Overthrowing barriers to empathy in healthcare: empathy in the age of the Internet

Introduction

Empathy-based medicine re-establishes relationship as the heart of healthcare. Practitioners often complain that their capacity to practise empathically is undermined by ‘tyrannical guidelines’,¹ insufficient time and an ever-increasing burden of paperwork.² Clinicians often see this system as lacking empathy – uninterested in practitioners’ perspectives, health or welfare. Within this context, it is unsurprising that NHS staff have significant work-related stress and ill health.³ As a result, patients suffer, claiming clinicians do not communicate adequately, often leaving their needs and concerns insufficiently addressed.⁴

Empathy, seeing the world through the eyes of another, can be challenging. Consider the following real-life example. The mother of an orthopaedic surgeon collapsed at home.⁵ She was admitted to her son’s hospital with uncontrolled atrial fibrillation. Within 20 minutes, she had an ECG, chest X-ray, bloods taken, and her heart was back in normal rhythm. After two days in hospital, she recovered and was sent home. Her son was proud of the care she had received. He later asked her what she thought about his hospital. He was horrified to find out that it had been the worst two days of her life; afraid she was going to die and not see her grandchildren again. Her care had been guideline-driven and effective, but her fear and confusion was overlooked. Even her own son failed to see the world through her eyes.

In this brief paper, we provide a preliminary roadmap elaborating on current barriers to empathy and how they can be overcome.

Does empathy make a difference?

Empathy-based medicine is not at odds with evidence-based medicine since systematic reviews show empathy benefits patients. A growing number of trials show that enhanced practitioner empathy can reduce pain and anxiety, together with several other health outcomes,^6,7 while improving general quality of care.⁸ Empathic care also increases patient satisfaction, and can benefit the growing number of multimorbid patients,⁹ increase practitioner wellbeing while reducing stress and burnout,¹⁰ and diminish medico-legal risks.¹¹ For example, Chassany et al.’s¹² empathy training for general practitioners (n = 180) significantly reduced pain in patients with arthritis (n = 842) by one point on a 10-point scale (p < 0.0001), similar to some pharmacological interventions.¹³ Observational data also show that empathic communication can modify more objective clinical outcomes such as HBA1c.^14,15

Studies also show that enhanced empathy makes a positive difference in both deprived and affluent populations.¹⁶ This is important in the context of the inverse care law.¹⁷

It is also likely that empathic care will lead to significant cost savings. Pain – a condition empathic care can reduce (see above) – accounts for 10% of NHS costs and around £442 million pounds are spent on prescription painkillers each year.¹⁸ Reducing this by just 10% would save the NHS over £44 million each year. Similarly, a recent randomized trial demonstrates that enhanced empathy can be cost-effective.⁹

Of course, implementing enhanced empathy must be done in a careful and evidence-based way to ensure that it avoids negative consequences, for example, resulting from the additional emotional labour of being a healthcare worker.¹⁹

What do we mean by empathic care?

Empathy can be described in a number of ways,^20–24 and future conceptual research is desirable to clarify the concept and disentangle it from other related ideas such as compassion, sympathy, judgement, as well as patient-centered care.^22,25 At the same time, clinical trials have shown that it is already possible to operationalise empathy well enough to design interventions that benefits patients. In the context of the empirical work on the clinical benefits of empathy, the following components have been taken to be important:^22,23

1. attempting, as far as possible, to understand another person’s situation, feelings and perspective, recognising the difficulties in putting oneself in another’s shoes;

2. communicating that understanding, checking its accuracy; and

3. acting on that understanding in a helpful way.

Numerous trials have interpreted this definition by specifying which clinician behaviours must be displayed to convey empathy. For example, in a trial that tested the patient benefits of enhanced practitioner empathy, Little et al. trained general practitioners to:

• take sufficient time to understand the patient’s history;

• talk about general topics;

• offer encouragement;

• give verbal signs that the patient has been understood (by saying hmm, ahh, etc.);

• be physically engaging (by using hand gestures, eye contact, appropriate touch and forward lean); and

• warm up throughout consultation (being professional but supportive at the beginning, warming up by the end).

Other trials have used related approaches to improve patient outcomes.⁹ These show that the patient benefits of enhanced empathy can be implemented now while conceptual philosophical research is carried out.

A paradigm shift

Thomas Kuhn claimed that new paradigms involve a new way of looking at the world, adopted when ‘anomalies’ or defects in the existing paradigm accumulate beyond a tipping point. The current healthcare paradigm is causing practitioner burnout and sub-optimal patient outcomes. Given that enhanced empathic communication benefits patients, and that it is not being implemented consistently, a change is needed¹ and has been called for.²⁶

The foundation for the new paradigm exists, since humans are primed to respond to each other empathically. Before modern medicine, practitioners had no choice but to rely on their relationship with the patient. At its best, this resulted in empathy and trust; at its worst, blind faith in a paternalistic practitioner. Modern medicine has given us interventions that have improved and lengthened our lives, while evidence-based medicine has attempted – with variable success²⁷ – to ensure that new interventions do more good than harm. Yet the focus on evidence has had the unintended consequence that the focus is on tests, treatments and targets while the therapeutic value of the clinical encounter has been lost.

The existing paradigm: empathic care obscured beneath a mountain of tests, treatments and targets

The current paradigm is underpinned by the following assumptions about the clinical encounter:

• The practitioner is valued as a dispenser of tests and treatments rather than as a therapeutic agent.

• Understanding and critically appraising evidence is central.

• Patients’ values, preferences and circumstances are not given the same weight as evidence.

• Diagnosis and treatment become routinised in checklists.

• Consultation times shorten and continuity of care is interrupted.

• Patients are passive recipients of care; their knowledge and expertise is overlooked.

• The system values targets over positive patient and staff experiences.

All this happens under considerable time pressure, often requires practitioners to gaze at computer screens while they think about targets and resources. As a result, empathic communication can be obscured. Patients are not given information about their condition and additional treatment options are not discussed. The patient provides no feedback about how they feel about their care; they go home, unclear about what may be wrong and often do not adhere to treatments. Managers impose targets and guidelines yet often display little understanding of what it is like to be a clinician.

Clinicians are not given the power to resist the increasing burden of paperwork, and their time with patients is not valued. In fact, clinicians who do take additional time are deemed to be inefficient in spite of the evidence that this may improve outcomes.²⁸ They are fearful of litigation.

The new paradigm: celebrating the therapeutic benefits of empathy

In this new paradigm the heart of the consultation is the human relationship, and the following are fundamental:

• Empathic patient/practitioner communication is understood to be an effective intervention in its own right.

• An empathic consultation is central to evidence-based practice.

• Clinical acumen and skill is used not just to discover symptoms and signs, but on a par in clinical importance with interventions.

• Patients’ views and experiences are valued as part of the shared decision-making process.

• Patients’ and carers’ capacity to access, understand and use health information is supported.

• Experience data are routinely collected and acted on at both individual and system levels.

• Staff use empathy in their interactions with each other and believe that the system is concerned with their health and welfare.

To achieve this, implementing existing technology must be used to enhance empathic care rather than present a barrier to it.²⁹ For example, we already have technology that could reduce the burden of practitioner paperwork by gathering basic information prior to the consultation.¹⁴ This can happen via email or a mobile device in the waiting room. Other technologies that can enhance empathy must be researched and implemented.³⁰ The patient/clinician encounter becomes free to discuss the patient’s understanding, fears and expectations.

During the consultation, the computer screen is placed so that the patient and clinician can see it, a help to both if needed, for example, to show infographics on risks and treatment options to aid decision-making. A treatment plan is developed jointly. The patient then receives written information about diagnosis and treatment. This is discussed, in order to ensure adequate understanding. Both leave feeling they have been listened to and understood, and have contributed to their care plan. Both patient satisfaction and outcomes, as well as practitioner wellbeing, improve.

After the consultation, patients provide feedback and staff experience is collected. The joint feedback is used constructively in appraisals for clinicians, as well as organisationally to improve patient and staff experiences.

New ways to integrate empathic care are being implemented. The Consultation and Relational Empathy measure, for example, is currently used in the United Kingdom for general revalidation and feedback is provided free of charge to practitioners (see www.caremeasure.org). The Consultation and Relational Empathy Approach is available for practitioners to use to improve their empathic consulting.^31–33 However at present, initiatives are fragmented, have not exploited new technologies, and so fall short of their potential.

Misunderstandings, barriers and how to overcome them

In discussing empathy-based medicine, we have found that the goal is sometimes misinterpreted. Noting the limitations of evidence, guidelines and checklists may be viewed as rejecting these routes to knowledge. On the contrary, these are all essential for good patient care; however, they should be embedded in a culture of empathy. In addition, empathic care is an evidence-based intervention.

Practitioners may be sceptical about the value of empathy or believe incorrectly that they already express empathy in a way patients believe. In fact, practitioners’ expression of empathy is highly variable, with women outperforming men.²⁸ It is also true that aspects of healthcare delivery can make practitioners less likely to express empathy – time pressure, conflicting priorities, bureaucracy, etc. By re-establishing the clinical encounter as the heart of healthcare, and exploiting available technologies, this can change.

Supporting empathic care

Role modelling

Consistently providing empathic care with patients is hard. It is harder if little empathy is expressed for you as a healthcare worker. Hence a culture of empathy requires all healthcare staff, from government mandarins to ward cleaners, need to receive and model empathy, creating systems and processes that support it. Patient representatives also need to be involved not merely to let their views be known, but to find ways that they might change behaviour to enhance how they behave towards healthcare practitioners.

Targets, checklists and guidelines are important, but so is expertise and overall experience. To create an empathic culture requires skills not emphasised in the pre-evidence-based medicine era of paternalistic medicine, and that have been obscured amid evidence-based medicine’s focus on quantifiable data.¹ Such a culture would be further supported if healthcare workers were recruited for their desire and ability to empathise, as well as their technical abilities.

Exploiting existing technology

Aspects of bureaucracy, such as the burden of paperwork can be greatly reduced by technology and by managers listening to clinician and patient perspectives. Yet, for example, computer-aided history-taking, long available, is underused.¹⁴ The spread of alternatives to face-to-face consultations is still in its infancy, as is our understanding of when a machine will do and when a person-to-person relationship is needed evolves. Similarly, the use of decision aids, both within the consultation and outside, is also not widely spread.²⁹

However, technology can also get in the way – a computer screen can become a barrier to communication rather than an aid to decision-making. Patients and carers need to be involved in determining the need for, and designing, new technologies. Integrating patients’ perspectives requires imaginative engagement in understanding the context of their lives and consideration of the ways in which formal healthcare can be integrated with other approaches, such as peer-to-peer support and community initiatives.

Training and development

Fortunately, empathic behaviour can be developed and many practitioners are keen to learn how.³⁴ Patients, carers and staff need to be involved in curriculum design, in delivering teaching and training, and in evaluating outcomes. Patient and carer feedback should be integrated into student placements, so that future practitioners understand that their patients should in part judge their skill as clinicians.

Of course, displaying empathy can be emotionally draining, particularly in challenging circumstances or with certain individuals. Self-knowledge, reflection and resilience are all required for empathic practice and should be supported as part of training and continuing professional development.

The paradigm shift will result in empathic communication being embedded in healthcare, requiring mostly a change in style rather than adding content to already overloaded curricula.

Conclusion

The limitations of guideline- and evidence-driven care and healthcare’s rising costs, together with the overwhelming evidence that empathic care can improve a wide range of outcomes in diverse patient populations, suggest a new paradigm for medicine necessary. Empathy-based medicine promises to improve patient outcomes, reduce practitioner burnout and save money. Empathy-based medicine uses skills we all have, and that most of us can enhance. These skills should be embedded within, rather than added on to existing training and practice. Methods for teaching these skills need to be refined and digital technologies exploited to help make this a reality. Directly observing and measuring its impact in healthcare will support changing culture to placing a greater value on empathy. We are encouraged by the overwhelming support for this initiative.

Key messages

• The evidence for the patient health and practitioner wellbeing benefits of empathy has become too abundant to ignore.

• While there is evidence that many healthcare practitioners do not express empathy in a way patients understand, practitioners do not usually lack empathy. Instead, they are forced to practice within a system that values targets over people, they are overloaded with paperwork, and they are not given the opportunity to express their inherent empathy.

• Practitioners alone cannot be the sole targets of attempts to enhance empathy; instead, a culture of empathy must be embedded and valued within all relationships between patients, practitioners and healthcare managers.

• Adding another checklist, guideline or extensive practitioner training programme will do more to increase practitioner stress and burnout than improve empathy.

• Digital technologies must be exploited to do tasks that do not require humans, freeing up the consultation to focus on human relationships.

• Empathy does not necessarily require more time because these skills can be embedded within, rather than added on to existing training and practice.

Declarations

Competing Interests

None declared.

Funding

None declared.

Ethics approval

Not required because it is not a clinical study.

Guarantor

JH

Contributorship

Other members of the Oxford Empathy Care Group (which includes patients, members of the public, healthcare managers, and clinicians) are: Agne Ulyte, Andrew Moscrop, Charlotte Albury, Charlotte Blease, Claudia Carvalho, Egle Dieninyte, George Lewith, Heather Mason, Jane Coomber, Jane Roblin, Jeanne Nicholls, Joshua Hordern, Julia Hamer-Hunt, Karin Meissner, Longret Kwardem, Luke Austen, Lynne Maddocks, Marney Williams, Matthew Willis, Michael Wee, Moacyr Roberto Cuce Nobre, Muir Gray, Neil Bacon, Paola Rosati, Sarah Morrish, Sarah Stewart Brown, Sue Ziebland, Susanna Graham-Jones, Therese Feiler, Tony Berendt, Valerie Keston-Hole. This essay is partly the product of a workshop held at the Nuffield Department of Primary Care, Oxford, on 25 and 26 October 2016 (see Supplemental File). JH, in communication with MG, conceptualised the idea for a reappraisal of the role of empathy in healthcare and developed the plan to hold a workshop to progress this idea. JH and SM facilitated the workshop. All authors attended the workshop and contributed to the development of key themes for the paper. JH wrote the first draft of the paper and refined it with important intellectual contribution from SR. All authors provided some feedback on earlier drafts of the paper and approved the final manuscript.

Acknowledgements

None.

Provenance

Not commissioned; editorial review.