Empathy & Its Role in Quality Care

CORRESPONDENCE:

Sherri Howell, DO | showell@bcomnm.org

INTRODUCTION

Empathy has become the subject of much discussion in the lay press as well as the medical literature. In April 2015, U.S. News and World Report published an article entitled “Why nice doctors are the best doctors,” and stresses empathy as a key component to patient care and satisfaction.1 An article in Harvard Business Review called for an “epidemic of empathy” in order to improve patient care. The author argues that healthcare has become too complicated, reducing the patient to feeling that they are “being treated like disease and organs rather than human beings.”2

The need for empathy is also recognized by health organizations worldwide. The World Health Organization issued a report in 2008 calling for an increased empathy in health care delivery.3 The American College of Obstetricians and Gynecologists has issued an opinion paper in 2011 and reaffirmed in 2014 entitled Empathy in Women’s Health Care.4 Both organizations state that patient centered, empathetic care is necessary to increase communication and empower patients.

The patient-physician relationship is complex. The nuances of the interaction are subtle and go far beyond the words that are spoken. Empathy is an important learnable skill that greatly enhances the patient-physician relationship. But what is empathy? Can we mea- sure it? Does it affect patient outcomes? Does empathy reduce risk exposure in healthcare? Can it be learned?

A sentinel article written by Mercer, which is widely used in em- pathy research, defined empathy as the ability to understand the patient situation, communicate that understanding, and check its accuracy.5 This definition appears straight forward, but there are numerous steps that must occur in order to fulfill it. The physician must gather large amounts of information while building an atmo- sphere of trust. Physicians should allow patient adequate time to tell their story, and when necessary, encouraging them to provide additional information. The physician must also be able to convey the desire to help the patient with their concern.

Empathy involves active listening. In other words, the clinician must listen to the patient’s words and monitor their nonverbal expressions. Listening to the patient’s words provides cognitive clues. Watching the patient’s facial expression, body language, and integrating the tone with which the words are spoken provides the emotions and details the words lack. Active listening also requires the clinician to respond in such a way that the patient feels under- stood. In other words, the body language, tone, and words of the clinician must reflect that the patients has been not only heard, but also understood. The words draw the outline, but the body lan- guage and tone provide the color to complete the picture.

Empathy also involves empowering the patient. For the patient to be empowered, the physician must take time to help the patient understand the diagnosis and treatment plan. This may come in the form of educating the patient on the diagnosis, discussing treatment options, or enabling the patient to cope better with their diagnosis. It may take the form of encouraging the patient to make lifestyle changes, making decisions about or understanding the use of medications.5 In short, the physician creates an envi- ronment that allows the patient to feel comfortable in asking ques- tions and engages them in their own care.

CAN EMPATHY BE MEASURED?

In 2001, Blasi et al undertook and extensive literature review to evaluate evidence that there is a therapeutic relationship between physician and patient. Unfortunately, there was little empirical ev- idence to support the clinical benefit of the physician-patient rela- tionship. Since then instruments have been developed to evaluate empathy and subsequent research into its value in patient care.6

The two instrument commonly used to evaluate physician empa- thy are the Jefferson Scale of Empathy (JSE)7 and the Consulta- tion and Relational Empathy (CARE) measure.8 Both use Likert formats that enable the participant to choose the strength of their responses (i.e. always, sometimes, never) consistently on a series of statements. JSE is completed by physicians to rate themselves on 20 items on a seven-point Likert-type scale. CARE is a 10 item five-point Likert-type scale that is completed by patients rating the physician after an encounter. Both instruments include aspects that define empathy such as listening, showing compassion, and understanding the patients’ concerns.

DOES EMPATHY AFFECT PATIENT OUTCOMES?

With the development of validated instruments, empathy has been measured and correlated favorably with a variety patient outcomes.

The common cold accounts for numerous office visits seasonally. In a study published in 2009 the interaction between the physi- cian and the patients were evaluated for length of illness, severity of symptoms, and provider empathy. They also had nasal swabs to measure the immune cytokine interleukin-8 (IL-8) at baseline and 48 hours. The patients that rated their provider with “perfect” CARE scores (50 points out of 50 possible), had higher rise in IL-8 and trended toward less severity scores. The patients also had shorter duration of illness than those who scored the providers with less than perfect scores.9

Diabetes management is difficult for both patient and physician. There are two studies that evaluated the role of empathy in dia- betic patients. The first was a study evaluated long-term glucose control and LDL control. The physicians were surveyed with the Jefferson Scale of Empathy. The study found that patients that reached glucose control (A1c <7%) and LDL goals (<100) were cared for by physicians with higher empathy scores than those that failed to reach their goals. The authors concluded that more empa- thy enhances mutual understanding and trust, which in turn leads to better alignment between patient needs and treatment plan.10

A second study reviewed the charts of 20,961 patients for meta- bolic complications and compared them to the 242 treating phy- sicians using the JSE measure. There were significantly fewer hospital admissions for diabetic ketoacidosis, coma, and hyperos- molar state for the physicians with empathy scores in the top third. These results were independent of the patient age, gender, and the length of time the patient had been cared for by the physician. The authors concluded that empathy had a significant correlation in clinical outcomes and should be considered an important compo- nent of clinical competence.11

Trauma patients were engaged in a study to rate their surgeons’ empathy. The CARE measure was administered six weeks and one year after their discharge. Those patients that rated their physi- cians as having high empathy scores (41-50 points) were more likely to perceive their treatment and outcome as successful. The study also found that the empathy scores were independent of age, gender, and severity of initial injury. The authors concluded that “the interpersonal treatment aspects such as emotional care are associated to a more positive valuation of the medical treat- ment and its effects.” 12, 13

Migraine management includes life style modifications, trigger avoidance, and medications. Patients that rated their physicians higher in empathy were more likely to be compliant with diet, ex- ercise, destressing, sleep pattern modifications, and medications. A decrease in migraine symptoms and disability was also noted.14

The patient-physician interaction can produce anxiety in many pa- tients. Surgical patients reported less preoperative anxiety when they perceived an empathetic attitude from the anesthesiologist. Patients also felt that the information provided was higher quality and their overall satisfaction was higher for those physicians that responded more empathetically.15

The authors of each study concluded that the positive relationship between the patient and the physician was a significant factor in patient outcomes. Some authors hypothesized that physicians with higher empathy scores had a better understanding of the pa- tients’ individual situation. Therefore, the authors concluded the patient plan facilitated improved compliance.10, 11 Increased di- agnostic accuracy can result from physicians obtaining more clini- cally relevant information. It is also reasonable to conclude that empathetic engagement enhances mutual understanding leading to increased trust and communication between patient and pro- vider.11 Other authors concluded that providing the patient with better understanding of the diagnosis framed patient expectations and improved outcomes.9

DOES EMPATHY REDUCE YOUR RISK IN PATIENT CARE?

A retrospective study published in JAMA determined that the majority of patient complaints were made against a minority of providers. Furthermore, those complaints resulted in the highest number of open risk management files, risk management expen- ditures, and lawsuits. The authors noted that the risk was not re- lated to complexity of illness or physician technical skills. Rather it was noted that risk was related to patient “dissatisfaction with their physicians with ability to establish rapport, provide access, administer care and treatment consistent with expectations, and communicate effectively.”15

Empathy takes time and time is money. Or is it? In 1997, a study was published that compared communication behaviors of phy- sicians that had had no malpractice claims versus those that had had two or more lifetime claims. Ten routine office visits were re- corded and reviewed for empathetic behaviors such as soliciting patients’ opinions, checking understanding, and encouraging pa- tients to talk. Out of 59 family physicians and internists, those with no claims spent a total of 18.3 minutes compared to 15 minutes for those with two or more claims.16 The small amount of additional time spent engaged in effective communications could be viewed as an investment in reducing the liability risk in patient care.

CAN EMPATHY BE TAUGHT?

Empathy has been recognized as an essential element in health- care. It is required within the undergraduate and postgraduate course curriculums of all training institutions. Healthcare organi- zations also recognize the importance of empathy. The Cleveland Clinic sponsors an annual seminar entitled Patient Experience: Empathy and Innovation Summit which is attended by profession within the healthcare delivery system.17 There are also online resources such as www.vitaltalk.org and www.empathetics.com which can be accessed by individuals and organizations for empa- thy training. Regardless of the methods of delivery, there is com- pelling evidence that each can be effective in improving communi- cation skills and empathy scores.

For example a study published in 2011 randomized oncologists to either receive a lecture (the control group) or a lecture and one hour interactive CD-ROM (the intervention group). The oncolo- gists were then videotaped during patient visits. The tapes were scored by trained personnel listening for statements of empathy. There was a statistically significant increase of empathetic state- ments in the intervention group over the control group. The pa- tients were surveyed one week later regarding trust and quality of communication. The patients’ also perceived greater empathy and trust in the intervention group of physicians.19

Massachusetts General Hospital developed E.M.P.A.T.H.Y. as an acronym used in teaching empathy. It stands for Eye contact, Muscles of facial expression, Posture, Affect, Tone of voice, Hear- ing the whole patient, and Your response. It was studied by ran- domizing 99 residents and fellows to receive either the standard residency or fellowships empathy training or three one-hour mod- ules. Patients were surveyed using the CARE measurement before the physicians underwent training and after the training modules. Those physicians that received the intervention showed statisti- cally significant improvement on patient ratings of physician em- pathy.20 The results were published in 2012. Since then the mod- ules have been taught nationally and internationally as a simple way for health professionals to perceive and respond to nonverbal emotional cues.21

WHAT ARE SOME PHRASES THAT BUILD EMPATHY?

Empathy involves gaining understanding and communicating that understanding back to the patient. A physician may need to ask for more information or clarify information, then respond so that the patient confirms that the information is correct. Table 1 has some words and phrases that facilitate empathy.22

CONCLUSION

Empathy is the ability to step into another’s shoes and understand their perspective and emotion. In healthcare, the display of empa- thy in the patient-provider relationship has been shown to improve patient outcomes in diabetes, migraines, trauma, and the common cold. It has also been shown to reduce patient anxiety. Improved perception of empathy reduces patient complaints and risk of liti- gation. The corollary is that it also increases patient satisfaction. Empathy can be learned and have long-term and persistent effects.

Empathic behaviors and phrases are taught in multiple settings and formats. These are available to physicians in all levels of train- ing and have shown to improve patient care and perceptions. Em- pathy takes a small amount of time but is cost-effective because it puts the patient at the center of care.23

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FINANCIAL DISCLOSURES: NONE