Empirical research on empathy in medicine—A critical review

https://doi.org/10.1016/j.pec.2009.06.012Get rights and content

Abstract

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.

Introduction

Empathy is generally considered important and positive to help patients in a good way, and empirical research on medical students’ and physicians’ empathy is growing. For example, many studies have shown that empathy may be stunted or reduced during medical training (see Section 3.5.1), and these tendencies have given rise to considerable concern.

Generally, empathy in medicine may be described as appropriate understanding of the patient [1]. However, there is no general agreement concerning how to define, teach, or study empathy. Some conceptual issues that have been hotly debated are whether empathy is emotional or cognitive, subjective or objective, and whether empathy includes communicating the understanding generated or acting appropriately based upon this understanding. Some researchers have argued that empathy is a multidimensional construct and have used more inclusive methods, while others have chosen to study selected dimensions. Empirical studies of empathy have been reviewed in various publications (see e.g. [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]). However, after reading publications in which empirical research on medical students’ or physicians’ empathy has been presented or discussed, my impression was that important methodological assumptions, ideals, and trends did not receive adequate attention. Furthermore, none of the previous reviews were systematic reviews including both qualitative and quantitative methods used to study empathy in medicine. Thus, this critical review was undertaken. The focus in this article is on the methods used to study empathy in medicine – in particular methodological limitations and challenges – and the reported results in the reviewed publications are only presented where relevant to illustrate methodological aspects. Thus, the publications reviewed include many positive contributions and interesting results not presented here.

Section snippets

Methods

A systematic literature search in Ovid MEDLINE(R), PsycINFO, EMBASE, and CINAHL was performed from May to August 2008. Publications presenting empirical research on medical students’ or physicians’ empathy were searched for (through subject headings related to empathy [AND] medical students or physicians [AND] empirical research; see Box 1. Languages included: English, German, Spanish, and the Scandinavian languages). In addition, other publications were identified through “unsystematic”

What methods were used?

In the majority of the selected publications (171 of 206) predominantly quantitative methods were used. Among the 171 predominantly quantitative studies, 38 various quantitative measures were identified (see Table 1 and Section 3.4). However, 51 of the predominantly quantitative studies selected did not describe how empathy was evaluated or indicated that empathy was measured in an implicit or imprecise way [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28]

Discussion

This review indicates that empirical research on empathy in medicine is abundant with quantitative measures and studies, and single-method approaches. The quantitative studies of empathy are often based solely on self-reports far away from medical practice and the patient, or uncritically focused on observable aspects, and in general remote from physician's and patient's concrete feelings, experiences and interpretations in practice. Some of the observer-based measures seem to presuppose that

Conflict of interest statement

The author has no conflict of interest (e.g. financial, personal or other relationships with other people or organizations that could inappropriately influence, or be perceived to influence, his work).

Acknowledgments

This paper is part of a Ph.D. project funded by the Research Council of Norway and supervised by Professor Jan Helge Solbakk and Professor Arne Johan Vetlesen.

References (236)

  • S.L. Swenson et al.

    ‘She gave it her best shot right away’: patient experiences of biomedical and patient-centered communication

    Patient Educ Couns

    (2006)
  • R.D. MacLeod

    On reflection: doctors learning to care for people who are dying

    Soc Sci Med

    (2001)
  • N.M. Bendapudi et al.

    Patients’ perspectives on ideal physician behaviors

    Mayo Clin Proc

    (2006)
  • S.W. Mercer et al.

    A qualitative study of patient's views on the consultation at the Glasgow Homoeopathic Hospital, an NHS integrative complementary and orthodox medical care unit

    Patient Educ Couns

    (2004)
  • T.S. Laidlaw et al.

    What makes a physician an exemplary communicator with patients?

    Patient Educ Couns

    (2007)
  • R. Pedersen

    Empathy: A wolf in sheep's clothing?

    Med Health Care Philos

    (2008)
  • C.M. Duan et al.

    The current state of empathy research

    J Couns Psychol

    (1996)
  • J.M. Hemmerdinger et al.

    A systematic review of tests of empathy in medicine

    BMC Med Educ

    (2007)
  • K.A. Stepien et al.

    Educating for empathy. A review

    J Gen Intern Med

    (2006)
  • J.M. Satterfield et al.

    Emotion skills training for medical students: a systematic review

    Med Educ

    (2007)
  • J. Rappaport et al.

    Accurate empathy: confusion of a construct

    Psychol Bull

    (1972)
  • H.M. Bachrach

    Empathy, We know what we mean, but what do we measure?

    Arch Gen Psychiatry

    (1976)
  • W.J.P. Reynolds et al.

    Empathy has not been measured in clients’ terms or effectively taught: a review of the literature

    J Adv Nurs

    (1999)
  • G.A. Gladstein

    Understanding empathy: integrating counseling, developmental, and social psychology perspectives

    J Couns Psychol

    (1983)
  • B.E. Chlopan et al.

    Empathy: review of available measures

    J Pers Soc Psychol

    (1985)
  • M.J. Lambert et al.

    Outcome research in Carkhuffs Human Resource Development Training-Programs—Where is donut

    Couns Psychol

    (1977)
  • J.M. Morse et al.

    Exploring empathy: a conceptual fit for nursing practice?

    Image J Nurs Sch

    (1992)
  • R. Gallop et al.

    The empathic process and its mediators. A heuristic model

    J Nerv Ment Dis

    (1990)
  • B. Buddeberg-Fischer et al.

    The influence of gender and personality traits on the career planning of Swiss medical students

    Swiss Med Wkly

    (2003)
  • E. Falkum

    What is burnout? Norwegian

    Tidsskr Nor Laegeforen

    (2000)
  • K.E.I. Ro et al.

    Does a self-referral counselling program reach doctors in need of help? A comparison with the general Norwegian doctor workforce

    BMC Public Health

    (2007)
  • J.E. Verby et al.

    Peer review of consultations in primary care: the use of audiovisual recordings

    Br Med J

    (1979)
  • L.L. White et al.

    Teaching students behavior change skills: description and assessment of a new motivational interviewing curriculum

    Med Teach

    (2007)
  • R.M. Epstein et al.

    “Could this be something serious?” Reassurance, uncertainty, and empathy in response to patients’ expressions of worry

    J Gen Intern Med

    (2007)
  • J. Shapiro et al.

    Point-of-view writing: a method for increasing medical students’ empathy, identification and expression of emotion, and insight

    Educ Health

    (2006)
  • I. Ofri et al.

    Attitudes of therapists toward Holocaust survivors

    J Trauma Stress

    (1995)
  • N. Scott et al.

    Longitudinal investigation of changes in interviewing performance of medical students

    J Clin Psychol

    (1976)
  • L.M. DiBartola et al.

    Perceptions of physicians’ interpersonal skills

    Acad Med

    (1997)
  • M.A. Cormack et al.

    Factors linked to the prescribing of benzodiazepines by general practice principals and trainees

    Fam Pract

    (1992)
  • C.G. Silber et al.

    Do global rating forms enable program directors to assess the ACGME competencies?

    Acad Med

    (2004)
  • M.J. Vernooij-Dassen et al.

    Quality assessment in general practice trainers

    Med Educ

    (2000)
  • V. Jenkins et al.

    Can communication skills training alter physicians’ beliefs and behavior in clinics?

    J Clin Oncol

    (2002)
  • M. van Zanten et al.

    Using a standardised patient assessment to measure professional attributes

    Med Educ

    (2005)
  • R. Charlton et al.

    Perceived skills in palliative medicine of newly qualified doctors in the U.K.

    J Palliat Care

    (2000)
  • R. Zachariae et al.

    Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease

    Br J Cancer

    (2003)
  • A. Pawelczyk et al.

    Medical students’ empathy and their career preference

    Psychiatr Psychol Klin

    (2007)
  • A. Rahman

    Initial assessment of communication skills of intern doctors in history-taking

    Med Teach

    (2000)
  • S.D. Nightingale et al.

    Sympathy, empathy, and physician resource utilization

    J Gen Intern Med

    (1991)
  • P.R. Yarnold et al.

    Comparing the resource use of sympathetic and empathetic physicians

    Acad Med

    (1991)
  • P.R. Yarnold et al.

    Androgyny predicts empathy for trainees in medicine

    Percept Mot Skills

    (1993)
  • Cited by (210)

    • Physicians, emotion, and the clinical encounter: A survey of physicians’ experiences

      2022, Patient Education and Counseling
      Citation Excerpt :

      While several studies have looked at the emotional experience of medical trainees [26–29], the emotional socialization of physicians [8,26,30], and physicians’ emotions in the context of end-of-life care [13], to our knowledge this is the first study to survey what challenges physicians experience while attending to emotions during routine medical encounters. Currently, the values of humanism and of feeling or conveying “empathy” are widely recognized in medical education as desirable [31], yet tangibly useful skill building has not caught up. In order for emotion training to be worthy of space in the medical education curriculum, its value must be made explicit.

    • A scoping review of empathy recognition in text using natural language processing

      2024, Journal of the American Medical Informatics Association
    View all citing articles on Scopus
    View full text