Jodi Halpern

What is clinical empathy

Patients seek empathy from their physicians. Medical educators increasingly recognize this need. Yet in seeking to make empathy a reliable professional skill, doctors change the meaning of the term. Outside the field of medicine, empathy is a mode of understanding that specifically involves emotional resonance. In contrast, leading physician educators define empathy as a form of detached cognition. In contrast, this article argues that physicians’ emotional attunement greatly serves the cognitive goal of understanding patients’ emotions. This has important implications for teaching empathy.

Rehumanizing the Other: Empathy and Reconciliation

The health effects of intra-ethnic conflict include hatred and fear among neighbors and friends who have become enemies. The dehumanization of specific groups through concomitant stereotyping does not stop when conflicts end. The inability to see former enemies as real people impedes reconciliation. While much attention has been paid to the reconstruction of infrastructure and the establishment of rule of law, little thought has been given to what is required at the day to day level in order to restore a sense of interpersonal security. To reverse the destruction of social and familial networks that normally sustain health and well-being, a process of rehumanization must occur. We suggest that the promotion of empathy is a critical component of reconciliation.

Empathy and Patient–Physician Conflicts

Physicians associate empathy with benevolent emotions and with developing a shared understanding with patients. While there have been many articles on managing “difficult” patients, little attention has been paid to the challenges physicians face during conflicts with patients, especially when both parties are angry and yet empathy is still needed. This topic is especially important in light of recent studies showing that practicing medicine increasingly requires physicians to manage their own feelings of anger and frustration. This article seeks to describe how physicians can learn to empathize with patients even when they are both subject to emotions that lead to interpersonal distancing. Empathy is defined as engaged curiosity about another’s particular emotional perspective. Five specific ways for physicians to foster empathy during conflict are described: recognizing one’s own emotions, attending to negative emotions over time, attuning to patients’ verbal and nonverbal emotional messages, and becoming receptive to negative feedback. Importantly, physicians who learn to empathize with patients during emotionally charged interactions can reduce anger and frustration and also increase their therapeutic impact.

Affective Forecasting : An Unrecognized Challenge in Making Serious Health Decisions

Patients facing medical decisions that will impact quality of life make assumptions about how they will adjust emotionally to living with health declines and disability. Despite abundant research on decision-making, we have no direct research on how accurately patients envision their future well-being and how this influences their decisions. Outside medicine, psychological research on “affective forecasting” consistently shows that people poorly predict their future ability to adapt to adversity. This finding is important for medicine, since many serious health decisions hinge on quality-of-life judgments. We describe three specific mechanisms for affective forecasting errors that may influence health decisions: focalism, in which people focus more on what will change than on what will stay the same; immune neglect, in which they fail to envision how their own coping skills will lessen their unhappiness; and failure to predict adaptation, in which people fail to envision shifts in what they value. We discuss emotional and social factors that interact with these cognitive biases. We describe how caregivers can recognize these biases in the clinical setting and suggest interventions to help patients recognize and address affective forecasting errors.

From idealized clinical empathy to empathic communication in medical care

Outside of healthcare settings, people use the term empathy to mean ‘‘feeling with’’ another person or putting yourself in someone else’s shoes. The assumption is that emotional resonance with another clues you in to how they feel. This has been problematic for doctors, who have historically believed that they could understand their patients’ feelings while striving for emotional detachment: objectivity is seen as crucial for making tough diagnoses, and stoicism is believed to be necessary for providing invasive, sometimes noxious, treatment. Additionally, there is concern with avoiding burnout, or more specifically, compassion fatigue. Thus doctors have aimed for their own idealized version of empathy, one in which they suppress personal emotions yet are motivated by an altruistic yet ‘‘detached’’ concern for patients. The term ‘‘detachment’’ can mean different things, some of which do not involve suppressing emotions but rather accepting them. For example, for Zen Buddhists ‘‘detachment’’ refers to allowing emotions to come and go without attaching to any particular emotion. In contrast, American physicians from the early twentieth century until the late 1960’s used it to mean suppressing emotional responses. Writing in 1906, Sir William Osler, father of ‘‘modern medicine,’’ describes how only if the physician was emotionally ‘‘imperturbable’’ so that his ‘‘blood vessels don’t constrict and his heart rate remains steady when he sees terrible sights’’ will he have the ‘‘equanimity’’ to ‘‘see into’’ the patient’s ‘‘inner life.’’ Once emotions are suppressed, what is the basis of the concern for patients? The ‘‘concern’’ in ‘‘detached concern’’ was not based on untrustworthy feelings, but rather on a duty or commitment to heal. Note that Osler acknowledges that physicians are prone to sympathetic identification with their patients, but hopes that they will avoid feeling sympathy and be moved by a purer professional attitude:

WHEN CONCRETIZED EMOTION-BELIEF COMPLEXES DERAIL DECISION-MAKING CAPACITY

There is an important gap in philosophical, clinical and bioethical conceptions of decision-making capacity. These fields recognize that when traumatic life circumstances occur, people not only feel afraid and demoralized, but may develop catastrophic thinking and other beliefs that can lead to poor judgment. Yet there has been no articulation of the ways in which such beliefs may actually derail decision-making capacity. In particular, certain emotionally grounded beliefs are systematically unresponsive to evidence, and this can block the ability to deliberate about alternatives. People who meet medico-legal criteria for decision-making capacity can react to health and personal crises with such capacity-derailing reactions. One aspect of this is that a person who is otherwise cognitively intact may be unable to appreciate her own future quality of life while in this complex state of mind. This raises troubling ethical challenges. We cannot rely on the current standard assessment of cognition to determine decisional rights in medical and other settings. We need to understand better how emotionally grounded beliefs interfere with decision-making capacity, in order to identify when caregivers have an obligation to intervene.

Physician Conceptions of Responsibility to Individual Patients and Distributive Justice in Health Care

PURPOSE Physicians’ values may be shifting under managed care, but there have been no empirical data to support this claim. We describe physician conceptions of responsibility to individual patients and distributive justice in health care, and explore whether these values are associated with type of managed care practice and professional satisfaction. METHODS We mailed a questionnaire to 500 primary care physicians from 80 out-patient clinics in 11 managed care organizations (MCOs) who were participating in 4 studies designed to improve the quality of depression care in primary care. RESULTS We received 414 responses (response rate 83%). Twenty-eight percent of physicians strongly agreed that their main responsibility was to the individual patient rather than to society (strong sense of responsibility to individual patients). Physicians with a strong sense of responsibility to individual patients were older (43% of physicians older than 50 years reported a strong sense of responsibility to individual patients, compared with 26% of physicians aged 36 to 50 years, and 21% of physicians younger than 35 years, P = .009) and tended to practice in network- rather than staff-model MCOs (33% of physicians in network-model MCOs reported a strong sense of responsibility to individual patients compared with 24% in staff-model MCOs, P = .077). Scores on a scale measuring egalitarian conceptions of distributive justice within the health care system were similar for physicians regardless of whether they reported a strong sense of responsibility to individual patients. When we controlled for physician and practice characteristics, physicians with a strong sense of responsibility to individual patients and physicians with higher scores on an egalitarian scale were more likely to be very satisfied overall with their practices (adjusted odds ratio [AOR] = 2.23, 95% confidence interval [CI], 1.11–4.49, and AOR = 1.18, 95% CI, 1.09–1.29, respectively). CONCLUSIONS Physicians with a strong sense of responsibility to individual patients are older and less likely to practice in staff-model MCOs. Stronger commitment to an egalitarian health care system and a strong sense of responsibility to individual patients are independently associated with greater practice satisfaction among physicians. The impact of these values on patient care should be a priority for future research and the subject of professional education and debate.

“Editing” Genes: A Case Study About How Language Matters in Bioethics

Metaphors used to describe new technologies mediate public understanding of the innovations. Analyzing the linguistic, rhetorical, and affective aspects of these metaphors opens the range of issues available for bioethical scrutiny and increases public accountability. This article shows how such a multidisciplinary approach can be useful by looking at a set of texts about one issue, the use of a newly developed technique for genetic modification, CRISPRcas9.

“Move or Suffer”: Is Age-Segregation the New Norm for Older Americans Living Alone?

Despite ethical claims that civic societies should foster intergenerational integration, age-segregation is a widespread yet understudied phenomenon. The purpose of this study was to understand the reasons that led community-dwelling older Americans to relocate into senior housing. Qualitative data were collected through participant observation and ethnographic interviews with 47 older adults living alone in San Francisco, California. Half of study participants lived in housing for seniors, the other half in conventional housing. Data were analyzed with standard qualitative methods. Findings illuminate the dynamics that favor age-segregation. Senior housing might be cheaper, safer, and offer more socializing opportunities than conventional housing. Yet, tenants of senior housing may also experience isolation, crime, and distress. Findings suggest that rather than individual preference, cultural, political, and economic factors inform the individual decision to relocate into age-segregated settings. Findings also call for an increased awareness on the ethical implications of societies increasingly segregated by age.

Professional Distress and Meaning in Health Care: Why Professional Empathy Can Help

For human service care providers working in hospitals, balancing the motivation for interpersonal engagement with patients alongside self-protective emotional boundaries is a familiar struggle. Empathy is a critical, although not thoroughly understood, aspect of patient care as well as an important ingredient for feeling work satisfaction and meaning. However, empathy can lead to feelings of sympathetic emotional distress and even burnout. This article uses an illustrative case study from a medical social worker in the emergency room to explore these themes of empathy, burnout, and the search for meaning in work. The discussion examines areas for further empirical study and intervention to support care-provider empathy and avoid burnout.