|Year : 2015 | Volume
| Issue : 2 | Page : 169-173
A value forgotten in doctoring: Empathy
Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Web Publication||16-Dec-2015|
Prof. Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shelley BP. A value forgotten in doctoring: Empathy. Arch Med Health Sci 2015;3:169-73
"No one cares how much you know, until they know how much you care"
- Theodore Roosevelt
What is the "art of doctoring"? Let us reminisce about what Dr. Bernard Lown, Professor of Cardiology Emeritus at the Harvard School of Public Health and the 1985 Nobel Peace Prize recipient had to say: "Caring without science is well-intentioned kindness, but not medicine. On the other hand, science without caring empties medicine of healing and negates the great potential of an ancient profession. The two complement and are essential to the art of doctoring."
In the current modern era of medical world and medical school training, the emphasis is on organ-based, technocratic, reductionist mechano-materialistic, pathogenesis-centered, and disease-centered model approach rather than a humanistic, patient-centered, integrated approach of systems medicine, complementary and alternative medicine (CAM), and "relationship-centered medicine" (RCM). Undue reliance on techno-medicine has resulted not only in "disuse atrophy" of clinical, cognitive, and metacognitive thinking skills but also a "social-disconnectedness," a "detached concern," and "heartlessness" in our clinical and professional encounters. I am highly critical of the current medical practices and devastated to see the "the dark side of medicine," a new "dis-ease" that I call as an "iatrogenic crisis in caring" where not only the "art of doctoring" but also the "art of healing" is lost. The art of doctoring does not mean abandoning the technologic marvels of modern science but rather incorporating them into a sensitive, humane, compassionate, and empathic care holistic approach. In medical schools, training no longer nurtures passion for compassionate medicine and it also does not create a learning environment to provide an opportunity for medical students to explore relationship-centered aspects of clinical practice. This unfortunately has resulted in physician empathy gap with an alarming void of compassion, humanism, and altruism in medical care.
I would assert that medicine is a plurality of science and humanitarian principles. The concept that physician medical objectivity and effectiveness would mandate emotional detachment from the patient or to maintain "clinical neutrality" has now been challenged. Humans are prosocial beings, and empathy is one of the most defining features of humanity, a unique human trait. The neural basis of empathy and "theory of mind" stems from functional neuroimaging research to involve a complex "empathy circuit," a network called the "human mirror neuron" system in our brains. If humans have developed adaptive changes in the evolutionary process where empathy and compassion are "hard-wired" human attributes, why are we witnessing an erosion of Oslerian medicine to the current "detached concern," "depersonalized," "dehumanized" technical medical practice at the heart of 21 st century health care? If the human evolutionary process has indeed hard-wired our brains for empathy, why are we not teaching, developing, and training physicians for clinical empathetic care in medical schools? Has the cultural and moral fabric of modern technocratic 21 st century medicine created an endangered Homo sapiens species deprived of "empathy, prosociality, and humanism" through epigenetic modification?
As a professional, physician, and "as a spokesman of the medical society," should we not wage a crusade to fight against this deep crisis of "dehumanization of medical practice" that plagues modern 21 st century medicine? Many vexed questions do traverse my free thinking mind. Is there not an urgent need to return to the traditional ethos of medicine and re-humanize medicine? Do we not need Sir William Osler and Dr. Francis Peabody in the lecture halls of medical schools today? Should there be a revival of "romanticism in medicine" to bridge the schism between the "science" and "art" of the practice of medicine? Will humanization of medical practice translate to positive therapeutic healing outcomes in the physician-patient equation? Do we need to have curricular reforms in medical schools to teach and develop the "art of doctoring" for tomorrow's physicians? The solution to these intriguing questions is evident from the research work of Dr. Jodi Halpern, psychiatrist, medical ethicist, and philosopher at University of California, Berkeley, California, USA. She strongly makes an argument for developing empathy in clinical encounters and health care as the way forward to humanize and transform the "depersonalized" medical practice at the heart of 21 st century health care. 
The etymology of empathy is from the German term "einfuhlung" (literally, "in-feeling") that described the emotional appreciation of another's feelings. "Clinical empathy" is an affective and cognitive understanding of the patient's reactions, thoughts, or feelings followed by a behavioral demonstration of that understanding back to the patient.  The components of empathy is said to be: 1. A cognitive-evaluative form of empathy, 2. An affective (emotional)-perceptual empathy, and 3. Compassionate empathy.
Therefore, empathy enables individuals to understand and respond to others' emotional states and thus, contribute to compassionate behavior and moral agency. It is interesting to note that clinical empathy was once traditionally considered as a "good bedside manner," a quality considered innate and impossible to acquire, and perhaps viewed not more important than technical acumen in professional competence.
How does empathy matter in the art of doctoring and health care? There is mounting credible evidence over the last decade to link physician empathy to positive patient-related health and healing outcomes. Behavioral empathy, as an outcome-relevant physician characteristic, forms the crux of a satisfactory doctor-patient relationship, and high-quality communication. Empathy is considered a major constituent in the practice styles of excellent "healing" clinicians and is a marker of the quality of medical care. The beneficial impact of therapeutic empathy may be explained on a social neuroscience perspective by unifying integrative neurocognitive theories such as social baseline theory (SBT) and the free energy principle (FEP) that emphasize the importance of social interactions, support, interpersonal relations, and cognitions in health as well as by neurocomputational theories and neuroanatomical and neurochemical foundations.
Is there any evidence for "empathy gap" in the art of doctoring in the medical world today? That there is a dearth of empathy in the current medical practice has been documented by some important studies. Pollack (2007) studied videotaped encounters of doctors with an advanced cancer patient that showed that doctors often overlooked or dismissed signs of distress communicated by their cancer patients, and provided empathic responses only 22% of the time. A similar trend was also evident in a study by Lown (2011) that surveyed 800 recently hospitalized patients. It was surprising to note that the results indicated that only 53% of the patients felt that their physicians were empathic and caring.
There has been a recent upsurge of rigorous empirical data and research to lend credence that affective and cognitive empathy and compassion in a meaningful patient-clinician relationship is certainly linked to a greater likelihood of positive therapeutic health outcome as evidenced by faster recovery from disease, higher levels of happiness, and well-being. Allow me to dwell on some of these pathbreaking and burgeoning studies on the relevance of "empathetic healing" and "therapeutic empathy." Two studies involving patients with common cold did underpin the importance of the patient-rated perception of physician empathy in their therapeutic encounter. The results showed unequivocal evidence that patients whose doctors had enhanced empathy had a significantly shorter duration of illness, a trend toward lesser severity of illness, and recovered faster resulting from an augmented immune system response as measured by nasal wash neutrophil counts and interleukin (IL)-8. In a study of 710 cancer patients in Germany, physician empathy was positively associated with improvement in patient-reported outcomes of depression and quality of life. In another two studies involving diabetes mellitus patients, researchers found that patients of physicians with high empathy scores (compared with patients of physicians with moderate and low empathy scores) had better outcomes with respect to acute metabolic complications, hemoglobin A1c, and good LDL-C control.
The breakthrough evidence by Ted Kaptchuk at Harvard Medical School in a randomized controlled trial (RCT) study design did demonstrate the so called "care effect" related to therapeutic empathy as opposed to the "placebo effect." Patients with irritable bowel syndrome were told that they would be participating in a study about the benefits of acupuncture. It was observed that the group of patients in the RCT study design who was seen by warm, friendly, and empathetic doctors but given fake acupuncture did report a marked reduction in their symptoms. This RCT study does indeed demonstrate that "connecting with the patient, rapport and empathy" in a "relationship-centered" encounter was not just an icing on the cake; instead it did mediate though neurobiologic underpinnings of mind-body self-healing processes. This does demonstrate the powerful healing effect of an empathetic exchange that led to the "care effect."
Having understood the positive impact of empathy on patent health outcomes, does empathy lead to physician burnout? There is accumulating evidence that does indicate that physicians who are empathic are more satisfied and have less burnout. Studies have shown that physicians with higher cognitive and affective empathy levels (empathic concern, perspective taking, and altruism) do experience a better professional quality of life (ProQoL) scores, professional satisfaction (healthy work-life balance) and thereby professional well-being since they do certainly experience less stress, cynicism, and physician burnout than those with less empathy. In a 2013 study by neuroscientists Jean Decety and Ezequiel Gleichgerrcht involving more than 7,500 practicing physicians, it was found that higher empathic concern toward patients was related to a decreased risk of job dissatisfaction.
Paradoxically, do current medical schools have certain inherent deficiencies and shortcomings in training? Much of the time, students training in medical schools have been found to actually impede a physician's ability to solve complex problems because they have been trained for the left brain-dominant, linear, stepwise, analytical, and evidence-based knowledge vertical thinking. This traditional thinking approach does not generate new ideas or discover innovative solutions to complex challenges since it does not ignite creativity, curiosity, inquisitiveness, and wonderment termed as the multidirectional creative, lateral or horizontal thinking. Similarly, medical schools do contribute to not only humanism and empathy deficiency but also a lack of philosophy of health, well-being, and relationship-centered whole-person care and healing outcomes in training the art of doctoring. Studies have documented medical schools to have a profound negative effect on empathy. Bellini and Shea (2005) measured empathy using the Interpersonal Reactivity Index (IRI) in 60 residents at six time points during their internal medicine residency training. The IRI scores showed a decline in empathic concern that persisted through residency. A recent longitudinal study by Mohammadreza Hojat, the Director of Thomas Jefferson University's Longitudinal Study of Medical Education, using a different measure of empathy the Jefferson Scale of Physician Empathy (JSPE), also demonstrated a clinically significant reduction in total empathy score during the third year of medical school when the curriculum was shifting toward patient-centered activities, a time when empathy was most essential.
What does contribute to the downregulation of empathy during medical school training? A significant reduction of empathy in medical school has been attributed to multiple and complex factors, both at individual dispositional and situational levels. The prime focus of current medical education underscores disease-centered approach, detachment and objective clinical neutrality, and places greater reliance on the technologic rather than humanistic aspects of medicine. Clinical hyposkillia, a lack of empathic role models, educational experiences with emphasis on controlled clinical trials, and evidence-based medicine for clinical decision-making, focus on research at the expense of teaching and learning, increased litigation and defensive medicine, and the market-driven health care system are other reasons for the erosion of empathy during medical education. Medical school stress, learning environment without a corresponding stress on humanistic values, and the "drudgery" of mastering medicine (strenuous demands including time pressure, sleep loss, heavy workloads, high volume of material to learn and mentors who model detachment when dealing with patients, increased student and resident numbers with shrinking resources) have overshadowed the importance of human interactions and empathy development during medical school training. 
Stress is also antithetical to empathy. Studies have shown a causal link between the inherent medical school stress and emotional exhaustion to the erosion of empathy. This in turn leads to an increase in emotional detachment from patients over the course of their medical training. A realistic goal to overcome medical school stress will be to practice mindfulness meditation, self-reflection and emotion skills for self-care and a healthy work-life balance. These experiential "mind-body" medicine techniques have been found to go a long way to help medical students and professionals to recognize, regulate, and behaviorally demonstrate altruism, empathy, and uphold humanistic and prosocial attitudes and behaviors during professional encounters.
Research has now rediscovered the once-forgotten virtue of physician empathy as a desirable quality in the art of doctoring. Considering the evidence base for therapeutic empathy of emotionally attuned physicians, patient-centered positive health outcomes, beneficial effects of empathy on the professional quality of life as well as the dearth of empathy not only in the medical profession but also among students in medical schools during training, what should be the way forward? How do we educate and train medical students for empathy as an integral part of patient care? Medical schools should develop and graduate more doctors not only through a competency-based educational paradigm but pledge to produce well-trained empathic and effective healers for compassionate healthcare and "whole person care" in the 21 st century. While mastering the science of medicine in medical schools, I would underscore the need to cultivate empathy and emotional intelligence since the art of doctoring is the pluralism of science and art of medicine and humanism.
The recent discovery in neuroscience of "mirror neurons" in specific parts of the human brain has indicated that we are hard-wired for empathy, prosociality, and humanism. Is empathy an innate trait or can empathy be nurtured? Although the capacity for human behavioral empathy is innate, empathy can be cultivated, improved, and enhanced. In recent years, researchers and psychometricians have shown empathy as a primarily cognitive attribute that is teachable, learnable, measurable, and sustainable, and can be role-modeled. Therefore, medical schools have an ethical obligation to create a humanism-based curricula and training as a learning environment for teaching empathic practices, which I would say is a formidable pedagogical challenge. Medical educators need to formulate effective Art of Doctoring (AoD) educational strategies, incorporate a mandatory, longitudinal "humanism and empathy"-targeted interventions, and workshops during medical training modeled on the principles of relationship-centered medicine (RCM). Innovative and structured AoD courses during the foundational years of medical school training would certainly help students to cultivate self-reflective skills; develop self-awareness; enhance altruism, empathy and compassion towards patients; and sustain commitment to patient care, service and personal well-being. Do medical schools need to establish CARE (Centers for Compassion, Altruism, Research and Education) to train a HEART team (Humanistic, Empathetic, Altruistic, Relationship-centered Team) in order to re-humanize the current 21 st century medical practice? It is equally important for medical schools to re-evaluate the screening of medical school entrants. Are we screening humanistic qualities (empathy, altruism, compassion) and assessing the student's emotional intelligence quotient (IQ) and knowledge on the behavioral, social, and psychological domains of health care during the medical admission selection process? However, screening medical school entrants may be an important first step but certainly cannot be the only step.
What are the focused educational interventions that could effectively foster empathy in medical students? The solution to this question comes from a review of 13 research primary data studies.  From the review, the educational interventional strategies for systematic training of empathy did include interpersonal skill workshop, audiotape-led communication skill workshop, communication skill lectures, humanistic interviewing skills (empathic listening), empathy, spirituality and wellness courses, and "clinical realism approach" through creative writing, writing assignments based on Meyer-Briggs type personal assessment, and narrative medicine. Healers' Art course by Dr. Rachel Naomi Remen of the Institute for the Study of Health and Illness (ISHI) at California, USA and an empathy-training program called "Empathetics," developed by Dr. Helen Riess of Harvard Medical School and Director of the Empathy and Relational Science Program in the Department of Psychiatry at Massachusetts General Hospital are other examples of innovative learning environments to explore and rediscover the humanistic meaning in medicine, healing relationship, compassionate, and whole-person care. These interventional strategies are centered on relationship-centered care (RCC) approach since the patient-doctor relationships does occur within a complex web akin to the traditional symbol of medicine, the staff of Asclepius with an encircling single serpent or the caduceus entwined by two serpents.
Using an RCT study design in residents and fellows from surgery, medicine, anesthesiology, psychiatry, ophthalmology, and orthopedics, Dr. Riess did show evidence that empathy could be taught and enhanced. The residents and fellows received either standard postgraduate medical education or education augmented with three 60-min empathy training modules. The results indicated that the empathy training group did show a greater change in patient-rated empathy scores. This novel RCT design underscores that the integration of the neuroscience of empathy into standard medical education does effectively translate to better the quality of empathic care and healing outcomes.
Since stress is antithetical to empathy, a course in stress management and mind-body medicine skills during the first year of medical school has also been found to be effective in enhancing traits such as mindfulness, positive affect, and empathic concern while reducing students' perceived stress and negative affect that cause erosion of empathy during medical school training. These curricular interventions (meditation, autogenic training, and guided imagery) will foster and build empathic concern, promote better physician-patient communication, and ultimately improve the quality of health care and patient-related outcomes.
A reappraisal of the social neuroscience of humans as "homo empatheticus" (with a heart to care, comfort, console, and heal) and the salutogenic functions of the brain would certainly enable a paradigm shift in our clinical and professional encounters from a physician-technocrat axis to empathic doctoring. This "emotionally-inclusive care" that is "relationship- and patient-centered" would be pivotal for evoking quantum healing and positive therapeutic healing outcomes in the chapters of life of our patients afflicted with "dis-ease" and sufferings. The culture of empathy, altruism, and the promotion of prosociality within the fabric of our clinical care and professional encounter is indeed a "desiderata" that is now unequivocally evidence-based. To conclude, Ovid the Roman poet said that "Medicine is the art of timeliness," and so during the journey of practicing medicine, please train to be "heart-centered doctors" having a "heart to care" and to "take care" of our patients for holistic wellness. Having been a patient myself, I cry out loud against the "rushed patient-physician encounters" by "elite" doctors practicing "nonbenevolent paternalism" since this does create an "iatrogenic health-scare" only to "close the door to auto-healing" in the anguished minds of patients! Patients recognize the "human touch" as a signal of caring because technology and machines do not comfort people. I close the editorial with the inspiring eternal words echoed by Francis Weld Peabody during his lecture, entitled "The Care of the Patient" to Harvard medical students on October 21, 1926. 
"One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient"
- Francis Weld Peabody
A physician, teacher, and humanitarian: A caring medical scientist, and a humanistic clinician of Harvard Medical School; 1881-1927.
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