Walking a Mile—Carefully: Empathy in Clinical Encounters
February 2019 Issue
The theme of walking in someone else's shoes is woven throughout Mary Lathrap's 1895 poem "Judge Softly." This metaphor has become a common way of referring viewing a situation through another person's perspective:
Pray, don't find fault with the man that limps,
Or stumbles along the road.
Unless you have worn the moccasins he wears,
Or stumbled beneath the same load.
This type of connection with others is almost universally considered one of the best ways to motivate good actions–the more we connect with others by feeling what they feel, the better our decisions and behavior will be. The terms used for this perspective-taking have changed over time, and in current usage empathy generally refers to a more meaningful connection than sympathy. However, even the most basic definitions can seem contradictory. One dictionary describes sympathy as "when you share the feelings of another; ‘empathy' is when you understand the feelings of another but do not necessarily share them."1 Another dictionary describes sympathy as "feeling compassion, sorrow, or pity for the hardships that another person encounters…" and empathy as "the capacity or ability to imagine oneself in the situation of another, experiencing the emotions, ideas, or opinions of that person."2 The difficulty distinguishing empathy from other types of emotional connection goes beyond inconsistent dictionary definitions. One psychologist describes eight different concepts that can be described as empathy (see "Eight Concepts..." below). According to Jamil Zaki, PhD, an assistant professor of psychology at Stanford University, "Most theorists agree that empathy describes multiple distinct but related processes through which people respond to others' emotions. These include an ‘affective' component, vicariously taking on others' feelings; a ‘cognitive' component, reasoning about others' emotions; and a ‘motivational' component, desiring for others' emotional states to improve."4
This article examines the complex concept of empathy and discusses its application in clinical encounters.
In a book aptly titled Against Empathy, Paul Bloom, PhD, a professor of psychology at Yale University, makes compelling arguments regarding the downside of empathy as a guiding principle for how we behave toward others.5 Bloom's objection is primarily to emotional (or affective) empathy, which involves actually feeling what another person is feeling, rather than cognitive empathy, or simply understanding what they are feeling. He identifies ways in which emotional empathy is not only insufficient as a guide to right behavior but can actually be harmful. One of Bloom's concerns is that empathy is innumerate—it favors action in specific cases over an understanding of those that are statistically better on a larger scale. Many important issues, like healthcare policy, affect the lives of a large population but rarely impact us as much emotionally as individual cases that may not accurately represent the broader problem. In one poignant example, Bloom describes how in some areas of the world giving money to a child begging on the street can strengthen a criminal network that forces children into these roles and counts on our empathic response. In this case, our emotional connection with the child causes us to behave in manner that may do more harm than good for more children.
Another of Bloom's concerns is that empathy is narrowly focused and acts like a spotlight, drawing our attention to those within our group or with whom we feel more connection. Since we couldn't possibly connect deeply with the suffering of the population of Syria or all of the homeless people in the United States, for example, we restrict this connection to those who are closest to us. This can influence us to behave in ways that are not based on more objective and unbiased standards for what is the right thing to do. While Bloom's research involves technical distinctions that at times seem more suited to the ivory tower than daily clinical practice, there are important ways in which these principles play out in clinical practice.
Mary Lathrap's poem points out how putting ourselves in the shoes of another can help overcome our biased judgements against them:
If just for one hour, you could find a way
To see through his eyes, instead of your own muse.
I believe you'd be surprised to see
That you've been blind and narrow-minded, even unkind.
Contrast this with Bloom's contention that unchecked empathy can actually reinforce biases. While it may be understandable that we feel more emotional connection with citizens of our own country and with family members than we do for the population of a war-torn country or thousands of homeless strangers, this represents a bias that can cause us to behave unfairly. For example, emotional empathy may cause us to treat patients who do not share our race or culture less favorably than those who do. It is clear that we need a more nuanced understanding of empathy to use it appropriately in our role as healthcare providers.
Carefully moderating our emotional connections with patients can help us avoid the common problems of compassion fatigue, burnout, and cynicism. In our high-touch profession, we frequently see individuals in difficult and painful situations. This exposure can be overwhelming, drain our emotional energy, and negatively impact the quality of our clinical decisions and our personal lives. According to Harvard Medical School psychiatrist Helen Riess, MD, "… empathic clinicians who are confronted with overwhelming degrees of pain and suffering may also experience significant personal distress. High emotional arousal may interfere with one's ability to help effectively."6 According to Jing Han, MD, a surgeon at The Ohio State University Wexner Medical Center, "The cost of being too empathic…is depleted executive functioning and emotional resources, manifesting as physician burnout and ironically, a subsequent steeper decline in cognitive empathy during training…. Students lose empathy during medical school when they enter the clinical practice phase of their training, a trend that continued through residency."7 Students, residents, and experienced clinicians who regulate their emotional connection with patients and use empathy appropriately will be much more effective clinicians over the long term.
Focusing on the Right Thing
There have been significant shifts over time regarding this issue within the medical subculture. In a 2003 article titled "What is Clinical Empathy," psychiatrist Jodi Halpern, MD, PhD, quotes the definition of empathy offered by the Society for General Internal Medicine: "…the act of correctly acknowledging the emotional state of another without experiencing that state oneself."8 According to Halpern, this definition "is consistent with the medical literature of the twentieth century, which defines a special professional empathy as purely cognitive, contrasting with sympathy."8 Halpern is critical of this historical emphasis on emotional detachment from the suffering of patients that favors a purely rationalistic application of clinical expertise. She describes two clinical scenarios that demonstrate the problems with emotional detachment. In one case, she consulted with an agitated male patient completely paralyzed by Guillain-Barre syndrome. She describes feeling uncomfortable with his incapacitation, and ashamed for imposing on him in his vulnerable condition. Noting that her gentle approach was causing the patient to withdraw from the conversation, she asked him directly and assertively what was bothering him about his care. The patient "began an angry tirade about how disrespected he felt," and this transparency formed the basis for "an effective therapeutic alliance."8 In the second case, a rape survivor described her feelings of increasing panic as her physician (who noted her anxiety) attempted to reassure her by discussing pain relief options during labor and delivery. Her fear, however, was not related to pain but to the loss of physical control she would experience. By describing medical options in a cheerful tone, the physician "signaled to her that he did not recognize how terrified she felt."8
Halpern contrasts these two cases by saying that in the first case "emotional attunement" guided "the time and tone" of the interaction, but in the second case it did not. She quotes a study that found that "nonverbal attunement led physicians to pause at moments of heightened anxiety, at which times patients disclosed more information. If physicians did not do this, patients did not share vulnerable information, despite the physicians asking the patients appropriate and accurate questions."8 Halpern clarifies that "the whole point of empathy is to focus attention on the patient. A listener who was busy having his or her own parallel emotions and introspecting about them would have the wrong focus."8 Instead, "emotional attunement operates by shaping what one imagines about another person's experience" and "often is a subtle nonverbal sense of where another person is emotionally."8
Helen Riess, MD, echoes this emphasis on nonverbal cues in an empathy teaching tool developed for healthcare providers (see graphic below). "Many patients…are reluctant to disagree verbally with their clinicians, and accurate detection of subtle nonverbal cues may be the critical entry point for discussions leading to shared medical decisions."6 In words that resonate with Bloom's concerns about emotional empathy, Riess states that "most of the pitfalls of empathy appear to be due to affective empathy looming too large in decision-making, while cognitive empathy is underused."6 Clinicians can use the input gained through appropriate clinical empathy for specific cognitive aims. "Most likely, there is no single question for which physicians need empathy to get an answer. Yet in the daily grind of medical practice, an empathic physician gains a source of information that is at least as efficient as having a checklist for each psychological need of patients."6 Emotional attunement is a skill that complements other clinical skills. "Logic alone cannot determine which matters are most important to pay attention to. Nonverbal attunement automatically directs attention to matters that have emotional significance to the patient. Of course, such intuitions in no way supplant thorough history taking and paying attention to other clinical cues. Rather, resonance offers shortcuts, the paths of which still need to be rechecked in a systematic way."6
Individuals who experience amputation, chronic health problems, or other conditions requiring O&P care are often anxious, confused, angry, and afraid. It is unlikely that our ability to share those feelings would positively impact the care we provide, and over time that type of connection may become detrimental. It is more likely that our patients want understanding, compassion, and kindness, rather than clinicians whose emotional state mirrors their own. As we accurately identify their emotional and psychological needs and give them time and space to express what they are feeling, we create a safe therapeutic space in which we can offer the best recommendations and care.
Bloom's suggestion that we replace empathy with rational compassion may help to clarify appropriate boundaries between patients and practitioners. We need to balance an emotional involvement with a rational assessment of benefits and risks when making clinical decisions and recommendations. Ignoring patients' emotions limits our access to information about important determinants of health and adherence, while an unregulated emotional connection may detrimentally impact the care we provide and our own long-term effectiveness as clinicians. In what, in the United States, has largely been a racially homogenous profession serving a diverse patient population, recognizing our natural inclination to feel less empathy for those unlike us can help us consciously improve our interactions with patients who are different from us. Structured education on nonverbal and verbal communication strategies can train us to focus our attention on the most important aspect of each patient's care. Most importantly, how we treat our patients and each other may be the best way to support efforts to provide the best care possible. According to Han, "Role modeling has been shown to be the most important inﬂuence on trainee attitudes."7 I suspect that Mary Lathrap would agree:
Remember the lessons of humanity taught to you by your elders.
We will be known forever by the tracks we leave
In other people's lives, our kindnesses and generosity.
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients.
3. Lanzoni, S. 2015. A short history of empathy. The Atlantic 15:10-5.
4. Zaki, J. 2017. Moving beyond stereotypes of empathy. Trends in Cognitive Sciences 21(2):59-60.
5. Bloom, P. 2017. Against empathy: The case for rational compassion. Random House.
6. Riess, H, and G. Kraft-Todd. 2014. EMPATHY: A tool to enhance nonverbal communication between clinicians and their patients. Academic Medicine 89(8):1108-12.
7. Han, J. L., and T. N. Pappas. 2018. A review of empathy, its importance, and its teaching in surgical training. Journal of Surgical Education 75(1):88-94.
8. Halpern, J. 2003. What is clinical empathy? Journal of General Internal Medicine 18(8):670-4.