OXFORD: A doctor friend – let’s call her Anne – was teaching three smart medical students who were told to diagnose a woman complaining of nonspecific pain and anxiety.
After 20 minutes of questions, the students wrote seven pages of notes and recommended two drugs: A painkiller and an antidepressant.
Anne considered the students’ analysis and agreed that it was based on sound medical evidence. But something told her there was more to the story.
She sat beside the patient, asked general questions and listened carefully. After a few minutes, the woman broke down in tears and told her about a personal tragedy involving a family member. After some comforting, the woman’s tears, shoulder pain and anxiety went away.
Anne’s dose of empathy cured the woman, without the need of resorting to drugs. This is an important consideration, given that even relatively mild painkillers may contribute to the opioid crisis as some patients subsequently seek stronger and stronger drugs.
The high value now placed on good empathic communication in medicine is relatively new. Until the 1970s, the doctor-patient relationship was often paternalistic. An anxious patient was less likely to be given a shoulder to cry on and more likely to be given a prescription for Valium (“mother’s little helper”).
In the best enactment of the paternalistic doctor, the fictional surgeon Sir Lancelot Spratt, in the 1969 British TV series Doctors in the House, tells a patient who has become distressed at being diagnosed with a serious tumour:
This is nothing whatsoever to do with you.”
Colleagues tell me that the scene is an accurate depiction of how things were. At that time, there was little if any communication skills training. Many doctors believed it was an innate skill that could not be taught.
Certainly, the current focus on good communication hasn’t made the problem of “too much medicine” go away. But promoting empathic communication as a therapeutic agent makes it more likely that people who can do without potentially harmful drugs, like tranquillisers and opioids, don’t get them.
MEASURING THE EFFECTS
We’ve recently quantified the effects of therapeutic empathy the same way drug effects are quantified. More and more carefully controlled trials are comparing what happens with healthcare practitioners who practice empathic, positive communication (being positive is a part of empathy), with those who carry on as usual.
The results are overwhelmingly encouraging, with empathic and positive communication improving conditions ranging from lung function and length of hospital stay, to pain, patient satisfaction and quality of life. There is even evidence that it makes the common cold go away faster.
From related research, we also understand more about how positive empathic communication works. First, you need empathy in order to make a correct diagnosis. Without it, patients may not share symptoms, especially embarrassing ones.
Next, an empathic doctor will help put a patient at ease and reduce their stress. Dozens of trials suggest that relaxation reduces pain, depression and anxiety and even lowers the risk of heart disease.
Being positive also activates the patient’s brain in such a way that the patient makes his or her own painkilling endorphins. Empathic positive communication also increases patient satisfaction. Satisfaction, in turn, is correlated with safer and better health outcomes.
By contrast, unfriendly doctors are less likely to get enough information from patients to make the right diagnoses or prescribe the right treatment. One study even showed that unempathic doctors could cause harm by scaring patients away from medical care when they need it.
Many commonly used over-the-counter drugs barely outperform placebos for back pain, cancer pain and many chronic conditions, yet they can have serious side effects. By contrast, a key finding of the study was that positive empathic communication does not seem to harm patients.
Empathy is considered an essential component of good communication, and there are now training courses on the subject in the US, UK and South Africa.
In healthcare, it has come to capture the idea of practitioners taking time to understand the patient’s condition, showing they understand, then caring for them. Understanding, communicating and caring all pre-date the word “empathy”.
Throughout the history of medicine, and across cultures, prominent medical practitioners and other smart people have recognised that treating a patient requires more than just dispensing medicine.
Hippocrates (460-370 BC) famously said that “it is more important to know what sort of person has a disease than to know what sort of disease a person has”.
Sun Szu-Miao (died 682, known as China’s King of Medicine) instructed doctors:
Commit oneself with great compassion to save every living creature.
Empathy got squeezed out as medicine became more professional and scientific. In the 18th century, paternalism wasn’t just normal, it was valued. Patients were expected to unquestioningly do what doctors like Sir Lancelot Spratt told them.
The American Medical Association’s first code of ethics (1847) stated:
The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions as to their fitness to influence his attention to them.
Today, healthcare practitioners in most developed countries couldn’t get away with ignoring patient views, even if they wanted to.
The move towards empathic communication has been helped by famous medical practitioners, such as Atul Gawande, who writes about the importance of good communication in end-of-life care, and Rana Awdish, who realised how important empathy was when she became a patient.
As strange as it seems to us, paternalism was not as bad as it appears. At the time when paternalism was the norm, “village doctors” lived in their patients’ communities, and knew their patients well. This helped them understand things about the patients that are now being eroded as continuity of care is less common.
IS EMPATHY INNATE?
Some people still believe that empathic communication – or any communication, for that matter – can’t be taught. Either you are born to be a good empathic communicator, or you are not.
Some other practitioners I’ve spoken to believe that all or, at any rate, the vast majority of healthcare practitioners already communicate with empathy. Both those statements are only partly true.
We all know people who have different levels of communication skills. But that doesn’t mean that we can’t improve those skills.
In fact, a systematic review of 13 trials (1,466 healthcare practitioners) found that empathic communication can be taught. Practitioners who start off being great communicators probably improved less than those who started off with less “innate” skill. But that doesn’t mean they didn’t improve.
It’s also only partly true that the great majority of healthcare practitioners already communicate empathy very well. Our latest research found that the extent to which patients feel that their practitioners express empathy varies widely.
In our study, we analysed the combined data from 64 published studies on doctor empathy. In the studies, the patients were asked ten questions such as: Does your doctor really listen to you? Did they make you feel at ease? And: Did your doctor put together a helpful plan of action for you? The highest empathy rating is 50.
We found substantial variability. Female practitioners were ranked as more empathic than male practitioners (43/50 versus 35/50), allied health professionals, such as physiotherapists, more empathic than doctors (45/50 versus 40/50), and practitioners from Australia and the US (45/50) being ranked as slightly more empathic than their counterparts in the UK (43/50), Germany (41/50) and China (41/50).
Among healthcare practitioners who were rated as less empathic (or who spend less time), it could be that they simply aren’t empathic or don’t want to spend more time with their patients. (Time, after all, is money in many healthcare practices.) But this seeming lack of empathy or willingness to spend more time with patients could be a result of outside pressures.
A recent study found that for every hour spent with patients, doctors spent two hours doing paperwork. That and other system-level factors are leading to burnout and worse care.
DISMISSING THE SCEPTICS
Most people believe that empathy in medicine is a good thing, but there are some sceptics. Some worry that too much empathy leads to burnout. And it’s easy to see how this might happen.
READ: Exhaustion, withdrawal and low performance, why diagnosing burnout is an urgent task, a commentary
A doctor who is always empathic with their patients might actually experience the emotions of all their patients, and this could be draining.
Trying to prevent this “compassion fatigue” is one explanation for why empathy seems to decline throughout medical school. Students may learn to protect themselves against that kind of burnout by becoming less empathic. But this only applies if you need to actually experience the emotions of another (this is called “affective empathy”).
Also, some evidence suggests that empathy actually reduces fatigue and burnout.
Moreover, empathic care improves patient satisfaction, reduces the risk of being sued for medical malpractice and thus removes a major source of stress.
Some people also claim that we don’t need empathy in really important cases. If you get into a serious car accident, you need a paramedic to do something not stop and ask you how you feel. A patient with advanced stage cancer who wants treatment needs prompt action more than long heart-to-heart chats.
In surgery, and other medical procedures that demand skill, we might only care about the person’s skill. If I need surgery, I want the surgeon with the best track record in that kind of surgery. I don’t care if they are empathic or even if they can talk.
Healthcare managers worry that empathy takes more time and is therefore unrealistic in a cash-strapped healthcare system. In fact, we found a link between time spent with patients and empathy.
What we don’t know is whether the additional time was cost effective. If the longer consultations lead to reduced medication and fewer hospital admissions, then it could be cost effective.
More importantly, expressing empathy doesn’t necessarily take more time. Empathic body language – looking at the patient instead of a screen, nodding to acknowledge the patient is heard, and smiling – doesn’t take more time.
And one study even showed that when doctors sat beside their patients (empathic body language), as opposed to standing up, patients thought they spent more time although it was the same.
From my research in this field, it is clear that most areas of healthcare (bar those emergency situations) could benefit from being more empathic. But it is also clear that systems need to change so that healthcare practitioners can spend more time on empathy than on paperwork.
In the words of the physician William Osler:
The good physician treats the disease; the great physician treats the patient who has the disease.
Jeremy Howick is Director of the Oxford Empathy Programme at the University of Oxford. This commentary first appeared in The Conversation. Read it here.