Mirror neurons and the need for slow medicine

How long does it take for a silence to become uncomfortable? 5 seconds? 20 seconds? A minute? Students of education are taught to give a child roughly 20 seconds to answer a question posed to him. How long do teachers actually give? About 5 seconds, if that. Now sit there and count out 20 Mississippis and see what an astonishingly long time it seems. Why, what if a web page takes that long to load on your browser? This becomes a major technological tragedy for most of us. The point is that 20 seconds is a longer time than we appreciate.

Now, let's talk about empathy. Yes, empathy. This seeming non-sequitur has a solid connection. How do we like to experience empathy? Silent attentive listening is a great example of empathic engagement. When we talk with out friends about emotionally charged topics, we do not want them to respond with "yeah, yeah", and move on rapidly to the next topic, do we? So, empathy takes time and engagement. And when 20 seconds of silence seems like a long time, imagine it in a doctor's office, following a hard revelation or an emotional response by the patient. Can you? Are you counting the Mississippis?

Well, it is no wonder that doctors miss opportunities to express empathy to their patients. In a study from Canada, where oncologists were recorded during patient encounters, these doctors seized fewer than 1 in 4 opportunities to respond to their patients with empathy; the other 3 chances they squandered on discussing clinical information. And this is a pity, as is rightfully acknowledged by the investigator quoted in the article. His conjecture for why docs miss these opportunities to be empathic has to do with their apparently erroneous idea that it takes too much time, and his guidance is the following:

Showing empathy does not mean a doctor has to feel what his or her patient is feeling, Buckman says. Rather, it means acknowledging patients’ fears and other emotions.

“It is perfectly OK for the doctor to remain detached, but it is not OK to talk detached,” he says. “Acknowledging what a patient is feeling is not the same as feeling it yourself.”

Well, I have to respectfully disagree. Here is the meaning of the word "empathy" from the trusted Merriam-Webster dictionary:

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 explicitmanner; also : the capacity for this

And in fact, looking to brain science to guide us on how we are wired to accomplish this, we realize that by definition empathy implies non-detachment, and, in fact, involves feeling what the other is feeling. Empathy is mediated by the so-called mirror neurons, residing in the cingulate gyrus of the brain. The great neurobiologist VS Ramachandran thinks that the discovery of these neurons is to the study of human behavior what the discovery of DNA was to biology. It has been said that mirror neurons help "dissolve the 'self vs. other' barrier." It is these neurons that make us feel others' pain, literally and figuratively. So, putting ourselves in the other person's shoes and "feeling what the patient is feeling" is truly the sine qua non of empathy.

So, if the docs' intuition is correct, and empathy does mean non-detachment and time (after all 20 seconds represents 3% of a 10-minute appointment), how does the medical profession go about relishing and leveraging the other 3 opportunities for empathy instead of throwing them away? I agree with the point of the article that medical students should be taught empathic communication. At the same time, we learn by example, and if harried mentors continue to skirt these issues in the office because they are running two hours behind schedule already, the students will get the point loud and clear. The bigger issue is the incredible shrinking appointment, which is not only likely driving up healthcare costs and the frequency and intensity of testing, with its attendant adverse events, but is eroding the opportunity for a meaningful therapeutic relationship. After all, if the doctor herself provides a therapeutic benefit, is this not of utmost importance?

In short, this is another argument for slow medicine, an argument that should not be weakened by the detachment reasoning. My guess is that it is our biologic imperative as humans to exercise our mirror neurons avidly and often, and being forced to blunt their firing may be yet another path to demoralization. And is the medical profession not already demoralized enough?  

Unidirectional skepticism

I thought I had coined that phrase. I have used it to refer to our tendency to examine ideas that are not aligned with our views of reality with less rigor than those that confirm it. It turns out that I am not the first to notice this phenomenon. In this Harper's article, Gary Greenberg uses the following quote from Mario Beauregard, a neuroscientist at the University of Montreal, writing about the seat of the "self":

The culture of popular science is one of unidirectional skepticism... It is skeptical of any idea that spirituality corresponds to something outside ourselves, but surprisingly gullible about any reductionist explanation for it.

Still, I think that my use of the term is somewhat broader, not simply alluding to the popular science, but also to professional science, and not only to the neurobiology of self. This idea goes hand in hand with the cognitive biases we are subject to.

This has got me thinking about a couple of things. Now, I am a big fan of neurobiology and the burgeoning field of research that it represents. We understand what goes on in the brain so much better now at the molecular level than we did, say, even 20 years ago. But what I am struck by is the comfort that this knowledge gives us about ideas of human behavior we had understood with lesser granularity in the prior era. For example, all parents have appreciated for millennia that teenage behavior is characterized by disinhibition of the higher self, if you will. Now we can say this in scientific lingo, that the area of the prefrontal cortex responsible for executive function lags in development behind other areas of the brain, as demonstrated in fMRI studies. Or how about the evidence from advanced neuroimaging that doing stuff that benefits our community lights up areas that correspond to happiness? We knew this before, only not in these words: we just had an idea that being a part of a community made us feel good. And those of us who subscribe to evolution can even come up with an explanation for why we should have developed this way.

Yet, aside from just gaining fascinating knowledge, we derive an odd sense of satisfaction from having our prior ideas, arrived through experience, observation and philosophical ruminations, confirmed by what we consider to be a more bona fide technique of science. The corollary to this is that, because we are so committed to the scientific method above all other possible ways of knowing, we may also be all too willing to discard rapidly closely-held notions that are not supported by science. But since science is ever-evolving and rather imprecise, in some areas more so than in others, are we always justified in such  prompt disposal of prior beliefs?

In the clinical world we often cite examples of when our intuition was wrong about some disease or another, and only after doing well controlled research studies were we able to arrive at the real understanding of the situation. But how often is it just our willingness to yield to what we think is scientifically sound at the moment? Is it possible that this unidirectional skepticism fueled by the cognitive bias in favor of new science, may not turn out to be the most efficient way to accumulate knowledge?

I do not know the answer to this question, as I am as guilty as my peers of falling in love with new scientific knowledge. But I also enjoy thinking about the nature of knowledge in general, and the many different ways of knowing. Are the materialism of science and other epistemologies mutually exclusive? I hope not.