Physician, heal thyself

I read the letter slowly, trying not to react until I got to the end.  It was a formal letter of complaint and had come to me from a patient via the HSE, with a copy to my GP partner.  One of the accusations was that I had not shown empathy. I had 28 working days to reply. How was I to reply to an accusation of lacking empathy? What is empathy? How does one show it or communicate it? Are patients entitled to it? Could I know for certain that I had, or had not, felt it for this particular patient, during that encounter?  If I had not, was it my fault and was this a justified complaint?

Empathy is defined as the ability to resonate with the feelings of others. We smile with those who are happy and cry with those who are sad. Former President Obama, in his farewell speech to the nation, argued that empathy for those who differ from ourselves is an essential pillar of democracy. He quoted Atticus Finch in <em>To Kill a Mockingbird</em>, saying “you never really understand a person until you consider things from his point of view, until you climb into his skin and walk around in it”. 

Many patients expect doctors to have empathy. They expect that we have a heightened understanding of individual suffering, that we can communicate this understanding and that we will be able do something to alleviate their distress. When a patient perceives that their doctor does not feel empathic, it becomes a further source of suffering, often more significant than the problem they first presented with.

But climbing into someone else’s skin is not easy. The continuous sharing of other people’s pain is not good for doctors.  Recent scientific studies have shown that doctors with high levels of empathy, as measured by the reliable and validated Jefferson Scale of Physician Empathy (JSPE), are at higher risk of burnout than those who score lower on this scale.  Evidence from neuroscience and psychology indicates that when we resonate with the pain and distress of another, we activate the ‘empathy for pain’ network in our brain.

Activity in this network results in a subjectively unpleasant experience.  Frequent exposure to such negative emotion leads to a downward spiral of wellbeing, resulting in empathic distress, an inability to resonate with others and a gradual withdrawing from the painful stimuli. In the case of the doctor, this may mean the end of clinical practice. 

Matthieu Ricard, a scientist and Buddhist monk and author of <em>Happiness: A Guide to Developing Life’s Most Important Skill, </em>and Richard Davidson PhD, Professor of Psychiatry and Psychology at the University of Wisconsin-Madison and author of <em>The Emotional Life of Your Brain</em>, have explored why some paragons of empathy, such as Mother Teresa, remain caring and connected, despite continuous exposure to the suffering of others. Their work indicates that compassion, rather than empathy, is the key to protecting oneself against empathy fatigue.  

Paul Gilbert, Professor of Psychology at Derby University, defines compassion as “being open to the suffering of self and others in a non-defensive way, having a cognitive understanding of suffering, as well as the motivation and behaviour required to relieve suffering”. The neural pathways activated by compassion are different to those activated by empathy and are experienced subjectively as positive emotion. Regular exposure to this emotion leads to an upward spiral of wellbeing and a strong desire and motivation to help others.

The good thing about compassion is that it can be taught.  Functional MRI scanning demonstrates that expert meditators activate compassion networks much quicker than novice or non-meditators, when exposed to other people’s suffering. In a similar situation, novice or non-meditators are more likely to activate the negative neural networks.

Compassion-focused therapy (CFT) is now a recognised treatment for depression, eating disorders, psychosis and many other mental health problems. But there is no need to wait for illness in order to gain the benefits of compassion.  The scientific analysis of the ancient Buddhist practices of compassion meditation (CM) and Loving-Kindness Meditation (LKM) indicate that these interventions can be of particular benefit to health professionals by increasing self-compassion and concern for others and significantly reducing the chances of burnout and empathy fatigue  (see www.compassionatemind.co.uk).

To return to my patient. Perhaps I did not display empathy. Perhaps it was not my fault. Empathy and compassion are complicated emotions that require maintenance and monitoring.  They are not necessarily intuitive, particularly when faced with obstacles like time constraints or perceived unrealistic demands. Long after my initial annoyance and frustration had subsided, I decided to be grateful to this patient for sharing their experience, renewed my attempt to understand their perspective and actively wished them well. Compassion begins with self. So, for now, this is all I expect of myself but I definitely feel better for it.