Making Empathy Count

Helen Riess, MD, an associate clinical professor of psychiatry at Harvard Medical School, knows most of her fellow physicians chose medicine as a profession because they care about people. They endured an expensive and difficult education to enter a challenging career field — often frustrating, sometimes heartbreaking — because they want to help others.

But the comments she heard from patients in her psychiatric practice caught her attention. “I was hearing repeatedly that they were dissatisfied with their medical and surgical visits and inpatient experiences,” Riess says. “And I realized that even the most well-meaning people who enter medical professions can lose an empathic approach if there are too many challenges.”

Every physician leader knows what she’s talking about.

“It’s their schedule, their workload, the degree of responsibility, the new documentation requirements, and the recent emphasis on measuring just about everything,” Riess says. “People start to take shortcuts — for example, going right to the computer before really greeting a patient and having them experience someone who is there to greet them and listen to them.”

The computer-over-patients example is the go-to image for the so-called “empathy movement” in U.S. medicine, especially when an apparent lack of physician empathy shows up on patient satisfaction surveys. But patient satisfaction scores might be the least important reason to focus on the issue.

Loss of empathy cuts away at the very reason physicians chose their profession, and the ramifications are far-reaching. Physicians who have low levels of empathy might be difficult colleagues, making a tough working environment even worse. They are more likely to suffer burnout, which threatens individual careers and the rest of the physician workforce. And perhaps worst of all, their patient outcomes lag compared to their more empathetic peers.

A Symptom and a Cause

Riess, who undertook a fellowship on the neuroscience of empathy, is one of many physicians who see physician empathy as both a symptom and a cause of other problems in the medical field — and a challenge that must be addressed. They are researching the issue from many angles, assessing empathy levels in medical students and practicing clinicians, developing interventions and training clinicians to regain the empathy that used to be second nature.

She developed an empathy training intervention that was tested in a randomized, controlled trial at Boston’s Massachusetts General Hospital in six specialties. The study demonstrated the trained physicians received significantly higher patient satisfaction scores than those who were not trained.

“This was a groundbreaking discovery, because many believed that empathy could not be taught,” Reiss says.

The demand for this training led to her founding Empathetics, an organization that delivers online and workshop empathy training; Riess is the organization’s chief scientist.

“This is a point in time where patient expectations have never been higher and the pressure on all clinicians has never been greater,” says Lynn Massingale, MD, chairman and co-founder of TeamHealth, one of the nation’s largest medical staffing companies. “It’s incumbent on all of us to try to use every tool we have to make those two things better, and empathy is one of those tools.”

Empathy vs. Sympathy

The term empathy can be defined in many ways, but this definition has gained traction in the fields of medical education and patient care: Empathy is a predominantly cognitive — as opposed to affective or emotional — attribute that involves an understanding — as opposed to feeling — of patients’ concerns, combined with a capacity to communicate this understanding and an intention to help by preventing or alleviating pain and suffering.

That definition was developed by a research team with Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania. It was advanced in “The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School,” a paper published by Academic Medicine in 2009. It is perhaps most easily grasped by contrasting it to sympathy. Using the terms empathy and sympathy synonymously is a mistake, says Mohammadreza Hojat, PhD, a research professor of psychiatry and human behavior at Jefferson, and one of the authors of that article.

“We believe that emotion is a major component of sympathy, and an abundance of emotion could be detrimental to patient care,” he says. “But empathy — understanding of the patient’s problem — can never interfere, could never be detrimental, always is beneficial. The more understanding, the better.”

Hojat, director of the Jefferson Longitudinal Study at the Center for Research in Medical Education and Health Care, and his colleagues used that definition to develop the Jefferson Scale of Empathy, a 20-item instrument designed to measure empathy in students and practitioners in the health professions.

The Jefferson Scale has been translated into 56 languages, used in more than 80 countries, and referenced in at least 200 publications, Hojat says. Studies using the scale have shown that medical students with high empathy scores were rated higher by medical school faculty on clinical competence than their low-empathy peers. Also, empathy scores predict specialty interest; medical students who choose a people-oriented specialty such as family medicine and internal medicine score higher on empathy than those who choose a procedure-oriented specialty like surgery and hospital-based specialties (e.g., anesthesiology, pathology and radiology), he says.

“But the most important findings that we have is that we found that clinical outcomes are influenced by physician empathy,” Hojat says.

In one study, patients with diabetes treated by physicians with high empathy scores were significantly more likely to have good control of hemoglobin A1c than those treated by low-empathy physicians; similarly, the proportion of patients with good cholesterol control was significantly higher for physicians with high empathy scores, Hojat and his colleagues reported in “Physicians’ Empathy and Clinical Outcomes for Diabetic Patients,” a 2011 article for Academic Medicine.

Although the study did not attempt to explain the causal factors, Hojat believes empathetic physicians engender more trust with their patients, prompting patients to provide more information and be more willing to follow the physician’s advice.

“This trusting relation leads to more accurate diagnoses, to higher level of compliance, and, certainly, this can lead to a more optimal patient outcome,” he says.

Why Empathy Wanes

Hojat’s research using the Jefferson Scale includes a study that documents a disturbing pattern among students preparing to be physicians. Empathy scores drop at the end of the third year of training — and do not rebound before graduation.

“Virtually all medical students come to medical school highly empathic, but the data shows us that empathy is vulnerable to erosion,” says Leonard Calabrese, DO, a rheumatologist at Cleveland Clinic. “It generally happens when they are launched into their clinical rotations.”

He speculates that might reflect students’ exposure to real-world medical practice, where empathy does not always get a star turn. “They may now encounter realities of life that aren’t in line with what they were taught in theory,” he says. “They are exposed to what we call the hidden curriculum of seeing people who are less than empathic to each other.”

Calabrese, who has been studying empathy among health care students and professionals for more than 15 years, is working with Hojat and others on a nationwide study of osteopathic medical students. By the time the study is completed, it will include Jefferson Scale scores from more than 20,000 students at 41 colleges at multiple points during their training.

“It’s going to be one of the largest studies ever done on empathy, and I think it should contribute not just to osteopathic medicine, but to all medicine,” he says.

Empathy as a Leadership Trait

TeamHealth, one of the nation’s largest medical staffing companies, employs more than 10,000 physicians — specialists in emergency medicine, anesthesiology, hospital medicine, urgent care and post-acute care — and 6,000 advanced practice clinicians. They work in small groups all over the country; each group — say, a team of anesthesiologists — is led by a facility medical director.

“We view these leaders as the linchpin of our success,” Massingale says.

Over the years, Massingale and his colleagues have learned that the best medical directors share certain traits that might not be revealed through transcripts and vitae. He says all the physicians TeamHealth hires are smart enough to succeed and all are good clinicians, but the ones who make the best physician leaders display emotional intelligence, consensus-building skills and empathy.

Empathy for patients is easy to find among TeamHealth physicians, Massingale says. “But we are also looking for empathy as it relates to your colleagues and subordinates, the people that you work with and lead,” he adds.

The organization uses a personality and behavior assessment tool to evaluate empathy and other soft skills in the physicians being considered for leadership positions. But observation is another good way to assess an individual’s empathy.

“We start to watch for the folks who are selfless about the schedule and to watch for people who demonstrate greater understanding of a patient’s plight without as much judgment,” Massingale says.

Once you start looking for it, physician empathy reveals itself.

“We had a physician a few years ago, who, literally, in the winter time, gave his shoes to a homeless patient who did not have shoes. Our doctor gave his shoes to the patient and worked the rest of his shift in his socks,” he says. “That kind of leadership by example is what we’re looking for.”

The Role of Empathy in Leadership

For an idea of how powerful empathy is as a leadership tool, consider this: The word is used 20 times in a 188-page manual for leaders in the U.S. Army.

By understanding what others are thinking, feeling or perceiving, leaders who demonstrate an empathetic nature can know if they’re reaching people when they communicate.

One contemporary example of leadership that didn’t get it right was when United Airlines dragged a physician off a flight in 2017, to empty his paid seat for an employee to travel instead. It took the airline’s CEO three tries before his public response showed empathy. The first was inadequate, apologizing for “having to re-accommodate these passengers.” The second blamed the passenger, describing him as defiant and belligerent. Only the third promised “we will do better.”

In an essay for Forbes, psychiatrist Prudy Gourguechon suggests that leaders who do not “suffer fools gladly” should take time to try to figure out what motivates his or her employees. “What’s behind a colleague’s wish to propose what immediately looks like a dumb idea?” she asks. A 90-second conversation can prevent an employee from feeling humiliated and disaffected in the long term.

— PLJ staff

Five Ways to Show Empathy

• Listen to your patients. This helps you get a full understanding of what’s going on with them. Your patients know their bodies and what they’re experiencing.

• Treat your patients the way you would want your family to be treated. Tailor your care to how you’d want your elderly mother to be treated.

• Walk a mile in your patients’ shoes. Imagine how you would feel if in the patient’s predicament. We often forget how it feels to be hopeless or confused.

• Place yourself at the patient’s level. Standing above the patient and having him or her look up at you might paint a lofty picture, but it could make the patient uncomfortable.

• Learn the culture of your patient populations. Knowing this increases your cultural awareness and sensitivity toward others.

Source: Jennifer Bradley, FNP-C, July 2018 at kevinmd.com

Test Your Empathy

The 20-item Jefferson Scale of Empathy asks participants to rate themselves on a seven-point Likert scale. A sample statement:

“It is difficult for me to view things from my patients’ perspectives.”

Source: Hojat, et al.

What to Know About Empathy

Like his colleagues across the country, Steven Strongwater, MD, the president and CEO of Atrius Health in Newton, Massachusetts, is working to mitigate burnout among the organization’s physicians and other medical employees. It’s a big organization — 825 physicians, more than 300 advanced-practice clinicians, and some 4,000 other employees working in 32 clinical locations.

One of Strongwater’s strategies: asking all staff members, including all physicians, to participate in empathy training.

“It seems like a soft topic because everyone in health care, at least in theory, would be empathetic to start with,” he says. “But it turns out there are some very concrete things that people can do that convey to patients and their families that they are listening, and that they are being responsive to their concerns.”

Strongwater’s focus on empathy as a wellness tactic is grounded in research. Higher scores on the Jefferson Scale of Empathy are associated with lower scores on burnout assessments, says Mohammadreza Hojat, PhD, a research professor of psychiatry and human behavior with Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania.

In 2016, Atrius Health conducted 251 empathy forums throughout the organization. It was a huge effort, requiring 131 facilitators. More than 4,000 employees — 92 percent of the entire staff — participated in one of the 90-minute forums.

Subsequently, Atrius Health embedded a two-hour workshop on empathy into its new-employee and new-clinician orientation programs and developed empathy videos and online learning materials.

Formal training programs are among many approaches people and organizations are using to improve empathy levels. Others include intentionally organizing small groups of peers who can allow individuals to discuss the stresses of medical practice in a safe space, while encouraging mind-body practices like meditation or yoga.

Whatever the approach, two concepts must be recognized:

• There is no quick fix to the complex nest of factors behind physician burnout. “Embedding cultural shifts into an organization like this takes time and practice, so one intervention is not enough to make substantial lasting change,” Strongwater wrote in an NEJM Catalyst summary of Atrius Health empathy forums.

• Physicians cannot be blamed for — or expected to fix — burnout by improving their empathy level. “I can tell you that mindfulness meditation is a way to build empathy,” says Leonard Calabrese, DO, a Cleveland Clinic rheumatologist and empathy researcher. “But if you take a burned-out physician who is already overworked, told to see more patients faster and make their patients happier, and tell them to go meditate, they will be angry — and I would be, too.”

If an organization has an empathy deficit, organizational factors — electronic health record systems, documentation hassles, workload and others — should be prime suspects.

“I always say that any of these practices that buffer empathy might reduce your burnout score by maybe 10 percent,” Calabrese says. “That’s good, but it’s really a much more comprehensive treatment that is required, involving both personal change and institutional change.”

Other insights from the experts:

• Co-workers are people, too. Psychiatrist Helen Riess, MD, is co-founder and chief scientific officer of Empathetics, which provides empathy and interpersonal skills training for medical professionals. The curriculum is rooted in her belief that empathic skills need to be part of the fabric of an organization.
  “It’s important for physician leaders to recognize that how professionals talk and treat one another is just as important as how they relate to patients,” says Riess, author of The Empathy Effect: Seven Neuroscience-Based Keys for Transforming the Way We Live, Love, Work and Connect Across Differences, to be published by year’s end.

• Being empathetic might actually save time. Physicians often cite the lack of time as the primary cause for a decline in empathy. Riess’ training makes the case that being empathetic makes a physician more efficient. “Very few patients talk a long time, but doctors tend to interrupt patients within 18 seconds,” she says. “If they even listened for one minute, they would probably learn a whole lot more than cutting off the patient and starting to fire their own questions at them.”
  She cites the example of a patient accepting a prescription order with no intention to get it filled. “Since the doctor didn’t notice a disgusted look on the patient’s face, he may not disclose that the last time he took that medicine, he started vomiting,” Reiss says. “So, if you miss that, you haven’t really saved any time. You’ve probably made sure a person isn’t going to get better and is going to be back for another visit, which is really wasting your time.”

• Empathy training is for everyone. Focusing empathy training only on individuals who have low scores is a bad idea, Riess says. “In the institutions that contract for our training just for people who are supposedly in need of remediation, we have noticed that it is seen as more of a punishment than an opportunity,” she says. “Everybody can improve — even people who are A can move to A-plus.”

Empathy scores can be seen as a barometer of organizational well-being, Calabrese says.

“It’s not ‘fix the empathy and we’ll fix the problem,’ ” he says. “You have to really take care of your people, believe it, act like it and provide institutional resources and space for individual self-care to foster this. If you have a healthy workforce, empathy will come forth naturally.”

— L.B.

Leonard Calabrese, DO, a rheumatologist and empathy researcher at Cleveland Clinic, says buffering empathy skills might reduce a physician’s burnout score “by maybe 10 percent.” He adds, however, that it’s only a start to a more comprehensive remediation strategy.