The importance of empathy--as I have studied and experienced it.

Empathy is a crucial component of the patient-physician relationship and has been associated with improved patient outcomes in multiple studies. The importance of empathy has been of major interest to me as a student of the John A. Burns School of Medicine (JABSOM). At the medical school I have learned that Kim, et al,1 for example, analyzed the role of patient-perceived empathy and demonstrated that affective empathy led to a greater exchange of information, increased partnership, and interpersonal trust. Both partnership and perceived empathy had the largest effect on patient compliance and satisfaction.1 Empathy has been shown to me to be the crux of a good therapeutic relationship. In order to emphasize its importance, the American Association of Medical Colleges (AAMC) has made it an essential learning-objective for medical professionalism so that schools will teach the meaning of and instill empathy. Meeting this challenging task requires an understanding of the meaning of empathy, the use of diverse educational techniques, and incorporation of students' personal experiences. Acknowledging the role of empathy is easy, but teaching empathy is difficult because empathy is an elusive idea. The word is derived from the Greek empatheia, which means emotions and feelings.2 Hojat, who developed the Jefferson Scale of Physician Empathy (JSPE), further clarified the meaning of empathy, differentiating it from sympathy in the following definition: “predominantly a cognitive (as opposed to affective) attribute that involves an understanding (as opposed to a feeling) of a patient's concerns and experiences with a capacity to communicate this understanding, and an intention to help.”3 Patients, however, perceive empathy as both cognitive and affective. They define it as their “feelings being understood and accepted by the physician” because empathetic physicians recognize and convey the patients' mental state (cognitive) and tend to the patients' emotional state (affective).4 Based on these definitions, teaching empathy must address two important aspects: the physicians' understanding of patient concerns and their ability to convey to the patient this understanding and compassion. In order to meet this AAMC learning objective, medical schools have employed various techniques to train students to be more compassionate and empathetic toward their patients. I am grateful that JABSOM has utilized nearly all of the primary teaching modalities that have been studied.5 First, JABSOM emphasizes proper communication techniques through lectures, problem-based learning, and clinical skills workshops. Our Hawaiian custom of “talking story” is initially encouraged at the beginning of an interview in order to establish rapport. Studies have demonstrated a significant increase in empathy from pre- to post-intervention when researchers employ communication techniques as a learning modality.5 Second, the JABSOM Family Medicine clerkship asks students to write a narrative on personal illness as a strategy to foster empathy. The focus of this assignment is to place the medical student in the role of a patient or her family member. In addition to this particular session, the JABSOM Department of Family Medicine also addresses patient care and empathy from other angles such as cultural consideration and understanding the needs of the marginalized in society. Participants in studies that employed narrative as a learning modality have reported increased empathy and understanding of illness.5 Third, several preceptors instill empathy by having students experience medical care from the patient's perspective, such as when several of my classmates had to wear a cast for weeks as though they had broken their arm. In a study by Wilkes, et al,6 students who were taught empathy by being admitted to a teaching hospital with fake diagnoses had reported that that experience would help them be more empathetic. Fourth and last, JABSOM stresses self-care (“taking care of your goose”) from the first day of medical school. As stress is inevitable in medicine, my professors promote wellness and balance so that students can attend to their own health and happiness via time with loved ones, exercise, healthy diet, hobbies, and spiritual activities. Because personal stress can be a barrier to compassion and patience,7 this lifestyle does foster empathy. Since I have studied at JABSOM, I feel well-trained and equipped with the necessary skills that will be useful in my patient interactions. The first time I really experienced the gift of my JABSOM training in empathy and communication was on my Internal Medicine rotation. As I spoke with my middle-age male patient, an alcoholic of 40 years, I did my best to utilize all the techniques that my professors had taught me in order to show this patient that I empathized with his suffering. Initially, my heart was filled with compassion when I heard him relate his childhood trauma that eventually led him to self-loathing and despair; I saw in him a reflection of all those I know who yearn for love and understanding in their darkest hours. Because of my JABSOM training, I was able to be empathetic with my patient by giving him my full attention, responding with comforting words or body language, nodding appropriately, and asking reflective questions. At the end of my history taking, the patient said that I was the first person he had told about his past trauma and that he did so because he felt I really cared about his welfare and had made him comfortable. As honored as I was by his comment, I also recognized that there were additional tests and physician consults that my team would have to order; these tests, which I would not have ordered otherwise, would be based on what he shared with me. Through this experience, I finally understood the supreme importance of the patient-physician relationship and the role of empathy in fostering that relationship. My interactions with this former alcoholic led to one of my most profound lessons in compassion and empathy to date. When I spoke of my experience with a JABSOM faculty member who is also a psychiatrist, he defined compassion to me as acknowledging that we all are interconnected and interdependent. He taught me that all people suffer; all people have a desire to be heard, to be loved. He insisted that practicing compassion is thus to identify and respond to my patient's innate desire to be heard and loved, which separates curing from healing. My patient had been cured of his alcoholism in the past, but he relapsed multiple times because he was not healed of his compounding suffering which had begun in his childhood; he continued to long for compassion and empathy. Our ability as health care providers to make him feel heard and understood makes us so different from a computer or person who follows algorithms. In conclusion, I realize that physicians fulfill a dual role, for which empathy is indispensable. One of my JABSOM professors told me, “We cure with modern medicine, and we heal with our presence and compassion.” Because we are both mind and body, as is evident in fields such as psychiatry, primary care, and oncology, this idea of healing and curing is rooted in the nature of humanity. Never have I learned so much about human nature as I have from my patients who are willingly open with me as I am open with them. Their emotions are raw—comprised of anger and despair as they face their impending death or happiness as they rejoice over the birth of their child, welcoming a new life. I am honored to share in my patients' emotions and experiences, and I will do my best to be a good, responsible steward of their trust. Working with patients during medical school has brought together all the lessons I learned about empathy and has taught me the privilege of being a physician: my journey to becoming a good doctor necessitates empathy, which is to understand my patients' multi-dimensional suffering and to convey my compassion to them because we are all interconnected. All of this reinforces my decision to continue studying medicine.