If one includes voice tone, inflection, cadence, etc., non-verbal communication contains most of the meaning in a conversation. Emotional intelligence includes the capacity to interpret others’ emotions, which are less often labeled by patients than expressed in their body language and voice tone. Physicians’ expressions of emotion affect patient satisfaction and adherence. Increased physician emotional expressivity is correlated with increased patient satisfaction. Conversely, a dominant voice tone has been correlated with the likelihood of being sued.

Nonverbal communication takes place at the same time as verbal communication, and, therefore, has the advantage of efficiency—it takes no added time. Simple acts can create the illusion of expanding time. Studies have shown that when a doctor sits down while talking to a patient, the patient in retrospect estimates that the doctor has spent more time in the interaction. Smiling, shaking hands, and nodding as the patient speaks enhance rapport. The electronic medical record, as the paper chart before it, has the potential to impede rapport. Eye contact has been shown to be critical in maintaining a connection with the patient, whereas computer screen gazing has been shown to disrupt it.

Empathy in Medical Training

There is evidence that empathy correlates with the fluctuation of mood state during residency (see Chapter 47, “Trainee Well-Being”). It is remarkable how the fresh enthusiasm and caring of medical students can quickly devolve into the wry cynicism of residents. What accounts for this withdrawal? The usual explanation is that insulating oneself in this way is an act of self-preservation in the face of overwhelming demands. It can be torturous to feel another’s pain, and if one’s self is already stressed because of long hours and the other exigencies of training, it may be more difficult to sustain an open posture.

The ways in which doctors withdraw depend on both their personalities and their environment. If the culture around the resident tolerates derogatory labels for patients, it can be easy to see patients as other, as not sharing some element of humanity with us. Even if such labels are not tolerated and caring for patients is a highly preserved value, dark humor may surface as a means of insulation. To take care of others, one must first take care of oneself. Finding the right balance is a major developmental task of the health-care professionals. Perhaps by attending to the well-being of trainees, we will make them better doctors (see Chapter 42). Since empathy directly correlates with well-being in internal medicine residents, it is important that training programs demonstrate that caring for others is valuable. Experienced physicians can attend to trainees’ growth, help them develop effective and healthy working styles, model those styles, and draw attention to the importance of being aware of one’s own development. There is a huge contrast between the concept of residency training as nurturing or mentoring and the concept of residency as “trial by fire.” And fire, we know, steels metal, making it harder.

Empathy in the Practice of Medicine

What happens after training? For some practitioners, the pressure becomes less, healthy coping styles develop, and the caring physician reemerges. Far too many, however, are casualties of the training process. Physicians’ compulsive personality styles are susceptible to a pattern of delayed gratification. Constantly nurturing others, physicians may have no time left for themselves. Relationships with family and friends may atrophy. The most effective physicians may be those who attend to their own needs as well as those of their patients, who understand their own unique struggles, so that these struggles—by making physicians aware of their own humanity—can enhance, rather than detract from, their relationships with patients.

Because the culture of an institution strongly influences the practice of medicine within its purview, physicians who practice together have a unique opportunity to enhance each other’s empathic skills. Patient-care conferences can incorporate psychosocial issues into the discussions of difficult cases. Reviewing videotaped interviews with difficult patients is a powerful tool that allows physicians to examine their own contributions to the difficulty of such interactions.

Regular videotaped conferences, in which physicians take turns presenting cases, allow them to feel at ease in front of the camera, demonstrate collaboration and mutual support, and reinforce the importance and value of empathy to the group. Balint groups or other types of support groups, which may include non-physician office staff, can help health practitioners cope with collegial interactions or family relationships that have become stressed by practice. Such groups also show that a psychosocial perspective can benefit both physicians and their patients.

Understanding the interaction between illness and emotion helps us become more effective clinicians. Familiarity and practice with the skills in this chapter can make us more comfortable discussing this interaction with our patients. Becoming aware of our own personal response to patients promotes personal growth as well. The emotional demands of the medical profession can be enriching or impoverishing. Using the skills of empathy, we may become more satisfied and effective clinicians, and at the same time, our patients also may become more satisfied and healthy.