Empathy: House of the Russian Doll (part three)

This is part 3 in a 3 part series on empathy:

Despite the growing interest in its potential benefits, empathy has struggled to find a place in traditional medical training. The emotional weight of empathy has always been considered counterproductive and potentially dangerous. Sir William Osler, one of the founders of Johns Hopkins and the architect of the medical residency system in the United States believed doctors should maintain a monastic posture and practice detached reasoning. He preferred a disciplined, intellectual approach to medicine that placed little value on identification with the emotional state of the patient or the usefulness of perspective taking. In his valedictory address, Aequanimitas, to the University of Pennsylvania’s School of Medicine in 1889, Osler set the stoic tone for the next century of US medical education. Borrowing the term from the deathbed epiphany of Antonius Pius, Osler advised physicians to be decisive and confident, but warned of the dangers of emotional identification with patients. “Curious, odd compounds are these fellow-creatures, at whose mercy you be full of fads and eccentricities, of whims and fancies;” Osler said, “but the more closely we study their little foibles of one sort or another in the inner life which we see, the more surely the conviction borne in upon us of the likeness of their weaknesses to our own. The similarity would be intolerable if a happy egotism did not render us forgetful of it.” This Victorian guild mentality pervaded medical training and became entrenched. Stoicism gradually surrendered to intellectual callousness and “hardening of the heart” that Osler warned against. As medicine advanced in lockstep with post-war technological progress, empathy and the emotional aspects of medical training were not only ignored but aggressively suppressed.

American sociologist, Robert K. Merton, captured the prevailing belief in the restriction of clinical empathy. In 1957, he wrote in The Student-Physician that the “physician must be emotionally detached in his attitudes towards patients, keeping his emotions on ice and not becoming over identified with patients.” This concept was echoed later by medical sociologist, Renne Fox. In her seminal work, Experiment Perilous in 1959, she wrote “the physician is expected to maintain a dynamic balance between ‘detachment’ and ‘concern’…to be sufficiently objective or detached towards the patient to exercise sound medical judgment and maintain his equanimity.” It was thought that by practicing safe empathy with detached concern and avoiding emotional involvement, a physician could objectively and rationally treat disease. Most mid-century medical educators preferred more detachment and less concern. American medical education and training not only recommended empathy be limited to intellectual curiosity, but actively discouraged emotional identification with patients. Despite the unmistakable influence her work had on medical training, Fox felt her concept of detached concern had been subverted and misunderstood as a dichotomy rather than a duality. She later wrote that her work was, “interpreted in a way that I did not intend….detached concern is considered to be a form of detachment; and it is viewed critically as representative of a traditional medical stance that places greater emphasis on cognitive detachment from patients’ feelings than on empathic emotional attunement to them.”

The rise of consumerism and a new interest in the emotional health of patients during the 1980’s led to a renaissance for clinical empathy. The emergence of the internet and patient access to an expanding pool of medical information strained the detached, but benevolent paternalism that marked the traditional doctor-patient relationship. Most physicians and medical educators struggled with their emerging parity with patients, but some appreciated the link between quality and empathy. In his presidential address to the American Orthopedic Association in 1987, J. Leonard Goldner, MD, the influential orthopedic chairman-emeritus of Duke University, recognized this new dynamic, stating “the physician’s goal is high-quality care obtained by knowledge, empathy, and altruism.”

Increasing the acceptance of empathy in medicine continues to be difficult. Empathy is a fragile trait and data suggests that the more medical education and training physicians receive, the less empathic they actually become. Recent work has tracked the steep decline in empathy over the course of the traditional four year medical school program. A similar longitudinal study of an internal medicine program demonstrated continued loss of empathy during residency training. New data shows that the more mental health clinicians learn about the biologic reasons for their patients’ disorders the less empathy they express. This apparent knowledge-based “empathy deficit” may be why research shows that doctors miss 70–90% of opportunities to express empathy during medical interviews.

Rather than the loss of empathy, the empathy gap physicians experience during their years of training may instead represent the existence of empathic flexibility. Rigorous work examining empathy in humans and mammals suggests that physical, social, and cultural differences decrease empathy between groups. These barriers diminish the capacity for empathy, discouraging both its cognitive and emotional components.The dehumanization of disease that results from technologically centered medical care may be impairing our ability to treat our patients with empathy. The more we strive to differentiate ourselves from the public through knowledge, the more difficult we are making it for us to emotionally resonate with our colleagues, community, and patients. Cloistering information alienates and divides us. The simple tradition of wearing white coats, begun in the latter portion of the nineteenth century to emphasize the science of medicine, separates us from our patients and makes it more difficult for us to feel empathy for them. Conversely, group identification and even imitation can sharpen empathic activity. For example, a simple experiment has shown that tapping in synchrony with someone else increases empathic brain activity. Common ground can be found in even the most culturally diverse or adversarial situations and can kickstart the empathic cascade.

The problem of restoring empathy in medicine is also challenged by the same neural architecture that allows us to feel empathy in the first place. Neurobiologists have found that the pathways for empathic and analytic thought may be mutually exclusive. In fMRI examinations of students at rest, brain activity cycles between the analytic and areas, but when presented a math or physics problem, the analytic process continues but empathy areas of the brain shut down. Emotional problem analysis conversely activity inhibited intellectual analysis. Reciprocal inhibition rules the mind. This perceptual rivalry between analytic thought and empathy is similar to the mechanics of an optical illusion. Is it a drawing of a duck on its side or a rabbit? You see one facing one way or the other but not both at the same time. This may explain why doctors generally find detached reasoning easier than emotional investment. If neural inhibition is involved in the empathy gap, techniques will be needed to ease this biologically driven repression by altering work patterns. If perceptual rivalry makes emotional multitasking difficult, then medical history and physical examinations may need to be distributed and data entry delegated to scribes. Even the social and medical aspects of history taking may need to be separated to improve accuracy.

If an empathic volume control does exist, can it be fine tuned through training? Yes. Helen Reiss, MD, a psychiatrist and professor at Harvard Medical School, has spent her career studying empathy in medicine. She instituted an empathy training program for resident physicians focusing on techniques designed to decode a patient’s emotional state, temporarily merge another’s perspective, and then analyze this data to improve treatment. Her clinical work has demonstrated the mutability of empathy. Levels of empathy in medical resident subjects rose with dedicated training or decayed over time with neglect. Her research demonstrates the efficacy of the empathic triad of cognitive empathy, affective empathy and empathic concern. It also shows how important non-verbal gestures and facial expressions are to our ability to decode someone else’s emotional perspective.

Facial expressions are vital in revealing true emotional content. In 1978, Ekman and Friesen catalogued both macro and micro-facial movements into a Facial Action Coding System designed to help interviewers, behavioral researchers, and therapists unravel a subject’s true emotional state. Humans use a complex mix of macro-facial expressions lasting ¼ to 4 seconds and fleeting unconscious micro-facial expressions lasting less than ¼ second. By paying close attention to the use of body language, facial expressions, and brief gestures, an interviewer can boost their emotional IQ.

The success of empathy education has led to the commercialization of emotional intelligence. Dr. Reiss is now the Chairman of Empathetics, Inc. a Harvard University sponsored healthcare startup that markets online empathy training. Dr. Ekman, whose work inspired the television crime drama, Lie to Me, now sells both Micro Expression and Subtle Expression Training Tools for professional facial recognition training. The federales have also gone into the empathy business. National Science Foundation grants paved the way to developing Oncotalk, a communication program designed to increase empathic behavior in oncology residents. The US Justice Department also funds research on empathy in the penal and criminal justice systems.

Empathy also has a treacherous dark side largely ignored in social research. All three limbs of the empathic triad need to function together in balance and remain finely tuned for empathy to be healthy. Too little affective empathy can lead to dehumanization and cruelty. Simon Baron-Cohen writes in, The Science of Evil, that evil arises from “empathy erosion.” The use of cognitive empathy without emotional identification may be the root of sociopathic behavior. In a unique 2014 study in Brain, Dutch neuroscientist Christian Keysers found that psychopathic criminals can finely modulate their levels of affective empathy and completely repress it when desired. This may be how they can hurt their victims yet remain socially seductive. Voluntary empathic control is likely behind cruel but effective techniques of interrogation and torture. Cold, detached intellect without emotional connection allows the torturer to know exactly what will inflict the most efficient type of pain on the victim.

If too little affective empathy is bad, then more must be good. Not necessarily. Too much affective empathy can result in empathic distress and cause guilt, fatigue, burnout, and even aggression. Emotional resonance must be brief and calibrated to be effective. If caregivers fail to emotionally disengage from a patient after assuming their emotional perspective, they risk blurring their own sense of self. Long periods of empathic distress, often experienced in intensive care unit workers or in combat, can result in symptoms similar to post-traumatic stress syndrome. If unrelieved, empathic fatigue can cause withdrawal and emotional isolation. Even brief periods of excessive emotional identification with a patient (or victim) can instill anger and the desire to exact punishment. In a provocative essay for The New Yorker, “The Baby in the Well”, Yale psychologist Paul Bloom writes “empathy can pull us in the wrong direction. The outrage that comes from adopting the perspective of a victim can drive an appetite for retribution.”

Empathic concern functions like an emotional pressure relief valve, releasing compassionate prosocial and altruistic action to lower levels of empathic distress. But unbridled altruism can cause substantial harm. A fascinating paper by systems engineer, Barbara Oakley, examines the potentially negative effects of empathy and altruism. Addictive co-dependency and acts of pathologic altruism often start with empathy and compassion. Governments may be the worst abusers of empathy and a fountain of pathologic altruism. Oakley writes, “that during the twentieth century, tens of millions individuals were killed under despotic regimes that rose to power through appeals to altruism.”

There is no denying the irresistible power of empathy. It can enlighten, connect, seduce, or heal. Empathy can be an invaluable tool for a physician dealing with a difficult patient, a businessman negotiating a complex international deal, or a parent struggling to understand a troubled child. The complex world of empathy is only now yielding to science. De Waal’s model of empathy is a good enough place to start. Tough outer intellectual layers fuse to protect a vulnerable emotional core like an empathy M&M. The multilayered bond forged by empathy requires accurate emotional identification. By quickly decoding a patient’s emotions through verbal and non-verbal cues, the mirror system is stoked and the cognitive component of empathy fires. The baton is then passed through to the deeper affective layers where the brain rapidly cycles between analytic and emotional neural nets. If properly tuned, this dials up the affective limb of empathy. Emotional resonance and echoing ensue, but even brief perspective shifts can be risky for both doctor and patient. Get in and get out. Touch and go. This can produce a wealth of emotional data and clinical insight for the trained mind. The result should be compassionate care that restores emotional balance and resets the empathic cascade. Sounds like a piece of cake, right? Wrong. Empathy is a fragile, complex, and sometimes dangerous tool. Welcome to the real house of the Russian doll.

About the author: Rocco Monto, MD is an award-winning and internationally recognized orthopedic surgeon, writer, and lecturer, based on Nantucket island. Dr. Monto is a health, fitness, and aging expert, as well as a spokesperson for the Americian Academy of Orthopaedic Surgeons and team physician for the United States Soccer. www.DrMonto.com

Follow Dr. Monto on https://www.facebook.com/RoccoMontoMD, https://twitter.com/RoccoMontoMD, and https://www.instagram.com/RoccoMontoMD

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