Empathy in Healthcare

One of my favorite experiences is running a didactic session for our Family Medicine residents  once (and often twice) each month.  Last week, however, I was a little nervous.  Having covered a lot of the core child health topics since the beginning of the academic year, I thought it time to tackle something "different" - the nascent field known as Narrative Medicine.

If Narrative Medicine (NM) has a founder, it would be Columbia internist Dr. Rita Charon. NM burst into our collective consciousness in 2004 with the publication of her seminal Perspectives essay in the New England Journal entitled "Narrative and Medicine."  Her thesis was that the telling and hearing of the patient's story - not his medical history, but his personal, self-defining narrative - constitutes a creative act, essential to the relationship between physicians and patients, and necessary to our understanding of the patient and his "dis-ease."

If Narrative Medicine is the answer, I asked our group, what is the question?  That is to say, what ailments (ours and our patients') does this new (or not-so-new) philosophy address?  One answer comes from a body of research that seeks to understand what happens to trainees between their entry to medical school and the completion of graduate training.  More exactly, what happens to their ability to recognize and connect with personal suffering, to their capacity for empathy?  

I was quite surprised to learn several years ago that empathy can be measured.  At least that is the view of the researchers who created the Jefferson Scale of Physician Empathy (JSPE).  What is even more interesting is that this validated tool has been applied in a number of research studies to the trajectory of empathy in physicians and other health professionals over time.  It turns out that those who choose Medicine enter training with a full measure of this desirable trait - more than the average person, in fact.  According to a meta-analysis of 18 studies published in 2011, the sad fact is in what happens next - empathic capacity declines.  Substantially.  For some, things get better later on, after residency and fellowship, but not for all.  

What causes this erosion of empathy?  Several factors have been proposed.  Most often discussed in teaching circles is a process of acculturation wherein a set of beliefs, attitudes and behaviors are role-modeled by more senior trainees to their younger reports.  Not only are these behaviors not sanctioned by leadership, they generally conflict dramatically with the stated mission and vision of our institutions of medical education - hence the term "hidden curriculum."  Another factor is the very frequency with which trainees encounter human suffering.  Because this suffering is a "normal" feature of the healthcare environment, the sensibilities necessary to feel for another are challenged and blunted.   As George Eliot noted in her novel Middlemarch,

"We do not expect people to be deeply moved by what is not unusual. That element of tragedy which lies in the very fact of frequency has not yet wrought itself into the coarse emotion of mankind and perhaps our frames could hardly bear much of it..." 

Narrative practice, whatever its other merits, seeks to serve as a corrective and an antidote to the hidden curriculum.  In an essay of the same name, NYU physician Jerome Lowenstein once asked "can empathy be taught"?  Since is it evident that empathy can be un-learned on the wards, perhaps, the argument goes, this novel approach to focusing attention on the humanity, the subjective and deeply personal experiences of those who seek our care, and those who provide it,  may mitigate this threat to our ability to be the physicians we intended to be. 

We should hope so.  It has been established that patient outcomes (including Hgb A1C levels in diabetic patients) are impacted by physician empathy.  There is a measure of this quality to be found in nationally-collected and publicly-reported patient experience data. ("During this hospital stay...how often did doctors listen carefully to you?").  Finally, we ourselves are impacted.  It has been observed that one feature of physician burn-out, an increasingly prevalent problem, is a sense of disconnection from our patients and of ineffectiveness in our work.  Empathic connection is exactly the inverse of burn out.  Dr. Lawrence Smith, founding dean of our heath system's School of Medicine, has stated as much by asserting that finding the stories of our patients is the best prevention for burn out.  It is curiosity about our patients and their lives, and indeed our privileged access to their most personal aspirations and fears, that creates a foundation for trust, and both defines us and sustains us as physicians.