INTRODUCTION
Over the past 15 years, empathy has been the subject of an exponential increase in the number of publications describing or attempting to explain its role in clinical practice. Why is this? Empathy is one of those concepts that is intuitively understood — at least until you try to explicitly define it. A doctor’s ability to establish an empathic understanding of their patient’s situation is considered essential to the development of a therapeutic relationship. This relationship is vitally important to practising medicine effectively. Empathy is therefore something worth trying to understand. One of the things that has occurred during the last two decades is the development of multiple validated tools that are used to ‘measure’ empathy. The paper by Hermans et al, in this issue of the journal,1 joins the list of reports that use a scoring tool to quantify empathy in an attempt to understand what it means.
We live in an age that privileges a focus on technical, statistically underpinned, evidence-based medicine in the training of new doctors. The core role of the therapeutic relationship in this practice of medicine is de-emphasised. Guidelines are followed, which require calculating scores to determine the ‘best’ treatment for the patient. However, knowing the latest clinical guideline and best practice is not enough to practise effectively as a doctor. A therapeutic relationship with the patient must be formed. This humanises the practice of medicine for both the patient and the doctor. Experienced general and family practitioners rightly take pride in being experts in establishing and using therapeutic relationships with their patients.
A therapeutic relationship is a complex phenomenon composed of many interacting, and difficult to define, factors. Empathy is consistently identified as one of these important factors. Medical schools attempt to teach empathy. Commentators wring their hands about medical students becoming less empathetic as their training progresses.2
Interestingly, the term empathy is of recent origin. It was first used in the English language by Edward Titchener in 1909.3 Lipps described the concept as ‘the experience of another human’.4 Multiple attempts to define empathy have occurred over the past century. These vary depending on the perspective of the discipline defining it. Many aspects of it remain enigmatic. Overlapping concepts such as sympathy and compassion make agreement on an exact definition of empathy difficult. Empathy is believed to be important, but … its nature, description, and effects remain debated. For example, Coulehan et al defined empathy as:
‘… the ability to understand the patient’s situation, perspective and feelings and to be able to communicate that understanding to the patient.’5
This definition stresses the cognitive component of empathy but does not explicitly state the emotional resonance between the doctor and the patient that is also identified as a component of empathy.6
The ability of caregivers to be, or at least appear to be, empathetic is clearly important to both the patient and the provider. A systematic review of the literature on the effects of empathy concluded that:
‘… empathy is an important factor in patient satisfaction and adherence, in decreasing patients’ anxiety and distress, in better diagnostic and clinical outcomes, and in strengthening patient enablement.’7
Empathy has also been linked to increased doctor satisfaction with primary care office visits.8
MEASURING EMPATHY
There are a variety of approaches used to study empathy. A number of quantitative global scoring scales have been developed. The Consultation and Relational Empathy (CARE) tool was developed in the general practice setting, but has also been used more recently in specialised settings and with other healthcare providers to measure empathy.9 The use of the CARE tool has become a component in the assessment of trainees and for revalidation of practising doctors.10 As a measure of quality of care, it is completed by patients to score their care givers. In a twist of the usual use of the tool, Hermans et al report, in this issue, the results of a small study comparing the CARE scores completed by both patients and doctors during the same consultation.1 The patient rated their GP, whereas the doctor assessed and reported their own empathy score obtained during the consultation.
The CARE tool, when completed by patients in a variety of settings, has consistently shown that patients rate their doctors quite highly in terms of empathy.11 Hermans and colleagues’ results showed this as well but also found there was a discordance between how the patient perceived the doctor’s empathy and how the doctor perceived their own empathy. The doctors consistently rated themselves less empathetic than how their patients scored them. The study has a few methodological drawbacks. The number of participants was small. This affects the validity and the ability to make statistical comparisons between subgroups of doctors. The doctors also knew what items they would be scored on before a consultation. The patients did not.
A study by Hall et al (44 physicians, 261 patients) regarding diabetes care compared physicians’ perception of their patients’ opinions and feelings with those of the patients’ themselves. The authors concluded:
‘… our physicians had very limited success in estimating their patients’ opinions and feelings, in spite of having enduring relationships with them. It is reasonable to speculate that when physicians and patients are less well acquainted, awareness would be even poorer.’12
The findings of Hermans1 and Hall12 suggest that doctors and their patients do not perceive the expression of the elements of empathy the same way, at least in the ways they were measured in those studies. This begs the question: how truly empathetic are doctors? Perhaps doctors are simply taught, or discover themselves, through experience in practice, that if they appear empathetic they will build a better therapeutic relationship when they make people feel at ease, listen intently, let the person tell their story, and/or explain things clearly. Perhaps doctors are empathetic but are more critical of themselves during self-reflection than their patients are. Does it actually matter, as long as the patients perceive their doctor as empathetic?
CONCLUSION
Patient-centred care is seen as an antidote to abstract, technical medicine.13 Patients want to be understood and treated with respect by their doctors. They want to have the context of their lives and their concerns taken into consideration when they are given treatment options. This is what patients value. The doctor’s ability to develop an understanding and take into consideration what is important to the patient (that is, their beliefs, hopes, desires, and possibilities) seems to be an essential element to the provision of this type of care. We call this ability empathy. It produces the connection between the doctor and the patient that is at the heart of the therapeutic relationship. I suspect, if you ask senior GPs what keeps them interested in practising medicine after 30 or 40 years, they will say it is the connection they have with their patients. I doubt it is a fascination with treating another case of congestive heart failure or hypertension that keeps them in practice. When the connection with patients is lost, we are burned out. Our patients and ourselves suffer when this happens. Whatever the phenomenon we call empathy is, it behooves us to keep trying to understand it better.
Notes
Provenance
Commissioned; not externally peer reviewed.
Competing interests
The author has declared no competing interests.
- © British Journal of General Practice 2018
