Three studies in this issue report on changes in empathy scores as measured on the Jefferson Scale of Physician Empathy in the United States,1 Italy,2 and Japan.3 As the authors remark with some fervor, the data compel a need for changes in how the subject of empathy is addressed in medical education, at least in America. Here, I offer some further reflections on empathy.
Is Empathy Felt or Thought?
Empathy is an emotion important to medical care. In saying that, I have long differed from the belief expressed in these papers and elsewhere by Hojat that empathy comprises a cognitive skill.4,5 For me, empathy arises out of our own feelings and reactions; it happens when “you and I” becomes “I am you” or “I could be you.” For clinicians, empathy is the spontaneous feeling of identity with someone who suffers—fellowship, if you will. It is a comfortable emotion generated by interactions with our patients. We are familiar with it, but we struggle to define it. For example, as the authors of these papers recognize, the borders between empathy and sympathy are fuzzy. In contrast to empathy, I believe sympathy requires compassion but not passion.
Why Has Empathy Been Lost?
Hojat and colleagues1 report a significant decline in empathy during the third year of medical school. I am sure that the enhancement or retention of empathy will have to come from more than one direction: (1) the selection of medical students and others who will care for the sick, (2) the training caretakers receive, and, more fundamentally even, (3) reconsideration of what we doctors do in a world so much changed and so diverse. In one extreme example of skewed priorities, I shuddered once when an aspirant to medical school, boasting of his research skills, explained that he had put a cat into a microwave oven to see what would happen.
Patients, Images, or Numbers?
Trained as a physician at Harvard in the mid-20th century, I have worked at Yale as a teacher of gastroenterology into the 21st century. During those years, I have seen how diagnosis has turned from the ear to the eye: Doctors, who used to listen to their patients, now look for disease on a screen or in a number. “Laptop docs,” patients name them. Patients in person long ago disappeared from our conferences, but even worse for physician education, “case” presentations now include a token history, physical findings, laboratory data, and the images. The patients remain unseen and unheard—no empathy for CAT scans!
My guiding slogan remains, however, The eye is for accuracy, but the ear is for truth. The eye discerns diseases on screens or films, but the ear hears complaints of patients. Even more than examining the body, listening to our patients taps our sense of empathy. When we take the time to listen, we begin to do so.
Images like CAT scans are useful indeed, but we physicians must decide which of our tools are most important. Eager for links to tradition in this 21st century, some physicians still praise the physical examination, but I find the chiaroscuro of ultrasound and other imaging more helpful than my fingers in detailing the abdomen, let alone the heart! In the high-tech environments in which we practice today, however, I emphasize that taking the time to listen to the patients lets me decode what is germane in their images, putting their wounded organs in context.
Yet, when I explore the patients’ emotions before looking into their dyspepsia, I am chided by some endoscoping colleagues for being too much the psychiatrist and not enough the gastroenterologist. I tell them that when I try to evaluate people with chronic complaints, understanding the person and his or her character proves more helpful than looking at his or her guts. So much abdominal pain can come from life as well as from the liver.
The triumphs of technology and the exploration of the genome figure in the changed habits of practitioners, but there is a limit to the usefulness of such “evidence.” We yet know so little of what will someday be clear; even certainty about the predictive value of the genome melts away with evidence of how the epigenome and iRNA command the goals of DNA, and how they too may be molded by diet and by distress. Empathy, though, has always been and will always be among a physician’s most essential tools of practice.
Empathy is a natural human emotion. Medical practitioners in recent years have risked losing their humanity in the crusade for “evidence-based” certainty, and that has led to a loss of empathy. Practitioners learn to treat and to trust numbers, yet recently one reads how controlling blood sugar levels too tightly, both in the clinic and in the intensive care unit, harms more patients than it helps. Even so, such studies conclude that it’s better for patients and physicians to reckon with the numbers anyway.6 Numbers, after all, are “concrete evidence.”
How much science do physicians need to have at hand? Old estimates, never quite discarded, suggest that many who visit a doctor come with problems of psychic, social, or economic origin. Physicians should be caring for patients, but the medical schools where I have worked seem to prefer training scientists to training caretakers. Telemedicine that lets doctors treat patients at a distance may foretell a future of distant doctors for faraway patients.
Empathy is the foundation of patient care, and it should frame the skills of our profession. It may be that empathy can be taught by example, but the minds of students, like soil, must be prepared before they can nourish seeds of knowledge, and in some soils little grows. Hojat and colleagues1 declare that the empathy of medical students in Philadelphia shrinks during clinical training. Yet, in Japan, empathy grows during medical school education.2 In both studies, women show more empathy than men. And yet, I have not yet found the increased empathy one hoped for from the influx of women into a largely male calling.
What Happens to Medical Students?
I am not sure whether medical students lose their empathy or whether selection for medical school favors the more scientific over the more social—young people with fewer personal relations but more scientific know-how over the more social humanists who enjoy personal relationships. Empathy goes unnoted in the most scientific pursuits.
Some medical students start out with a cargo of empathy and genuine love, a hope to help others, but curricular emphasis on molecular biology to the exclusion of the humanities focuses students’ attention on diseases, not on the patients who have them. The advances in science and technology are so beguiling to us all, and what we learn from the humanities seems so old-hat, that we cannot blame the young of our profession for fixing on the astounding advances that have been so helpful. That I have lived to 85 is partly thanks to luck, but it is partly also thanks to scientific medicine and its technology, which I do not wish to demean here.
Medical students, selected because of their victories in the college fray, learn that hard work brings rewards. In the selection process, energy seems more important than contemplation. Students lose their empathy for the humble, who have not made it to the top, and even for the sick. Those last two years of medical school further strain students’ ability to empathize, for reasons well covered by the articles in this issue. Moreover, medical schools have moved from teaching professionalism by example to scheduling lectures and seminars on the topic. The experienced practitioners who showed me how to care for patients have been replaced by academics going “on the wards” for a month or two to exhibit what they know about science.
I emphasize history taking mainly because it builds up a narrative that helps to explain what is going on, but also because it strengthens the human connections that lead to empathy. The narrative that ensues from history taking can teach students about empathy, but any doctor taking the history with free-floating attention can feel empathy instinctively and intuitively.
Empathy can be curative, or at least helpful, for patients with the “existential pain” that comes from the troubles of living. Their complaints will be relieved by catharsis. But, for that, physicians must be ready to hear the words that will bring relief, and they must have the time to listen. Listening can create empathy—if physicians remain open to be moved by the stories they hear.
Empathy withers in silence. What Martin Buber7 called “The I and Thou” represents an encounter, a struggle of words that brings empathy. That is why so few clinicians are deaf from birth, even though there are many doctors who have been blind since birth. Those of us who grow deaf with age learn how difficult it is, after a lifetime of listening, to have others strain to give us understanding. It is just too hard to achieve true understanding—true empathy—when you cannot hear.
One of the problems in teaching empathy comes from what Osler labeled “equanimity,” which in medical school is praised as detachment. In extreme examples, doctors try to suppress emotion, even when they themselves fall sick. They learn to talk about the case and not about the person. These matters are commented on by Hojat and colleagues.1
Can empathy be taught? It can be strengthened by reading the iconic stories that we all know. It can be analyzed, and questionnaires can detect its intellectual aspects, but college students who will become medical practitioners should be selected as much by their character as by their knowledge. After all, evidence-based medicine lays out what the practitioner should know or do, while UpToDate tells them how to go about it. Scrupulous scientific education may no longer be as essential for medical care as in the past.
It really doesn’t matter whether empathy is a thought or an emotion. Retaining or enhancing it in medical caregivers is worth doing. In this protocol-based era, selecting medical students as much for their character as their knowledge may be one way to promote empathy; ensuring that faculty and preceptors are reliable role models of empathic behavior is another. But regardless of how it is done, we clinicians must be dedicated to cultivating empathy within our profession and making sure it thrives.