No energy for empathy?

Picture this: A nurse is working with her team to cultivate a feeling of calm, of quiet, in a birthing room where a woman is about to deliver a stillborn baby. Then the doctor bursts in, full of urgency and completely shatters the careful mood. It’s a jarring moment that the family will remember forever in their grief. This story was told to London, Ont.’s Dr. Taryn Taylor by a nurse as Dr. Taylor was researching the impact of fatigue on physicians’ practice. In this case, the physician failed to provide empathetic care because they were exhausted. After the pivots, pitfalls and tragedies of the pandemic, have we become a nation of physicians who are often—or always—too emotionally, mentally and physically exhausted to provide empathetic care? Are patient interactions becoming purely transactional? Have physicians lost their ability to feel empathy? What is empathetic care? In general conversation, it can be tricky to pin down a definition of empathy because we tend to think about the whole spectrum of this type of caring, which includes both empathy and compassion. “Empathy is the perception and understanding of another’s emotions; being able to put ourselves in other people’s shoes is a core part of what makes us human,” explained Dr. Mamta Gautam, a psychiatrist at the Ottawa Hospital and the University of Ottawa who specializes in physician wellness. Compassion is acting on that empathy, or “the response to the perception of another’s suffering, which involves acting to reduce the suffering in some way,” Dr. Gautam said. Dr. Pierre-Paul Tellier, an associate professor of family medicine at McGill University, provided a concrete example of empathy and compassion in his practice. Currently, Dr. Tellier is working on a clinic for sexually gender-diverse individuals who are racialized immigrants or asylum-seeking. “I got into that because I was asked by a person who was dealing with transgender individuals and dealing with kids on the street who were accessing their medication on the street,” he said. “I related to their emotional state, so I wanted to help. And that’s compassion: wanting to do something for somebody else.” In Empathy: Turning Compassion into Action, former Governor General David Johnston and his co-author Brian Hanington provide tangible ways to live life in an empathetic way. Their definition of empathy stretches the length of the spectrum, but it doesn’t really matter. Empathy without action is not helpful in medicine, nor in many parts of life. It’s not enough to just feel empathy, it must be communicated to patients to show that you understand—or at least are trying to understand—what they’re going through. The CMA goes further and says that practising with empathy is important not only for patients but for physicians: “Studies show that practising empathy in patient care helps physicians find more meaning in their work, reduces burnout and improves wellbeing,” it states on its website. Can physicians lose empathy? In the past, Dr. Chandi Chandrasena would hear from her colleagues about how much they loved their job. She’s a family physician and chief medical officer of OntarioMD, a company owned by the Ontario Medical Association (OMA) that supports physicians in their use of technology. She said that she’s no longer hearing that; many physicians have lost the parts of medicine that brought them joy, including the connection to patients. Over time, and accelerated during the pandemic, some physicians have lost their energy for empathetic care. Dr. Chandrasena explained it this way: “I have empathy for you, but I’m emotionally exhausted and I just cannot take it to the next level, which before I was able to do quite easily.” Having empathy, and expressing it appropriately, takes time and energy, Dr. Gautam said. It requires active listening and being curious and attentive. “When we are emotionally overloaded, feeling overwhelmed, or burned out, our capacity for empathy can decline as a result of the degree of emotional labour expended. This cost for caring for others has been described as compassion fatigue,” she said. Can empathy be taught? Is empathy innate, or is it learned? It may be a bit of both. The general consensus is that physicians are naturally empathetic, but the skills to provide empathetic care are honed in medical school. “I’m probably generalizing, but I think most family doctors have empathy because without empathy we’d really be horrible doctors,” Dr. Chandrasena said. One way to teach empathetic care is to involve patients. Dr. Tellier gets his medical learners to watch recordings of their interactions with patients, so they can revisit how they relate with the patient, how they obtain information, how they came up with a diagnosis and how they explain that to the patient. “There are some people who have it naturally, and there are some people who don’t,” Dr. Tellier said. Those who struggle with empathetic care need more help, but even those who have it need training. “The ones who have it, what you have to do is have them learn how to control it during the interview time. Because if you are over-compassionate, you may spend an hour or an hour and a half with the patient,” he said. Communicating with the patient is a big part of providing empathetic care. “I think a large part of a physician caring is to make sure that their patient understands what they are talking about, what the important things are and asks them about their worries and their concerns and address those—which is in part empathy as well,” Dr. Tellier said. There’s a caveat to empathy: As psychiatrist Dr. Helen Riess explains in her 2017 paper The Science of Empathy, it’s easier to feel empathy for someone similar to you. This means there’s a threat of unconscious bias when providing empathetic care to those you instinctively understand. To cheat that evolutionary-derived bias, physicians need to engage in “enhanced perspective taking”—seeing a person’s situation from their point of view—and “enhanced value” putting value on a person’s welfare when they are different from you. This may be especially important in certain patient populations where physicians may struggle to comprehend the patients’ journey. For example, in a paper on self-harm, the authors warn that these patients can bring on compassion fatigue in healthcare professionals because recovery from self-harm takes a long time and there are many relapses. “As physicians, we need to be aware of our attitudes and biases and be more consciously ready to empathize with these specific patient populations. This cognitive empathy component can be useful when emotional empathy is less naturally present,” Dr. Gautam said. Yet even with training, empathy can decline. Studies show this is a common phenomenon as medical learners progress in their training. Dr. Gautam notes this decline may be a buffer to protect against psychological and moral distress that medical learners tend to experience as they care for patients during their training. Some physicians may fall back on medical explanations, and work less on building trust, the CMA noted. But since empathy, or communicating empathy, can be enhanced with training, it can also be re-kindled with training. What’s the solution? While it’s up to the individual to engage their empathy to provide empathetic care, if some physicians are having trouble doing that, it’s not necessarily their fault, said Dr. Chandrasena. Technology can get in the way of providing empathetic care. An obvious example is the EMR, which can create a physical barrier between a physician and patient. “If I’m not making eye contact and all I’m doing is typing and opening up charts and looking for reqs, it changes that dynamic,” Dr. Chandrasena said. “I’m probably not going to get up and hold your hand because there’s a computer and a printer and if I get up, I’m going to have to put in my login again.…” The technology also puts more burden on the physician, leaving less energy for empathy. Where the administrative staff used to go through files and faxes and only put the urgent ones on the physician’s desk, now all information is in the physician’s inbox, waiting to be sorted through. Physicians have to do more tasks because of privacy issues, passwords and systems not talking to each other. “That onslaught of information because of technology has left us anxious,” Dr. Chandrasena explained. This leaves less room for empathetic care. There’s not a lot of research into sleep deprivation and a physician’s bedside manner, but in her many interviews with healthcare professionals, Dr. Taylor heard that sleep deprivation “made it hard to interact with other healthcare team members, and maybe made them less compassionate or patient with patients as well.” The system of training medical residents and staffing hospital shifts also impacts empathy. It leaves people sleep-deprived, and research demonstrates that people who are sleep-deprived have problems detecting facial cues and responding appropriately to humour. “It’s not a major leap to imagine that would manifest as challenges in our work as physicians,” said Dr. Taylor, an assistant professor in the department of obstetrics and gynecology and a scientist in the centre for education research and innovation at Western University. Expecting physicians to perform normally when fatigued is problematic on many levels. “This empathy and compassion piece is a big part of it that has been underexplored in terms of the impact of prolonged sleep deprivation and fatigue on our ability to be compassionate and present for our patients,” Dr. Taylor said. If part of the fault lies in the healthcare system, solutions lie in system change. “It’s not an individual solution, it’s not a clinic solution, it’s not that ‘I need to go and do more yoga or I need to be more resilient or I need to go find time in my day and what’s wrong with me for not doing that’—those aren’t the solutions we’re targeting. It’s a health system solution,” Dr. Chandrasena said. Medical associations are pushing for change. For example, the OMA’s Prescription for Ontario campaign includes solutions targeted at reducing paperwork and fixing technology snags so physicians have more energy for patient care. The College of Family Physicians of Canada and others are advocating for more team-based care and fewer administrative tasks. Success in these areas could give physicians more energy to re-engage their empathy. In the meantime, Dr. Chandrasena proposes that physicians use the services of OntarioMD, or similar agencies, to hack the system. A team can come into your clinic and see if tasks can be re-distributed to take some administrative burden off the physician, leaving more energy for patient care. To address fatigue, Dr. Taylor said the first step is acknowledging that it’s not right for physicians to be sleep-deprived. “We are putting physiologic demands on our bodies that are not normal,” she said. A number of residency programs are changing shift rotations in the hopes that medical residents get more sleep, although more changes may be needed to address the problem. Dr. Tellier said what he finds tiring is a new “continuing demand for service” from patients, who were used to increased access during the pandemic. But what makes him feel great on a difficult day is when he shows empathy to a patient in need and it helps, like when he reached out to a grieving widow and she was then able to share her troubles. “It’s the fulfilling part of medicine, shall we say. At least for me,” Dr. Tellier said. Physicians haven’t lost their empathy. It’s still there. It just needs a boost. That boost won’t come with a pizza party or yoga session, but with real system change that leaves physicians emotionally, physically and mentally available to engage their empathy and communicate it effectively to patients. And by being able to provide empathetic care, physicians might get a boost back, and find their profession fulfilling again.

No energy for empathy?

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