Pathways to Empathy?

Dipping into the vast[1] literature on clinical empathy, one quickly discerns the dominant storyline.  Everyone agrees that empathy, while hard to define,  hovers around a kind of physicianly caring that incorporates emotional connection with patients.  The connection conveys sensitivity to the patient’s life circumstances and personal psychology, and gains expression in the physician’s ability to encourage the patient to express emotion, especially as it pertains to his medical condition.  Then the physician draws on her own experience of similar emotions in communicating an “accurate” empathic understanding of how the patient feels and why he should feel that way.

Almost all commentators agree that empathy, whatever it is, is a good thing indeed.  They cite empirical research linking it to more efficient and effective care, to patients who are more trusting of their doctors, more compliant in following instructions, and more satisfied with the outcome of treatment. Patients want doctors who give them not only the appointment time but the time of day, and when they feel better understood, they simply feel better.  Furthermore, doctors who are empathic doctor better.  They learn more about their patients and, as a result, are better able to fulfill  core medical tasks such as history-taking, diagnosis, and treatment.  Given this medley of benefits, commentators can’t help but lament the well-documented decline of empathy, viz., of humanistic, patient-centered care-giving, among medical students and residents, and to proffer new strategies for reviving it.  So they present readers with a host of training exercises, coding schemes, and curricular innovations to help medical students retain the empathy with which they began their medical studies, and also to help overworked, often jaded, residents refind the ability to empathize that has succumbed to medical school and the dehumanizing rigors of specialty training.[2]

It is at this point that empathy narratives fork off in different directions.  Empathy researchers typically opt for a cognitive-behavioral approach to teaching empathy, arguing that if medical educators cannot teach students and residents to feel with their patients, they can at least train them to discern what their patients feel, to encourage the expression of these feelings, and then to respond in ways that affirm and legitimize the feelings.  This interactional approach leads to the creation of various models, step-wise approaches, rating scales, language games (per Wittgenstein), and coding systems, all aimed at cultivating a cognitive skill set that, from the patient’s perspective, gives the impression of a caring and emotionally attuned provider.  Duly trained in the art of eliciting and affirming emotions, the physician becomes capable of what one theorist terms “skilled interpersonal performances” with patients.  Seen thusly, empathic connection becomes a “clinical procedure” that takes the patient’s improved psychobiological functioning as its outcome.[3]

The cognitive-behavioral approach is an exercise in what researchers term “communication skills training.”  It typically parses doctor-patient communication into micro-interactions that can be identified and coded as “empathic opportunities.”  Teaching students and residents the art of “accurate empathy” amounts to alerting them to these opportunities and showing how their responses (or nonresponses) either exploit or miss them.  One research team, in a fit of linguistic inventiveness, tagged the physician’s failure to invite the patient to elaborate an emotional state (often followed by a physician-initiated change of subject), an “empathic opportunity terminator.”  Learning to pick up on subtle, often nonverbal, clues of underlying feeling states and gently prodding patients to own up to emotions is integral to the process. Thus, when patients don’t actually express emotion but instead provide a clue that may point to an emotion, the physician’s failure to travel down the yellow brick road of masked emotion becomes, more creatively still, a “potential empathic opportunity terminator.”  Whether protocol-driven questioning about feeling states leads patients to feel truly understood or simply the object of artificial, even artifactual, behaviors has yet to be systematically addressed.  Medical researchers ignore the fact that empathy, however “accurate,” is not effective unless it is perceived as such by patients.[4]

Medical educators of a humanistic bent take a different fork in the road to empathic care giving.  Shying away from protocols, models, scales, and coding schemes, they embrace a more holistic vision of empathy as growing out of medical training leavened by character-broadening exposure to the humanities. The foremost early proponent of this viewpoint was Howard Spiro, whose article of 1992, “What is Empathy and Can It Be Taught?” set the tone and tenor for an emerging literature on the role of the humanities in medical training.  William Zinn echoed his message a year later: “The humanities deserve to be a part of medical education because they not only provide ethical guidance and improve cognitive skills, but also enrich life experiences in the otherwise cloistered environment of medical school.”  The epitome of this viewpoint, also published in 1993, was the volume edited by Spiro and his colleagues, Empathy and the Practice of Medicine.  Over the past 15 years, writers in this tradition have added to the list of nonmedical activities conducive to clinical empathy.  According to Halpern, they include “meditation, sharing stories with colleagues, writing about doctoring, reading books, and watching films conveying emotional complexity.”  Shapiro and her colleagues single out courses in medicine and literature, attendance at theatrical performances, and assignments in “reflective writing” as specific empathy-enhancers.[5]

Spiro practiced and taught gastroenterology in New Haven, home of Yale University School of Medicine and the prestigious Western New England Psychoanalytic Institute. One quickly discerns the psychoanalytic influence on his approach.  The humanistic grounding he sought for students and residents partakes of this influence, whether in the kind of literature he wanted students to read (i.e., “the new genus of pathography”) or in his approach to history taking (“The clues that make the physician aware at the first meeting that a patient is depressed require free-floating attention, as psychoanalysts call it.”).

A variant of the “humanist” approach accepts the cognitivist assumption that empathy is a teachable skill but veers away from communications theory and cognitive psychology to delineate it.  Instead, it looks to the world of psychotherapy, especially the psychoanalytic self psychology of Heinz Kohut.  These articles, most of which were published in the 90s, are replete with psychoanalytic conceptualizations and phraseology; they occasionally reference Kohut himself but more frequently cite work by psychoanalytic self psychologists  Michael Basch and Dan Buie, the psychiatrist Leston Havens, and the psychiatrist-anthropologist Arthur Kleinman.

Authors following a psychoanalytic path to empathy assign specific tasks to students, residents, and clinicians, but the tasks are more typically associated with the opening phase of long-term psychotherapy.  Clinicians are enjoined to begin in a patiently receptive mode, avoiding the “pitfalls of premature empathy” and realizing that patients “seldom verbalize their emotions directly and spontaneously,” instead offering up clues that must be probed and unraveled.  Empathic receptiveness helps render more understandable and tolerable “the motivation behind patient behavior that would otherwise seem alien or inappropriate.”  Through “self-monitoring and self-analyzing,” the empathic clinician learns to rule out endogenous causes for heightened emotional states and can “begin to understand its source in the patient.”  In difficult confrontations with angry or upset patients, physicians, no less than psychoanalysts, must cultivate “an ongoing practice of engaged curiosity” that includes systematic self-reflection.  Like analysts, that is, they must learn to analyze the countertransference for clues about their patients’ feelings.[6]

There is a mildly overwrought quality to the medical appropriation of psychoanalysis, as if an analytic sensibility per se – absent lengthy analytic training – can be superadded to the mindset of task-oriented, often harried, clinicians and thereupon imbue them with heightened “empathic accuracy.” Given the tensions among the gently analytic vision of empathic care, the claims of patient autonomy, and the managerial, data-oriented, and evidence-based structure of contemporary practice, one welcomes as a breath of fresh air the recent demurrer of Anna Smajdor and her colleagues.  Patients, they suggest, really don’t want empathic doctors who enter their worlds and feel their pain, only doctors who communicate clearly and treat them with courtesy and a modicum of respect.[7]

And so the empathy narratives move on.  Over the past decade, neuroscientists have invoked empathy as an example of what they term “interpersonal neurobiology,” i.e., a neurobiological response to social interaction that activates specific neural networks, probably those involving the mirror neuronal system.  It may be that empathy derives from an “embodied simulation mechanism” that is neurally grounded and operates outside of consciousness.[8]  In all, this growing body of research may alter the framework within which empathy training exercises are understood. Rather than pressing forward, however, I want to pause and look backward.  Long before the term “empathy” was used, much less operationalized for educational purposes, there were deeply caring, patient-centered physicians.  Was there anything in their training that pushed them in the direction of empathic caregiving?   I propose that nineteenth-century medicine had its own pathway to empathy, and I will turn to it in the next posting.

[1] R. Pedersen’s review article, “Empirical research on empathy in medicine – a critical review,” Pat. Educ Counseling, 76:307-322, 2009 covers 237 research articles.

[2] F. W. Platt & V. F. Keller, “Empathic communication: a teachable and learnable skill,” J. Gen Int. Med., 9:222-226, 1994; A. L. Suchmann, et al., “A model of empathic communication in the medical interview,” JAMA, 277:678-682, 1997; J. L. Coulehan, et al., “’Let me see if I have this right . . .’: words that help build empathy,”  Ann. Intern. Med., 136:221-227, 2001; H. M. Adler, “Toward a biopsychosocial understanding of the patient-physician relationship: an emerging dialogue,” J. Gen. Intern. Med., 22:280-285, 2007; M. Neumann et al., “Analyzing the ‘nature’ and ‘specific effectiveness’ of clinical empathy: a theoretical overview and contribution towards a theory-based research agenda,” Pat. Educ. Counseling, 74:339-346, 2009; K. Treadway & N. Chatterjee, “Into the water – the clinical clerkships,” NEJM, 364:1190-1193, 2011.

[3] Adler, “Biopsychosocial understanding,” p. 282.

[4] Suchmann, et al., “Model of empathic communication”; Neumann, “Analyzing ‘nature’ and ‘specific effectiveness’,” 343; K. A. Stepien & A. Baernstein, “Educating for empathy: a review,” J. Gen. Int. Med., 21:524-530, 2006; R. W. Squier, “A Model of empathic understanding and adherence to treatment regimens in practitioner-patient relationships,” Soc. Sci. Med., 30:325-339, 1990.

[5] H. Spiro, “What is empathy and can it be taught?”, Ann. Int. Med., 116:843-846, 1992; W. Zinn, “The empathic physician,” Arch. Int. Med., 153:306-312, 1993; H. Spiro, et al., Empathy and the Practice of Medicine (New Haven: Yale University Press, 1993); J. Shapiro & L. Hunt, “All the world’s a stage: the use of theatrical performance in medical education,” Med. Educ., 37:922-927, 2003; J. Shapiro, et al., “Teaching empathy to first year medical students: evaluation of an elective literature and medicine course,” Educ. Health, 17:73-84, 2004; S. DasGupta & R. Charon, “Personal illness narratives: using reflective writing to teach empathy,” Acad. Med., 79:351-356, 2004; J. Shapiro, et al., “Words and wards: a model of reflective writing and its uses in medical education,” J. Med. Humanities, 27:231-244, 2006; J. Halpern, Empathy and patient-physician conflicts,” J. Gen. Int. Med., 22:696-700, 2007.

[6] Suchmann et al., “Model of empathic communication,” 681; Zinn, “Empathic physician,” 308; Halpern, “Empathy and conflicts,” 697.

[7] Halpern, “Empathy and conflicts,” 697; A. Smajdor, et al., “The limits of empathy: problems in medical education and practice,” J. Med. Ethics., 37:380-383, 2011.

[8] V. Gallese, “The roots of empathy: the shared manifold hypothesis and the neural basis of intersubjectivity,” Psychopathology, 36:171-180, 2003; L. Carr, et al., “Neural mechanisms of empathy in humans: a relay from neural systems for imitation to limbic area,” Proc. Natl. Acad. Sci., 100:5497-5502, 2003; G. Rizzolatti & L. Craighero, “The mirror-neuron system,” Ann. Rev. Neurosci., 27:169-192, 2004; V. Gallese, et al., “Intentional attunement: mirror neurons and the neural underpinnings of interpersonal relations,” J. Amer. Psychoanal. Assn., 55:131-176, 2007.

Copyright © 2012 by Paul E. Stepansky.  All rights reserved.


2 responses to “Pathways to Empathy?

  1. Perhaps I am way off-base here — after all, I have nothing to back up my assertions but my own observations — but I can’t help but think that the “well-documented decline in empathy” has a great deal more to do with changes in the healthcare system than with changes in medical education.

    If anything, I think that the medical field has become much more aware of the need to teach empathy as it moves away from the traditional paternalistic approach. However, the system has changed; with relatively standard 20-minute appointment times, the family doctor no longer has the time to get to know his patients personally. Furthermore, medicine has become far more complicated and therefore (partly out of necessity) far more specialized, which means that one person may see many doctors instead of building a personal relationship with one.

    In any case, as a medical student, I can say that my experience with ethics classes have been mixed. I enjoy them much more than many of my counterparts, who find them to be a waste of time. I think they are interesting and helpful. At the same time, I think that there is only so much one can do to teach empathy. The true solution to the empathy problem, if there is one, lies in a radical overhaul of the fee-for-service system.

    In any case, that is my 2 cents, for what they are worth. Thank you for an interesting post!

    • Thanks for these thoughtful remarks. I’m not sure one can make a radical distinction between changes in the healthcare system and changes in medical education; these are interlocking variables, with changes in education always responsive to changes in the healthcare system. Remember that the movement away from the “traditional paternalistic approach” really began in the 60s with the civil rights movement, second-wave feminism, and other forms of empowerment associated with Lyndon Johnson’s “Great Society” legislation. Then it picked up steam with the birth of bioethics and the patient rights movement of the 70s. Yet the decline of empathy, as researchers document it from a variety of directions and with a variety of measures, only becomes an issue from the late 80s-early 90s onward.

      So what happened? I think the decline of empathy has a lot to do with the technology-driven nature of contemporary practice taken in conjunction with the reliance on protocols, evidence-based treatment decisions, and legally strengthened notions of accountability up and down the line. And then there’s the fact, as you note, that medicine is far more complicated than it was 40-50 years ago, so that medical students will, in the nature of things, be stressed and exhausted simply trying to imbibe the dizzying amount of information before them. I don’t think there is any single explanation for the decline of empathy; there’s a comglomeration of intersecting factors that encompass the structure of practice, the role of technology, the ascendence of defensive medicine and evidenced-based care, and what scholars refer to as the “managerial revolution” in healthcare. Some medical students and residents no doubt survive their training and emerge as empathic practitioners, but the consensus among educators and researchers is that they are increasingly in the minority, and they manage to retain their values despite the system, not through it or because of it.

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