Can ’empathy’ be learned?

How many psychiatrists does it take to change a lightbulb? Only one … but the lightbulb has to want to change.

I was reminded of this joke when the discussion of ‘empathy training’ was proffered as a solution to the appalling misconduct of our federal politicians.  As yesterday’s piece in ‘The Conversation’ points out, referencing the underwhelming benefits of ‘diversity programs’ (of which ‘empathy training’ is part), unless participants are enthusiastic and self-motivated attendees, these programs often make things worse. Unsurprisingly, it seems that forcing people to attend programs creates defensiveness, resistance and resentment which can lead to reinforcement of pre-existing beliefs and may also result in a backlash from participants (see: https://theconversation.com/andrew-laming-why-empathy-training-is-unlikely-to-work-158050).

Being empathetic is something that varies from person to person. Certain reflective and internalising temperaments, coupled with support through hardship and traumatic events, appear more likely to make a person more ‘naturally empathetic’. However, research also shows that empathy can be taught … if the person is willing to change.

Most of the research in this area comes from the education of the medical profession in enhancing interpersonal communications. Dr Helen Riess, a psychiatrist and medical educator at Massachusetts General Hospital and Harvard Medical School, has developed empathy training based on neuroscience (Empathetics). Consisting of three hours of ‘empathy education’ spaced over 6-8 weeks, Riess found significant improvement in patient ratings of patient-related physician empathy which was sustained over time. More about Empathetics can be found at: https://empathetics.com/

I became aware of ‘empathy education’ when I joined in the education of medical students at the University of Melbourne. For the past two years, I have facilitated tutorials in ‘Professional Practice’ for students in their third and fourth (final) years of the postgraduate medical degree. For each medical year, time is set aside on a regular basis in small groups to discuss a range of issues related to patient care and in these sessions ‘empathy’ is of prime importance.

Apart from the discussion of patients clerked by the students, a number of things are included in the way this teaching is approached.  For example, students are required to listen to personal stories from the Empathy Museum. The Empathy Museum is a series of participatory art projects dedicated to helping people look at the world through other’s eyes. Created by London-based artist, Clare Patey, one project was the storytelling exhibition ‘A Mile In My Shoes’ which was held at the Melbourne Arts Centre in November 2019.  More about the Empathy Museum’s projects can be found at: https://www.empathymuseum.com/

Participants found a shipping container, ‘fashioned’ as a shoe box, which contained a diverse collection of  worn shoes – each pair linked with an audio-story. Visitors were invited to wear another person’s shoes and listen to the owner’s story via a headset. The 35 stories from Melbourne’s residents covered different aspects of life ranging from love, to grief, to hope – taking the listener on an empathetic as well as physical journey. Students are encouraged to listen to a range of stories and then re-tell them and comment on them from their own perspective, and then imagine telling the story from the perspective of a future treating doctor. More information can be found at: https://www.artscentremelbourne.com.au/community/participation-programs/a-mile-in-my-shoes-story-library

Another way that medical students are encouraged to explore empathy is through a focus on  ‘narrative medicine’ and ‘medical humanities’ as part of expanding their world view away from a pure science basis. ‘Narrative medicine’ grew out of the work of physician, Rita Charon, who describes it as: ‘medicine practised by someone who knows what to do with stories’.  Training in this area utilises literary theory and the application of creative writing skills to situations and interactions commonly encountered in medicine. Students are encouraged to very closely observe patients and then write both ‘ordinary case clinical notes’ and ‘impressionistic ideas’ about the patient – which can take any literary form from diary entry to short story to poetry.

The ‘writing component’ is augmented by suggested readings from three different genres in ‘medical humanities’. First, there are classic illness narratives written by patients about their illnesses and treatments. ‘The diving bell and the butterfly’ by Jean-Dominique Bauby, ‘Dying: a memoir’ by Myfanwy and Donald Horne, and ‘The Undying’ by Anne Boyer are just a few of the possibilities.  Second, there are books written by doctors about their experiences providing care. These include authors like Oliver Sacks, Irvin Yalom and Melbourne-based oncologist, Ranjana Srivastava. Not all experiences are recounted in a sober manner, and doctor (now comedian) Adam Kay’s ‘This Is Going To Hurt’ is a recent and perennial favourite – especially with interns. Finally, there are meta-narratives about illness and health. Susan Sontag’s ‘Illness as metaphor’ which examines the power of metaphor and myth in cancer, Simone de Beauvoir’s ‘A very easy death’ about her mother’s final days; and Arthur Frank’s ‘The Wounded Storyteller’ which discusses the roles and limitations of different illness narratives, are all recommendations.

As well as literary methods for exploring empathy, art also plays a role (remember that art was instrumental in the development of the concept of empathy). Careful observation and awareness of others is facilitated by the ‘Visual Thinking Strategies’ developed by Abigail Housen and Philip Yenawine. Using figurative or narrative art, students are instructed to describe, and find meaning in, works of art that they have no information about. Small groups spend up to half an hour on a work and the intense looking helps students notice details that otherwise would have been overlooked. This is then extended to students needing to establish information about their patients while at the bedside from close observation of their patient’s environments.

As an adjunct to this, the work of Ray William’s and his ‘Personal Response Tour’ is very helpful. Best conducted in a gallery (in the past, medical students had tutorials in the Potter Museum),  small groups of participants are randomly each given a ‘provocation’ which could include choosing a work of art that might embody love or courage, or make one laugh. Alternatively, it might be an artwork that reminds one of a difficult patient or is incomprehensible. Or it might connect with family, or culture, or loss – the provocations are endless. Students have 10 minutes to find the work and then reconvene with peers to explain their choices. This inevitably involves sharing personal information which increases the connections within the group as students open up about themselves. Empathy is not just about doctor-patient relationships but also about relationships with others with whom one is working.

The medical curriculum provides regular ‘Professional Practice’ tutorials each year for the four years of the medical course. While the topics vary and include discussions about ‘communication skills’, ‘dealing with uncertainty, ‘open disclosure’, ‘collaborative practice’, ‘end of life issues’ and ‘consent in specific populations’ – it is clear that the ability to appreciate the world from another’s perspective is fundamental to the practice of a good clinician.

From the foregoing, it is obvious that developing/enhancing empathy is not a quick and  simple undertaking. It requires time and reflection. It also requires a safe space where people do not feel challenged or demeaned but are empowered to step back from their beliefs and judgements and are willing to think outside themselves.

In my work with the medical students I am aware that, while some are easily ‘enrolled’ in the process, others are a ‘slow burn’ who, through the encouragement of their peers, come to realise the benefits of expanding their horizons and can see the benefits of a greater holistic person-centred approach to health.

The first person that the Federal Government has nominated to explore ‘empathy training’ is Dr Andrew Laming. I wonder what might have happened to this doctor’s mindset if he had been involved in ‘empathy training’ in his medical school days.