Tagg, A. The Hidden Curriculum – Empathy, Don't Forget the Bubbles, 2017. Available at:
When I mentioned the importance of acting as a role model in a recent post the esteemed Daniel Cabrera tweeted a short response – “Empathy, that’s all“. So what is it? Can we do without it? And if we can’t is it something we are born with or is it something we can learn and, importantly, teach?
What is empathy?
I could try, but I would never be able to explain it as well as Brené Brown does in this short (less than three minute) video from the RSA.
According to Wiseman, it all boils down to these four core components:
- See the world as others see it
- Understanding another’s feelings
- Communicate the understanding
What does this look like in our setting? Let’s take a fictional example of a young parent that has brought their 18 month old in to the department with a snuffly nose and low grade fever. The experienced and empathic nurse sees this dyad and knows the child is essentially well. She listens to the mother’s concerns in a non-judgemental way, nodding her head and not interrupting as Dad explains how he has been up all night with his child and has barely slept. He has had to take the day off work to help out as his wife is sick too and he just wants to sleep. The empathic nurse reflects this back, again without judgement, “If I understand you correctly you are worried that there is something wrong with young Aidan and caring for his and your wife has really wrung you dry, physically and emotionally? Is that right?”
Another way of thinking about it is this – there is no such thing as too much empathy but too much sympathy can paralyse a physician.
What about emotional intelligence?
Closely linked with the idea of empathy is that of Emotional Intelligence. It’s that ability to identify and manage your own emotions as well as those of others.
How is this relevant to looking after children (or indeed any patients)?
Everyone has a story to tell. And if you believe Robert Ford in Westworld, it is the backstory that makes us who we are. By developing our narrative competence we can help bridge the gap between patient and doctor – them and us – in order to provide better medical care. With every advance in technology we step further away from the humanity in front of us and so it behoves us to bridge that divide. Empathy can help us do that.
Listening to stories of illness and recognizing that there are often no clear answers to patients’ narrative questions demand the courage and generosity to tolerate and to bear witness to unfair losses and random tragedies.
From Charon R. Narrative medicine: a model for empathy, reflection, profession, and trust. Jama. 2001 Oct 17;286(15):1897-902.
Empathy, as a history taking tool, allows us to get the most information (both verbal and non-verbal) from each patient and parent encounter.
It has also been associated with better health outcomes. One of the leading researchers in this area, Hojat, found an association between increased levels of physician empathy and levels of HbA1c and LDL cholesterol in diabetic patients. Why might this be the case? Perhaps better non-verbal communication, positive talk and prolonged patient encounters lead to increased patient satisfaction and thus increased compliance.
Are women more empathic than men?
It all depends on how you measure empathy. There is a big difference between women and men when self-reporting scales are used, a moderate sized difference when self-reporting in a lab setting and no difference if you just look at potential physiological surrogates of empathy or discrete observation. So, women may think they are more empathic – and would no doubt score more highly in a Cosmo quiz on the subject – but are probably the same as their male counterparts.
How do you know if you have it?
Tyrell: Is this to be an empathy test? Capillary dilation of the so-called blush response? Fluctuation of the pupil. Involuntary dilation of the iris…
Deckard: We call it Voight-Kampff for short.
It would be nice if there was a simple test like the Voight-Kampff test that would let us determine our levels of empathy.
Instead we might use the Jefferson Scale of Physician Empathy to help us. This 20 item scale uses a 7 point Likert scale to determine a health-care professionals empathy. Studies have shown that psychiatrists score more highly than most (mean empathy score 127.0) with paediatricians following close behind (mean score 121.5) and emergency physicians (mean score 121.0). To put this in perspective orthopods had a mean empathy score of 116.5.
Can you learn it?
It’s certainly possible to increase one’s narrative competence. By reading the stories of others one might become better at eliciting a patients story. Take a look at the Doctors Book Club for some places to start and add some of your own suggestions in the comments section below. And rather than just passively absorbing the words of others, creating your own, reflecting on your own emotional states has also been suggested to boost ones Emotional Intelligence.
It is certainly possible to unlearn it. A number of studies have pointed out a drop in empathy levels in medical students from their pre-clinical years to their years of patient exposure and then their time as junior doctors. We’ve all been exposed to cynical junior staff who dehumanize their patients, perhaps as a self-protective coping mechanism. If it can be unlearned it can certainly bolstered by the right teaching.
But isn’t empathy an intrinsic personality trait or is it something else?
Certainly Krasner and colleagues thought so and set out to prove it. They instituted a formal mindfulness programme for a group of primary care physicians. It encompassed formal mindfulness meditation, narrative medicine and appreciative enquiry. By using such methods they found an overall increase in physician empathy scores at the end of the programme, coupled with an overall increase in physician sense of wellbeing. Whilst it was not a rigorously conducted randomized controlled trial it does lead one to hope.
When Johanna Shapiro asked clinicians how they taught empathy she found a number of interesting similarities between those who did it well. There was a focus on the attitude towards the patient encounter – listening, really deeply listening – rather than just wondering which unit the patient should be referred to. And whilst some may see the teaching of empathy as passing on an attitude, there are those that might use a pure skill based approach – teaching the the non-verbal communication skills that are necessary for an empathic transference of information. All of the clinicians she surveyed also stressed the importance of role modelling empathic behaviour. This was nothing, however, without debriefing the encounter. So perhaps next time you take another member of staff in to see a patient you could ask them to watch you and take some time afterwards to talk about the encounter. Ask them how they saw the patient, as a person, not as a diagnosis, and get them to reflect on the story behind the visit.
An interesting article that I suggest you all read from the Annals of Internal Medicine helps us with some of the language we should use. Beyond active listening (using those little sounds that we make – Umm, Uh-hur) there are other ‘tricks’ we can employ.
Framing – “Let’s see if I have this right…sounds like what you are telling me is…”
Reflecting – Repeating back both content and sentiment of the patients’ words
Identifying emotions – “Tell me how you are feeling about this.”
Asking for, and accepting, correction – “Is there anything I have left out?”
Being a more mindful, empathic practitioner need not take any more time and is certainly more rewarding, both for you and your patients. I’d love to see a resurgence in truly reflective practice, perhaps using informal shift reports, to make better doctors.
[Addendum] If you want to hear more on the subject then listen to Casey Parker’s great talk from SMACCGold.
Wiseman T. A concept analysis of empathy. Journal of advanced nursing. 1996 Jun 1;23(6):1162-7.
Eisenberg N, Lennon R. Sex differences in empathy and related capacities. Psychological Bulletin. 1983 Jul;94(1):100.
Charon R. Narrative medicine: a model for empathy, reflection, profession, and trust. Jama. 2001 Oct 17;286(15):1897-902.
Hojat M, Gonnella JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician empathy: definition, components, measurement, and relationship to gender and specialty. American Journal of Psychiatry. 2002 Sep 1;159(9):1563-9.
Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ, Quill TE. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. Jama. 2009 Sep 23;302(12):1284-93.
Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians’ empathy and clinical outcomes for diabetic patients. Academic Medicine. 2011 Mar 1;86(3):359-64.
Shapiro J. How do physicians teach empathy in the primary care setting?. Academic Medicine. 2002 Apr 1;77(4):323-8.
Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, Veloski J, Gonnella JS. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Academic Medicine. 2009 Sep 1;84(9):1182-91
Coulehan JL, Platt FW, Egener B, Frankel R, Lin CT, Lown B, Salazar WH. “Let me see if I have this right…”: words that help build empathy. Annals of Internal Medicine. 2001 Aug 7;135(3):221-7.
Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient satisfaction and compliance. Evaluation & the health professions. 2004 Sep 1;27(3):237-51.
Halpern J. Empathy and patient–physician conflicts. Journal of general internal medicine. 2007 May 1;22(5):696-700