**2. Meeting patients' needs through empathy: an educational challenge**

Empathy, a Greek word that implies understanding the feelings of another, came to the English language to designate the perception that someone has when contemplating a work of art. Only later, from 1918 onwards, Southard incorporates it into the scenario of the doctor-patient relationship as a tool that facilitates diagnosis and treatment [15]. Empathy has to do with deeply understanding the other and is a path to bridge scientific knowledge with compassion for better caring.

Empathy, one of the most studied humanistic attitudes today, is the cornerstone of ethical and humanized behavior and medical professionalism. Empathy has also been considered an essential element in any humanization strategy [16]. It is a personal quality necessary for understanding the inner experiences and feelings of patients. It represents the essence of the doctor-patient relationship. Developing meaningful interpersonal relationships between patients and physicians is important even for improving clinical outcomes [17].

Before entering the concept of empathy in the context of the patient- physician relationship, it is worth pausing to understand the term from a philosophical point of view. In this field, we cannot fail to cite the work developed by Edith Stein (1891 – 1942), a philosopher who developed his doctoral thesis on empathy. Macintyre [18] in his book on the philosophical action of Edith Stein comments that an essential feature of empathic awareness is the awareness of the feelings of others. The relationship we have with the feelings of others is analogous to the relationship we have with our own past feelings. We may notice what the other

#### *Reflections in Medical Education: Empathy, Emotions, and Possible Pedagogical Resources… DOI: http://dx.doi.org/10.5772/intechopen.101832*

is feeling, but we do not have to feel the same as him/her. The same is true when we remember our own feelings - even clearly - does not mean that we will feel the same way we have in the past. A deep understanding, real understanding, but no need to incorporate it. We can fully understand what we feel on one occasion, but we do not have to feel it equally at this time.

It takes caution to state that "I am putting myself in another's shoes." Yes, it is possible to do so, but with our own patterns (our feelings, our reactivity, our understanding of vital reality, our own biographical history) and not his own, so that I cannot truly understand. It is not enough to put ourselves hypothetically in the other's place and continue to be ourselves experiencing this place in which I place myself. One must also be detached from one's own standards to arrive at empathic knowledge. Regarding this perspective, Stein reminds us that empathy is not simply intuition, but an attitude that requires reflection, to turn back and again on ourselves and others, a course that enriches one's own and others' knowledge. It is not a spasm of knowledge, but something worked.

In the context of medical education, the concept of empathy has a broad and varied spectrum. Some authors consider empathy to be a predominantly cognitive quality: it would encompass an understanding of the patient's experiences and concerns combined with communication skills [19]. Irving and Dickson [20] define it as an attitude that contemplates behavioral ability along with the cognitive and affective dimensions.

Most authors place empathy on the affective dimension, giving it the ability to experience the other person's experiences and feelings. In this case, it can be deduced that the ability to be empathic implies a spontaneous feeling of identification with the suffering person, a process in which emotion is involved.

Most of the authors with an affective-oriented approach presuppose that, during the empathic event, there is something that can be characterized as a partial identification of the observer with the observed. This aspect also becomes clear especially in Carl Rogers' definition, which describes empathy as being the ability "to sense the client's private world as if it were your own, but without losing the 'as if' quality". According to this definition, the differentiation between one's own experience and the experience of another is the decisive criterion for defining effective empathy [21].

It is necessary to distinguish empathy from sympathy [22] because this distinction, which is not just semantic, has important consequences in the doctor- patient relationship. The patient's emotions, which must be addressed, cannot become an obstacle to care. On the other hand, a sympathetic doctor may lack objectivity and professionalism. Empathy leads the physician to consider the quality of the patient's emotional experience, while simple solidarity focuses more on the intensity and quantity of suffering. Researchers conclude that empathy does not need limits, while sympathy does need to be moderated [23].

It is not easy to separate the emotional from the cognitive components that make up empathy. Even so, two conclusions can be drawn from this difficult navigation in the definitions and components of empathy. The first is that an excessive preoccupation with oneself (of the subject who intends to act empathically) is an obstacle to helping others [24]. It is necessary to detach from the image itself to understand the other and understand him as "another me". The second conclusion is that empathy could be an element of this necessary bridge to unite evidence-based medicine with patient-centered medicine. A personalization resource with broad diagnostic and therapeutic potential.

The question that arises at this point is whether it is possible to teach empathy, and what would be the teaching-learning process of this attitude [25, 26].

#### **2.1 Teaching the non-teachable issues**

It is worth remembering a classic study [27] designed to help choose candidates for medical schools, which emphasizes that those who have the potential to be good doctors, and not simply good students, should be chosen. In this way, 87 characteristics of a good doctor were classified, and classified according to the importance and ease of teaching-developing this characteristic. In this way, what the authors call the NTII was arrived at, an index that combines these two variables.

Thus, important and necessary characteristics for an excellent doctor are pointed out, which are very difficult to teach in medical school, or in further training. At the top of the list -important and difficult to teach characteristics- appear factors related to empathy: understanding of people, concern for others, idealism and compassion, service capacity, ability to persevere in difficulties with resilience, learning to establish priorities in care. All of these factors are important, but very difficult to teach - at least with the resources employed today in medical education.

Some neurophysiological studies provide some clues [28, 29] to resolve the dilemma of how to teach something that is difficult to teach. This is the case of empathy that can be fostered through examples. The so-called mirror neurons in the brain are involved in certain actions related to behavior and emotions. Contemplating another's attitudes, mirror neurons somehow evoke those same attitudes and emotions [30]. It is the simple case of children who, without having a clear perception of their own emotions, end up mirroring the emotions they contemplate in their parents. In this way, the example -of the teacher, the doctor preceptor- is a resource to provoke empathy in the student. Something is known, but now it has a neurophysiological basis [31, 32]. The mechanism of functioning of mirror neurons can be considered a prerequisite for empathy [33].

Several questions arise here: would not "imitated" empathy be something artificial that the patient perceives as such? Wouldn't this attitude end up being summarized in a checklist of routines that a physician must follow to build an empathetic attitude? The student's own experiences -which are even more powerful than a simple example- would be a condition for growing in empathy. In other words: is it necessary for a physician to go through personal and family suffering to be empathetic with the patient's suffering?

The experiences and biographical experiences are an important resource in medical education, when well used. Also, the example that promotes reflection and the construction of attitudes. Thus, establishing an educational setting where examples and experiences have space to be assimilated through reflection and facilitated discussion, seems to be a favorable resource to foster empathy. This model, which is classic -seeing doing, seeing acting, incorporating the example- is what is called Tag Along. A resource that has always been used, and that now, with modern communication tools, runs the risk of falling into oblivion. It must be rescued with a modern perspective. Along with this example-learning model, the experiences can be amplified through the arts. Humanistic education, cultural foundation, is necessary to promote those characteristics difficult to teach by traditional pedagogical methods. Literature, poetry, music, cinema bring resources that evoke experiences in students and allow for reflection [34].

Beside tag-alongs, some authors emphasize the importance of art, literature, cinema and reflecting over one's own life in developing empathy [35]. To give an example, it is worth quoting a literary classic about a rural doctor, (A Fortunate Man) [36] where empathy is magnificently described under the name of recognition: "The task of the doctor is to recognize the man. (..) I am fully aware that I am here using the word recognition to cover whole complicated techniques of psychotherapy, but essentially these techniques are precisely tools for furthering the

#### *Reflections in Medical Education: Empathy, Emotions, and Possible Pedagogical Resources… DOI: http://dx.doi.org/10.5772/intechopen.101832*

process of recognition. (..) To treat the illness fully, the doctor must first recognize the patient as a person. Good general diagnosticians are rare, not because most doctors lack medical knowledge, but because most are incapable of taking in all the possible relevant facts – emotional, historical, environmental as well as physical. They are searching for specific conditions instead of the truth about a patient which may then suggest various conditions. (..) A good doctor is acknowledged because he meets the deep but unformulated expectation of the sick for a sense of fraternity. He recognizes them. Sometimes he fails, but there is about him the constant will of a man trying to recognize".

Role modeling, giving the right example to follow, caring carefully for the emotional dimension of medical students and for that using arts and humanities are possible resources for preventing the erosion of empathy. Because, at the end, is not just about to teach how to be empathetic -people that enter in a medical school already have quite a degree of empathy- but, mainly, to prevent of losing empathy through the so-called educational process that in many cases lacks this perspective [37, 38].

While teaching ethics requires establishing rules, guidelines and rational decisions, creativity and recognizing the role that emotions play in decision-making are also required. The educator has, therefore, to go beyond protocols and to have the creativity for bringing together objective guidelines, prudence, and wisdom, as well as incorporating the affective dimension. It is not possible to ignore emotions because they get involved in the decisions that ethical dilemmas imply. Furthermore emotions, when properly handled, become an essential tool. Therefore, opening space to share emotions in an environment with pedagogical support is to pave the way for a true education of affectivity that will transform into better patient care [39, 40].

Fostering reflection is a permanent objective for educators who intend to go beyond the simple transmission of knowledge. Creating favorable environments for joint reflection allows us to get to know the students better, personalize teaching by adapting it to each one, and implement the pedagogical excellence that knows how to unite intellectual creation with the art of teaching. Art is necessary for dealing with the student's unexpected questions. The humanities help to polish this artistic dimension of medical education [41].

## **3. Why do we need humanities for educating patient-centered doctors?**

#### **3.1 Humanities in medical education: from emotions to ethical attitudes**

To care implies comprehending the human being and the human condition and for this endeavor, humanities and arts help in building a humanistic perspective of doctoring. Humanities must be included in medical education, not as a simple appendix or a dilettantism, but with the same emphasis as teaching internal medicine, differential diagnosis, or complex case discussions. They are a tool that educates physicians, understanding the patient as a whole -as the person's own unitto provide the best care for that specific patient [42].

A doctor without humanism would be nothing more than a mechanic of people. To provide effective care, it is essential to incorporate the human dimension into medical practice [43]. This is the role of the humanities that bring the necessary balance to the reductionism related to positive science. Approaching the patient only with "technical objectives" resources will possibly lead to inefficiency in care. Technical progress requires constructing a new, modern, updated medical humanism to provide the necessary balance [44].

When incorporated into medical education, the arts and humanities allow us to approach human emotions, both patient and physician. The humanities make us

think about the human being, about illness, about terminality, about transcendence. They lead us to reflect on the attitudes necessary to build professionalism and ethics in medical practice. The wide variety of issues raised with pieces of art, film clips, songs, and music, intuitively help in the decision that involves complex moral choices. As a well-known researcher put it, "the humanities are like the midwife who helps in the birth of human experience, with its mysteries and its certainties". When cinema, poetry, music is used, student's emotions arise easily, and teachers can take advantage of this scenario to broaden perspectives and educate affectivity. The characters that appear in the performing arts, and the values they carry, impact as an example, they are a learning path. Being attentive to the awakening of emotions in students is an expression of affection and love from the teacher, which strengthens learning more than a theoretical model [45].

Typically, students' emotions precede concept construction. Affective intuition precedes emotion. First, the heart gets involved, then the rational process helps to build learning. This is the normal path, in medical education and in life, to assimilate sustainable concepts and values. But this does not mean that teaching should be limited to simple emotions [46]. Students, who are usually immersed in a culture where feelings and visual impact prevail, awaken to learning that, later, will be solidly leveraged, through the necessary reflection. Emotions are thus the gateway to learning processes, a shortcut, a runway for higher educational flights [47].

The arts and humanities, impregnated with narratives, arouse emotions, and prepare the ground for the transmission of concepts. Using students' empathetic language, moving in the familiar terrain of the emotions that the student feels, acts as a facilitator that allows to provoke reflection and suggest attitudes. The teacher's role is that of a catalyst for the process that takes the student from emotions, through reflection, to incorporate attitudes and values.

The teacher's role is to identify emotions and then stimulate reflection. Based on this experience of reflected emotion, it is possible to generate attitudes that modulate behavior [48]. Through an environment that allows for reflection, the development of qualities that will enrich personal development becomes possible.

On the other hand, teachers also use emotions - although little time and space are left to discuss them. When this reflective environment is provided among teachers -a faculty development scenario-, joint reflection leads to improving teaching methods and understanding with the students themselves [49]. Teacher meetings are often monopolized by addressing problems, and problematic students. Little time remains to reflect and help each other, and thus build resources for better teaching performance. Here, too, the medical humanities are an effective resource. After all, any process that aims to humanize medical education must include reflection at all levels, both among professors and students, in addition to facilitating the environment and making time for this reflection to be regular and fruitful [50].

#### **3.2 Narrative medicine: reloading a millenary resource for caring**

A predominantly biomedical focus attributed to teaching and practice in health sciences contributes to a dehumanization process. Any strategy that intends to address the issue depends on the presence of well-educated health professionals from both the technical and humanistic points of view. The greatest deficits concern humanistic education. Research about the effectiveness of using narratives as a didactic resource in humanistic education points out issues related to the concealed curriculum and the importance of medical students' exposure to a patient-centered teaching model that gives priority to ethical reflections [51].

#### *Reflections in Medical Education: Empathy, Emotions, and Possible Pedagogical Resources… DOI: http://dx.doi.org/10.5772/intechopen.101832*

It is true that narratives are an important educational topic in the context of Medicine. Narrations, life stories, allow us to contemplate the patient's world, meet him as a person, so that we can take care of him in a competent manner. There is also a tendency to think that the narrations are just a complement to positive science, which is not possible to measure with laboratory results. Thus, it would be just a methodology that broadens a way of aiming to reach out to the person, and focus on her care, without deterring the illness that affects her. That perspective takes the risk of being "complementary", that is, the soft edge of what really matters. The dissociation between science and art remains, as two forces that act synergistically, but in parallel, and therefore never found themselves. The medical action that would fall would be condemned to these complementary positions, in which competency and compassion never meet.

Medicine as Art recognizes that each patient is unique. Not only from the perspective of the disease that attacks him/her, but in the way that pathology "becomes incarnate and concretized": this is an illness, being sick [52]. The disease is always personalized, installed in someone who will become sick "in their own way", according to their personal being. A bifocal perspective is necessary, which manages to unite in artistic symbiosis the attention to the disease - with all the technical evolution - and to the patient who feels sick – with the vital understanding that entails. This is a person-centered medical performance, simultaneous exercise of science and art [53].

Listening carefully is a skill that the doctor needs to heal [54]. This requires the rescue of the ancient resources of medical art [55]. Patients show subtle clues about their experience with the condition, but doctors often ignore them because we hear only "the voice of medicine" and have trained us to ignore the emotional side, that is, the "voice of the patient's life." [56].

Already in the middle of the twentieth century, Gregorio Marañón [11]– paradigm of art and science – warned of the danger of using purely technical tools without knowing the patient, without listening carefully, without really caring about him: "It must be admitted that ordinary medicine is usually reduced, or to problems that are easy to solve, or completely insoluble for the most gifted man of wisdom. The fundamental thing in any case is that the doctor be with his five senses in what he is, and not thinking about other things." When the doctor sits and listens to the patient, he is communicating a humanistic attitude for excellence. Today we have sophisticated technology - important - but we are losing the pleasure of sitting down and hearing narratives of life. We lack chairs or, perhaps, patience to sit and listen.

A well-known researcher in medical humanities quotes: "we are midwifing a medicine that makes contact with the mysteries of human experience along with its certainties—a medicine that appreciates the deep beauty of health, the silence of health, the wisdom of the body, and the grace of its genius. It is an arch to far times and places, a site for all the living and the dying that go on; it is a link to what it means to be human" [57].

Teaching through humanities includes several modalities in which art is involved [58]. Literature and theater [59], poetry [60], opera [61] are all useful tools when the goal is to promote learner reflection and construct what has been called the professional philosophic exercise [62]. Teaching with movies is also an innovative method for promoting the sort of engaged learning that education requires today [63, 64]. For dealing with emotions and attitudes, while promoting reflection, life stories derived from movies fit well with the learners' context and expectations. Teaching with films engages the emotions and could serve as a great launching point for discussions of both the emotions and ethical scenarios [65–67]. The crucial role

of teaching is to help frame these discussions in such a way as to foster reflective practice among clinicians and clinicians-in-training.
