Wednesday, December 23, 2009

On Empathy (Marin IJ)

Contemporary medical practice has many virtues – it is diverse, e-savvy, and employs an amazing array of diagnostic and therapeutic tools. Modern medicine can open clogged arteries, replace vital organs, and restore 20/20 vision. It can defeat nasty germs and remove tumors with microscopic precision. And, lest we forget, it can also laser away body hair and make wrinkles disappear (temporarily, that is). I think you’ll agree, medical care today is truly amazing – most of the time. One area, however, where the system struggles is in the practice of empathy – the acknowledgment and understanding of a patient’s physical and emotional condition. It’s not that we don’t understand the benefits of empathy; on the contrary, evidence shows that patients with empathetic physicians are more satisfied and more compliant with their treatment regimens. Rather, it’s that empathy, in comparison with the nuts and bolts of diagnosis and treatment, is both underappreciated and under-nurtured.

According to a study in Academic Medicine (2008), the “hardening” of physician’s hearts begins in medical school. Using a standardized questionnaire, the vicarious empathy (spontaneous empathetic response) of 419 University of Arkansas medical students was measured at the beginning of each year of school. Over time, the researchers found a significant decline in student empathy scores – especially after the first and third year. There are a number of potential explanations for these findings – academic work-load and stress, poor clinical role models, and, especially after medical rotations begin in the third year, a need for an emotional defense system. But whatever the reason or reasons, the empathy drain often continues from training into clinical practice. Even those doctors who can recover their emotional idealism find that the realties of the business – crowded waiting rooms, voluminous charting and coding, complicated protocols and guidelines, and litigation – tend to squeeze out the very thing they need most to act empathetically – time…time to listen to what patients have to say. But, since time and patient volume tend to be unyielding obstacles, are there other ways that medical professionals can nurture their empathy back to health?

Karl Pilkington, co-host of the Ricky Gervais Guide to Medicine, has a far-fetched solution: a machine that transports the patient’s feelings directly into his or her doctor’s body. In other words, an empathy machine that “makes my doctor feel like me.” In Pilkington’s farcical universe, physicians-in-training would use this machine to experience a vast array of sensations that their patients may someday visit them with. For example, they may experience “a swift kick in the bullocks so that they can remember what that feels like.” As ridiculous as this example is, there is a spot on principle embedded in Pilkington’s proposal. A recent study found that new mothers scored higher on empathy scores when watching videotapes of other new mothers than did women without children. But, absent a means of making medical professionals experience all relative conditions, what else can be done?

A group of seventy Rochester, New York, primary care physicians received a 12-month training (2 months intensive, 10 months maintenance) in mindfulness that included a component of cognitive empathy – which is distinguished from vicarious empathy in that the providers make a conscious effort to understand what their patients are experiencing. These providers were tested before, during, and after this training on a series of wellness scales – including burnout, mindfulness and empathy – and the results were published in JAMA this past September. The investigators found modest, but consistent improvements across many scales, including a several percent improvement in empathy scores, leading them to conclude that “participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care.” This study offers hope that it is possible to train physicians in the practice of empathy, but is certainly limited in its wide-scale feasibility (the program required approximately fifty total hours of training) and its results (modest improvements that may or may not have persisted after the maintenance program ended). And while I applaud such efforts to remind doctors of the importance of empathy, both for their own good as well as for that of their patients, ultimately we must take a broader view of the topic.

Look around you, or think about the interactions you’ve had so far today. I think you’ll agree with me when I say that empathy is in short supply these days. And while few of us expect empathy from the executives of a Fortune 500 company, most of us expect it from our doctors. But, the two are connected. Doesn’t it make sense that the amount of empathy in our medical system would closely mirror the amount of empathy practiced in our society? In a get-rich-fast, quick fix, “me” time, bottom-line driven society like ours it is awfully difficult to expect a different ethos from medicine. So, while individual physicians can and should (and do) attempt to bring greater empathy to their care, as we enter the holiday season, we might each consider how we can bring greater empathy into our society at large.