Cultivating Empathy Like Learning to Hear Grasshoppers?

So I read this story in the New York Times about how important it is for doctors to show empathy, sit down and listen to their patients. The author is a nurse who cited a couple of papers supporting her point [1,2].

I can’t tell you how many times I’ve walked into a patient’s room and not found a chair available to sit down. Often, I have to go out to the nurse’s station to steal one. Frequently those chairs are way too tall and I inwardly hope, as I struggle awkwardly into a seat that is cranked high enough to persuade me I might as well stand, I joke about breaking a hip and needing a hospital bed myself.

The Larson reference puts me off because of all the jargon about “clinical empathy” (how is that different from regular empathy?), “emotional labor,” “deep acting” as opposed to “surface acting” as compared to “method acting.”

Are they kidding? The abstract alone sounds like the paper was written by managers and technicians, not by doctors.

I get it that they’re presenting empathy as a sort of competency which includes:

  • A consciously cultivated attitude based on reflection by the physician of the importance of the doctor-patient relationship to foster trust and healing,
  • Knowledge of who the patient is as well as what disease or disorder the patient suffers.
  • A skill set (the “acting”) which is not simply instrumental interrogation designed to collect data for diagnosis, but the creation of a sort of stage for the actors who actively seek trust and understanding.

Props are helpful on this stage and a chair is one of them. Maybe if I carried a folding chair, my act of unfolding the chair in front of patients and families will in some way facilitate an unfolding of the empathic “process.”

Larson’s analysis may help, but I fear that it may cover more than uncover. I wonder if using words like “target” for the patient stretch rather than shrink the emotional distance between us.

Doctors are doers by nature and by training. When faced with the need to show empathy, which can sometimes feel like not doing anything, doctors may feel uncomfortable. And when we “can do nothing” this can contribute to feeling helpless yet responsible–leading to burnout.

Little wonder why the dictum “Don’t just do something, sit there, ” seems so freighted with the deep meaning of connecting with another human being, which we seek– and which we find so unsettling.

Larson and Yao talk of the emotional labor management research involving flight attendants, which made me think of the different smiles we can show. One of them is the Pan Am smile, which is polite but looks a little frozen. The other is the Duchenne smile, after the 19th century French neurologist who first described it. The Duchenne smile activates muscles around the mouth and eyes, the Pan Am, just around the mouth.

On the other hand, you can manage to feel an emotion by simply acting. Just stretching your face into a smile can lead to feeling more positive emotions [3].

All the talk about method acting in the Larson paper made me think of the old story of a brief exchange about method acting between Sir Laurence Olivier and Dustin Hoffman, which may be apocryphal. Hoffman was a method actor and was sort of working himself into near exhaustion in order to get into his character. Olivier turned to him and said simply, “Try acting, dear boy…it’s much easier.”

Caine Kung FuSo that might be about surface acting versus deep acting. There must be a better way to convey the process of empathy other than technical, bureaucratic jargon or mystical exchanges like Caine and Master Po had in the 1972 Kung Fu TV series in which David Carradine as Caine sought water only to be regularly compelled to empathically kick 8 bad guys in their  throats:

Master Po: [after easily defeating the boy in combat] ha ha, never assume because a man has no eyes he cannot see. Close your eyes. What do you hear?

Young Caine: I hear the water. I hear the birds.

Master Po: Do you hear your own heartbeat?

Young Caine: No.

Master Po: Do you hear the grasshopper that is at your feet?

Young Caine: [Looking down and seeing the insect] Old man, how is it that you hear these things?

Master Po: Young man, how is it that you do not?

Most of us have the innate predisposition to be empathic. On the other hand, many of us must somehow become aware of this ability and deliberately develop the skill to express express it. It’s probably like learning to sense another person without using your eyes.

Hear the grasshopper at your feet.

References:

1. Swayden, K. J., K. K. Anderson, et al. (2012). “Effect of sitting vs. standing on perception of provider time at bedside: A pilot study.” Patient education and counseling 86(2): 166-171.

Patients commonly perceive that a provider has spent more time at their bedside when the provider sits rather than stands. This study provides empirical evidence for this perception. We conducted a prospective, randomized, controlled study with 120 adult post-operative inpatients admitted for elective spine surgery. The actual lengths of the interactions were compared to patients’ estimations of the time of those interactions. Patients perceived the provider as present at their bedside longer when he sat, even though the actual time the physician spent at the bedside did not change significantly whether he sat or stood. Patients with whom the physician sat reported a more positive interaction and a better understanding of their condition. Simply sitting instead of standing at a patient’s bedside can have a significant impact on patient satisfaction, patient compliance, and provider–patient rapport, all of which are known factors in decreased litigation, decreased lengths of stay, decreased costs, and improved clinical outcomes. Any healthcare provider may have a positive effect on doctor–patient interaction by sitting as opposed to standing during a hospital follow-up visit.

2. Larson, E. B. and X. Yao (2005). “Clinical empathy as emotional labor in the patient-physician relationship.” JAMA 293(9): 1100-1106.

Empathy should characterize all health care professions. Despite advancement in medical technology, the healing relationship between physicians and patients remains essential to quality care. We propose that physicians consider empathy as emotional labor (ie, management of experienced and displayed emotions to present a certain image). Since the publication of Hochschild’s The Managed Heart in 1983, researchers in management and organization behavior have been studying emotional labor by service workers, such as flight attendants and bill collectors. In this article, we focus on physicians as professionals who are expected to be empathic caregivers. They engage in such emotional labor through deep acting (ie, generating empathy-consistent emotional and cognitive reactions before and during empathic interactions with the patient, similar to the method-acting tradition used by some stage and screen actors), surface acting (ie, 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. Overall, we contend that physicians are more effective healers–and enjoy more professional satisfaction–when they engage in the process of empathy. We urge physicians first to recognize that their work has an element of emotional labor and, second, to consciously practice deep and surface acting to empathize with their patients. Medical students and residents can benefit from long-term regular training that includes conscious efforts to develop their empathic abilities. This will be valuable for both physicians and patients facing the increasingly fragmented and technological world of modern medicine. http://leeds.colorado.edu/asset/publication/larsonyaojama2005.pdf

3. Reddy, S. (2013) Stress-Busting Smiles: A Genuine Grin Can Help the Heart; Is Polite Faking Enough to See Benefits? The Wall Street Journal. Stress-Busting Smiles – WSJ.com

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Comments

  1. There’s also sincerity. Once you’ve learned to fake that, you’re all set.

    For me, empathy is generated by the awareness of, “There but for the grace of god go I.” Sympathy is feeling something for the patient’s suffering. Empathy is allowing yourself to recognize what it would feel like to be in the patient’s position.

    Oh, and did you know that the teenage Caine in the series was played by David Carradine’s younger half-brother, Keith?

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    • Well said. And I did not know that the teenage Caine was played by Keith. Funny how seeking water always led to kicking ass–empathetically, of course.

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  2. I wonder, if a doctor truly wants to help someone, “fix his problem” so to say… isn’t he automatically being empathic?
    Even if he has zero natural insight in the emotions and thoughts of others, wanting to solve the patient’s problem to the best of his abilities would cause him to ask questions and do research until understanding of the situation, a certain “reasoned” empathy, is reached.
    I think the problem isn’t doctors who have no empathy, but doctors who have no true interest in their patients. And no amount of clever acting can help that, I’m afraid.

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  3. Jim,
    I don’t know about grasshoppers, but I always hear my heart beating. I thought it was a sign of anxiety.

    I consider empathy to be a tool that needs to be honed during psychiatry training and practice. I see it more of a cognitive appreciation of an affective state and in that capacity it can be confirmed with the person you are interacting with. It is therefore a critical piece of that old existential concern of meaningfulness. Human beings find interactions more meaningful when they feel that the person they are communicating with has a full appreciation of their problems, emotions, and viewpoint. You don’t get that just offering the technical side of care but I would consider empathy to be a skill that should be considered as part of the technical expertise of psychiatrists.
    I also thought I would insert Sims definition of empathy here because I think it is a good one:

    “In descriptive psychopathology the concept of empathy is a clinical instrument that needs to be used to measure another person’s internal subjective state using the observer’s own capacity for emotional and cognitive experience as a yardstick. Empathy is achieved by precise, insightful, persistent and knowledgeable questioning until the doctor is able to give an account of the patient’s experience that the patient recognizes as their own.” (Symptoms of the Mind, 3rd ed, p3).

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  4. Joseph Shader says:

    Great post. I’ve always had trouble with the “technical” aspects “demonstrating” empathy. I’ve always thought that doctors who need to be trained in empathic techniques–those for whom empathy is not natural or the default position–are the least likely to care enough to actually employ those techniques and thus to benefit from “training “.

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    • Joe, I tend to agree. It’s also something Maintenance of Certification and Maintenance of Licensure processes will never capture.

      Great to hear from you!

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