In 2015, our daughter Alma was delivered by emergency caesarean section at a local
children's hospital. I listened for her cries, but she was silent. The medical team,
too, was eerily quiet, gripped with concern. Alma struggled to live. We learned later
that during her birth she had suffered a stroke. In those first moments as a parent,
I realised two things. First, I wanted to protect my daughter more than anything I'd
ever wanted. Second, I had already failed.
Alma was whisked to the intensive care nursery (ICN), where the staff treated us with
heroic kindness. Physicians, social workers, and nurses took time to answer all our
questions, welcomed our emotion, and even cried with us. Alma is thriving now, but
those first weeks could have been much worse.
As a research psychologist and neuroscientist, I have spent my career studying empathy—people's
ability to share, understand, and care about each other's emotions. But I have never
needed empathy from strangers, or received it from them, the way I did after Alma's
birth. In some ways, the ICN staff members were closer to us than anyone else during
our hardest moments. Their compassion helped us get through an agonising time.
Our family is not alone. Once viewed as a fuzzy soft skill, empathy is now regarded
as a key element in effective medical treatment. Patients of empathic, versus less
empathic, physicians are generally more satisfied with their care and more likely
to heed medical recommendations. Receiving empathic care also seems to improve some
This does not mean empathy is easy, especially for clinicians. As my family's haze
of worry cleared in Alma's early days, I began to wonder about the people caring for
her. A few feet to her right and her left were other struggling babies; hovering over
their incubators, other anguished families. The ICN specialises in treating very premature
babies, many of whom die. If suffering were light, the ICN would be visible from space.
How could these nurses and doctors witness so much pain, go home to their families,
and then return the next day to do it again? For how long? And at what cost?
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Many months after Alma's birth, these questions remained with me. I had begun work
on a book, The War for Kindness, which focuses on how individuals can learn to empathise
more effectively. As background research, I shadowed people in the “trenches” of empathy,
including teachers, actors, police trainers, and the ICN staff.
My return to the ICN was eerie. The intense emotions I had felt as a parent were gone,
but many other things were familiar. The pastel-coloured flower murals and uncomfortable
vinyl chairs rang bells. I recognised some staff members, but only vaguely, like they
were characters from a dream. My phone remembered the unit's Wi-Fi.
Just like before, the ICN nurses' and physicians' compassion shone through in all
their interactions with patients and families. But this time I also realised how deeply
many of them struggled. In interviews, one nurse remembered a patient she had worried
about constantly, even outside of work. A physician recounted a time he had avoided
delivering bad news clearly, for fear of causing further pain. Other staff members
reported symptoms of anxiety and depression related to difficult cases and patient
deaths. I asked one staff member how he dealt with the emotion of his job, and he
responded, “I just push it down until it becomes a health problem.”
These are examples of caregivers' psychological struggles, which include secondary
trauma—PTSD-like symptoms associated with witnessing others' suffering—compassion
fatigue—emotional numbing in the face of that suffering—and burnout—general exhaustion
and loss of meaning. Research has shown that burnout, the most studied of these phenomena,
is more prevalent among physicians in the USA than in the general working population.
It's tempting to view trauma, fatigue, and burnout as empathy's repetitive strain
injuries. In my conversations at the ICN and beyond, health-care professionals voiced
this concern so often I have come to think of it as the caregiver's dilemma—the notion
that chronic, full contact caring can contribute to burnout in health-care workers.
Medical professionals who believe in the caregiver's dilemma might see themselves
as trapped by a double bind. Do they keep connecting with their patients but wear
down in the process, or preserve themselves by turning their empathy off?
Whether they know it or not, some clinicians seem to make the second choice. Medical
students' empathy declines sharply in their third year of training, just when they
begin regular patient contact. Physicians may exhibit blunted physiological empathy,
and both nurses and physicians can underestimate patients' pain and suffering. Some
caregivers engage in defensive dehumanisation, whereby they reduce their distress
by ignoring or denying patients' emotions. Others might derogate patients or blame
them for their suffering. These strategies might protect caregivers in the short term,
but can damage the therapeutic alliance, undermine clinicians' ability to treat the
whole person, and leave patients feeling alienated.
Yet the caregiver's dilemma is a false choice. Systemic changes, such as reducing
administrative burden, efforts to foster positive learning environments, and creation
of strong peer support networks, can help. So can individual-level practices such
as mindfulness, counselling, and self-care. And crucially, research from psychology
and neuroscience offers strategies for sustainable empathy, through which clinicians
can emotionally connect with their patients without sacrificing themselves. Two insights
are especially worth considering.
First, empathy is more than one thing. Psychologists largely agree it is best considered
an umbrella term that describes related but distinct ways people respond to others'
emotions. These include emotional empathy—vicariously sharing others' feelings—cognitive
empathy—inferring what others feel and why—and empathic concern, also referred to
as compassion—a desire for someone else's wellbeing to improve. Although these elements
of empathy are related, they can also split apart. For instance, emotional and cognitive
empathy develop at different ages, are affected by different psychiatric conditions,
and are supported by different systems in the brain. One distinction could be useful
for medical practice. Emotional empathy—especially taking on others' distress—is a
risk factor for burnout and fatigue among physicians, but empathic concern may help
reduce the risk of those same negative outcomes. In other words, caregivers need not
choose between their own wellbeing and empathy for their patients. If they can feel
for patients and families without feeling as they do, empathy can be both connective
This is especially useful given a second insight: empathy is a skill. People often
assume that empathy is a fixed trait, baked into our genes and hard-wired into our
brains. In fact, it is more like a skill. Empathic ability is partly genetic, but
our experiences also shape how we empathise. Crucially, this means that through the
choices we make and habits we adopt, people can purposefully grow, broaden, and fine-tune
their capacity for care.
Medical schools have increasingly leveraged this insight. Whereas “bedside manner”
was once viewed as a quality professionals simply had or lacked, various training
programmes now teach empathy in patient care. These include role playing in which
trainees practise delivering bad news, perspective taking exercises through which
they simulate patients' experiences, and education around the power of empathy to
improve clinical outcomes.
Nursing and medical students could also benefit from an additional strategy: learning
to tune their empathy away from sharing others' distress and towards empathic concern.
Research suggests that such tuning is possible. Some studies have examined the effects
of short-term contemplative practices, such as compassion meditation, aimed at strengthening
empathic concern. These practices may increase individuals' generosity and their ability
to decipher what others are feeling. They may also reduce personal distress in the
face of others' suffering, suggesting that they could be useful in solving the caregiver's
dilemma. Compassion training classes may also help caregivers to develop greater connection
A tenet of compassion training holds that rather than trying to escape suffering,
we can recognise that it knits us together through shared struggle. The ICN staff
saw my family's suffering; it was an honour for me to witness theirs as well, and
to realise that in caring for people like us, they felt emotions not so different
from our own.
Medical professionals often try to withdraw their emotions from interactions with
patients, so as to maintain professional distance. But we patients and family members
always see someone on the other side of those conversations. If that person appears
unfeeling, we imagine they do not care. They recede behind a white coat and a degree,
and seem fundamentally unlike us. By sharing some of their feelings, and their concern
for our feelings, caregivers can cross that divide, reach out, and turn painful moments
into opportunities for fellowship, meaning, and healing together.
This is all the more important now, as the COVID-19 pandemic has multiplied these
painful moments. In countless tragic cases, physicians and nurses have been the only
company for patients with COVID-19 as they take their final breaths. The pandemic
has adversely affected mental health of some citizens and also front-line health professionals.
Addressing these difficulties will require comprehensive efforts, including broadening
access to psychological services and formalising social support networks within health-care
settings. I also believe that efforts based on developing sustainable empathy and
human connection may be another way to help if we hope to manage the pandemic's long-term
I will forever remember the warmth with which the ICN staff treated my family in our
darkest hours. My hope is that my own and others' research on empathy can reciprocate
in some small way—by helping medical professionals continue to connect with patients
while also maintaining their own wellbeing.