When you feel anxious, overwhelmed and uncertain about decisions related to your care, what characteristics do you seek in your doctor other than that “they know their stuff” (i.e. are clinically competent)? There has been a lot of talk over the years about the importance of empathy. The thought is that a distressed patient needs an empathic doctor. What is empathy, and why is it considered so important to clinical practice? I wonder whether the term draws too much attention to what the doctor is feeling and not enough to whether they are actually responding helpfully to whatever their patient needs.
Empathy has been defined as “an affective reaction caused by, and congruent with, another person’s inferred or forecasted emotions.” In the clinical setting empathy is described as “an experiential way of grasping another’s emotional states.” Because the term has a variety of meanings it is to difficult to assess whether it is an asset, but I’ve often felt the word is inadequate and perhaps misleading for capturing what a person who is in distress values and needs.
Speaking personally, the people I turn to in times of distress are those who will try to figure out what is going on with me to see if they can help. Some may feel empathy and others may not. If I recently had a heart attack I might be grappling with a foreboding sense of vulnerability and awareness of mortality. At the same time there could be practical concerns about my capacity to exercise, to have sex, to manage side effects of my medications and to reshape my self-image such that I am not pre-occupied with my health. If I hinted at these concerns, I’d want my physician to follow up with questions and then provide me with direction and reassurance if warranted.
That may all sound obvious, but our research indicates that most of the time doctors don’t do any of it. In one study we trained 8 actors to work as undercover patients carrying audio recorders, presenting to their doctors with relatively common clinical problems while, at the same time, dropping clues that they were facing serious challenges that were undermining their health or healthcare. In one case the “patient” presents with deteriorating asthma while taking an expensive brand name inhaler. He comments to his physician “boy, it’s been tough since I lost my job.” We saw three different responses: The largest group just ignored the comment. Busy typing their note, we’d hear something along the lines of “uh, huh….and do you have any allergies?” The second, relatively small number of physicians, acknowledged the comment along the lines of “I’m sorry to hear you are out of work. It’s been a rough economy lately.” The third, a minority, would inquire: “Can you tell me what you are struggling with?” Only to this group would the actors reply “I can’t afford my medication anymore so I’m taking it every other day.”
The first two groups got the care plan wrong every time because they never learned the real reason why the asthma was getting worse. They typically increased the dosage of a medication the patient already could not afford. Among the third group, doctors got the plan right about half the time. They’d switch the patient to a less costly generic. The other half, despite having learned the real reason their patient is clinically worse, still went up on the dosage of an unaffordable medicine. Although our actors dropped 4 hints at each encounter of a specific life challenge interfering with their care, physicians asked a follow up question and then addressed the concern just over 20% of the time.
What is going on here? Is the problem a lack of empathy? Are the 20% more empathic? I don’t think it is possible to answer such questions both because of the many ways the term is defined but also, more importantly, because one can never know what drives an individual’s behavior. What we can say is that the physician who notices signs of distress and asks about them, then tries to do whatever he/she can to help, is fundamentally caring. Her full attention is upon the patient. What she is feeling inside is unknown, perhaps even to her.
However one defines the term, to me at least, it puts too much emphasis on what the physician is feeling rather than on what they are doing to help the patient. The physician who feels empathy towards a patient who is struggling with their illness, but doesn’t find out whether there is something they can do to help is not helpful. Conversely, the physician who probes to learn that the patient can not longer afford his medication, is embarrassed to admit it, but would benefit from a generic may not feel anything in particular other than the satisfaction of being helpful. Which doctor would you prefer?
A colleague and I explored this topic in a paper titled From Empathy to Caring: Defining the Ideal Approach to a Healing Relationship. Part of the fun of writing that paper was that my co-author who I have observed to be one of the most caring individuals I know describes himself as entirely lacking in empathy. What he does acknowledge, however, is that he’d “stand on his head” during a visit if he thought it would help. That’s the kind of doctor I want.