The following is an essay I wrote for Physicianship class, on the subject of whether empathy is a teachable quality. In a lot of ways, the essay is a continuation of my exploration of a subject I have been thinking about for a while…
Corpus Sanus in Mente Sana: “A Healthy Body in a Healthy Mind”
Empathy is distinct from sympathy. Whereas the latter focuses on understanding and supporting the feelings or interests of another person, the former encompasses being able to experience the feelings, thoughts, and emotions of another person. (1) Sympathizing often refers to feeling sorry for someone, whereas empathizing allows one to understand the perspective and concerns of another person, and by extension, their decision-making process, without necessarily agreeing with their actions personally. The question of whether empathy is teachable requires the exploration of several factors, including whether this is a skill versus a virtue, how this quality produces better physicians, what tangible methods might exist to teach empathy, and most importantly, whether the medical education should strive to teach empathy at all.
Smajdor et al. (1) argue that “‘empathy’ as it is commonly understood, is neither necessary nor sufficient to guarantee good medical or ethical practice.” First, they believe that empathy is often described as a virtue, a quality that makes a good person and thus a good doctor, but this reasoning is flawed, in part because possessing empathy does not a good person make, and being a good person does not equate to a good doctor. Empathy is the ability to understand another person’s intentions and actions, but this power can be used for evil as well as good, as in “a gunfighter may use his empathetic powers to predict an opponent’s next move without losing the urge to kill him”. (2) There may be an unwarranted association between possessing empathy and using it to take care of patients.
Smajdor et al. (1) goes on to point out that a good person may not make a good doctor, especially as more time spent on soft skills means that time needs to be taken out of another part of the medical curriculum. Furthermore, medical doctors require clinical objectivity to function effectively, the professional distance with patients that allows surgeons to operate without cringing at the sound of the bone saw. Arguably, a physician overly concerned with feeling their patient’s pain may be unnecessarily distracted from practicing effective medicine, to the detriment of both the doctor and the patient.
And yet, there is much evidence for the power of empathy in medicine. Even Samjdor et al. (1) admit to the value of subjectivity and empathy in specialties where longer-term relationships are established with patients, such as general practice or psychiatry. Physicians with greater empathy scores were correlated with significantly better diabetes control in their patients. (3) This may be due in part to the physicians’ abilities to better understand their patients’ individual circumstances, allowing for recommendations and treatment options that better catered to unique lifestyles and thus allowed for better adherence. Empathy may also have created a better therapeutic alliance and greater trust between doctor and patient, again leading to increased adherence. This empathic relationship has been shown to lead to “better immune function, shorter post-surgery hospital stays, fewer asthma attacks, stronger placebo response, and shorter duration of colds”. (4)
It is the author’s belief that one’s capacity for empathy is, like intelligence, genetically determined. One piece of supportive evidence is the finding that administration of testosterone significantly impaired the ability of women to cognitively empathize, and the effect can be predicted by fetal testosterone effects on the right-hand second digit-to-fourth-digit ratio, suggesting that empathetic powers may be at least partially determined prenatally. (5) However, in the way that one’s potential IQ is a range whose exact number is determined by the interplay between genetics and environment, so, too, can one’s empathetic powers be developed. Thus, although empathy may not be teachable, certainly one can strive to ensure that students enter medical school somewhat equipped with this ability and with the desire to use it to help others. This has been accomplished using such screening tools as the multiple mini-interviews, with evidence of valid assessment of non-cognitive attributes, including empathy. (6) After admission, courses should be aimed at offering skills to refine empathetic powers, such as the ability to recognize paralanguage and better understanding of different religions, but ultimately, these should not be sold as lessons on empathy. Experience with patients in different settings is perhaps the best way for students to discover their own empathetic abilities, because the empathy we should strive for is one where doctors understand unique patient life circumstances (1), which requires exposure to these varied scenarios. Yuen et al. (7), for example, found that even a half-day exposure to chronically ill older patients improved medical students’ appreciation for chronic illness care, as well as empathy and sensitivity towards individualized care of chronically ill patients, even after graduation.
Empathy commonly decreases in the third year of the medical curriculum, likely due to a combination of reasons, including a shift in focus to professional distance and clinical neutrality, increased time pressures, an adoption of technological advances that minimize human contact, a paucity of proper role models, and inappropriate treatment of the students. (4) Again, it suggests that the problem with empathy is not necessarily that it needs to be taught, but that individual powers can wax and wane depending on the type of education that students receive. Both empathy and professionalism have been demonstrated to decrease with increasing medical student burnout (8), so it is vital for a medical education to cultivate empathy, if only to help maintain mental health and prevent burnout, which is estimated to be experienced by 60% of practicing physicians. (4) Decreased empathy leads to a poorer physician-patient relationship, which is associated with decreased trust in physicians and more patient complaints and malpractice claims, as well as decreased job satisfaction, quitting the profession, substance abuse issues, and suicide. (4)
The question is thus not how to teach empathy, but how to develop this existing attribute in students, and prevent its loss during the medical curriculum. Smajdor et al. (1) make a distinction between etiquette and empathy; whereas the latter is perhaps an innate, unteachable ability to understand individual experiences, the former are more generalizable skills in clear and courteous communication, which is much more teachable, such as with classes on how to listen to paralanguage, make eye contact, and conduct patient-centred, holistic medical interviews. Perhaps through practicing these etiquette skills and appreciating their emphasis in school, students will reflect on the importance of empathy and nurture their own abilities.
As to how to prevent loss of empathy, research at McGill (9) suggests that there simply needs to be a concerted effort to remove barriers to the medical students’ natural desires to care for their patients. These barriers include the sometimes seemingly incompatible teachings of empathy and efficiency, the common practice of prioritizing medical education over patient care, the objectification of patients, and the institutionalized practice of wounding patients (e.g., performing unnecessary IVs on anaesthetized patients without their consent) for the sake of learning.
All of the evidence above suggests three key methods of cultivating empathy in students: reflective writing, for students to record their own experiences and process their own reasons and ways to empathize (10); practice in communication and interaction with patients to hone these skills and better understand what caring is on an individual basis; and, most importantly, better role models in senior physicians who must practice what they preach and work to change the systemic inefficiencies in empathic education.
Clinical objectivity is arguably well integrated into the medical curriculum. As to empathy, although it may not be teachable, one’s medical education should certainly cultivate this quality in future physicians. It is the balance between objectivity and subjectivity, professional distance and empathic relationships, which allows for proper maintenance of mental health in both physicians and patients, and a healthy mind is the key to a healthy body for everyone involved.
Corpus sanus in mente sana.