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Monday Mar 28, 2016

Thoughts on Empathy Under the Northern Lights

The other night I was treated to a spectacular display of the aurora borealis. The sky glowed with shimmering light in a spectrum of green and red. It is amazing how something as ephemeral and yet complex as solar wind interacting with Earth’s magnetic field and atmosphere can create such beauty.

At the same time, I have been thinking a lot lately about empathy and how it relates to patient care, burnout and electronic health records (EHRs). Like the northern lights, empathy has a scientific basis, but is still nebulous and beautiful.

I use empathy as a diagnostic tool. My mind is geared to understand and mirror the emotions of others. Although I use logic and evidence-based medicine, I cannot deny that a large part of my assessment in the exam room is based on my reaction to how the patient feels. Our brains are uniquely wired for precisely this process and the trillions of neural connections along with experience trigger patterns of diagnosis. The way a patient moves onto the exam table, the small facial expressions, eye contact, skin color and the way the heart beats mean as much to me as do the history and lab work. I use all of this information to answer the fundamental question: Is this patient sick or not?

To feel what someone else is feeling is a gift given to us by an evolutionary legacy of living as social animals, and I use this gift in my work each day. Several years ago I walked into an exam room and within seconds realized that my 4-year-old patient had cancer. Knowing instantaneously what my diagnosis would be, I dedicated the remainder of the visit to fleshing out the history, conducting a physical exam and obtaining lab work that would identify her leukemia. This is not the only time this has happened to me, and I am not alone.

When the aurora is bright, the light comes in shimmering streamers from multiple directions at once across a large part of the sky. It is not sequential or directional, but manifests as parallel lines of color and light that come in waves and swirls.

Advances in neuroscience, such as functional magnetic resonance imaging, have shown us similar action in specific parts of the brain correlated with empathy. The neurologic basis of empathy(www.annualreviews.org) is extremely complex and involves multiple areas of the brain. Memory is connected to our senses. Interpretation of visual cues is balanced with experience. Mirror neurons, the cingulate gyrus, and anterior insula, are all involved and all of this parallel processing occurs beneath the level of cognition. There is a good body of evidence to show that the same parts of the brain activate in response to pain -- whether it is personal or vicarious -- through empathy.

Our patients need this connection as well. As physicians we use empathy as a diagnostic tool, but both we and our patients need it to cope with disease at hand. Touch and eye contact have been shown to be an essential part of the physician-patient relationship and healing in and of themselves. A patient of mine once told me that she wished someone could see through her eyes and feel what it is to live with her chronic condition. The reality is that I try. I must because that is how our brains are wired. Empathy requires that to some degree, I model what others are feeling.

In medical school I was taught that it was important to empathize, but not sympathize. The intended lesson was for physicians in training to learn how to go home at the end of each day and be unaffected by the pain and suffering that we witnessed in the medical world. But our neuroanatomy precludes this model of training, especially in family medicine. We have to use every tool at our disposal to care for an undifferentiated complex population, and empathy is supremely important. However, there is a cost. We feel our patient’s pain. I have learned how to grieve efficiently.

Computers work differently, in series rather than in parallel and often the complex interplay experienced in the exam room does not translate to an electronic record. Further, stressful events may limit the use of an EHR entirely. I recently had such an experience. There was a tragic accident during a snowstorm, and after resuscitation I could not transfer my patient to a tertiary care hospital because of the weather. For 12 hours, I sat at her bedside with her family, completely in tune with my dying patient, her family and the team I was working with. For days after, I found that I was unable to use my EHR. I could see patients. I needed to see patients. But I could not use the EHR. It was like I had EHR aphasia, and it frustrated me immensely.

The burnout rate among family physicians has increased significantly since the advent of the EHR. There are many reasons for this, including increased administrative burden, less time per patient, and less time for family and exercise, which all leaves us with a feeling of decreased autonomy. Perhaps one of the problems is that computers are interfering with our ability to connect with our patients. Checking boxes decreases our ability to hold eye contact, and computers often get in the way of patient care. We need this connection as much as our patients do.

We feel the pain of our patients. To deny this is to discount one of the primary ways that we interact with one another. Our brains are wired to feel what others are feeling, and we need empathy if we are to care for our patients. And as with all gifts, there is a cost. We take some of our patient’s pain onto ourselves and share their burden. We need to recognize that as a result we often are grieving, and that this is the natural consequence of what we do.

We need to take care of ourselves physically and emotionally, turn to loved ones, have faith in a higher power and appreciate beauty where we find it. That was exactly my intention when I walked outside late that cold night to watch and to wonder at the phenomenon of the aurora borealis.

John Cullen, M.D., is a member of the AAFP Board of Directors.


Posted at 11:31AM Mar 28, 2016 by John Cullen, M.D.

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