The Context-Dependence of Empathy

by David Scales MD, PhDchoice

If you follow Twitter, KevinMD or the medical literature on clinical empathy you start to get the impression that empathy – and a physician’s lack of it – is the result of a personal failing. You’ll read about how physician-reported empathy scores are associated with positive patient outcomes from diabetes to the common cold. You’ll find physicians citing success stories of how empathy changed their practice. And you’ll read about wellness and training programs that have shown positive results in promoting more physician empathy.

You would be forgiven for thinking we have this problem solved: lets just get doctors to really listen to patients and take some of these trainings. Case closed. Ok, good talk. Lets call it a day.

But as I point out in a recent piece on Aeon, the social science literature suggests something else – that how much empathy we display is context dependent. It can fluctuate depending on the culture we work in, our own anxious tendencies, and our stress level. It isn’t a constant that, once learned or trained, automatically becomes part of us and our practice.

Neuroscience supports this as well, as research on “mirror neurons” has shown that they help us reflect other people’s emotions. But they stop working if we are under duress, and as the burnout statistics suggest, many of us are under a lot of duress.

When you dig deeper, it is clear this “empathy gap” has environmental – not personal – origins. A number of medical studies have shown how medical student empathy scores decline through training and residency, noting the sharpest drops as students enter their third year of medical school.

Having just finished residency, I cannot claim to have unfailingly practiced empathy or modeled it for the medical students or interns I supervised. I still think about the many times I could have lingered at a bedside longer, and I probably always will.

But I also recognize my own limits within the constraints of a system that pushed us to see more patients more quickly. The context has never really changed, in fact, some have argued, it has gotten worse. The response of the medical system to the decline in empathy during medical training has not been to step back and ask ourselves: How can we improve the context in which we practice and teach medicine so we don’t inhibit the natural empathy most students bring with them to medical school?

Sure, some physicians have called for “culture change” as if we could all just decide to be less stressed at work. Some heroic physicians have found ways to be empathetic anyway, blocking out the chaos of our hospitals and clinics and tuning into each patient, in that moment, and reflecting their emotions. These physicians should be lauded, but they should also serve as a wake up call for the profession because culture change cannot be an individual crusade. As more physicians go into E-ROAD specialties (emergency medicine, radiology, ophthalmology, anesthesiology and dermatology), as we choose to leave primary care to go into concierge practice, we should resist the idea that daily heroism is required to survive as a physician on the front lines.

Rather, we should ask ourselves, “How do we change the incentives that require our hospitals and clinics to survive by the volume of patients they treat rather than the quality of their care?” Imagine a hospital that was reimbursed based on how much empathy physicians showed their patients. I expect we’d rapidly see changes to the practice environment that make it easier for clinicians to empathize with their patients. But until the lack of physician empathy has an impact on the bottom line, hospitals – hospital administrators, really – will have little incentive to change the way they structure their business.

So the next time you read a piece about empathy and how doctors should just listen more, be kinder, or take some new and improved mindfulness or empathy training, ask yourself: what is anyone doing to change the practice environment – the context that shuts down our mirror neurons? What is anyone doing to prevent medical students from losing their empathy and to make it easier for all of us to let our natural empathetic tendencies rise to the surface?


David Scales MD, PhD is a sociologist and practicing physician at Cambridge Health Alliance. In addition to his writings on clinical empathy, he has also focused on how doctors can be reassuring to patients. Follow him on twitter at @davidascales.