Loss of an empathic connection between doctors and their patients

It has been reported that up to 60% of doctors suffer from symptoms of psychological job-exhaustion, or physician burnout, leading to diminished career satisfaction, substance abuse, divorce, quitting the profession, and suicide.

An article in a recent Journal of the American Medical Association by Helen Riess, a Harvard psychiatrist, attributes much of this psychosocial carnage to the loss of an empathic connection between doctors and their patients.

The author summarizes a number of studies positing that empathy resides in specific areas and structures of the brain, such as the anterior cingulate cortex and amygdala. In one report, 17 experimental subjects viewed images of patients experiencing intense pain; simultaneous magnetic resonance imaging (MRI) of the study subjects’ brains revealed heightened neuronal activity in the purported empathy centers.

It also appears that the amount of empathy one is capable of mustering from these locations—which can be measured by psychotherapy tools like the Empathic Understanding Scale—is not static, and can be modulated up or down by external circumstances. The article describes the phenomenon of “empathy erosion” documented in third-year medical students—caused, perhaps, by a reflexive, self-protecting down-regulation of empathic neural circuits in order to keep the students from being overwhelmed by their exposure to so much pain and suffering.

But too much of this self-protective down-regulation by physicians can give rise to a permanent empathy deficit. They become hardened to human misery, and rupture the vital empathic connection between doctor and patient that is the cornerstone of all medical care. Patients who bond emotionally with their physicians have better outcomes, and physicians who are emotionally engaged with their patients are happier and more satisfied with their jobs—and less likely to suffer from the destructive malady of physician burnout. Dr. Riess advocates education and the use of certain acquired behavioral skills to help prevent the erosion of physician empathy.

So what does the crippling syndrome of physician burnout have to do with Quasimodo? Regular readers of this blog know the answer lies at the nexus of literature and medical science, in the realm of the discipline known as narrative medicine.

Victor Hugo’s hunch-backed bell-ringer of Notre Dame Cathedral is one of the most sympathetic characters in all of Western literature. Only someone possessing the heart of one of the gargoyles crouched atop the roof of the Cathedral could remain unmoved by this deformed, grotesque foundling who, at the same time, is the very soul of innocence and purity. We pity him for his deafness—caused by the loudness of the bells that are his greatest love—even as we share the bewitching Esmeralda’s disgust at his desire for her.

The act of identifying deeply with a complex literary character such as Quasimodo cannot help but result in the beneficial stimulation of the brain’s empathy centers that Dr. Riess advocates. Her failure to mention the reading of literary fiction as a time-tested means of increasing empathy is my one criticism of her article.

It is an effortless, natural way of healing hearts and souls one book at a time.

Richard Barager is a nephrologist who blogs at The Literary Doctor.

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  • http://www.google.com Guest

    “attributes much of this psychosocial carnage to the loss of an empathic connection between doctors and their patients.”

    Bottom line, doctors are becoming over worked, underpaid and held to God like standards from their patients, all while they have a huge financial bullseye on their back………Medicine has evolved to adopt defensive medicine practices because of our litigious society.

    Unfortunately I’ve heard doctors say, “Thy patient, thy enemy.”

    Something has to change.

    • Justin

      absolutely.

    • Matt

      Empathy in many ways is time. Perhaps if physicians were paid for their time and relative skills, empathy wouldn’t be so difficult for them.

      As far as doctors being “underpaid”, they control that. As it stands, US doctors are the highest paid profession in the world by a good bit.

      And their patients clearly don’t hold them to “God-like” standards, nor does society, when one looks at all objective evidence. Perception is not reality.

      • pj

        Matt… sigh… Where is your proof that we are the world’s highest paid profession? Many opinions of that sort fail to account for national differences in hours worked, gov’t funded pension plans, etc. It isn’t difficult to find other nations that treat their Docs better than we do- Canada for one. Better hourly pay, less malpractice risk. Germany, I believe, guarantees their Docs get retirement pension funding that we don’t get here.

    • r watkins

      Patient A needs B but insurance company C refuses to authorize. Both A and C attack doctor, blaming him for problems. Doctor instinctively reacts to both patient and insurance company as enemies. Happens to all of us. It’s not right, but understandable.

  • http://www.theschwartzcenterblog.com Jamie Rauscher

    I couldn’t agree more about the importance of empathy. A recent poll of 500 doctors and 800 patients found both groups believe that compassionate healthcare makes a difference in how well patients recover from illness and even whether a patient survives: http://www.theschwartzcenterblog.com/2010/11/patients-doctors-strongly-support.html

    Jamie Rauscher

    • http://myheartsisters.org/2010/06/19/women-heart-attack-worse-than-men/ Carolyn Thomas

      Hi Jamie – not only how a patient recovers from illness, but also in whether that patient will one day decide to SUE for malpractice!

      For example, landmark research from the University of Toronto’s Dr. Wendy Levinson (considered among the world’s foremost researchers on physician-patient communication) looked at how two groups of physicians communicated with their patients: one group had never been sued, the other group had all been sued at least twice. Her research found no difference in the two groups in the amount or quality of information doctors gave their patients; the never-sued doctors didn’t provide more details about medication or the patient’s condition.

      The difference was entirely in HOW the doctors talked to their patients!

      More at: “Why Doctors Get Sued” on THE ETHICAL NAG: MARKETING ETHICS FOR THE EASILY SWAYED – http://ethicalnag.org/2010/10/15/why-doctors-get-sued/

  • http://www.humanism-in-medicine.org Arnold P. Gold Foundation

    The Gold Foundation is proud to have provided funding to support this important research. We are often asked whether empathy can be taught and now there is another significant study that answers with a resounding “Yes!” Visit us on the web to learn about the many ways we support medical students, residents and physicians in practice to provide the most clinically excellent AND compassionate care. New this week: patients can Find a Caring DOC – one who has been recognized by colleagues for outstanding care.

  • http://www.themusicwithinus.com Lisa Chu

    Isn’t it interesting that the purely rational, scientific-based models are breaking down when it comes to matters of human interaction and understanding?

    Perhaps rationalism is not the route to grasping the heart of the problem with burnout, empathy, overwhelm, and the myriad crises of *spirit* that doctors are increasingly complaining about.

    Perhaps the answer to the dilemma is not yet another “scientific study” which tries to find a brain-based model or explanation for what are obviously more subtle interactions among the mind, body, heart, and (gasp!) spirit of each individual connecting with another (gasp!) vulnerable human being.

    Whether doctor or patient (no matter what our training or profession or cultural upbringing), we share one diagnosis: being human. Let’s acknowledge the vulnerability of doctors and start creating spaces for them to BE human, not just STUDY them.

  • http://www.drwadegrindle.com/mutual-caring-in-the-provider-patient-relationship/ Wade Grindle MD

    Patch Adams gave an impassioned, heartfelt keynote address on this same topic at a medical conference I attended. His point was that a major cause of provider burnout is when the physician is unreceptive to the gratitude/compassion flowing back from the patient.

  • http://noone jay h

    so…we should attempt to organize, more non for profit consortiums to manage patients, take this burden of up coding and financial incentives away from physicians, but still reward them well financially, i then suspect even the national health care burden diminishes…

  • http://twitter.com/freddynande Freddy

    Hello!
    First of all, I’m a medical student from Chile, and in your blog I found a very interesting page, I have revised many posts of many categories and each one is amazing, in your blog I can see the differences between the medical practice here and in other country.

    In relation to this post I agree with the importance of empaty, I’m beginning to go to the hospital and to see patients, how they have more trust with an empathic doctor and I can confirm, with sadness, how even the students in superior courses loose, little by little, the empathy with those that are their reasons of studying medicine, the patients.

    I hope it doesn’t happen to me.