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TLDR: Empathy is a SKILL

If you have gone through medicine, you have likely heard this alarming statistic - People come into medical school with very high levels of empathy, but this declines throughout the course of training, and ultimately bottoms out during third year of clinical clerkship.


Why is this?


Well, like anything else, I am sure it is multi-factorial. For one, its pretty hard to be empathetic when you are physically and mentally exhausted. It can also be hard to focus on the experience of another when you know your own performance is constantly being evaluated. I believe, however, that there is a bigger issue at play here. And I think it has to do with a lack of understanding about what empathy really is, because in actuality, clerks are thrown into the clinical environment without knowing how to empathize in a way that both enables meaningful connection, while also protecting their own emotional longevity.


Look no further than me for exhibit A.


I recently had a patient who came into the Emergency Department after months of feeling progressively run-down and weak, to the point where it was now impacting their ability to go about their day-to-day life. For an otherwise young and healthy person, this was unusual. But I figured we would admit them, figure out what was going on, treat it, and get them back home to their busy family life in a few days. Unfortunately, I was wrong. When following up on the investigations we had ordered, I was slapped in the face with the very worst case-scenario. The culprit was an advanced, aggressive, inoperable cancer, and the prognosis was as dismal as it sounds. A wave of hopelessness and sadness washed over me, as my stomach fell out of my body and onto the floor. Nothing about this was fair.


For the rest of the day, I was enveloped in a strange sort of grief; a longing for meaning and understanding - a reason to explain why this was happening. I couldn't find one. This was also a grief that didn't really feel fair for me to be feeling. After all - it wasn't me who had received this gut-wrenching, life-altering news. How selfish was I to have imagined what this would mean to myself or my family if it had been us? Was I feeling despair for this family, or at the thought that it could have just as easily been my own? Without really knowing it, I had hijacked a moment that belonged to that patient and their family; this was an experience that they were going through, not me. I was trying to be compassionate with myself as I noticed my harsh self-talk, but I was struggling.


When I got home and reflected, I realized that in trying to foster meaningful connection, I had somehow missed the boat on empathy. I turned to my emotional bible, Atlas of the Heart, to help understand where I had gone wrong.


First thing's first, I was reminded that these uncomfortable emotions were telling me something, and could even be the spark for meaningful change. As Joseph P. Forgas so eloquently puts it, "Evolutionary theory suggests that we should embrace all of our emotions, as each has an important role to play under the right circumstances." So, I wondered, what exactly was the role? Here is what I learned.


Compassion is a pre-requisite for empathy; you need the former to have the latter. Here is the definition of compassion that came out of Brené Brown's research:


"Compassion is the daily practice of recognizing and accepting our shared humanity so that we treat ourselves and others with loving-kindness, and we take action in the face of suffering."


Clearly, compassion involves more than just feeling; compassion involves actually doing something, in an attempt to alleviate suffering. If you are anything like me, you will be shocked to learn that 'action' doesn't equate to 'fixing' someone else's suffering. Rather, it means getting in touch with the part of ourselves that understands what they are feeling, and gently moving towards that. But this can get tricky, and we need to be careful when we do this. As Jack Kornfield puts it:


"An[other] enemy of compassion is despair. Compassion does not mean immersing ourselves in the suffering of others to the point of anguish. Compassion is the tender readiness of the heart to respond to one's own or another's pain without despair, resentment, or aversion. It is the wish to dissipate suffering."


But how do you avoid immersing yourself in the suffering of others to the point of anguish?


Boundaries. I love the way Brené Brown puts it, telling us "We can't connect with someone unless we're clear about where we end and they begin." I think this is part of what drove my empathic failure - I was so focused on putting myself in my patient's shoes to understand what they were going through, that I lost sight of where the line was between what they were experiencing and what I was experiencing.


To further understand what went wrong, we need to break down empathy; it turns out, there is more than one kind. Cognitive empathy is what allows us to take the perspective of another in order to understand what they are feeling. Affective empathy, on the other hand, involves feeling what the other person is feeling in order to understand their emotional experience. This can be dangerous, as if we lose ourselves and become enmeshed with the other person's suffering, we are no longer able to meaningfully support them. Uh oh. Not what you want from your doctor, I am sure.


We also hear the concept of compassion fatigue thrown around quite often - some of you might know it as emotional exhaustion, or burnout. Many people think that this arises when we empathize too much, however, I believe it arises when people empathize in the wrong way. And guess what, that is what the research shows too. As Brené puts it,


"Compassion fatigue occurs when caregivers focus on their own personal distress reaction rather than on the experience of the person they are caring for. Focusing on one's own emotional reaction results in an inability to respond empathically to the person in need. We're not hearing the story, we're inserting ourselves in the story."


Compassion fatigue occurs when we practice affective empathy instead of cognitive empathy. Maybe part of the reason burnout is such an issue right now (beyond the massive systemic factors) is that people are not able to make this distinction and, as a result, they become overwhelmed with their own emotional experience in trying to connect with their patients. What if people had the knowledge and the language to change how they empathize? I imagine things would look a lot different.


One final thing I want to touch on is comparative suffering. As you may recall, my own self-talk was running RAMPANT with this as I grappled with what I was feeling. How could I possibly be suffering when this wasn't even happening to me? Well, now I know it is because I allowed myself to be dragged into affective empathy, rather than deploying the healthier skill of cognitive empathy. I have also learned this - my patient and their family do not benefit more if I conserve my concern only for them; having compassion for myself does not reduce the amount of compassion I have for them.


Wow. You're telling me I can be concerned for how my patient is feeling, AND ALSO be concerned about how I am feeling, WITHOUT taking anything away from them? Truly mind-blowing.


Brené puts it a little more eloquently,


"Empathy is not finite, and compassion is not a pizza with eight slices. When you practice empathy and compassion with someone, there is not less of these qualities to go around. There's more. [...] Yes, perspective is critical. But sharing how we feel is okay as long as we do so with a little perspective. Hurt is hurt, and every time we honour our own struggle and the struggles of others by responding with empathy and compassion, the healing that results affects us all."


I don't want to be one of those doctors who lacks the emotional reserve to connect with their patients because they have been burned by caring 'too much' earlier in their career. Now that I am armed with this knowledge about compassion, empathy, and boundary setting, I am confident that I wont have to be.


The question isn't "Am I empathizing too much?", it is, "Am I empathizing in the right way?" Empathy is a skill. And the sooner you start treating it as such, the better off you will be.



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