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The case for empathy

2017; Wiley; Volume: 125; Issue: 8 Linguagem: Inglês

10.1002/cncy.21902

1934-6638

Bryn Nelson,

Innovations in Medical Education

Part 1 of a 2-part series on the push for more compassionate care and the growing evidence for positive patient outcomes. As a physician, caregiver, and cancer survivor, Frederick Kron, MD, has witnessed many disturbing interactions. Dr. Kron, a family medicine practitioner and screenwriter in Madison, Wisconsin, has seen patients, including his own mother, break down in tears after medical encoun-ters left them feeling as if no one cared. As a college student, Dr. Kron endured intense pain in his right testicle for months. No one told him he had cancer until the day he woke up from an explor-atory surgery during which the surgeon had found a mass and removed his testi-cle. “He said the ‘C word’ to me and it's like my brain exploded,” Dr. Kron recalls. “And he never came back to discuss it. When I saw him for visits, he was like, ‘OK, now we're going to do radiation.‘ You didn't get a chance to ask a question. It wasn't polite.” Nearly everyone who studies physi-cian-patient relationships concurs that medical education and training often de-emphasize or drum out skills of empathy, to the detriment of both physi-cians and patients. “I think the increased distance is robbing doctors of the joy and the gratification of really feeling like they make a difference in people's lives, and it's leaving patients feeling like they're just a number or a body part to be fixed,” says Helen Riess, MD, an associate profes-sor of psychiatry at Harvard Medical School in Boston, Massachusetts. As researchers are finding, subpar physician-patient interactions can lead to medical errors, distress, poorer patient outcomes, and other harms. “It's not that clinicians don't care; it's that we still have to learn how to communicate that we care,” says Katie Neuendorf, MD, medi-cal director of the Center for Excellence in Healthcare Communication at the Cleve-land Clinic in Ohio. However, despite broad agreement that medical professionals exhibit too little empathy, researchers have yet to reach a consensus regarding what the attribute means within the context of patient care. This leads to confusing empathy with related concepts such as sympathy and compassion. “Empathy is predominantly a cogni-tive attribute that involves understand-ing of the patient's pain, experiences, and concerns combined with a capacity to communicate this understanding to the patient and an intention to help,” says Mohammadreza Hojat, PhD. Dr. Hojat, a research professor of psychiatry and human behavior at Thomas Jeffer-son University in Philadelphia, Pennsyl-vania, says empathy mainly is a cogni-tive, rather than an affective, attribute that involves understanding patients' pain rather than feeling it. Sympathy, Dr. Hojat says, is predomi-nantly affective and connotes actually feeling a patient's pain and suffer-ing. “Too much affect is overwhelm-ing and can lead to physician burnout and exhaustion, and to the patients' emotional dependency to the caregiver,” he says. It also may cloud a physician's ability to make objective judgments. However, compassion is the overlap or intersection of empathy with regulated sympathy, Dr. Hojat believes. “Compas-sionate care is always good, because you control for the excessive sympathy in that relationship,” he adds. Dr. Riess defines empathy through a neurobiological lens. She explains that in individuals with “empathic capacity” who see others suffering, the forebrain's cognitive centers and midbrain's emotional centers both light up. The rational thinking part allows an empathic person to imagine the pain of another, whereas the affective part allows that individual to feel their pain. Dr. Riess agrees that a person can become overwhelmed as a result of affec-tive empathy, and that potentially can lead to compassion fatigue. The cogni-tive component of empathy, however, provides self-regulation. So can empathy be learned? Researchers haven't reached a consensus here, either. “Empathy is an internal state,” Dr. Kron says. “It's a subconscious reaction to the ‘other’ in social interaction. Since it's as involuntary as a knee jerk, it's not really something that can be taught.” Howev-er, he also argues that in its purest state, empathy entails feeling as the patient feels and is, therefore, not desirable in a medical setting. “You want to be a doctor, not a buddy over a beer,” Dr. Kron points out. What can and should be taught and evaluated in students and physicians are “different behaviors that will express to a patient that they're interested, they care, they get it,” he says. “You could call it an empathic relationship. I'd call it building rapport and building trust.” Dr. Kron is the founder and president of Medical Cyberworlds Inc, located in Madison, Wisconsin, which helps to train medical professionals to become better communicators. In his system, called MPathic-VR, a virtual patient or colleague interacts with a health professional in various scenarios, such as breaking the news of a leukemia diagnosis. A high-definition camera and sensors record the real-time interaction, and the virtual human reacts to the user's words, facial expressions, and body language. In a similar vein, Dr. Riess is the founder and chief scientific officer of Boston-based Empathetics, which offers training in empathy and interpersonal skills at all levels of medicine. Empathet-ics, she says, helps medical profession-als perceive what other individuals are feeling, accurately decode others' facial expressions, and manage themselves through self-regulation skills. The target result, she says, is an “optimal blend of cognitive and affective empathy” that leads to a meaningful connection and genuine sense of caring. She agrees with Dr. Kron that some people are born with a greater capacity for empathy, just as some have a larger capacity for intelli-gence, but adds that both are mutable. “I agree you can't turn a sociopath into Mother Teresa,” Dr. Riess says, although her own clinical trials suggest that train-ing can improve a physician's empathy to the point that patients perceive a significant difference. Research suggests that establishing a better relationship with a patient, often through empathy, leads to fewer errors, better treatment adherence, and more efficient appointments. Dr. Neuendorf reports that her center at the Cleveland Clinic has trained more than 7000 clinicians in evidence-based, relationship-centered communication skills since 2011. The center's 8-hour foundational course includes discus-sions, demonstrations, and practice sessions on empathy and the specific power of an empathic statement. “For me, the idea of empathy is imagining what it is like to be another person,” she says. An empathic statement, she says, lets patients know that the physician can imagine how they are feeling. To better measure empathetic skills, Dr. Hojat and his colleagues developed the 20-question Jefferson Scale of Empathy in 2001.1 Women consistently tend to score higher on the scale than men, he says. So do physicians in people-oriented special-ties such as internal medicine, family practice, and pediatrics. Their counter-parts in procedure-oriented specialties such as pathology, radiology, and surgery tend to lag behind. What about patient outcomes? Accu-mulating research suggests that estab-lishing a better relationship with a patient, often through empathy, leads to fewer errors, better treatment adherence, and more efficient appointments. Empathy saves time because it gener-ates more trust and honesty regard-ing what is really on a patient's mind, Dr. Riess says. In a meta-analysis of 13 randomized controlled trials, she and her colleagues also found that better physi-cian-patient communication and more patient-centered care demonstrated a small but statistically significant benefit in those with conditions such as obesity, asthma, and lung infections.2 “It's not just a nice feeling. It actually means your health is better,” she says. A 2011 correlational study by Dr. Hojat and colleagues found that diabetic outpa-tients seen by family physicians with higher empathy scores were more likely to have their diabetes under control.3 His 2012 retrospective study of nearly 21,000 patients with diabetes in Parma, Italy, similarly found that physicians with high empathy scores had fewer diabetic patients with acute metabolic complica-tions who required hospitalization.4 As a palliative care physician, Dr. Neuendorf views empathy and the abil-ity to communicate it as key to discover-ing what is most important to a patient and developing an individualized end-of-life care plan. “I can only do that if I can go back to that definition and imag-ine what it is like to be in that person's shoes,” she says. Whether you call it empathy or some-thing else, any skill that makes it safer for patients to trust and disclose more information will make their physicians more effective, believes Dr. Kron. “I may disagree on some technical points, but can we teach people to do better? Yes, we can,” he says.