Understanding others — whether a patient, a colleague or a direct report — can make you a better physician leader and lead to the best outcomes.
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.”
Lola Butcher is a freelance health care journalist based in Missouri.