Bioethics Forum Essay
Sustaining Clinical Empathy During the Pandemic
As Covid-19 continues to spread throughout the United States, doctors, nurses, and other clinicians are facing unmistakable tragedies. But something less perceptible is afoot. Empathy in medicine is under siege.
Across the country, clinicians are showing evidence of psychological exhaustion, demoralization, and the sine qua non of burnout — empathy depletion. The effects are not insignificant. Clinical empathy is crucial for providing effective care for patients and families during a crisis. It promotes trust and disclosure, and can be directly therapeutic. Empathy is beneficial for clinicians too: it is central to finding clinical practice meaningful.
Some empathy depletion during the pandemic is of course to be expected. The uncertainty and anxiety created by unprecedented clinical demands undermines clinicians’ capacity for empathy. But some of it is preventable. If clinicians felt that they had the resources and equipment to minimize risks to their own health and that of their patients, for instance, their psychological distress would be much lower. Instead, clinicians are experiencing anxiety magnified by outrage at not having these essential protections. Outrage can distort perceptions of risk, amplifying anxiety and further undermining our ability to mobilize empathic responses and maintain our emotional health.
What can clinicians do to sustain empathy? Under usual circumstances, clinical empathy is triggered by resonance with a patient’s feelings. This resonance helps clinicians follow the patient’s moods and imagine the sequence of feelings they convey as they give a narrative of their illness. It is this process that reveals nonverbal cues to what the patient is most concerned about.
We have noticed moments of this resonance in action—clinicians connecting isolated patients to screens of their loved ones as they are dying, or using music to steal away a patient’s despair. But we also notice how hard it can be when there is empathic resonance, yet the pressures of the pandemic interfere with making such important, human connections. Limitations to how clinicians’ can interact and comfort their patients can worsen clinicians’ feelings of helplessness and lead, over time, to numbness and exhaustion.
Yet, emotional attunement with patients is perhaps more imperative now than ever before. It is what the hospitalized patient with Covid-19, fearful and anxious herself, needs from her internist. It is also what the single parent, recently unemployed and caring for an autistic son at home who has lost all his services, seeks from the pediatrician. It is what the new mother, separated from her newborn while the clinical team awaits her coronavirus test results, desires from her obstetrician.
The best way to preserve clinical empathy during this crisis is to try not to suppress negative feelings. Rather, be aware of them. This can be done quickly with a momentary body check—clinicians can become aware of feeling muscle tension, holding their breath, and other signs of fear and anxiety. They can learn to take a few breaths before entering patient’s rooms. Accepting the fact that patients are understandably anxious and frustrated allows clinicians to take simple, mindful steps to center themselves.
Another important strategy is engaged curiosity. This is not a time when clinicians can necessarily expect to automatically resonate with their patients’ feelings. Clinicians may need to consciously be curious about who their patients are and what their world is like. Ask simple questions like: “Where would you rather be right now?” “What are you most worried about?” “What are you most hoping for?” A patient’s answer — “I’m most afraid of leaving my wife without a caretaker,” or “I’m most hoping to see my grandchildren again” –– often stimulates empathy.
When clinicians find themselves in tragic situations –– a patient arrives in need of a ventilator but none are available –– protecting empathic connections is especially critical. To do so, hospital policies need to ensure bedside clinicians are focused on providing care to the individual patient in front of them, not making triage decisions intended to benefit a group of patients. Clinicians also need to expect anger from patients and their families. It is a good, not bad, sign when families express their anger at clinicians directly. Clinicians should try to listen to their anger as a cry of pain, as this is what it is. Stay in the room with them and listen. When the time is right to leave the room, clinicians should try to seek a private space for a moment of solace — with another trusted clinician, by calling someone at home, through music played on a personal device. Feel free to curse the situation. Cry.
These are unprecedented times. Demands on clinicians are enormous. Tragedies abound. There already are too many fatalities because of this pandemic. Let’s not have empathy in the clinical encounter be one of them.
Jodi Halpern MD, PhD, is a professor of bioethics and medical humanities at the UC Berkeley-UCSF Joint Medical Program and the School of Public Health and leads the Covid-19 Crisis Resiliency and Mental Health Task Force at the University of California, Berkeley School of Public Health; jodihalpern.com. Douglas J. Opel MD, MPH, is an associate professor of pediatrics at the University of Washington School of Medicine and the associate director of the Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Research Institute.
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