What’s happened to clinician empathy?

In 2006, the Mayo Clinic asked 192 patients an important question: What makes an ideal physician? From their responses, several characteristics emerged. Among the top criteria, they wanted doctors to be “personal,” “empathetic” and “humane.” This shouldn’t come as much of a surprise.

Of course, we want doctors who relate to their patients as people instead of just another “case.” We want doctors to have sympathy for patients — to form real relationships with them. Empathetic physicians enjoy better patient compliance and better patient health outcomes. But medical training seems to push doctors in the opposite way. Doctors are emotionally drained, and unable to connect with patients. When patient care suffers, this is a major issue.

When does the empathy drop off? Based on the results of a 2011 review of 18 studies, empathy appears to decline during the formative years of medical school and residency. Empathy was specifically seen to “[decline] significantly on entering the clinical practice phase of training and with increased contact with patients.” So clearly, we have a problem. The question is, can we fix it?

Let’s start with a bigger picture view. Declining empathy may actually be a pervasive trend among Americans in general, with a 2010 study of nearly 14,000 college students showing a dramatic drop-off in empathic concern between 1979 and 2009. Despite this type of data, it’s interesting to note that most research in how to regain empathy nevertheless focuses on medical trainees. This interesting detail means that research that looks at improving the emotional states of medical staff may well provide important insight for a problem plaguing the general population.

In one innovative trial, researchers at Stony Brook University created an elective for medical, nursing and dental students. A core component of their intervention was the use of improvisation in an effort “to teach students to communicate with empathy and clarity.” Improvisation in this context “emphasized empathetic listening, where individuals became attentive to the words that were spoken and the emotions they invoked.” The experiment appeared to have been a resounding success, with 100 percent of the participants polled recommending the class.

A rather interesting 2002 study hospitalized healthy second-year medical students for around 24-30 hours so they could experience health care from a patient’s perspective. While the students commented positively about the care they received from nurses, they “were particularly upset about the distance and coldness they felt from the medical staff.” This contrast was seen as something that might lead to positive changes in the students’ interactions with patients moving forward.

Another way to create empathy may be through exposure to non-medical fields. A 2018 study asked 739 medical students to describe their level of exposure to the humanities. A questionnaire asked the students to describe how much “passive” and “active” involvement they had in “engaging in visual arts, singing, playing musical instruments, listening to music, dancing, writing for pleasure, reading for pleasure, attending theater, going to museums/galleries and attending concerts.” The students also filled out questions used to determine their level of empathy. While the study is only associative, the students with more exposure to the humanities were significantly more likely to score higher on the test of empathy. It’s notable that both passive and active engagement with the humanities were significantly linked to a higher empathy score. This suggests, for example, that you may gain an empathy benefit from listening to music, even if you can’t play the instrument.

Many have attempted more straightforward methods of increasing empathy in medical trainees. Interpersonal and communication skill workshops are popular options that generally seem effective in cultivating empathy. Mindfulness-based stress relaxation techniques also appeared to improve empathy in health care providers in five out of seven trials in a systematic review.

The aforementioned studies, though still rather preliminary, should make us optimistic that empathy can be re-learned. Most of these trials stress the value of putting ourselves in another’s shoes or exposing ourselves to varied viewpoints. The success of mindfulness exercises speaks to the benefit of taking a step back to observe our actions towards others. However, even though these studies appear to indicate that interventions to increase empathy in medical trainees are feasible and effective, we must not forget to ask a deeper question.

The medical profession prides itself on a deep desire to help others. Empathy clearly embodies a core aspect of this mantra. Empathy also seems crucial to delivering the best patient care. Why are we losing empathy while doing the jobs that would seem to make this skill a necessity?

I’ve previously written about the need for an honest, systemic discussion of how psychological issues arise in medical trainees. To this point, we can’t overlook the statement made in the above-mentioned review of empathy decline in medical trainees, that “trainee distress is a key determinant of empathy decline, which can be considered a coping mechanism for dealing with various stress factors.” “Distress,” as stated in the review, represents burnout, a low quality of life and depression. Is it any wonder that when these factors combine, the result is low empathy and worse patient care? While empathy-developing interventions similar to those described above are a step in a positive direction, prevention of empathy loss (through a systemic evaluation of the medical training paradigm) must also be addressed.

In this vein, I’d like to propose we consider another intervention to improve empathy in medical providers. Though medicine currently favors a cutthroat “gunner” mentality throughout training, we should start to create space for the development of more inter-provider empathy. In a community where mutual compassion and understanding were promoted from the start, we could move away from a constant need to defend our own egos and instead focus on improving patient care. In this environment, we’d have opportunities to avoid the deep isolation and sense of personal failure that result from a need to appear impervious. As individuals, we’re far less resistant to the realities of medical training than we are as a unified front. We all struggle, but we’re largely conditioned to do it in secret. Empathy is about relating to others, but we can’t get there unless we’re willing to tell the truth.

Austin Perlmutter is an internal medicine physician.

Image credit: Shutterstock.com

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