Walking the Clinical Empathy Tightrope: How Much is Too Much?

Learning to manage our emotions and share them with others is a fundamental part of the human experience. As author Glennon Doyle succinctly writes, “feelings are for feeling.” But is that always true for healthcare providers? The intersection of empathy, burnout, and clinician satisfaction has been well studied, and expert opinions have shifted a good deal over the past several decades.

This 1964 paper from New England Journal of Medicine states, “The ‘neutrally empathetic’ physician will do what needs to be done without feeling grief, regret, or other difficult emotions.” That prevailing 1960s wisdom is a far cry from this 2015 quote by empathy expert and University of Chicago neuroscientist Jean Decety: “The most critical aspect of healthcare is that patients perceive that their doctors care about them. Doctors should not be afraid of their emotions.”

It would appear that we’ve done a complete 180 on the subject of clinical empathy. While experts once touted “detached concern” as the ultimate goal, most modern-day clinicians agree that less detachment and more concern are our new objectives. This is especially important for physical therapists, as we often spend more time with our patients than other types of providers. Our general consensus that clinical empathy is a positive and necessary trait in our profession, but it’s often too vaguely or narrowly defined. So what, exactly, does clinical empathy encompass? And is there a limit to how much empathy rehab therapy clinicians should have?

Is there such a thing as too much empathy?

Those urging caution around excess empathy cite concerns of clinician performance and personal well-being. Some argue that because clinicians often encounter patients in pain—and sometimes must perform procedures that cause pain—being hyper-focused on the patient’s experience of pain would do both patient and clinician a disservice. Furthermore, clinicians who are better able to compartmentalize may be better able to focus brain power on solving the clinical problems in front of them. Harvard physician Omar Sultan Haque and Northwestern University psychologist Adam Waytz argue that a surgeon discussing surgical options with an apprehensive patient should express an abundance of empathy during that conversation—but later, while performing the procedure, the surgeon should demonstrate less empathy in order to retain a clearer mind.

There’s more than one kind of empathy.

Even among those who agree that our goal should be to recruit, develop, and retain empathetic clinicians, there is still some debate as to what ideal clinical empathy looks like. The working definition of empathy has evolved from a singular skill to a competency involving multiple layers. Empathetic arousal, understanding, concern, and regulation are all vital interworking elements for clinicians to develop and master comprehensive empathetic ability.

Cognitive Empathy vs. Affective Empathy

Other leaders in the field describe ideal components of empathy using different terms. Dr. Mohammadreza Hojat of Thomas Jefferson University believes clinicians should possess a great deal of “cognitive empathy”—that is, an understanding of the patient experience as well as an ability to communicate that understanding. He contrasts this with “affective empathy,” in which an emotional response may be elicited. Hojat believes too much of the latter may actually hinder patient care and negatively impact the practitioner as well.

But Decety disagrees: in a 2013 study, he and colleague Ezequiel Gleichgerrcht concluded that more concern is better, and, as quoted above, “doctors should not be afraid of their emotions.” They argue that it’s not excess empathy that leads to burnout, but rather what they refer to as alexithymia, a dysfunction in emotional awareness. Alexithymia, in combination with personal distress (defined as discomfort in reaction to the emotions of others), is the recipe for compassion fatigue.

Empathetic clinicians may be less prone to compassion fatigue.

So, should clinicians wear their heart on their sleeve? Not exactly. According to Gleichgerrcht’s and Decety’s research, the secret sauce lies in the clinician’s ability to interpret a patient’s thoughts and feelings, while understanding they are separate from the clinician’s own thoughts and feelings. Clinicians who were able to do this—and thus, could develop an “other-oriented motivational state for someone in need or distress”—scored highest on measures of compassion satisfaction. All in all, clinicians who successfully practice awareness of others—and simultaneously regulate their own emotions—experience more positive feelings and satisfaction as a result of helping others.

Conversely, those who were less able to take on patients’ perspectives—and who developed negative feelings when encountering patients in distress—scored higher on measures of compassion fatigue. A practitioner’s cognitive abilities are heavily taxed when completing tasks, and this impacts the practitioner’s capacity to:

• have empathetic concern, and
• self-regulate emotions.

Overworked and overstressed clinicians can quickly max out their cognitive empathy, leaving them more susceptible to burnout. When it comes to compassion fatigue, it would appear that empathy is not the culprit; rather, insufficient support, demanding schedules, and impossible expectations are often to blame.

Empathetic clinicians are good for patient outcomes.

A strong body of research demonstrates superior outcomes for patients of highly empathetic practitioners. Results from a study at a large rehabilitation hospital showed patients who perceived their doctors as displaying high levels of both affective and cognitive empathy had the highest satisfaction rates. Another paper described a strong association between high physician empathy ratings and better health outcomes after discharge from a trauma surgical ward—perhaps due to increased trust and communication from patients who believe their clinicians truly care about their well-being. In addition to being more willing to communicate openly, these patients may also experience less anxiety and be more likely to adhere to their prescribed treatment regimens.

Just as high marks in empathy can greatly improve patient satisfaction and health outcomes, a decreased ability to identify with patients’ experiences and understanding can produce negative outcomes. Consider the language many physical therapists use on a daily basis to describe medical conditions. For instance, what might an anxious patient in pain think after hearing a new diagnosis of degenerative joint disease? A PT who is less able to identify with the patient may miss that this term has heightened the patient’s fears, whereas an in-tune clinician may be able to pick up on cues of distress—and then work to alleviate concerns.

How do we foster more empathy?

To help build empathy, some leaders in the healthcare field are starting at the entry point into the profession. Darrell Kirch, who served as president and CEO of the Association of American Medical Colleges (AAMC) until 2019, took steps to revise the MCAT, the exam required for admission into medical school, in an attempt to screen for more empathetic medical school candidates who are better able to understand the biopsychosocial background of patients.

But research has shown that beginning in their third year of medical school, students display a sharp decrease in empathy—ironically, at a time when patient-care activities become even more central to their program. Additionally, researchers Derek Burks and Amy Kobus found that students exposed to “non-humanistic informal practices inherent in the culture of medicine” face an increased likelihood of detachment from patients and subsequent burnout.

Empathy is becoming part of the healthcare training curriculum.

These findings beg the question: Is empathy actually being trained out of our future clinicians? If so, then screening for empathetic clinicians may not be the most important or only road to a solution. Burks and Kobus recommend training in emotional skills as well as the acceptance of empathy and humanism into the culture of medicine.

Helen Riess of Harvard Medical School is of a similar opinion. To help medical students learn how to cope with difficult emotions, Riess developed a course called Empathetics. The goal is to teach students how to:

1. pick up on the emotional cues of patients, and
2. recognize and regulate healthy responses.

Researchers are studying the outcomes of this class, and it’s showing promise—which means these types of initiatives will likely continue garnering support.

Mindfulness may help improve empathy.

Another solution to building empathy may lie in the practice of mindfulness, which in recent years has gained popularity and prominence in the healthcare field. Mindfulness can help relieve stress and potentially improve empathy. In fact, several recent studies show that teaching healthcare students to practice mindfulness may lessen emotional distress and improve the cognitive capability needed to take on the viewpoints of others.

In the PT research world, physical therapy students who participated in an intensive service learning curriculum developed an increase in civic-mindedness—a commitment to engage responsibly with their community—which was tied to higher levels of empathy. In the same vein, nursing students who served low-income or homeless patients experienced greater levels of empathy, and medical students who volunteered at a free clinic experienced less decline in empathy than their non-volunteering peers. It appears that specific training to develop empathy skills combined with opportunities to practice may be the recipe for success. (If you’re interested in volunteering as a PT, check out these tips.)

A growing body of research points to the benefits of clinical empathy—for patients and healthcare practitioners. The call to develop and sustain empathy in clinicians is shared by professors, clinical instructors, and mentors in the healthcare space. An equally important factor is the continuing culture shift within healthcare from the old model of detached concern to a greater acceptance of the merits of empathy. Feeling our feelings is not inherently bad, after all. In fact, we can greatly benefit from learning to recognize, understand, and regulate our emotions in response to tough situations that arise in healthcare interactions.