Full citation:
Riess, H. (2010, October 13). Empathy in Medicine—A Neurobiological Perspective. JAMA. 2010;304(14):1604-1605. doi:10.1001/jama.2010.1455
Empathy in Medicine—A Neurobiological PerspectiveThis article appeared in the Journal of Higher Education - Inside Higher Ed - and looks at empathy in college students.A physician's attitude and approach affect every aspect of medical care for patients and their families. An empathic bedside manner is no quaint relic of the past. To restore and ensure public trust in the medical profession, new generations of physicians must understand the emotional, physiological, and practical consequences of discarding empathy. One legacy of medical education is overvaluing scientific measurement and undervaluing subjective experiences. The neurobiology of empathy offers hope for those who value the subjective experience of empathy and for those who find comfort in what can be measured.
Advances in neuroimaging have provided tools to measure activity in the neuroanatomical and physiological relay mechanisms that translate the emotional experiences of others to self-experiences in the observer.1 The study of empathy is no longer a "soft science," but is increasingly grounded in empirical data. Mirror neurons, a specialized class of neurons in the premotor cortex and the inferior parietal cortex, provided the first neurobiological basis for translating actions that an individual observes in others into internal representations in the observer's brain and have spawned research among neuroscientists who study hemodynamic patterns of "self" and "other" representations of somatic sensations, pain, and empathy.1
Early studies examined physiological states between patients and physicians in which the autonomic arousal of both members of the dyad were simultaneously measured during psychotherapy. Using measures of heart rate and skin conductance, these studies suggested that patients and physicians were highly reactive to each other, producing physiological responses that could vary together in "concordance" or in "discordance," with the highest correlation between affect intensity and the degree of skin conductance activity.2
Physiological concordance has been correlated with patient perception of physician empathy. A study of 20 patient-physician dyads demonstrated a significant correlation between physiological skin conductance concordance and patient-perceived empathy on the Empathic Understanding Scale during psychotherapy (r = 0.47; P = .03).3 Clinical relevance emerged when the skin conductance tracings were reviewed in one therapy dyad in which the patient's skin conductance revealed some peaks of autonomic arousal that were 3 times that of the physician’s. For defensive reasons, the patient had learned to conceal her anxiety since childhood and had used overeating to contain her anxiety, becoming 70 lb overweight. On "seeing" the autonomic arousal on the skin conductance tracings, greater empathy for the patient's distress was possible, facilitating verbal expression of her anxiety and changes in diet and contributing to a 40-lb weight loss that year.4 The attunement to the hidden internal state of the patient may not have been possible without the physiological data.
In addition to physiological correlates of empathy, significant overlap exists between neural structures that control skin conductance fluctuations and the neuroanatomical structures implicated in neuroimaging studies of empathy.1 Converging neuroimaging and clinical findings suggest that activity in the dorsal and genual regions of the anterior cingulate cortex is strongly associated with affective and bioregulatory processes, including nociception and representation of somatosensory, viscerosensory, and autonomic arousal states, including responses to emotional stimuli. These findings highlight the role of the anterior cingulate cortex in the integrative control of sympathetic skin conductance responses, particularly in generating physiological states necessary to appropriately meet contextual behavioral and emotional demands.5
The role of the anterior cingulate cortex and empathy for pain as a shared neural representation was demonstrated in a study of 16 couples6 that showed that when loved ones say "I feel your pain," it is not just a figure of speech; they actually do feel it through neural pain representations in their own brains. In that magnetic resonance imaging study, the female partner in the scanner received a series of painful shocks through an electrode on her hand and could see her male partner receive similar shocks (via a cleverly angled mirror). A flashing light pointed out the next shock recipient. Whether the woman felt pain directly or anticipated her partner's pain, a similar pain matrix was activated in her brain.6 In the "self pain" condition, the entire pain matrix was activated, while in the "other pain" condition, a large portion was activated. Thus, humans share neuroanatomical representations of pain, but they experience third-person pain only in attenuated form. This enables observers to experience another's pain to the extent that it may motivate an empathic response but not overwhelm the observer with personal distress and self-protection.1 These mechanisms may facilitate altruistic behavior and may be a factor in choosing medical careers.
Empathy appears to be regulated by perspective-taking and by cognitive appraisal. In a magnetic resonance imaging study of 17 adults, participants were shown images of patients in pain. Higher activity was seen in the amygdala, anterior cingulate cortex, and insula when participants were asked to imagine that the pain was happening to them than when they viewed patients in pain. Additionally, when participants were informed that the pain they observed in others was part of an effective treatment that resulted in a cure, there was decreased activity in these emotional centers in the brain.1
Fluctuations in empathy have been documented in medical trainees.7 Empathy begins to decline in the third year of medical school for complex reasons, including an emphasis on emotional detachment and clinical neutrality, overreliance on technology that limits human interactions, lack of role models, and inappropriate treatment of medical students.7 In a neuroimaging study involving physicians (n = 15) and controls (n = 15) who were observing others being pricked by a needle,8 physicians down-regulated their pain empathy response by inhibiting neural circuits involved in pain processing areas (somatosensory cortex, insula, anterior cingulate cortex, and periaqueductal gray). Down-regulation of the pain response dampened negative arousal in response to the pain of others. Without emotion regulation skills, constant exposure to others' pain and distress may be associated with personal distress and burnout, suggesting that down-regulation may have some beneficial consequences.
Although down-regulation of empathy may have important protective elements during medical training, the practical consequences of unempathic medical care may also have serious implications. Lack of empathy dehumanizes patients and shifts physicians' focus from the whole person to target organs and test results. This is not simply a moral or philosophical issue; empathy is an important component of clinical competence, without which there can be serious consequences. Empathic physicians can obtain critical information and insights that affect quality of care and, ultimately, medical outcomes. Evidence supports the physiological benefits of empathic relationships, including better immune function, shorter postsurgery hospital stays, fewer asthma attacks, stronger placebo response, and shorter duration of colds. Low physician empathy also affects physicians and trainees. An estimated 60% of practicing physicians experience symptoms of burnout, which is linked to lower job satisfaction, leaving the profession, increased substance abuse, and suicide.9 Low physician rapport is correlated with lack of trust in physicians by patients as well as increased patient complaints and more malpractice claims,10 which are linked to the costly practice of defensive medicine.
It is possible that empathy can also be up-regulated through education. Medical educators can teach students about the neurobiological correlates of empathy, demonstrate behavioral skills that build an empathic connection, and scientifically validate the importance of empathy in the patient-physician relationship, while also teaching self-regulation strategies that may help prevent emotional distress during medical training and other challenging situations. Advancing physician empathy with deliberate, neurobiologically informed training and research may be a helpful approach to enhance the professionalism and compassion that are the hallmarks of medicine.
AUTHOR INFORMATION
Corresponding Author: Helen Riess, MD, Massachusetts General Hospital, Wang Ambulatory Care Center, 15 Parkman St, Ste 812, Boston, MA 02114 (hriess@partners.org).Financial Disclosures: None reported.
Funding/Support: The following foundations have funded my research on empathy: the Arnold P. Gold Foundation for Humanism in Medicine, the Josiah Macy Jr Foundation, the David Judah Fund, and the Risk Management Foundation.
Role of the Sponsors: The funding foundations had no role in the preparation, review, or approval of the manuscript.
Author Affiliations: Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston.
REFERENCES
1. Lamm C, Batson CD, Decety J. The neural substrate of human empathy: effects of perspective-taking and cognitive appraisal. J Cogn Neurosci. 2007;19(1):42-58. FULL TEXT | WEB OF SCIENCE | PUBMED2. Glucksman ML. Psychological measures and feedback during psychotherapy. Psychother Psychosom. 1981;36(3-4):185-199. FULL TEXT | WEB OF SCIENCE | PUBMED
3. Marci CD, Ham J, Moran E, Orr SP. Physiologic correlates of perceived therapist empathy and social-emotional process during psychotherapy. J Nerv Ment Dis. 2007;195(2):103-111. FULL TEXT | WEB OF SCIENCE | PUBMED
4. Marci C, Riess H. The clinical relevance of psychophysiology: support for the psychobiology of empathy and psychodynamic process. Am J Psychother. 2005;59(3):213-226. PUBMED
5. Critchley HD, Mathias CJ, Josephs O; et al. Human cingulate cortex and autonomic control: converging neuroimaging and clinical evidence. Brain. 2003;126(Pt 10):2139-2152.
FREE FULL TEXT 6. Singer T, Lamm C. The social neuroscience of empathy. Ann N Y Acad Sci. 2009;1156:81-96. FULL TEXT | WEB OF SCIENCE | PUBMED
7. Hojat M, Vergare MJ, Maxwell K; et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182-1191. FULL TEXT | WEB OF SCIENCE | PUBMED
8. Decety J, Yang CY, Cheng Y. Physicians down-regulate their pain empathy response: an event-related brain potential study. Neuroimage. 2010;50(4):1676-1682. FULL TEXT | WEB OF SCIENCE | PUBMED
9. Shanafelt TD. Enhancing meaning in work: a prescription for preventing physician burnout and promoting patient-centered care. JAMA. 2009;302(12):1338-1340. FREE FULL TEXT
10. Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J, Bost P. Patient complaints and malpractice risk. JAMA. 2002;287(22):2951-2957.
FREE FULL TEXT
Empathizing 101
November 24, 2010Are you often quite touched by things you see happen? Do you try to look at everybody’s side of a disagreement before you make a decision? When you see people being taken advantage of, do you feel protective of them?
If you are a college student or recent graduate, you are more likely to answer “no” to the above questions, which are excerpts from a University of Michigan test designed to measure the presence of empathy in people of different ages. What they found was disconcerting: College students today are 40 percent less empathetic than those who graduated two or three decades ago.
Capital University may have demonstrated perfect timing, then, in launching its Empathy Experiment. It’s a year-long project spearheaded by President Denvy Bowman, in which he’ll work closely with six students to attempt to determine whether empathy can be taught and, if so, whether that empathy affects broader social change.
The general consensus among empathy scholars is that the answer is yes and yes – but only under specific circumstances.
For instance, it is unrealistic to expect students to become more empathetic if they aren’t actually committed to the idea. In other words, they have to have the desire to change, said Sara H. Konrath, the adjunct assistant professor of psychology who led the Michigan study on college students’ empathy. “It’s probably possible in the context of what they’re doing,” she said. “If people are willing to do that and to try, then I think there are ways to change empathy.”
The details of the project are largely under wraps – to protect the “intensity and authenticity” of the student experience, Bowman says – so students don’t get a lot to go off of when deciding whether to apply. What they do know: they will be immersed in and learn about one social issue through “different experiences designed by community partners” over a six-week period. The time commitment is a few hours a week and the experiment will conclude in late spring with an event on Capital’s main campus. Students will meet with Bowman throughout.
People at Capital aren’t the only ones excited about the project. Also intrigued is Mary Gordon, founder of the Roots of Empathy classroom program that works to develop empathy in children (and their parents). As she puts it, “empathy cannot be taught, but it can be caught.” The key to developing empathy, she says, is for people to witness others engaging in empathetic behavior. (Note: This article was updated from an earlier version to correct an error.)
“This idea of teaching empathy – it’s just not doable in the traditional way,” Gordon said. “The word I loved about this university president’s approach was that he was ‘immersing’ them in empathy. That’s very different from instruction. That’s very different from 250 university students sitting in desks while someone pontificates and lectures up in the front of the lecture hall.”
People are most likely to develop empathy as children, before they have the chance to form notions about the world as a good or bad place. If parents are abusive or neglectful, it can have a lifelong impact on their self-worth and ability – or lack thereof – to empathize. The idea is that instilling values of understanding and perspective-taking in children will then carry on through parenting from generation to generation.
But just because children develop empathy more easily doesn’t mean adults – or college students – are incapable of it. Quite the opposite, says clinical psychologist Arthur P. Ciaramicoli, whose new book The Curse of the Capable describes how people are so focused on achievements like career goals and material items that they sacrifice relationships and healthy lifestyles.
“You absolutely can teach empathy – there’s no question about that,” said Ciaramicoli, who has written and counseled extensively on the topic. But in today’s fast-paced and technology-driven culture, people’s self-absorption leads to more narcissism – and, consequently, less empathy. “I think we have become a society where we rate status over relationships. We relate image over character and when you do that, you place much less emphasis on the skill or the ability of empathy.”
Empathy is so strongly believed to be a promoter of civility and understanding that the European Union is funding a three-year project to build empathy in Irish children, in hopes of a more stable future between Northern and Southern Ireland. To speak with Inside Higher Ed about the value of empathy, Gordon telephoned from Dublin, where she was working on the project and preparing to lecture at Trinity College.
“The educated young people are the people who are going to be changing policies in the future,” Gordon said. “We better be sure that they’re empathetic.”
That will certainly be on the mind of Bowman, the Capital president, when he selects the six student participants next month. As of the application deadline Friday, 164 students had either applied or been nominated for the Empathy Experiment (about 3,600 total attend Capital). The 28 students who were nominated have this week to decide whether to apply.
Bowman's ultimate goal for the project is to empower and motivate his students to effect social change through empathy. Ideally, these students would inspire their friends to empathize, those people would inspire their friends, and so on. The idea, birthed through Bowman's conversations with community members inquiring about the next generation of leaders, is pertinent to everyone, he says.
“My hope is to speed up that brighter future that I’m sure lies out there, and which everyone I know would like to see as quickly as possible,” Bowman said. “Perhaps beyond all of this, we hope that this is a continuing dialogue as broadly as possible, which is the kind of dialogue that enhances rather than impairs understanding.”
No comments:
Post a Comment