|Should We Train Doctors for Empathy?
||Nine years ago, I was told that I needed a full hip replacement. I was 46 years old and athletic, and had none of the precursors for the condition. I was devastated.
The orthopedist who gave me my diagnosis, however, was not particularly sympathetic. He pointedly ignored my tears while presenting me with the hard facts, answering my questions—like, “How could this happen to me?”—with answers that were technically precise but emotionally detached. And, while he spoke, he didn’t make eye contact, reassure me, or make any other effort at acknowledging my pain and confusion.
Needless to say, I didn’t choose him as my surgeon. Instead, I later found an orthopedist I could talk to—someone who listened, didn’t use bluster to convince me of the right course to take, and seemed to genuinely care about my welfare. Luckily, my surgery proved successful.
All of us probably have similar stories of doctors who’ve been kind and caring, and others who’ve been less so, maybe even rude. While we all want great medical care, we also want doctors who listen to us and convey empathy—an understanding of our feelings and concerns, reflected in a warm demeanor. This can help us to trust and feel connected to them.
But that combination can be hard to find. A 2011 survey of 800 recently hospitalized patients found that only 53 percent of them felt that their physicians were empathic and caring. And it’s not just in their heads: In one study that videotaped doctor-patient encounters, researchers found that doctors often overlooked or dismissed signs of distress communicated by patients, providing empathic responses only 22 percent of the time. Other studies have found similar results.
These shortcomings have long dismayed patients like myself—but recently they seem to be troubling leaders in the medical profession as well. Following a wave of research suggesting the far-reaching benefits of emotionally attuned physicians, these leaders have been exploring ways to infuse more empathy into the medical field. That includes re-evaluating the criteria for who should get admitted to medical school in the first place, and what they should learn while they’re there.
Their reforms raise questions about what constitutes quality medical care, how (and whether) it can be trained, and how much change is even possible in the American medical system today.
Why do doctors need empathy?
“Every patient wants their doctor to be academically prepared—to know the medicine that they need to know,” says Darrell Kirch, president and CEO of the Association of American Medical Colleges (AAMC). “But equally important, they want their doctors to have personal attributes that contribute to their professionalism—what a patient might call their ‘bedside manner.’”
Indeed, according to recent studies, patients whose doctors listen to them and demonstrate an understanding of their concerns comply more with those doctors’ orders, are more satisfied with their treatment, and enjoy better health—for instance, they get over a cold more quickly and show physiological signs of a stronger immune system. And patients who rated their surgeons as highly caring during their stay in the hospital were 20 times more likely to rate their surgery outcome as positive.
In addition, evidence suggests that physicians with higher empathy levels—meaning that they are aware of their patients’ emotional needs and respond appropriately to their concerns—experience less stress, cynicism, and burnout than those with less empathy.
In light of the research, Kirch wants to produce more doctors who show care and sensitivity toward their patients. To this end, one of the steps he and the AAMC are taking is to screen for them: They have revised the MCAT, the admission test for medical school, so that the test now includes a new section measuring student knowledge on the behavioral, social, and psychological elements of health care—a way to gauge applicants’ understanding of how a patient’s background, psychology, and experience impacts their health. Kirch sees this change as important for the development of empathic, effective healers.
“What medical schools want, and what the country needs, are people who have a solid academic base, who have certain kinds of personal qualities, and who appreciate the diversity of the patients they would take care of,” he says.
In addition to changes to the MCAT, Kirch and his team are looking at other ways to assess applicants’ readiness for entering a career in medicine. These include using trained interviewers or standardized tests that measure applicants’ reactions to different doctor-patient scenarios, as well as allowing schools to assess applicants on more personal qualities, such as how they make decisions, handle stress, and respond when encountering patients from different backgrounds.
“We need other tools … that can help us see how students might interact with real people in real situations,” says Kirch.
Screening medical school applicants may be an important first step: If schools look for qualities like empathy and resilience in their aspiring doctors, they are less likely to produce MDs who lack the bedside manner needed for optimal care—doctors like my original orthopedic surgeon. But if empathy is the goal, research suggests that enhanced screening can’t be the only step.
How to build empathy in medicine
Mohammadreza Hojat, the director of Thomas Jefferson University’s Longitudinal Study of Medical Education, has shown that empathy levels tend to decrease as students go through medical school—especially during the third year, when they start to see patients—suggesting that the erosion of empathy may be more about what’s happening during training rather than the capabilities students possess upon admission.
“While I agree that adding a completely new scale to the MCATs is a very good idea, hopefully it is supported by some changes in medical education emphasizing the art of caring for the patient,” he says.
Hojat believes that what medical students need is more training in “cognitive empathy”—an understanding of experiences, concerns, and perspectives of the patient and the ability to communicate that understanding. He distinguishes cognitive empathy (which he just calls “empathy”) from “affective empathy,” which he calls “sympathy,” or the emotional response that a physician might experience in response to a patient. Several of his studies have shown positive correlations between physicians’ cognitive empathy and improved patient outcomes, including one study in which diabetic patients had better control over their illness and fewer diabetes-related complications requiring hospitalization if their physician scored high on cognitive empathy.
While Hojat says that you can never have too much cognitive empathy, too much affective empathy can be detrimental to good healthcare—and to a physician’s well-being.
“Too much affect or emotion may interfere with performance or clinical decision-making,” he says. “Physicians should not become too emotionally involved in the patients’ suffering. If they are too sympathetic, at the end of the day they’ll be exhausted and burnt out.”
Not necessarily, says Jean Decety, a neuroscientist at the University of Chicago and an expert on empathy. While he agrees with Hojat and others on the importance of cognitive empathy in healthcare, he believes doctors should not tune out their emotional responses to patients because those responses motivate doctors to have concern for their patients, which patients appreciate and value.
“The most critical aspect of healthcare is that patients perceive that their doctors care about them,” he says. “Doctors should not be afraid of their emotions.”
In addition, doctors who don’t feel concern for their patients, he argues, are at an increased, not decreased, risk of job dissatisfaction and burnout. In a recent study, Decety and neuroscientist Ezequiel Gleichgerrcht gave questionnaires to more than 7,500 practicing physicians and found that those who reported showing empathic concern toward patients were significantly more likely to also report feeling satisfied with their jobs. In addition, physicians who were unable to regulate their intense emotions toward patients and felt the need to disengage from them were more likely to suffer burnout. In other words, problems stem not from having feelings but from not being able to manage them in a positive way.
Some experts also argue that when doctors try to detach themselves emotionally from their patients, the quality of their work suffers. Jodi Halpern, a professor of bioethics and medical humanities at the University of California, Berkeley, believes that emotional detachment prevents doctors from understanding their patients and getting important clues about what they need in their care. “To ‘not feel’ is simply to be more likely to act in ways that impair judgment and listening,” says Halpern, author of From Detached Concern to Empathy: Humanizing Medical Practice.
That argument is supported by a 2014 study in which Decety and Gleichgerrcht had doctors from different specialty areas and with varying years in practice watch videos of patients in pain and gauge the patients’ pain levels, as well as disclose their own level of personal distress. Those doctors who were in practice longer tended to underestimate patient pain levels more than younger doctors, though they reported the same amount of personal distress in watching patients suffer.
These findings, and those from earlier studies, suggest that being in practice longer may lead doctors to tune out patient suffering and make less accurate diagnoses. At the same time, being less in-tune with their patients’ suffering won’t necessarily protect them from distress and burnout.
What’s more, Decety argues that affective empathy is linked to better diagnoses—and thus better patient health—because patients who see their doctors as emotionally engaged and concerned will disclose more about themselves. They’ll also be more compliant and active in their treatment, possibly because an emotionally empathic physician provides a sense of safety that can help soothe patients’ anxieties.
“If a patient realizes you are not genuinely concerned,” he says, “there will be long lasting consequences, such as no more trust.”
Rather than emotional disengagement, Decety believes that doctors must learn to accept their own empathic feelings toward patients, yet not confuse their feelings with those of their patients, so that they can respond in the best way possible. This important discernment can become difficult when physicians are working under stressful conditions. In other words, stress—not emotion—is the true enemy of the caring physician.
“Stress plays a role in diminishing our ability to keep the self/other distinction at an optimum, healthy level,” says Decety. “Studies demonstrate that stress and the hormones secreted when we are stressed not only alter brain function, but also disrupt emotional empathy.”
Stress may be antithetical to empathy, but it is rampant in medical schools. According to a 2006 study by Liselotte Dyrbye of the Mayo Clinic and her colleagues, nearly half of the 545 medical students they surveyed suffered from burnout, which researchers define as a state of emotional exhaustion characterized by a lack of motivation, enthusiasm, and efficiency at work.
Other evidence connects medical school stress to the erosion of empathy: In their 2012 analysis of medical studies published from 1980 to the present, researchers Derek Burks and Amy Kobus at Oregon Health and Science University found that medical students face increasingly heavy workloads, strenuous demands, and mentors who model detachment when dealing with patients—to the point that students’ own capacity for empathy decreases and their emotional detachment from patients increases over the course of their medical training. Another, more recent survey of doctors echoes this finding.
Although Kirch recognizes that medical students face a huge amount of stress, he also believes that, for the most part, it can’t be avoided.
“It’s important to say that there’s inherent stress in medicine and in caring for patients,” he says. “So, the goal of a stress-less preparation for physicians isn’t realistic.”
A more realistic goal, perhaps, is to equip medical students and physicians with the skills to deal with the stress they face in a healthy way.
One of these efforts may involve training in contemplative practices that help quiet and focus the mind, such as mindfulness meditation. In their paper, Burks and Kobus suggest that training in mindfulness could potentially help medical students increase their empathy for patients.
At least one recent study, by Neha Harwani and colleagues at Georgetown Medical School, lends support to this idea. Harwani and colleagues gave 118 first-year students an 11-week course in “mind-body” medicine that included training in mindfulness meditation, guided imagery, and other techniques to focus the students on their inner experiences. Data obtained before and after the course showed significant increases in mindfulness, positive emotional states (like inspiration, interest, or joy), and concern for others, and significant decreases in stress and “interpersonal reactivity,” or how one responds to perceived negative interactions with others.
Kirch praises this work on mindfulness and is enthusiastic about its broader applications. He also points to other ways that medical schools are trying to increase physician self-reflection, including classes like the one he taught at Penn State’s medical college called “Patients, Physicians, and Society,” which had small groups do selected readings and reflect on the nature of suffering in illness—how it impacts stress in patients and their caregivers.
“The course laid the groundwork to help students be better prepared for the stress they would encounter,” he says. “That course always got high marks from the students, especially in their later clinical experiences, where they’d find themselves thinking back to the first year course.”
Yet, there is probably more that could to be done to directly teach stress management in medical schools. Decety believes aspiring doctors could use “reappraisal techniques” to handle difficult emotions. For example, a doctor experiencing frustration when talking to a recalcitrant patient could learn to “reappraise” his frustration as a reaction to time constraints rather than a response to anything the patient is doing in the moment, allowing him to soften his attitude toward the patient. The goal here would be to help doctors better understand and regulate their emotions rather than simply cut them off, which jeopardizes losing their empathic concern for patients.
One recent empathy-training program, called “Empathetics,” developed by Helen Riess of Harvard Medical School, incorporates strategies for helping doctors handle difficult emotions and has shown some promising results.
Based on the neuroscience of empathy, Empathetics teaches medical students how to read emotional cues in their patients in order to better respond to their emotional needs, while also helping the students to recognize their own emotional responses and modulate them using breathing exercises and mindfulness. In a recent trial, medical school residents who went through the program had greater improvements on patient-rated empathy scores than doctors who received standard physician training, suggesting that the program could be an important addition to medical training.
While not everyone may agree on how best to teach empathy or how to improve emotional regulation, there is at least more consensus now among researchers and practitioners on the need for them. Twenty years ago, no one was talking about the role of empathy and emotions in healthcare, according to Halpern, and detachment was still part of the traditional formula for a good doctor.
“My book was written in the dark ages,” she says. “Now, because of all of the research, there’s so much more great stuff happening around getting empathy into medical training.”
And that’s bound to benefit us all.