Her grin couldn’t get any wider. The 4-year-old pressed the toffee to her mouth, wrapper and all, and did not seem inclined to remove it from there. As I quickly took my cue and started examining her while she was thus distracted, her mother gently tried to explain to her that the wrapper had to be removed. But she remained oblivious. Her mother slowly extracted it from her mouth and started undoing the wrapper. However, the child had started wailing, sweeping her arms in front of her, not understanding where her toffee had gone. She was blind: congenital bilateral anophthalmia. And then, the mother, with tears in her eyes, looked up at me and asked if her child would ever be able to see. All at once, tears welled up in my eyes and I felt ill equipped to deal with both child and mother, as it seemed that even my genuine concern and consolation would sound hollow and inadequate. What words could possibly reassure this distraught parent? This child’s plight is probably shared by the estimated 1.4 million other blind children in the world (1).

The couple entered the orbit clinic with some apprehension. He would have been around 90 years old, and she around 80. He had no functional hearing left, had one phthisical and another cataractous eye, and was bent double by severe osteoporosis. His wife was a tiny, frail woman on whom he was totally dependent. On her part, she made sure that he was always holding her hand as she guided him around. When it was his turn to be examined, I explained to the woman that she could wait outside till I was done, since there were no free seats inside the clinic for her to sit in. She hesitated for a moment and then headed outside. As I started evaluating his ocular status, I found to my dismay that he would not follow any of the instructions he was given. I tried every tactic I knew, but to no avail. Finally I called in his wife with the intention of telling her I was unable to make him cooperate for a proper examination. She shuffled into the cubicle, heard me out, and then went straight to him and took his hand. At that moment I knew how I had erred grossly. I had neglected the simple act of human touch and reassurance needed by a deaf and nearly blind man, who was in an alien environment and had inadvertently been deprived of his familiar guardian.

These two experiences left me wondering if I, in fact, possessed the qualities that it takes to be called a “healer”. I may be skilled in clinical evaluation and diagnosis, and yet I did not seem to be able to give these two patients what they required: comfort. Perhaps my approach to their problems was wrong. In the first case I felt much too involved with the patient to be of any use. In the second I seemed to lack a fundamental empathetic attitude in my dealings with the patient.

When we are asked to reflect on why we chose to enter the medical profession, many of us say that it was a desire to “alleviate suffering” or “help and heal the sick,” a humanitarian and altruistic intention. As we proceed through our medical education, we are taught that the most objective way to do this is by practising emotional detachment. Empathise with the patient, not sympathise. We are trained to hone skills that aid in cure and ruling out disease, and to focus on the more objective aspects of patient care, in the process alienating our patients. There may be many reasons for a lack of a satisfactory empathetic relationship developing between a doctor and a patient. Doctors may have little time to establish an adequate rapport with their patients. The crowded and chaotic environment that sometimes prevails in busy hospitals prevents the development of empathy for patients. And many of us thus proceed without actually fully grasping the entire meaning of the concept of empathetic care through our years of patient interaction that follow our basic training.

Sympathy and empathy: the difference

In the 1880s, German psychologist Theodore Lipps coined the term “einfuhlung” (literally, “in-feeling”) to describe the emotional appreciation of another’s feelings. Having its roots in Greek (em-into, pathos-feeling), empathy in the context of health care is “a cognitive attribute, which involves an understanding of the inner experiences and perspectives of the patient as a separate individual, combined with a capability to communicate this understanding to the patient” (2). Subtle differences exist in the usage of the words “sympathy” and “empathy” in the context of a doctor and patient. Empathy involves developing a rapport with the patient, and interpreting non-verbal cues from his or her body language. In the case of empathy the physician identifies with the patient and at the same time maintains a distance. Empathetic communication is said to enhance the therapeutic effectiveness of the clinician-patient relationship (3) whereas sympathy is “a relationship or an affinity between a person in which whatever affects one correspondingly affects the other” (4). Sympathy implies sharing the pain of the sufferer.. It is, thus, shared suffering. Therefore, the implications are that a physician sharing the plight of the patient would be unable to help, since he or she would not be in a position to evaluate, judge and act in an unbiased manner.

Although empathy was initially referred to as “bedside manner”, which was assumed to be just an alternative way of expressing sympathy, it is now recognised as a powerful communication skill, denoting an engaged detachment, and is no longer considered purely intellectual. In empathy we “borrow” another’s feelings to observe, feel and understand them, but not to take them on ourselves; empathy can, therefore, be described as “feeling with”, whereas sympathy is better described as “feeling into”. Both concepts involve sharing, but empathetic doctors share their understanding, while sympathetic physicians share their emotions with their patients (5). It is thus evident that these concepts are not independent of each other.

Are we empathetic doctors?

In today’s world, where the emphasis is on a technology-based approach rather than a humanistic one, we would rather place ourselves on a self-constructed pedestal of eliteness than actually consider ourselves plain enough to deal with each patient with concern on a personal level. So how, then, do we evaluate ourselves, determine if our empathy hasn’t dwindled to indifference, gauge if suppressed emotions haven’t decomposed to a lack of any, and, of course, rectify the problem?

The concept of empathy has been well studied and analysed. Studies done on third-year medical students and internal medicine residents in the United States have demonstrated a progressive loss of empathy during the course (6). There have also been various tools developed to test empathy, such as the Jefferson Scale of Physician Empathy (JSPE) questionnaire and the Interpersonal Reactivity Index (IRI) (6). Such studies and tools may aid in evaluating and monitoring the level of empathy that forms a part of the necessary clinical practice among doctors.

Can empathy be taught and learnt?

Although there are few, if any, educational courses focusing on teaching empathetic patient care, empathy is not something that cannot be learnt. In fact, empathy and empathetic communication are teachable, learnable skills (7). Empathy is better acquired when one is trained in interpersonal skills, has positive role models to emulate, and is exposed to a greater number of educational experiences (7). Therefore, a teaching programme for medical students that incorporates a systematic training of humanistic qualities may enhance their empathetic qualities.

Is there a need to include training in empathy as an integral part of patient care?

Studies show that patient compliance with prescribed medication improves (3). when care is delivered with empathy, which can enhance and promote a two-way communication. There is an increase in the level of satisfaction of both patients and doctors, thereby reducing the incidence of litigation associated with medical care (8). It may also have a positive effect on health outcomes (9). Hence, there is a definite indication to attempt empathic training of doctors.

In the course of medical practice a doctor sometimes becomes ordained as a magical healer. This perceived image is highly overrated and requires that the physician educate his or her patient about curtailing such irrational expectations. Safe and respectful medical care is a two-way process as patients have the right to decide on the type of medical treatment they prefer, and it is mandatory that they be offered the choice by a dutiful physician. But the exercise is not to be performed mechanically. As much as patients of today demand proof on paper, after the complex and latest laboratory tests have given confirmation that their disease is indeed what we suspect it is, they also expect, not unreasonably, the reassurance that we, doctors, have their genuine interests in mind, and will stand by them as both physician and friend. And that should be within our power to provide.