Empathy Can Be Taught,and Patients Teach it Best

Abstract

Empathy toward patients is an essential skill for a physician to deliver the best care for any patient. Empathy also protects the physician from moral injury and decreases the chances for malpractice litigations. The current graduate medical education curriculum allows trainees to graduate without getting focused training to develop empathy as a core competency domain. The tools to measure empathy inherently lack validity. The accurate measure of the provider’s empathy comes from the patient’s perspectives of their experience and their feedback, which is rarely reaching the trainee. The hidden curriculum in residency programs gives mixed messages to trainees due to inadequate role modeling by attending physicians. This narrative style manuscript portrays a teachable moment at the bedside vividly. The teaching team together reflected upon the lack of empathy, took steps to resolve the issue. The attending demonstrated role modeling as an authentic and impactful technique to teach empathy. The conclusion includes a proposal to include the patient’s real-time feedback to trainees as an essential domain under Graduate Medical Education core competencies of professionalism and patient care.

As another refreshing off-week passed, I looked forward to my hospitalist service and teaching my residents. I always love the July summer freshness, its beautiful outlook, with longer days and warmer weather. As a physician teacher, I also cherish July, for it brings the new batch of learners. They come with passion, curiosity, and unassuming questions that make me strive to stay current with my knowledge and skills.

On this busy post-call day, we triaged patients’ acuity to match our time and attention. Our patient, Ms. JC, was on her third day of sickle cell crisis at the hospital. As per the intern, she continued to complain of constant, non-radiating pain in her legs and back, grade 10/10, which did not improve with as-needed 4-hourly intravenous morphine. She had mild sinus tachycardia, normal blood pressure, 96% oxygen saturation on pulse oximetry, and no fever. The complete blood count (CBC) and basic metabolic profile (BMP) laboratory reports were unremarkable except for mild hypokalemia, and notably, her hemoglobin was around her baseline of 9 g/dL.

After summarizing, my intern informed me of the patient’s request for better pain control through hydromorphone patient-controlled analgesia (PCA). He added hesitantly, “Hey, Dr. T, I am not so sure if we should start a PCA for her? She looks comfortable, watching television shows and playing games on her phone. Every day she wears makeup and appears well-dressed. She reports pain with a severity of 10/10, but she does not look like someone in pain to me. I think she should go home.” Our senior resident (SR) believed that the patient had opioid tolerance and dependence more than a pain crisis. The SR suggested prescribing oral opioids and discharging the patient with a plan to wean her off opioids over a few days at home.

My resident and intern alerted me to the patient’s angry mood that morning. Ms. JC’s actual words to them had been, “I don’t wanna talk to any of you anymore. Can I see a different doctor?” Given years of experience with challenging patients, I was confident my encounter with Ms. JC would go as anticipated. I planned on using scripts from my attending playbook: “acknowledge, validate, ask open-ended questions, and engage in shared decision making.”

As we entered Ms. JC’s room, the tension was palpable. I first apologized that she was still in pain, despite our efforts. Ms. JC did not even acknowledge my presence. I validated her concern and her perception of our team not delivering the care she deserved. She remained silent, appearing sad, and angry. I told her, “I know how you feel. How about I review your medications and suggest some options?”

Ms. JC burst into tears. Surprised by her reaction, I could only observe in silence, offer her a tissue, sit by her bedside, and wait for her to resume the conversation. I was trying to contain the situation. She recouped herself and slowly began to talk. She said, “Hey, doc, don’t just say that. You have no idea how I feel. When did you ever have a sickle cell crisis? I am living with it all my life.”

She continued, “I had sickle cell crises even before I could spell a word. I spent many days curled up in my bed while my friends played in the park. I missed many days at school to be at the hospital to treat my pain. I coped with pain and pulled through every stage of my childhood and adolescence. You guys are judging me and thinking that I am lying about my pain, since you all see me watching TV, playing on the phone, and doing my nails. If I stopped doing these things whenever I had pain, I wouldn’t have any life. These small things are the few comforts that bring brief moments of joy for me, and they help me cope and get through many difficult days.”

I remained silent, actively listening, as did my team.

The intern felt the urge to take responsibility and said, “Ms. JC, I am so sorry. Please forgive me for everything, and allow us to care for you.” The SR understood, in what became a valuable teaching moment. She reassured the patient that we would start the PCA immediately. Although the trauma and disconnect were apparent, the team’s commitment to behavioral change toward better patient care was real.

The encounter reinforced my belief that one teaches best by role modeling. While some scripts from my “playbook” became irrelevant, my teaching experience helped me in the end. I consciously avoided being a sage on the stage, giving prescriptive solutions. I instead adopted the role of a learner along with the residents.

A week later, Ms. JC went home, thanking us for lending an empathetic ear. I was happy to be part of that shared experience. My team felt more camaraderie, and a page turned in teaching professionalism at the bedside.

Unlike personality traits, empathy is a cognitive skill that can be invoked, taught, re-awakened, and nurtured. ¹ Clinical empathy is the physician’s complex mental simulation of a patient’s psychological state and their ability to help the patient in physical and mental recovery. ² Empathy has several psychological domains: cognitive, affective, behavioral, and moral. ³ The physician should balance the dynamics between these domains to best impact the patient’s healing.

Empathy is not merely a tool to gain patient trust but an expression requiring a range of physician behavior that adapts to each situation. Physician communication includes tuning in at the right moments and taking the time to listen, not just hear. Active listening is a skill that improves with training and practice. The critical step we often miss is reflection. To stimulate and enable that behavior, the teacher should be a consistent role model, for the learner to notice and be inspired.

The teacher should allow the time and psychologically safe space for the learner to reflect through active coaching. The learner engages best when the teacher acts as a sounding board for their thoughts, fears, inadequacies, and weaknesses, to slowly derive their answers. The learner thus invests in the solution, leading to better engagement to practice the new behavior. This is unlike traditional teaching, where the teacher preaches empathy but fails to model it. It forms the powerful hidden curriculum that trainees assimilate. ⁴ The hidden curriculum is messages conveyed through actions, inactions, and norms—powerful drivers influencing the medical education experience, ⁵ which determine the behavior of trainees and physicians, irrespective of what is measured in self-reported survey tools such as the Jefferson Scale of Empathy (JSE).

Unfortunately, physicians and trainees are incentivized to prioritize clinical productivity and efficiency over connecting with patients and families. Different concerns compete for time and attention, and empathy is often deprioritized. The medical curriculum focuses disproportionately on molecular pathobiology and tests. It ignores the humanistic qualities essential to develop a physician capable of delivering holistic care for the patient and community. ⁶ The resident trainee curriculum and evaluation tools are not necessarily built to train and encourage empathy. Worldwide, this has led to a de-emphasis of patient interaction and decline in empathy among physicians. ⁷ Empathy is necessary for building strong physician–patient relationships and hence better clinical outcomes. It naturally leads to less physician moral injury and malpractice litigation.^8,9

Empathy tends to be overlooked when the only reliable measure is patient feedback, which rarely reaches the trainee. Further factors that work against empathy are the deterioration of communication skills after medical training, professional distancing, and patient resistance. The balance between practicing empathy and maintaining professional distance in patient interactions is a challenge. In the background of a sometimes-overwhelming trainee curriculum, learning this professional psychosocial skill can be daunting. Still, it should be considered essential, even if it needs several years of deliberate practice. ¹⁰

In the current scenario of pandemic-driven changes, likely to be the new routine, virtual meetings and remote work are necessary, safe, and convenient. Graduate medical education (GME) core competencies, some undoubtedly medical knowledge, can be taught by a combination of recorded audiovisual media, asynchronous modules, and abstract didactics. Professionalism and empathy are best assimilated as consistent, long-term, natural behavior when learned through shared experiences by the teacher and learner together, in the moment, with the patient, often at the bedside. This should be followed by the essential elements of teaching, such as reflection and repeated deliberate practice with active coaching. ¹¹

The JSE has been the instrument to measure physician empathy to enhance professionalism in medicine for the past 2 decades in several countries. Studies have examined the reliability of the scale,^12,13 but its validity is inadequate, considering its self-reporting nature for the physician. Instead, the best judge of empathy is the patient receiving the care. Although a 360° evaluation method exists for trainee assessment, most programs complete the evaluation conveniently using feedback from inter-professional team members, and the patient’s feedback is not considered essential.

It is time we attach a tangible cost to not prioritizing empathy for our patients. The resident trainee and attending physician should seek real-time feedback from their patients, and a formal resident evaluation by the patient should be included in the overall assessment of the learner’s growth. The Accreditation Council for GME should emphasize empathy as an essential domain under the GME core competencies of professionalism and patient care. This proposal reinforces the value of empathy and the patient’s role in shaping the education and growth of residents, who shall become clinician-educators themselves in the future. ¹⁴ As patients might say, “Nothing about us without us” (nihil de nobis, sine nobis).