British Clinical Epidemiologist Dr Jeremy Howick recently wrote a very well researched essay on empathy. Published in Australian Doctor in June 2019 under the title “Empathy in Healthcare is finally making a comeback”, it was also published in The Conversation about a month earlier.

He traces the generally unempathetic origins of the doctor/patient relationship, noting that the 1980s saw the beginning of a turnaround in this respect, with the introduction of empathy as a taught skill. We now know of course, that empathy is very teachable. The authors of this review note that while the skills can be taught we’re not yet certain how often they may need to be retaught or reinforced and what the beneficial impact on patient care is. But…you would have a hard time convincing me (and I suspect most health practitioners), that congruent displays of empathy have no beneficial impact for patients.

Howick clearly notes the importance of empathy not just from health care providers but also to them. If practices of empathy manifested by health practitioners and from health administrators tohealth practitioners can become inherent in the healthcare system, I would consider this a “systemic empathy” or if you will a “perfusion” in which the desired element (empathy) is delivered broadly and evenly through the entire system.

While some research suggests that empathy is emotionally and professionally protective, other research suggests that empathy may lead to burnout and this is where it gets interesting. It’s certainly the case that burnout can lead to impairment of empathy but what about an opposite direction relationship? At this point we need to be clear about what empathy is and isn’t, I think. In my experience as a Psychologist, empathy and sympathy are often conflated.

For my money, one of the most helpful ways to define empathy is the capacity to recognise, identifyunderstand and reflect the emotional state of another. Each of these steps is an important component of the whole and difficulties with any of them can lead to an impairment of the relationship and feelings of inefficacy on the part of the health care provider. Similarly, some have defined empathy as having two components – affective and cognitive.

Sympathy, on the other hand, can probably be well summed up by that everyday phrase we’ve all heard: “I feel your pain”. It’s fairly easy to see how the regular practice of sympathy would lead to burnout!

So if we accept that the development of empathy is desirable both from the perspective of the patient and indeed for the well-being of the health care provider (and I accept both of these propositions), what should we do to ensure that empathy is both practiced by and protective of health care providers? I’m going to leave aside here the question of developing empathy systemically in healthcare as that’s at least partly a system reform question.

Firstly, empathy must be taught as a discrete skillset for all health care providers and it must be taught within a context in which it can be efficaciously applied. The capacity to display empathy and the knowledge of how this is integrated into a relationship – regardless of whether it’s professional or personal – is the cornerstone of thriving human relationships. Secondly, the capacity to recognise an over-focus on either affective or cognitive empathy at the expense of the other dimension must be taught, so that health care providers have the capacity to be self corrective to some extent. Over engaging in affective empathy risks emotional “flooding”. While this may be manageable in the short term, chronic responses like this become the basis of burnout. Over engaging in cognitive empathy risks the “intellectualising” of another’s experience and a lessening or even fracturing of the relational bond. Each dimension feeds the other and provides a counterbalance to the other.

Secondly, if we’re to protect the emotional well-being of health care providers, I really see only one broad solution to this – we must seek to develop and to be in mentoring/coaching/supervisory relationships with each other. Supervision here does not imply authority gradient or the suggestion of lesser quality work. Rather, it points to the capacity of someone else to be able to gain a different perspective. You may be able to capture the majestic view from a high altitude mountainside. But your climbing companion is the only person who can see both you and the majestic view you’re seeing at once.

The costs of burnout to both healthcare providers and patients are enormous. Providers  risk the experience of chronic poor wellbeing, financial impacts, family and relationship impacts and ultimately professional reputational damage. Patients receive poorer quality care and experience reduced efficacy in managing their own health. Learning to effectively communicate profound human understanding and experience without the emotional drain brought by not truly grasping what it means to be empathetic benefits every stakeholder in the healthcare system.

Ultimately, I don’t hold the view that one can have “too much” empathy. I do know that empathy can be conflated with sympathy and compassion (literally “suffering with”) and I do know that any professional who hasn’t learnt the skills and works in an environment in which the concept of empathy is foreign or, at best, tolerated, is at risk of experiencing the pain of emotional depletion and exhaustion.

As an approach to patient care, health coaching promotes the capacities of empathy, patience and presence which in turn foster genuine relationship,  meaningful engagement in work and greater well-being outside of work. Developing the skills of health coaching is an excellent way to achieve the aims of increasing empathetic connections between providers and patients for the benefit of all. When coupled with mentoring relationships and peer relationships for health practitioners, the stage is set for healthcare delivery that minimises the likelihood of burnout for healthcare providers. More importantly, it maximises the likelihood of genuine human relationship, meaningful engagement in work and perfuses the healthcare system with empathy, self-care and true human presence.

This commentary has been written for the Australasian Society of Lifestyle Medicine (ASLM) by the documented original author. The views and opinions expressed in this article are solely those of the original author and do not necessarily represent the views and opinions of the ASLM or its Board.

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