May 12 2010

I Don’t Feel Your Pain

A recent study uses EEG to look at brain activity in doctors and control subjects while viewing another person being poked with either a needle or a cotton swab. The control subjects showed activity in parts of the brain consistent with empathy – a negative experience in reaction to the pain of  the other. The doctors, however, did not demonstrate this brain activity.

These results, while preliminary, are not surprising to me at all. You may find it odd that a doctor, who is supposed to be especially attentive to the comfort of their patients, would be inured to their pain. But this makes perfect sense.

Let me start by recounting my own personal experience as a representative anecdote. The first invasive procedure most medical students learn is blood drawing, which involves sticking a needle into the vein of a patient in order to fill tubes with blood to send off to the lab.

This is no big deal, but when I first learned to do this I felt a strong inhibition against the deliberate infliction of pain on another person. Obviously the purpose of the procedure was diagnostic, the patient consented to the procedure because they knew it was medically necessary. But there was simply a negative emotional reaction to the pain I was inflicting, as minor as it was.

This was a problem. Optimal blood drawing technique, to minimize patient discomfort, requires no “flinching” or hesitation on the part of the blood drawer – one quick smooth motion is ideal. I found I had to consciously suppress the instinctive inhibition, which took a little practice. After a few weeks of regular blood drawing, however, I found that I could focus on the procedure and was no longer distracted by any pesky empathy.

This experience prepared me for the more elaborate and uncomfortable procedures I would learn as my training progressed.

This desensitization is both unavoidable and necessary. I also found that it is part of a broader principle in medicine, the distinction between sympathy and empathy.

Doctors and other health care providers need to have sympathy and sensitivity toward their patients. They need to understand what their patients are going through, and make every effort to minimize emotional and physical discomfort, as well as treat their patients with dignity. This is part of being a professional.

Empathy, however, goes beyond sympathy – it involves experiencing a negative emotion in response to your patient’s pain (mental or physical). While sympathy is good, empathy is counterproductive – for both the physician and patient.

For the physician, the main problem is burn-out. If you actually experienced all the emotion you encountered on a daily basis as a physician (granted – depending on your specialty) you wouldn’t last long. A bit of professional distance is necessary for your own emotional health.

But further, empathy is not in the best interest of the patient. Getting emotionally wrapped up in a patient’s situation compromises objectivity. This can be a subtle but devastating problem. I have seen doctors over-treat pain with narcotics to the patient’s detriment, because they were emotionally bothered by the patient’s pain. Empathy can also lead to failing to consider terrible diagnoses, or ordering tests, procedures, or interventions out of desperation, even when the risks outweigh the benefits.

Patients need their physicians to be detached, objective, and professional – not emotional. This is exactly why physicians should not treat their own family members or loved-ones.

And to emphasize this point – detached does not mean uncaring. The professional relationship means that we are sympathetic, caring, and non-judgmental in a universal systematic way – regardless of our feelings for a patient or sympathy for their situation. We give the same care to patients we like as to those who are confrontational and irritating. We are detached from the positive and negative emotional reactions to patients.

To further emphasize – I think it is important for physicians to really understand what their patient’s go through. Modern medicine can be scary, embarrassing, and uncomfortable at times. When physicians experience that themselves, or through a family member, or at least really try to imagine what it would be like – they are in a better position to tend to their patient’s needs.

It can be a delicate balance, but it is an important one to strike. In general, in my experience, medical education does adequately address this issue. It can always be better, but most physicians I know are very attuned to this situation.

So, while this is a small study, the results confirm what most physicians already know. We don’t feel your pain, and you don’t want us to. But we do understand and sympathize with it.

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20 responses so far

20 Responses to “I Don’t Feel Your Pain”

  1. daijiyobuon 12 May 2010 at 10:42 am

    Just remember, if you have no empathy for the suffering of animals…

    then you are a Replicant!

    -r.c.

  2. Jim Shaveron 12 May 2010 at 11:05 am

    Steve, do you think this level of necessary and professional suppression of empathy by doctors could be a contributing factor when many doctors tend to allow, or at least be complicit towards, some of the more dubious techniques practiced by nurses (e.g., therapeutic touch, accupucture, etc.)? In other words, since doctors have been trained to distance themselves emotionally from a patient’s pain, are they therefore more willing to turn much of that type of assistance over to lower-level medical workers, even if those workers are using pseudoscientific methods?

    I don’t know if my proposed connection makes sense, but somehow, the medical establishment has to figure out how these completely crappy “tharapies” are making their way into hospitals.

  3. Draalon 12 May 2010 at 11:11 am

    I’d like to see this study repeated but for nurses. They are more involved with the physical care of patients. Patients and their families will interact with nurses differently than they do with their doctor. Often, the nurses are the subject of verbal abuse and even physical abuse. I believe this is exacerbated by hospital policy that is ever increasing pressure on nurses to simultaneously care for more and more patients. Nurses are therefore under pressure to not spend quality time with patients but rather forced to constantly move from one patient to the next while performing a checklist of required procedures in shorter and shorter time. In the end, I believe nurses become jaded. They are less sympathetic and empathetic the longer they work under these conditions.

  4. ccbowerson 12 May 2010 at 11:33 am

    I’m not sure that I agree with the use of the term “sympathy.” Sympathy can also imply an emotional understanding of what another person is feeling, making it at times overlapping with empathy. The distintion that I was taught was empathy versus perspective taking ability. Perspective taking does not (necessarily) involve the feelings of the other at a given moment, but a big picture understanding of what the person is going through.

    This topic seems to be most important when procedures are involved, although it probably matters in all areas that involve judgement. I can’t imagine that there is a good surgeon out there that doesnt completely turn his/her empathy off during a procedure. The problem occurs when they cannot turn empathy back on when they are done… I think this is one way that burn out can manifest.

  5. kvsherryon 12 May 2010 at 11:43 am

    In nursing school, we were taught “empathetic communication”. The mantra was, if you have sympathy, you feel sorry for your patient, if you have empathy, you feel for them and that is better because you can do something for them.

    I would also love to see that study done with nurses. So many of my female colleagues can’t separate the emotion and do become wrapped up in the case, losing objectivity sometimes. Being fairly new and also a young male, I sometimes find it hard to assert to these women that they are approaching it wrong. I feel that in most cases, I can turn the ‘empathy’ switch off and do what has to be done. The very few times that I was unable to separate myself, I regretted it a lot.

  6. daedalus2uon 12 May 2010 at 2:43 pm

    I have never stuck someone with a needle, but for me, when I donate blood it is less painful if I watch the needle go in. Usually the people doing the needle insertion don’t like to have me watch while they do it.

    I am able to dissociate pretty well (is that good or bad?), so maybe having the visual stimulus to actively dissociate from works better for me.

  7. ltayloron 12 May 2010 at 4:14 pm

    The problem with this study is using the needle as the painful stimuli. My experience as a dentist, giving many needles every day, is that the fear of needles is disproportionate to the pain. I know it’s not THAT painful so if I see someone getting a needle I’m not going to be able to summon up much sympathy or empathy. I may have more sympathy or empathy if I thought they were truly in pain. ….This doesn’t mean I’m not kind to people when I give them needles.

  8. JAEon 12 May 2010 at 4:35 pm

    This reminds me of an fMRI study – a solid study using acupuncture practitioners! Not studying acupuncture itself, but rather brain activity when acupuncture practitioners vs. people not accustomed to sticking needles in others watched movies of needles penetrating skin.

    Expertise Modulates the Perception of Pain in Others
    Yawei Cheng, Ching-Po Lin, Ho-Ling Liu, Yuan-Yu Hsu, Kun-Eng Lim, Daisy Hung, Jean Decety
    Current Biology – 9 October 2007 (Vol. 17, Issue 19, pp. 1708-1713)

    and another fMRI study, in which people watched movies of “patients receiving a painful therapy”, and reactions varied depending on whether the subjects were told the treatment was successful or not.

    The neural substrate of human empathy: effects of perspective-taking and cognitive appraisal. Lamm C, Batson CD, Decety J. J Cogn Neurosci. 2007 Jan;19(1):42-58.

  9. tjk65on 12 May 2010 at 4:38 pm

    Steve,

    It seems that many pseudo-scientific modalities of treatment present themselves as promoting empathy, spirituality, and some mysterious understanding of the afflicted. As you know, patients seek empathy especially when feeling most vulnerable , and this will genuinely improve their psychological comfort and sense of well-being. (Empathy being only one factor that can produce perceived improvement )

    Empathy alone can reinforce belief in a modality of treatment. A mother kissing the scraped knee of her three year old has not done much to hasten the healing of the skin, but the child sure feels better and knows to go back for 100mg of TLC the next time.

    I couldn’t agree with you more in terms your sympathy/empathy argument. I do believe, though, that the peddling of empathy is one of the pseudo-practitioners most effective tools, and can account, to a large degree , for the longevity of a form of pseudo treatment.

  10. HHCon 12 May 2010 at 4:46 pm

    The recent EEG study refers to poking with a needle or cotton swab. I wonder if empathy/sympathy would be garnered in the subject or physician if the eye were used as the anatomical part that was jabbed.

  11. SARAon 12 May 2010 at 6:05 pm

    To me there are implications in this study confirming what was already intuitively known = that humans can control their emotional responses. Apparently in this case by forcing repetitive confrontation with the trigger.

    Does it not suggest that this should work in other cases of excessive emotional response such as phobias?

    But I think those types of “confrontation” treatments are not always successful. I wonder why.

  12. tmac57on 12 May 2010 at 7:14 pm

    daedalus2u- The probable reason that they don’t like you to watch while they insert the needle,is that they are wary about subjects that might have a vasovagal syncope (fainting) episode due to needle phobia. This can affect something like 10% of people, and is more likely if you are watching the procedure. It is not necessarily about the pain, but more about an instinctive fear of invasive medical procedures, and it can even be occasionally dangerous. Not watching, and having your head lower to maintain blood flow to the brain can help avoid an episode.

  13. hippiehunteron 12 May 2010 at 7:33 pm

    I have been a Registered Nurse for 25 years and live down the road from the university i trained in. That University recieved a bent spoon award from the Australian Skeptics for offering a degree in naturopathy but that’s another story.

    We were taught about empathy v sympathy too along with numerous postmodern feminist tripe and a good dose of woo ( louis hay et al ).

    I believe that nurses eventually succumb to the mentioned desensitisation but , in my experience , to a lessor degree to , say surgeons.
    Its role dependent , an experienced emergency department or ICU nurse will be much less emotional about an invasive procedure than a nurse who works in admin only.

    I wonder how this study would apply to ambulance officers and nurses working in resus bays in the E.D.

    Thanks for another great article, again I feel myself a little embarressed by the amount of woo associated with my job.

  14. Treyon 12 May 2010 at 9:20 pm

    I work in medical labs, and have, in the past, been an instructor for students learning phlebotomy (drawing blood). I’ve taught everyone from high school students to resident doctors, and I agree. Everyone flinches at causing pain at first, but it goes away with practice.

    I’ve always had a decreased empathetic response, I’ve noticed. I never flinch when the tetherball smacks the dad in the groin during America’s Funniest Home Videos, or when another person is in pain. This seems to just be a part of my personality, from childhood on.

    This makes me a very good phlebotomist. Only a certain type of person can stick a newborn baby or an infant, and have the stability of hand to hit a tiny vein, and even a little flinch is going to miss. Even though I don’t work in that part of the lab anymore, I still get called over regularly to get a difficult patient.

    I’ve never really correlated the two, but it makes good sense.

  15. The Dicklomaton 13 May 2010 at 12:51 am

    Steve’s article focuses on the benifits of desensitization but not the mechanism for it. This is of course not what the article was about, but this is the “Neurological” blog, so Steve could you perhaps expand on this to include what is happening behind the scenes?

    When you learn to drive, you are hyper aware of everything that you are doing. Your actions are all disjointed, you hesitate, overthing and the other drivers probably think you’ve been drinking, iuntil they see the “trainer” sign on the back and they happily stay clear of you.

    Once you get better at it, you no longer think about it. The car becomes an extension of you and instread of thinking “see turn, signal, watch your back, freak out, merge out, slow down, freak out again, wave at the honker, turn the wheel, not that much, straighten out, park, cry” and spend the next year feeling guilty about the kitten that you tried and failed to avoid, you think, “hey, I’m hungry and these’s a McDonalds over there” and next thing you know you’ve ordered a cheeseburger without much recollection of what happened in between.

    From what I recall, “learning” behaviors and “learned” behaviors operate from different parts of the brain. I expect there is some correlation between the source or triggering of our empathic senses and the locations of the brain where we operate at concious and unconcious levels?

  16. locutusbrgon 13 May 2010 at 12:34 pm

    two points I will try to be brief.
    Steve
    I agree with some of the other bloggers. You have it backwards between empathy and sympathy. I referenced several sources and empathy and my understanding of the definitions is more detached than empathy. The way you used them is the opposite of their respective relative definitions. It is most often taught empathy not sympathy.

    Starting with Jim.. there are several issue with some statements I have read here about nurses. My biases are obvious. I have been a RN for 20 years. Emergency medicine for 10. I have been an Nurse Practitioner for 10 years. I was trained and I practiced science based medicine. I took the same undergrad science courses that the pre-med students took at my university. I never took homeopathy 101 nor was I required to learn some woo to graduate.
    In my particular case my graduate school of nursing was at a medical school and I received my graduate education from the same physicians that the medical students did. I was in the cadaver lab every day with a medical student next to me. There is a wide variation in nursing training and I cannot speak for all. Still characterizing nurses as the only source of medical psuedoscience is unfair and incorrect. I do not see a “Nurse OZ” show on the TV everyday do I?
    Secondly despite popular perception registered nurses are not indentured servants to doctors whims. I will not even try to explain what I do or what my qualifications are as a NP. As a RN I had my scope of practice, I did things (Horror) without checking with a doctor. Often in a progressive university environment I was treated as a peer by the attending physician.
    Doctors are the ultimate arbitors of medical decisions and treatments. They would not tell me where or how the want an IV placed. They know that it is my decision. The need for an IV and the type of IV treatment is their decision. Nurses are ethically and legally responsible to refuse a doctors order when they feel it is detrimental or in error.
    Please do not generalize or characterize My profession, when you do not practice in it, and do not understand what we do.
    As an aside, it is my opinion that RN’s are wrongfully encouraged to pursue alternative medicine practice in certain education situations. I have had students and could do a whole blog on the problems with the nursing education system.

    Still anecdotally everyone I associate with does science based nursing practice. I hold my Practice as a NP to rigorous scientific based medical practice. It is more than my Philosophy it is the way I was trained at the graduate and undergraduate level.

    Steve P

  17. rmgwon 14 May 2010 at 4:01 am

    Surely a similar mechanism explains how Stanley Milgrams subjects (they weren’t “participants” back then) overrode their sympathy for the apparent shockee? Or, indeed, how humans can disregard suffering in other species when they have managed to convince themselves that it is necessary and all for a good cause?
    Manipulating our own feelings of sympathy/empathy for a good end or simply habituating to overriding an impulse not to cause pain is a handy ability in all sorts of situations, (perhaps submission postures in other species trigger this impulse?) but it seems pregnant with possibilities on both sides……therapeutic and quite the reverse.

  18. BillyJoe7on 14 May 2010 at 8:48 am

    lotusbrg,

    “I agree with some of the other bloggers. You have it backwards between empathy and sympathy. I referenced several sources and empathy and my understanding of the definitions is more detached than empathy. The way you used them is the opposite of their respective relative definitions. It is most often taught empathy not sympathy.”

    I can’t quite make sense of what you’ve written above so I don’t know exactly what you’re trying to say, but you’re wrong if you’re saying Steve has it wrong because his version is actually quite correct.

    Sympathy is a shallow version of empathy. It’s about actions rather than feelings. Whereas, empathy is all about feelings.

  19. Brian The Coyoteon 14 May 2010 at 12:30 pm

    When I was being trained as a paramedic it was drilled into us over and over that we had to keep dispassionate while maintaining some sympathy. When I think about it, it is really using a science-based approach to emergency interventions. What the patient reports you pretty much take on the level of anecdotal evidence. Your findings on examination are given much more weight. The classic example almost always given is that a broken finger will hurt much more than a femoral bleed but only the bleed is life-threatening.

  20. locutusbrgon 19 May 2010 at 1:07 pm

    Billy Joe:
    I have provided two Webster’s definitions for your perusal below.
    It is subjective but I think the empathy over sympathy statement does have validity. I have no wish to argue semantics or list 20 definitions. To clarify for you simplistically. It is my opinion that sympathy conveys a indication that I am “feeling sorry for you” whereas empathy is more a intellectual understanding of a patients pain without the actual experience. To be empathetic is to acknowledge a persons discomfort without the “fake” impression that you know what they are going through. It was my understanding that Steve was indicating the opposite and sympathy is more detached than empathy. I missed the fact that I repeated empathy twice in my last statement making my point confusing. I don’t think “actions” have a direct association with either word used in this context.
    At least that is my impression.

    Sympathy: an affinity, association, or relationship between persons or things wherein whatever affects one similarly affects the other b : mutual or parallel susceptibility or a condition brought about by it c : unity or harmony in action or effect
    2 a : inclination to think or feel alike : emotional or intellectual accord b : feeling of loyalty : tendency to favor or support
    3 a : the act or capacity of entering into or sharing the feelings or interests of another b : the feeling or mental state brought about by such sensitivity
    4 : the correlation existing between bodies capable of communicating their vibrational energy to one another through some medium
    Empathy:
    Etymology: Greek empatheia, literally, passion, from empathēs emotional, from em- + pathos feelings, emotion — more at pathos
    Date: 1850
    1 : the imaginative projection of a subjective state into an object so that the object appears to be infused with it
    2 : the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner; also : the capacity for this

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