The role of EMPATHY: view of a medical student.
The Uses of Empathy: A Medical Student’s Perspective
11 March, 2008 11:14:00 James Fleming
Discussion of empathy in medical practice.
"Empathy is the feeling that 'I might be you' or 'I am you,' but it is more than just an intellectual identification… empathy brings emotion."[1]
While experienced health care practitioners may agree on a general definition of “empathy” and perhaps even recognize its theoretical appeal, they continue to disagree on its usefulness in clinical practice. For this reason, if we hope to discover its uses, then we must study empathy both in theory and through clinical experience. As Immanuel Kant once asserted, "Experience without theory is blind, but theory without experience is mere intellectual play." 2]
While I studied philosophy before medical school, I only began to understand the force of Kant’s dictum during my first clinical rotation as a medical student. In light of Kant’s advice, I will begin this essay by sharing a personal narrative.
***
I was half asleep in the library when my trauma pager flashed "Red Alert: female, motor vehicle collision, estimated time of arrival - ten minutes."
I raced to the Emergency Department. In the trauma bay I found a young woman covered with abrasions and contusions; she had been thrown from her vehicle. The resuscitation team, wearing blue non-latex gloves, surrounded her bed quickly. They intubated, administered intravenous fluids, inserted a Foley catheter, and ordered portable X-Rays. As suddenly as it had arrived, the ocean of blue gloves ebbed in all directions until I alone was left.
Our patient was not a candidate for immediate surgery. As a medical student on trauma surgery call, my job was to follow the surgical team. Nevertheless, because I already felt attached to this young woman I decided to stay by her side. What if she were to awaken? As her parents had not yet arrived, I wanted to stay close by.
Tom, her nurse, was adjusting the monitors and I remarked that her movements seemed purposeful, and that I did not think she was brain....
"Don't talk like that!" he yelled back at me.
At once I understood. She might be able to hear us. Tom turned to me and asked her name. Reaching for her hand I replied, “Her name is Sarah.”
Tom proceeded to call out to her loudly and with passion, “Sarah, can you hear us?” She did not respond. Yet, as I held her warm hand, I could not accept the possibility that her grip was mere reflex.
About this time I had to take on an unexpected role. Sarah’s parents had just arrived at the reception desk desperate for information. Yet, all of the residents who had cared for her that evening were busy treating patients elsewhere in the hospital. The staff at the reception desk wanted someone to take the parents to see their daughter immediately. As I had been with her throughout the night - to the CT scanner and through assessments by multiple consult services, and so on, it was clear that I knew the most about her injuries and current status. But who was I?
Surgery was my first medical clerkship, and I had only been on the service for a couple of weeks. What I knew of clinical medicine I had learned holding the camera in a handful of laparoscopic cholecystectomies. As I stumbled to the reception area, I knew that I could not rely on my two weeks of surgical training to get me through this encounter. I would have to rely on my twenty-six years of experience being human.
What would anyone do in this situation?
Well, I can tell you what I did. I identified with her parents emotionally. To tell the truth, I suffered with them.
When I had first arrived at Sarah’s bedside that evening, I had taken off my white coat and left it on a chair. As I went to find her parents, I grabbed it. Then I dropped it again; I could not hide behind the white coat any more than I could hide behind my two weeks of medical training.
From several paces away, I saw her parents. There was no mistaking them. Their eyes scanned the emergency department again and again, periodically and mechanically, like the strobe light on a light-house. I fixed my eyes on them, and they knew it was time to see their daughter.
"This way," I said. I took them close to Sarah’s bed, so they could look at their daughter as we talked. Then I tried to address their questions.
"I am not a doctor," I said. “I am a medical student who has had the honor to stay at Sarah’s bedside since her arrival at our hospital. What I can tell you is that she was involved in an unrestrained car wreck. She was flown in by helicopter immediately. She has multiple fractures, but her CT scan does not show any bleeding in the brain, which is encouraging.”
"We drove as fast as we could," the mother cried. The father was also in tears but less vocal. "Is she going to be OK?"the father eventually asked.
"I don’t know, but her doctors are doing the best they can. I’m sorry,” I said. “I can only imagine what this must be like for you."
Her parents began to speak to their daughter, "Sarah, Sarah, can you hear us? We love you. You are going to be alright. There are a couple of handsome doctors taking care of you and they are going to continue to take good care of you."
Around one o’clock in the morning, I left for the night. Sarah’s parents, however, were not interested in sleep. Even though rounds would not start for five or six hours, they waited anxiously for any report of her condition.
The next day I returned to her bedside, worried about over what I would find. I found Sarah's mother crying quietly. She had just been told that her daughter suffered from diffuse axonal injury (DAI), and might, or might not, wake up. The “handsome doctors” taking care of her could not do much more.
Nevertheless, Sarah’s mother managed to smile when I reassured her that Sarah looked much more comfortable in the ICU, without the bright lights and noise, than she had in the ER. She responded that she had also noticed that Sarah’s long brown hair had been combed free of debris from the accident. She thanked me for coming by.
I continued to visit Sarah during the two weeks thereafter- meeting her brother, her uncle, and her pastor on different occasions. As I became acquainted with each of them, I felt Sarah’s parents’ suffering more deeply. With each visit, I became slightly more nauseated from the anxiety I felt for the family. I would often delay my visit by stopping at the nurses’ desk to check lab values and progress notes – so that I could muster the bravery needed to stand in silence, yet again.
During the two weeks Sarah remained in the hospital, I found her in the neurosurgery ICU, then the burn ICU, and, finally, the trauma ICU. A busy hospital does not have enough free beds to keep a patient resting in any one place for long. Then suddenly, to my surprise, I returned to the ICU to discover that Sarah had been discharged to an outside facility. I had seen her for the last time.
I found myself wondering one afternoon, nearly four months later, whether Sarah’s condition ever improved. To find out, I looked to see whether she had been admitted to the hospital on any other dates since that discharge (the only information I was permitted.) I was relieved to discover that she had underwent several orthopedic operations as well as traumatic brain injury rehabilitation; Sarah survived her injuries and continues to recover. I continue to hope for the best.
***
Why did I experience so many feelings during my time caring for Sarah and her family? Where did these feelings come from? I was not yet a parent. I had not faced the prospect of losing a child. Nevertheless, I suffered from witnessing and then sharing Sarah’s parents’ suffering.
This sort of emotional identification is empathy as commonly defined. To revisit Howard Spiro’s definition, “Empathy is the feeling that ‘I might be you’ or ‘I am you,’ but it is more than just an intellectual identification… empathy brings emotion.”[1]
Richard Selzer adds, “The word empathy means the power of projecting one’s personality into the object of contemplation, and so fully understanding it.”[3]
Most everyone has feeling, but the ability to experience emotion does not automatically lead to the acquisition of emotional experience. One has to live life to appreciate the full range of human emotion. As Spiro also noted, to recognize sadness in a face, one at some time must have felt sad.[4]
While all of us have felt sad, a few of us have felt a deeper sadness. Several parents have told me that the loss of a child is one of the deepest forms of sadness; Sarah’s parents faced that possibility. Does the fact that I have not lost a child prevent me from relating to her parents’ sadness? I hope not; otherwise, the world would be a very lonely place. If we medical students listen carefully to a patient’s story and draw on the little experience we have, we can begin to imagine how the patient feels. In the process, we will suffer in proportion to our life experience. The discomfort brought on by such suffering will then compel us to ameliorate the patient’s suffering so that we might end our own.
Consider an analogy from the philosopher David Hume. In his work on human nature, Hume explains that with respect to our feelings we are each like strings on the same musical instrument, “As in strings equally wound up, the motion of one communicates itself to the rest; so all the affections readily pass from one person to another…”[5]
For example, who can bear the cry of a child? One feels compelled either to comfort the child or to leave the room. Perhaps “comforting the child” could be a metaphor for attending to patients - whether they require open-heart surgery or just a cup of ice chips. Perhaps “leaving the room” could be a metaphor for not listening to the patient long enough to determine if the patient understands the illness or treatment. Even the best protocols do not provide hope to the patient who does not understand the illness or the treatment.
Why do some physicians take the time to explain what is going on? I suggest that we look to empathy for the answer. The same empathy will enable the physician to recognize “the problems of living – existential, socioeconomic, and emotional”[4] that accompany major illness.
How does empathy function in this extraordinary way? Hume believed that we naturally identify with the emotions of others through an appreciation for cause and effect in the way that I have described. Hume described his own feelings as he witnessed the beginning of an 18th century operation:
“Even before it begun, the preparation of the instruments, the laying of the bandages in order, the heating of the irons, with all the signs of anxiety and concern in the patient and assistants, wou’d have a great effect upon my mind, and excite the strongest sentiments of pity and terror.”[5]
In this passage, Hume tells how the “signs of anxiety and concern in the patient,” rather than any knowledge of possible outcomes, aroused within him the feelings of pity and terror. In other words, the outward expression of emotion by the patient, once perceived by Hume, led to empathy.
Similarly, when I approached Sarah’s parents, I observed the distress in their eyes - a distress that I understood - even though I was no more a parent than Hume a victim of surgery. I listened as they told me that Sarah was a good girl and that they were proud of her. Their comments increased my empathy because they allowed me to feel how deeply her parents were suffering.
As a third year medical student, I have the luxury of time and limited responsibility. The technical aspects of patient care provided by the residents do not burden me. During my time caring for Sarah and her family, I now believe that my principle function was to care.
On the other hand, residents must master the technical aspects of patient care. That comes first in emergency room medicine. Does empathy add anything of value to their interaction with the patient?
Richard Landau, an experienced physician, says no and therefore argues for the ”desensitization and de-empathization” of medical students in training.[6] He believes that the expression of empathy often undermines a physician’s ability to function in the health care setting. While I disagree with Landau’s conclusions, my opinions are mere theory without experience, as I am not yet able to satisfy the demands of Kant’s dictum (i.e. understanding requires theory and experience.) But with each patient encounter I get a little closer.
The residents involved in Sarah’s care did not have the luxury of visiting for the length of time that I did. Does this imply that they could not have empathy? Not necessarily. Empathy, like forming a diagnosis, is a skill that improves with time. Just as many family physicians can diagnose influenza within seconds of laying eyes on a patient, many experienced physicians can identify suffering, and respond appropriately, in less time than perhaps they would have required as a medical student.
Young physicians must also learn to maneuver from patient to patient without becoming “emotionally spent.” Otherwise, listening and identifying emotionally with one patient may come at some expense to the next patient. Aristotle first recognized this danger and cautioned us as follows, “It becomes difficult… to sympathize closely with the joys and sorrows of many, because one is likely to be faced with sharing the joy of one and the sorrow of another simultaneously.”[7] I have worked with physicians who seem to have met Aristotle’s challenge and perhaps some who have failed. Those who have succeeded are ideal role models for doctors in training.
If the concept of empathy is championed early in medical school training, where every doctor’s journey begins, doctors will ask the question, “What are the uses of empathy?” for themselves. As they choose different specialties, lifestyles, and patient loads, they will surely answer this question differently, but at least they will have been encouraged to ask it in the first instance. As for myself, as I advance from student to resident, I can only hope that the memory of caring for Sarah will serve as a reminder of what I should strive for in each patient encounter.
FRIEND MARGARET; IF YOU GOT THIS FAR, PLEASE LEAVE A COMMENT FOR ME.
References
1. Spiro, Howard. “Empathy: An Introduction.” Ed. Spiro H., Curnen M., Peschel E., St. James D., Empathy and the Practice of Medicine. New Haven: Yale University Press, 1993. 1-6.
2. Darwall, Stephen. Philosophical Ethics. New York: Westview Press, 1998. 23.
3. Selzer, Richard. “Foreword.” Ed. Spiro H., Curnen M., Peschel E., St. James D., Empathy and the Practice of Medicine. New Haven: Yale University Press, 1993. ix-x.
4. Spiro, Howard. “What is Empathy and Can it be Taught?” Ed. Spiro H., Curnen M., Peschel E., St. James D., Empathy and the Practice of Medicine. New Haven: Yale University Press, 1993. 7-14.
5. Hume, David. A Treatise of Human Nature. Oxford: Oxford University Press, 2004. 368.
6. Landau, Richard. “…And the Least of These is Empathy.” Ed. Spiro H., Curnen M., Peschel E., St. James D., Empathy and the Practice of Medicine. New Haven: Yale University Press, 1993. 103-109.
7. Aristotle. Ethics. Trans: J. Thompson. London: Penguin Books, 1976. 308.
Author's bio
This essay also appeared in Yale's Journal for Humanities in Medicine.
11 March, 2008 11:14:00 James Fleming
Discussion of empathy in medical practice.
"Empathy is the feeling that 'I might be you' or 'I am you,' but it is more than just an intellectual identification… empathy brings emotion."[1]
While experienced health care practitioners may agree on a general definition of “empathy” and perhaps even recognize its theoretical appeal, they continue to disagree on its usefulness in clinical practice. For this reason, if we hope to discover its uses, then we must study empathy both in theory and through clinical experience. As Immanuel Kant once asserted, "Experience without theory is blind, but theory without experience is mere intellectual play." 2]
While I studied philosophy before medical school, I only began to understand the force of Kant’s dictum during my first clinical rotation as a medical student. In light of Kant’s advice, I will begin this essay by sharing a personal narrative.
***
I was half asleep in the library when my trauma pager flashed "Red Alert: female, motor vehicle collision, estimated time of arrival - ten minutes."
I raced to the Emergency Department. In the trauma bay I found a young woman covered with abrasions and contusions; she had been thrown from her vehicle. The resuscitation team, wearing blue non-latex gloves, surrounded her bed quickly. They intubated, administered intravenous fluids, inserted a Foley catheter, and ordered portable X-Rays. As suddenly as it had arrived, the ocean of blue gloves ebbed in all directions until I alone was left.
Our patient was not a candidate for immediate surgery. As a medical student on trauma surgery call, my job was to follow the surgical team. Nevertheless, because I already felt attached to this young woman I decided to stay by her side. What if she were to awaken? As her parents had not yet arrived, I wanted to stay close by.
Tom, her nurse, was adjusting the monitors and I remarked that her movements seemed purposeful, and that I did not think she was brain....
"Don't talk like that!" he yelled back at me.
At once I understood. She might be able to hear us. Tom turned to me and asked her name. Reaching for her hand I replied, “Her name is Sarah.”
Tom proceeded to call out to her loudly and with passion, “Sarah, can you hear us?” She did not respond. Yet, as I held her warm hand, I could not accept the possibility that her grip was mere reflex.
About this time I had to take on an unexpected role. Sarah’s parents had just arrived at the reception desk desperate for information. Yet, all of the residents who had cared for her that evening were busy treating patients elsewhere in the hospital. The staff at the reception desk wanted someone to take the parents to see their daughter immediately. As I had been with her throughout the night - to the CT scanner and through assessments by multiple consult services, and so on, it was clear that I knew the most about her injuries and current status. But who was I?
Surgery was my first medical clerkship, and I had only been on the service for a couple of weeks. What I knew of clinical medicine I had learned holding the camera in a handful of laparoscopic cholecystectomies. As I stumbled to the reception area, I knew that I could not rely on my two weeks of surgical training to get me through this encounter. I would have to rely on my twenty-six years of experience being human.
What would anyone do in this situation?
Well, I can tell you what I did. I identified with her parents emotionally. To tell the truth, I suffered with them.
When I had first arrived at Sarah’s bedside that evening, I had taken off my white coat and left it on a chair. As I went to find her parents, I grabbed it. Then I dropped it again; I could not hide behind the white coat any more than I could hide behind my two weeks of medical training.
From several paces away, I saw her parents. There was no mistaking them. Their eyes scanned the emergency department again and again, periodically and mechanically, like the strobe light on a light-house. I fixed my eyes on them, and they knew it was time to see their daughter.
"This way," I said. I took them close to Sarah’s bed, so they could look at their daughter as we talked. Then I tried to address their questions.
"I am not a doctor," I said. “I am a medical student who has had the honor to stay at Sarah’s bedside since her arrival at our hospital. What I can tell you is that she was involved in an unrestrained car wreck. She was flown in by helicopter immediately. She has multiple fractures, but her CT scan does not show any bleeding in the brain, which is encouraging.”
"We drove as fast as we could," the mother cried. The father was also in tears but less vocal. "Is she going to be OK?"the father eventually asked.
"I don’t know, but her doctors are doing the best they can. I’m sorry,” I said. “I can only imagine what this must be like for you."
Her parents began to speak to their daughter, "Sarah, Sarah, can you hear us? We love you. You are going to be alright. There are a couple of handsome doctors taking care of you and they are going to continue to take good care of you."
Around one o’clock in the morning, I left for the night. Sarah’s parents, however, were not interested in sleep. Even though rounds would not start for five or six hours, they waited anxiously for any report of her condition.
The next day I returned to her bedside, worried about over what I would find. I found Sarah's mother crying quietly. She had just been told that her daughter suffered from diffuse axonal injury (DAI), and might, or might not, wake up. The “handsome doctors” taking care of her could not do much more.
Nevertheless, Sarah’s mother managed to smile when I reassured her that Sarah looked much more comfortable in the ICU, without the bright lights and noise, than she had in the ER. She responded that she had also noticed that Sarah’s long brown hair had been combed free of debris from the accident. She thanked me for coming by.
I continued to visit Sarah during the two weeks thereafter- meeting her brother, her uncle, and her pastor on different occasions. As I became acquainted with each of them, I felt Sarah’s parents’ suffering more deeply. With each visit, I became slightly more nauseated from the anxiety I felt for the family. I would often delay my visit by stopping at the nurses’ desk to check lab values and progress notes – so that I could muster the bravery needed to stand in silence, yet again.
During the two weeks Sarah remained in the hospital, I found her in the neurosurgery ICU, then the burn ICU, and, finally, the trauma ICU. A busy hospital does not have enough free beds to keep a patient resting in any one place for long. Then suddenly, to my surprise, I returned to the ICU to discover that Sarah had been discharged to an outside facility. I had seen her for the last time.
I found myself wondering one afternoon, nearly four months later, whether Sarah’s condition ever improved. To find out, I looked to see whether she had been admitted to the hospital on any other dates since that discharge (the only information I was permitted.) I was relieved to discover that she had underwent several orthopedic operations as well as traumatic brain injury rehabilitation; Sarah survived her injuries and continues to recover. I continue to hope for the best.
***
Why did I experience so many feelings during my time caring for Sarah and her family? Where did these feelings come from? I was not yet a parent. I had not faced the prospect of losing a child. Nevertheless, I suffered from witnessing and then sharing Sarah’s parents’ suffering.
This sort of emotional identification is empathy as commonly defined. To revisit Howard Spiro’s definition, “Empathy is the feeling that ‘I might be you’ or ‘I am you,’ but it is more than just an intellectual identification… empathy brings emotion.”[1]
Richard Selzer adds, “The word empathy means the power of projecting one’s personality into the object of contemplation, and so fully understanding it.”[3]
Most everyone has feeling, but the ability to experience emotion does not automatically lead to the acquisition of emotional experience. One has to live life to appreciate the full range of human emotion. As Spiro also noted, to recognize sadness in a face, one at some time must have felt sad.[4]
While all of us have felt sad, a few of us have felt a deeper sadness. Several parents have told me that the loss of a child is one of the deepest forms of sadness; Sarah’s parents faced that possibility. Does the fact that I have not lost a child prevent me from relating to her parents’ sadness? I hope not; otherwise, the world would be a very lonely place. If we medical students listen carefully to a patient’s story and draw on the little experience we have, we can begin to imagine how the patient feels. In the process, we will suffer in proportion to our life experience. The discomfort brought on by such suffering will then compel us to ameliorate the patient’s suffering so that we might end our own.
Consider an analogy from the philosopher David Hume. In his work on human nature, Hume explains that with respect to our feelings we are each like strings on the same musical instrument, “As in strings equally wound up, the motion of one communicates itself to the rest; so all the affections readily pass from one person to another…”[5]
For example, who can bear the cry of a child? One feels compelled either to comfort the child or to leave the room. Perhaps “comforting the child” could be a metaphor for attending to patients - whether they require open-heart surgery or just a cup of ice chips. Perhaps “leaving the room” could be a metaphor for not listening to the patient long enough to determine if the patient understands the illness or treatment. Even the best protocols do not provide hope to the patient who does not understand the illness or the treatment.
Why do some physicians take the time to explain what is going on? I suggest that we look to empathy for the answer. The same empathy will enable the physician to recognize “the problems of living – existential, socioeconomic, and emotional”[4] that accompany major illness.
How does empathy function in this extraordinary way? Hume believed that we naturally identify with the emotions of others through an appreciation for cause and effect in the way that I have described. Hume described his own feelings as he witnessed the beginning of an 18th century operation:
“Even before it begun, the preparation of the instruments, the laying of the bandages in order, the heating of the irons, with all the signs of anxiety and concern in the patient and assistants, wou’d have a great effect upon my mind, and excite the strongest sentiments of pity and terror.”[5]
In this passage, Hume tells how the “signs of anxiety and concern in the patient,” rather than any knowledge of possible outcomes, aroused within him the feelings of pity and terror. In other words, the outward expression of emotion by the patient, once perceived by Hume, led to empathy.
Similarly, when I approached Sarah’s parents, I observed the distress in their eyes - a distress that I understood - even though I was no more a parent than Hume a victim of surgery. I listened as they told me that Sarah was a good girl and that they were proud of her. Their comments increased my empathy because they allowed me to feel how deeply her parents were suffering.
As a third year medical student, I have the luxury of time and limited responsibility. The technical aspects of patient care provided by the residents do not burden me. During my time caring for Sarah and her family, I now believe that my principle function was to care.
On the other hand, residents must master the technical aspects of patient care. That comes first in emergency room medicine. Does empathy add anything of value to their interaction with the patient?
Richard Landau, an experienced physician, says no and therefore argues for the ”desensitization and de-empathization” of medical students in training.[6] He believes that the expression of empathy often undermines a physician’s ability to function in the health care setting. While I disagree with Landau’s conclusions, my opinions are mere theory without experience, as I am not yet able to satisfy the demands of Kant’s dictum (i.e. understanding requires theory and experience.) But with each patient encounter I get a little closer.
The residents involved in Sarah’s care did not have the luxury of visiting for the length of time that I did. Does this imply that they could not have empathy? Not necessarily. Empathy, like forming a diagnosis, is a skill that improves with time. Just as many family physicians can diagnose influenza within seconds of laying eyes on a patient, many experienced physicians can identify suffering, and respond appropriately, in less time than perhaps they would have required as a medical student.
Young physicians must also learn to maneuver from patient to patient without becoming “emotionally spent.” Otherwise, listening and identifying emotionally with one patient may come at some expense to the next patient. Aristotle first recognized this danger and cautioned us as follows, “It becomes difficult… to sympathize closely with the joys and sorrows of many, because one is likely to be faced with sharing the joy of one and the sorrow of another simultaneously.”[7] I have worked with physicians who seem to have met Aristotle’s challenge and perhaps some who have failed. Those who have succeeded are ideal role models for doctors in training.
If the concept of empathy is championed early in medical school training, where every doctor’s journey begins, doctors will ask the question, “What are the uses of empathy?” for themselves. As they choose different specialties, lifestyles, and patient loads, they will surely answer this question differently, but at least they will have been encouraged to ask it in the first instance. As for myself, as I advance from student to resident, I can only hope that the memory of caring for Sarah will serve as a reminder of what I should strive for in each patient encounter.
FRIEND MARGARET; IF YOU GOT THIS FAR, PLEASE LEAVE A COMMENT FOR ME.
References
1. Spiro, Howard. “Empathy: An Introduction.” Ed. Spiro H., Curnen M., Peschel E., St. James D., Empathy and the Practice of Medicine. New Haven: Yale University Press, 1993. 1-6.
2. Darwall, Stephen. Philosophical Ethics. New York: Westview Press, 1998. 23.
3. Selzer, Richard. “Foreword.” Ed. Spiro H., Curnen M., Peschel E., St. James D., Empathy and the Practice of Medicine. New Haven: Yale University Press, 1993. ix-x.
4. Spiro, Howard. “What is Empathy and Can it be Taught?” Ed. Spiro H., Curnen M., Peschel E., St. James D., Empathy and the Practice of Medicine. New Haven: Yale University Press, 1993. 7-14.
5. Hume, David. A Treatise of Human Nature. Oxford: Oxford University Press, 2004. 368.
6. Landau, Richard. “…And the Least of These is Empathy.” Ed. Spiro H., Curnen M., Peschel E., St. James D., Empathy and the Practice of Medicine. New Haven: Yale University Press, 1993. 103-109.
7. Aristotle. Ethics. Trans: J. Thompson. London: Penguin Books, 1976. 308.
Author's bio
This essay also appeared in Yale's Journal for Humanities in Medicine.
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