Should Doctors Be Less or More Empathetic?

Empathy is an important trait in medical decisions, but a delicate balance is needed.

I have always been an empathetic person, both professionally and personally. My notion was that it was a requirement in my profession as a physician, as one cannot understand illness if one cannot empathize with one's patient.

While caregiving can be a career, caring in general is a learned behavior. Empathy is not innate, but as humans, we can choose to be so at varying degrees on a spectrum. Readers of fiction, for example, are found to be more empathetic than readers of nonfiction.

In medicine, there is a balance that has to be reached with empathy both for the patient and the provider. On the one hand, it is necessary to truly feel what someone else feels, especially when going through a medical issue. Only in this way can you treat a patient like your own family, which is the only way to practice medicine (in my humble opinion).

On the other hand, can too much empathy lead to faster burnout?

Doctors think they know

Dr. William Osler was one of the founders of Johns Hopkins Hospital and started the idea of a medical residency training program. In his 1912 essay, “Aequanimitas,” Osler argues that by neutralizing their emotions to the point that they feel nothing in response to suffering, physicians can “see into” and hence “study” the patient’s “inner life.” The viewers stand apart from what they observe. This contrasts markedly with the ordinary meaning of empathy as “feeling into” or being moved by another’s suffering.

Many physicians think this way, especially those in the “old school” like Osler because they think that they know better than their patient who is directly affected by an illness. They know the patient, and they know what is going on clinically. This is a phenomenon known as anchoring bias because clinicians think that they know an answer based on all previously known information.

But diagnosing a disease is often half the work in medicine. The emotional connection with a patient and the building of trust is the other part. That is how you garner the most useful information from a person. This is where empathy plays more of a role and helps clinicians move their anchor.

Empathy builds a patient’s trust, which leads to disclosure. This can be nonverbal by matching tone of voice or just simply making eye contact, something we see less of in our computer-driven world. When doctors attune to patients nonverbally, patients feel more comfortable and give fuller histories.

In almost every case, I am surprised by what I learn from the patient and end up leaving the room with a completely different plan than I had when I first entered. I am often reminded, as soon as I step into a patient’s room, how little I know. In this way, having an empathetic connection helps me in my job just as much as it helps my patients. Empathy is the key to patient-centered care.

Patient-centered care

In my most-read article, I discussed that medical decision-making must be a shared task between the clinician and their patient. It matters for everything from trust in your provider to how often a patient will take recommended medications. Empathy is understood to have key dimensions: emotive, cognitive, and behavioral.

The emotive and cognitive components relate to clinicians’ abilities to experience and share in another person’s feelings and understand another person’s feelings from an objective stance. The behavioral dimension refers to a clinician’s ability to communicate their understanding of another person’s perspective. All components are required for the best course of action for a patient.

People have reported that a clinician’s ability to firstly understand them (cognitive dimension) and secondly express this understanding (behavioral dimension), is a key aspect of the therapeutic relationship. While these are key in a patient-centered relationship, there are barriers to empathy as well.

The barriers to empathy are the same ones that may result in poorer outcomes since the patient-physician relationship breaks down when empathy is missing.

Time constraints are one barrier to empathy. If I am seeing 35 patients in 8 hours, it will be extremely hard to empathize with each one, especially since disease severity is variable. I will spend more time with and empathize more with people who I think are more ill, whether I am right or not.

The stakes are higher, and the attention goes to those who need it the most. However, this leads to another barrier as many physicians will only take the disease into account, not the emotional state of a patient. If emotional needs are not seen as a key to health and illness, the outcomes in the patient-physician relationship will be poor.

Physicians who feel angry with patients and yet find such feelings unacceptable face barriers to thinking about the patient’s perspective. If these barriers prevent an emotional connection, then shared decision-making will be less feasible. This is detrimental. But, too much empathy can be a barrier of its own.

Burnout from caring too much or too little

Burnout is defined as a psychological syndrome involving physical depletion, feelings of helplessness, and negative attitudes toward work, life, and others. More and more workers in the medical field are feeling burned out, especially since the pandemic.

Less staff in a system that has more patients leads to time constraints and, therefore, a barrier to empathetic care. There is an inverse relationship between empathy and burnout. Clinicians have less time to spend with patients, which leads to not being able to express empathy rather than a lack thereof. In one review of ten different studies on the relationship between empathy and burnout, eight of them showed a negative correlation.

The one study that showed a positive correlation postulated that compassion fatigue was the reason for those feelings. Psychologist Heidi Allespach, Ph.D., of the University of Miami’s Miller School of Medicine, knows that the big hearts that propel people into caregiving careers also put them at risk of developing compassion fatigue. “Without enough of a shield, everything just comes in,” says Allespach. “And being overwhelmed with the feelings of others can feel like drowning.”

Empathy is finite

To reiterate my perspective, I cannot imagine being less empathetic when it comes to my patients. There seems to be less of a risk in running out of empathy from direct patient relationships than there is in losing it to the burdens of the modern medical system. The providers within our systems have enough empathy to go around, but they need support from the systems themselves. This is the shield Dr Allespach referred to.

Staring at a computer screen while talking to someone going through a severe illness leads to less connection and less empathy. After all, it is hard to connect to a person when worrying about clicks on a screen simultaneously. Likewise, being a patient who has to beg their insurance company for medicine leads to anger towards their providers, regardless of how hard they may be working. Empathy must be nourished and replenished.

My only choice is to listen and connect for as much time as I have available. I understand how limited time is in general, but especially in a 15-minute visit. Utilizing that time to understand someone else’s pain and illness makes physicians better. Because without an understanding of someone’s struggles, how can we understand happiness and good health?