What I couldn’t say – but wanted to – was the truth: I don’t care.
Seriously. I don’t. I can’t.
Keith P states “I don’t care.” And, I think he’s right. A certain type of detachment from the potential suffering and emotional struggles of patients is vital for a clinician. The ability to assess, analyze, and make proper decisions may be clouded if those treating are overly emotionally involved in the circumstances of those they treat. Further, shouldering the burden of the many unfortunate clinical, emotional, and social situations encountered within healthcare can easily leave one with a sense of hopelessness. It’s quite easy to succumb to pessimism and apathy when the grand scale of suffering, inequality, and just plain bad luck occupy the beds and treatment tables daily. But, is this ideal for patient interaction? What do patients prefer? Establishing and enhancing alliance, rapport, and an environment of care is necessary. An explicit connection with the patient is a precursor to, or maybe even the foundation of, the therapeutic process. Too far to one extreme and the risk is burnout. Too far to the other and the risk is a cold, distant clinician (and still burnout). As in anything, explicitly defining terms and concepts is helpful.
Definitions and Terms
Sympathy, empathy, compassion, and caring are connected concepts, but have differing definitions. And, specifically within healthcare these concepts require more specific exploration. While various, and vague, characterizations of sympathy exist within and outside of healthcare, for the sake of clarity sympathy generally centers around an emotional state of feeling. It can manifest as pity or sorrow for another, a common feeling, or a relationship in which that which affects one mutually affects the other. The simplest definition is entering into or sharing the feelings of another. Empathy, by contrast, is characterized by identification and understanding. But, empathy has been sub-characterized into two, or even three, separate conceptualizations: emotional (or affective), cognitive, and compassionate empathy. To complicate matters, compassion itself is an awareness of suffering of another and a desire to act in order to relieve it. Therefore, compassion is best understood as an action, or potential action. This desire and subsequent action may stem from both rationale and emotional sources.
Healthcare & Empathy: Emotional vs. Cognitive vs. Compassionate
Daneil Goleman briefly outlines and discusses the three (potentially) separate kinds of empathy. Empathy is founded upon understanding and identification which may include projecting ourselves (hypothetically) into another’s situations. And, it can happen emotionally and/or cognitively. Emotional empathy is the ability of a person to feel a similar emotion as another (which confusingly can be accomplished cognitively). Although this appears to mirror sympathy, sympathy is a sharing of emotion, or emotional state, feeling along with another. In contrast, cognitive empathy relates to recognizing, understanding, or even appreciating a person’s feelings. To be fair, the definitions of sympathy and empathy as well as cognitive verses emotional empathy appear to overlap. It seems they are, at times, used interchangeably. Specifically to healthcare, empathy is “a cognitive attribute that involves the ability to understand the patient’s inner experiences and perspective and a capability to communicate this understanding,” Many in healthcare education recognize IQ and didactic skill are only a portion of the ideal clinician equation. The ability to understand and perform within the above constructs relates to emotional intelligence. And, “…empathy, as defined here, must be included in the curriculum. It is a powerful communication tool that enables a clinician to clearly express his or her understanding of another’s suffering while protecting his or her own psychological integrity.”
Do you have to care to be caring in your practice?
A major issue in health care professions generally, but therapy specifically, is mistaking the necessity of cognitive empathy for a requirement to sympathize and feel with patients. Front line clinician burn out is in part due to an understandable inability to sympathize with every patient, and the resulting cold, concrete distance that can result in situations when sympathy is not feasible. Whether clinician fatigue, a need for emotional distance, or carryover from the patient before feeling the emotions, sympathizing, and providing pity to every patient is likely not possible. And, probably not effective. The issue is likely further clouded by a lack of understanding regarding the differences of sympathy and empathy. I don’t ever remember learning about this stuff. But, it’s vital. The concept of objective empathy grossly changed how I approach patient interactions. Patients and practitioners report “compassionate care” is important to successful medical treatment. So, what’s to be done?
The role of the clinical instructor is paramount in helping students to become aware of behaviors that can block empathy. We can no longer simply hope that our students will become mature professionals with compassion and empathy for patients. We must create experiences to develop these attributes, and we must take responsibility for modeling these behaviors and reflecting on them with students, to raise their consciousness about the nature of a mature healing presence.” The art of healing is, in part, made up of a therapeutic use of oneself or a therapeutic presence for patients. This presence is more than knowledge and skill alone; it is also composed of a compassionate understanding of the patient and a communication that the therapist is worthy of the trust that the patient has bestowed. Empathy enhances the therapist’s therapeutic presence and deepens the patient practitioner interactions without fear of losing one’s self in the process. This shared meaning seems to enhance the patient’s process of healing. Carol Davis, Can Empathy be taugh? PTJ, 1990
To the observer I’m sure it appears I do care, and care deeply. But, in the end Keith, you’re right. I don’t care. And, I don’t need to. Does that mean I never engage with patients on an emotional level? That patient’s circumstances never affect me? That I never feel a connection, or shared emotional states with a patient? Or, a powerful emotional response during the course of treatment? Of course not. It happens. And, that’s OK. But, we don’t need to strive for it. Someone inquired to Keith “I wonder if being detached from our patient makes for a better clinician… Any thoughts?” He responded:
A therapist needs an appropriate amount of attachment for success, but that attachment, I reason, needs to be to a high professional standard of care, not the patient’s outcomes themselves.
You don’t need to sympathize to provide appropriate empathy. You don’t need to care to be caring. You don’t need to feel the emotions of your patients to address the emotions they feel.
When I freed myself from the responsibility for the “outcome” of the clinical encounter, something interesting happened. I freed my patients from blame, also. –Jason Silvernail
It’s important to care, but maybe not in the assumed emotional involved ways. And, I think we should not apologize for claiming not to care. I’m still, I think, a caring clinician. I just don’t make a point of feeling pity for the suffering I encounter. I am passionate, empathetic, and hopefully a thoughtful interactor.
…an older relative of mine who has cancer is going back and forth to hospitals and rehabilitation centers. I’ve watched him interact with doctors and learned what he thinks of them. He values doctors who take the time to listen to him and develop an understanding of his situation; he benefits from this sort of cognitive empathy. But emotional empathy is more complicated. He gets the most from doctors who don’t feel as he does, who are calm when he is anxious, confident when he is uncertain. And he particularly appreciates certain virtues that have little directly to do with empathy, virtues such as competence, honesty, professionalism, and respect. –Paul Bloom, Against Empathy
We need to be able to treat our patients, all of them, and still function in our own lives. If not, we risk riding the roller coaster of sympathy and pity in clinic at the potential expense of engaging emotionally in our personal lives. It’s a bad outcome all around. Our patients need us to understand, interact, and guide them along the best possible course of recovery. So, whatever we call it, put your pity aside. I’m not sure our patients want it anyway. Be resilient. You don’t need to care to provide compassionate care. Our patients need us to listen, but also to initiate difficult, honest conversations.
Credit: https://practicepath.com/advancedmd-pm-and-ehr-services-and-solutions/
I think the word caring should have different set of level and limits. Especially when it comes to execution of treatment. Let’s just take my case on how my Pt works with me.
My Physical Therapist CARES a lot when it comes to my quick and speedy recovery from shoulder and lower back injuries. That’s why he DOESN’T CARE to listen everytime I complain of how the exercises seem to be hard and strenuous.
Hope that helps. haha
Nice addition to Kieth’s piece Kyle!
I find that we certainly do care, but as you mention, there are boundries to it all.
As far as having to be a caring person: turns out you can just follow a script, or act caring, and the results seem to be the same. I have a hard time with that statement, but those recent papers (earlier in the Spring) on Therapeutic Alliance saw no differences in outcome with PT personality. Crazy! They just gave the patients attention. (I wrote on it here- https://ptbraintrust.wordpress.com/2014/05/19/the-therapeutic-alliance/ )
Either way, caring, or showing you care in some fashion as you mentioned above (cognitive/emotional etc), does make a difference. We have a few classes on it and some projects here in school… I beleive there is a push to further develop this aspect of treatment/care. N=1
Thanks for writing…
The way chaplains capture this balance between detachment and sympathy is to strive for “a non-anxious presence.” “Non-anxious” refers to the distance needed to understand enough about the patient to help him or her, and “presence” refers to the connection (s) we feel towards the patient. Karen, of offbeatcompassion.com
Both your point and Keith’s is a rhetorical one and although I agree with points of your argument I disagree with the style presented. The fact is you do care. You just don’t care about some of the things we have been traditionally (although largely implicitly) taught–outcomes. The changing face of medicine rewards outcomes–rewarding provider behaviors by proxy of the patient behaviors. Of course this leads to burn out because we cannot control another human being just like we control our computer or car. Your argument is simply that we need to CARE about something different–how the patient is reacting to our behaviors in the moment, not the downstream outcome.
The second part of your argument, which is more implicit, is reactionary to what typically caring behaviors look like in healthcare–excessive displays of sympathy. Sometimes caring involves being real with a patient that is not excessively outwardly sympathetic, humorous, happy or otherwise positive. Stereotypical and often inappropriate positiveness is just a much a sign of lack of empathy and caring as route detachment. How many therapists have you worked with that have been excessively upbeat and positive? Heavy handed tactics of being positive are certainly ways providers can cope with stressful environments (i.e. delivering care to distressed persons)
There is dark-side to your arguments, not that you necessarily presented them as such, which is if you fail to acknowledge the fact that you do CARE, the result may be deriving value from a stoic detachment. This sort of new-age Buddhist ideal may have some merits as a temporary way to get through a distressful period but responding to the emotions of others (i.e. patients, friends and family) in a social environment occurs without awareness–i.e. it is not a “cogntiive” process.
If I were to revise you’re definitions I would state that compassion cannot be an action because it is a noun. One either has compassion or does not. To care is to say that if an outcome (this does not mean we are all focused on the exact same outcomes) is not achieved then one will experience an aversive response. For you, it means you CARE about the outcome of the patient’s real-time action to your behavior not the downstream outcome (often rewarded by hospital admin). Prolonged exposure of aversive responses leads to extinction of behaviors; if you are taught and rewarded on patient outcomes as central to you being a good provider and person, given our modest effect sizes in treatment you are going to extinct yourself right out of the profession.
Finally, central to this entire problem is how we are taught. We come out of PT school filled with a history of success. I studied for the test, I got a good grade, I passed the class, I got a degree–rinse and repeat. The problem is that the real world of patient treatment is complicated, messy and filled with modest effect sizes. We should give students this caveat as they leave school, “The success that you encountered through all your learning WILL NEVER BE REPEATED in patient care.” One may seek it, or may think that more con-ed can replace a sense of defeat in the face of modest effect sizes but…it never will, like your shadow it’s always there. Instead we should encourage new students to take up a novel task of immense difficulty (golf or learning to play the violin come to mind) for their final PT project in school and say, “How does learning that new skill feel? That’s what it’s like to CARE, get used to it!”
Kyle and Keith, I know you care. I have had many conversations with you both. You just don’t care about what we are inundated with by hospital admin or the false ideals taught in PT school. There is value in pointing this out, but in the end you still care as much as the next guy 😉
Tim Cocks on NOI Jam writes about A Different Way of Listening
Eric says, “There is dark-side to your arguments, not that you necessarily presented them as such, which is if you fail to acknowledge the fact that you do CARE, the result may be deriving value from a stoic detachment. This sort of new-age Buddhist ideal may have some merits as a temporary way to get through a distressful period but responding to the emotions of others (i.e. patients, friends and family) in a social environment occurs without awareness–i.e. it is not a “cogntiive” process.”
Thank you for the time that you took to reply, Eric.
The issue I tried to raise in my own posting is that I am a fairly detached personality to begin with. And while I may have confused the sympathy displayed by others as a more genuine or emotional form of empathy, I am tempted to argue that I once valued my stoic detachment, but now often think that I miss out on things in life (both personally and professionally) that less-stoic individuals get to experience. Not sure if stoicism is the answer, but that is what comes most naturally. I can assure you that I am not well-read or wise enough to reference Buddhism to have arrived at this state. In my estimation, my own ‘stoicism’ is not necessarily a temporary way to cope, but is my default setting.
I find it interesting that you claim that responding the emotions of others is not a ‘cognitive’ process – I would think that mental practice and reviewing previous experiences has informed me of how I think I should behave or respond to emotional situations in varying social environments and that I am very much aware of how I am responding via facial expression, posture, tone of voice, choice of words, etc. Do you think that this is but an illusion and that it is not the ‘cognitive’ process that I imagine it to be?
Eric says, “To care is to say that if an outcome (this does not mean we are all focused on the exact same outcomes) is not achieved then one will experience an aversive response. For you, it means you CARE about the outcome of the patient’s real-time action to your behavior not the downstream outcome (often rewarded by hospital admin). Prolonged exposure of aversive responses leads to extinction of behaviors; if you are taught and rewarded on patient outcomes as central to you being a good provider and person, given our modest effect sizes in treatment you are going to extinct yourself right out of the profession.”
THIS is SO well-stated, sir.Thank you for putting these words to the screen – I have not fully considered ‘caring’ in the context you clearly outline here…although I admit that my own posting hinted at (but fell short) of this important distinction that you draw between what I ‘care’ about and what administration (or others) care about. The goal remains, of course, to allow the patient to feel that their own goals/outcomes (what they care about) are addressed via interaction with their therapist, in real-time.
Eric says, “…in the end you still care as much as the next guy ;)”
I fold.
Beating Around the Bush via NOI Jam
Teaching and learning communication skills in physiotherapy: what is done and how should it be done?
The Role of Therapist Attachment in Alliance and Outcome: A Systematic Literature Review.
Contributing Factors of Change in Therapeutic Process
First person neuroscience in understanding of pain
An important point is made when you say, “It’s important to care, but maybe not in the assumed emotional involved ways.” There should be a level of care about the therapy provided. Overall, thought provoking read. Thanks for sharing.
The Difference Between Empathy & Sympathy
“Empathy is feeling with others”
An interesting view on being intimate and connecting via Maria Popova (@BrainPicker) of Brain Pickings citing Sherwin Nuland’s (author of How We Die and How We Live) insight on What Everyone Needs
It is important to be able to distinguish being a caregiver and a friend. Analysis is critical in these situations and one can’t afford to have their judgement clouded.
The case for caring about your work