Word of the Issue: Sonder A Discussion of its Power in Medical Practice

Daniella Baruch

Sitting for hours in an awkwardly placed chair watching consultations, or loitering behind single-minded registrars on ward-rounds, a medical student can’t help but notice a few strange things about the way doctors behave towards their patients. I should preface the following article with the disclaimer that I do not, in any way, intend to generalise about, or pass moral judgement on all doctors, nor am I in the position to - this is solely my perspective on some patterns I’ve observed during the first few months of my clinical years, in some, though of course not all, medical professionals. What I began to notice in the clinical environment was a disconcerting - albeit some might argue understandable - sense of indifference, verging on dismissiveness, towards patients: whether it be snide comments as anxious mothers left appointments, a lack of concern at the distress of those undergoing painful procedures, or something seemingly as innocent as the glossing over of concerns regarding medication. 

These experiences brought to mind a word that I have always loved, which I felt epitomised what appeared missing from these clinical environments: sonder. Sonder is a term coined by US Writer John Koenig in his blog The Dictionary of Obscure Sorrows; the Dictionary aims to fill gaps in our linguistic expression of emotion, defining hundreds of experiences we may all feel, but (at least in the English language) do not yet have a word to describe. Sonder, put simply, describes the feeling of realising that everyone - from family and friends to acquaintances and strangers - has a life as intricate and complicated as your own, in which you, the hero of your own story, might only appear as a supporting cast member, or even as an extra. 

Described more eloquently by Koenig, it is the realisation that “each random passerby is living a life as vivid and complex as your own - populated with their own ambitions, friends, routines, worries and inherited craziness - an epic story that continues invisibly around you like an anthill sprawling deep underground, with elaborate passageways to thousands of other lives that you'll never know existed, in which you might appear only once, as an extra sipping coffee in the background, as a blur of traffic passing on the highway, as a lighted window at dusk” (1) (scan the adjacent QR code for an interesting 2 minute video explanation). 

As medical students and, in the future, as doctors, we are left in a tricky position when considering this concept. We have the burden and privilege of accompanying people at critical junctures in their lives, whether it be informing them of a cancer diagnosis, or as the first to be confided in about worsening depression. We are, or will be, to many patients, more than simply an extra, but a crucial cast member. On the other hand, to the seasoned doctor, the 500th presentation of chronic kidney disease one sees might, again, understandably, seem like little more than a case to examine, a task to complete, and an extra amongst thousands of other ‘cast members’. This imbalance, I believe, is at the heart of the disconnect that seems to occur so often between doctor and patient. What to doctors is just another day at work is, to patients, the shattering of ambitions we cannot know, the disruption of routines we do not depend on, and the loss of family members we have not loved. 

Of course, it would not be possible for any single human being to contemplate this all at once, for every patient one sees. Studies show that while empathic communication with patients is critical to providing effective care, excess empathy and over-identification with patient experiences also increases susceptibility to compassion fatigue and professional emotional exhaustion (2). Some have argued that the decline of empathy in medical students and doctors throughout training serves as a coping mechanism for extreme emotional arousal in the face of continuous patient distress and professional burnout (2); one neuroscientific study from 2013 even demonstrated that the brains of doctors show a reduced empathic response to witnessing distress compared to controls (3).

But surely the current medical landscape, marked by reliance on objectivity and emotional detachment, cannot be the only way forward. Critics of this system rebuke it as one which overlooks the innately subjective and human aspects of disease: its psychological, social, and moral dimensions (4). This “dehumanised” approach has been argued to diminish the quality of care patients receive, with practitioners working under such a paradigm expressing a narrow commitment to "eradicate disease”, over a sincere holistic interest in “providing care” (4, p.574).  

One middle ground approach might include practicing something called clinical empathy; clinical empathy involves correctly acknowledging and responding to the emotional state and perspective of another without fully experiencing that state oneself (5-6). Critically, clinical empathy differs from emotional empathy in that it does not involve wholly sharing in a patient’s distress, which might lead to practitioner burnout, but places emphasis on a patient feeling seen and heard alongside a clear focus on their health outcomes (6, 8). It encompasses, firstly, a concerted attempt to understand what a patient is saying and feeling by consciously putting oneself in a patient's shoes; secondly, communicating this understanding to the patient e.g. through words or actions; and thirdly, acting on that understanding through an intention to help said patient (6-7). This might involve something as simple as acknowledging a patient’s fears regarding a procedure or medication, and subsequently reassuring them with clear, comforting language. Other common features of clinical empathy include active listening, maintaining eye contact, an open stance, and warm tone of voice (9). Tones of voice conveying warmth and concern for patient wellbeing have even been correlated with reduced instances of litigation against doctors (9). 

Crucially, studies have shown that practicing clinical empathy brings significant benefits to both patients and healthcare practitioners (4). Amongst patients, clinical empathy is associated with improved therapeutic outcomes, greater well-being, shorter hospitalisation stays, and increased treatment compliance (4). Health outcomes in chronic health conditions like diabetes, which often require major lifestyle changes and regular patient monitoring, show particular improvement with greater clinical empathy from clinicians (4). One study from 2011 found that patients of physicians with high empathy scores were significantly more likely to have good control of Hb A1c (56%) (an indicator of blood sugar levels) than patients of physicians with low empathy scores (40%) (10). Amongst healthcare practitioners, clinical empathy is associated with greater well-being and job satisfaction, alongside a decrease in stress levels, malpractice claims and patient litigation (4). The advantages of clinical empathy, to both doctor and patient, are abundantly clear. 

Ultimately, in practicing clinical empathy, and thus consciously acknowledging patients’ subjective experience of illness, it may become feasible to apply the concept of sonder to everyday medical practice. This in turn has the potential to redress the disconnect that exists between doctor and patient, without perpetuating professional emotional exhaustion. 

Utilising the principles of clinical empathy, a nephrologist’s 500th case of chronic kidney disease might simultaneously be understood as a patient’s first experience of long-term illness, a total upturning of the routines around which their lives are built, and the dashing of countless hopes for the future. 

The recognition underlying this shift in perspective: that everyone has a story as intricate, vibrant and deserving of attention as our own, is as immensely powerful as it is overlooked. Sonder, therefore, is a concept which, applied in moderation, has the potential to make us into better doctors, and human beings.

Sonder (accessed with QR code, near beginning of article):

https://www.youtube.com/watch?v=AkoML0_FiV4&ab_channel=DictionaryofObscureSorrows 

References (accessed with QR Code): 

1. Koenig J. Sonder [Internet]. Dictionary of Obscure Sorrows. 2019 [cited 2024 Dec 1]. Available from: https://www.dictionaryofobscuresorrows.com/post/23536922667/sonder
2. Samra R. Empathy and burnout in medicine—acknowledging risks and opportunities. J Gen Intern Med. 2018 Apr 16;33(7):991-3. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6025677/
3. Gleichgerrcht E, Decety J. Empathy in clinical practice: how individual dispositions, gender, and experience moderate empathic concern, burnout, and emotional distress in physicians. PLoS One. 2013 Apr 19;8(4):e61514. Available from: https://pubmed.ncbi.nlm.nih.gov/23620760/
4. Guidi C, Traversa C. Empathy in patient care: from “clinical empathy” to “empathic concern.” Med Health Care Philos. 2021 Jul;24(4):573-85. Available from: https://link.springer.com/article/10.1007/s11019-021-09977-6
5. Halpern J. What is clinical empathy? J Gen Intern Med. 2003 Aug;18(8):670-4. Available from: https://doi.org/10.1046/j.1525-1497.2003.20856.x
6. Hojat M, Maio V, Pohl CA, Gonnella JS. Clinical empathy: definition, measurement, correlates, group differences, erosion, enhancement, and healthcare outcomes. Discover Health Syst. 2023 Feb 27;2(1):e100027. Available from: https://link.springer.com/article/10.1007/s44250-023-00020-2
7. Tan L, Le MK, Yu CC, Liaw SY, Tierney T, Ho YY, et al. Defining clinical empathy: a grounded theory approach from the perspective of healthcare workers and patients in a multicultural setting. BMJ Open. 2021 Sep;11(9):e051524. Available from: https://pubmed.ncbi.nlm.nih.gov/34521657/
8. Jain B. Top examples of showing empathy to patients [Internet]. Emitrr. 2024 [cited 2024 Dec 1]. Available from: https://emitrr.com/blog/examples-of-showing-empathy-to-patients/
9. Jayakrishnan B, Kesavadev J, Shrivastava A, Saboo B, Makkar BM. Evolving scope of clinical empathy in the current era of medical practice. Cureus. 2023 Jun 6;15(6):e35538. Available from: https://www.cureus.com/articles/119354-evolving-scope-of-clinical-empathy-in-the-current-era-of-medical-practice
10. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med. 2011 Mar;86(3):359-64. Available from: https://journals.lww.com/academicmedicine/Fulltext/2011/03000/Physicians_Empathy_and_Clinical_Outcomes_for.7.aspx