Empirical research on empathy in medicine—A critical review

Objective

There is a growing amount of empirical research on empathy in medicine. This critical review assesses methodological limitations in this body of research that have not received adequate attention.

Methods

Scientific publications presenting empirical research on medical students’ or physicians’ empathy were systematically searched for.

Results

206 publications were identified and critically reviewed. Multiple empirical approaches have been used. However, there are some remarkable tendencies given the complexity of the study object: empathy is often not defined. Qualitative approaches are rarely used and the predominant quantitative instruments have a relatively narrow or peripheral scope. For example, the concrete experiences, feelings, and interpretations of the physician and the patient, and empathy in clinical practice, are often neglected. Furthermore, possible influences of medical training and working conditions on empathy have not been adequately explored.

Conclusion

The empirical studies of empathy in medicine tend to separate empathy from main parts of clinical perception, judgment, and communication. Thus, important aspects and influences of empathy have been relatively neglected.

Practice implications

Future studies should include transparent concepts, more than one method and perspective, qualitative approaches, the physician's and the patient's concrete experiences and interpretations, and the context in which empathy is developed and practiced.     

Changes of empathy in medical college and medical school students: 1-year follow up study

Background

This study aims to determine the correlation between medical education systems, medical college (MC) and medical school (MS), and empathy by investigating the changes in empathy among students with each additional year of medical education.

Methods

The subjects were MC and MS students who had participated in the same study the previous year. All participants completed the same self-report instruments: a questionnaire on sociodemographic characteristics, and the Korean edition of the Student Version of the Jefferson Scale of Empathy (JSE-S-K), Among 334 students, the final analysis was conducted on the data provided by 113 MC and 120 MS students, excluding 101 with incomplete data.

Results

The age and sex did not affect the changes in empathy. Though the JSE-S-K score of MS was significantly higher than that of MC in initial investigation, this study found no difference of empathy between MC and MS.

Conclusion

Empathy increased significantly after one year of medical education. The difference between two education systems, MC and MS, did not affect the changes in empathy.

     

Physician empathy and subjective evaluation of medical treatment outcome in trauma surgery patients

Objective

To analyze whether patients’ perception of their medical treatment outcome is higher among patients who experienced a higher empathy by trauma surgeons during their stay in hospital.

Methods

127 patients were surveyed six weeks after discharge from the trauma surgical general ward. Subjective evaluation of medical treatment outcome was measured with the corresponding scale from the Cologne Patient Questionnaire. Clinical empathy was assessed by using the CARE measure. The influence of physician empathy and control variables on a dichotomized index of subjective evaluation of medical treatment outcome was identified with a logistic regression.

Results

120 patients were included in the logistic regression analysis. Compared to patients with physician empathy ratings of less than 30 points, patients with ratings of 41 points or higher have a 20-fold higher probability to be in the group with a better medical treatment outcome on the CPQ-scale (α-level < .001, R² 46.9).

Conclusion

Findings emphasize the importance of a well-functioning relationship between physician and patient even in a surgical setting where the focus is mostly on the bare medical treatment.

Practice implications

Communication trainings i.e. in surgical education can be an effective way to improve the ability to show empathy with patients’ concerns.     

Psychosocial predictors of attitudes toward physician empathy in clinical encounters among 4732 1st year medical students: A report from the CHANGES study

Objective

Medical school curricula intended to promote empathy varies widely. Even the most effective curricula leave a significant group of students untouched. Pre-existing student factors influence their response to learning experiences. We examined the individual predictors of first semester medical students’ attitudes toward the value of physician empathy in clinical encounters.

Methods

First year students (n = 4732) attending a stratified random sample of 49 US medical schools completed an online questionnaire that included measures of dispositional characteristics, attitudes and beliefs, self-concept and well-being.

Results

Discomfort with uncertainty, close-mindedness, dispositional empathy, elitism, medical authoritarianism, egalitarianism, self-concept and well-being all independently predicted first year medical students’ attitudes toward the benefit of physician empathy in clinical encounters.

Conclusion

Students vary on their attitude toward the value of physician empathy when they start medical school. The individual factors that predict their attitudes toward empathy may also influence their response to curricula promoting empathic care.

Practice implications

Curricula in medical school promoting empathic care may be more universally effective if students’ preexisting attitudes are taken into account. Messages about the importance of physician empathy may need to be framed in ways that are consistent with the beliefs and prior world-views of medical students.     

Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department

Objective

We assessed emergency department (ED) patient perceptions of how physicians can improve their language to determine patient preferences for 11 phrases to enhance physician empathy toward the goal of reducing low-value advanced imaging.

Mimicking non-verbal emotional expressions and empathy development in simulated consultations: An experimental feasibility study

Objective

To explore the feasibility of applying an experimental design to study the relationship between non-verbal emotions and empathy development in simulated consultations.

'It gives you an understanding you can't get from any book.' The relationship between medical students' and doctors' personal illness experiences and their performance: a qualitative and quantitative study

Background

Anecdotes abound about doctors' personal illness experiences and the effect they have on their empathy and care of patients. We formally investigated the relationship between doctors' and medical students' personal illness experiences, their examination results, preparedness for clinical practice, learning and professional attitudes and behaviour towards patients.

Methods

Newly-qualified UK doctors in 2005 (n = 2062/4784), and two cohorts of students at one London medical school (n = 640/749) participated in the quantitative arm of the study. 37 Consultants, 1 Specialist Registrar, 2 Clinical Skills Tutors and 25 newly-qualified doctors participated in the qualitative arm. Newly-qualified doctors and medical students reported their personal illness experiences in a questionnaire. Doctors' experiences were correlated with self-reported preparedness for their new clinical jobs. Students' experiences were correlated with their examination results, and self-reported anxiety and depression. Interviews with clinical teachers, newly-qualified doctors and senior doctors qualitatively investigated how personal illness experiences affect learning, professional attitudes, and behaviour.

Results

85.5% of newly-qualified doctors and 54.4% of medical students reported personal illness experiences. Newly-qualified doctors who had been ill felt less prepared for starting work (p < 0.001), but those who had only experienced illness in a relative or friend felt more prepared (p = 0.02). Clinical medical students who had been ill were more anxious (p = 0.01) and had lower examination scores (p = 0.006). Doctors felt their personal illness experiences helped them empathise and communicate with patients. Medical students with more life experience were perceived as more mature, empathetic, and better learners; but illness at medical school was recognised to impede learning.

Conclusion

The majority of the medical students and newly qualified doctors we studied reported personal illness experiences, and these experiences were associated with lower undergraduate examination results, higher anxiety, and lower preparedness. However reflection on such experiences may have improved professional attitudes such as empathy and compassion for patients. Future research is warranted in this area.     

Analyzing the “nature” and “specific effectiveness” of clinical empathy: A theoretical overview and contribution towards a theory-based research agenda

Objective

To establish sound empirical evidence that clinical empathy (abbreviated as CE) is a core element in the clinician–patient relationship with profound therapeutic potential, a substantial theoretical-based understanding of CE in medical care and medical education is still required. The two aims of the present paper are, therefore, (1) to give a multidisciplinary overview of the “nature” and “specific effectiveness” of CE, and (2) to use this base as a means of deriving relevant questions for a theory-based research agenda.

Method

We made an effort to identify current and past literature about conceptual and empirical work focusing on empathy and CE, which derives from a multiplicity of disciplines. We review the material in a structured fashion.

Results

We describe the “nature” of empathy by briefly summarizing concepts and models from sociology, psychology, social psychology, education, (social-)epidemiology, and neurosciences. To explain the “specific effectiveness” of CE for patients, we develop the “Effect model of empathic communication in the clinical encounter”, which demonstrates how an empathically communicating clinician can achieve improved patient outcomes. Both parts of theoretical findings are synthesized in a theory-based research agenda with the following key hypotheses: (1) CE is a determinant of quality in medical care, (2) clinicians biographical experiences influence their empathic behavior, and (3) CE is affected by situational factors.

Conclusion

The main conclusions of our review are twofold. First of all, CE seems to be a fundamental determinant of quality in medical care, because it enables the clinician to fulfill key medical tasks more accurately, thereby achieving enhanced patient health outcomes. Second, the integration of biographical experiences and situational factors as determinants of CE in medical care and medical education appears to be crucial to develop and promote CE and ultimately ensuring high-quality patient care.

Practice implications

Due to the complexity and multidimensionality of CE, evidence-based investigations of the derived hypotheses require both well-designed qualitative and quantitative studies as well as an interdisciplinary research approach.     

Empathy in high-tech and high-touch medicine

Objective

Surgeons and psychiatrists have been described as two contrary groups, the one healing by hands and the other by words. Empathy is needed in every physician–patient relationship. We tested whether (1) surgeons and psychiatrists show different levels of cognitive and emotional empathy; (2) measurements of cognitive and emotional empathy correlate with physician-specific empathy; and (3) gender, experience, and career choices are influencing factors.

Methods

56 surgeons and 50 psychiatrists participated. We measured empathy with the Jefferson Scale of Physician Empathy (JSPE), cognitive empathy with the Reading the Mind in the Eyes Test Revised (RME-R6), and emotional empathy with the Balanced Emotional Empathy Scale (BEES).

Results

Male psychiatrists scored significantly higher than that of male surgeons (118.0 ± 9.86 vs. 107.5 ± 13.84; p = 0.0006) in the JSPE. Analytically trained psychiatrists scored significantly higher in the JSPE than that of behaviorally trained psychiatrists (p = 0.024, F test, adjusted for gender). Both the RME and the BEES correlated positively with the JSPE.

Conclusion

Higher scores for empathy were found in male psychiatrists than in male surgeons.

Practice implications

Further research is needed to learn about the effects of general medical training on empathy.     

In which context is physician empathy associated with cancer patient quality of life?

Objective

In cancer settings, physician empathy is not always linked to a better patient emotional quality of life quality of life (eQoL). We tested two possible moderators of the inconsistent link: type of consultation (bad news versus follow-up) and patient emotional skills (emoSkills, i.e., the way patients process emotional information).

Residents’ and standardized patients’ perspectives on empathy: Issues of agreement

Objective

We investigated correlations between residents’ scores on the Jefferson Scale of Empathy (JSE), residents’ perceptions of their empathy during standardized-patient encounters, and the perceptions of standardized patients.

Methods

Participants were 214 first-year residents in internal medicine or family medicine from 13 residency programs taking standardized patient-based clinical skills assessment in 2011. We analyzed correlations between residents’ JSE scores; standardized patients’ perspectives on residents’ empathy during OSCE encounters, using the Jefferson Scale of Patient Perceptions of Physician Empathy; and residents’ perspectives on their own empathy, using a modified version of this scale.

Results

Residents’ JSE scores correlated with their perceptions of their own empathy during encounters but correlated poorly with patients’ assessments of resident empathy.

Conclusion

The poor correlation between residents’ and standardized patients’ assessments of residents’ empathy raises questions about residents’ abilities to gauge the effectiveness of their empathic communications. The study also points to a lack of congruence between the assessment of empathy by standardized patients and residents as receivers and conveyors of empathy, respectively.

Practice implications

This study adds to the literature on empathy as a teachable skill set and raises questions about use of OSCEs to assess trainee empathy.     

Effectiveness of empathy in general practice: a systematic review

Background

Empathy as a characteristic of patient–physician communication in both general practice and clinical care is considered to be the backbone of the patient–physician relationship. Although the value of empathy is seldom debated, its effectiveness is little discussed in general practice. This literature review explores the effectiveness of empathy in general practice. Effects that are discussed are: patient satisfaction and adherence, feelings of anxiety and stress, patient enablement, diagnostics related to information exchange, and clinical outcomes.

Aim

To review the existing literature concerning all studies published in the last 15 years on the effectiveness of physician empathy in general practice.

Design and setting

Systematic literature search.

Method

Searches of PubMed, EMBASE, and PsychINFO databases were undertaken, with citation searches of key studies and papers. Original studies published in English between July 1995 and July 2011, containing empirical data about patient experience of GPs’ empathy, were included. Qualitative assessment was applied using Giacomini and Cook’s criteria.

Results

After screening the literature using specified selection criteria, 964 original studies were selected; of these, seven were included in this review after applying quality assessment. There is a good correlation between physician empathy and patient satisfaction and a direct positive relationship with strengthening patient enablement. Empathy lowers patients’ anxiety and distress and delivers significantly better clinical outcomes.

Conclusion

Although only a small number of studies could be used in this search, the general outcome seems to be that empathy in the patient–physician communication in general practice is of unquestionable importance.     

How do lay people assess the quality of physicians’ communicative responses to patients’ emotional cues and concerns? An international multicentre study based on videotaped medical consultations

Objective

to establish which kind of physician communicative responses to patient cues and concerns are appreciated by lay people.

Methods

A balanced sample (259 people) was recruited in public places to participate in a full day observation of four videotaped standardized medical consultations. In a two-step procedure participants gave their individual quality ratings of the whole consultations and then of a set of four fragments from each consultation. They contained a patient negative emotional expression and the subsequent physician response, according to the VR-CoDES.

Results

Higher quality ratings were given to physician responses which provided space to the patient to talk and to the explicit expressions of empathy. The explicit responses were favored above non-explicit responses. Participants’ global evaluation of the whole consultation affected their quality assessments of the fragments (halo-effect). In a multivariate model, lay people's background characteristics appeared to be relevant: to be female, of lower educational level and living in Belgium or Italy predicted higher ratings.

Conclusions

Providing space to patients is appreciated by all participants, combined with the need for tailor made communication.

Practice implications

To teach physicians listening skills and how to show empathy with distressed patients should be a core element in medical education.     

Effects of mode of presentation on ratings of empathic communication in medical interviews

Objective

To test the impact of nonverbal behaviour on the assessment of a clinician's level of empathic communication.

Methods

One hundred volunteers were asked to assess a clinician's level of empathic communication using the Rating Scales for the Assessment of Empathic Communication in Medical Interviews (REM). Participants were randomly assigned to three groups differing with regard to the level of nonverbal information made available to them. Participants either watched a simulated medical interview, listened to an audio-only version of this interview, or read a transcribed version of the interview.

Results

Compared to watching a video and listening to an audiotape, respectively, reading a transcribed version of the interview produced lower empathy ratings and interrater reliabilities.

Conclusions

The findings suggest that assessments of a clinician's level of empathic communication may differ according to the level of nonverbal information made available to the raters.

Practice implications

Focusing on the verbal level of communication alone ignores the fact that empathy can be expressed through nonverbal means. Hence, nonverbal channels need to be taken into account in addition to the verbal channel when conducting research on empathic communication in health care.     

Characteristics associated with empathic behavior in Japanese oncologists

Objective

Oncologists must have empathy when breaking bad news to patients who have incurable advanced cancer, and the level of empathy often depends on various individual characteristics. This study aimed to clarify the relationship between these characteristics and empathic behavior in Japanese oncologists.

Methods

We videotaped consultations in which oncologists conveyed news of incurable advanced cancer to simulated patients. Oncologists’ empathetic behaviors were coded, and regression analysis was performed to determine the existence of any relationships with factors such as age, sex, and specialism.

Results

Sixty oncologists participated. In a multivariate model, only age was related to the empathy score (r = 0.406, p = 0.033); younger oncologists scored higher than did older oncologists.

Conclusions

We found that empathic behaviors were more frequent in younger oncologists.

Practice implications

This information could be useful in determining the best approach for implementing future empathy and communication training programs for experienced oncologists in Japanese medical institutions.     

Evaluation of a task-based community oriented teaching model in family medicine for undergraduate medical students in Iraq

Background  

The inclusion of family medicine in medical school curricula is essential for producing competent general practitioners. The aim of this study is to evaluate a task-based, community oriented teaching model of family medicine for undergraduate students in Iraqi medical schools.