The practice of medicine is a moral endeavor, one that focuses intimately on the lives and well-being of others. Medical education has excelled at teaching the technical aspects of medicine. While the technical skills and empirical basis for medicine have grown, however, educators are particularly challenged to know how—and when—to address the moral aspects of medical practice. "Professionalism" or "humanistic aspects" might appear as a category on student evaluation forms while they learn interviewing skills or participate in clinical rotations. These general terms, however, give faculty and students little guidance about the behaviors the school strives to cultivate. Occasionally the humanistic attributes will be listed in greater detail: respect, compassion, or empathy. Taught without critical discussion of what specific behaviors are meant by these concepts, these too fall short of the goal for medical education.

Among these attributes, empathy has been the subject of two anthologies¹ and multiple articles,² literature proposing that empathic physicians are an ideal. Most critiques of empathy, however, argue that empathy is not an appropriate stance for physicians to take with patients.³ The critics question the therapeutic value of the physician identifying with the patient, arguing that it blurs objectivity. Proponents of empathy argue that teaching medical students empathy helps humanize medicine in important ways.

I agree that the education and practice of medicine do need significant humanizing. But I remain leery of relying on empathy in therapeutic relationships, albeit for different reasons than the usual critiques. This essay discusses specifically what is problematic about presuming an empathetic stance with patients. Consider an experience physician-poet Rafael Campo shared in his memoir, The Poetry of Healing:

Campo's response to his patients, with whom he was overidentifying, was to invoke the objective, distancing stance he had been taught in medical school. In his case, neither empathy nor objectivity could help establish therapeutic relationships with his patients. In fact, both empathy and objectivity seemed to be getting in the way.

As a learning objective within medical education, empathy has the potential to work against responsible care for patients. As educators and practitioners of medicine, we should articulate carefully the skills it takes to provide compassionate care for patients. One place to start is the work of theological scholar Martin Buber, who provides stories and theories of responsiveness and responsibility that may give medical educators more meaningful ground from which to work. This essay explores some common conceptions of empathy and outlines limitations of these views, then considers ways to guide medical students and faculty in developing a relational stance that is both valuable and necessary for an enriched healing relationship.

EMPATHY DEFINED
The most often quoted article on empathy comes from physician Howard Spiro. He defines empathy this way:

Carl Rogers, a psychotherapist, has also had a significant impact on the current understanding of empathy in clinical arenas. He takes Spiro's notion of empathy even farther:

Key features of these definitions are elucidated further in the following descriptions of five pitfalls of empathy.

TRIVIALIZATION OR "SO YOU FEEL SAD"
One approach to teaching empathy is to operationalize empathy in a way such that it becomes trivial. Medical education, which traditionally favors pedagogical approaches that can be broken down into lecture formats and multiple-choice tests, is particularly susceptible to this pitfall. Empathy begins to look something like: "Touch your patient on the arm; look them in the eye; and, if they stop talking, repeat the last word that they said to show you are listening and interested." Developing techniques that effectively foster connections with patients is important. But doing so without also developing a genuine interest in the resulting connection can lead to an empty charade. In an example from John Stewart and Milt Thomas' essay, this pitfall looks something like this:

Perhaps the most common hazard of teaching empathy, trivialization has arguably caused the most harm to the practice of it. Patients and physicians alike can feel the artificial and contrived nature of the actions. Both quickly grow fed up with the notion and abandon it.

DEVALUATION OR "THIS IS ICING"
Related to the pitfall of trivializing is the devaluing of empathy. On one hand, empathy is seen as the icing on the cake in a patient interaction. Technical competence is of foremost importance and any humanistic touch is nice but not necessary. The gendered nature of medical team roles contributes to this view of empathy; that is, the physician's role is to provide medical expertise and the nursing staff (traditionally female, and therefore, traditionally devalued) provides the care.⁸ This view pervades the discourse in medical education where time is at a premium and battles are waged daily for curricular space. As a human trait, empathy is expected to come naturally or not at all. And in a tight curriculum, attention to biochemistry is given priority over building character.

This pitfall is evident in the ways most schools teach physician-patient relationships. Explicit teaching often occurs, appropriately, in small groups with faculty volunteers. The strength of these groups is jeopardized, however, by lack of faculty training and the limited consideration of objectives or teaching strategies.⁹

These same faculty volunteers can contribute to the devaluing of empathy by engaging in "danger discourses." If the physician's primary duties are to be objective and technically proficient, empathic engagement with the patient is seen as a distraction. As one critic of teaching empathy, Richard Landau, frames the danger, "Encouraging physicians to cultivate empathy in their relations with patients will undermine their ability to function as wise, understanding doctors who give of themselves in guiding patients through life's concerns."¹⁰ To be empathic, in this view, is to lose oneself in the patient's experience of illness. Indeed, we see this suggested in both of the traditional definitions of empathy that began this critique. A false dichotomy is set up, professional distance pitted against empathic immersion. Technical roles are seen as separable from relational obligations.¹¹ If empathy is seen as secondary, or even harmful, to clinicians' primary duties, it is no wonder that it becomes difficult for students and faculty to take up the practice.

IDENTIFICATION OR "I AM YOU"
But is empathy as identification with patients even possible? Can one ever set oneself aside, as Rogers' definition of empathy suggests, when interacting with another? Clearly not. We always understand the world and those we meet through our own horizons.¹² I presume Spiro and Rogers also know this to be an impossible task. They are asking physicians to act as if they are setting themselves aside when they enter the experience of another. But is this a desirable stance to take toward another, particularly within a medical relationship?

Entering a relationship with the aim of identifying with another's experience provides a replicative, not a productive, focus. By engaging in this way, we are trying to know the other in order to develop further insight into the patient's illness. This approach conceives of the other (the patient) as a knowable source that can be mined for information and the self (the physician) as a clean, reflective slate. It takes attention off the self (the physician)—where awareness and responsibility must reside—and fixes it on the other, who can be known only partially.¹³ This approach also effectively turns a dialogue into a monologue by focusing on only one of the selves engaged in the relation.

Identification with the other can cause trouble when a person encounters others positioned very differently from oneself. For example, I often identify with stories of struggle and disrespect told by people of color, since I am positioned as a woman working in a masculine field. However, to mistake my resonance with such stories as knowing the experience of, say, a black colleague is to miss his point entirely.¹⁴

EMOTIONAL ATTUNEMENT OR "I DON'T LIKE YOU, NOW WHAT?"
An understanding of empathy that involves emotional resonance, or "entering the private perceptual world of the other" as Rogers describes it, becomes problematic when we find we cannot, imaginatively or otherwise, enter the world of the other. Resonating with another is surely a real, felt experience. Many have felt sad in the face of another's sadness. But if emotional attunement is required for empathy, it is no wonder that students and faculty can have difficulty engaging it with strange, and occasionally repulsive, others. Those of us who care about humanistic practices between physicians and patients find in those moments the greatest need for engagement because the opposite is too frequently the case. But is empathy a help to clinicians here? Again, I would argue not. Rather than projecting oneself into the world of this difficult patient, setting aside any attendant shame, disgust, or anger that the clinician might feel, the clinician's attention should perhaps again turn inward. Rather than "hid[ing] the effects of prejudice,"¹⁵—arguably what one is doing when losing sight of oneself in the relationship—one could ask all sorts of questions: What button of mine is this patient pushing? Why am I so frustrated in his presence? What am I bringing to this relationship that is making our interaction so much more difficult?

While one cannot know the experience of the patient, and it would be hopelessly unhelpful to act as if one did, what the clinician can and should attend to is her own role in the relationship. Skills such as self-awareness and dialogue can facilitate, or even initiate, the healing process.

DOMINATION OR "I KNOW JUST HOW YOU FEEL"
To approach another as knowable, or to act as if one has entered another's experience, can be a very dominating stance. This pitfall stems from the problematic ownership of another's experience that is implied in most conceptions of empathy. If the aim of engaging empathically is to know the other, what are the costs of getting it wrong? It is unlikely that a physician, a relative stranger and one with limited knowledge of this patient's life, will get it right much of the time. The dangers here follow from holding a person to too tight a script.¹⁶ Identifying with another effectively limits them to our (limited) understanding.

Rather than remaining open to the "real of the other,"¹⁷ the clinician with empathy co-opts the patient's experience by saying blithely, "Oh, I know just how you feel." And again, to what effect? Patients, perhaps feeling misunderstood and alienated, build walls between themselves and their well-meaning physicians. Physicians, encountering a difficult patient, become frustrated.

ALTERNATIVES TO EMPATHY
When teaching and practicing humanistic medicine, it is crucial to get it right. I have enumerated the pitfalls and attendant hazards of getting empathy wrong. And yet, medicine is a relational practice, one that occurs between and about people. Many of the excellent essays that are included in the anthologies on empathy could actually be collected under a very different title. Julia Connelly, for example, talks about listening to, and hearing, her patients. Rita Charon writes compellingly about narrative curiosity. Lucy Candib surfaces the importance of empowerment and mutuality.¹⁸

This complex territory is the area medical educators should mine for inspiration regarding ways to humanize medicine. The conceptual umbrella under which I would group these approaches would not be empathy. It would be professional responsibility.

BUBER'S ALTERNATIVE: I-THOU
Underlying the pitfalls of empathy offered above is the idea that to approach another as knowable is to have what Martin Buber would call a mismeeting.¹⁹ The quality of these closed-ended encounters is quite different from an open-ended one. Unlike the technical aspects of medicine, the moral aspects of medicine require a more open-ended approach. Conceptions of empathy that ask the clinician to set aside his or her self in the encounter effectively create a monologic meeting. What stance requires both persons to be present in the relationship? Both persons are crucial to the relational stance Buber describes: "[The] meaning of the conversations is to be found neither in one of the two partners nor in both together, but only in their dialogue itself, in this 'between' which they live together."²⁰

Buber's philosophical anthropology begins with the claim that our human reality is relational.²¹ The quality of these relationships, however, is variable. The self who we are in these relations changes. We have a "two-fold orientation," by which he means we have the capacity for relationships along a continuum anchored by two points, the "I-It" and the "I-Thou." The "I" in an "I-It" relation is closed, experiencing, but not participating in, the world.

One needn't look far for examples of these sorts of relationships in the medical school. A classic example would be the lecturer in the lecture hall, delivering his talk without regard to the students in attendance. The self of the lecturer, the "I" in this case, is static and not responsive to the world around him. Heading down the hall, we might see the students dissecting in the anatomy lab, seemingly participating in a one-way exchange. Looking into the teaching clinic, a specialist confirms a diagnosis of chronic obstructive pulmonary disease, her 10,000th case—or so it seems. This pulmonologist has ceased to experience her work as new and fresh. Even her phrases of empathy have been rehearsed many times over and she cannot say that she actually feels anything for this patient. It is such a routine case for her that perhaps in her mind she makes the grocery list or replays the fight she had with her partner that morning.

"I-It" relationships are instrumental in that the persons involved accomplish a task or an exchange, but it matters little who the person is delivering the service or being served. For example, in checking out at the grocery store, the transaction can take place with little genuine human contact. Buber did not intend to judge these relationships as less than "I-Thou" relationships. Indeed, they have their place in our day-to-day functioning. Buber directs us to notice that the quality of the self, the "I," changes depending on the sort of relationship one is participating in. The "I" of the "I-It" does not engage with the other as a person. More important, if people lack connection, they can do serious harms to one another (e.g., warring nations). Said another way, there are relationships that enhance us and those that diminish us.²² Perhaps there are also relationships with others that neither provide growth nor diminish us, relationships that leave us simply unchanged. One might imagine a life comprised of relationships that are diminishing or neutral, but it is difficult to imagine flourishing in such a life.

There is another sort of self and relationship possible in Buber's world that does promote human flourishing. This is the "I-Thou" relation. The self in these relations is different from the self, the "I," of the "I-It" relations. The "I" of an "I-Thou" relation is open and there is a reciprocal exchange with the world.²³ As Buber describes, "The basic word 'I-Thou' can only be spoken with one's whole being. The basic word 'I-It' can never be spoken with one's whole being."²⁴ This quality of relationship can also be found in the medical school, though it requires more careful attention. Students meeting in small groups with the same facilitators throughout the year bring their concerns and fears and are heard. A preceptor in a community clinic engages with Hispanic patients in the appropriate Spanish dialect, while a student admires the instructor's skill and sensitivity. An oncologist creates the space to talk about the experience of dying with his patients, then makes a point of reflecting with his team about the importance of such moments for good patient care.

Buber's relational stance of "I-Thou," in which people can "become," is crucial to professional responsibility. There is openness in this movement of turning toward that invokes the responsive feature of therapeutic relationships. To maintain this moral stance, the clinician makes a shift: "This man is not my object; I have got to do with him."²⁵ If a clinician approaches the therapeutic relationship with the aim of engaging, the clinician would still have her attendant emotional responses, some resonant and others not, and would maintain the flexibility to get it wrong as she allowed the patient and herself to become within the space of the relationship.

A more helpful conception of empathy (or relational practice) remains fluid and responsive, resisting the trivialization of an oversimplified checklist. It is possible that empathy, or resonance with another, should serve only as a beginning—a spark of curiosity, a desire to understand—rather than an end.²⁶ Professional responsibility, on the other hand, fosters therapeutic relationships while drawing on the skills of responsiveness and attention that physicians employ when practicing clinical judgment. If this notion of professional responsibility were to guide Campo in the case that began this essay, he might have asked, "What is going on?"²⁷ In asking this, Campo might have recognized how his self-loathing was coloring his encounters with patients. He needed to turn toward his patients instead of away from them. Eventually, this is what Campo does. He learns his best lessons about the human face of medicine from his patients. For Campo, writing becomes the outlet through which he can do the self-reflective work necessary to meet his patients once again as a whole person himself.²⁸

CONCLUSION
While one could take much more time to build an argument for the importance of relationships in healing, suffice it to say here that attending to relationships merits our consideration. The traditional principles that form the backbone of medical ethics—beneficence, respect for persons, and justice—cannot be effectively enacted without attending to how we are with one another. Obligations to "advance interests," "respect persons," and "do justice" all require some meeting with the patient. It follows that we should attend to relationships within the medical school since relational skills and stances are learned in relation with others.²⁹ If the medical school truly values empathy and the physician-patient relationship, it would do well to teach explicitly and model a relational stance that addresses the pitfalls outlined above.

Empathy is frequently invoked in medical education discourses, yet it is little understood and all too often carelessly taught. Significant pitfalls exist within the current rubric of empathy: trivialization, domination, and loss of attention to the physician's self. Medical educators should develop a robust notion of empathy that is responsive to these critiques. This is the challenge presented by the need to meet, to find understanding between familiar and strange, between self and other. Within medicine, there is an obligation to attend to this meeting. Rather than being forced to make distinctions between "empathy at its best" and "bad empathy,"³⁰ what is needed is a shift to a new metaphor, stance, and practice.

There are significant implications for medical education when one shifts from empathy to an alternate relational stance such as professional responsibility. Clinicians begin to attend to being present, rather than trying to identify with patients. Clinicians and teachers alike can strive for open understanding rather than closed knowledge. Pedagogical strategies shift to cultivating responsiveness, imagination, respect, and self-awareness. These integral pieces of competent professional practice are skills and behaviors that can be taught, modeled, and cultivated to become habits. It is in this relational space that I find hope for effectively teaching useful approaches to physician-patient relationships.

ACKNOWLEDGMENTS
A version of this paper was presented at the American Society for Bioethics and Humanities Annual Meeting in Philadelphia, October 30, 1999. My sincere thanks to my colleagues in the Social Foundations Colloquium at the University of Washington for their critique and support. The reviewers at Second Opinion were most helpful in moving this paper forward.

NOTES
1. Howard M. Spiro et al., eds., Empathy and the Practice of Medicine (New Haven: Yale University Press, 1993); Ellen Singer More and Maureen A. Milligan, eds., The Empathic Practitioner: Empathy, Gender, and Medicine (New Brunswick, New Jersey: Rutgers University Press, 1994).