Imagine a medical student sitting in the room across from a 50-year-old female standardized patient who presents with fatigue and vague abdominal pain. It’s their second year of medical school, and they know generally how to conduct a patient interview. They eventually reach the family history, concerned that any incidence of pancreatic cancer in the family may mean the standardized patient is in for a long, scary and painful journey of diagnosis and treatment. The question finally arises, “any family history of a cancer diagnosis?” The standardized patient, without skipping a beat, calmly tells you that her father passed away from pancreatic cancer over ten years ago at age 59. The student knows what to do; they have been trained extensively in the ways of empathy. They pause, say “I’m sorry to hear that,” then pause again for dramatic effect.
During feedback, the student’s preceptor and the standardized patient applaud their excellent empathy. They really showed the standardized patient that they cared for her in providing consolation for her deceased relative. The student is sure to make an excellent doctor one day. Medical students are told that they need to constantly insert “empathy statements” into the medical interview, so they throw in “I’m so sorry” when the standardized patient tells them anything remotely negative. They make these statements, get the grade, and move on. But is this empathy?
No, that was not empathy. But that was an easy one. Medical students must know already to throw away the “I’m so sorry” and are trying their best to relate actively to their patients. But is empathy even the best way?
Check out another scenario: that same student is on their first day of their ER clinical rotation their 3rd year. The first patient they see is a 30-something guy with ten-out-of-ten abdominal pain. They check his charts, and it’s the fifth time he’s been here for the same complaint. The diagnosis? Drug-seeking. Well, actually, it’s opioid withdrawal causing abdominal pain. Either way, they (as a team, of course) have a decision to make: they can give the man the Dilaudid, immediately relieve his pain and suffering and send him on his merry way with hopes of outpatient follow-up. Or they can do the dirty work by safely allowing him the pain and suffering of withdrawal to the fullest extent and having the hard but important conversation regarding his drug use to find him the resources and means of acquiring the help he needs. Which option should they choose? Which option displays empathy?
I’d argue option two is the best option, though it is not the option that displays empathy. The biggest issue in the empathy dilemma is how we define empathy. The dictionary defines empathy as “the psychological identification with or vicarious experiencing of the feelings, thoughts or attitudes of another.” Or, as author Paul Bloom puts it in a Vox interview about his book Against Empathy, “by empathy I mean feeling the feelings of other people. So if you’re in pain and I feel your pain …If you’re being anxious, I pick up your anxiety. If you’re sad and I pick up your sadness.” Essentially, empathy (what more modern research has called “emotional empathy”) is when you put yourself in the shoes of the other person and feel the feelings they feel.
Counter to this runs compassion (known as “cognitive empathy” in the literature). As Paul Bloom puts it, “I give your concern weight, I value it. I care about you, but I don’t necessarily pick up your feelings.” Compassion is the modality of caring tremendously about the person you are engaging with, just like with empathy. However, the distinction is drawn there. For compassion, you care for them unconditionally (and not just when they are hurting, as in empathy) and do your best to help them in the most logical and appropriate ways you can. Paul Bloom makes the distinction clear with this example, “if I have empathy toward you, it will be painful if you’re suffering … It will lead me to avoid you and avoid helping. But if I feel compassion for you, I’ll be invigorated. I’ll be happy and I’ll try to make your life better.”
This piece is focused on the applications of empathy and compassion in decision-making. In its simplest form, empathy deals with feelings while compassion deals with understanding. If I see the drug addict in the emergency department bed in ten out of ten pain, and I take on the pain and feel it as if twisting my own innards, that’s empathy. As I argue throughout this piece, this emphasis on feeling what the patient is feeling can cloud one’s ability to best provide for this patient. If I instead see the same patient, have a sense and understanding of the kind of pain he is in (even if I have never felt the same pain) and work to alleviate the pain in the most appropriate and beneficial long-term fashion, I am showing compassion. Through compassion, I am able to properly distance myself from his pain, think rationally about what is best for his case (as I am not bogged down by the anguish taking on his abdominal pain myself) and act on it to help this young man become overall healthier. Through empathy, I take a dose of Dilaudid for myself.
One of the main issues with focusing on empathy is that empathy can only be properly applied to a narrow spectrum of people. Empathy acts as a spotlight and can effectively highlight only a single individual or very small group of people at a time, and the person or persons are usually from a background most similar to ours. In order to truly empathize with someone, we must be able to relate personally to their background and situation and feel like we can intuitively understand their lifestyle. Since feeling empathy is a deeply personal connection, it cannot be properly and effectively applied to a larger group of people due to each individual’s unique situation and identity. The implications? Paul Bloom notes, “It’s because of empathy we often care more about a single person than 100 people or 1,000 people … We care more about an attractive [person] who went missing than we do a 1,000 starving children who don’t look like we do or live where we don’t live.” Empathy’s main issue is a deeply human one: we care far more for those in our in-group than we do for those in the out-group. And it’s through the utilization on empathy, not compassion, that our preference for the in-group can cloud out the more rational decision making that may benefit the larger group of people.
Take the anti-vaccination community for example. We know that, according to the WHO, vaccines have saved around 732,000 lives in just the last 20 years and have saved $1.38 trillion in societal costs. So why have their tactics been so effective that, according to a 2016 survey, around 20% of respondents in the USA denied that vaccines were important for children to receive and 30% denied that vaccines were safe and effective? You guessed it: empathy.
Take this story from a mother in Canada, “In December 2007, my five-month-old daughter was given [a series of vaccines]. Two days later she had a grand mal seizure. I told the doctor and nurses that she just had her shots two days ago and they said well maybe she had a fever from the shot and that caused her seizure … My concerns were ignored and brushed off.” The post continues, “ In July 2008 she received five vaccines. Within a week she was having two seizures a week, then three and multiples in a day. She also stopped talking — she won’t even babble, just moans different pitches.” Hearts ache for the mother and child. Vivid pictures of a baby girl suffering pop into minds and hearts. The story ends as one could imagine, “I cry every day for my child and those responsible must be held accountable for doing this to our children. I don’t want even one more mother and child to go through what we’re going through. It’s preventable and avoidable.”
What responses does one have to this? Trying to rebuttal generally sounds like “but banning vaccines will inevitably lead to thousands of children dying randomly of preventable infectious diseases.” But how do you empathize with that? That’s a statistical abstraction. This is why we have heard time and time again that statistics don’t work to persuade people who make their choices out of empathy rather than logical thinking. It’s so much easier to be scared of vaccines when, for example, your best friend’s first-born suffers anaphylaxis as a result of administration of a TDaP shot than to recognize the thousands of children potentially saved from devastating muscle contractures, whooping cough, respiratory distress and likely death as a result of the development of the TDaP vaccine in 1948. Compassion, on the other hand, has one recognize the pain of the mother who lost her child to a vaccine allergy but, by not being burdened with the anguish themselves, is able to recognize that this is a literal one-in-a-million occurrence and is significantly outweighed by the tremendous personal and societal benefit of herd immunity.
This is not to say empathy is useless. Empathy is what makes watching movies and TV shows so entertaining. Think back to how you felt when, in the face of adversity and likely defeat at the hands of Thanos, Captain America turns around to find that the rest of the Avengers, each with their own marvelous entrance, have finally made it to the battlefield to support him in the quest to save the world. The relief in his eyes, accentuated by the background solo trumpet crescendoing into an upbeat marching melody, made him, and the audience in his shoes, feel supported and confident that he can defeat his foe, emulated by his ultimate “Avengers, assemble!” Or when you listen to the newest Ariana Grande song and feel with her as each of her relationships blossoms and crumbles. As she learns her lesson from each ex-relationship, listeners do too. But in decision-making scenarios, empathy is not the right tool to use.
Take a look at health care. As health care providers, from doctors to nurses to pharmacists to everyone in between, we are expected to be the epitome of empathy. We are taught empathy from day one in graduate school through standardized patient encounters similar to the one described above. Nurses are constantly told that their job revolves around empathy and that it is their job to be the empathetic shoulder for patients to find relief. From blog posts to research studies to YouTube videos, we are constantly told we need to improve our empathy to become better providers. When faced with this heavy burden of suffering, we are expected to find empathy around every corner at all times.
However, constant empathy leads to what research has called “burn-out” or “compassion fatigue,” but what I believe should really be called “empathy fatigue,” as it is defined as “an extreme state of tension and preoccupation with the suffering of those being helped to the degree that it is traumatizing for the professional.” How can providers spend all day absorbing the misery and sadness of the hospital wards and come out unscathed? Now burn-out is not solely due to emotional exhaustion; there are a myriad of other factors that can lead to it, including overwhelming bureaucratic tasks, spending too many hours at work and the burden of the electronic health record system. However the health care provider reaches the state of burn-out, the catastrophic result is the same: suboptimal care. When health care providers burn-out, they develop diabetes, coronary heart disease, musculoskeletal pain, insomnia, depression and job dissatisfaction, all influencing the provider’s ability to effectively practice medicine.
Paul Bloom puts the distinction between empathy and compassion in the health care community another way, “Suppose you come to me and you’re freaked out, you’re anxious. Do you really want me to get anxious too? … If you’re depressed, you don’t want me to sink into depression … You want me to sort of be uplifting, cheer you up, put things in perspective.” This is what we as physicians should be doing for our patients. Instead of absorbing their troubles and wanting to do our best to immediately block out their pain, we should instead be understanding of their troubles and be detached enough to remain level-headed and properly manage the issue at hand.
Remember back to the standardized patient encounter at the beginning? Here’s a quote in Paul Bloom’s book from a standardized patient on that same situation, “I have this checklist and I have to measure empathy. But when I got sick and went to the doctor, I was grateful to [the doctor] who kept a reassuring objectivity … His calmness didn’t make me feel abandoned, it made me feel secure. I needed to look at him and see the opposite of my fear, not its echo.”
What can we do to solve this epidemic of “empathy fatigue” and health care burnout? It begins with learning about the proper definitions of these two distinct forms of patient relation and properly utilizing them. If we can’t even define empathy correctly, how can we hope to understand the damage it can cause? The next step involve becoming more mindful during your workday and noting when you are being empathic and when you are being compassionate.
Consistent awareness of your thought processes will make you more easily recognize which route you normally take and allow you to be more mindful of choosing the compassionate versus empathic route with patients. Buddhist meditation for millennia have focused more on compassion than empathy, preferring to provide unrequited love to all beings rather than overwhelm their emotions with the burden of one single person’s problems. This may be another way to work on developing the skills of compassion. Lastly, continue to take action and find ways to be more compassionate for your patients rather than empathetic. We must be confident and articulate in our decisions with patients and have them realize the long-term benefit of the suggested treatment plan. Patients pay hundreds of thousands of dollars out-of-pocket for all sorts of cosmetic plastic surgery augmentations to endure pain, swelling, and the risks of deformation in the short-term to achieve their desired physical appearance in the long run. We need to push for this same time of long-term thinking in all other aspects of health care.
What are the benefits of this shift from empathy to compassion? Besides the mitigation of burn-out, studies have shown the changes in wellness when participants used compassionate versus empathetic meditation techniques. They have MRI-proven reduced amygdala reactivity and heightening amygdala-ventromedial prefrontal cortex connections, which led to improved overall mood and affect. As one veterinarian puts it, “because compassion generates positive emotions, it counteracts negative effects of empathy elicited by experiencing others’ suffering. Compassion does not fatigue — it is neurologically rejuvenating!”
I strongly believe that compassion, not empathy, is the fix to a major problem plaguing health care. It provides a way for providers to care for their patients and do what is best for them in the long-term without absorbing their distress and worry and causing detrimental physical and psychological effects. So the next time you hear that standardized patient congratulate you on your amazing “empathetic statements,” think to yourself: is that kind of empathy really what my patients need?