The importance of nonverbal attunement seriously undermines the “detached concern” model of empathy. However, what remains to be clarified is what exactly such attunement involves. If engaged empathy (herein referred to simply as empathy) requires experiencing emotions in parallel with each patient, this would be absurdly demanding (even for psychotherapists). Further, general internists do not have the time that psychotherapists do to focus on emotions.
One key point of this article is that empathy does not require that physicians vicariously experience and introspect about patients' emotions. The physician's attention should not be unduly diverted to introspection. The whole point of empathy is to focus attention on the patient. A listener who was busy having his or her own parallel emotions and introspecting about them would have the wrong focus.
Emotional attunement operates by shaping what one imagines about another person's experience. In trying to imagine what the patient is going through, physicians will sometimes find themselves resonating. This is not an additional activity to imagining, but rather a kind of involuntary backdrop to it. Further, resonance is not a special professional skill, but a part of ordinary communication. While listening to an anxious friend, one becomes anxious, while talking with a coworker, one feels heavy, depressed feelings. Importantly, attuning to patients does not always involve resonating with strong feelings, but often is a subtle nonverbal sense of where another person is emotionally.
The special professional skill of clinical empathy is distinguished by the use of this subjective, experiential input for specific, cognitive aims. Empathy has as its goal imagining how it feels to be in another person's situation. Outside medicine, imagining how an experience feels is similar to daydreaming or fantasizing. An emotion or mood sets the tone of the imagined scenario. In clinical practice, the challenge is to use skillful attunement, not in leisurely fantasy, but in multiple, rapid, ordinary clinical interactions. For example, if a patient says that she has stopped taking her medication, empathy involves taking cues from her tone. This patient may be angry about sexual side effects, or she may be upbeat, and see the medication as unnecessary because she doesn't feel sick, or she may see the medication as useless because she feels hopeless about getting well. In each case, addressing the patient more or less appropriately depends upon attuning to the patient's emotions.
At this point, the busy physician reader might be wondering about the clinical utility of empathy when a physician can do a quick checklist review and cover the common reasons people stop taking medications. I do not disagree with this point. Most likely, there is no single question for which physicians need empathy to get an answer. Yet in the daily grind of medical practice, an empathic physician gains a source of information that is at least as efficient as having checklists for each psychological need of patients. Here are 4 ways that physicians can capitalize on their emotional responses to enhance medical care.
Empathy Involves Associative Reasoning
First, emotional attunement helps physicians appreciate the personal meanings of patients' words. Emotions guide thought by linking one idea to another in an “associative” way: in addition to thinking logically, we link ideas that have affective, sensory, and experiential similarities. What doctors say to patients has associative as well as logical meanings. For example, a patient may take the term “degenerative joint disease” to signify that she is falling apart. Of course, a detached physician can recognize this meaning of the word degenerative. Yet an emotionally attuned doctor has an additional source of noticing which words are particularly loaded for a particular patient. Alongside the logical meanings conveyed in conversations is an ongoing flow of associative or emotional meanings. By attuning to another person, one follows this flow with much more ease than if one were to try to get at all this meaning through asking questions and consulting checklists. (Gleaning meanings by associating involves all kinds of inaccuracies, so that at some point the doctor needs to check his or her understanding with the patient more directly.)
Associative listening need not be an added task. Physicians can make use of what they already notice but have learned not pay attention to. For example, a patient suddenly refused previously wanted life-sustaining treatment. She wouldn't talk to anyone, and wanted to be sedated and never wake up. She wound up telling me her painful story, but then became angry and said that asking her to talk was “the cruelest thing anyone had ever done” to her. Her striking words were an important clue to what I learned about her situation. Just a few days before, when she had just gotten out of surgery, her husband of many years had told her that he was leaving her. Patients' words communicate meanings that cannot be summarized on a preformed checklist.
Emotions Help Guide and Hold Attention on What is Humanly Significant
Second, physicians' emotions focus and hold their attention on what the patient is anxious about. Consider a physician who sees a patient who suffers from headaches and fatigue. When asked about her home life, the patient says that everything is fine. Yet, something about the patient's body language, perhaps an evasive gaze, worries the physician. By resonating with the patient's anxiety, the physician is more likely to slow down at this point in the history and gather more information.
The skeptic might ask, can't a detached but thorough physician notice the patient's gaze? The answer is yes, of course. However, it would be difficult for even the most thorough but nonintuitive physician to consciously observe and attend to the dozens of signals that have emotional import in each patient interview. Emotional attunement spontaneously directs attention to some aspects of patient's histories over others.
Neuroscientist Antonio Damasio9
and philosopher Ronald de Sousa10
describe this focusing and riveting of attention as necessary because human beings are so cognitively complex that events in daily life involve too many possible things to pay attention to. The cognitive tasks physicians face are at least as complex as the tasks of daily life, and logic alone cannot determine which matters are most important to pay attention to. Nonverbal attunement automatically directs attention to matters that have emotional significance to the patient. Of course, such intuitions in no way supplant thorough history taking and paying attention to other clinical clues. Rather, resonance offers short cuts, the paths of which still need to be rechecked in a systematic way.
Empathy Facilitates Trust and Disclosure and Can Be Directly Therapeutic
A third related contribution of empathy is that it facilitates patient trust and disclosure. Physicians express empathy not only by grasping the personal meanings of patients' words, but also by (automatically) matching patients' nonverbal style, for example, their vocal tones. When doctors attune to patients nonverbally, patients feel more comfortable and give fuller histories.8
Further, there is a growing body of evidence suggesting that empathy directly enhances therapeutic efficacy. Engaged communication has been linked to decreasing patient anxiety,11,12
and, for a variety of illnesses, decreasing anxiety has been linked to physiologic effects and improved outcomes.12,13
An expert panel on how physicians deliver bad news concluded that patients cope better in the long term if their doctors are empathic.14
The skeptic might ask why it matters whether physicians respond emotionally if they just behave empathically. My response to this is threefold: 1) The observational studies mentioned above show that patients sense whether physicians are emotionally attuned.8
2) Patients trust physicians who respond to their anxiety with their own responsive worry. Trust has been associated with better treatment adherence.15
3) It matters when and how physicians ask patients about their feelings, and empathic attunement guides physicians about when to ask questions, when to stay silent, and when to repeat important words.
Empathy Makes Being a Physician More Meaningful and Satisfying
Finally, empathy makes practicing medicine more meaningful. Many physician narratives attest to this. There is also some research supporting this claim, although there are alternative hypotheses that could explain the findings. For example, Roter et al. found that physicians with an engaged, psychosocially oriented communication style burn out less frequently than others.16
Robert Coles, writing about William Carlos Williams as well as himself, says that during moments of empathic connection, the real meaning of medical practice is suddenly illuminated in terms of hidden personal meanings.17
Physicians who allow their patients to move them enrich their own experience of doctoring.