Finding Empathy, and Self-Preservation, in the Practice of Medicine

This transcript has been edited for clarity.

Arefa Cassoobhoy, MD, MPH: Welcome, everyone. We're here today to talk about empathy as it relates to the physician-patient relationship, doctor burnout, and ultimately even the bottom line. I am Arefa Cassoobhoy. I'm an adviser on the Medscape internal medicine board and senior medical director at WebMD.

I'm joined today by Dr Helen Riess, a psychiatrist and medical educator at Massachusetts General Hospital and Harvard Medical School in Boston. She's also the cofounder of a company called Empathetics, and the author of The Empathy Effect.^[1] Thank you so much for joining us today, Dr Riess.

In his forward to your book, Alan Alda mentions how empathy is really a way of reading another person's mind, and how that can have an impact on commerce and even politics. Tell me more about empathy and contrast it with sympathy and compassion.

Helen Riess, MD: Empathy is more than one process. Our brains use a number of different parts to perceive the emotions and imagine the thoughts of others, and then to process that information. All that produces an empathic concern that motivates us to show caring. And that caring is evidence of compassion. So it's a perception, processing, and responding arc. The difference between empathy and sympathy is that sympathy sort of stops at caring for people, whereas empathy is caring with people—it involves shared emotions and our ability to overlap with the hearts and minds of others.

Cassoobhoy: Why is this important for physicians and nurses? What should they know about this?

Riess: I believe that physicians and nurses are drawn to medical professions because, for the most part, they have empathy; they have this motivation to help others. Otherwise, why would they choose these professions?

Cassoobhoy: Exactly.

Riess: But we have observed that a number of forces blunt people's natural-born empathy. Healthcare is going through enormous changes right now. It's increasingly technical. We have the introduction of the computer into the exam room, which has proven to be quite a distraction away from the patient-doctor and patient-nurse relationship. I believe these inborn traits need to be reawakened and re-enlivened now that we recognize that these distractions have taken our focus away from the patient.

Cassoobhoy: The most common scenario that illustrates this is the clinic visit. We have the doctor and the patient, and then the third "person" is that computer, with the electronic medical records. Maybe there's an assistant or a scribe. How can we improve our skills and empathy to impact that relationship and that experience?

Riess: Remember that the whole reason you're in the room is to interact with the patient. The electronic health record has required a lot of learning, so much of our focus has been on getting up to speed with it, making sure we're clicking the right boxes. With any learning curve, it's the steepest at the beginning. I think what we've seen is too much focus on getting it right for the computer. And we have forgotten that the person we really need to get it right for is the patient and maybe the patient's family member or caregiver.

Cassoobhoy: I want to shift the conversation toward doctor burnout. How does improving empathy skills affect doctor burnout and help with resiliency?

Riess: That's a big question. We know burnout is kind of a national epidemic in healthcare right now, and it's gotten the attention of most healthcare leaders. Addressing burnout begins with the leaders' empathy for the people working in their organizations, because the standards and the norms that are set for caring really have to start at the top, and then they can trickle down and permeate the whole organization. So if an organization says that its institutional mission is to provide compassion and care, but the work conditions aren't conducive to that, there's a disconnect and that can lead to cynicism and burnout. We need to foster work conditions that make it possible for healthcare professionals to spend enough time with patients to actually make a connection. It starts with prioritizing the relationships.

Cassoobhoy: What can doctors themselves do to build these skills so they can nurture their own resiliency and improve their interactions with their patients?

Riess: One thing that's come to the forefront is the importance of self-care. Traditionally, doctors and nurses have been expected to give, give, give, give; they are rewarded for not spending a lot of time taking care of themselves. But I believe that is beginning to shift. Many institutions are implementing mindfulness curricula and empathy training, and emphasizing the importance of physical exercise and eating well, because if we don't take care of ourselves we can't provide that kind of care to others. So it starts there.

Cassoobhoy: We've talked about the physician-patient relationship and doctor burnout. I want to take it a step further. I loved the section in your book about digital communications and the widespread belief that emojis are a way to show empathy online, and even your topics related to Internet trolls. What kind of advice do you give doctors related to their presence on social media and how they communicate?

Riess: First, maintaining a professional demeanor on social media is extremely important. I believe that how you present yourself at work needs to comport with how you portray yourself out in the world. You need to be aware that you represent not just yourself but your whole profession. Thus, having a respectful Web and social media presence is important to maintaining patient confidence in who you are.

Cassoobhoy: What kinds of tips do you give for understanding where other people are coming from when they are angry or inappropriate on the Internet?

Riess: Unless someone's being quite disrespectful and rude, I always say the first place to start is with curiosity. You ask the hostile person, "What seems to be driving your comments or your sentiments? Help me understand." Just by showing that you're willing to listen, sometimes you can get to the kernel of truth that's right in the middle of the rage a person is expressing.

Cassoobhoy: That applies to the physician-patient relationship as well, right there in the room.

Riess: I think we're really talking about how you show up in a room where you're making space to be fully present, and welcoming the main concerns of the person that's right in front of you.

Cassoobhoy: Talk a bit about the seven keys to empathy.

Riess: Through a neuroscience fellowship I completed at Harvard, I tried to compile the ways we connect with people in a manner that would be easy to understand. The word EMPATHY can be the acronym for remembering this.

E is for eye contact. M is for trying to read the muscles of facial expression, so we ask ourselves, is this person doing well? Is she happy or is she upset, sad? We make that assessment by looking at the patient's face, which also means we're not always looking at the computer.

The P stands for posture. We can tell a lot about a person's emotions just by how they're holding themselves in space. And it also refers to position. Very often you see doctors standing up and talking to patients who are sitting down, or doctors standing at the bedside. We recommend getting at eye level so that people feel like they're talking to someone who's fully there for them.

Sitting down does not take more time. When people say I don't have enough time for empathy, I strongly challenge that. So much can happen through sitting and making eye contact.

The A stands for affect, which is the scientific word, as you know, for emotion. T is for tone of voice. H is for hearing the whole person, which means if you're an orthopedic surgeon, you're not just hearing about an injured elbow, but you're remembering that the elbow is attached to a whole person, who may have concerns about what this is going to mean for their livelihood.

Then Y is your response—the feeling you're getting when you're with another person, because most feelings are mutual. And if we feel calm and understood, chances are the person we're with feels the same. But if we're getting signals that things are a little askew or awry, it's best to ask about it, so that you don't leave an encounter with people feeling upset or bad without knowing why.

Cassoobhoy: One thing I wanted to take a deeper dive into was understanding empathy as it relates to doctor burnout. How does improving that influence the patient-doctor relationship?

Riess: That's an important question. First of all, it affects the patient's experience, how they're going to leave that office, and how likely they are to listen to or follow any of the recommendations. It affects how they think about the organization the physician works for. It affects patient safety, and also patient adherence to treatment.

Cassoobhoy: Because of the trust it builds?

Riess: Yes. When patients trust the physician, then they're likely to follow through with taking their meds. Empathy and compassion are directly linked to health outcomes. My research group at Massachusetts General Hospital did a systematic review and a meta-analysis^[2] that showed that it has a direct impact on important health outcomes of obesity, diabetes, hypertension, and asthma, for example. Trust also affects whether patients are likely to file a claim if something goes wrong.

Cassoobhoy: Sure. So it's impacting the bottom line.

Riess: In that way, it also impacts the bottom line for healthcare systems and organizations. The Centers for Medicare & Medicaid Services (CMS) have now decided to withhold certain moneys based on patient satisfaction scores. So they no longer pay the full amount that's billed if patients are reporting that they haven't had a good experience. It definitely affects the amount of money the hospitals will be reimbursed, not just from CMS but now also from private health insurers. It has become something that has drawn attention to the importance of this, not just because it's the right thing to do but because there are also financial consequences.

Cassoobhoy: So it's not just about improving that patient-doctor relationship and building trust, and that old school, good feeling. This is impacting the entire business.

Riess: And hopefully it all circles back around to everyone having a better experience of healthcare.

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