Friday Reflection 13: Empathy Earned and Learned

AC is a 40-year-old man with back pain. He is healthy and has never had similar symptoms before. While out for a run, he developed a severe, spasm like pain in his right lower back. The pain worsened over 24 hours leaving him unable to sit, stand or lie comfortably.

“Sympathy vs. Empathy” was the title for a session in the “Patient-Doctor” course during my first year of medical school. Fresh out of a pricey (for the time) liberal arts education, I had no problem distinguishing these two emotions. Nonetheless, the class inspired me and I left it committed to becoming an empathic doctor. I began sprinkling my patient interviews with terms like:

“I know how you feel.”

“I certainly understand that.”

“That is a very difficult situation.”

I think I succeeded in sounding empathic.

It took a few decades for me to realize that true empathy takes work. It is acquired only through mindfulness combined with the experience of pain, illness and loss. In short, empathy can be learned but not taught.[i]

That my early career empathy was well meant but a bit of a sham became clear after an episode of back pain. As a general internist I seldom go a week without seeing someone with back pain. I’d always done a good, caring, evidence-based job with these patients. One morning, however, my entire approach to the complaint changed.

I was about five minutes into a jog when I felt like I was pierced by a spit. My right lower back seized up and I limped home. Over the day, the pain worsened until I was left sleeping on the floor in a broth of acetaminophen, ibuprofen, Percocet and cyclobenzaprine – basically whatever happened to be under my bathroom sink at the time. It was awful. Four weeks and a whole lot of physical therapy later, I had acquired a daily exercise routine and a new appreciation for “lumbago.”

Now, just watching a person with back pain enter the exam room, sit on the table, discuss their days, brings back my own experience. I am more patient. I listen better. I am more thoughtful in my approach to diagnosis and management. I am more forgiving of non-adherence. I am more empathic.

Aging has yielded too many opportunities for heightened empathy: orthopedic injuries; sinusitis; pneumonia; a bout of Clostridium difficile; a PE. I could, unfortunately, go on (and on). For a physician, maybe the perfect outcome of an illness is recovery with no lasting disability but a newfound empathy for others with the same problem. When I enter a room to find a patient with a labral tear, the empathy is there. This is direct empathy; empathy arising from having experienced what your patient is experiencing.

Inferred empathy is less physically painful but does take some work. It requires applying a personal experience to a patient’s unrelated condition. Inferred empathy is critical as no one person can experience all the traumas that would be necessary to otherwise become an empathic physician. We learn to use a personal experience with pneumonia to understand a patient’s experience with endocarditis. We apply lessons learned from the death of a parent to the patient who has lost her spouse. Inferred empathy is what younger, less experienced physicians and trainees need to be taught.

Learning to be empathic is, in some sense, self-perpetuating. Knowing what it feels like to empathize with someone with back pain makes it clear when you lack empathy for someone with, say, insomnia or chronic abdominal pain. This mindful practice allows you to continue to  get better at the job. It also makes it possible to recognize when empathy is impairing practice. Too much empathy is good neither for the doctor nor his patients.

A few years ago, my mother suffered a serious neurological event. For two weeks – two weeks that I was scheduled to attend on our inpatient general medical service – I accompanied her from the “Neuro ICU” at NYU, to the neurology ward, to Schwab Rehabilitation Hospital in Chicago. When she was ready for the move to subacute rehab, I returned to work, picking up a service from the colleague who had graciously stepped in for me. 

Let’s just say that I was not at my best during my two-week stint in the hospital. There were situations for which my heightened empathy rendered me nearly worthless. Every one of our patients had me obsessing about how this man might or might not recover, what sort of disability this woman might end up with, and how this parent’s illness would affect her adult child. These, of course, were important issues, but my obsessing kept me from thinking about the critical tasks intrinsic to caring for hospitalized medical patients, such as generating differential diagnoses and determining management plans.

One interaction was unforgettable. The patient was an older man who had been admitted with a lower extremity cellulitis. He was recovering from his infection but it had become clear that he was failing at home. Sending him home would be somewhere between inadvisable and dangerous -- there was no question he would be readmitted within weeks. I stood with my resident, speaking to our patient and his daughter, and I knew the look on her face. It was a look I had worn two weeks before. Concern for a parent combined with the realization that her own life, as well as their relationship, had changed forever. The conversation about the risk of discharge, the need for better home supports or facility placement was one I’ve led hundreds of times. In these conversations, I usually successfully combine honesty, directness, authority and reassurance. On this day, I had to excuse myself and let my resident take over.

Months later, my empathy-related impairment had matured into a strength. Not only had I learned what happens to all those people I “discharged to rehab” – not through a lecture but by having lived it at my mom’s side -- but I also more fully understood the effect of serious illness on people and those who love them. I understood how people experienced their own loss of independence. For the first time I saw how disability can make one’s world contract. I could read the anxiety in the eyes of children as they came to terms with what was now expected of them. I could now address all these issues, even when the questions went unasked – either because people did not know the questions to ask or were afraid to voice them.

Our challenges as doctors change as our careers progress. During training, the young physician can hardly avoid being knowledgeable of the newest practices and most robust evidence. Her challenge is to translate often-limited life experiences into the empathy that will make her someone in whom a patient can put his faith. For the older doctor, empathy comes more easily but staying current may be more difficult. The experienced physician also needs to guard against empathy impairing the disinterested decision making that medicine requires.

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[i] As a medical educator, it pains me to write that.