1. Sledge, George W. JR., MD

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If I were allowed to choose a new profession to work in for the next half century, I am sure I would become a neuroscientist. Cancer biology has been the most exciting of the medical sciences for the past two decades, and I count myself blessed to have been involved in its development. It still has some legs that will carry it forward over the next few years, and no doubt many surprises yet to be revealed. But with the increasing reach of the genomic revolution one can imagine that most of the secrets of human cancer will be uncovered in the near future. I don't mean that we will have a solution to every human cancer any time soon-the practical working out of our new knowledge will take a bit longer-but we will have a pretty good idea what drives most human cancers within the decade.

GEORGE W. SLEDGE JR.... - Click to enlarge in new window

The human brain, on the other hand, is still mysterious to a significant degree, and only in recent years has it moved past its 19th century anatomic roots. What is coming out of modern neuroscience studies is astounding, as the confluence of genomics, functional imaging, and evolutionary biology paints an entirely new picture of the brain.


I thought of this the other day when I came across an interesting systematic review on empathy in medical trainees, published by Melanie Neumann and colleagues in a recent issue of Academic Medicine (2011;86:996-1009).


First, a definition: those who study physician empathy define it as the ability to "(a) understand the patient's situation, perspective and feelings (and their attached meanings); (b) communicate that understanding and check its accuracy; and (c) act on that understanding with the patient in a helpful (therapeutic) way."


This is as good a definition as any, I suppose, though to the scientist it still has a soft, mushy feel to it. But as a working definition it allows measurement, so it is a start.


If you measure empathy levels in medical students and residents, what you discover is a progressive decline in empathy as one progresses in training. In fact, the greatest decline in medical students occurs when they first encounter patients. The authors of the paper identified a number of likely causes for this decline in empathy, but the bottom line is that becoming a doctor does not make you a better human being, if you believe that good human beings are empathic.


I'm not terribly surprised. It is one thing to love humanity in the abstract, quite another to have to deal with the flood of sociopathy, pain, self-destructiveness, brutality, and ignorance encountered the first night one spends in a busy emergency room. Add to this chronic stress, personal feelings of inadequacy, sleep deprivation, and the macho culture that historically pervaded many training programs, and it is almost to be expected that our empathy quotients decline.


I remember, in my pre-med days, having romantic visions of pounding on the chest of a patient in cardiac arrest and then humbly accepting his gratitude upon his regaining consciousness. And then, in the middle of a night early in my internship, I performed CPR on a patient, whom upon waking spent 15 minutes swearing up a blue streak at me. He was a demented drunk who wanted nothing so much as to return to the street and a bottle and the oblivion he craved. His daughter, when contacted, refused to come to the hospital to see him. He was already dead, as far as she was concerned. Had you measured my empathy quotient later that day, after 30 hours with no rest and an utter sense of futility, I can imagine how I would have scored.


So I don't find this study all that surprising. I've lived it, after all. There is even a term for this in the medical literature: compassion fatigue, the "debilitating weariness brought about by repetitive, empathic responses to the pain and suffering of others."


But that isn't the end of the story. Back to the neurosciences. Empathy isn't just some philosophical construct, some feel-good tale we tell ourselves to prevent us from slitting each other's throats. As with a growing number of human emotions (love, altruism) it is inherent, hardwired into us by Mother Nature. It has distinct genetic and neuroanatomic underpinnings. It has biologic reality.


We know this because there are diseases characterized by an inability to experience empathy. These include antisocial personality disorder, narcissistic personality disorder, and autism. Autistic children do not smile in response to their mother's smiles; they "do not exhibit the biologically based ability to automatically resonate with others which consists of [the] very basic level of empathy," in the words of Jean Decety and Yoshiya Moriguchi.


They note that empathy has an anatomic location, in the spindle cells of the anterior insula and anterior cingulated cortex of the brain, and that these regions are significantly more developed in adult humans than (in order) children, gorillas, bonobos, and chimpanzees, and are nonexistent in macaque monkeys. Antisocial personality disorder, with its pathologic inability to empathize, can be created by brain trauma.


So empathy isn't mushy at all: it has a physical presence, and evolutionary significance. We are human, at least in part, because we are capable of empathy. It defines us as a species. The inability to empathize is not a mark of success (Wall Street bankers and Third World despots notwithstanding) but evidence of a diseased or underdeveloped mind. Somewhere in the human genome there lurks a gene or genes for empathy. I find this a comforting thought.


Which brings us back to the clinic. We are not all that good at empathy. One study in the Journal of Clinical Oncology (Pollak KI et al: J Clin Oncol 2007;25:5748-5752) suggests that oncologists ignore what the authors termed "empathic opportunities" with our patients the great majority of the time. Why? Are we too busy, or do we suffer from compassion fatigue, or have we suffered a lesion (hopefully reversible) in the empathic centers of our brain?


If our training renders us either autistic or macaque-like (take your pick, with no insult intended for either category), how do we regain that which makes us most human, and most adult? Because empathy is important for physicians, practically important: empathic physicians, multiple studies show, are better diagnosticians, better patient educators, and better at enabling patient compliance with medical instructions. In short, not just better human beings, but better doctors. As much as our technical knowledge, empathy is part of the stock-in-trade of caregivers.


The comedian George Burns joked that "Sincerity is everything-if you can fake that, you've got it made." But that is the philosophy of a Ted Bundy. You can't fake empathy, or at least not convincingly and not for very long. Patients detect phony empathy in short order, just as they dislike and distrust doctors who lack empathy. Regaining or maintaining our empathy probably deserves as much or more attention as does most of the detritus that clutters CME courses. But how to teach it, or create it?


Many cancer centers now have regular Schwartz Rounds to encourage open discussion of the "touchy-feely" parts of cancer care, but as in all aspects of life you only benefit if you participate, and to a certain extent if you already believe that empathy is valuable.


I'm somewhat skeptical about our ability to "train in" empathy in one hour a month dollops, though I would be happy to be proven wrong. All I know for sure is that we need more of it, individually and collectively.


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