Empathy Training as a Tool to Improve Medical Outcomes

After he was diagnosed with pemphigus vulgaris in 2004, Paul Konowitz, MD, lost 25 pounds, was out of work for 16 months and developed depression and a dependency on painkillers. He also received very different reactions from the 10 doctors who treated him. “I had some experiences that were totally unempathetic [with] people who I never got the feeling understood what I was going through,” he said. Leaving his oncologist’s office one day, a physician offered him a slice of pizza, which he could not eat because of the severe sores in his mouth. When he had strong abdominal pain, his gastroenterologist neglected to call him back at first with biopsy results; when he finally did call, “it was clear he did not care,” Dr. Konowitz said.

Armed with firsthand experience of the patient’s perspective, Dr. Konowitz, medical director for the South Suburban Center for Otolaryngology at Mass Eye and Ear Associates and clinical professor of otology and laryngology at Harvard Medical School, connected with Helen Riess, MD, creator of an empathy training program designed to teach physicians about the neurobiology and physiology of emotions. With Dr. Konowitz’s help, Dr. Riess later piloted her empathy training program with 11 otolaryngology residents at the Massachusetts Eye and Ear Infirmary (MEEI). After participating in three 90-minute sessions, the residents reported an increased ability to empathize with their patients (Otolaryngol Head Neck Surg. 2011;144:120-122).

Since then, more than 800 physicians across specialties have participated in the training, and with good reason: The benefits go beyond increasing doctors’ ability to empathize. Physicians who exhibit empathy also have patients who are more likely to adhere to treatment plans and have better medical outcomes.

Why Empathy Training for Otolaryngologists?

Otolaryngologists are increasingly serving patients with mental health issues. As of 2010, 1.5 million veterans had service-related auditory problems, making hearing loss and tinnitus the top two disabilities among veterans, according to the Department of Veterans Affairs. More recently, researchers at Yeshiva University found that young children with sleep apnea and other sleep-disordered breathing issues are more likely to be hyperactive and aggressive (Pediatrics. 2012;129(4):e857-e865).

Patients with conditions that require long-term follow up and care, such as head and neck cancers and chronic rhinosinusitis, also face emotional and physical challenges. “These conditions affect the way patients interact with the outside world by altering the way they eat, the way they speak, the way they look,” said Stacey Gray, MD, co-director of the Massachusetts Eye and Ear Sinus Center at MEEI. “This can have a profound effect on their quality of life.”

Otolaryngologists who specialize in pediatrics have to try to understand the feelings of their patients and their patients’ parents, who may get nervous about even minor procedures, said Dr. Konowitz. “We as doctors think of [some of these procedures] as something so simple. But understanding what a parent is going through is important. This is their child.”

Research shows that when these patients feel they have empathetic physicians, they also have better medical outcomes. In a 2011 study, 56 percent of diabetes patients who felt that they had empathetic primary caregivers were likely to have greater control over their blood sugar levels, compared with 40 percent who felt their providers were not empathetic (Acad Med. 2011;86(3):359-364). In another study that same year, patients who thought their physicians were empathetic were more likely to adhere to treatment recommendations for preventive tests such as mammograms and colonoscopies (Int J Med Educ. 2010;1:83-87).

Understanding a patient’s perspective is also important for practical reasons. “Currently, our performance and outcomes are being measured and judged,” said Dr. Gray. “How we perform on these metrics will eventually translate into how we are reimbursed, [and] many outcome measures are related to patient satisfaction. Developing a deeper connection with our patients through empathetic care can translate into improved patient satisfaction.”

Dr. Riess’s empathy training program has helped physicians develop that deeper connection. In a second and more recent study, 100 residents and fellows from six subspecialties participated in three 60-minute sessions; afterward, patients reported significant improvement in their physicians’ ability to empathize with them (J Gen Intern Med. 2012;27(10):1280-1286).

The Nuts and Bolts of Empathy Training

When Dr. Riess was developing her empathy training program, her first goal was to help clinicians understand the neurobiological and physiological reactions they may have when treating patients who are in distress. “It’s not an abstract feeling,” said Dr. Riess, who is associate clinical professor of psychiatry at Harvard Medical School and director of the empathy and relational science program at Massachusetts General Hospital in Boston. “When you see somebody suffering, your own pain receptors actually light up. [But] that response can be blunted if you get too overwhelmed with too much personal distress. The danger is that physicians can become detached. So we teach them to recognize pain and how to manage themselves so they can be responsive without getting overwhelmed.” (See Empathy for Patients on the Decline Among Medical Students and Residents, p. 6)

A key part of the training is a series of videos that show difficult doctor-patient interactions. Skin conductance tracings are superimposed on the videos to show the characters’ autonomic nervous systems—and the internal distress they are having during those interactions.

“It’s not just about being nice; it’s about really becoming skilled in connecting with people in nuanced and meaningful ways.”

—Helen Riess, MD

For Linda Lee, MD, a fellow in the Johns Hopkins Division of Facial Plastic and Reconstructive Surgery in Baltimore and one of the otolaryngology residents who participated in Dr. Riess’ pilot study, the video images of the doctors’ and patients’ autonomic nervous systems still stick with her. “It was a good reminder that if people initially seem like difficult patients, they may have other stressors in their lives that are not as obvious,” she said.

In the training, physicians also learn to recognize facial cues and nonverbal behaviors that can indicate a patient in distress. For example, if a patient who learns she needs a tonsillectomy says she is worried about how many days she’ll have to take off work, this could mean she has financial concerns. Nonverbal cues include expressions of confusion, which may affect treatment adherence, and subtle signs of anger.

“Most physicians really have no training in learning how to read nonverbal cues,” Dr. Riess said. “It goes beyond making good eye contact and shaking hands. There is just another whole layer of learning how to read people. It’s not just about being nice; it’s about really becoming skilled in connecting with people in nuanced and meaningful ways.”

Being reminded of ways to respond to these nonverbal cues—sitting in a chair to come down to a patient’s level and really listening to her concerns before taking notes, for example—was helpful for Dr. Lee. “As a surgeon, you don’t spend much time talking about [these things],” she said.

The training’s value also lies in giving physicians the space and time to think about empathy and their patients’ feelings, Dr. Konowitz said. “Once you graduate from medical school, the word ‘empathy’ isn’t even necessarily mentioned again. We were just bringing this to [doctors’] consciousness [and] getting them to think about it. Doctors may not necessarily remember the neurobiology [Dr. Riess] taught them. But they will hopefully remember when they hear the word ‘empathy’ that they had some training and some of the lessons they learned.”

As an otolaryngologist who worked in private practice for a decade before joining MEEI, Dr. Konowitz also said that empathy training can benefit physicians in both sectors. “The patients and issues are the same. Listening to the patient and trying to understand the patient as a real person is really an important part of what every physician should be doing.”

For more information on patient empathy and medical students and residents, see