What really is empathy?
Let us take some similar words – sympathy, compassion, kindness, humanity, pity; and the Buddhist concepts of Meththa (loving kindness); Karuna (compassion), Muditha (vicarious joy – the pleasure that comes from delighting in other people’s well-being.)
What is sympathy? – feelings of sorrow for someone else’s misfortune; Compassion? – concern for the sufferings or misfortunes of others; Kindness? – a pleasant disposition, and a concern for others; Humanity? – a set of strengths focused on “tending others”; Pity? – feeling of sorrow and compassion caused by the suffering and misfortunes of others. They all have to do with “the other”.
EMPATHY is distinctly different. It is the capacity to understand or feel what another person is experiencing from within the other person’s frame of reference, i.e., the capacity to place oneself in another’s position. It is elicited by a sense of altruism. Altruism is implicit in its true meaning. Phrases such as ‘being in another’s shoes’, ‘seeing things through their eyes’, ‘imagining their frame of reference’, all suggest empathy.
Some even consider it a “drive”. The word “drive” suggests that empathy is automatic, spontaneous, beyond one’s control, and thus worthy of neither praise nor blame. That it is a state of mind – it is there, or it is not.
Considering the above definitions and interpretations, I would like to think that a combination of “empathy” and “Muditha” would be the ideal state of mind of an ideal doctor.
That is, (i) having the capacity to understand or feel what another person is experiencing from within the other person’s frame of reference, i.e., the capacity to place oneself in another’s position; and (ii) having the pleasure that comes from delighting in another’s well-being. That is, those amongst doctors, who have the capacity to feel a patient’s feelings and gain pleasure in the joy of a cured happy patient. But it is also said that this second aspect must be distinguished from the pleasure or self-satisfaction a doctor will get from his/her achievement of curing a patient of illness. That would be an emotion of egoistical self-aggrandisement. That is OK, but that is not the quality of Muditha.
A very tough call, isn’t it? Therefore, it is not surprising that many doctors fall below achieving this difficult ideal.
Empathy in the Practice of Medicine
It is increasingly being accepted within the medical profession that ‘empathy’ is a necessary attribute in a doctor. Therefore, some believe that this attribute should be evaluated in the doctor at different times of their careers. Either at the point of entry (selection) as medical students; or during the period of their undergraduate and postgraduate training. To do this, a reliable and valid test of empathy is required. There are many instruments for the ‘measurement’ of empathy, but most have inherent weaknesses.
That is not good news. But the good news is that it is surmised that “empathy can be learnt”. Which means that it can be taught. Teaching methods include making students and doctors sensitive to, and developing the ability to, read facial expressions for emotions in their patients; recognizing body language and other non-verbal cues of patients; and maintaining constant eye contact with the patient. But a fundamentally important characteristic would be developing a doctor’s ability to be a good and patient listener.
Another characteristic that is said to go hand in hand with empathy is the “expression of enthusiasm”. Though it is generally accepted that ‘empathy’ has to be genuine, it is argued that ‘enthusiasm’ can be faked. A doctor can pretend to be ‘enthusiastic’ when in fact he is far from it. It is argued that fake empathy is better than no empathy.
That is fine. But, unfortunately, too many doctors show a ‘grimace of impatience’. Not the ‘Humanistic Mask’.
Empathy – a current topic
Why has empathy become increasingly a subject for discussion and debate among medical professionals?
On the one hand, there is research evidence that ‘empathy’ improves positive patient outcomes. More patients recover when treated by an empathic doctor. The slogans are “Nice doctors are better doctors”; “Kind doctors have healthier patients”.
On the other hand, I am prepared to bet my bottom dollar that if there is a controlled study, empathetic doctors will have better personal health outcomes with lesser cardiac episodes.
In the book “Intoxicated by My Illness” by Anatoly Broyard, she says: “The emotional burden of avoiding the patient may be much harder on the physician than he/she imagines . . . a doctor’s job would be so much more interesting and satisfying if he simply let himself plunge into the patient, if he could lose his fear of falling.”
The argument here is that doctors will find it easier and gain greater satisfaction in their work if they are empathetic; if they are fully committed to the patient – they will have better health outcomes for themselves.
Dilemmas and Challenges
Modern scientific western medicine’ – Inherent in that phrase is that the modern physicians belong to a profession that has increasingly placed itself within the logico-scientific tradition. Medicine’s positivist worldview, which prioritizes technological progress, hierarchy, certainty, and efficiency, encourages conceptualizing patients as objects and can lead to the doctor feeling alienated from, rather than empathic towards, the patient. Not too rarely, patients are often conceptualized by doctors as tasks to finish or by medical students as objects from which to extract learning.
A widely-accepted view of medical professionalism is that its practitioners should respond to the suffering of patients with objectivity and detachment. Hence the operative phrases are ‘clinical detachment’; ‘detached concern’; clinical neutrality’ or ‘affective distance’. Doctors are expected to maintain emotional detachment and distance from patients – i.e., not get ‘emotionally involved’ in the patient’s illness or condition. An extreme illustrative form of it is that a doctor should not be crying by the bedside of his dying patient; or a doctor should not run around wildly excited about a patient admitted to ‘accident and emergency’. The doctor’s objectivity and efficiency in the urgent tasks ahead will depend on that ‘clinical detachment’. An ‘emotionally attached’ doctor may not be objective and efficient. But that detachment is expected to be not just plain detachment, but ‘detachment with concern’.
This apparent conflict in the mindset of the doctor – ‘detachment’ and ‘empathy’ – is said to lead the doctor/medical student to ‘emotional burnout’ or ‘compassion fatigue’. It is this dual and contrary ‘emotional’ requirement of developing empathy while at the same time acquiring ‘concerned detachment’ that puts a doctor in an emotional dilemma; in mental discomfort. Or to put it more terminologically correctly, in a state of ‘cognitive dissonance’. How does a doctor develop empathy in this situation? I believe that at best, it is difficult. Unless the doctor has that urge to go that ‘extra mile’ to be caring.
What are the major challenges that we face in Sri Lanka towards developing an empathic doctor? I believe that one is what we disinterestedly call “patient load”. Doctors are expected to see too many patients – both in the state as well as the private sector. This creates a mindset where doctors “clear the crowd” at the OPD or post-casualty in State Hospitals and limit the time of patient encounters to a bare minimum in the private sector – the notorious “2-minute consultation” followed by a plethora of tests – that many patients who have experienced it, describe. A serious, negative fallout of this is that the medical students and young doctors are faced with a lack of sufficient role models to emulate.
Unless there is a complete overhaul of the entire state health system, this situation will not change. But we have to be thankful for small mercies or, in fact miracles; that in spite of all these limitations and stresses at the workplace, there are still many doctors who continue to be truly and sincerely ‘empathetic’. That is remarkable indeed.
(This article is excerpted from the ‘Dr. GR Handy Memorial Oration 2017’ delivered by the author under the auspices of the Sri Lanka Heart Association.)
Prof. Susirith Mendis was the Former Vice-Chancellor of the University of Ruhuna