Empathy: How Does It Help Us Relate To Others and What Is Its Role in Medicine?

Empathy is a frequently misunderstood term that refers to one’s ability to understand and identify with another person’s emotional experiences and feelings.  The true empathic individual is aware and accepting of the other person’s thoughts, reactions, and feelings in a non-judgmental way.  In the ideal situation empathy essentially allows one to walk in the other person’s shoes and see what that’s like.

Donald M. Friedman, MD
Donald M. Friedman, MD

This can result in significant validation for the receiving person and be a very healing experience because of that sense of being understood.  Empathy can bolster confidence and bring a person out of deep isolation.  It is a very humanizing process that has a spiritual and sacred aspect because of the connectedness that can occur between the two people involved in the interaction.

The more a person is aware of his/her own feelings and experiences, the easier he/she can show empathy for another’s feelings and experiences, because it is easier to identify potential similarities.  Once you acknowledge and accept your own feelings, you can empathize with another person.

If there are no shared feelings or experiences, it is still possible to envision what it might be like for another person by using your imagination and also allowing yourself to emotionally resonate with what the person is sharing with you.  Most of the time people don’t communicate well about what they are feeling, so in being empathic you have to be intuitive, ask the person, pay attention to facial expressions, body language, and other non-verbal communication.  Finally, once you have a sense of what the person might be feeling, it is important to acknowledge that feeling and convey the sense you understand why they are feeling as they do.

It is important to note that in sensing another person’s feelings and seeing their perspective and the way they see the world, you don’t necessarily have to agree with them or condone their choices or actions.  But in showing someone empathy, you allow them to accept their own emotions and their own experiences and even express themselves more fully.  It is a wonderful gift to give someone, as it may lighten the burdens that person may be carrying around.

Empathy is frequently confused with sympathy.  The difference is essentially one involving boundaries.  Dr. Charles D Aring in his article “Sympathy and Empathy” (Journal of the Amer. Medical Assoc., May 24, 1958, p.448-52) relates that

“the definition of sympathy refers to an affinity, association, or relationship so that whatever affects one, similarly affects the other.  The act or capacity of entering into or sharing the feelings of another is known as sympathy.”

It is more difficult to maintain one’s separateness and one’s own personal identity with sympathy than it is with empathy.  Empathy, like sympathy, appreciates another’s feelings, perspective, and problems, but does not involve joining in with the other person in experiencing the feelings.  As will be discussed below, empathy is much more appropriate for the physician to have in the healthcare setting, for as Dr. Aring comments, “Empathetic understanding allows a better opportunity  of defining what is transpiring, and what the behavior of another signifies.”  So empathy allows for more perspective and less emotional investment, although it still promotes emotional resonance and identification with the other person.  But, the empathic listener does not have to experience the intense feelings the speaker may convey, but only understand these feelings and relate to them while maintaining his/her own sense of identity.

So how does one show empathic listening to another person?  Here are the guidelines that Madelyn Burley-Allen sets out in her book, Listening, the Forgotten Skill:

1. Be attentive, interested, alert, and not distracted.  Be positive through non-verbal behavior.

2. Be a sounding board – allow the speaker to bounce ideas and feeling off you while assuming a non-judgmental non-critical manner.

3. Don’t ask a lot of questions.

4. Act like a mirror – reflect back what you think the speaker is saying and feeling.

5. Don’t discount the speaker’s feelings by using phrases like “You’ll feel better tomorrow”.

6. Don’t let the speaker get you angry, upset, or involved in an argument.

7. Indicate you are listening by:

a. Providing brief responses like “I see”.

b. Giving non-verbal acknowledgements such as head nodding and eye contact

c. Invitations to say more such as “Tell me about that”.

8. Follow good listening rules: don’t interrupt, change the subject, interrogate, teach, give advice.

9. Do reflect back to the speaker what you understand and how you think the speaker feels.

These guidelines help one to stay focused while trying to be empathic to another person.  They will help convey you are trying to understand the other’s feelings and viewpoint and may allow you to empower the person by showing he/she is important to you.  It may also offer the speaker an opportunity for an emotional release.

Empathy has a huge role in the practice of medicine.  There has been a movement in medicine away from the stance of “detached concern” on the part of the physician to a more empathic approach to the patient.  In his article, “Empathy Revisited” (Arch of Internal Medicine, Jan 22, 1966 Vol. 156:135-6), Dean Gianakos, M.D. comments,

“An empathic physician imagines what it is like to think, feel, and suffer like the patient.”

This process can comfort the patient, lead to a strong and more therapeutic doctor-patient relationship, empower the patient to participate in his/her care, allow the physician to obtain crucial information that will help in the care of the patient, enable the physician to understand a patient’s emotional reactions to an illness, and make the physician’s work more satisfying and meaningful.

There is some debate in the medical literature whether empathy in medicine is a cognitive (intellectual) or affective (emotional) process.  It actually has elements of both, but the important thing is that the physician emotionally resonates with the patient so that there is understanding of how the patient thinks, feels, and responds to being ill.

Empathic interaction with the patient will also reveal the social, familial, and experiential framework that the patient is operating in.  Where clinical empathy goes beyond the usual empathic interaction is that it has specific aims and leads to clinical decision making and action based on what the physician learns by tuning in to the patient’s emotions.  Objective medical data are, of course, of prime importance, but what the physician learns from empathic interaction with the patient will influence how decisions concerning that data are made and applied to the patient in the most therapeutic way possible.

Here are more specific ways in which empathy can be of therapeutic value in the clinical setting.  As mentioned, empathy can allow the physician to have greater knowledge and insight into the patient.

In “Empathy Revisited,” Dr. Gianakos states,

“Through empathy, physicians try to reconcile their own beliefs about what is best for the patient with the patient’s beliefs.”

In other words, understanding the patient allows the physician to help the patient make decisions that are indicated medically, but also consistent with the patient’s beliefs and values.  Also, the patient’s feeling of being understood strengthens the working relationship between the physician and patient so that there is trust and a more likely acceptance of the physician’s advice.

Patients will also more likely divulge information if they feel the doctor understands their feelings and experiences.  They are also more likely to participate in decision making, because they feel the doctor will listen to them.  Empathy allows the physician a chance to understand the meaning the illness has for the patient.  This can help the physician better support the patient and clarify medical explanations the patient is given.

Empathic listening can also give the patient a chance for emotional release, a therapeutic process in itself.  Physician empathy can lead to a more emotional bond between the physician and patient and encourage a more tender and caring interaction of the doctor with the patient because the doctor has more understanding of what it is like to be that patient.

Dr. F.W. Peabody, in a 1927 JAMA article, said, “The secret of the care of the patient is in caring for the patient.”

Other positive effects of physician empathy are mentioned in an article, “The Empathic Physician” by William Zinn, M.D. (Arch of Internal Medicine Feb 8, 1993 Vol. 153:306-12).  Empathy may enable the patient to have a stronger sense of who he/she is and to be empowered by that knowledge.  Physicians who are perceived to be more empathic have greater success in lessening their patients’ concerns about their illness.  Patients prone to shame and humiliation that can be inherent in the medical encounter are more comfortable with sensitive and empathic physicians.  Patients who have underlying emotional or psychosocial issues associated with their illness or patients who have somatic symptoms related to emotional problems rather than physical pathology are more likely to discuss their emotional problems with an empathic physician.

Finally, Dr. A. Kleinman, in his book. The Illness Narratives, notes that chronic illness can lead to grieving and a sense of powerlessness because of the loss of physical function, self-image, and connection with family and friends.  This can result in painful loneliness.  The patient may have a great need to tell his/her personal life story in order to give some meaning and order to his/her life.  If the empathic doctor acts as a witness to the telling of the story, great healing of and comfort for the patient can occur.  In fact, if a physician is present in an empathic way, healing can occur in all the above situations.  The healing is on an emotional and spiritual level that can have a positive effect on the course of the patient’s disease.

Empathy on the part of the physician is not always easy to achieve.  As Jodi Halpern, M.D. Ph.D. points out in her article, “What is Clinical Empathy?” (Jour General Internal Medicine, 2003 Vol. 18:670-74), there are barriers working against a physician being empathic in today’s medical world.  One is the anxiety that comes from time pressure in seeing a large number of patients.  But empathic listening can make patient care more efficient.  Allowing a patient a few minutes to speak spontaneously at the start of the medical encounter helps to encourage trust and disclosure.  And the patient may feel freer to share helpful information at a later time because of the trust and comfort established.  Another barrier to empathy is physician discomfort in experiencing or sensing the patient’s emotions, since this may stir up the physician’s own difficult emotional issues.  This can be a good learning situation because it might force the physician to confront his/her own emotions and be aware of them.  Such a process would enable the physician to be more emotionally resonant with and aware of others’ feelings and emotions.  And it would emphasize the importance of physicians acknowledging and seeking support for their own emotional needs.

Dr. Halpern also mentions another barrier – many physicians still do not see patients’ emotional needs and problems as an integral part of their illness and an important part of their care.  But it has been shown that physicians who address psychosocial issues in their patients’ care communicate better and have better patient satisfaction.  Finally, the physician might be concerned that encouraging the patient to talk about difficult feelings and emotions while the patient is ill might be harmful for the patient.  But usually the patient has had these feelings anyway, possibly for a long time, and expressing them in the presence of a caring physician might bring comfort and/or emotional release.

The question is always raised of whether empathy can be taught or learned or whether it is something people innately already have.  In the medical world, there is no doubt that some physicians have a tremendous capacity for empathy as part of their personality, while others simply do not.

Howard Spiro, M.D., in his article, “What is Empathy and Can It Be Taught?” (Annals of Internal Medicine May 15, 1992 Vol. 116:843-46) argues that many physicians have natural empathy (it may be why they went into medicine in the first place), but in medical school and subsequent training, empathy is not encouraged and in fact, is actually stamped out.

Medical students focus on learning science and facts rather than learning to pay attention to the whole patient, even though medical school curricula have started to emphasize doctor-patient relationships, spirituality, ethics, and medical humanities more strongly.  There are now elective courses encouraging medical students to explore their own feelings instead of masking or denying them.  And residency programs with their long hours, multiple tasks, lack of sleep, and constant demands do not encourage empathy either, although many improvements have been made so that resident physicians and interns have more time for themselves now and less demanding schedules.

Still, Dr. Spiro feels that empathy can be restored in physicians by emphasizing in medical schools and training programs the importance of human life and human experience.  Also, history taking and listening to the patient as great sources of both information and the chance to bond with the patient can be more strongly encouraged.  Stressing the importance of narrative and hearing the patient’s story during and beyond the initial interview can enhance empathic behavior as well.  Dr. Spiro also feels that encouraging physicians to meet in unstructured ways as colleagues where stories, experiences, and feelings can be shared will also promote the development of empathy and a chance to explore one’s own feelings.  Dr. Rachel Naomi Remen, in her course, The Power of Story, also stresses the importance of physicians sharing their stories and humanity with each other.

On a practical level, how does a physician show empathy to a patient during a medical interview or other clinical encounter?  All of the features of a good listener, mentioned above, apply here as well, but it is particularly important that the physician help the patient name the emotion the patient is trying to convey.

This is discussed in detail with good examples by Frederic W. Platt, M.D. and Vaughn F. Keller, MFT in their article “Empathic Communication” (Jour of General Internal Medicine April, 1944 Vol. 9:222-226).  The physician must first convey interest by body language and facial expression and also words of encouragement, such as “Go on” or “Could you tell me more about that?”

If the physician senses what Platt and Keller call an “affective moment” (i.e., moment of emotion), such as anger, grief, or fear, the physician should help the patient name the emotion, if the patient doesn’t do it him/herself first.  Statements such as “You sound angry” or “You seem sad” will help the process.  Once the emotion is named, the physician should acknowledge it and convey to the patient how understandable and justifiable it is to have that feeling.  This is how the understanding and support of the empathic process is shown to the patient.  And then the physician can also communicate availability if the patient wants to discuss his/her emotional reactions, issues, and associated concerns further.

Finally, what does the physician’s empathic approach do for the physician?  Many will agree that it makes the practice of medicine so much more meaningful, satisfying, and human.  Dr. Halpern points out that physicians who are engaged with their patients and are oriented to the emotional and psychosocial issues of their patients less frequently experience burnout.  And very importantly,  physicians who allow their patients to move them have more enriched professional lives.  Physicians may become better attuned to their own emotions because of the mirrors patients hold up for the physicians to look into.  We as physicians can learn about living life and facing adversity from what our patients teach us.

And patients benefit from the empathy shown them as well – comfort, healing, support, understanding, and knowledge are inherent in an empathic doctor-patient relationship where the individual’s personal response to illness is of paramount importance and respected and understood.

This situation is best summed up by Anatole Broyard, a patient with metastatic prostate cancer, in his book, Intoxicated By My Illness: And Other Writings on Life and Death.  He said, “To the typical physician, my illness is a routine incident in his rounds, while for me it’s the crisis of my life.  I would feel better if I had a doctor who at least perceived this incongruity.  I just wish he would give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way.”

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