Tag Archives: Harvey Cushing

Caring Technology

Posted on October 11, 2012 | Leave a comment

The critique of contemporary medical treatment as impersonal, uncaring, and disease-focused usually invokes the dehumanizing perils of high technology.  The problem is that high technology is a moving target.  In the England of the 1730s, obstetrical forceps were the high technology of the day; William Smellie, London’s leading obstetrical physician, opposed their use for more than a decade, despite compelling evidence that the technology revolutionized childbirth by permitting obstructed births to become live births.[1]  For much of the nineteenth century, stethoscopes and sphygmomanometers (blood pressure meters) were considered technological contrivances that distanced the doctor from the patient.  For any number of Victorian patients (and doctors too), the kindly ear against the chest and the trained finger on the wrist helped make the physical examination an essentially human encounter.  Interpose instruments between the physician and the patient and, ipso facto, you distance the one from the other.  In late nineteenth-century Britain, “experimental” or “laboratory” medicine was itself a revolutionary technology, and it elicited  bitter denunciation from antivivisectionists (among whom were physicians) that foreshadows contemporary indictments of the “hypertrophied scientism” of modern medicine.[2]

Nineteenth-century concerns about high technology blossomed in the early twentieth century when technologies (urinalysis, blood studies, x-rays, EKGs) multiplied and their use switched to hospital settings.  Older pediatricians opposed the use of the new-fangled incubators for premature newborns. They  not only had faulty ventilation that deprived infants of fresh air but were a wasteful expenditure, given that preemies of the poor were never brought to the hospital right after birth.[3]   Cautionary words were always at hand for the younger generation given to the latest gadgetry.  At the dedication of Yale’s Sterling Hall of Medicine, the neurosurgeon Harvey Cushing extolled family physicians as exemplars of his gospel of observation and deduction and urged  Yale students to engage in actual “house-to-house practice” without the benefit of “all of the paraphernalia and instruments of precision supposed to be necessary for a diagnosis.”  This was in 1925.[4]

Concerns about the impact of technology on doctor-patient relationships blossomed again in the 1960s and 70s and played a role  in the rebirth of primary care medicine in the guise of the “family practice movement.”  Reading the papers of the recently deceased G. Gayle Stephens, written at the time and collected in his volume The Intellectual Basis of Family Practice (1982), is a strong reminder of the risks attendant to loading high technology with relational meaning.  Stephens, an architect of the new structure of primary care training, saw the “generalist role in medicine” as an aspect of 70s counterculture that questioned an “unconditional faith in science” that extended to medical training, practice, and values.  And so he aligned the family practice movement with other social movements of the 70s that sought to put the breaks on scientism run rampant:  agrarianism, utopianism, humanism, consumerism, and feminism.  With its clinical focus on the whole person and liberal borrowings from psychiatry and the behavioral sciences, family practice set out to liberate medicine from its “captivity” to a flawed view of reality that was mechanistic, protoplasmic, and molecular.[5]

Technology was deeply implicated in Stephens’ critique, even though he failed to stipulate which technologies he had in mind.  His was a global indictment: Medicine’s obsession with its “technological legerdemain” blinded the physician to the rich phenomenology of “dis-ease” and, as such, was anti-Hippocratic.  For Stephens, the “mechanical appurtenances of healing” had to be differentiated from the “essential ingredient” of the healing process, viz., “a physician who really cares about the patient.” “We have reached a point of diminishing returns in the effectiveness of technology to improve the total health of our nation.”  So he opined in 1973, only two years after the first crude CT scanner was demonstrated in London and long before the development of MRIs and PET scans, of angioplasty with stents, and of the broad array of laser- and computer-assisted operations available to contemporary surgeons.[6]  Entire domains of technologically guided intervention – consider technologies of blood and marrow transplantation and medical genetics – barely existed in the early 70s.  Robotics was the stuff of science fiction.

It is easy to sympathize with both Stephens’ critique and his mounting skepticism about the family practice movement’s ability to realize its goals. [7]  He placed the movement on an ideological battleground in which the combatants were of unequal strength and numbers.  There was the family practice counterculture, with the guiding belief that “something genuine and vital occurs in the meeting of doctor and patient” and the pedagogical correlate that  “A preoccupation with a disease instead of a person is detrimental to good medicine.”  And then there were the forces of organized medicine, of medical schools, of turf-protecting internists and surgeons, of hospitals with their “business-industrial models” of healthcare delivery, of specialization and of technology – all bound together by a cultural commitment to science and its  “reductionist hypothesis about the nature of reality.”[8]

Perceptive and humane as Stephen’s critique was, it fell back on the very sort of reductionism he imputed to the opponents of family practice.  Again and again, he juxtaposed “high technology,” in all its allure (and allegedly diminishing returns) with the humanistic goals of patient care.  But are technology and humane patient care really so antipodal?  Technology in and of itself has no ontological status within medicine.  It promotes neither a mechanistic worldview that precludes holistic understanding of patients as people nor a humanizing of the doctor-patient encounter.  In fact, technology is utterly neutral with respect to the values that inform medical practice and shape individual doctor-patient relationships.  Technology does not make (or unmake) the doctor.  It no doubt affects the physician’s choice of specialty, pulling those who lack doctoring instincts or people skills in problem-solving directions (think diagnostic radiology or pathology). But this is hardly a bad thing.

For Stephens, who struggled to formulate an “intellectual” defense of family practice as a new medical discipline, technology was an easy target.  Infusing the nascent behavioral medicine of his day with a liberal dose of sociology and psychoanalysis, he envisioned the family practice movement as a vehicle for recapturing “diseases of the self” through dialogue.[9]  To the extent that technology – whose very existence all but guaranteed its overuse – supplanted  the sensibility (and associated communicational skills) that enabled such dialogue, it was ipso facto part of the problem.

Now there is no question that overreliance on technology, teamed with epistemic assurance that technology invariably determines what is best, can make a mess of things, interpersonally speaking.  But is the problem with the technology or with the human beings who use it?  Technology, however “high” or “low,” is an instrument of diagnosis and treatment, not a signpost of treatment well- or ill-rendered.  Physicians who are not patient-centered will assuredly not find themselves pulled toward doctor-patient dialogue through the tools of their specialty.  But neither will they become less patient-centered on account of these tools.  Physicians who are patient-centered, who enjoy their patients as people, and who comprehend their physicianly responsibilities in broader Hippocratic terms – these physicians will not be rendered less human, less caring, less dialogic, because of the technology they rely on.  On the contrary, their caregiving values, if deeply held, will suffuse the technology and humanize its deployment in patient-centered ways.

When my retinologist examines the back of my eyes with the high-tech tools of his specialty – a retinal camera, a slit lamp, an optical coherence tomography machine – I do not feel that my connection with him is depersonalized or objectified through the instrumentation.  Not in the least.  On the contrary, I perceive the technology as an extension of his person.  I am his patient, I have retinal pathology, and I need his regular reassurance that my condition remains stable and that I can continue with my work.  He is responsive to my anxiety and sees me whenever I need to see him.  The high technology he deploys in evaluating the back of my eye does not come between us; it is a mechanical extension of his physicianly gaze that fortifies his judgment and amplifies the reassurance he is able to provide.  Because he cares for me, his technology cares for me.  It is caring technology because he is a caring physician.

Modern retinology is something of a technological tour de force, but it is no different in kind from other specialties that employ colposcopes, cytoscopes, gastroscopes, proctoscopes, rhinoscopes, and the like to investigate symptoms and make diagnoses.  If the physician who employs the technology is caring, then all such technological invasions, however unpleasant, are caring interventions.  The cardiologist who recommends an invasive procedure like cardiac catheterization is no less caring on that account; such high technology does not distance him from the patient, though it may well enable him to maintain the distance that already exists.  It is a matter of personality, not technology.

I extend this claim to advanced imaging studies as well.  When the need for an MRI is explained in a caring and comprehensible manner, when the explanation is enveloped in a trusting doctor-patient relationship, then the technology, however discomfiting, becomes the physician’s collaborator in care-giving.  This is altogether different from the patient who demands an MRI or the physician who, in the throes of defensive medicine, remarks off-handedly, “Well, we better get an MRI” or simply, “I’m going to order an MRI.”

Medical technology, at its best, is the problem-solving equivalent of a prosthetic limb.  It is an inanimate extender of the physician’s mental “grasp” of the problem at hand. To the extent that technology remains tethered to the physician’s caring sensibility, to his understanding that his diagnostic or treatment-related problem is our existential problem – and that, per Kierkegaard, we are often fraught with fear and trembling on account of it – then we may welcome the embrace of high technology, just as polio patients of the 1930s and 40s with paralyzed intercostal muscles welcomed the literal embrace of the iron lung, which enabled them to breath fully and deeply and without pain.

No doubt, many physicians fail to comprehend their use of technology in this fuzzy, humanistic way – and we are probably the worse for it.  Technology does not structure interpersonal relationships; it is simply there for the using or abusing.  The problem is not that we have too much of it, but that we impute a kind of relational valence to it, as if otherwise caring doctors are pulled away from patient care because technology gets between them and their patients.  With some doctors, this may indeed be the case.  But it is not the press of technology per se that reduces physicians to, in a word Stephens disparagingly uses, “technologists.”  The problem is not in their tools but in themselves.

[1] A. Wilson, The Making of Man-Midwifery: Childbirth in England, 1660-1770 (Cambridge: Harvard, 1995), pp. 97-98, 127-128.

[2] R. D. French, Antivivisection and Medical Science in Victorian Society (Princeton:  Princeton University Press, 1975), p. 411.

[3] J. P. Baker, “The Incubator Controversy: Pediatricians and the Origins of Premature Infant Technology in the United States, 1890 to 1910,” Pediatrics, 87:654-662, 1991.

[4] E. H. Thomson, Harvey Cushing: Surgeon, Author, Artist (NY: Schuman, 1950), pp. 244-45.

[5] G. G. Stephens, The Intellectual Basis of Family Practice (Kansas City: Winter, 1982), pp. 62, 56, 83-85, 135-39.

[6] Stephens, Intellectual Basis of Family Practice, pp. 84, 191, 64, 39, 28.

[7] E.g., Stephens, Intellectual Basis of Family Practice, pp. 96, 194.  Cf. his comment on the American College of Surgeon’s effort to keep FPs out of the hospital: “There are issues of political hegemony masquerading as quality of patient care, medicolegal issues disguised as professional qualifications, and economic wolves in the sheepskins of guardians of the public safety” (p. 69).

[8] Stephens, Intellectual Basis of Family Practice, pp. 23, 38, 22.  In 1978, he spoke of the incursion of family practice  into the medical school curriculum of the early 70s as an assault on an entrenched power base:  “The medical education establishment has proved to be a tough opponent, with weapons we never dreamed of. . . .We had to deal with strong emotions, hostility, anger, humiliation. Our very existence was a judgment on the schools, much in the same way that civil rights demonstrators were a judgment on the establishment.  We identified ourselves with all the natural critics of the schools – students, underserved segments of the public, and their elected representatives – to bring pressure to bear on the schools to create academic units devoted to family practice” (pp. 184, 187).

[9] Stephens, Intellectual Basis of Family Practice, pp. 94, 105, 120-23, 192.

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

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Posted in Family Doctors, Then & Now, Medical Instruments, Medical Technology, Old & New, Primary Care

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Humanitas, History, Empathy

Posted on June 1, 2012 | Leave a comment

In the nineteenth century, no one was devising courses, workshops, or coding schemes to foster empathic care-giving.  In both Europe and America, students were expected to learn medicine’s existential lessons in the manner they long had:  through mastery of Latin and immersion in ancient writings.  This fact should not surprise us:  knowledge of Latin was the great nineteenth-century signpost of general knowledge.  It was less an index of education achieved than testimony to educability per se.  As such, it was an aspect of cultural endowment essential to anyone aspiring to a learned profession.

I have written elsewhere about the relationship of training in the classics to medical literacy throughout the century.[1]  Here I focus on the “felt” aspect of this cultural endowment: the relationship of classical training to the kind of Humanitas (humanity) that was foundational to empathic caregiving.

The conventional argument has it that the role of Latin in medicine progressively diminished throughout the second half of the nineteenth century, as experimental medicine and laboratory science took hold, first in Germany and Austria, then in France, and finally in Britain and the United States, and transformed the nature of medical training.  During this time, physicians who valued classical learning, so the argument goes, were the older men who clung to what Christopher Lawrence terms “an epistemology of individual experience.”  In Britain, aficionados of the classics were the older, hospital-based people who sought to circumscribe the role of science in clinical practice.  Like their younger colleagues, they used the rhetoric of science to bolster their authority but, unlike the younger men, they “resisted the wholesale conversion of bedside practice into a science – any science.”  For these men, clinical medicine might well be based on science, but its actual practice was “an art which necessitated that its practitioners be the most cultured of men and the most experienced reflectors on the human condition.”[2]

For Lawrence, classical learning signified the gentleman-physician’s association of bedside practice with the breadth of wisdom associated with general medicine; as such, it left them “immune from sins begotten by the narrowness of specialization.”  In America, I believe, the situation was different.  Here the classics did not (or did not only) sustain an older generation intent on dissociating scientific advance from clinical practice.  Rather, in the final decades of the century, the classics sustained the most progressive of our medical educators in their efforts to resist the dehumanization of sick people inherent in specialization and procedural medicine.  Medical educators embraced experimental medicine and laboratory science, to be sure, but they were also intent on molding physicians whose sense of professional self transcended the scientific rendering of the clinical art.  Seen thusly, the classics were more than a pathway to the literacy associated with professional understanding and communication; they were also a humanizing strategy for revivifying the Hippocratic Oath in the face of malfunctioning physiological systems and diseased organs.

Consider the case of Johns Hopkins Medical College, which imported the continental, experimental model to theUnited States and thereby became the country’s first modern medical school in 1892.   In the medical value assigned to the classics, three of Hopkins’ four founding fathers were second to none.  William Welch, the pathologist who headed the founding group of professors (subsequently known as “The Big Four”), only reluctantly began medical training in 1872, since it meant abandoning his first ambition:  to become a Greek tutor and ultimately a professor of classics at his alma mater, Yale University.  Welch’s love of the classics, especially Greek literature and history, spanned his lifetime.  “Everything that moves in the modern world has its roots in Greece,” he opined in 1907.

William Osler, the eminent Professor of Medicine who hailed from the Canadian woodlands north of Toronto, began his education as a rambunctious student at the Barrie Grammar School, where he and two friends earned the appellation “Barrie’s Bad Boys.”  On occasion, the little band would give way to “a zeal for study” that led them after lights-out to “jump out of our dormitory window some six feet above the ground and study our Xenophon, Virgil or Caesar by the light of the full moon.”  Osler moved on to the Trinity College School where, in a curriculum overripe with Latin and the classics, he finished first in his class and received the Chancellor’s Prize of 1866.  Two years later, he capped his premedical education at Trinity College with examination papers on Euclid, Greek (Medea and Hippolytus), Latin Prose, Roman History, Pass Latin (Terence), and Classics (Honours).[3]  Ever mindful of his classical training, Osler not only urged his Hopkins students “to read widely outside of medicine,” but admonished them to “Start at once a bed-side library and spend the last half hour of the day in communion with the saints of humanity,”  among whom he listed Plutarch, Marcus Aurelius, Plato, and Epictetus.[4]

When Howard Kelly, the first Hopkins Professor of Gynecology and arguably the foremost abdominal surgeon of his time, began college in 1873, he was awarded the Universityof Pennsylvania’s matriculate Latin Prize for his thesis, “The Elements of Latin Prose Composition.”  Kelly, like Welch and Osler, was a lifetime lover of the classics, and he relished summer vacations, when he could “catch up on his Virgil and other classics.[5]

Of the fourth Hopkins founding father, the reclusive, morphine-addicted surgeon William Stewart Halsted, there is no evidence of a life-long passion for the ancients, though his grounding in Latin and Greek at Phillips Academy, which he attended from 1863 to 1869, was typically rigorous.  Far more impressive bona fides belong to one of  Halsted’s early trainees, Harvey Cushing, who came to Hopkins in 1897 and became the hospital’s resident surgeon in 1898.  Cushing, the founder of modern neurosurgery, entered Yale in 1887, where he began his college career “walking familiarly in the classics” with courses that included “geometry, Livy, Homer, Cicero, German, Algebra, and Greek prose.”  In February, 1888, he wrote his father that Yale was giving him and his friends “our fill of Cicero.  We have read the Senectute and Amicitia and are reading his letter to Atticus, which are about the hardest Latin prose, and now we have to start in on the orations.”[6]

In the early twentieth century, Latin, no less than high culture in general, fell by the wayside in the effort to create modern “scientific” doctors.  By the 1920s, medical schools had assumed their modern “corporate” form, providing an education that was standardized and mechanized in the manner of factory production.  “The result of specialization,” Kenneth Ludmerer has observed, “was a crowded, highly structured curriculum in which subjects were taught as a series of isolated disciplines rather than as integrated branches of medicine.”[7]  Absent such integration, the very possibility of a holistic grasp of sick people, enriched by study of the classics, was relinquished.

The elimination of Latin from the premed curriculum made eminently good sense to twentieth-century medical educators.  But it was not only the language that went by the wayside.  Gone as well was familiarity with the broader body of myth, literature, and history to which the language opened up.  Gone, that is, was the kind of training that sustained holistic, perhaps even empathic, doctoring.

When in the fall of 1890 – a year after the opening of Johns Hopkins Hospital – Osler and Welch founded the Johns Hopkins Hospital Historical Club, it was with the explicit understanding that medical history, beginning with the Hippocratic and Galenic writings, was a humanizing building block in the formation of a medical identity.  The first year of monthly meetings was devoted exclusively to Greek medicine, with over half of 15 presentations dealing with Hippocrates.  Osler’s two talks dealt, respectively, with “The Aphorisms of Hippocrates” and “Physic and Physicians as Depicted in Plato.”  Over the next three years, the Club’s focus broadened to biography, with Osler himself presenting essays on seven different American physicians, John Morgan, Thomas Bond, Nathan Smith, and William Beaumont, among them.  His colleagues introduced the club to other medical notables, European and American, and explored topics in the history of the specialties, including the history of trephining, the history of lithotomy in women, and the ancient history of rhinoscopy.[8]

The collective delving into history of medicine that took place within the Hopkins Medical History Club not only broadened the horizons of the participates, residents among them.  It also promoted a comfortable fellowship conducive to patient-centered medicine.  The Hopkins professors and their occasional guests were not only leading lights in their respective specialties, but Compleat Physicians deeply immersed in the humanities. Residents and students who attended the meetings of the Club saw their teachers as engaged scholars; they beheld professors who, during the first several years of meetings, introduced them, inter alia, to “The Royal Touch for Scrofula in England,” “The Medicine of Shakespeare,” “The Plagues and Pestilences of the Old Testament,” and “An Old English Medical Poem by Abraham Cowley.”   Professors familiar with doctor-patient relationships throughout history were the very type of positive role models that contemporary medical educators search for in their efforts to counter a “hidden curriculum” that pulls students away from patient-centered values and into a culture of academic hierarchies, cynical mixed-messages, and commercialism.[9]

Medical history clubs were not uncommon in the early decades of the twentieth century.  The Hopkins Club, along with the New York-based Charaka Club founded in 1899, had staying power.  In 1939, the third meeting of the Hopkins Club, which presented a play adapted by Hopkins’ medical librarian Sanford Larkey from William Bullein’s “A Dialogue Against the Fever Pestilence” (1564), drew a crowd of 460.  The following year, when the Hopkins Club celebrated its fiftieth anniversary, Baltimore alone boasted two other medical history clubs: the Osler Society of the Medical and Chirurgical Faculty of the State of Maryland and the Cordell Society of the University of Maryland.[10]

Although medical history clubs are a thing of the past, we see faint echoes of their milieu in contemporary medical student and resident support groups, some modeled on the Balint groups developed by Michael and Enid Balint at London’s Tavistock Clinic in the 1950s.[11]  All such groups seek to provide a safe space for shared reflection and self-examination in relation to physician-patient relationships.  In the late-nineteenth and early-twentieth centuries, history clubs filled this space with topics in medical history.  Their meetings broadened the care-giving sensibility of young physicians by exposing them to pain and suffering, to plagues and pestilences, far beyond the misery of everyday rounds.  Medical history and the broadened “medical self” it evokes and nurtures – now there’s a pathway to empathy.

[1] P. E. Stepansky, “Humanitas: Nineteenth-Century Physicians and the Classics,” presented to the Richardson History of Psychiatry Research Seminar, Weill Cornell Medical College, New York, NY, October 3, 2007.

[2] C. Lawrence, “Incommunicable knowledge: science, technology and the clinical art in Britain, 1850-1914,” J. Contemp. Hist., 20:503-520, 1985, quoted at pp. 504-505, 507.

[3] S. Flexner & J. T. Flexner, William Henry Welch and the Heroic Age of American Medicine (Baltimore:  Johns Hopkins University Press, 1968 [1941]), pp. 63-65, 419-420; H. Cushing, The Life of Sir William Osler (London: Oxford University Press, 1940), pp. 25, 39, 52.

[4] W. Osler, Aequanimitas, with other Addresses to Medical Students, Nurses and Practitioners of Medicine, 3rd edition (New York: McGraw-Hill, 1906), pp. 367, 463; L. F. Barker, Time and the Physician (New York: Putnam, 1942), p. 86.

[5] A. W. Davis, Dr. Kelly of Hopkins: Surgeon, Scientist, Christian (Baltimore: Johns Hopkins University Press, 1959),  pp. 17, 21.

[6] David Linn Edsall, who, as Dean of Harvard Medical School and of the Harvard School of Public Health during the 1920s, engineered Harvard’s progressive transformation, entered Princeton the same year (1887) Cushing entered Yale.  Edsall came to Princeton “a serious-minded young classicist” intent on a career in the classics. See  J. C. Aub & R. K. Hapgood, Pioneer in Modern Medicine: David Linn Edsall of Harvard (Cambridge: Harvard Medical Alumni Association, 1970), p. 7.  On Cushing and the classics, see  E. H. Thomson, Harvey Cushing: Surgeon, Author, Artist (New York: Schuman, 1950), p. 20.

[7] K. M. Ludmerer, Learning to Heal: The Development of American Medical Education (New York:  Basic Books, 1985), pp. 256-57, 262.

[8] V. A. McKusick, “The minutes of the Johns Hopkins medical history club, 1890 to 1894,” Bull. Hist. Med., 27:177-181, 1953.

[9] F. W. Hafferty, “Beyond curriculum reform: confronting medicine’s hidden curriculum,” Acad. Med., 73:403-407, 1998;  J. Coulehan, “Today’s professionalism: engaging the mind but not the heart,” Acad. Med., 80:892-898, 2005; P. Haldet & H. F. Stein, “The role of the student-teacher relationship in the formation of physicians: the hidden curriculum as process,” J. Gen. Int. Med., 21(suppl):S16-S20, 2005; S. Weissman, “Faculty empathy and the hidden curriculum” [letter to the editor], Acad. Med., 87:389, 2012.

[10] O. Temkin, “The Johns Hopkins medical history club,” Bull. Hist. Med., 7:809, 1939; W.R.B., “Johns Hopkins medical history club,” BMJ, 1:1036, 1939.

[11] K. M. Markakis, et al., “The path to professionalism: cultivating humanistic values and attitudes in residency training,” Acad. Med., 75:141-150, 2000; M. Hojat, “Ten approaches for enhancing empathy in health and human services cultures,” J. Health Hum. Serv. Adm., 31:412-450, 2009;  K. Treadway & N. Chatterjee, “Into the water – the clinical clerkships,” NEJM, 364:1190-1193, 2011.  On contemporary Balint groups, see A. L. Turner & P. L. Malm, “A preliminary investigation of Balint and non-Balint behavioral medicine training,” Fam. Med., 36:114-117,2004; D. Kjeldmand, et al., “Balint training makes GPs thrive better in their job,” Pat. Educ. Couns., 55:230-235, 2004; K. P. Cataldo, et al., “Association between Balint training and physician empathy and work satisfaction,” Fam. Med., 37:328–31, 2005.

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

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Posted in Classics and Medicine, Empathy, Medical Education, Medical Humanities, Nineteenth-Century Medicine

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Empathy, Psychotherapy, Medicine

Posted on March 27, 2012 | 1 comment

What passes for psychoanalysis in America these days is a far cry from the psychoanalysis Freud devised in the early years of the last century.  A sea change began in the 1970s, when Heinz Kohut, a Vienna-born and Chicago-based psychoanalyst, developed what he termed “psychoanalytic self psychology.”  At the core of Kohut’s theorizing was the replacement of one kind of psychoanalytic method with another.   Freud’s method – which Freud himself employed imperfectly at best – revolved around the coolly self-possessed analyst, who, with surgeon-like detachment, processed the patient’s free associations with “evenly hovering attention” and offered back pearls of interpretive wisdom.  The analyst’s neutrality – his unwillingness to become a “real” person who related to the patient in conventionally sympathetic and supportive ways – rendered him a “blank screen” that elicited the same feelings of love and desire – and also of fear, envy, resentment, and hatred – as the mother and father of the patient’s early life.  These feelings clustered into what Freud termed the positive and negative transferences.

Kohut, however, found this traditional psychoanalytic method fraught with peril for patients burdened less with Freudian-type neurotic conflicts than with psychological deficits of a preoedipal nature.  These deficits gained expression in more primitive types of psychopathology, especially in what he famously termed  “narcissistic personality disorder.”  For these patients – and eventually, in Kohut’s mind, for all patients – the detached, emotionally unresponsive analyst simply compounded the feelings of rejection and lack of self-worth that brought the patient to treatment.  He proffered in its place a kinder, gentler psychoanalytic method in which the analyst was content to listen to the patient for extended periods of time, to affirm and mirror back what the patient was saying and feeling, and over time to forge an empathic bond from which interpretations would arise.

Following Kohut, empathy has been widely construed as an aspect, or at least  a precondition, of talking therapy.  For self psychologists and others who draw on Kohut’s insights, the ability to sympathize with the patient has given way to a higher-order ability to feel what the patient is feeling, to “feel with” the patient from the inside out.  And this process of empathic immersion, in turn, permits the therapist to “observe” the patient’s psychological interior and to comprehend the patient’s “complex mental states.”  For Kohut, the core of psychoanalysis, indeed of depth-psychology in general, was employment of this “empathic mode of observation,” an evocative but semantically questionable turn of phrase, given the visual referent of “observe,” which comes from the Latin observare (to watch over, to guard).   More counterintuitively still, he sought to cloak the empathic listening posture in scientific objectivism.  His writings refer over and over to the “data” that analysts acquire through their deployment of “scientific” empathy, i.e., through their empathic listening instrument.

I was Heinz Kohut’s personal editor from 1978 until his death in the fall of 1981.  Shortly after his death, I was given a dictated transcript from which I prepared his final book, How Does Analysis Cure?, for posthumous publication.  Throughout the 80s and into the 90s, I served as editor to many senior self psychologists, helping them frame their arguments about empathy and psychoanalytic method  and write their papers and books.  I grasped then, as I do now, the heuristic value of a stress on therapeutic empathy as a counterpoise to traditional notions of analytic neutrality, which gained expression, especially in the decades following World War II, in popular stereotypes of the tranquilly “analytic” analyst whose caring instincts were no match for his or her devotion to Freud’s rigid method.

The comparative perspective tempers bemusement at what would otherwise be a colossal conceit:  that psychoanalytic psychotherapists alone, by virtue of their training and work, acquire the ability to empathize with their patients.  I have yet to read an article or book that persuaded me that  empathy can be taught, or that the yield of therapeutic empathy is the apprehension of “complex psychological states” that are analogous to the “data” gathered and analyzed by bench scientists (Kohut’s own analogy).

I do believe that empathy can be cultivated, but only in those who are adequately empathic to begin with.  In medical, psychiatric, and psychotherapy training, one can present students with instances of patients clinically misunderstood and then suggest how one might have understood them better, i.e., more empathically.  Being exhorted by teachers to bracket one’s personal biases and predispositions in order to “hear” the patient with less adulterated ears is no doubt a good thing.  But it  assumes trainees can develop a psychological sensibility through force of injunction, which runs something like:  “Stop listening through the filter of your personal biases and theoretical preconceptions!  Listen to what the patient herself  is saying in her voice!  Utilize what you understand of yourself, viz., the hard-won fruits of your own psychotherapy (or training analysis), to put yourself in her place!  Make trial identifications so that her story and her predicament resonate with aspects of your story and your predicament; this will help you feel your way into her inner world.”

At a less hortatory level, one can provide trainees with teachers and supervisors who are sensitive, receptive listeners themselves and thus “skilled” at what self psychologists like to refer to as “empathic attunement.”  When students listen to such instructors and perhaps observe them working with patients, they may learn to appreciate the importance of empathic listening and then, in their own work, reflect more ongoingly on what their patients are saying and on how they are hearing them say it.  They acquire the ability for “reflection-in-action,” which Donald Schön, in two underappreciated books of the 1980s, made central to the work of “reflective professionals” in a number of fields, psychotherapy among them.[1]  To a certain extent, systematic reflection in the service of empathy may help therapists be more empathic in general.

But then the same may be said of any person who undergoes a transformative life experience (even, say, a successful therapy) in which he learns to understand differently – and less tendentiously – parents, siblings, spouses, children, friends, colleagues, and the like.  Life-changing events  — fighting in  wars, losing loved ones, being victimized by natural disasters, living in third-world countries, providing aid to trauma victims – cause some people to recalibrate values and priorities and adopt new goals.  Such decentering can mobilize an empathic sensibility, so that individuals return to their everyday worlds with less self-centered ways of perceiving and being with others.

There is nothing privileged about psychotherapy training in acquiring an empathic sensibility.  I once asked a senior self psychologist what exactly differentiated psychoanalytic empathy from empathy in its everyday sense.  He thought for a moment and replied that in psychoanalysis, one deploys “sustained” empathy.  What, pray tell, does this mean, beyond denoting the fact that psychoanalysts, whether or not empathic, listen to patients for a living, and the units of such listening are typically 45-minute sessions.  Maybe he simply meant that, in the nature of things, analysts must try to listen empathically for longer periods of time, and prolongation  conduces to empathic competence.

Well, anything’s possible, I suppose.  But the fact remains that some people are born empathizers and others not.  Over the course of a 27-year career in psychoanalytic and psychiatric publishing, I worked with a great many analysts and therapists who struck me as unempathic, sometimes stunningly unempathic.  And those who struck me as empathic were not aligned with any particular school of thought, certainly not one that, like self psychology, privileges empathy.

Nor is it self-evident  that the empathy-promoting circumstances of psychotherapy are greater than the circumstances faced day-in and day-out by any number of physicians. Consider adult and pediatric oncologists, transplant surgeons, and internists and gerontologists who specialize in palliative care.  These physicians deal with patients (and their parents and children) in extremis; surely their work should elicit “sustained empathy,” assuming they begin with an empathic endowment strong enough to cordon off the miasma of uncertainty, dread, and imminent loss that envelops them on daily rounds.  Consider at the other end of the medical spectrum those remaining family doctors  who, typically in rural settings, provide intergenerational, multispecialty care and continue to treat patients in their homes .  The nature of their work makes it difficult for them not to observe and comprehend their patients’ complex biopsychosocial states; there are extraordinary empathizers among them.

When it comes to techniques for heightening empathy, physicians have certain advantages over psychotherapists, since their patients present with bodily symptoms and receive bodily (often procedural) interventions, both of which have a mimetic potential beyond “listening” one’s way into another’s inner world.  There is more to say about the grounds of medical empathy, but let me close here with a concrete illustration of such empathy in the making.

William Stevenson Baer graduated from Johns Hopkins Medical College in 1898 and stayed on at Hopkins as an intern and then assistant resident in William Halsted’s dauntingly rigorous surgical training program.  In June, 1900, at the suggestion of Baer’s immediate supervisor, Harvey Cushing, Halsted asked Baer to establish an orthopedic outpatient clinic at Hopkins the following fall.  With no grounding in the specialty, Baer readied himself for his new task by spending the ensuing summer at the orthopedic services of Massachusetts General Hospital and the Boston Children’s Hospital.  At both institutions, many children in the orthopedic ward had to wear plaster casts throughout the hot summer months.  On arrival, Baer’s first order of business was to alter his life circumstances in order to promote empathy with, and win the trust of, these young patients.  To wit, he had himself fitted for a body cast that he wore the entire summer.  His sole object, according to his Hopkins colleague Samuel Crowe, was “to gain the children’s confidence by showing them that he too was enduring the same discomfort.”[2]

Psychotherapists are generally satisfied that empathy can be acquired in the manner of a thought experiment.  “Bracket your biases and assumptions,” they admonish, “empty yourself of ‘content,’ and then, through a process of imaginative identification, you will be able to hear what your patient is saying and feel what she is feeling.”  Baer’s example reminds us that illness and treatment are first and foremost bodily experiences, and that “feeling into another” – the literal meaning of the German Einfühlung, which we translate as “empathy” – does not begin and end with concordant memories amplified by psychological imagination.[3]  In medicine, there is an irremediably visceral dimension to empathy, and we shall consider it further in the next posting.

[1] Donald A. Schön, The Reflective Practitioner: How Professionals Think in Action (NY: Basic Books, 1983); Donald A. Schön, Educating the Reflective Practitioner (San Francisco: Jossey-Bass, 1987).

[2] Samuel James Crowe, Halsted of Johns Hopkins: The Man and His Men (Springfield, IL: Thomas, 1957), pp. 130-31.

[3] The imaginative  component of empathy, which is more relevant to its function in psychotherapy than in medicine, is especially stressed by Alfred Margulies, “Toward Empathy: The Uses of Wonder,” American Journal of Psychiatry, 141:1025-1033, 1984.

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

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