The concept of empathy dates from the early years of this century, when discussions of the topic were restricted to psychotherapists’ analyses of their interactions with patients. More recently, the concept has received renewed attention from a wide spectrum of health practitioners and educators. They believe that empathy can positively affect communication with patients and thus lead to improved therapeutic outcomes. Many of the lay public regard empathy as an avenue to the restoration of compassion and humanism to the doctor–patient relationship, which has been increasingly impersonal and threatened by technology and financial pressures. Indeed recent studies have demonstrated that physician empathy increases patient satisfaction and improves clinical outcomes.

The Neurobiology of Empathy

Novel research tools, such as functional MRI scanning, which permit real-time investigation of the brain under experimental conditions, have revealed new insights into the functional neuroanatomy of empathy. The discovery of sensorimotor neurons in the cortex has suggested a mechanism whereby behaviors can trigger an unconscious reciprocal response in an observer. These mirror neurons fire when the subject performs a particular task or when the subject simply observes another individual performing the same task. Most of us have had the experience of reflexively smiling when a stranger walking down the street smiles at us. Our motor response often precedes a conscious reflection of what transpired.

This research is preliminary and some of the conclusions speculative. Nevertheless, a model of empathy is emerging in which connections between mirror neurons and other brain structures could facilitate the observed components of empathy. For example, in our example of the stranger-triggered smile, the mirror neuron projections that are downward to the facial muscles and limbic system could provoke the feeling of happiness concomitant with the motor expression of a smile. These responses are rapid and unconscious. Secondary projections to the more newly evolved cortex provoke awareness of the feeling, thoughts about the social context of the transaction, and decisions about further actions. These are slower, more conscious elements of a complex response.

Empathy as a Clinical Tool

In medical practice, the power of empathy lies in its ability to help us cross, if only for a moment, the divide between clinicians and patients created by their very different circumstances. To briefly bridge that divide and to become simply two humans sharing an experience can help in accomplishing professional diagnostic and therapeutic tasks. We have all experienced the gratitude of patients, isolated by depression or family loss, for our expression of understanding of their sadness.

Succeeding at the greater challenge of putting aside our disagreement with a patient requesting chronic narcotics or perhaps our negative judgment of a patient unable to quit smoking can have proportionally greater rewards. Being willing to imagine what it must be like for these more challenging patients can provide us with insights into what motivates them or what might help them. That is diagnostic information. Communicating that insight may encourage patients to change their behavior, and that is therapeutic. Our disclosure also allows us to check the accuracy of what we think we know about the patient’s state. We relinquish nothing of ourselves or our role in that moment; we simply expand our perspective.

Empathy can be defined as an intellectual identification with, or vicarious experiencing of, the feelings, thoughts, or attitudes of another. Thus, there are both cognitive and affective dimensions of empathy. Despite having found neurobiological correlates of both, there remains disagreement about their functional relationship and relative importance. Some have described empathy as a momentary identification with another person in which our human capacity to feel what another feels erodes the boundaries of self. If we, in fact, temporarily lose awareness of self, the process might better be termed “sympathy for” or “feeling with” someone else. Remaining aware that we are experiencing empathy prevents total dissolution of ego boundaries and permits a more salutary stance. Empathy skills are behaviors that demonstrate empathy. They are among the clinician’s most powerful therapeutic tools.

Research suggests that empathy skills can be taught. This chapter will describe how to develop and improve these skills. Research has recently shed light on the frequency of empathic opportunities in clinical practice, on how physicians respond to or neglect these opportunities, and the implications of such choices. Empathic opportunities occur in more than half of surgical and primary care visits, although on average there are more opportunities per visit in primary care than in surgical care. Patients initiate most of the opportunities. Contrary to common belief, surgeons respond empathically at least as frequently as primary care physicians, but both miss opportunities to respond more frequently. Empathic behaviors enhance the effectiveness of care as well as patient satisfaction, and their absence may predispose patients to initiate malpractice suits.

There are numerous barriers to discussing emotions with patients (see Table 2-1), from the impersonal office setting to the disinclination of both physician and patient to address particularly sensitive topics. Nonetheless, appropriate skilled communication can break through these barriers.

Understanding the feelings, attitudes, and experiences of the patient is the first step toward a more potent therapeutic alliance. Many patients, however, may not be skilled in revealing their feelings to their providers. They need to be made aware that their doctor is interested in their feelings and values them, and that feelings are a legitimate topic for discussion in a medical interview.

Emotions can be difficult for both doctors and patients, and doctors, in particular, may prefer the certainty of science. From the patient’s point of view, if difficult emotional issues are manifested as a somatic complaint, denial might be the first reaction to a psychological interpretation of the symptoms. The physician must appreciate and mirror the terms in which a patient will speak about illness. In many cultures, emotions are simply not discussed. In the United States, where the biomedical model of disease predominates over the biopsychosocial model, patients may feel that it is more acceptable to have physical rather than emotional complaints. Because this expectation is often reinforced by their physicians, it is important for physicians to establish a climate conducive to the expression of emotional material and a language useful to that end. Physicians often mention the following barriers to discussing emotions with patients.

1. 
   

   It takes too much time. In a busy practice, concerns about time are legitimate. Given an organized framework, however, it takes only a few minutes to deal effectively with emotion, and the strategies discussed later in this chapter can prove time efficient for the physician. Recent studies suggest that interviews in which physicians respond to emotions may actually be shorter than those in which they do not. An explanation of this finding is that it may be more time consuming to deal with the indirect effects of unaddressed emotions during the rest of the interview. Moreover, it may be useful to distinguish between “acute efficiency” and “chronic efficiency.” “Efficiency” should take into consideration not only the duration of a particular visit but also the total amount of time required to address the patient’s concerns. Even if it were to take a few extra minutes to address emotions, that time is more than compensated by fewer phone calls and fewer unscheduled visits.

   
   
2. 
   

   It is too draining. It is unrealistic to expect all providers to be emotionally available at all times to all their patients. A physician who has been awake all night or is emotionally needy may be justified in putting off a discussion of emotions that should otherwise occur. If the physician chooses to defer, it would be wise to return to the topic at another time. Primary care providers sometimes exert a tremendous amount of energy avoiding emotions in the belief that dealing directly with them will be draining. However, it can be far more efficient to make an emotional connection than to expend so much energy in resisting it.

   
   

   At times, patients may inadvertently raise issues that are emotionally difficult for their providers. Sometimes the clinician can discuss the difficulty with friends, family, or colleagues; at other times it may be most fruitfully addressed in the physician’s own therapy. (A longer discussion of this area is beyond the scope of this chapter, but difficult encounters with patients offer physicians an opportunity for personal growth; see Chapter 4.)

   
   
3. 
   

   The interview will get out of control. Although many doctors worry that addressing emotions will cause feelings to escalate, the opposite is often true. Addressing emotions helps diffuse them. Learning a language to handle emotions creates a comfortable distance from the emotions themselves, so that neither the doctor nor the patient becomes overwhelmed.

   
   
4. 
   

   I cannot fix it for the patient. Primary care providers are used to “fixing” things. Feelings, however, simply exist, and cannot be “fixed.” Patients do not expect their feelings to be eliminated; they just want them to be understood.

   
   
5. 
   

   It is not my job. Some doctors believe that their job is to address disease and the psychotherapist’s job is to address mental illness. There are several problems with this attitude. Although it is certainly true that collaboration with mental health practitioners is important, at least two-thirds of patients with mental and behavioral problems are cared for mainly by primary care physicians. Physicians who insist on interpreting the physical symptoms of psychiatric disease, such as panic disorder or depression, in purely biomedical terms miss the point—and their patients will not get better. Telling a patient who develops chest pain on the anniversary of his father’s death (see “The Therapeutic Language of Empathy”) that there is nothing wrong with him will help the patient only briefly. Moreover, many physical illnesses have psychosocial sequelae that must also be addressed.

   
   

   When a patient keeps returning with the same complaint, unimproved by a physician’s interventions, the patient is trying to communicate a message. Physicians are often frustrated by these patients; this frustration can be alleviated and the doctor’s satisfaction improved by the progress that comes with addressing the underlying problem.

   
   
6. 
   

   Perceived conflicts of interest. Although the more apparent financial conflicts of interest presented by managed care may have diminished in recent years, it is likely that new potential conflicts of interest will continue to arise even as the field upon which these play out changes. Physicians have always needed to balance the needs of the patients in front of them with those of society at large. Research has now demonstrated that patients prefer having their concerns acknowledged and validated rather than the physician blaming an external party for shared constraints. Physicians who feel challenged by patients’ questioning their motives are likely to act defensively. The empathy skills offer an alternative that makes the physician a partner again.

Feelings that arise in the provider during an encounter may be useful in forming a diagnostic hypothesis about the patient. For example, a doctor who feels burdened, heavy, or “down” during an interview might consider the possibility that the patient is depressed.

All clinicians have had the experience of trying to help a patient with a behavior change, such as weight loss, only to have each suggestion rejected: “I’ve already tried that, Doc; it doesn’t work.” The physician’s own feelings of frustration and powerlessness in trying to motivate the patient are often mirrored by the patient’s sense of frustration and powerlessness in attempting to accomplish the change in behavior. The physician can confirm the hypothesis that the patient is frustrated, as with any other diagnosis, by testing: “I’m feeling frustrated with this problem, and I’m wondering if you’re feeling the same way.”

Some patients consistently elicit dislike and rejection from their providers. It may seem that the patient is intentionally trying to manipulate the provider into becoming angry. This may in fact be true. When providers become aware of these feelings, they should consider the possibility that their own impulses to punish the patient may be playing into the patient’s self-image as deserving of punishment. This pattern may be consistent with a borderline personality disorder (see Chapter 29).

The physician’s experience does not invariably reflect the patient’s experience. Rather, physicians should notice their own feelings and ask, “Does the way I feel tell me something about the patient or something about myself?” For example, a physician who has recently seen a number of patients seeking drugs begins to feel angry and defensive on noticing that the nurse has recorded “low back pain” as the next patient’s chief complaint; these negative feelings indicate more about the physician’s recent experiences than they do about the next patient. Feelings are primary data about the person in whom they arise and indirect data about others. The next section clarifies how to test the hypothesis that a patient is feeling a particular emotion and outlines how to respond.