Why We Need to Have Affective Empathy for Our Patients
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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Podiatry Today or HMP Global, their employees, and affiliates.
"It is more important to know what sort of person has a disease than to know what sort of disease a person has." —Hippocrates, the father of medicine1
I recently composed a letter to prospective students detailing why they should investigate podiatric medicine and pursue a career in podiatry. I also wrote about what drove me to desire a career in podiatry and the holistic medical education I have had the privilege of receiving for the last 4 years as a podiatric medical student.
As a fourth-year student, I am coming to the cusp of finishing my medical school journey and have recently completed residency interviews. During interviews, residency directors asked me, "Is there anything you wish you could teach the older generation of medical providers as someone from the younger generation?" Before delving further, it's essential to acknowledge that the list of things I have yet to learn within podiatry and medicine, in general, is far more extensive than my current knowledge.
I'd like to share my response and my personal experience as a patient, shedding light on how the latter has significantly influenced my perspective. Resilience is a prerequisite for anyone pursuing a career in the medical field, especially for those who endured residencies without the 80-hour work week limit and adhered to the "I had to endure this in training, so should you" mentality from their superiors.
People don't seek medical care when everything is fine. Whether it's a routine physical, emergency room visit, or a mandatory sports exam, there's always a reason behind someone walking through the doors and consciously deciding to enter your office. As health care providers, we are constantly surrounded by injured, ill, or dying patients throughout much of the day. This exposure could desensitize providers and hinder their ability to offer the empathy that patients often require. As medical professionals, we possess a certain level of resiliency due to surviving medical school, residency, and the mental struggle of continuing our day after delivering bad news or dealing with a demanding patient.
While it's easy to advocate for increased empathy among health care providers, my response to the question prompted me to delve into research on empathy within the medical field. Contemporary researchers delineate two main types of empathy: affective empathy, which involves feeling the emotions of others; and cognitive empathy, which entails understanding and identifying with another person's emotions.2 Clinical empathy, further dissected, involves a provider's proficiency in understanding a patient's situation and emotions, communicating accurately and empathetically, and acting in a therapeutically beneficial manner.3,4 Such expectations for medical providers are significant. However, the literature supports those physicians perceived as warm, friendly, and understanding, who reassure patients, noting these physicians tend to yield more effective outcomes, including better therapeutic results.4-6
When I conceived this blog, I intended to narrate my medical challenges and share my experiences as a patient. However, I am currently immersed in my orthopedic rotation. After early rounding, I would spend a packed day in clinic and navigating a continuous stream of "difficult" patients—some of whom insisted that I lacked understanding, labeled me a "dumb nurse," and lamented the repeated failures of the health care system, in particular highlighting their extensive list of over 30 drug allergies. This experience seemed to leech what felt like all the compassion and empathy from my body. Reflecting on these challenging encounters, I am reminded of the importance of providers embracing more empathy.
Transitioning to my own experience as a patient, during the latter part of my third year in medical school, I began experiencing persistent low-grade headaches and various unusual symptoms. Over 3 months, these symptoms worsened, and new ones emerged. When I contacted my primary doctor, she said she had no appointments for months and suggested I visit the emergency department if things became severe.
Eventually, securing an appointment with another provider a month later, I explained the progression of my symptoms. However, after learning about my medical student status, the doctor focused on stress management without addressing my concerns. Following a brief physical exam, he reluctantly ordered what he deemed "unnecessary" lab work, assuring me that the results would likely be normal, and emphasized stress management. He even went as far as to suggest I consider a less stressful specialty than surgery. When my labs returned with high-normal values, I received a message stating no follow-up was necessary.
Another two months passed with ongoing symptoms, prompting me to contact my primary care physician (PCP) and obtain a telehealth session. She emphasized stress management, acknowledged the challenges of medical school, and ordered repeat labs. Despite even more elevated and now abnormal results, she deemed them acceptable.
Four additional months went by with persistent symptoms that, while not severe enough to hinder my studies or significantly impact my daily life, still troubled me. Seeing another doctor covering for my PCP, I explained my symptoms, and she completed a physical exam. Concerned by the findings, she reordered labs. Horrified by the newest lab values, the doctor promptly referred me to endocrinology for magnetic resonance imaging (MRI) of my brain.
The MRI revealed a treatable benign pituitary microadenoma. I was able to see an endocrinologist promptly and receive the necessary treatment. However, the endocrinologist expressed shock that it took so long for me to be referred, given my "classic clinical presentation."
I have complete confidence in the competence and intelligence of my health care providers. They observed a seemingly healthy 25-year-old navigating a stressful phase in life. They drew on their own experiences with residency applications and interviews to assume that my symptoms were simply due to stress. Although my lab results showed mild elevation, and I acknowledge that stress can manifest in various physical ways, I recognize the complexity of my situation. Despite my persistent belief that something was wrong with my body, I understand that, had I been in the provider's shoes, I might have overlooked the significance of a seemingly "dramatic" young woman expressing a constant 2/10 headache, especially considering that medical students often tend to worry about the diseases they study.
While I grasp the circumstances, the main lesson I take from this experience is that, even as a patient with significant medical education and literacy—with access to care, self-advocacy, and family support—it took 4 appointments and 5 lab draws for someone to order a workup beyond routine labs for my concerns. My doctors talked to me about stress, but there was no referral for mental health resources. They simply encouraged me to persevere and reminded it would all be worth it. My providers demonstrated empathy; they listened to me, shared their own experiences as fourth-year medical students, and used that to connect with me and form a diagnosis.
However, the issue lay in their use of cognitive empathy—understanding how I felt based on their own experiences, rather than employing affective empathy to consider that I might be genuinely experiencing concerning symptoms. As someone entering the health care field, I harbor no resentment about the treatment I received because I understand the challenges they face. They were busy, and it was perhaps easier to label my experience as stress, given the high patient load they had to handle.
If there's one thing I wish to see more of in the "older generation" of providers, it's the recognition that people don't visit the doctor when everything is okay, which emphasizes the importance of offering empathy. However, I acknowledge that this is no simple task; it requires a delicate balance. As health care providers, I have observed that there's an expectation that we are flawless individuals, perfectly attuned to our patients, possessing all-encompassing knowledge, and capable of diagnosing everything. Through my research, I've understood that empathy is challenging and profoundly important for our patients. Not letting fatigue and a heavy workload affect how I communicate with and assess patients is crucial. I am both excited and incredibly nervous about how I will navigate and grow as I transition into residency and assume the role of a medical provider.
I look forward to the ongoing learning experiences of both those older and younger than me. As well as the humbling realization that I will always need to learn and adapt, continuously changing how I approach things adds another layer to this exciting and challenging journey. I, like many, entered a health care career because of a desire to help others. My recent experiences as a patient will strengthen my ability to empathize with my patients and better understand their concerns, providing patient-centric care, and ultimately, pursuing optimal patient outcomes.
Student Doctor Santiago is a fourth-year student at Western University of Health Sciences, College of Podiatric Medicine.
Dr. DeHeer is the Residency Director of the St. Vincent Hospital Podiatry Program in Indianapolis. He is a Fellow of the American College of Foot and Ankle Surgeons, a Fellow of the American Society of Podiatric Surgeons, a Fellow of the American College of Foot and Ankle Pediatrics, a Fellow of the Royal College of Physicians and Surgeons of Glasgow, and a Diplomate of the American Board of Podiatric Surgery.
Dr. DeHeer is a Partner with Upperline Health and the Medical Director of Upperline Health Indiana. Dr. DeHeer discloses that he is a speaker for Paragon 28, and that he owns stock in and is employed by Upperline Health.
References
1. Valentino M, Pavlica P. Medical ethics. J Ultrasound. 2016 Jan 7;19(1):73-6. doi: 10.1007/s40477-015-0189-7. PMID: 26941884; PMCID: PMC4762847.
2. "Empathy Definition: What Is Empathy." Greater Good. Accessed 8 Feb. 2024.
3. Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet. 2001;357(9258):757-762. doi:10.1016/s0140-6736(00)04169-64.
4. Larson EB, Yao X. Clinical empathy as emotional labor in the patient-physician relationship. JAMA. 2005;293(9):1100–1106. doi:10.1001/jama.293.9.1100
5. Rakel DP, Hoeft TJ, Barrett BP, Chewning BA, Craig BM, Niu M. Practitioner empathy and the duration of the common cold. Fam Med. 2009;41(7):494-501.
6. Yu CC, Tan L, LE MK, et al. The development of empathy in the healthcare setting: a qualitative approach. BMC Med Educ. 2022;22(1):245. Published 2022 Apr 4. doi:10.1186/s12909-022-03312-y
7. Derksen F, Bensing J, Lagro-Janssen A. Effectiveness of empathy in general practice: a systematic review. Br J Gen Pract. 2013;63(606):e76-e84. doi:10.3399/bjgp13X660814
Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of Podiatry Today or HMP Global, their employees and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, anyone or anything.
