It is disappointing to read such a naive perspective on interpersonal engagement from a psychiatrist. It suggests the swing from psychological-mindedness to biological training has diminished our capacity to contribute to medical education. Reading poetry or writing in journals (Blumenthal never mentions Rita Charon's efforts to expand sensitivity) can be lovely activities, popular with many students. But it is a genuine CLINICAL SKILL founded on the basic science of attachment, anxiety/defense, intersubjectivity and unconscious communication that should be taught to medical students as they plunged into comnplex patient encounters. Of course canned phrases are phony. 'Acting empathic' is an oxymoron. Dealing with one's true reaction to a patient (assiduous self-reflection) is the hardest first step. Then deciphering a simple response from this strumming generates authentic engagement...empathy. Apparently, Dr. Blumenthal has not focused on transference-counterftransference experience in his clinical life. It is from this substantive literature that we must generate useful elements to help medical students become competent in complex interpersonal situations. Sara Hartley, MD Clinical Faculty UCB/UCSF Joint Medical Program

I recall my 1st clinical rotation in medical school & chastised by an endochrinology prof. I abreviated my PE on a dying patient after he had undergone 4-5 previous workups. He died that night & I was dressed down in the AM for "missing a chance to see the pathology"! John Raasoch MD

Thanks, Dr. Blumenfield, for a very thoughtful and nuanced discussion of this complex construct called "empathy". If we define this as an intrapsychic state of some sort, it may indeed be impossible to "teach"someone to be empathic.

If we define it in more "behavioral" terms, such as being tactful and not humiliating patients, we may at least be able to inculcate medical students in appropriate demeanor and conduct. (As you may know, in the rabbinical tradition, humiliating another person is considered the equivalent of bloodshed).

I remember, as a third-year medical student, hearing one of my classmates speaking to a very sick inpatient. My classmate said he would return a bit later to finish his interview with the patient. When the patient asked "What time?", my classmate replied, "What difference does it make? You're not going anywhere!"

I would have settled for tact and professional demeanor at that point, Dr. Blumenfield!

But perhaps there is a way to go deeper than this, with our students. My thought: use poetry as a way of emotively creating the conditions for empathy. We have done this  with medical students at SUNY Upstate Medical University, in a creative writing course that involves both reading and writing poetry. I think it works, though I can't prove it!

Best regards, Ron Pies MD

Having just graduated from medical school, I feel I am far less emapthic now than I was when I started this process of medical training.  I consistently had attendings push me harder and harder, so that there just was no time for empathy.  There was too much to do, too much studying required, there was always another patient then another patient, constant exhaustion and no balance in the students life.  If I had the opportunity to have a more balanced and healthy life during school, I may have been a happier and more balanced student which who translate into a more balanced approach to patients with more caring and empathy.

In response to Ron Pies - equating humiliation with bloodshed - I would not attiribute this only to "rabbinical tradition" but considerate it endemic in all of Israel on both sides of the Green Line and probably rampant throughout the Middle East. John Raasoch MD

Normal 0 false false false /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman"; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} I can understand the frustration articulated by Dr. Hartley. There was a time when medical students were understandably wowed by the skill of psychiatric faculty demonstrated in acts of grasping unconscious communications, nonverbal expressions, and all manner of communicated affects in order to deepen discussions with patients. Many years of deemphasizing the psychological aspects of our field have made those moments less likely. Now there are attempts to teach empathy-by which the instructor typically means sympathy-and to apply "interviewing techniques"that would be more appropriate in the human resources divisions of corporations. The end of the apprenticeship model and the subsequent hegemony of "educationalists" in the medical schools have introduced endless simulations of medical encounters by way of actors, role plays, and other forms of artifice. For years medical students have been tested on their ability to ignore their own experience and any intuitive skills they might possess by pretending to relate to actors pretending to be patients in examination settings. The only reasonable question, "Why would you travel one hundred miles to be paid $25 to pretend to be a schizophrenic?", is, of course, off the table. Under such circumstances, training students to be civil is probably ambitious. Phillip Freeman MD

One of the best methods for developing empathy is mindfulness meditation training. And one of the best for communicating empathy is Marshall Rosenberg's nonviolent communication model. Learning to communicate with empathy is more than just "feel good." It is THE most efficient way to communicate. In the nonviolent communication model, people learn to discover what the other's needs are and to respectfully and nonjudgmentally make their own needs known. For example, if one's need is to be heard and taken seriously, and the person isn't getting that need met, he or she will be more likely to take other routes -- such as litigation. Please take a look at the site for Marshall Rosenberg's Center for Nonviolent Communication.

Although the teaching interventions described are most appropriate, they do one thing: they teach people to behave in empathic ways.They do not create empathic people. Unfortunately, my experience in teaching and training leads me to believe that we are ineffective in teaching adults to be empathic people. Once they reach adolescence they either have the capacity to be empathic or, they don't. However, we can be quite effective in assisting people, both professionals and our patients, to behave in empathic ways which has a positive impact on their relationships and our ability to help change to occur. David B. Saltman, LCSW, Faculty Stempel College of Public Health and Social Work, Florida International University

Posted on behalf of:
Lauretta Young MD
Chief Emeritus Kaiser Mental Health Portland Oregon
OHSU Division of Management Professor currently
I applaud the thoughtfulness of various methods used to increase empathy in the medical profession.
However, I wonder about an underlying issue which is the unnecessary brutality of medical training itself which may erase any pre-existing tendencies to be empathetic we select for in the admissions process.
We all still read in the JAMA editorials wondering if limiting residents to an 80 hour work week can be "afforded" and if there is really sufficient evidence about error reduction to allow this. Despite the innumerable studies in NASA and airlines about the effects of sleep deprivation on learning and other higher cognitive skills we still are debating this. What is worse is that most of the effects of sleep deprivation are on what makes us most human--our energy, our enthusiasm, our passion, our positivity, our creativity and our self care and connections to our families, our spirituality, and our communities. Can one really honestly think that having young people work 80 plus hours a week is good for them, good for their health, good for their relationships or good for empathy?
Besides sleep deprivation we all are still acutely aware of less than desirable teaching practices. There is overall an acute lack of consideration of students' needs not just at the school with which I am most familiar but in speaking to MDs who have graduated around the country it appears to be widespread.
So what can we as individuals do--we can certainly volunteer our time at our medical schools, we can lobby the deans and we can participate in community wide efforts to treat younger physicians with more respect and consideration.

I think to ensure empathetic doctors medical schools should primarily choose students with social phobias because I understand we have empathy in spades...

Back in the 1970's I applied to go to College to become a Registered Nurse. Part of the entry test was to do psychological tests to make sure I had the "right stuff" to become a nurse. This included a healthy level of empathy. I gather, based on what I'm reading here, the doctors don't have to go through this test.  That is too bad.  Why? Because a healthy, and reasonable amount of empathy will foster an immense improvement in both physical and mental health.

This is an important topic that often gets overlooked in medical training.  There is a heavy emphasis on treatment, but little emphasis on caring.  I suppose this occurs because treatment and having a good outcome is ultimately important whether the health care provider cares or not.  However, competent treatment delivered with empathy or compassion has a more positive impact on a patient's well-being.  I don't think you can actually teach someone to be empathic, but you can help facilitate a person to develop compassion.  Unfortunately, medical training predominantly values the art and science of diagnosing and treating medical conditions to the exclusion of promoting the compassionate delivery of care.

It used to be said that knowing the person who has the disease was at least as important as knowing the disease. Rapport and empathy are part of the art (and must be distinguished from sympathy). If these seem to be lacking, simply ask your patient, "What is going on?" If that doesn't work, call in the family and ask the question again. Do not refer to psychiatry without first doing this, otherwise the referral is like a rejection, a dump job, in which the psychiatrist is put at a disadvantage.  Let this be taught to students.

very touchy article.... sympathy, empathy and apathy, these are the three things the medical students should know... empathy is  the best tool for psychiatrists or to every good doctor... i very much agree to your last paragraph.."life experiences teach empathy"

As a psychiatrist for  25 years I have
worked side by side with many doctors from many different
countries I  have come to realize that neither race nor ethnic
background makes any difference - the most empathic doctor is also the one who appreciates the value of his/her peers and the nursing staff and ancillary staff .   Doctors or nurses who try to bully their colleagues are usually the same ones who are unable to appreciate a
patient's pain . Despite the fact that empathy is a very com-
plex issue it is possible for medical schools and hospital
administrations to model empathy and other beneficial behaviors  when they train the  medical professionals of the future and to weed out those
who should not be dealing with real live people.
 
 

I don't think that you can teach empathy.  Children develop empathy and attachment in early childhood with possibly some genetic predisposition.  If you want to screen for empathy, then we need to understand the right interview techniques that work.  Medical students who are sauvy will quickly find out that their empathy is being assessed and they will start to behave in a way that seems like they have empathy.

I agree with the author's comments that empathy is a complex issue.  My experience is that, even in a clinician who is usually "empathic, compassionate,"etc. a number of factors can affect empathy (interpersonal factors, fatigue, etc.). I think it's easier to teach technique than empathy itself. My own pre-med background in music/theatre was helpful, but in med school, one of the internal medicine residents actually said to me, "We're going to have to 'desensitize you'". It was kind of an eye-opener to realize that some people actually thought this way...

In psychiatric training we met in a group once a week with an experienced mentor and shared life experiences - losing a child, a relative with cancer, a friend with mental illness and so on - it was a moving experience and I think that we all experienced empathy for each other and for others. Perhaps this could be part of the medical school experience. Research has shown that empathetic physicians have better patient outcomes and fewer malpractice problems. I recently had serious orthopedic surgery and the empathy of my surgeon was an enormous help to me and my recovery. Leah Thronson MD

I am a psychiatric RN on an inpatient unit in a large teaching hospital. In my nearly 18 years working alongside medical students, residents, and young attendings, It has become clear to me that the skills of empathy are sorely lacking in their education. There are those who I can tell are naturally empathic or not; however, overall, I haven not seen much empathy in the way our psychiatrists interact with their patients. I am a graduate student working on my masters as a Marriage and Family Therapist. Part of the requirements for our licensing hours is that we are involved in our own personal therapy, party for support, and partly to learn what it is like to be a patient. From my observations, I believe many of our psychiatrists, student or otherwise, could learn a few things about empathy from being in therapy themselves, and I think it should be required as part of their studies, especially when they enter residency in psychiatry.

I have the honor of being intraining with possibily the most empathic team I have encountered in my carreer and it spans two cultures and continents. Empathy is a quality of character we learn as we grow up and I have seen young 12, year olds who seem to have more empathy and an understanding of others feelings then some grown mature people.Empathy comes naturaly to some and some learn it as a tool. If empathy is used as a tool then it is just as good as the practice, that is better than not having it at all though. It is important to appreciate students who show this natural talent, especially by the attendings because it does need time to be spent with the patient may seem like a not so good use of the time to some. Too much emphasis is on the biology of life and too little on the psychology and spirit.

Below is a quote from the article. There is nothing wrong with acting.   I look forward to the publication of Ron Pies' book.  I think Dr. Pies has suggested in this and other places that acting is often an act of charity.   "They felt it was artificial, phony, and they did not want to be actors when they were trying to be doctors. Other groups had similar responses. This was another indication of how teaching medical students to be empathic was quite complicated."

Perhaps this publication could set an example by allowing anonymous comments. Show that you can empathize with patients who may not want to know their psychiatrist's opinions and with psychiatrists who might feel reluctant to burden patients with those opinions.