Throughout medical school, my instructors stressed the importance of empathy, generally defined as the understanding of and identification with another person's emotional state. Sympathy and empathy, commonly confused with each other, are not the same. Sympathy is a statement of emotional concern while empathy is a reflection of emotional understanding. The applications of empathy are widespread [1,2], and are especially relevant in fields such as medicine, where the successful treatment of patients depends on effective patient-physician interactions. This article explores the concept of empathy and examines its utility in medicine from the perspective of a medical student.
What is Empathy?
Empathy is an emotional experience between an observer and a subject in which the observer, based on visual and auditory cues, identifies and transiently experiences the subject's emotional state . In order to be perceived as empathic, the observer must convey this understanding to the subject. During the initial phase of the process, the observer must not only identify but also understand the basis of the subject's feelings. For example, a physician may encounter a patient who appears depressed, expresses feelings of sadness and informs the physician that a close relative has recently passed away. This may cause the physician to recall subconsciously his emotional state during a similar situation in which a close relative died. Alternatively, he may not have experienced death in his family but may understand the emotional response to death in the patient's culture. In both of these situations, he may be able to respond empathically because he understands and can relate to the patient's current grief. In a different situation, the physician may have a dissimilar cultural background in which death is not associated with sadness but with joy and celebration of the deceased's life. Due to the conflicting associations with death, the physician may feel confused because he does not understand the basis of the patient's sorrow. Without understanding the nature and circumstances of the patient's emotional state, it may be difficult for the physician to generate an empathic response.
There is more to empathic understanding than simply knowing and evaluating objective information about a patient, however. Researchers have found that male friends have higher empathic accuracy than male strangers . While this is not surprising, it is interesting to note that the greater accuracy was correlated with a higher quality of shared information rather than a greater quantity of information. This result is especially relevant for practicing physicians, for it indicates that it is not enough to know a large amount of factual information about a patient. The physician who understands each patient on a personal level stands a far better chance of experiencing and conveying empathy and treating the patient and illness effectively than the physician who does not have that level of understanding.
It is also important that the physician possess sufficient communication skills to convey the feeling she is experiencing to the patient. In everyday life, people who are poor communicators and cannot adequately express their feelings are misunderstood by people around them. Thus, it is possible for a physician to be perceived as nonempathic when in actuality, she feels empathy but is unable to express it. Conversely, a physician who may not actually feel empathy may still be able to generate an appropriate response because she understands how she should respond in the situation and possesses excellent communication skills . As these examples illustrate, many factors influence the generation, expression and perception of an empathic response.
Researchers have long examined and discussed the utility of empathy in medicine and have found differing results. Some argue that it is not possible for a physician to genuinely empathize with every patient—to do so would be emotionally draining and difficult under modern time constraints . These researchers paint a picture of a physician who is best able to care for his or her patients by remaining "clinically detached" . By not becoming emotionally involved with patients, the argument goes, the detached physician is able to make objective decisions concerning their care.
Yet there is increasing evidence that, when choosing a physician, patients value affective concern as much as, if not more than, technical competence . As a medical student, I often heard descriptions of the characteristics of a "good doctor" from patients, instructors and even my family members. The one attribute that was always mentioned as necessary to being a good physician was being a good listener. Each patient wants to be treated as a person, not as an illness, and wants to be reassured that the doctor understands the nonmedical aspects of his or her condition. A doctor may be listening carefully to a patient, but the only way for the patient to know that is for the doctor to reflect that he understands the patient's concerns; i.e., to respond empathically. If it is a goal of medicine to treat the patient—to alleviate suffering and not simply cure disease—then empathy is a necessary clinical skill. It seems, then, that the physician must perform a difficult internal balancing act: by becoming too emotionally involved with the patient, she may lose objectivity; by not becoming involved enough, she may be unable to relate as a human being.
Research has shown that empathy is also useful on other levels; it has been found to be directly therapeutic by reducing anxiety in patients . When a patient feels that a physician understands his condition and apprehensions, he may feel more comfortable confiding in the physician. This process of telling one's story can be therapeutic  and may also help facilitate the healing process. Moreover, patients often do not explicitly state their psychosocial concerns , which may manifest as physical illnesses (somatization). The prevalence of somatoform disorders has been estimated to be as high as 30 percent , and can only be diagnosed by a physician who is carefully attuned to the patient . And, finally, empathy is beneficial to physicians; it has been demonstrated that doctors who are more attuned to the psychosocial needs of their patients are less likely to experience burnout .
Teaching and Learning Empathy
Although there is not a consensus on the best method of doing so, many researchers currently think that it is possible to teach and learn empathy [13-15]. When considering ways to develop the ability to be empathic, it is important to consider that empathic responses result from the interaction between behavioral and emotional factors. Thus, it is possible that increasing one's sensitivity to either of these factors will improve one's capacity for empathic response. For example, enhancing observation skills should make it easier to detect a patient's emotional state, while improving communication skills should help a physician convey his feelings to the patient.
The actual emotional process of empathy may be aided by exercises such as self-reflective writing, which helps an observer become more aware of her own emotions and subsequently improve her ability to be empathetic towards another . Cultural education and a wide range of interests should give physicians a greater frame of reference with which to understand and relate to a patient, thus making an empathic response more likely. Finally, it has recently been suggested that physicians who act empathically may be perceived by patients as being genuinely empathic . Physicians who practice this "deep acting" technique may, over time, learn to be genuinely empathic; thus, teaching acting may be a method of teaching empathy .
During the first two years of our medical education, my classmates and I were instructed in empathy and medical professionalism in a course that also entailed cultural awareness and the patient-physician relationship. Course methods included lessons in cultural awareness, ethics discussions and role-playing, in which we acted the parts of physician, patient and other members of the care team. During a typical session we attended a lecture and then met in groups of 24 to explore the current topic with our faculty mentors. Several sessions were devoted to each topic, after which we were required to complete a written self-reflection form.
Initially, it was somewhat difficult for me to understand the importance of these sessions. I appreciated our instructor's intentions but often felt that the material could have been more effectively presented. In retrospect, I was probably one of the milder critics of the course; a large number of students did not take the curriculum seriously, seeing it as a waste of time that could have been better spent studying. Possibly this reflects the views of many people in the medical community who see cultural education and professionalism training as being "soft." Another possibility is that medical students, who have been trained throughout their academic careers to value objective performance, simply do not want to spend their time with a subject that cannot be measured objectively.
The turning point for me came while I was working on this essay. After several months of research and discussion with my mentors, I began to understand that our professionalism course was building a base of knowledge and experience for us to use when relating to patients. A computer can read a list of signs and symptoms and give a diagnosis, but it does not have a range of experiences and cultural knowledge to draw on that would enable it to treat the person, as well as the illness. The empathic component of medicine is what makes a physician special; without it we are, in essence, highly trained computers.
The challenge for medical educators is to present the information in a format that makes it relevant and actively engages the students. Although students may not immediately see the value of this type of education, it is to our benefit that my generation of physicians is specifically instructed in empathy and professionalism. Programs such as these build a strong foundation for empathic interaction and give us the tools to be both effective communicators and skilled physicians.
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