The Need for Compassion

Massachusetts General
  • Meera Lee Sethi

It has been more than 20 years since the Association of American Medical Colleges last revised its Medical College Admission Test. The MCAT has traditionally focused on basic scientific concepts—asking, for example, how stomach acidity changes the function of the enzyme pepsin. But starting in 2015, those aspiring to the Hippocratic oath will also have to tackle some 67 questions that test their knowledge of how behavioral, social and cultural factors might influence patients’ health.

Suppose that word about a recent HIV diagnosis has spread to someone in a different social group; imagine a heterosexual man, for example, hearing that a gay acquaintance has found he has the virus. Would this news leave the first man more fearful about his own chances of contracting the disease, or less? To tackle this problem, students must understand the psychological phenomenon of “comparative optimism”—which tends to make people underestimate their own vulnerability to a disease compared with someone in a group they don’t identify with.

The new MCAT structure reflects an increasing concern within the medical community that the profession, ever more technically proficient, has lost touch with the human dimensions of providing care. That missing element—empathy—lets physicians understand patients’ unique perspectives and feelings, seeing them as whole human beings rather than an amalgamation of symptoms. An empathic physician understands and a compassionate physician communicates that understanding to patients and acts on it in a way that’s therapeutic.

Empathy is there in abundance when first-year medical students meet patients, says Beth Lown, an internist at Mount Auburn Hospital in Cambridge, Mass. “They lean forward, make eye contact and listen intently,” she says. “You can see them resonating with the person in the bed. They’re like mirrors.” But by the time those students get their medical degrees, the mirrors don’t reflect nearly as well. Research has suggested that a novice physician’s ability to empathize with patients wears down during training, and a recent study noted that clinical empathy begins to decline during the third year of medical school—typically when students turn from academics to providing direct clinical care to patients.

Other research indicates that this trend continues during residency and establishes habits of approaching patients that last throughout a physician’s career. University of Rochester scientists who analyzed audiotapes of interactions between oncologists and people with lung cancer, for example, found nearly 400 occasions in which patients expressed concerns. But physicians responded with emotional support only 1 out of 10 times; they were much more likely to offer what the researchers called “biomedical questions and statements.”

Those missed opportunities don’t surprise Lown, medical director of the Schwartz Center for Compassionate Healthcare, a nonprofit organization that works to nurture positive relationships between patients and their clinical caregivers. In 2010, a survey Lown helped conduct found that although the vast majority of patients and physicians consider effective communication and emotional support “very important” to successful medical treatment, only 53% of patients and 58% of physicians said they believe the U.S. health system is a compassionate one.

Clearly, physicians must be technically proficient. The question has always been whether that expertise must come at the expense of being able to connect emotionally with patients. The eighteenth-century surgeon William Hunter famously argued that dissecting corpses would give his students “necessary inhumanity.” And in 2001, Jack Coulehan and Peter C. Williams, professors in the department of preventive medicine at Stony Brook University, contended that an unspoken bias toward detachment and objectivity runs through the curricula of most American medical schools—leading some trainee physicians to emerge thinking of themselves “primarily as technicians.”

A dozen years later, amid remarkable advances in medical technology, physicians may be all the more likely to see empathy as expendable. Yet new research is showing that the human side of doctoring also has observable, quantifiable effects. These latest studies are demonstrating that empathy training may improve the quality and effectiveness of care. And while compassion isn’t a magic pill, it may help address some of the problems of a medical system that the nonpartisan Institute of Medicine has said “falls short on such fundamentals as quality, outcomes, cost and equity.”

Mohammadreza Hojat, a psychologist and research professor at Jefferson Medical College in Philadelphia, has spent more than a decade studying the relationship between physicians and patients, and he’s at the vanguard of recent attempts to make the slippery concept of empathy more measurable. “When I started,” Hojat recalls, “I heard people all around me talking about empathy, but even though everyone agreed it was important, no one had done any empirical studies of how much this personal quality actually mattered in medical education and patient outcomes.”

Seeking hard data, Hojat scoured research linking concrete traits to empathy. He points to evidence that studying literature and art, for example, improves the understanding of human suffering. “It has also been reported that stress in a physician-patient relationship is lifted if both share a sense of humor,” says Hojat, who drew on a comprehensive literature search to design a 20-item questionnaire that measures physicians’ empathy. Created more than a decade ago, the Jefferson Scale of Empathy (JSE) has become a standard tool in clinical empathy research, and it has a version for students that lies at the heart of that 2009 study showing a precipitous decline in empathy during the third year of medical school.

Convinced that becoming a physician erodes empathy in some physicians-in-training, Hojat wanted to figure out how that loss might affect patients. He and his colleagues sorted a group of family physicians who had completed the JSE into high, medium and low scorers. Then they examined the clinical records of 891 diabetic patients those doctors had treated. Hojat chose to study diabetes because it’s so common and because there are quantifiable factors that indicate how well a patient is doing. They correlated physicians’ empathy scores with their patients’ levels of low-density lipoprotein (LDL) cholesterol, a major risk factor for cardiovascular disease and stroke, and with patients’ hemoglobin A1C levels. (The A1C test measures what percentage of hemoglobin is coated with sugar, or glycated.) Low levels (<7.0%) are a commonly accepted indicator that diabetics are successfully controlling blood sugar levels.

Almost 6 in 10 of the patients seen by the highest-scoring physicians had well-managed hemoglobin A1C levels, versus only 40% of those treated by physicians with low empathy scores. Patients of more empathic physicians also tended to have lower levels of LDL (<100), the so-called bad cholesterol.

A year later, Hojat and a group of collaborators at Jefferson Medical College and in Italy studied nearly 21,000 diabetic patients in Parma, Italy. Having an empathic caregiver, the researchers discovered, reduced the risk that a patient would have certain life-threatening complications such as diabetic ketoacidosis (in which toxic acids build up in the bloodstream). The fact that Italy has universal health coverage only under- scored the significance of the results, says Hojat, because there were no variations in health insurance coverage or financial barriers to receiving care that could have muddied the findings. In another recent trial, University of Wisconsin researchers recruited 350 patients with colds and gave them either standard physician visits or “enhanced” visits with physicians trained to make direct eye contact, touch patients and spend more time with them. All of the cold sufferers completed a questionnaire scoring their physician’s empathy. Over a two-week follow-up period, the 84 people who gave their physicians perfect empathy scores recovered an average of one day sooner than the rest of the group. Nasal wash samples pointed to a possible bio- chemical explanation: As a group, patients with empathic doctors tended to have more than double the increase that other patients experienced in cytokine interleukin-8, an infection-fighting protein the immune system produces.

One way empathy may translate into concrete physiological benefits is by countering patients’ tendency not to follow their physicians’ advice. “Half of all patients in this country don’t follow through with their doctors’ treatment recommendations,” says Lown, citing a widely accepted World Health Organization figure. And though the medical community has long tried to address this problem with adherence-improvement strategies, two recent meta-analyses of such interventions suggest that most fall short of changing patient behavior.

What may be missing, say proponents of empathy, is trust. “A patient who trusts a doctor,” says Hojat, “is much more likely to comply with instructions. And we know that greater compliance leads to better outcomes.”

Crucial to establishing trust is a skill that Rita Charon, professor of clinical medicine and director of the Program in Narrative Medicine at Columbia University’s College of Physicians and Surgeons, calls “narrative competence”—the ability to understand and act on others’ stories. Charon recalls a diabetic whose blood sugar remained out of control despite years of visits to specialists, largely because she tended to skip insulin doses and eat erratically. Simply listening to her for 10 minutes revealed the woman’s preoccupation with the loss of several teeth to diabetic gum disease. A new set of dentures transformed her outlook—and made her an ally of her physician. Only then did she become willing to embrace proper habits that helped her blood sugar stay within healthy limits.

An emerging body of data connecting empathy, adherence and treatment outcomes supports such anecdotal evidence. In 2011, researchers at the University of California, Davis, found that patients whose physicians were empathic tended to need fewer consultations with specialists, were hospitalized less frequently, required fewer lab and diagnostic tests, and had lower overall medical costs. And a 2006 study of HIV-positive patients found that those who answered yes to “My HIV provider really knows me as a person” were significantly more likely to follow the exacting schedules required for retroviral medications to be effective. Blood tests revealed that the answer to this question also had much to say about whether patients would have undetectable serum HIV RNA, a marker of infection whose absence is a sign of treatment success.

With more and more research confirming that empathy is important, there remains the question of whether it can be taught. In one training effort, physicians who received computer feedback on audio recordings of patient visits doubled the number of empathic responses they provided. And a pilot study Hojat recently conducted showed that having residents visit a new mother’s home and help her assemble a rocking chair significantly increased empathy scores among the test group.

In 2012, psychiatrist Helen Riess, director of the Empathy and Relational Science Program at MGH, showed that empathy training could produce noticeable changes in physicians’ behavior. Riess randomized 100 physicians-in-training to receive either standard post-graduate medical training or that training in addition to three 60-minute empathy modules that she developed. That extra instruction prepared residents to maintain empathic behavior in specific situations, such as when delivering bad news. Participants practiced using photographs to decode subtle facial expressions, learned about neurobiological mechanisms involved in empathy and watched videos of interactions between doctors and patients. The videos were paired with real-time physiological overlays showing changes in both parties’ galvanic skin conductance—a non-invasive gauge of nervous system activity that measures emotional arousal. “Residents could see the direct physiological impact of comments that were dismissive, arrogant or otherwise failed to consider the patient’s perspective,” says Riess. “They began to realize that when a patient is in emotional pain, there is also a physical event happening that we can measure.”

After a few months, the test group earned significantly higher patient-rated empathy scores than those physicians had gotten at the outset; meanwhile, the scores of the control group went down significantly.

Riess now teaches empathy to clinicians all over the world through an online version of her course. She acknowledges that much of what she does is focused on changing behaviors. “You can’t be empathic if you don’t make eye contact, for instance, or if you don’t take the time to look at a patient’s facial expression and try to interpret what it means,” she says. But training physicians to engage in those behaviors can be an effective first step in transforming how they practice, and physician feedback indicates that this transformation is happening.

The Schwartz Center, meanwhile, takes a complementary approach that directly addresses physician attitudes. In its flagship program, the center works with health care institutions across the United States and in the United Kingdom to conduct monthly forums for physicians, nurses and other caregivers. Unlike clinical rounds, which focus on evaluating patients’ medical progress and making decisions about treatment, these sessions deal with the emotional and social aspects of a case.

On a recent Friday afternoon at the Kaiser Permanente Sacramento Medical Center, for instance, a ripple of sympathy flowed through a packed room when a young resident described being “fired” by the family members of a patient. Some in the crowd reassured the resident that she had done nothing wrong; others reminded her that family members who lash out in anger often do so because they feel vulnerable.

Jeffrey Stenger, a specialist in internal medicine who coordinates the Sacramento center’s Schwartz Center Rounds program, says that the sessions encourage participants not to suppress their own emotions that arise as they focus on addressing their patients’ medical problems. And that, says Lown, “has profound benefits for caregivers as well as patients. People tend to think that connecting with patients’ suffering is very draining. But what we’re learning is that by helping doctors find meaning in the work they do, empathy actually helps to counter burnout.“ For example, a continuing education course that trains physicians to understand their own and others’ emotional experiences significantly reduced “emotional exhaustion.” And a six-week course of meditation practices designed to foster compassion was found to ease participants’ neurochemical responses to a stressful event.

Most proponents of compassionate care believe that medical practice needs to move toward a model that supports the time and effort it takes to consider patients’ psychological and social states. There are signs that such a shift is beginning to occur, with many medical schools instituting programs during the past decade that emphasize the emotional aspect of the physician-patient relationship. The University of New Mexico’s Division of Geriatrics and Palliative Medicine, for instance, recruits adults 70 and older to help first-year medical students become more attuned to patients’ health issues. And since 2005, first- and second-year students at Brown University’s Alpert Medical School have been required to take a course that uses reflective writing exercises to deepen their insights into their patients’ experiences.

According to Riess, empathy is also gaining momentum in hospitals. “More and more institutions are looking for practical tools they can use to help their staff become more empathic,” she says, and the recent expansion of Schwartz Center Rounds may be a good example. Between 1997 and 2007, approximately 100 hospitals implemented its program. Since then, more than 200 more have signed up.

The most surprising thing about a movement that’s struggling against the immense pressure of costs and time constraints may be how small an investment it requires to create meaningful change. Data collected by an independent research firm shows attending monthly Schwartz Center sessions significantly improves caregivers’ abilities to attend to the psychosocial and emotional aspects of patient care. When that occurs, the evidence now suggests, positive effects are likely to manifest themselves in all sorts of measurable ways.

Originally published in Proto, focusing on the promise of biomedicine, published by Massachusetts General Hospital.

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