All of us clinicians are in the business of alleviating the suffering of the people who seek our help and curing them of disease, when possible. By virtue of our being in this ‘helping’ profession, we are often asked – by ourselves or by others, implicitly or explicitly – to be empathic and to show compassion.

Today, I focus on various forms of empathy, two that are beneficial and sustainable, and one that should be managed and limited.

Empathic Concern

This is the ‘price of entry’ into a helping profession. Empathic concern is concern for the sufferings of others and a dedication to alleviating them. If a person lacks a requisite degree of empathic concern, being in a helping profession will be difficult and ungratifying work for them. They will lack the requisite concern for the other person to sustain attention to diagnosing the problems, implementing the treatment, and putting up with all of the bureaucracy and other friction such work entails.

Empathic concern is demonstrated by placing the patient’s interests over my own or any other interests. The patient must trust that I am working on their behalf and doing so conscientiously. I have both an ethical and legal obligation to do so based on the fiduciary relationship I have established with the patient.

Immersive Empathy

Immersive empathy is usually called emotional empathy. I believe immersive empathy more fully captures the nature of the phenomenon. Immersive empathy is putting oneself in another person’s shoes through experiencing the hurt, pain, distress, or suffering they have experienced.

On the one hand, for example, if a patient recounts the horror of being in a house fire, suffering extensive burns, and undergoing painful and extended treatment on a burn unit, then I have to carefully consider those situations and their effects on the patient. Otherwise, the patient’s telling of their experience will be too abstract and distant for me to understand the issues at play and relevant to this patient’s treatment. On the other hand, if I take on the patient’s traumatic experiences too fully, in too much visual and other detail and too much emotional reliving, then I may harm myself while doing the patient no favors. This imaginative experiencing of the patient’s traumatic events is akin to having a full-bodied flashback of a traumatic event I did not undergo but am now living through. Of course, I will be unable to relive it in the full pain and horror engendered by the actual events, but I may still attempt to make it as real to myself as I can.

Notice that the way I describe this immersive empathy includes imagining the sensory and emotional details of those events – the heat of the fire, the smell of burning flesh, the fear of imminent death, the panic triggered by being intubated and immobilized, etc.

I will write more at another time about why some people are moved to engage in such immersive imagining of others’ trauma, but here, suffice it to say, that this form of empathic immersion is unnecessary, exacts a high cost on the clinician, and may be detrimental to the patient.

Regarding cost to the clinician: yes, the clinician, even at their most empathic, can only imagine what someone else actually experiences. But these empathic immersions, though limited, are often repeated multiple times with multiple patients. And even merely imagined trauma, when immersive enough and done enough times, can lead to compassion fatigue, burnout, or traumatization of the clinician to the point of developing an acute and posttraumatic stress disturbance.

Cognitive Empathy

Cognitive empathy is, first, recognizing and then coming to understand the patient’s pain and suffering and the contributors and consequences of this pain and suffering. The keyword here is ‘understanding.’ It’s derived from under-, which in this case means in the midst of or among (rather than beneath), and -standing, which means remaining present in the place where the relevant knowledge is manifest. So, understanding is staying in the middle of the issues of a patient’s life, relevant to what the clinician is there to do. As such, cognitive empathy is a type of immersion too, but a conceptual or intellectual one, one that does not require emotional, let alone full-body immersion in the painful, traumatizing events of the patient’s life.

In fact, a clinician who is too immersed in the patient’s pain and suffering is not in a good position to help the patient. The patient does not seek a fellow patient or a mirror image of themselves in their clinician, but, instead, a competent and empathically concerned professional who is positioning themselves to effectively resolve the patient’s life problems and sources of suffering. The clinician places themselves in the best position to help by asking questions, gathering other relevant information, considering the sources and consequences of the problems and their possible resolutions, and doing so with focus and dedication – all this to develop a good option or options, which can then be thoughtfully presented to the patient and family and then implemented. 

Cognitive empathy achieves the right balance between closeness to understanding and distance to the patient’s suffering. This achieves the warmth of concern and the coolness of an objective, rational, emotionally steady professional deploying their skills in service to the patient.

I like to say that I strive to be clear of mind, pure of heart, and steady of hand when serving my patients. So, then, I can go home and be present for my family and be fully engaged in other important life aspects.

Until next time,
Dr. Jack

Quotes of the Week

“Our only hope will lie in the frail web of understanding of one person for the pain of another.” – John Dos Passos

“Without some sense of separation, our capacity to help clients erodes. Keeping something in reserve doesn’t make us heartless or cold.” – Babette Rothschild

“And yet, empathy at full throttle–felt and projected 100 percent with our bodies, hearts, and minds–has its risks.” – Babette Rothschild