First, I want you to read the descriptions of these four patients and imagine, really imagine, them in front of you as if this is their triage and you're just about to see them:
A teenager with leukaemia on chemotherapy who's presenting with a fever, shortness of breath and a productive cough
An elderly lady who has tripped on the pavement whilst collecting for charity and is presenting with right hip pain and shortening and external rotation of her right leg
An intravenous drug user who presents with left groin pain and swelling with fever two days after injecting there
A middle aged man in police custody after being arrested at a far right rally for smashing a window brought to you with a laceration to his right arm who's being racially abusive
You're probably already making working diagnoses based on these statements: possible neutropenic sepsis, right neck of femur fracture, groin abscess, laceration needing sutures. But how do you feel reading them? Sure, you're going to do your best and you'll be professional but how would you be inside as you see these hypothetical patients? Would you feel compassion? Sympathy? How about empathy?
Empathy has been an important factor in the reflections all healthcare professionals underwent following the Mid Staffs scandal:
“food and drinks were left out of reach of patients…the standards of hygiene were at times awful with families forced to remove used bandages and dressings from public areas…people…suffered horrific experiences that will haunt them and their loved ones for the rest of their lives” (Campbell, 2018).
The Francis Report identified empathy as one of the main professional attributes that enable compassionate care (Webarchive.nationalarchives.gov.uk, 2018). The Department of Health and NHS Commissioning Board 2012 recommended that, “care is given through relationships based on empathy, respect and dignity” (Webarchive.nationalarchives.gov.uk, 2018). This leads us to the obvious question:
WHAT IS EMPATHY?
I think it's fair to say that empathy's meaning can get lost in translation. A straw poll of colleagues on a certain shift led to a number of different suggestions, "it's when you feel sorry for someone", "it's when you show you care", "it's when you can put yourself in their shoes".
Empathy is defined by Merriam-webster.com (2018) as:
the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner; also the capacity for this
the imaginative projection of a subjective state into an object so that the object appears to be infused with it
I like this line from Harper Lee's 'To Kill a Mockingbird' -
"You never really understand another person until you consider things from his point of view - until you climb inside of his skin and walk around in it."
First things first: empathy is not about feeling sorry - that's sympathy. But let's look at the above definition from Merriam-Webster. "Understanding, being aware of, being sensitive to" - all sound very appropriate for the caring professional. But "vicariously experiencing the feelings, thought and experience of another...the capacity for the imaginative projection" - is this necessary? Is it healthy for healthcare professionals exposed to challenging environments every day to be put through such an emotional wringer?
THE BIOLOGY OF EMPATHY
We certainly know that empathy has a biological framework. Empathy has a proven genetic basis (Knafo, 2008) acting as an evolutionary advantage by promoting altruism and other prosocial behaviours (de Waal, 2008). Displaying empathy is linked to known neuronal pathways such as those involved in facial mimicry (Sonnby-Borgstrom et al, 2003) and imitation (Field et al, 1982 and Fornan et al, 2004) as well as the mirror neuron (Iacoboni, 2008) and limbic systems (Carr el al, 2003, Iacoboni and Dapretto, 2006 and Preston and de Waal, 2002). In contrast deficits in empathy are particularly evident after focal prefrontal cortex damage with poor empathic development seen in children with early damage to their frontal lobes (Eslinger, 1998). Further evidence of the innateness of empathy has been reproduced in several studies showing how children as young as 18-hours-old are distressed at other’s crying (Martin and Clark, 1982, Sagi and Hoffmann, 1976 and Simner, 1971).
Behavioural psychologists have hypothesised that everyone falls somewhere on a spectrum of emphasising and tendency towards system creation (empathy-systemising theory) (Baron-Cohen, 2009).
EMPATHY AS BEHAVIOUR - THE CHECKLIST APPROACH
If we accept empathy as behaviour we can focus on the prosocial behaviours in a simulated environment with our students. Kahn’s Etiquette Based Medicine (EBM) (Kahn, 2008) is an interesting development in this area. He looked at clinical checklists such as Pronovost’s checklist for inserting central lines (Thelancet.com, 2018) and used the same principle for empathetic behaviour in a potentially simulated environment giving the following example:
1. Ask permission to enter the room; wait for an answer.
2. Introduce yourself, showing ID badge.
3. Shake hands (wear glove if needed).
4. Sit down. Smile if appropriate.
5. Briefly explain your role on the team.
6. Ask the patient how he or she is feeling about being in the hospital.
Let’s imagine designing a simulation where this could be assessed. Our students could cycle through simulated patients with a variety of different diagnosis: a patient in pain, a patient with substance abuse, a patient with mental health issues. The simulation could also look at the standard A-E and diagnostic approach but also include this empathic assessment just as prominently. The simulated patient would be very useful in feedback:
“When I mentioned that my husband had died it was nice that you held my hand.”
“You didn’t always look me in the eye which made me feel like you were talking over me sometimes.”
Those observing the simulation can also give similar feedback based on their third person observations in a purely objective format: we saw or heard this therefore it appeared as this. It would be useful to include fellow students as part of this audience to help learn from each other. Further studies have expanded on Kahn's initial checklist to include suggestions for a second meeting with a patient (Castelnuovo, 2013).
Kahn accepts the pedagogical limitations here; this is behaviour not feeling. But he argues that this is a useful first step for students to start to develop empathy. This reminds me of the ‘Hello my name is...’ campaign, an incredibly successful movement based on a very simple premise. As Kahn himself argues, it is easier to change behaviour than attitude.
We already use simulation and observed exercises as the basis of teaching and assessing communication skills. A student could in theory pass without issue on a station marked communication skills when they know that is being assessed before forgetting communication skills when it comes to further stations. The current move towards more holistic and OSCE assessment partially recognises this possibility; a station is no longer marked for one particular topic but instead assesses focused examination, investigation interpretation and communication skills. We have to make sure that empathy is consider in all observed real and simulated patient encounters both assessed and not.
EMPATHY - REFLECTING AND REPORTING
Experiential attempts to foster empathy in students have focused on immersion and realism such as ageing simulation (Through Their Eyes Project, 2018) and reflection and simulation (Counseling.org, 2018). These are time and resource heavy. The Jefferson Scale of Physician Empathy offers a psychometric assessment of students and practitioners and has a growing evidence base (Tavakol, Dennick and Tavakol, 2011). The JSPE is based on self-reporting via a questionnaire. This suggests that a reflective model can be encouraged either via simulation and immersion or through qualitative questioning of subjects. This obviously relies on resources and honesty.
So can empathy be taught? The truth is this depends on how you view empathy, as a skill or a behaviour. Even then, some of the greats of education have been unable to agree and have changed their minds.
In 1951 humanist Carl Rogers wrote that empathy was a skill that can be taught (Rogers, 1951) but by 1975 changed his opinion and argued that it wasn’t a skill but behaviour that had to be willingly displayed (Rogers, 1975). This definition sounds closer to behaviourism but still includes the element of free will. Fellow humanist Martin Buber disagreed arguing that feeling empathy was a passive event that had to be allowed to happen (Buber, 1955).
However, some have argued that empathy cannot be taught. The philosopher Edith Stein repeated Buber’s idea of empathy only being noticed ‘post-event’. However she disagreed with Rogers arguing that what they called empathy was in fact ‘self-transposal’ – a person actively listening to another – and that empathy was only achieved after crossing-over to the other’s viewpoint before returning back. She believed that empathy was a ‘happening’ not behaviour and as such was impossible to teach (Stein, 1970). Davis agreed with Stein believing that self-transposal could be taught as it is cognitive process but as a behaviour empathy cannot be taught as a skill (Davis, 1990). She did however argue that through experiential learning, humanism and reflection empathy could be facilitated (Davis, 1989).
So we have a dictionary definition of empathy and we know there are checklists and questionnaires we can use as well as immersive simulation to help foster, if not teach, empathy in our students even if we can’t agree if that is a skill or a behaviour we are fostering. This brings me to my next question: Is empathy even that useful? Could it even be harmful?
Although some authors have concluded that empathy makes for better clinicians (Quince et al, 2016) the evidence and models used to make these conclusions is sketchy at the best. One study Quince (2016) referred to concluded that clinicians can improve their ability to recognise emphatic moments in clinic not that it made them better at their job (Levinson, 2000). I can think of medical students so caught up in feeling for patients they'd seen in a trauma call they reported not concentrating well afterwards to the detriment of their studies. Previous studies have shown how empathy actually declines with experience until a "minimum level of empathy" is found which is all that's needed "to benefit from the positive aspects of professional quality of life in medicine" (Gleichgerrcht and Decety, 2014).
EMPATHY AND DECISION MAKING
Paul Bloom wrote a very interesting article in the New Yorker called The Baby in the Well (Bloom et al., 2018) explaining how individuals actually make bad assessments of situations based on empathy. He cites several studies where empathy skews our emotional response and decision making disproportionately. In one such study participants were given the choice between donating to save the life of one named individual with a photograph and back story or a group of 8 nameless individuals. Participants consistently gave more money to save that one individual whose name they knew and who they could empathise to even though money to the other group would have saved more lives (Kogut and Ritov, 2005).
This means we could be liable to make bad decisions for the patients we feel more empathetic toward. Never mind the potential risks of counter-transference that inexperienced practitioner or student may not be aware of when they first encounter patients. So if empathy might be risky what else should we encourage?
EMPATHY OR COMPASSION?
According to Singer and Klimecki (2014) whenever we meet a person in distress we are inspired to feel either compassion or empathic distress. The two pathways have two distinct basis in neurobiology. First, the empathy training activated motion in the insula (linked to emotion and self-awareness) and motion in the anterior cingulate cortex (linked to emotion and consciousness), as well as pain registering). The compassion group, however, stimulated activity in the medial orbitofrontal cortex (connected to learning and reward in decision making) as well as activity in the ventral striatum (also connected to the reward system). The two types of training led to very different emotions and attitudes toward action. The empathy-trained group actually found empathy uncomfortable and troublesome. The compassion group, on the other hand, created positivity in the minds of the group members. The compassion group ended up feeling kinder and more eager to help others than those in the empathy group.
This suggests there is an importance to encourage healthcare workers towards the positive outcomes and to encourage compassion rather than empathy. The Loving Kindness Meditation model of mindfulness has been shown to foster positive emotions (Fredrickson et al., 2008).
In debating whether empathy testing could be introduced to medical school applications Schwartzstein (2015) suggested the following four stage model for supporting compassion development at medical school:
APPROACHES TO SUSTAINING COMPASSION AND COMMUNICATION SKILLS IN MEDICAL SCHOOL
Implement curricular changes that support students' idealism, kindness, and focus on patients, such as providing earlier clinical experiences or requiring participation in student-directed clinics.
Select clinical faculty for their ability to support the desired values.
Refine measures and instruments for assessing interpersonal skills, support faculty in completing these assessments, and prohibit students deficient in the necessary skills from advancing in their training.
Advocate for financial and logistic systems that enable doctors to spend more time with patients.
I find this model fascinating as it suggests a complete overhaul of a medical education facility based purely on compassion and communication. Would it work? It’s too early to tell and it will be interesting to see if it gets any mileage.
Back to our hypothetical patients. Would attempting to place ourselves in the shoes of a fascist be helpful? Obviously we have to be professional and ignore fundamental-attribution bias but what about empathy? Empathy has been shown to motivate an individual to help another person based purely on altruism - the 'empathy-altruism hypothesis' - rather than any gain to the individual (Batson et al, 1991). If a healthcare professional is doing their best for their patient does it matter if it is empathy or professional duty motivating their actions? Is it better to teach our students the behaviours and values of treating our patients with compassion and respect rather than obsessing about empathy? Use feedback from patients both real and simulated to reflect on clinical behaviour and encourage the actions which make others feel respected and listened to regardless of motivation. Make students aware they are entering an emotionally challenging profession and that they should expect complex feelings. Encourage them to reflect and support them if they don't feel empathy, support them if they do and support them if they feel too much.
This is obviously a massive topic and it’s impossible to cover everything. Let me know what you think, I’d love to continue this debate.
- Jamie (@mcdreeamie)
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