Empathy or the ability to appreciate someone else’s emotions and express this emotional awareness is a capacity that differs amongst individuals.
Cognitive empathy refers to imaginatively understanding another person’s thoughts, feelings and actions. Emotional empathy is feeling the emotion of another person, but maintaining a compassionate, other-focused perspective
Cognitive empathy can be tested with facial expression recognition. High scores on empathy is associated with higher accuracy at brief exposure of six different emotional expressions presented in 42 pictures during 50 milliseconds each picture. When these facial expressions of 6 different emotions were shown for a longer duration the social skills was significantly related to accuracy instead of the empathy score. Difficulty reading facial expressions leads to impaired social understanding.
Another important areas of empathic accuracy research is the ocular level or the area around the eyes. This region is important because of its evolutionary and neurobiological significance. This region expresses important information about the expresser and as such creates the ability to accurately read the mental states of others through cues provided by the ocular region. From recent research it’s concluded to be able to accurately “read or experience” another persons feelings by watching their eye region is unrelated to gender, self-esteem, Big Five personality, and a number of empathy related traits. This results in a lack of individual factors that predict empathic accuracy.
However, imagination or individuals who often use imagination in imagining how another person feels and thinks does accurately predict empathic accuracy when observing the ocular region
individuals who have a tendency to imagine themselves in situations or relate to fictional characters may be better able to simulate others’ feelings and thoughts and thus be better able to infer accurately the mental states of others. Perhaps, this habit of imagining the inner world of others develops one’s empathic accuracy ability through sustained and motivated practice.
I guess some small steps in understanding empathy and individual differences.
Besel, L., & Yuille, J. (2010). Individual differences in empathy: The role of facial expression recognition Personality and Individual Differences DOI: 10.1016/j.paid.2010.03.013 Lee, S., Guajardo, N., Short, S., & King, W. (2010). Individual differences in ocular level empathic accuracy ability: The predictive power of fantasy empathy Personality and Individual Differences DOI: 10.1016/j.paid.2010.03.016
Empathy is an important asset for a doctor. This ability to appreciate patients’ emotions and express this emotional awareness improves clinical outcomes, professional satisfaction, and patient adherence to medical recommendations, and is believed to significantly improve patient satisfaction. More on empathy and what it is can be read here
Moreover, empathy for the mentally ill is often more difficult for physicians and med students, probably because they are unable to imagine the suffering of mental illness. Teaching empathy during medical education is difficult. They studied a variety of interventions, ranging from literature and medicine courses, attending a theatrical performance, and reflective writing to participating in a student hospitalization experience lasting 24–30 consecutive hours. These studies reported a qualitative increase in student empathy.
A recent study was published about the challenge of teaching medical students empathy for the mentally ill and the task of helping medical students understand what it is like to suffer from a mental illness.
While the students were listening to the auditory hallucinations, they underwent a psychiatric interview and simplified cognitive testing and were asked to socially interact in the community.
Before and after the experiment the Jefferson Scale of Physician Empathy, Student Version, were used. After listening to the simulated auditory hallucinations and participating in the simplified neurocognitive testing, the students’ empathy score increased. Students in the comparison group had no significant difference in their empathy scores.
This study suggests that empathy may be increased when med students are given a brief glimpse into the mind of mentally ill patients. Students could better understand the behavior of patients with mental illness after this experience.
This study didn’t have a follow up, which is necessary to see whether the increase in empathy is maintained over time. William Bunn, D.O. and Jan Terpstra, M.D. (2009). Cultivating Empathy for the Mentally Ill Using Simulated Auditory Hallucinations Academic Psychiatry DOI: 10.1176/appi.ap.33.6.457
There is a significant decline in empathy occurs during the third year of medical school. This decline occurs during a time when the curriculum is shifting toward patient-care activities.
There is a significant decline in empathy during third year of medical school, regardless of gender or specialty interest.
Every year women scored significantly higher than men.This seems to be regardless of population studied. It also appeared in Italian Physicians and Japanese medical students.
Except for scores at baseline, students interested in people-oriented specialties scored significantly higher than students interested in tech-oriented specialties.
The magnitude of the decline (effects) was much smaller for women and students interested in people oriented specialties.
Why is empathy important?
Responsiveness to the emotional state of another plays a fundamental role in the patient doctor relationship (PDR) as well as in other human interaction. Sympathy and empathy are not the only responses in the PDR. Other responses can be consolation, kindness, politeness,compassion, and pity.
What is empathy (the long version)?
The most clarifying definition of empathy is based on viewing it as a process. This process of empathy consists of the following stages.
The patient expresses feelings by way of verbal and non-verbal communication. Patients are not always aware of these expressions.
The doctor also notices these emotions in himself more or less voluntary, more or less conscious. He or she coming aware of these feelings usually comes after the fact (affective empathy).
Realizing these feelings as being from the patient is the cognitive empathy. Together with everything the doctor knows about the patient as a patient and as a person, he or she is coming to know the inner feelings of the patient(cognitive empathy).
The doctor can now express these feelings for the patient or act on them for the patient(expressed empathy).
The patient receives this empathy (received empathy).
What is the difference with sympathy? Empathy is an effortful process by which we try to comprehend another’s experience, while sympathy would be a direct perceptual awareness of another person’s experience akin to the phenomenon of sympathetic resonance. Sympathy does not necessarily require feeling any kind of congruent emotions on part of the observer, a detached recognition or representation that the other is in need or suffers might be sufficient.
The authors of a recent study in which they followed a cohort of medical students (n=456) with the Jefferson Scale of Physician Empathy at five different times also stress important distinctions between empathy and sympathy:
expressing empathy, as opposed to expressing sympathy, is more objective and accurate,
intellectual rather than emotional, altruistic, requires more effort but conserves energy, has more positive effects on the clinician (such as personal growth and career satisfaction), and leads to better patient health outcomes
Empathy is a cognitive skill with an affective root that can be taught, and that attitudes toward it can be reliably assessed.
The authors also discuss causes of this decline during medical education which to my opinion can sometimes be applied to residents and specialists.
Lack of adequate role models.
A high volume of materials to learn.
Time pressure, sleep loss.
Overreliance on computer-based diagnostic and therapeutic technology which limits their vision for the importance of human interactions in patient encounters.
To much emphasize on market-driven health care systems and evidence based medicine.
The most important factor to my opinion, as also stated in the accompanying editorial, is the impact of role models. Inappropriate role models such as the use of vulgar humor, unprofessional behavior or keeping a to great professional distance to the patient and their care result in a negative effect on empathy by those who still have to find their way into the medical profession. In the future another danger is awaiting such as the restrictions due to the increasing load of administrative work, many hospital guidelines restricting autonomy. Medicine is not Business.
In another commentary by Howard Spiro he emphasizes the change from listening to a patient towards using the computer for looking at images and lab results. He states
The eye is for accuracy, but the ear is for truth.
I think this especially applies to our somatic colleagues.
Since empathy is partly a cognitive skill and since it can be measured the autors suggest 10 approaches for enhance empathy during medical training.
improving interpersonal skills
analyzing audio- or video-taped encounters with patients
being exposed to role models
role-playing (aging game)
shadowing a patient (patient navigator)
experiencing hospitalization
studying literature and the arts
improving narrative skills
watching theatrical performances
engaging in the Balint method of small-group discussion.
Hojat, M., Vergare, M., Maxwell, K., Brainard, G., Herrine, S., Isenberg, G., Veloski, J., & Gonnella, J. (2009). The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School Academic Medicine, 84 (9), 1182-1191 DOI: 10.1097/ACM.0b013e3181b17e55 Spiro, H. (2009). Commentary: The Practice of Empathy Academic Medicine, 84 (9), 1177-1179 DOI: 10.1097/ACM.0b013e3181b18934 Crandall, S., & Marion, G. (2009). Commentary: Identifying Attitudes Towards Empathy: An Essential Feature of Professionalism Academic Medicine, 84 (9), 1174-1176 DOI: 10.1097/ACM.0b013e3181b17b11
There are patients with congenital insensitivity to pain (CIP) this is a rare condition. They don’t feel pain, cognition and sensation is otherwise normal; for instance they can still feel discriminative touch (though not always temperature), and there is no detectable physical abnormality. They offer a unique opportunity to test the model of empathy. Does the lack of self-pain representation influence the perception of others’ pain.
According to the doctor who started and runs a private facility that offers the best spinal pain treatments in the world and also has four patients that suffer with CIP, CIP patients globally underestimate the pain of others when emotional cues were lacking, many doctor recommend to use for diferent pains Bodyice icepack joint specific ice and heat compression system that moulds around injured joints and body parts, and that their pain judgments, in contrast with those of control subjects, are strongly related to interindividual differences in empathy trait. More empathy better pain judgment.
Patients with CIP showed normal fMRI responses to observed pain. The same regions for observed pain in anterior mid-cingulate cortex and anterior insula, were activated. In contrast to healthy controls their empathy trait predicted ventromedial prefrontal responses to somatosensory representations of others’ pain and posterior cingulate responses to emotional representations of others’ pain. CIP patients can acknowledge the pain of others. The amount strongly correlates with their empathic capacity which mainly relies on the engagement of anterior the ventromedial prefrontal cortex (vmPFC) and posterior the ventral posterior cingulate cortex (vPCC) midline structures, which may in part compensate for the patients’ lack of automatic resonance mechanisms.
Why is this study important?
It provides insights into the brain’s ability to evaluate others’ feeling to observed pain without having a specific sensory experience of pain itself. These findings can elucidate the three components of pain processing.
It can be simplistically divided into three domains that are interconnected and/or influence each other through direct or indirect pathways. Most of the regions commonly activated in the CIP-group and C-group are shown in bold in the figure and include regions thought to be involved in emotional processing of pain
Some regions were active in both groups this suggests a generalized or common circuitry for emotional processing. Some regions differ in activation. These differences in activation in regions (medial frontal gyrus and posterior insula and caudate for body parts and the cingulate [mid and posterior]) noted in this study are of greater interest. These four regions are differentially activated in the CIP-group and not in the control group. These regions may provide some interesting insights into the processing of empathy.
The medial frontal gyrus is involved in regulation of cognitive control.
The mid- and posterior cingulate gyrus is involved in conscious awareness and might also be involved in processing self-relevant emotional and nonemotional information.
The posterior insular cortex, sometimes termed the ‘‘sensory insula,’’ may be involved in perception and object recognition
How was this study done?
we used event-related functional magnetic resonance imaging (fMRI) to study the neural correlates of empathy for pain in a group of 13 CIP patients and a control group of 13 healthy subjects. Participants were scanned while observing body parts in painful situations (Experiment 1) or facial expressions of pain (Experiment 2), and were instructed to imagine how the person in the picture feels. We anticipated that CIP patients, deprived as they are of the depicted pain experiences, would show decreased activation in regions supposedly involved in automatic resonance to others’ pain, including the anterior insula (AI) and anterior mid-cingulate cortex (aMCC). In addition, we predicted that the patients’ effort to build a representation of others’ pain might engage brain areas known to be involved in emotional perspective taking, especially midline structures such as medial prefrontal and posterior cingulate cortices
N DANZIGER, I FAILLENOT, R PEYRON (2009). Can We Share a Pain We Never Felt? Neural Correlates of Empathy in Patients with Congenital Insensitivity to Pain Neuron, 61 (2), 203-212 DOI: 10.1016/j.neuron.2008.11.023
D BORSOOK, L BECERRA (2009). Emotional Pain without Sensory Pain—Dream On? Neuron, 61 (2), 153-155 DOI: 10.1016/j.neuron.2009.01.003
In a prior post on this blog about empathy sometimes a distinction is made between cognitive and affective empathy. These two concepts refer to our ability to put ourselves in the shoes of another person, be it in their mental or emotional shoes. These concepts are difficult to differentiate. Especially for cognitive empathy this is a simplification since mental states could in principal also include feeling and emotional states.
Affective empathy refers to the process which allows us to experience what it feels like for another person to experience a certain emotion or sensation. The capacity to understand other people’s emotions by sharing their affective states is fundamentally different in nature from the capacity to mentalize.
That is to my opinion the reason why empathy can be taught to a certain level. We can teach empathy to a cognitive level not to an affective level as explained in another recent post on this blog about teaching empathy in med school.
The last post about this subject will be posted on next Monday 4th of August.
Prior neuroimaging studies of empathy have shown that by observing another’s emotional state, part of the neural circuitry underlying the same state becomes active in oneself, whether it is disgust, pain or social emotions.
In a recent review of the neuronal basis of empathy the authors concluded that:
sharing sensations and emotions with others is associated with activation of circuitries involved in the processing of similar states in ourselves, involving the secondary somato-sensory cortices for touch, insular cortex and anterior cingulate cortex (ACC) for pain and disgust and amygdala for fear. Globally, these regions constitute the ‘‘emotional’’ brain and most of these structures are usually referred to as limbic and para-limbic structures. They are crucial for emotional processing and developed early in phylogeny. By contrast, mentalizing abilities have been shown to be associated with activation in pre-frontal and temporal cortices, most importantly the medial pre-frontal lobe (mPFC) and posterior superior temporal sulcus (STS), structures which belong to the neo-cortex and developed late in phylogeny
This means that the ability for affective empathy was acquired earlier in our development throughout our evolution than cognitive empathy.
Empathy is based on limbic and para-limbic structures as well as on somato-sensory cortices should develop earlier than our ability for cognitive perspective taking because the former rely on structures which develop early in brain development, whereas the latter rely on structures of the neo-cortex which are among the latest to mature, such as the prefrontal cortex and lateral parts of the temporal cortex.
Moreover, the finding that the dorsolateral prefrontal cortex (DLPFC) has not fully matured up to an age of 25 is interesting since this suggests that the full capacity for effective and adaptive empathic responding is not developed until late adolescence.
Anyway, far to less of hard results to fully understand empathy from a neuroscience view point but nevertheless an exciting area with a lot of new discoveries in the near future, and I will keep you posted.
A robot with empathy sounds like the stuff of sci-fi movies, but with the aid of neural networks European researchers are developing robots in tune with our emotions. The tantalising work of the Feelix Growing project is grabbing the world’s attention.
Through the combination of cameras,sensors, artificial neural networks and software development ICT results are developing robots that can respond to human emotions.
If someone shows fear or cries out in pain, the robot may learn to change its behaviour to appear less threatening, backing away if necessary. If someone cries out in happiness, it may even detect the difference, and one day fine-tune its responses to individuals.
These developments can be promising to all kinds of employments:
Robots that can adapt to people’s behaviours are needed if machines are to play a part in society, such as helping the sick, the elderly, people with autism or house-bound people, working as domestic helpers, or just for entertainment, according to Canamero.
In the video on the website you can see some of the actions and uses of these robots, it is amazing.
No I don’t think so. For several reasons. Empathy is a process with different steps. Especially feeling what the patients feels is a quality not every doctor has. And if they do it is not always appropriate nor possible to be sensitive enough to use it. Moreover this process not only needs the quality it is also costs energy, depends on the relationship with the patient, and needs experience.
Along with their education medical students loose some of their humanistic attitudes such as empathy especially during their medical clerkship, often they become more cynical during their clinical training. Empathic feelings are difficult to generate when they have no experience or when the patient is difficult to know or communicate with, while further barriers include a stressful working environment and lack of time.
Empathy is somewhat beleaguered these days in an era in which “quick fixes” are encouraged by a managed care system driven by economic values. In The Netherlands we call it the DBC system.
Next post on Patient Doctor Relationship Series about self disclosure Friday 25th of July. What can we clinicians teach them?
First of all good bedside manners:
Ask permission to enter the room; wait for an answer.
Introduce yourself, showing ID badge.
Shake hands (wear glove if needed).
Sit down. Smile if appropriate.
Briefly explain your role on the team.
Ask the patient how he or she is feeling about being in the hospital.
Teaching empathy is as argued before in this post not possible. But we can teach empathy to a cognitive level instead of an affective level. It is important to learn the students during their clerkship to conduct an interview in a way that encourages the patient to share their concerns. Instead of a disease centered interview teach them a patient centered interview.
Proposed methods for promoting the ability of medical students to elicit the patient’s feelings, distress, and concerns:
Ensure as much privacy as possible when interviewing the patient. “Break the ice” by expressing sustained respect and interest throughout the interview, e.g., maintain eye contact and a body posture slightly bent forward.
Listen carefully to the patient’s account of her history and do not interrupt her for at least two minutes. Encourage the patient’s spontaneous narrative by nodding and permit the patient to take control of the interview.
Watch for indirect verbal and nonverbal clues of the patient’s feelings. Respond with an accurate and explicit acknowledgment of the patient’s emotions, distress, and concerns. Encourage the patient to talk not only about his symptoms, but also about his personal and family situation, preferences, and feelings.
Toward the end of the interview, if appropriate, ask one or more of the following questions:
Of all your problems, which is the one that worries you most?
Do you have any preferences or suggestions about what your management should be?
Do you have any ideas regarding what caused your illness?
What are your plans for the future?
How does all this make you feel?
How did you/your family feel when you were told about your illness?
Encourage the patient to ask questions about his disease and his main concern(s) by asking Do you have any questions regarding your condition?
This last list is from a article published in Academic Medicine.
I like the comparison with acting. Real empathy is comparable to deep acting, engage in emotional labor, generating empathy consistent emotional and cognitive reactions before and during empathic interactions with the patient.(Deep acting is comparable to the method-acting tradition used by some stage and screen actors). What can be learned by all medical students is surface acting or forging empathic behaviors toward the patient, absent of consistent emotional and cognitive reactions, or both.
Although deep acting is preferred, physicians may rely on surface acting when immediate emotional and cognitive understanding of patients is impossible.
What do you think about empathy and doctors, can it be learned? Am I being to pessimistic?
Let me know in the comments.
Previous posts in this series about patient doctor relationship: Empathy Consolation reduces stress Benbassat, J., Baumal, R. (2004). What Is Empathy, and How Can It Be Promoted during Clinical Clerkships?. Academic Medicine, 79(9), 832-839.
Responsiveness to the emotional state of another plays a fundamental role in the patient doctor relationship (PDR) as well as in other human interaction. Sympathy and empathy are not the only responses in the PDR. Other responses can be consolation, kindness, politeness,compassion, and pity.
Empathy and sympathy: at first glance, the 2 concepts fit perfectly with medical practice. Clearly, these are emotions competent clinicians must know how to display; they are a part of good bedside manner.
This is the first post in a series about the Patient Doctor Relationship.The next post will be on Saturday, July 19th.
Next post on this subject: Consolation reduces stress
My point is that good bedside manners is something each doctor can and has to learn as well as sympathy when called for. Empathy is a quality not every human or doctor possesses. Moreover, experience and age enhance the use of empathy. Not to say that lack of experience or being young excludes the possibility for showing empathy, there are still natural talents out there.
What is empathy?
The most clarifying definition of empathy is based on viewing it as a process. This process of empathy consists of the following stages.
The patient expresses feelings by way of verbal and non-verbal communication. Patients are not always aware of these expressions.
The doctor also notices these emotions in himself more or less voluntary, more or less conscious. He or she coming aware of these feelings usually comes after the fact (affective empathy).
Realizing these feelings as being from the patient is the cognitive empathy. Together with everything the doctor knows about the patient as a patient and as a person, he or she is coming to know the inner feelings of the patient(cognitive empathy).
The doctor can now express these feelings for the patient or act on them for the patient(expressed empathy).
The patient receives this empathy (received empathy).
The best and shortest explanation of empathy is in the German word for it: Einfühling
Empathy usually is part of a process such as the patient doctor relationship, psychotherapy, counseling or caring by a nurse.
The difference between empathy and sympathy?
As far as empathy and sympathy are concerned it is unclear whether they represent distinct phenomena or whether they reflect parallel processes that covary across situations.
Empathy is an effortful process by which we try to comprehend another’s experience, while sympathy would be a direct perceptual awareness of another person’s experience akin to the phenomenon of sympathetic resonance. Sympathy does not necessarily require feeling any kind of congruent emotions on part of the observer, a detached recognition or representation that the other is in need or suffers might be sufficient.
The difference between emotional contagion and empathy
In a recent article in the New York Times: At Bedside, Stay Stoic or Display Emotions?, to my opinion some examples of emotional contagion are displayed:
Dr. Benita Burke, skipped lunch to spend extra time with her cancer patients. They dubbed this time “mental health rounds,” during which they could address issues that were not strictly medical. Many times, Dr. Burke would wind up in tears or giving an embrace.
Emotional contagion – This is when someone identifies with the strong emotions of others and tends to become subjective to the same emotions themselves. Emotional contagion however does not require that one is aware of the fact that one experiences the emotions because other people experience them, rather one experiences them primarily as one’s own emotion.
With empathy there is no confusion between the feelings and needs belonging to the patient and to the doctor. Empathy is neutral, aimed at understanding the other and not about feeling for the other, empathy is unselfish, free from prejudice.
Empathy to me is a valuable tool in the patient doctor relationship, but not a simple one. It costs a lot of energy, emotional energy. It usually needs at least a working alliance with a patient or other therapeutic forms of a relationship. A lot of questions remain about empathy. Is empathy a trait or a state or a combination of both? Can you teach empathy?
What do you think about empathy? Let me know in the comments.
Jahoda, G. (2005). Theodor Lipps and the shift from sympathy to empathy. Journal of the History of the Behavioral Sciences, 41(2), 151-163. DOI: 10.1002/jhbs.20080
Empathy, cooperation, fairness and reciprocity — caring about the well-being of others seems like a very human trait. But Frans de Waal shares some surprising videos of behavioral tests, on primates and other mammals, that show how many of these moral traits all of us share.
Excellent lecture by one of the great Dutch scientists.
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