Turning diversity from a barrier to a facilitator of empathy in health care

A BARRIER TO EMPATHIC CARE IS A BARRIER TO GOOD CARE

Barriers to empathic care are barriers to effective care. Empathic care is a cornerstone of person-centred care,⁴ and a growing body of increasingly robust evidence is showing that lack of empathy causes harm,⁵ while empathic care improves patient outcomes. A cohort study of 867 people with type 2 diabetes found an association between empathic care and reduced mortality.⁶ Meanwhile, several randomised trials also suggest that empathic care reduces patient pain while improving their satisfaction with care.⁷ A parallel series of randomised trials also shows that therapeutic empathy can be taught.⁸ A happy side effect of empathy’s benefit to patients is that it also appears to decrease the risk of burnout among healthcare professionals.⁹ A caveat to the evidence on empathy’s effectiveness in health care is that most of the large studies have involved predominantly White patients. The extent to which empathic care benefits patients from ethnic minorities and other diverse groups is therefore an area where future research is required.

RELATIVE LACK OF HEALTHCARE PRACTITIONER DIVERSITY

The relative lack of diversity among healthcare practitioners could exacerbate the challenge to empathy posed by increasingly diverse patients. In the US¹⁰ and the UK,¹¹ most healthcare practitioners identify as ‘White’. Healthcare practitioners are also better educated than the average person, but this is a double-edged sword. While we need well-educated doctors, they are more comfortable with medical jargon than most patients, and using medical jargon has been shown to inhibit good communication and even harm patients.¹²

This problem is aggravated further if the patient’s first language is not English. While the effect of the relative homogeneity of practitioners is under-researched, we know that diversity of practitioners matters. Female practitioners are rated by patients as being more empathic than males,¹³ and practitioner ethnicity seems to influence empathy levels.¹⁴

Differences between practitioners and patients can affect empathic care. A secondary analysis of data from over 25 000 practitioners found that their implicit attitudes towards patients who are disabled can be negative.¹⁵ Furthermore, a systematic review of 18 studies with almost 10 000 patients found that patients with lower socioeconomic status experienced lower levels of empathy from their clinicians, and White patients experienced higher levels of empathy than their ethnic minority counterparts.¹⁶ A medical trainee in one qualitative study stated: ‘It is challenging to empathise with those patients who do not understand your language. You can extract some factual information; however, you cannot build up an empathetic relationship with the patient.’¹⁷ Left unaddressed, the problems arising from differences between practitioners will get worse, since diversity among practitioners is increasing at a slower rate than the diversity of patients, particularly in relation to certain forms of diversity such as disability.¹⁸

EMBRACING DIVERSITY AS A SOLUTION

While patient diversity is a potential impediment to empathy, it also points towards a solution.¹⁹ Exposing patients to healthcare professionals from a diverse range of ethnic and social backgrounds, and vice versa, creates fertile ground for fostering unconscious (and, perhaps, conscious) normalisation and acceptance of different opinions, cultures, and beliefs. Diverse environments also provide opportunities for patients and practitioners to learn the necessary skills to be able to adapt communication, clinical, and empathic practices to the person they are working with, whatever that individual’s background. By contrast, when practitioners work within a homogeneous group to which they already belong, they may rely on (perhaps often correct) assumptions about patients, thus allowing their ‘empathy muscle’ to atrophy. Embracing diversity can therefore transform it from a barrier to a facilitator of empathic care.

SUGGESTIONS FOR USING DIVERSITY AS A TOOL TO ENHANCE EMPATHY

There are several concrete things that can be done to turn diversity from a barrier to a facilitator of empathy.

• Communicate in plain English. Communicating in ways that the lay public can understand is a simple yet powerful tool that can lay the groundwork for empathic care and will reduce obstacles to such care in many different groups, especially for patients whose first language is not English.

• Embrace diversity as an opportunity to stimulate the ‘empathy muscle’. When faced with patients we perceive as ‘different’, we should adopt an attitude of ‘empathic curiosity’. Jodi Halpern,²⁰ who coined the term ‘empathic curiosity’, encourages us to begin by recognising that we do not always understand what people are thinking or feeling, then allowing our emotional responses to guide our imagination (supplemented, of course, by communication with the patient!).

• Introduce empathy and diversity training. The value of diversity as an empathy-enhancing tool can be integrated into practitioner education via the art and science of therapeutic empathy. Similarly, cultural competency can be developed by discussing and reflecting on the impact of cultural diversity on health throughout professional training.

• Encourage students from all walks of life and cultures to attend medical school.