“Are there specific ways empathy will be tested in the standardized patient exam?” a medical school classmate of mine earnestly asked following a lecture years ago. I laughed, thinking that teaching empathy was impossible. As an optimistic and naive medical student, I had thought of myself as naturally empathetic. During those days, I was able to spend hours with patients, gaining their confidence while hearing their stories and concerns. I felt that by doing so, I was integral to their healing process. Sadly, this attitude faded over time as my training progressed. I started to see patients as diseases and discharges. I was frustrated with patients who refused to listen to our recommendations. Such an “erosion of empathy” has been described to occur as medical training progresses. The minutia of medicine can be like a dense, heavily wooded forest, and after years of training, I was lost in the overgrowth.
During life, there are times of reckoning, when something earth-shattering makes you question everything. For me, life changed on an unusually mild February afternoon. I had just gotten home from a brisk walk from the hospital where I was doing my fellowship training. As I walked through the door, refreshed by being able to lose my thoughts for a few minutes, my phone rang, and the screen flashed “Dad.” I cheerily answered but was met with silence. After the longest of pauses, he stammered the words, “The worst possible thing has happened. Your brother has taken his own life.”
The days that followed were a blur. There was a quiet ceremony, tears, and then resolved silence. Months went by, and although I was at work, my mind was elsewhere. But as I slowly went through the healing process, something unexpected happened. I found myself becoming a better doctor, friend, husband, and colleague. I enjoyed challenging family discussions and hearing the stories of my patients again. In a support group that I joined for siblings lost to suicide, I often hear the phrase, “No one ever wanted to be part of this club, but we are in it together.” Experiencing loss or death, personal illness, or a monumental challenge of changes people forever, making them more resilient. I also believe it makes them more empathetic. Without ever wishing such an experience on anyone, I have wondered how medical trainees could get an insight into the club without having to join.
While buzzworthy phrases and initiatives attempting to focus clinicians on the importance of the patient experience are pervasive, the idea that empathy is a characteristic that physicians should possess is not new. In the modern Hippocratic oath, thousands of medical students each year state, “I will remember that there is an art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.” I said these words proudly along with my classmates, but is it really possible to incorporate them into a curriculum for trainees in a way that produces meaningful results?
Or is the idea of empathy in medicine overrated, or even dangerous? An article in Scientific American cited neurocognitive research has shown that empathy suppression may be an adaptive response, and “being too focused on the patient’s pain can make the doctor less effective.” The author argues, “It should not be the goal of physicians to be more empathetic. They should aim to find the right balance, the golden mean that optimizes care.” The earliest version of the Hippocratic Oath, dated to the 4th century B.C., makes no mention of an empathetic trait being a requirement to practice medicine.
While research on the subject is inherently difficult, data with more clinically oriented outcomes suggest that physician empathy has been tied to improved patient satisfaction, decreased physician anxiety and burnout, and better clinical outcomes such as lower A1C and LDL levels.
Empathy can be taught with good results. A meta-analysis of 18 studies showed educational interventions consistently led to increases in medical student empathy scores. A separate meta-analysis of 52 studies found that there was evidence that targeted training could enhance physician empathy and compassion. Five key behaviors were shown to be effective at improving empathy. These five were sitting (versus standing), detecting a patient’s non-verbal emotional cues, responding to opportunities to show compassion, non-verbal communication such as eye contact and statements of support and acknowledgment. Through lectures, observed patient interactions, and other methods of experiential learning, these behaviors are teachable.
Teaching and measuring these skills in a vacuum will never be enough. The process of reflecting and focusing on my own loss in group settings has helped me to be more supportive for my patients. While no one will have the same experience, perhaps encouraging trainees to reflect on their own personal and professional challenges through writing or group exercises will help them better understand the challenges their patients are facing. We must speak frankly with one another on an ongoing basis, beginning at the earliest stages of training. I am now a believer that through integrated and innovative methods, it is vital that we teach empathy in medicine.
When I was admitted to medical school, my brother, a scholar of the classics, gave me a hand-written etymology guide to assist me as I learned the new language of medicine. Buried among roots like opthalmos, cardia, and pneuma, was the meaning of a word not discussed during anatomy class, “Em Pathos” meaning, “in feeling.” My brother knew then what I know now, that we must strive to be more empathetic. While it takes time, patience, reflection, and formal teaching, being both empathetic and effective is possible.
Nikhil Sikand is an advanced heart failure and transplant cardiology fellow.
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