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Book Forum: Clinical Practice   |    
From Detached Concern to Empathy: Humanizing Medical Practice
JULIA FRANK, M.D.
Am J Psychiatry 2003;160:2069-2069. doi:10.1176/appi.ajp.160.11.2069
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Washington, D.C.

By Jodi Halpern. New York, Oxford University Press, 2001, 115 pp., $37.95.

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George Bernard Shaw once remarked, "Christianity might be a good thing if anyone ever tried it." Empathy in physicians, like true Christianity, world peace, and even managed care, is an idea that everyone applauds in the abstract. Anyone who attends daily rounds, however, soon realizes that empathy is a concept primarily enshrined in commencement speeches, white-coat ceremonies, and elegies for great physicians. In clinical practice, commitment to empathy is honored more in the breach than in the observance.

This apparent hypocrisy requires a rigorous examination of why empathy is essential to good care, why so many who practice this virtue must do so in secret, and why the social and intellectual organization of medicine so often discourages its development and expression. Jodi Halpern, a practicing psychiatrist and a well-trained philosopher, explores the contradictions between the empathic ideal and modern medical practice. Her analysis reflects a unique blend of clinical experience and scholarly rigor, derived from two decades of experience, research, and reflection. The result is a concise volume that links cognitive science, medical ethics, and the philosophy of knowledge into a clear, clinically relevant narrative accessible to any interested physician.

Dr. Halpern begins and ends with the bedside dilemma of the caring physician, who must make difficult judgments on behalf of patients who are already anxious, angry, in pain, or depressed. The prevailing medical wisdom assumes that such judgments are best made from a position of detached concern, what Halpern describes as "detachment with a veneer of tenderness" (p. 25). Patients’ emotions do not directly indicate the extent or nature of their underlying disease—the expression of pain, for example, derives from culture, expectation, and past history as much as from degree of tissue damage. Physicians’ emotional responses to patients are similarly idiosyncratic. To achieve reliability, objectivity, and reproducibility in medical intervention, the argument goes, the physician must learn to factor out all these unique elements and rely on the evidence of controlled observations of group responses.

From Detached Concern to Empathy gently exposes the fallacy of this argument, demonstrating the critical role that patients’ emotions play in the process of many diseases and in physicians’ treatment decisions. Patients’ emotions affect their motivation to pursue and follow treatment as well as their ability to accommodate to the necessary losses of chronic disease. In a more basic sense, emotions are an organizing principle of cognition, so that patients and physicians both think differently depending on their mood. Rather than compromising good judgment, Dr. Halpern argues, empathic understanding of a patient’s experience and the physician’s awareness of his or her own emotional state in response to it enhance clinical reasoning and improve patient outcome. Moreover, this type of empathy is not some mysterious process of merging that develops over years of psychotherapy. As her examples show, bedside empathy can be cultivated to good effect in relatively brief encounters with unknown patients.

Dr. Halpern makes her argument with both clinical examples and reference to scholarly works in philosophy and cognitive science. She speaks most directly to general physicians and physicians in training. Psychiatrists, especially those of us who teach future generalists, have much to learn from her reflections, especially her conclusions about how to foster empathic capacities in ourselves, our colleagues, and trainees. Few of us will ever read Heidigger, Wittgenstein, Descartes, or even Lacan—for that you need a Ph.D. in philosophy. Dr. Halpern went to the trouble and expense of getting one, and the result is a concise, closely reasoned, and gracefully expressed analysis and resolution of an important problem in clinical medicine. This book should prove of great value to those who hope to preserve and cultivate the values of clinical care within the frame of scientific rigor and social accountability in which we must all practice.

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