People who choose to go into medicine as a career are driven in part by their desire to serve others in the most intimate of ways, by healing bodies and minds. A good dose of empathy, the ability to understand and share the feelings of another, should come with the job. But an increasingly technological approach to healthcare, reliant on machines and data that prioritize analytic skills, can diminish the physician’s focus and ability to approach the patient with this most critical of skills.
“Research shows that when we engage in analytic thinking, we turn off brain areas for empathy. By contrast, when we engage in genuine empathy, we turn off brain areas for analytic thinking,” said Anthony Jack, PhD, who has used brain-scanning technology to look at the functioning of the brain during analytic and empathetic states in his research as principal investigator at the Brain, Mind and Consciousness Lab at Case Western Reserve University in Cleveland, Ohio.
“Effective care providers need to learn to switch between analytic and empathetic modes rapidly, so that while they are making a diagnosis they are also providing social cues to the patient that indicate genuine concern for their well-being,” he said.
How do physicians do that?
One way is to actively focus on and enhance recognition of the importance of empathy in a healthcare climate in which analytic skills increasingly dominate. For Helen Riess, MD, and other researchers who have looked at the neurophysiology of empathy, the key is to actively teach skills that enhance empathy.
“Empathy needs to be taught as an exclusive skill and also needs to be presented as a reminder throughout the medical profession, because sometimes humanistic skills go by the wayside when people get more focused on things like documentation requirements,” said Dr. Riess, who developed and directs the Empathy and Relational Science Program at Massachusetts General Hospital in Boston, the first hospital-based empathic training of its kind.
In 2011, Dr. Riess and her colleagues published the first results of a pilot study to test the effectiveness of an empathy-relational skills training protocol in residents in the otolaryngology program at Harvard (Otolaryngol Head Neck Surg. 2011;144:120-122). Since then, a number of studies have been published supporting the positive effects of physician empathy training on patient satisfaction and health-based outcomes, as well as on physician career satisfaction.
The empathy training, which was first tested on otolaryngology residents in 2010 and then incorporated into the educational curriculum in the Harvard Otolaryngology Program, was based on three empathy training sessions that incorporate key teachings of the program.
Among these are decoding patient expressions, determining nonverbal emotional cues of patients (i.e., not only about getting the facts about symptoms but also about interpreting how the patient is affected by the symptoms), and asking open-ended questions to gain perspective on the patient, as well as gaining emotional intelligence and emotional regulation skills, said Dr. Riess.
Stacey T. Gray, MD, program director at the Harvard Otolaryngology Residency Program at Massachusetts Eye and Ear in Boston, highlighted the importance of this training for residents in particular, who are experiencing, among other things, increased stress levels due to long hours and lack of control over their own schedules, resulting in a reduced ability to be attuned to the emotional needs of their patients. “What I have found is that just talking about empathy and making sure residents know this is something that is valued actually helps, because it makes empathy a bigger focus,” she said. “If you’re not specific about it in training, the residents may miss that point.”
For Dr. Gray, who was trained at a time when physician modeling was the key to learning both technique and empathy in the clinical setting, this practitioner model no longer works as it did because of the rapid changes taking place in healthcare, which demand less time with patients and more with technology. “It’s harder to express empathy with patients if you don’t have a history to build on,” she said, “so we emphasize empathy with people who are in training.”
G. Richard Holt, MD, MSE, MPH, professor emeritus in the department of otolaryngology and head and neck surgery at The University of Texas Health Science Center in San Antonio, highlighted the important role of educators in guiding young physicians to understand the role and importance of empathy in clinical practice. “For the educator, one must understand the spectrum of empathy found in physicians and guide improvement and appropriateness,” he said. “We have so many assaults on the patient-physician relationship that empathy can be lost in the midst of electronic health records, shorter patient contact times, onerous regulations and laws, and financial issues.”
In advocating for honesty, compassion, and empathy in every patient-physician encounter, Dr. Holt said that these traits may be especially important in patients with cancer of the head, neck, and face, situations in which outcomes are uncertain. “The patient is scared and needs an empathetic surgeon to provide a special level of caring in the relationship to help the patient and family through tough times,” he said.
Evidence on Empathy Training
The pilot study found that residents’ knowledge of the physiology and neurobiology of empathy significantly increased after the empathy training, as did their self-reported capacity to empathize with their patients.
A year later, Dr. Riess and her colleagues published the results of another randomized clinical trial that looked at the benefits of empathy training for resident physicians and fellows in multiple specialties—surgery, medicine, anesthesiology, psychiatry, ophthalmology, and orthopedics (J Gen Intern Med. 2012;27:1280-1286). That study also found that physicians randomized to empathy training experienced greater changes in empathy, as measured by the Consultation and Relational Empathy (CARE) measure, when compared with those randomized to standard post-graduate medical education, as well as significantly greater changes in their knowledge of the neurobiology of empathy and their ability to decode facial expressions showing emotion.
In a more recent systematic review and meta-analysis of randomized controlled trials that looked at the influence of the patient-clinician relationship on healthcare outcomes, researchers found that the patient-clinician relationship had a small but significant effect on healthcare outcomes (PLOS One 2014;9:e94207).
According to Dr. Riess, the senior author of the study, the review highlighted the reality that the patient-clinician relationship affects not only patient satisfaction but also hard outcomes such as diabetes and hypertension. “The study showed a significant impact on health outcomes, so that relationship building is not only about patient satisfaction but also engages patients to work toward [solving] their own health problems,” she said, adding that these relationship factors are extremely important for the overall state of healthcare and healthcare spending in the United States.
A particularly rewarding benefit of the training, said Dr. Riess, is the response she’s heard from established physicians who say that they enjoy their jobs again. “One of the key side benefits of more engagement with patients is that doctors start to feel that their jobs are meaningful again,” she said, noting how important this is when so many physicians show signs of burnout.
Challenges of Teaching Empathy
There is no surprise that one challenge to empathy training is time. “We need to be aware of not just piling on teaching for trainees and practicing physicians,” said Jo Shapiro, MD, division chief of otolaryngology–head and neck surgery and associate professor of otology and laryngology at Harvard Medical School, Brigham and Women’s Hospital in Boston, adding that new training has to be done in ways that don’t create negative feelings.
Dr. Shapiro, who thinks that empathy training covers only part of the communication skills that need to be taught, emphasized the importance of avoiding too narrow a focus in terms of training. “What we’re looking for is for people to behave in a way that is the most conducive to relationship building in the clinical setting, and to me that has been taught in the framework of communication,” she said, adding that empathy is important but is only one component in that framework.
Dr. Shapiro highlighted the need for physicians to take into account patient preferences and priorities when talking to them about treatment options, and not just focusing on the benefit/risk conversation that often is not about what the patient wants. She also emphasized the need to ask the question, “What matters most to you?” when talking to a patient about treatment options.
Drs. Gray and Riess both emphasized that the empathy skills taught—such as making eye contact and sitting down at eye level with patients—do not take any additional time in the clinic to implement. Dr. Gray stressed, however, that it does require time as an educator to think about how to teach these skills.
To that end, she said that a web-based learning curriculum developed by Dr. Riess in partnership with the company Empathetics is a very helpful online tool that allows residents to learn on their own time and at their own pace (see “Web-Based Curriculum for Teaching Empathy,” p. 14).
Dr. Riess’s goal is to provide the training on a broader scale. “My aim is to get people doing this so they don’t need the training, but I think there is a steep climb before we get there,” she said.
Mary Beth Nierengarten is a freelance medical writer based in Minnesota.