Preface: This post is actually my humanities elective essay. I thought I’d throw it up here in case any one is interested in the subject of empathy in medicine, or curious about what it’s like to jump into a white coat after being a patient for most of your living memory.

I have vivid childhood memories of the time I spent as a patient with Crohn’s disease in the children’s hospital here in Halifax. I was 11 when I was diagnosed, and thus I’ve spent more than half of my life living with it. Medicine became important to me as a career during my third year of university, when I realized it is the perfect confluence of everything that makes me happy in life. Even still, I have spent far more time identifying as a patient with Crohn’s than I have as an aspiring doctor. This post is a reflection on my experience of moving toward equilibrium between these roles; patient and doctor in training. I reflect on the degree to which my previous experience as a patient affects my bedside manner and clinical judgment with regard to patients whose position reflects my childhood experience.

I had initially only the broad goal of observing my reflexive response to patients who, in my estimation, were enduring experiences similar to mine. I decided that doing an elective in the pediatric GI clinic where I had been a patient was the best strategy to see myself in action. Indeed, to illustrate how similar, for me, the environment was since I had been there, shortly after my arrival I was recognized by two staff members.

Initially, I was concerned about my ability to balance my emotions and reason while interactions with patients similar to myself at their age. It occurred to me, that making clinical decisions whilst comforting distressed patients was not going to be easy if I was in a similar emotional state. I think I’m making a fairly intuitive argument; if we are a sobbing wreck, a perfect reflection of the patient, how on earth might we comfort them? Profound compassion, on it’s own, would be an aspect of their practice I hope every physician struggles to reconcile. But, I reasoned, as a matter of circumstance, I would constantly be experiencing emotions equally salient to those of the patient, because I had, some 13 years ago, endured similar ordeals.

The dilemma I’ve outlined above, as I understand it, is about empathy, and its place in medical practice. Before undertaking this elective, I had always understood empathy to be the experience of shared emotion; that is, arriving at an emotional state as a consequence of observing it in another. I was further concerned, then, by the widespread belief that empathy was an essential part of compassionate clinical practice. As I began to try and conceptualize the application of empathy in practice, it seemed to me empathy could only compromise my ability to reason and make balanced judgments. I reasoned that one of two things had gone awry: either I, or the medical establishment, had totally flubbed the definition of empathy. If I had misinterpreted the definition, I was determined to discern by what inferential blunder I had internalized an ambiguous understanding of the term. On the other hand, if the medical establishment had appropriated the word as jargon and incorporated it’s own meaning; I would have to come to understand that.

To the dictionaries! My searches however, lead me to believe I would never know the solution. In keeping with (what seems like) the majority of English words, there are multiple definitions of empathy. And, even if the exact definition you prefer is lacking from the dictionary of your choice, it seems to be acceptable to start using the word the way you’d like to anyhow. The Oxford English Dictionary definition is: “The power of projecting one’s personality into (and so fully comprehending) the object of contemplation” (Oxford English Dictionary Online, 2008). And the slightly, but (I believe) not completely overlapping, unabridged definition from the 5th edition of Stedman’s Medical Dictionary is:

1. The ability to sense the emotions, feelings, and reactions intellectually and emotionally that another person is experiencing and to communicate that understanding to the person effectively. 2. The anthropomorphization of humanization of objects and the feeling of oneself as being in and part of them. (Stedman’s Medical Dictionary, 2005)

If we throw out the idea that a single definition is ‘right’, and think instead about appropriately pairing definition with application, the resolution to my original dilemma is nearer at hand; that is, I believe the second definition of empathy I mentioned above, from Stedman’s Medical Dictionary, is the more locally applicable. It allows for the empathetic physician to objectively observe emotion, but it also admits experiencing the patient’s emotion. The equation is balanced, I believe, by the degree of emotion we experience. Experiencing a small degree of emotion gives meaning to the intellectual recognition of another’s pain or joy etc. Letting that emotion govern us however, clearly negates the whole exercise. Thus, I reasoned that it is acceptable for me to feel, in manageable doses, the emotions the patient may be feeling. I believe the struggle for me will be in not letting those emotions overwhelm me.

Now that we’ve traveled through this odyssey into the semantics of empathy, we should find it ironic that it didn’t matter at all, once I began spending more time with patients. I realized that my fumbling with the definition of empathy was irrelevant because I was seldom experiencing empathy while observing patients; I was rather only recalling my own experiences, a narcissistic conflation with empathy. In fact, upon this insight, I realized that dwelling in my own experience inhibited my ability to empathize. Allow me to offer an anecdote from my elective that illustrates my point. I was called over to observe the peri-anal exam of a young boy. I was suddenly struck by a memory of being in a hospital at his age. Under the watchful eye of my doctor several residents began a physical exam without ever having introduced themselves or asking for permission. This induced in me an extremely distressing feeling of objectification and complete loss of control. I now wonder if many children in a pediatric clinical setting feel similarly. In fact, in this case I was overcome with the need to return, what seemed to me, to be his lost sense of control. I couldn’t bring myself to approach him without his permission, so I asked if I could come over. Returning then to my exploration of empathy, I realized that in this case empathy played no part in my relationship with this patient. Regardless which definition one prefers, all definitions require a relationship between two beings. By dwelling only in my memory, I neglected to truly to consider the boy on his terms. I was not feeling what the patient was feeling; I was feeling what I felt in a similar situation. I couldn’t be sensitive to what the patient was feeling, so immersed was I in my own memories and emotions.

I’m not tying to make the argument that what I did that day was detrimental to the patient. I am however, sounding a cautionary note, about how deceptively easy it is to conflate empathy and compassionate narcissism. To react solely from your own experiences, while perhaps not harmful to the patient, certainly precludes a circumspect assessment of the patient’s experience. I think we can and should be sensitive to our patient’s emotional state – and reflect that at an emotional level – so that we can share a degree of their experience; I assert that doing so is essential to a compassionate approach to medicine. This experience has taught me to be careful not to substitute my own emotions for those of my patients. Hereafter, I will be introspectively vigilant; I will reflect upon my motives – emotional and rational – to ensure that my considerations of patients’ feelings are just that – their feelings.