Committee on Ethics
This Committee Opinion was developed by the Committee on Ethics of the American College of Obstetricians and Gynecologists as a service to its members and other practicing clinicians. While this document reflects the current viewpoint of the College, it is not intended to dictate an exclusive course of action in all cases. This Committee Opinion was approved by the Committee on Ethics and the Executive Board of the American College of Obstetricians and Gynecologists.
ABSTRACT: Empathy is the process through which one attempts to project oneself into another’s life and imagine a situation from his or her point of view. Most individuals do have an innate capacity to show empathy toward others. Empathy is as important to being a good physician as technical competence. However, at times the health care environment and educational process overly emphasize technological competence, curing disease rather than healing the patient, or the economic aspects of medicine. This may interfere with an empathic approach in the clinical setting. In this Committee Opinion, the Committee on Ethics of the American College of Obstetricians and Gynecologists defines empathy and related terms, describes the role of empathy in medicine, outlines objections and barriers to incorporating empathy into clinical care, reviews research on measuring empathy, discusses the inclusion of empathy in medical education, and makes recommendations about empathic care for health care providers and the health care system.
Empathy is the process through which one attempts to project oneself into another’s life and imagine a situation from his or her point of view 1 2. Empathy plays an important role in caring for and healing the whole patient, as demonstrated by the inclusion of the subject of empathy in the curriculum of all levels of medical education. Providing empathic care improves the physician–patient relationship, resulting in improved patient outcomes and satisfaction 3. This is particularly true in reproductive medicine, where events often take place at critical stages of the development of individuals and families. Most individuals do have an innate capacity to show empathy towards others. However, at times the health care environment and educational process overly emphasize technological competence, curing disease rather than healing the patient, or the economic aspects of medicine. This may interfere with an empathic approach in the clinical setting. Therefore, the Committee on Ethics makes the following recommendations:
Empathy is as important to being a good physician as technical competence. Physicians should continue to incorporate empathy into their interactions with patients because this contributes to the restoration of emotional, spiritual, and physical health of patients.
Empathy needs to be effectively reinforced through regular use at all stages of physicians’ training and careers or it will be lost from physicians’ professional identities and skill sets. Medical students and residents should continue to be taught the skills of empathic care as part of their training. After residency, empathy should continue to be reinforced regularly through continuing medical education.
An empathic relationship can be established with a patient in one encounter. Physicians should make every effort to do so because empathy helps physicians enter into the patient’s perspective, leading them to be attuned to aspects of the patient’s world that physicians may otherwise overlook.
Physicians should aim to become proficient at identifying and responding to the verbal and nonverbal clues that patients often give regarding their emotional states, inviting patients to express their concerns.
Changes are needed throughout the health care system to promote empathy. These changes include cultural and financial shifts that value empathy. Making empathy part of relationships between all levels of health care providers and also part of relationships between health care providers and administrators also is needed. Improving physician well-being will improve empathy toward patients.
Imagine a patient: a 34-year-old pregnant woman comes to the office with vaginal bleeding. Ultrasonography reveals the demise of a 14-week-old fetus. How should a physician relate this information to her? Does the physician’s demeanor change if this was an undesired pregnancy or a fetus with a previously or newly diagnosed lethal abnormality? How differently might the physician approach her if this was a pregnancy achieved after years of infertility or if the patient had experienced other losses like this in the past?
The physician may sympathize and say, “I’m so sorry for your loss.” This general statement of sympathy is a useful first step, but an empathic response goes a step further and uses knowledge about the personal meaning of this loss and the circumstances that surround the experience to help the patient. Empathy allows the physician to better understand each patient’s feelings and perspective. By empathizing with the patient, the physician can help her more effectively cope with this loss, providing her with the appropriate physical, emotional, and spiritual support she needs.
Empathy gives insight into how the patient’s lifelong identity shapes the patient’s view of her illness and decisions about her illness 4. It allows physicians to understand a patient’s relationship with her family and how that relationship may influence her autonomy and decision making. Empathy is as important to being a good physician as technical competence. This is especially true in reproductive medicine where emotional concerns may be as important to patients as physical concerns. Moreover, not empathizing with a patient because of time or other constraints may limit the quality of medical care a physician provides and may introduce a greater margin for medical error 5.
Empathy, Sympathy, and Compassion
The three related terms 1) empathy, 2) sympathy, and 3) compassion all play an important part in physicians’ relationships with their patients. However, the three terms, although very similar, are not completely interchangeable because each has a distinct meaning and role in the care of patients.
Empathy is the process through which a physician attempts to project himself or herself into the patient’s life and imagine the situation from the patient’s point of view 1 2. It goes beyond sympathy and compassion because it involves an appreciation of each patient’s story and an understanding of the differences among individual patients and their situations 6 7. Empathy enhances the physician’s ability to understand individual patients’ unique concerns, life experiences, and decisions. It also allows for the provision of medical care that is more effective and acceptable to patients because the care is consistent with their values and needs.
Sympathy has etymological roots that mean “feeling with” or “like-feeling” 8. Sympathy allows the physician to know the patient’s emotions, resulting in parallel feelings between the physician and patient. Sympathy is described as “an effortless feeling of sharing or joining the patient’s pain and suffering” 9. It also can mean feeling sorry for another. Unlike empathy, sympathy does not require the physician to understand from the patient’s point of view what the patient is feeling or experiencing. Empathy is a genuine attempt to understand the patient’s unique experience 6 9.
Compassion, the sharing of another’s emotional burden, goes beyond merely feeling another’s suffering as occurs with sympathy. Compassion engenders a desire that the physician then acts upon to relieve the patient’s suffering. But it does not involve the insight into the unique context of a patient’s life that empathy provides 10 11.
Role of Empathy in Medicine
Empathy is at the heart of the physician–patient relationship because it promotes the physician’s understanding of the patient’s perspective 12. Studies show that empathy enhances the physician–patient relationship by improving trust, diagnostic accuracy, communication, clinical outcomes, and both physician and patient satisfaction 12 13. Studies also show that empathy not only decreases professional liability claims, but also enables patients to better understand and cope with their illness 12 14.
In the clinical setting, empathy enables the physician to “(a) understand the patient’s situation, perspective and feelings; (b) to communicate that understanding and check its accuracy; and, (c) to act on the understanding with the patient in a helpful (therapeutic) way” 3. However, it is impossible to know exactly how the patient feels or to completely share the patient’s experience 15. Empathy requires imagination, patience, and curiosity on the part of physicians as they attempt to enter a patient’s world, because this world can be very different from their own 13 16. Empathy allows the physician to become attuned to aspects of the patient’s world that the physician may otherwise overlook.
Being empathic with patients who do not share the physician’s culture or values or who are nonadherent to medical recommendations can be challenging 15. But empathy can help resolve conflicts with difficult or angry patients. The curiosity and imagination that are a part of empathy allow the physician to understand the difficult patient’s position more effectively than an intellectual, detached approach 17. Empathy also allows physicians to be open to a greater understanding of an individual patient’s cultural experiences that shape each patient’s unique approach to her illness.
Counterintuitively, empathic responses to patients throughout the clinical encounter actually shorten the patient visit. When patients’ emotional concerns are not acknowledged by physicians, patients will continue to make multiple attempts to express these concerns until they are addressed, thereby lengthening the visit 18 19. Studies show that effective empathic responses can be brief, as short as one sentence, and do not require the physician to greatly alter his or her style 19.
Empathy is not only important to the patient–physician relationship, but it is also important to relationships between health care team members because it improves interactions between clinicians. Clinicians’ understanding of and respect for other colleagues’ views and concerns promotes teamwork, bridges differences, and allows collaborative learning to occur 20. The results are productive resolution of disagreements, decreased staff turnover, and increased staff recruitment, along with improved communication, trust, and mutual respect between staff, and a greater likelihood that staff will regularly reach personal and professional goals 20. Increased communication, trust, and respect between clinicians leads to increased collaboration in patient care among health care team members and improved patient outcomes 21.
Objections and Barriers to Incorporating Empathy Into Clinical Care
Professional Training Issues
Positive empathic and communication role models are crucial to medical education at all levels. Such positive role models for medical students and clinicians are present in all learning environments, including the clinical setting. Observing and interacting with these exemplary role models is one part of an informal or hidden curriculum that is important in learning how to be a physician. The hidden curriculum results from “the processes, pressures, and constraints which fall outside of, or are embedded within, the formal curriculum, and that are often unarticulated or unexplored” 22. This hidden curriculum can have both positive and negative influences. In most instances this informal curriculum models positive behavior, including empathy. These positive influences include attending physicians, residents, nurses, and other personnel who take time to listen, communicate with patients, and understand what each individual patient is experiencing with her illness. However, negative role models can contribute problematic aspects to the hidden curriculum 23 24. The ever-expanding volume of information that must be included in the medical education curriculum at all levels may limit the time available for learning empathy and communication skills 13 25 26. For example, on the wards, a medical student may see overworked residents, nurses, or attending physicians who lack the time or training to express empathy. The medical student may incorrectly assume from this that empathy may not always be as important as he or she had learned in the classroom or had seen in other positive role models for empathy in the clinical setting.
Fear of Overattachment
Another concern with empathy is that it may lead to some physicians becoming too attached or emotionally involved with patients, resulting in a loss of objectivity 16 27 28. Other physicians and health care providers may find trying to imagine the experience of a patient uncomfortable or even frightening in some cases, causing them to distance themselves emotionally from a patient, because it raises the possibility that they or their loved ones could experience the same medical problems 16. This distancing can sometimes result in patients’ wishes and desires for care being overlooked to some degree. “Empathetic equipoise” is the midpoint that avoids these two extremes of involvement and detachment 28. Physicians achieve this by learning about their own emotional responses to patients and how to appropriately deal with these emotions. The responses will vary with each individual patient and influence how detached or empathic the physician may want to be. However, as physicians gain more experience in managing their own emotional responses to patients, they can achieve more meaningful interactions with patients without becoming too detached or involved 29 30.
Financial Obstacles to Empathy
Changes in the economic and business aspects of medicine can present other obstacles to empathy in medicine. Many health care systems, businesses, and insurance companies are justifiably concerned with controlling costs associated with providing health care 9. The result may be less time overall for physicians and other health care professionals to spend with patients, frequent physician changes by patients because of changing or lack of insurance coverage, and decreases in staffing for patient care because of reduced reimbursements 25. This may result in physicians communicating less with patients and overlooking opportunities to incorporate empathy into clinical care.
Health Information and Misinformation
Information-based obstacles to empathy include the large amount of medical and technical information that physicians must keep up with and the large volume of both accurate and inaccurate information available to patients about their illnesses from the Internet and other sources. Some physicians’ negative reactions to patient research and the time required to correct the misinformation patients find on their own may create yet another obstacle to incorporating empathy into clinical care.
The Culture of Health Care Delivery Systems
The culture of the health care system that physicians practice within can be an additional barrier to empathy. Researchers have found that “the energy and enthusiasm that a practitioner brings into the consultation with a patient is profoundly influenced by the practice and larger organization’s values and integrity” 20. Lack of empathic relationships within a medical practice, with administrators, or between consulting specialists may affect the physician’s relationships with his or her patients because the physician may be forced to engage with patients in a manner that can be different from how he or she is treated by others in the health care system. Health care system cultures that do not value empathy will not reward physicians’ empathic relationships with patients and may actively discourage physicians from being empathic with patients.
Research on Empathy and Clinical Outcomes
Because empathy is important to the physician–patient relationship, more research is being conducted on empathy and how to measure it, with methodological tools evolving rapidly. The Jefferson Scale of Physician Empathy has been developed and validated for measuring empathy of physicians, medical students, residents, and nurses using a self-reporting method. A similar tool is the Jefferson Scale of Patient Perceptions of Physician Empathy in which patients fill out a questionnaire concerning how empathic they perceive their physicians to be 31 32 33. These tools are available from their authors and in the book Empathy in Patient Care by Mohammadreza Hojat 9.
Studies of Physician Behavior
Studies conducted using the Jefferson Scale of Physician Empathy and the Jefferson Scale of Patient Perceptions of Physician Empathy show that both physicians’ ability to be empathic and patients’ perceptions of physician empathy affect clinical outcomes. The findings also demonstrate that an empathic relationship can be established in just one visit 31.
Additional research on empathy examined recorded interactions between patients and primary care physicians, oncologists, and surgeons, looking for the number of empathic responses from these physicians during patient visits. Empathic responses to patients by physicians ranged from 10% to 22% in two studies of cancer patients 5 19. Empathic responses were greater from younger physicians, female physicians with female patients, and oncologists who characterized themselves as having a “socioemotional” orientation rather than a technical orientation 5. A different study of primary care physicians found that patients usually offer clues that physicians need to acknowledge and encourage patients to elaborate upon, as opposed to patients providing direct and spontaneous expressions of emotions to which physicians can respond 18. The researchers hope that these studies will eventually evolve into educational models for physicians to use to improve empathic communication with patients by teaching physicians to become proficient at recognizing and responding empathically to patients’ verbal and nonverbal clues, thereby inviting patients to express their concerns.
Studies of Empathy in Medical Education
Research using the Jefferson Scale of Physician Empathy and Jefferson Scale of Patient Perceptions of Physician Empathy demonstrated a decrease in empathy among third-year medical students 34. Medical students with higher empathy scores performed better during clinical clerkships, but not on objective examinations of medical knowledge such as the Medical College Admission Test and the United States Medical Licensing Examination 12 34. An additional study of internal medicine residents found a correlation between empathy and resident well-being, with higher mental well-being associated with higher cognitive empathy scores 35.
Teaching and Reinforcing Empathy in Medical Practice
Medical educators are increasingly recognizing the importance of empathy in improving physician–patient interactions and relationships, thereby improving patient outcomes and satisfaction 9. Empathy is successfully being incorporated into the formal curriculum of medical schools, especially in the clinical setting 3. Empathy is included in the Accreditation Council for Graduate Medical Education competency requirements for residency training under the categories of patient care, interpersonal and communication skills, and professionalism 36. Empathy is also the focus of continuing medical education courses for physicians after residency.
There is no one specific model for teaching empathy to medical students and physicians. The use of narratives and stories, patient histories, role playing, and conversations are effective ways of teaching empathy. This includes physicians and medical students paying attention to patients’ stories of illness in the context of the patients’ lives, especially when taking patient histories. Physicians and medical students also can learn empathy by developing narrative competence, which is the ability to acknowledge, absorb, interpret, and respond to a patient’s story and plight. Narrative competence allows physicians and medical students to join patients in their illnesses 37.
Physicians’ personal experiences with illness or learning about experiences of illness through novels, fictional stories, and paintings also effectively teach empathy 38. Point-of-view writing from the patient’s perspective by medical students increases the students’ empathy, ability to identify others’ feelings, expression of emotions, and development of insight 39. Minimizing medical students’ and physicians’ distress and improving their quality of life and the work environment increases empathy towards patients 35. Providing medical students with physician role models who demonstrate empathy towards patients, along with showing students how to overcome their anxieties associated with patients’ illnesses and suffering, also increases medical students’ empathy toward patients 27 40. Physicians and medical students also should take time to learn about the availability of resources and other professionals (eg, counselors, clergy, and psychologists) in their area who can provide additional support and empathy to patients when indicated. However, these other resources should not be a substitute for physicians and medical students learning how to be empathic toward their patients.
Communication is vital to empathy in the physician-patient relationship. Teaching medical students and physicians the use of open-ended questions and continuers (phrases that invite the patient to continue expressing her thoughts and feelings), techniques for recognizing patients’ verbal and nonverbal emotional cues, and language for empathic responses to patients results in improved communication and understanding 5 40 41 42. Please see Box 1 for examples of open-ended questions, continuers, phrases to facilitate empathy, and examples of direct and indirect opportunities for empathy that arise in the course of the patient–physician encounter.
Communication Tools for Improving Empathy
Examples of Open-Ended Questions and Phrases*
“Tell me more.”
“How did you feel?”
“What concerns do you have?”
Examples of Phrases to Facilitate Empathy†
“I want to make sure I really understand what you are telling me.”
“I don’t want us to go further until I’m sure that I’ve gotten it right.”
Examples of Continuers‡
“I can see this is making you angry.”
“I can imagine how scary this must be for you.”
“Tell me more about what is upsetting you.”
Examples of Empathic Opportunities Expressed by Patients‡
Direct empathic opportunity (explicit verbal expression of emotion) – “I have been really depressed lately.” “I’m scared about what my test result means.”
Indirect empathic opportunity (implicit verbal expression of emotion) – “Does this mean I’m going to die?” “Oh no. What do we do now?”
*Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: have we improved? JAMA 1999;281:283–7.
†Halpern J. Practicing medicine in the real world: challenges to empathy and respect for patients. J Clin Ethics 2003;14:298–307.
‡Pollak KI, Arnold RM, Jeffreys AS, Alexander SC, Olsen MK, Abernethy AP, et al. Oncologist communication about emotion during visits with patients with advanced cancer. J Clin Oncol 2007;25:5748–52.
Regardless of how it is taught, empathy requires effective reinforcement through regular use at all stages of physicians’ training and careers or it will disappear from physicians’ professional identities and skill sets. Empathy is a “use it or lose it” skill 9. It is important for physicians to use and not lose the ability to be empathic toward patients because empathy contributes to the restoration of emotional, spiritual, and physical health of patients.