Why it's so difficult for physicians to be empathetic and analytic at the same time

Anthony Jack, PhDFor years, physicians have been urged to show more empathy during patient encounters, but most doctors would tell you it isn't quite that simple.

For physicians who struggle to balance empathy with analytic thinking during patient visits, neuroscience researcher and brain-imaging expert Anthony Jack, PhD, has a somewhat comforting explanation: It's not your fault, it's your brain's.

Jack, who leads Case Western Reserve University's Brain, Mind and Consciousness lab, has employed brain-scanning technology to discover that, the more active the region of the brain responsible for analytic thinking is, the less active the region governing empathy becomes. In other words, the brain's analytic and empathetic systems operate in constant tension with one another.

In the interview below, Jack talks about what his research has revealed on how physicians can better promote behavior change in patients and why it isn't just doctors who'll benefit from developing a greater sense of empathy.

Q: What does your research suggest about why it can be so difficult for doctors to engage in analytical thinking and empathetic behavior at the same time?

We know that when we engage in analytic thinking, such as making a medical diagnosis, then we suppress brain areas involved in thinking about others' experience. On the other hand, when we are empathetic, then we switch off brain areas for analytic thinking. So, in order to make good diagnoses and also be empathetic with their patients, doctors need to switch fluidly between the two modes. That isn't necessarily hard to do, if you are practiced at it, but there is another problem that gets in the way - and that is that we tend to get stuck into responding to a person in one way. We know that when people are described as having qualities similar to animals (e.g. behaving irrationally) or objects (i.e. thinking of them as mechanisms) then this tends to suppress our empathy towards them by increasing activity in analytic brain areas. So many medical activities, such as taking a history to inform a diagnosis, present numerous barriers to empathy. Doctors need to think about this information analytically, at least some of the time, to make the diagnosis. In addition, when they hear the patient report behaviors that are not health-promoting, they may think of them as irrational.

 Q: For the practicing physician, what are the implications of your research? In other words, how should physicians change their behavior to make it more likely that patients will change their behavior?

Physicians typically give prescriptions - they tell their patient how they ought to behave if they want to get healthier, whether that is taking drugs at regular times, exercising more, or changing their diet. We have looked at the effects of this in the brain scanner, and compared it to a different approach, coaching with compassion, and we see clear differences. The problem is that telling people what they ought to do is not an effective way of getting people to change their behavior. This is reflected by appalling compliance rates in medical practice, even for severely at-risk patients. We know that patients are more responsive to physician's advice the more they feel a positive emotional connection with their physician - the more they feel genuinely cared about. Changing habits is hard, and another important factor is for people to be motivated by a positive vision of their future. That can be achieved in a few quick coaching session. Their are good training programs that can teach physicians and nurses in this type of coaching.

Q: Given the implications of your research, what changes do you think need to happen in medical education to produce more well-rounded physicians?

The first thing that needs to happen is simply greater awareness. The tension between analytic and empathetic thinking is very obvious in the brain - it is one of the most pronounced effects one can see with brain imaging. And the studies on doctor-patient relationships, coaching and behavioral change makes it very clear how important empathy is to patient outcomes. But this hasn't translated through in a thorough way to current medical training. The medical world is still more focused on treating the disease rather than the patient. However, there are many pilot programs which will inform future medical training. For instance, there is a program at Harvard which trains doctors on the nature of empathy which has been showing results. 

Q: We’ve talked about the physician having a greater sense of empathy and social connection with patients, but are there health advantages for the patient in developing in those same areas?

This is the big news in medicine of the last few years. Loneliness is worse for your health than any number of commonly cited health problems, including obesity. The effect of loneliness is approximately equivalent to the worst risk factor of all, smoking. We also know loneliness is very bad for mental health, in particular it is a risk factor for both depression and for cognitive decline with aging. Patients can benefit enormously by enriching their everyday social lives, volunteering and finding ways to interact with people from different walks of life. The human is a social animal. It turns out that having an increased sense of social connection with others decreases inflammatory responses - it makes the immune system recalibrate to fight viruses rather than bacteria. That turns out to be one important mechanism by which increased social connection improves health, but there are likely others as well.

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