2 Empathy

I still remember the white van entering the parking lot of the medical camp where I was working the summer following my junior year in college. As the head counselor, I was managing the registration desk. Campers and their families were just starting to arrive. I watched as Patrick’s parents unloaded his wheelchair with care and precision to the hot pavement of the parking lot. Summers in Central Arkansas were hot and humid. It had rained earlier in the day and the steam was still rising from the pavement. I noted Mr. and Mrs. Thompson were very attentive parents as they carefully placed Patrick into his wheelchair before bringing him to the check-in desk where I was seated. I was grateful that the check-in desk was under a large oak tree that provided shade.

The Thompsons had brought a large suitcase I suspected would contain two or three changes of clothes per day for his full week at camp. They also carried a large bag with supplies for his daily care, including diapers. I could not imagine how much these items cost each family per year. Though our camp provided many of these supplies in the event a camper’s family underestimated their child’s needs for the week, I suspected Patrick’s parents had overpacked judging from the size of their bags and their attentive care of their son.

Each week of camp was dedicated to children with a specific medical condition. This week of camp was devoted to children with cerebral palsy. Most campers were confined to wheelchairs. Though I recognized many of the names from last summer’s cerebral palsy camp, I knew this would be the first week of camp for many of the children. Given the challenges associated with caring for campers who were totally dependent on their counselors for activities and daily care, we had decided the year before to reduce the number of campers during the cerebral palsy week. We also decided to add a second week for more campers, that way we could accommodate what was always the longest waitlist of all the summer camp weeks. Despite the challenges, this was traditionally our counselors’ favorite week of camp as the campers were inspiring as well as fun to work with. In addition, we were allowed to add a couple of junior counselors to each cabin to assist with the care of the campers. Many of our senior counselors had started as junior counselors so there was a long waitlist of high school students waiting to serve as junior counselors each summer.

Patrick appeared very nervous as his family approached the check-in desk. I noticed his parents had already started to tear up. Before I could greet the family, Patrick’s mother immediately stated that he had never been away from home before. I suspected their decision to send their son to summer camp for the first time had been difficult. As I observed Patrick’s growing uneasiness, I began to empathize with his parents’ probable conflict with their decision to send him to camp. At this point, I felt ill-equipped to navigate the complexities of Patrick’s uncertainty and his parents’ intense emotions but knew I needed to do something to ease their distress. Relying on basic but untested instincts, I left my folding chair behind the check-in desk and carefully knelt in front of Patrick’s wheelchair. I was now looking directly into his searching eyes. His father and mother stood quietly on either side of him staring at me.

As a seasoned pediatric anesthesiologist, I know how important it is to quickly bond with an anxious child by establishing a connection in an age-appropriate manner. At this moment, I was simply a premed college student working as a camp counselor experiencing an encounter with a child and family experiencing anxiety. I cheerfully told Patrick he was about to have the best week of his life, hoping I was being truthful. He looked up at his parents for affirmation, and then a big smile spread across his face. This smile would not leave his face for his entire week at camp that summer. His parents then looked at each other and smiled as well. I hoped they felt assured that it was the right decision to send Patrick to camp. I also knew I had just assumed a big responsibility as I would be Andrew’s guardian for his upcoming week at camp.

I decided to transfer Patrick to my cabin for the week and made sure his bunk was next to mine. I personally oversaw his counselor assignments each day at the swimming pool and for lake activities. This was often the most stressful part of the camping experience for newbie campers who were not independent in the water. I will admit that I was a bit selfish with his assignments given the strong bond I had developed with Patrick and how much fun I had seeing him several times each day. I hoped he felt the same way. While lifeguarding at the pool and lake, I found myself constantly looking for him. When our eyes met, he always responded with that big smile.

My favorite time of the day was bedtime after we had finished showers and placed each camper in their respective bunks. It was a tradition that counselors would tell the campers about the adventures that were planned for the next day. It was also common for counselors to tell a few jokes and share humorous stories about past campers. Given most of the campers this week were non-verbal, we were dependent on our campers’ guttural sounds for affirmation that our jokes had hit the mark. Some of the most memorable and rewarding feedback I have ever received was hearing these charming sounds coming from the campers in my cabin. I think this was our campers’ favorite part of camp. I suspect it would also be their most lasting memory. For some of our campers, this may have been the only time they felt completely accepted and included in such a diverse group activity. For many of our junior counselors, this week of camp provided a new perspective that physical limitations and an impaired ability to communicate does not necessarily limit that person’s ability or desire to participate in social activities.

I still reflect on my initial interaction with Patrick at check-in and that positive feeling I had whenever a smile came across my young camper’s face during that week at camp. It turns out my effort to understand and comfort this child probably meant more to me than to him. Over the course of my medical career, I have always remembered my bond with Patrick and tried to recapture this same positive connection with each child I have interacted with. I now know that an inspiring relationship can impact your career and reaffirm your commitment to better understand and provide empathetic care to your patients.

I learned from a friend who I had shared this story with that Patrick had graduated from college and was volunteering at a local hospital as a patient-care advocate. It turns out Patrick and his family had continued their work with nonprofit organizations focused on children and adults with cerebral palsy and other physical challenges. My subsequent internet search looking for pictures and stories about Patrick revealed that as an adult he still had a big smile on his face.

Aspiring physicians who embark on a career in healthcare share the same long-term goal of simply wanting to care for others. Empathy is necessary to cultivate trusting relationships with your patients to deliver optimal care. For physicians, a definition of empathy is the ability of a practitioner to understand a patient’s feelings to provide compassionate patient-centered care.

There is a growing body of evidence documenting a steady decline in empathy and compassion across the years of medical school that continues through postgraduate medical training. It is reasonable to assume that this phenomenon also occurs in nursing and other allied health professional training programs as well. It is important that professionals do not forget their primary motivation for pursuing a healthcare career or the importance of understanding each patient’s perspective and concerns. Formative professional experiences that confirm the virtues of providing empathetic patient care are an important component of your professional development and can serve to anchor your commitment to providing empathetic and compassionate care when you are subjected to challenging professional environments with productivity pressures and the associated stress.

Figure 1. Benefits of empathetic patient-centered care

We know that patient compliance with prescribed therapies and subsequent clinical outcomes are improved when there is a strong physician-patient relationship (Figure 1). A primary goal of each patient encounter for the practitioner is to develop a deeper understanding of their patient’s concerns. With such understanding, it becomes easier to deliver compassionate care even with the inevitable challenges associated with educating the patient and family, diagnosing disease, and prescribing therapies. Practitioner awareness of and respect for a patient’s unique perspective and values is an important component of empathy that is especially important when obtaining informed consent. The logical reason for improved outcomes is the trust embedded in the physician-patient relationship that results from this empathy, which enhances collaboration and compliance with the mutually agreed upon therapies.

One study that focused on patients with diabetes mellitus in Italy found that patients cared for by physicians with high empathy scores on the Jefferson Scale of Empathy had a significantly lower incidence of acute metabolic complications while under the care of the physician. Patients of physicians with moderate to low empathy scores did not do as well. Neither the demographics of the physicians nor the practice models were associated with a variance in metabolic complications. The authors of this study concluded the positive impact of empathy on the physician-patient relationship led to improved compliance and an overall reduction of adverse events in the treatment of this chronic medical condition. It is reasonable to predict similar positive outcomes of high physician empathy for other disease states, especially those requiring long-term treatment where patient trust and compliance is of added importance.

There are best practices associated with delivering patient-centered care and building trust centered on developing good communication skills with a focus on listening to a patient’s concerns. A strong physician-patient relationship starts with letting a patient share their history and concerns in an open-ended manner with minimal interruptions. Lengthy discussions should provide opportunities for a patient to ask questions, especially if they appear confused. Sitting and facing the patient assists with signaling physician engagement and a shared interest in their medical care. Physicians should avoid spending long periods of time writing or typing at a workstation and should instead maintain eye contact with their patient. If a physician must multitask during the visit, a simple explanation helps minimize the impression they are not being attentive.

It is helpful for physicians to adopt a very descriptive style of documenting a patient’s medical history with a focus on their personal and family history to provide added context for their concerns. Unfortunately, both the production pressure placed on physicians and the introduction of electronic medical records are potential challenges for personalizing the delivery of healthcare. The use of electronic medical records has standardized the documentation of personal healthcare information. Adoption of this technology with the incorporation of drop-down menus and uniformity of questions desensitizes a practitioner to the uniqueness of each patient, especially if another colleague has already populated the database. Many practitioners are then incentivized to simply ask a series of closed-ended questions to confirm a patient’s medical history.

Medical schools and postgraduate training programs are utilizing simulated patient encounters with actors to assist trainees in acquiring the necessary professional and communication skills to provide patient-centered care. Actors are sometimes given scripts with directives to frustrate physicians and challenge their tolerance, requiring the physician to exercise their patience, understanding, and compassion. The debriefings that follow these sessions often involve viewing a video with opportunities for self-reflection along with receiving feedback from a preceptor.

It is notable that the American Board of Anesthesiology (ABA) recently added objective structured clinical examinations (OSCEs) to their traditional written and oral examinations to better assess many fundamental skills and attributes, including professionalism. For each communication and professionalism OSCE scenario, a key action is demonstrating empathy. As described in the content outline for the ABA OSCE exam, the successful candidate “demonstrates understanding of and concern for the situation of the patient.” This provides a straightforward description of empathy for practicing physicians. Postgraduate specialty training programs and their respective certifying boards continue to promote the development of empathy as a foundational element of professionalism for physicians.

Diversity and equity initiatives are designed to increase awareness and understanding of others with different cultures, ethnicities, and perspectives. I am gratified to see that current students and trainees embrace initiatives focused on understanding and accepting diversity in ways of thinking. Hopefully, a secondary benefit for physicians who embrace diversity is enhanced empathy and compassion for patients, resulting in more patient-centered care. Practitioners who seek to better understand their patients and colleagues have the added benefit of more meaningful relationships and fulfilling professional careers.