The doctor enters the exam room. You talk about why you’re there. The doctor responds. And then what?
According to researchers, how the physician responds can make a difference in your progress. If you feel understood and cared about, your condition is likely to improve faster than if you felt alienated or ignored.
The difference is empathy, and researchers such as Thomas Jefferson University’s Mohammadreza Hojat, a research professor of psychiatry and human behavior in the Center for Research in Medical Education & Health Care, are gaining a new understanding of how important it can be, and how to measure it.
He spoke to us recently about empathy.
What is empathy, as it relates to patient care?
The concept of empathy is a bit vague. Different researchers offer different definitions. But in the context of patient care, we define empathy as a personality attribute that involves three concepts. One involves understanding of a patient’s experiences, concerns, and suffering. Second is the ability to communicate this understanding. And third, the intention to help.
People in the general population have different degrees of empathy. Why some people have a lot and some do not depends on many factors, including genetic factors, environmental factors, cultural factors, and educational factors. It also depends on a person’s interactions, their experiences, their relationship with their parents. All influence empathy in adulthood.
Why is empathy in a medical setting so important?
We have shown that physicians who score higher on empathy have more positive patient outcomes. In one study, we administered a test to family practitioners to determine their level of empathy. Then we examined the electronic records of their diabetic patients. What we found is that those physicians who scored higher on empathy had a higher proportion of diabetic patients whose disease was under control.
There are several reasons that could explain this, and it’s a little bit complicated. But briefly: When there is empathic engagement in patient care, this would lead to a trusting relationship. Because of it, the patient might reveal the narrative of his or her disease more completely, not try to conceal anything. They would be honest with their physician. That leads to a better diagnosis because the physician gets all the important information.
On the other hand, the patient is more likely to follow the orders of an empathic physician. The compliance rate is higher. Better diagnosis and better compliance lead to more positive outcomes.
What is the Jefferson Scale of Empathy that you developed? How can it be used?
The scale is the only test to specifically measure empathy, or empathic orientation to patient care. It has 20 questions that can be answered in a few minutes. Isn’t it amazing, what you can see in a few minutes? This scale has so far been translated into 57 languages and has been used in more than 85 countries.
One way it can be used is for research purposes. If you have a course or a workshop with the goal of increasing students’ or physicians’ understanding of patients, you could administer this test before and after the workshop to see if there’s a significant difference.
This instrument can also be used in medical school admission decisions. Admission to medical school, at least in the U.S., is mostly based on academic achievement, meaning higher scores on medical college admissions tests or higher undergraduate grade point averages.
But medicine is based on two components: the science of medicine, and the art of medicine. Often, we are too concerned with the science. But as I mentioned, empathy is related to clinical competence and patient outcome. I think medical schools should choose applicants that have the best potential to become a caring physician, not physicians that can pass examinations of acquired knowledge. A score on biology doesn’t say anything about ability to communicate with the patient.
In another recent study, you and your colleagues developed a national norm for empathy in medical students. Tell us about that.
This is a landmark study of medical students in 41 out of 48 medical colleges of osteopathic medicine in the U.S. It’s a seven-year study. The purpose is to find out what the correlates of empathy are among medical students. Is it related to ethnicity, gender, undergraduate studies, or other things?
We also want to find out whether the level of empathy changes — declines or increases — in medical school. In previous studies, we have found it declines. But that was in allopathic, or conventional, medical school. But osteopathic medical schools have a somewhat different focus, including a more holistic approach.
This study is still ongoing. But in the first phase, we developed a national norm for the scores on the Jefferson Scale of Empathy. It serves as a benchmark for assessing the individual performance of students. The raw score of an empathy test by itself doesn’t mean anything. It’s just a number. But now, we can look at this national norm and convert raw score to a percentile score.
We developed norms for males and females separately, because females tend to score significantly higher in many of these studies. We also developed separate norms for different levels of medical education.
All this looks at a practitioner’s current level of empathy. Can empathy be taught?
Yes, indeed. In our studies, and others have replicated them, we have found that empathy can be changed. It can decline; it can be improved.
In one study, we found that empathy often erodes in medical school, starting in the third year. This is a critical year because it’s when the curriculum shifts from basic science to clinical science. It’s the year that the students officially get involved with patients, when empathy is most needed.
It’s an interesting phenomenon. Why is it happening? First, they have had an overreliance on the science of medicine, not the art of it. There is an overreliance on computer-based diagnostics and computer technology, so a need for interpersonal relationships is minimal.
There is also a new mentality, or culture, of defensive medicine. Medical students and physicians are afraid of malpractice litigation. In that case, every patient could be a potential adversary of a physician. So naturally, the physician becomes a detached figure, not an attached figure.
Also, there are fewer positive role models now. Cynicism, exclusiveness, and snobbery can develop as the students progress. Some think they are a different breed of human being because they are becoming a doctor. They are sleep-deprived. They encounter some disrespectful and overdemanding patients. Rather than handling it well, they take it as an argument against establishing a good relationship with a patient.
Unfortunately, in medical education, we do not have any programs about the benefits of human connections. Any kind of program that increases understanding of others would be helpful. In one study, I showed clips of commercial movies that involved physician/patient interactions. Then I asked the students to analyze the interaction and discuss the positive and negative aspects. This exercise by itself could increase empathy.
We don’t pay attention to classic literature, art, or music in medical schools. These can all help us understand human pain and suffering.