Clinical Empathy

What this comes down to is a concept called clinical empathy, defined as “a cognitive attribute that involves an ability to understand the patient’s inner experiences and perspective and a capability to communicate this understanding.”

Clinical empathy has been linked to improved outcomes for patients with diabetes, colds, and depression. Yet many patients don’t experience it in their healthcare encounters: one study found that doctors interrupt patients within an average of 18 seconds.

To understand why, we must also empathize with doctors. In the 1950s and 60s, medical journals began spreading a concept called ‘neutral empathy,’ based on detached reasoning. They argued that truly experiencing the patient’s pain could bias decisions. In a 1963 article, “Training for Detached Concern,” Renée Fox and Harold Leif described how “physicians believe that the same detachment that enables medical students to dissect a cadaver without disgust allows them to listen empathically without becoming emotionally involved.” This perspective has shaped the way physicians are trained and incentivized.

A 2011 study showed that empathy decreased during both medical school and residency, attributed to curriculum, experiences in clinical practice, and overall stress.

Detachment also develops during this period as a protective mechanism. As a friend in residency expressed to me, “If every time a patient of mine dies it has the same effect on me that my grandmother dying would, I would be unable to do my job for any patients.” Navigating that middle ground can be scary and complicated, but there’s an art to it he believes can be taught.

In medical school today, students undergo mock patient encounters, which Leslie Jamison, a ‘medical actor,’ recounted in detail in The Believer. Jamison was responsible for playing the role of patient and evaluating students. During her encounters, she found students struggled to move beyond scripts and a transactional level of patient understanding toward true empathy:

In this sense, empathy isn’t measured just by checklist item 31 — “Voiced empathy for my situation/problem” — but by every item that gauges how thoroughly my experience has been imagined. Empathy isn’t just remembering to say “That must really be hard,” it’s figuring out how to bring difficulty into the light so it can be seen at all. Empathy isn’t just listening, it’s asking the questions whose answers need to be listened to. Empathy requires inquiry as much as imagination. Empathy requires knowing you know nothing. Empathy means acknowledging a horizon of context that extends perpetually beyond what you can see: an old woman’s gonorrhea is connected to her guilt is connected to her marriage is connected to her children is connected to the days when she was a child. All this is connected to her domestically stifled mother, in turn, and to her parents’ unbroken marriage; maybe everything traces its roots to her very first period, how it shamed and thrilled her.

In Jamison’s evaluations, there was one checkbox (‘item 31’) for indicating whether a student voiced empathy, as if empathy can only be communicated through words. She expressed a complex web of emotional relationships stemming from her character’s gonorrhea that, if understood by a clinician, could equip that person with information to perform root cause analysis and motivate the patient to treat her condition in a healthy way and prevent it from reoccurring.

This is a process designers are particularly skilled at through use of design thinking. Design thinkers don’t begin solving until they understand the root human-centered problem, using investigative tools designed to build empathy, and then they consider a wide range of possible solutions across disciplines. Rebecca Onie used this kind of process when she founded Health Leads. While working at Boston Medical Center, she realized many low-income patients kept getting sick because of problems related to nutrition and mental health. The clinicians knew this all too well, but the system in which they operated constrained what they could prescribe. Onie now offers services not traditionally considered medical or covered by health insurance, like food, housing, and heat. This complex set of practices required to build empathy and treat human problems is a far cry from ‘bedside manner,’ the basis of ratings systems like ZocDoc’s.

Professional stresses and checkbox evaluations continue through much of a doctor’s career. Pressure from health systems and payers require more of physicians with less time for each patient. The result is standardized scripts to review with patients and alerts and checkboxes to click through in their Electronic Health Records, diverting their attention from the patient across the room.