The Suitcase of Empathy

Marvin Minsky called words that carry a variety of meanings “suitcase words.” Empathy is such a word. Over the last ten years, research into empathy has exploded. The number of research papers in psychological journals, on the topic, has increased dramatically and popular interest in the concept matches what is found in these journals. A Google Trends search reveals a steady progression in search trends over the last 10 years. Similarly, Google’s Ngram viewer, shows an exponential rise in the usage of the word, “empathy”, in English books. Barack Obama famously stated in a commencement speech that it is more important to focus on the “empathy deficit” rather than the “federal deficit.”

Empathy is also implicated in professional exhaustion syndrome (burnout). Even though burnout is multifactorial with varied causes, one feature that is peculiar to caregivers such as physicians is the “pathology of care relationship.” In this model, burnout arises from the dynamic of the patient-physician relationship. However, the direction of linkage is equivocal with some studies suggesting a positive relationship and others suggesting an inverse relationship. The confusion partly arises due to the ambiguity of the definition of empathy. The dictionary defines empathy “as the ability to understand and share the feeling of others.”  Therefore, there is a cognitive (understand) and emotional (share the feeling) component of the term. Psychologists typically divide empathy into two separate components. “Affective empathy” refers to the sensations and feelings we get in response to others’ emotions and “cognitive empathy” (perspective taking) refers to our ability to understand other people’s emotions. In extreme forms of affective empathy, the boundary between self and other is blurred and the other’s pain is felt as if it is our own. Neurobiologically, modules of the brain correlated with emotional arousal such as the ventromedial prefrontal cortex (vmPFC), insular cortex, and the amygdala are activated with the concomitant downstream sympathetic (fight or flight) response of increased heart rate, dilated pupils, anxiety, and increased stress hormones. In contrast, perspective-taking reinforces boundaries between us and others and regions of the brain associated with cognition such as the dorsolateral prefrontal cortex (dlPFC) is activated. In reality, the boundaries between affective empathy and cognitive empathy are blurry and the empathetic state is more accurately depicted on a continuum. Experimenters can relatively easily manipulate the subject’s response by priming subjects to take a self-oriented perspective, increasing their cognitive load, making them hungry, or more stressed. In all of these scenarios, subjects tend to shift towards a more emotionally laden sympathetic response leading towards psychologically “easy” acts that primarily serve to decrease the cognitive or emotional load rather than solutions that might help the sufferer. Empathy just as often represents a decision not about others, but about ourselves.

Is it no wonder that the Emergency physicians are experiencing burnout symptoms at an unprecedented rate? We work in the prototypical high-stress environment with chronic exposure to complex, psychosocial suffering that can render us with a feeling of helplessness. The ubiquity of suffering coupled with a disproportionate affective response and its downstream activation of sympathetic and long-term glucocorticoid stress response leads to the psychical (i.e depression), psycho-behavioral (i.e. sleep disorders, drug abuse), and physical symptoms (i.e abdominal, musculoskeletal pain) associated with burnout. Furthermore, at extremes, empathy pushes us toward psychologically easy solutions that generate the least cognitive load. Moreover, just because emergency providers are exposed to this pain, it does not mean that we have any special ability to cope with it. In fact, physicians who are most inclined to feel empathy also suffer the most from its side effects. Fortunately, this is not at a static state and the scales can be tilted towards the more emotionally neutral cognitive empathy with training. For example, in studies utilizing a technique such as loving-kindness meditation or compassion training, there was activation dlPFC and the  mesocorticolimbic pathway correlated with positive emotions. In essence, compassion meditation provided practitioners with an exercise in sharpening their fixed point to a more cognitive state. It is hypothesized that “meditation training is fundamentally no different than other forms of skill acquisition” and it allows practitioners to tune empathy towards an emotionally neutral, but cognitively sound detached state.

Medicine at its core is about deep-seated emotions such as fear, anger, hope, and pain. It has repeatedly been shown that and it is not surprising that patients thrive on an emotional connection with their providers. However, the pressure on the caregiver is unremitting and physicians who provide this connection often wilt under its force. In my opinion, the continuous stress of empathy demands in a high-stress environment is no doubt contributing to the burgeoning numbers of physicians showing signs and symptoms of burnout. However, empathy is an encompassing mental state that includes not only emotional but also cognitive components. These states are not mutually exclusive but on a continuum. Shifting the scales towards cognitive empathy leads to a decreased sympathetic and cortisol mediated stress response. Unfortunately, we cannot reason and consciously choose a cognitive response but compassion meditation training can make the cognitive empathetic response implicit and automatic. Like most skill-building, compassion and meditation training requires time and training. It is not a quick fix and the scalability of behavioral approaches often requires shifts in deep-seated cultural norms. Nevertheless, if the current and future generations of frontline physicians are to provide care empathetically, these providers will have to be trained to cope with the stressors of this responsibility. Techniques such as compassion meditation should be introduced early in the medical careers of the providers.   

Sources:

Behave: The Biology of Humans at Our Best and Worst

Buddha’s Brain: Neuroplasticity and Meditation