Against Empathy?

Paul Bloom, Professor of Psychology and Cognitive Science at Yale University, recently wrote a thought provoking (and emotion provoking) post on Boston Review, entitled, Against Empathy?. He writes about the downside of relying on empathy, particularly "emotional empathy", as a guide to action. Emotional empathy, he argues, is biased, clouds our thinking, and promotes moral errors, which may have dire consequences. He writes:

"Empathy is biased; we are more prone to feel empathy for attractive people and for those who look like us or share our ethnic or national background. And empathy is narrow; it connects us to particular individuals, real or imagined, but is insensitive to numerical differences and statistical data." 

"Our policies are improved when we appreciate that a hundred deaths are worse than one, even if we know the name of the one, and when we acknowledge that the life of someone in a faraway country is worth as much as the life a neighbor, even if our emotions pull us in a different direction."

Too much emotional empathy, he notes, can also produce "empathetic exhaustion", particularly among those who try to apply empathy as a clinician or aid worker. Some may also experience "pathological altruism" and seek to heal or soothe others at their own expense.

Bloom concedes that it is appropriate for clinicians to respond to a patient's pain or angst, though he argues that too much clinician empathy will generate burnout and promote ineffective and even unwanted clinician behavior. 

Bloom contrasts emotional empathy with compassion, which he describes as "concern and love ....., and the desire and motivation to help" which need not involve mirroring or experiencing the anguish of others. Compassion, he argues, is a more effective, and more sustainable response.

Personally, as I read his blog, I found myself arguing against Bloom and for empathy. When I think about the application of empathy in clinical settings, I have trouble seeing the cognitive and emotional components of empathy as separate processes. 

Though there may be distinct neural pathways for these 2 aspects of empathy, clinical empathy is a therapeutic interactive process that integrates eliciting, exploring, listening, observing, perceiving, imagining AND responding to others' expressed emotions, values and needs. 

As I noted in a previous EmpathyWorks blog post, Brene Brown has described empathy as having 4 critical elements:

1. perspective taking
2. staying out of judgement
3. recognizing emotion; and
4. communicating what you notice

In another EmpathyWorks post, I cite others' conceptualization of clinical empathy as a relational process that includes both cognitive and emotional elements. See: Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA: 1997;277(8):678-682.

Jodi Halpern, another clinical educator, emphasizes the relational process of "emotional attunement"  that comes from perspective taking (the cognitive aspect) together with exploring and responding to the "meaning" of the feeling. 

For those interested in learning more about clinical empathy, I also recommend the book, Empathy Reconsidered, New Directions in Psychotherapy (Eds: Arthur Bohart & Leslie Greenberg. American Psychological Association, Washington, 1997) which provides further perspectives on the role of empathy in clinical encounters, particularly in psychotherapy. 

In my own experience, empathy happens when I:

• allow myself to be fully present,

• listen generously,

• seek to fully understand the meaning of the patient's feelings,

• respond with genuine reflections about what I am hearing and experiencing, and

• allow the patient to correct, refine or elaborate upon my attempts to understand.  

This process may continue for a bit, as the patient elaborates about the meaning of their situation or feeling. More often than not, the patient eventually responds by saying, "Yes, that's it, exactly".  Afterwards, some will indicate that they felt better being heard and responded to.

In previous posts on EmpathyWorks, I have shared the evidence for clinicians' use of empathy and a wide variety of positive outcomes, including enhanced patient satisfaction, increased patient follow through, positive health behavior change and even improved illness outcomes. For just 1 example, see: Hojat, M., D. Z. Louis, et al. (2011). "Physicians' empathy and clinical outcomes for diabetic patients." Acad Med 86(3): 359-64.

Whether or not you agree with Bloom's arguments, the post is worth reading, as are the many insightful and often brilliant responses written by a broad spectrum of commentators, including: Marco Iacoboni,  neuroscientist; Peter Singer, ethicist; Barbara Fried, law professor and public policy expert; Maryanne LaFrance, psychologist and women's studies expert; Nomy Arpaly, philosophy professor; Christine Montross, physician/poet; and Leslie Jamison and Simon Baron-Cohen, writers/commentators with  strong interests in empathy.

Graphic on Mind the Gap Emphasizes Impact of Clinician-Patient Communication

A new posting on the blog, Mind the Gap, by Stephen Wilkins, graphically shows the value of good clinician-patient communication. See: Mind the Gap Graphic.

I really like the quote he included from George Bernard Shaw, "The problem with communication is the illusion that it has occurred".

Shaw's quote reflects a key finding from research on clinician-patient communication: clinicians who have lover levels of skill are least likely to be aware of their skill deficit. For example, a review on the effectiveness of self-assessment of learner needs by I. Colthart and colleages (Medical Teacher, 30(2):124-45, 2008) found evidence that that the least competent are also the least able to self-assess accurately. This is why we can't count on clinician self-report and need to assess the competency of clinicians using methods that provide direct evidence of clinician communication skills, such as audio or videos of actual encounters,  evaluations of simulated encounters, assessment of patient experience. (See: Levinson et al.,  Health Aff (Millwood) 29(7): 1310-8.)

The good news is that the accuracy of self-assessment can be enhanced by feedback, particularly video and verbal feedback.

Several Recent Articles Stress the Value of Empathy in Medical Care.

The importance of empathy in medical care is the focus of several articles recently published in the medical literature. See below for a brief comment on each and a link or reference to the article.

In an article that appeared in the March, 2012 issue of Perspectives on Psychological Science, Hacque and Waytz include empathy reduction in clinicians as one of the "causes of dehumanization" in medicine. They suggest that clinicians have difficulty being empathic when actively engaged in demanding cognitive processes, such as diagnostic reasoning and problem solving. Empathy reduction can be countered, however, by strategies which promote clinician awareness of the human and emotional aspects of patient care, such as learning about the whole patient (e.g., interests, roles, values, preferences) and recognizing the dehumanizing aspects of medical settings, technology and the procedural elements of care. The article citation is: Hacque, OS, Waytz A. Dehumanization in Medicine: Causes, Solutions, and Functions. Perspectives on Psychological Science March 2012 vol. 7 no. 2 176-186. doi: 10.1177/1745691611429706                                 

In the May, 2012 issue of the Journal of General Internal Medicine, Helen Reiss and colleagues reported that training in empathy improves physician use of empathic skills. Reiss reports that providing three 60-minute empathy training modules to residents and fellows (physicians undergoing specialty training post medical school) produced significantly greater changes in a patient-rated measure of empathy than residents undergoing standard training. Trained physicians also showed greater changes in their ability to decode facial expressions of emotion. An abstract of the article can be found at: http://www.ncbi.nlm.nih.gov/pubmed/22549298

And, the most inspiring article of the recent articles was written by Bernie Lown, MD's on his personal blog. See: http://bernardlown.wordpress.com/2012/04/29/social-responsibility-of-physicians/ . Bernie is a renowned cardiologist, educator and researcher who has been a proponent of patient-centered care for 60 + years! Dr. Lown is a leading voice in medical ethics and social responsibility and was a recipient of the Nobel Peace Prize for his leadership of the Physicians for Social Responsibility during this organization's campaign to educate the public about the medical consequences of a nuclear catastrophe. He has also been an outspoken critic of overtreatment and
unnecessary use of medical technology, especially in advancing cardiovascular health,  and has emphasized the value of addressing health behaviors and promoting patient engagement and empowerment in his publications. The current article is a transcript of his address to the April, 2012 Avoiding Avoidable Care Conference held in Cambridge, MA. (See http://avoidablecare.org/ for more on the conference). Here is my favorite section:

Sixty years of doctoring has taught me that taking a history, namely listening, is the quintessential part of doctoring. Proper listening is a skill, an art and a core element of medical professionalism. History taking is far more than providing key elements for a diagnosis. It is the basis for nurturing trust. I am persuaded that nothing of science taught to medical students is as difficult to master as is the fine art of listening.

Empathy and Reflective Statements in Primary Care Discussions About Weight

A recent study of discussions of weight concerns in primary care, published in the Journal of the American Board of Family Medicine (http://www.ncbi.nlm.nih.gov/pubmed/22086809), found that physician empathy (assessed by trained raters who coded audiotapes of primary care visits) was linked to improved patient satisfaction, while physician use of reflective statements was associated with patients'  perception that the physician suppported their autonomy. The study included 40 physicians and 320 of their overweight or obese patients. Of note, physician empathy was only rarely expressed in these encounters; only 18 of the 320 encounters were rated as demonstrating a physician empathy score of greater than 1 on a scale of 1-5! Of those encounters with empathy scores greater than 1, 27% of the patients rated their satisfaction as excellent, compared to 11% of the visits with empathy scores equal to 1. Reflections were rated as present in only 38% of the encounters. When reflections were present, 47% of patients reported high levels of autonomy support, a measure dervied from Self-Determination Theory (SDT). Previous studies suggest that increased autonomy support is associated with increased intrinsic motivation as well as improved patient follow-through. The authors conclude that strategies that increase physician empathy and number of reflective statements could improve patients’ adherence to recommendations. Limitations of this study include the small sample of physicians, high patient refusal rate and a rather well-educated patient population.

 

My First Post

With much trepidation, I write this first post to my own blog. I have to admit that, though I have been hesitant to create a blog, I have secretly wanted to have a public space to share my views.

For a long time, I have been been a passionate advocate for patient and family-centered health care and have spent the last 25 years trying to learn, and teach, skills that foster strong clinician-patient relationships. I have been very fortunate to have had many wonderful teachers, mentors, colleagues and patients who have helped me along the way. Though I believe I have become a pretty decent communicator, and some might say a very good teacher, I am humble enough to realize that I still have a lot to learn

In my efforts to enhance my own skills as a clinician and educator, I have hungrily sought out training, scoured the clinician-patient communication research literature, conducted some research myself and experimented with a variety of teaching techniques and formats. Relatively early on in my personal journey as a clinician-educator, I realized that the most basic skills were also the most important. If we can't communicate well, can't connect with patients on a personal level, can't understand the patient's concerns, how can we hope to help them heal, cope and recover?

The most basic skills are linked to what my colleagues and friends Steven Cole and Julian Bird have call the 3 functions, or tasks, of the clinician-patient encounter (which I have adapted a bit):

1. Eliciting the patient's story/problems/concerns/needs
2. Building a strong clinician-patient relationship
3. Developing a shared understanding of the problem/condition and collaborating on a plan for treatment and self-management

Each of these tasks can be accomplished though the use of specific skills....a long list of skills i might add, though some are more basic than others.

Empathy, in my humble opinion, is THE most important and powerful skill that clinicians can employ to enhance communication and forge strong healing relationships with patients and families. Empathy helps us to truly understand the experience of patients so we can ultimately help them. Through empathy, we strive to "stand in another's shoes" and see the world through their eyes. To be truly empathic this requires us to maintain an open heart and an open mind. This is not easy....and requires clinicians to be willing to spend the time it takes to understand, remain relentlessly curious and suspend all judgement. However, the payoff is immense....shared understanding, stronger relationships, and even better diagnosis and treatment outcomes.

So, I continue striving...and learning...and sharing...now here as well.

Michael