Empathy: House of the Russian Doll (part 2)

This is part two of a three part series on empathy:

Empathy has become the central focus of a new battlefield in medicine.  Patients seek it, researchers analyze it, doctors debate it, and some companies are even trying to sell it. In a field where technical prowess is presumed, emotional content has become the new currency. Despite all this attention, the nature of empathy remains controversial.   

What is empathy? The word empathy did not even exist in the English language until the early twentieth century. The German philosopher, Robert Vischer first derived the term, Einfühlung, in his doctoral thesis, On the Optical Sense of Form, in 1873. He derived it from the Greek word, empathea, meaning “feeling into,” and was used to describe how art could convey emotion. The word was then translated into English by Edward Titchener in 1909 to describe the act of perspective change. He broadened the definition of empathy beyond the appreciation of art and nature to include interpersonal relations and the structural theory of the mind. But even before there was a word for it, Western philosophers grappled with the concept. In his 1759 treatise, The Theory of Moral Sentiments, Adam Smith, a Scottish philosopher considered the father of free market capitalism, proposed “that by changing places with the fancy of the sufferer, we come either to conceive or be affected by what he feels.” Empathy is the heart of the cathartic experience of theater and sport. It is why we cheer for the hero and jeer the villain. It allows us to share in another’s victories and defeats as if they were our own.   

In his book, Social Intelligence, psychologist Daniel Jay Goleman divides empathy into three primary components. The first is cognitive (intellectual) empathy, the ability to understand another person’s point of view or perspective. The second is affective (emotional) empathy, to emotionally resonate and feel what someone else feels. The final component of the empathic triad, empathic (compassionate) concern, is the ability to understand the emotional needs of someone else.   Empathic concern ideally leads to compassionate acts and assistance. For empathy to function effectively, all three elements must be present and work in concert.

We are all emotional detectives. Our success as individuals and as a species has always been linked to empathy. But are we born with empathy or do we learn it? The answer is probably both. Even in infancy, humans demonstrate a kind of instinctual empathy. Babies cry when others cry. They smile when held by a smiling mother and yawn when other family members do. These primitive emotional responses spread like viruses—sociologists even refer to them as emotional contagions. Once thought of as a uniquely human trait most researchers now concede that primates and other mammals also demonstrate this rudimentary form of empathy. The ability to sense group fear is basic to survival. The sight of a lion’s silhouette can trigger a life-saving stampede in the African savannah. An explosion at a sporting event can lead to a crowded and deadly rush to an exit tunnel. But fight or flight is not the only choice that can be made by rapidly decoding unspoken intentions. A casual twirl of the hair, a gentle tilt of the head, or the flash of a playful smile can trigger flirtation and spark romance. The accuracy of our mood sensing and mind reading is crucial for building trust and relationships. Empathy is woven into the fabric of our family life, work, play, and health.

One of the most influential experts studying empathy today is primatologist, Frans de Waal. In his book, The Age of Empathy, De Waal likens empathy to a Russian doll with multiple deepening shells of intellect, recognition, and imitation surrounding a central emotional core. De Waal has found that the use of imitation and body contact eases the faculty of empathy. This elegant model suggests an emotional parallelism between the individual development of empathy and the evolution of this trait. It concludes humans are naturally empathic and that we share this quality with primates and many other animals. 

It seems our brains are hard-wired for empathy. The possibility that the brain couples perception and action had long been speculated, but it wasn’t until the late twentieth century that evidence for the actual existence began to emerge. Italian neurophysiologist, Giacomo Rizzolatti, then made an accidental discovery that fundamentally changed the perception of empathy and emotional intelligence. His team recorded electrical brain activity patterns in the motor cortex of macaques as the monkey picked up a peanut. The strange thing was that when the monkey watched a lab technician pick up another peanut, the same neurons fired. The brain did not distinguish between itself and the tester. Doing and seeing were the same.  Rizzolatti called these pathways “mirror-neurons.”

Advanced functional magnetic resonance imaging techniques (fMRI) allow scientists to observe dynamic three-dimensional brain activity as it occurs. In 2004, Singer first utilized fMRI to investigate how we perceive pain in others. His group discovered striking similarities in fMRI brain activity of volunteers who were given a painful stimulus and then simply watched a loved one in the same room receive a similar painful shock. Once again, the line between self and other appeared to blur as affective center of the pain matrix was activated. When we see someone in pain, the imagined pain we experience comes in large part from this mirror neuron network. What we see, we feel. 

Two decades of intense neurologic research followed the discovery of the mirror neuron system. Despite a growing body of evidence supporting the presence of mirror cells in humans, direct evidence of their existence has proven elusive. One of the prime barriers hindering work in this field has been the hesitancy to use invasive single-cell measurement techniques in humans. In 2010, neuroscientist, Marco Iacoboni and his group at UCLA took advantage of a rare opportunity to study intracranial electrode recordings of brain activity in patients being treated for intractable epilepsy. Their controversial study was the first to confirm the presence of individual mirror cells in several areas of the human brain that fired both individually and in groups during the execution and observation of actions. What they found was a rich web of activity bridging zones in the motor, visual, and memory zones of the brain. Iacoboni believes that this complex, distributed mirror neuron network allows humans to learn through imitation and modeling. 

Humans are among nature’s most social creations. In his book, Mirroring People, Iacoboni theorizes that we connect with one another through this automatic matching system like emotional chameleons. By enabling emotional attunement and synching visual observation with motor behavior, the mirror pathway leads to empathy. In a way, the mirror system functions like a robust social media pipeline- always on, always engaged. Despite the absence of a unified neural theory of social cognition, the fascinating mirror system should not be ignored. Future research may help define the various types and locations of mirror neurons, how they interact and adapt, and perhaps clarify their role in empathy.

Why should empathy be important to physicians?  Simply put, it makes us better at our jobs.  Psychiatrist Jodi Halpern presented the case for clinical empathy in her 2001 book, From Detached Concern to Empathy. Halpern argued that doctors could gain invaluable clinical information by emotionally engaging their patients. Empirical research has since supported this theory. Doctors who display more empathy have happier patients, better clinical results, and fewer malpractice suits. But there is more to it. Patients want empathy. They really, really want it.  Physician empathy ranks near the top of the every published patient wish-list. Technical prowess is no longer sufficient to satisfy patients. Studies indicate that a high standard of medical competence is presumed and patients assess physician performance in a primarily behavioral context. 

Once dismissed as simply good bedside manner, data now clearly links increased empathy with improved medical care. Recent studies of diabetics demonstrate better blood sugar control and fewer complications in patients whose doctors scored higher on the Thomas Jefferson University Empathy Scale, an objective test for empathy. Another study found that pain tolerance is improved in patients who believe their doctors are empathic. In this experiment, patients were randomized into two groups for different types of clinical interviews. The first group was given a standard medical interview restricted to a series of clinical and medication questions while the second group received a patient centered interview stressing empathy and covering a broad range of occupational, personal, and social interests. Results of post-interview questionnaires showed that patient centered group had higher rates of confidence and satisfaction with their doctor than the traditional group. But there’s more. Each patient was then placed in an fMRI scanner, shown a picture of the physician that performed the interview and told that this doctor was supervising the test. The patients were then given a series of mild electric shocks similar to the pain intensity of an intravenous catheter insertion. The patient centered interview subjects reported less pain and showed decreased activity in the pain centers of the brain than those who did not identify with their doctor.

Patients are not the only beneficiaries of empathy. Enhanced levels of empathy also produce happier physicians. A cross-sectional survey of medical residents at the Mayo Clinic showed that those with higher levels of empathy also scored higher for mental well-being than their less empathic colleagues. Analysis of patient complaints and malpractice depositions point to decreased empathy as an important cause of litigation. Empathy firms the doctor-patient connection, it is not surprising that this data recognizes that it also facilitates improved communication and more satisfied patients.

Ignoring the importance of empathy can negatively impact your bottom line. The medical insurance and malpractice industry has taken a keen interest in clinical empathy. The potential benefits of empathy in medicine have also drawn the focus of the government. The Accountable Care Act of 2010 links physician reimbursement and patient satisfaction, making empathy a national priority. By 2018, 90% of Medicare payments will be value-driven based on a blend of objective quality metrics, cost analysis, and patient satisfaction surveys. This sweeping transformation in payment formula from quantity to quality now primarily affects hospitals but is quickly spreading to physician practices as private insurers adopt the expanding federal guidelines. The linkage between HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) patient satisfaction survey results and hospital reimbursement will continue to broaden and encompass private practices. The CGCAHPS (Clinician and Group Consumer Assessment of Healthcare Providers and Systems) is nearing adoption and will soon be accompanied by similar payment linked satisfaction surveys of pediatrics, emergency medicine, hospice care, mental health, and Accountable Care organizations. Reimbursement changes are not the only financial side effect of the affective revolution. Paychecks are at risk as well. Most hospital and health networks already use patient satisfaction measurement in their physician compensation calculations. Now that the big dogs have come to feed, you would think that empathy would become a central focus of medical education.  You would be wrong.

Next week we wrap up, Empathy: House of the Russian Doll (part 3)