by Thomas H Lee
No single outcome tells the story for any subset of patients. There are multiple outcomes that matter, and the fact is that they should all be measured and reported. Porter has described a hierarchy of outcomes, with Tier 1 outcomes (hard clinical outcomes) being the most important.7 However, he argues, Tier 2 outcomes related to the processes of care (e.g., readmissions and the disutility of care) matter as well, as do Tier 3 outcomes, which reflect the durability of health interventions, such as the likelihood of a patient needing a repeat procedure. (There is more on this topic in Chapter 4.)
If an institution is statistically worse than expected on Tier 1 outcomes such as mortality, the data should precipitate an all-hands-on-deck effort to dissect whether patient selection, poor guideline adherence, or suboptimal safety is causing the gap. However, organizations cannot expect to pull away from the crowd on the basis of the hardest Tier 1 outcomes such as survival because other good organizations are likely to have similarly excellent mortality data. Attention should then be turned to other clinical outcomes, including patients’ experience of care.
In summary, the strategic imperative for healthcare organizations reflects the demands of a healthcare marketplace increasingly driven by competition to create value for patients. To hold on to and increase their market shares, providers need to deliver coordinated and compassionate care. And to provide such care, providers must be reliable and constantly seek to improve their outcomes and costs.
These strategic, business, and clinical imperatives complement one another, but they are all disruptive for healthcare providers. The stakes are high because failure to respond makes it likely that organizations will fail to compete. They will lose market share and lose personnel to other organizations with better business prospects and higher morale.
The truth is that virtually everyone in healthcare wants to provide compassionate and coordinated care, and most clinicians recognize and admire such care when they see it. The question is how to drive its spread, and that process begins with a deeper understanding of what “it” is.
CHAPTER
3 The Response: Empathy
WE KNOW THE problem: Over the last century, medical progress has taken fatalism out of medicine but has introduced chaos to the care of many patients and narrowed the focus of most clinicians. Doctors and nurses are working harder than ever at what they perceive to be their jobs, but many are getting less satisfaction from that work, and patients often feel lost in the shuffle.
We understand the imperative for healthcare providers to address the problem. We are entering a new healthcare marketplace that is being driven by competition that is based on value: meeting the needs of patients as efficiently as possible. To meet those needs, providers must be reliable in giving excellent care that is supported by evidence and doing it safely. However, such reliability is table stakes in modern healthcare. With competition in the air, reliability in technical quality is absolutely essential to be in the game but not enough to ensure success.
Thriving in the new healthcare marketplace requires more than physicians complying with guidelines. Patients want good clinicians who work well together and understand their patients’ worries and concerns. Patients want coordinated and empathic care. They want to trust their individual clinicians and the organizations in which those clinicians work.
Organizations that can meet these needs and do so efficiently have the best chance of increasing their market share and retaining good personnel. The personnel in those organizations can have their cake and eat it, too: enjoy business success as well as professional pride. In fact, healthcare organizations should recognize that they can no longer have one without the other. They should also recognize that they can have both by delivering coordinated, empathic care.
Why Empathy Is Essential
The word empathy is really quite new, dating to the early twentieth century. It was coined by the psychologist Edward Titchener from two Greek roots: em (“in”) and pathos (“feeling”). Titchener’s aim was to translate the German term Einfühlung, or “feeling into,” which was used in the study of aesthetics to describe a response to a work of art. It was subsequently extended to describe responses to living creatures as well. Just as people could feel into a Beethoven symphony or a Renoir painting, they could feel into their child’s disappointment or a friend’s grief.
As contemporary psychologists and philosophers have drilled more deeply into the concept, subclasses of empathy have emerged. In his bestseller Emotional Intelligence, the psychologist Daniel Goleman discusses three kinds of empathy: Cognitive empathy is the ability to understand what another person is experiencing. Emotional empathy is the ability to feel what another person is feeling. Empathic concern is the ability to sense what another person needs from you.
This is the trifecta that is sought and expected in healthcare, and clinicians are supposed to manifest all three. That is why I compare empathic care to dancing. The clinician has to pay attention to his or her partner in this dance, but selectively. Dancers who try to respond to every blink of the partner’s eye are likely to lose the beat and become exhausted. If all doctors picked up every feeling in every one of their patents, they would burn out pretty quickly. Fortunately, empathic care doesn’t require the full trifecta and that degree of emotional synchrony in every case. Cognitive empathy is adequate—or at least a good start—in most clinical situations. For example, patients are more interested in clinicians understanding that they are afraid than in having clinicians actually experience their fear.
The hazards of actually trying to feel what a patient is feeling are particularly powerful in psychiatry, in which clinicians have to learn to convey empathy while protecting themselves against getting swept into their patients’ emotional maelstroms. In a 2007 essay in the New York Times, the psychiatrist Richard A. Friedman described having to explain to patients how he could imagine their pain even though he hadn’t suffered clinical depression or experienced the death of a spouse as they had. “In the end, empathy is what makes it possible for us to read each other. And it is the reason your doctor can understand your problem without actually having to live it,” he concluded.1
Friedman was right. We all do this all the time, often unconsciously. We understand our spouse’s stress and frustration; we tap into our kids’ excitement; we celebrate a friend’s promotion with him or her; we know how hard it is for our aging parents to give up the family house for assisted living. This type of empathy is the glue that holds families together and cements social relationships.
Extending empathy to people we don’t know or don’t like is less natural and takes greater effort, but humans have been implored to do this perhaps since the dawn of civilization. Empathy is espoused by most religions as some version of the Golden Rule: treat others as you would like to be treated. Philosophers as varied as Plato, Thomas More, and Adam Smith invoked something that resembles what we think of as empathy in their doctrines for society.
Healthcare providers will benefit from doing the same thing. Three sets of insights are useful in transforming empathy from a vague concept to a focus of healthcare strategy. The first is that empathy has a verified biological basis. The second is that empathy can be a cognitive process. The third is the acknowledgment that empathy can be eroded by distraction and stress and regained with a little work. In short, empathy is not a reflection of how good people may be but of how willing they are to be good.
The Biological Basis of Empathy
Sociologists have hypothesized that we are hardwired for empathy, probably because it is essential to the survival of our species. It drives us to care for infants and help others through rough patches. Households, businesses, and military units function better when their members have empathy for one another. Like two other essentials for survival—food and sex—empathy makes us feel good.
Neuroscience gives support to that theory. A series of experiments in the last decade has identified neurons in the inferior frontal and posterior parietal regi
ons of the human brain that are active both when one is performing a task and when one is watching another person performing that task. Functional magnetic resonance imaging (fMRI) scans have shown that the same regions of the brain—dubbed the mirror neuron system—are active in people relaying an experience and those who are merely hearing about it. Mirror neurons may be at work when a mother’s smile elicits a smile in her baby or when an outbreak of yawning erupts in a staff meeting.
A few years ago researchers took on the work of determining how contagious yawning originates and spreads. In one experiment, people yawned while undergoing fMRI scans and researchers noted their brain activity. When a second group of people was shown images of yawning people while being scanned, not only did the same regions of their brains light up, but the subjects yawned in response.
Although babies haven’t been subjected to fMRI scans to test their mirror neuron activity, behavioral studies have determined that they begin to develop empathy early in infancy. Emotional contagion comes first. That is why babies seem to smile back at grinning adults. There is also evidence that infants begin to express cognitive empathy—attempting to comfort siblings who are crying—even before their first birthdays.
My colleague from Harvard Medical School Helen Riess, MD, has described how physiologic changes detectable through advanced imaging technologies demonstrate real resonance between patients and empathic clinicians.2 The very regions of the brain that are activated in suffering patients are active in the physicians who care for them, although less intensely. This milder version of experiencing another person’s pain may enable the observer to understand a person’s distress without being overwhelmed by it.
Other research has shown that heart rate and skin conductance change when empathic relationships are at work. The bottom line from these various researchers is that empathy is real; it is based in neurobiology and is not a reflection of how good a person one is.
Empathy as a Cognitive Process
A second major useful insight about empathy is that it is ultimately based on thinking rather than feeling. In his book Empathy in Patient Care, Mohammadreza Hojat from Thomas Jefferson University describes empathy as “a predominantly cognitive (rather than emotional) attribute that involves an understanding (rather than feeling) of experiences, concerns and perspectives of the patient, combined with a capacity to communicate this understanding.”3
Hojat draws a useful distinction between empathy and sympathy, which he describes as an emotional response, for example, feeling bad that a patient is enduring pain and suffering. Empathy has its roots in sympathy, of course, but it does more. Empathy enables clinicians to take actions that address the patient’s concerns. At the end of the day, patients don’t really want clinicians to feel badly about their pain (sympathy); they want clinicians to understand that they are in pain (empathy) and do something about it.
In the last 20 years we’ve seen what using cognitive empathy can accomplish on a global level. The Truth and Reconciliation Commission in South Africa brought together people with seemingly insurmountable prejudices to engage in an ongoing dialogue through which they have come to better understand one another’s perspectives on apartheid. We have seen the recognition of same-sex marriage in most U.S. states and in nations as disparate as Uruguay and Ireland.
These watershed societal changes weren’t accomplished by enforcing abstract principles but because humans met face-to-face and got to know “the other” personally. Political scientists have noted that the work of the Truth and Reconciliation Commission was most successful in smaller villages and towns where the participants—whatever their ethnicity—were known to one another. The same is true for same-sex marriage. These days, it seems almost clichéd to hear people say that their resistance to same-sex marriage was broken down when they got to know a gay couple in their neighborhood or understood that their own child was homosexual.
The participants in these dialogues didn’t come to feel like people of a different race or sexual orientation, but they came to better understand how those people felt through hearing their stories. They acquired cognitive empathy by focusing on others and thinking about what they were seeing and hearing. They had to work at it.
The Work of Empathy
The realization that empathy can be acquired by working at it is good news, of course. After all, none of us is perfect, and it is hard to drive social change by urging everyone to become a better person. I daresay that most of us in healthcare are not lazy, and we are ready to work hard if we understand the task at hand.
In their memorable paper on empathy as emotional labor, Eric Larson and Xin Yao described empathy as “a psychological process that encompasses a collection of affective, cognitive, and behavioral mechanisms and outcomes in reaction to the observed experiences of another.”4 That description wasn’t what made the paper memorable for me, however.
The authors address the “verb”—what it really means to build empathy and deliver empathic care. They write, “To cultivate an acute ability to empathize with others, one needs patience, curiosity, and willingness to subject one’s mind to the patient’s world. However, there are many obstacles that contemporary physicians face as they aspire to develop empathy.” (They describe the distractions of modern life in healthcare and the lack of training that clinicians receive in the delivery of empathic care.)
But what really captured my attention was this statement: “We believe that better understanding of empathy—and more importantly, framing the psychological and behavioral activities in this process as acting methods used in emotional labor—would help physicians successfully incorporate empathy in their daily practice.”
“Acting methods”? The phrase gave me pause when I first read this paper. Doctors as actors? I worried that this comparison might seem demeaning to many of my colleagues. But I thought about how, when I am about to walk into a room where a patient waits, I often stand for an instant and take a deep breath before entering, much as I imagine an actor does before striding onto the stage. And then I play my role.
I have long wondered how stage actors are able to play their roles night after night without feeling stale and pondered whether that consistency is akin to the consistency needed in healthcare. Patients—and audiences—want to see the stars at their best. I’ve spoken to some actors about this, and they tell me that their work is not just about reciting lines and making facial expressions but about reading and responding to the emotions of other actors onstage. That is how they never go stale.
In their article, Larson and Yao trace the concept of emotional labor to the service industry, in which workers who deal with the public are encouraged to display emotions consonant with the goals of their employer. In a sense, we all perform emotional labor when we are asked to reflect the ethos of a group to which we may belong but with which we may not be fully engaged. An example would be a person who has no interest in football being expected to cheer wildly for the local team.
Emotional labor can begin as acting in which one person observes the facial expression and body language of another. The observer then extrapolates what the other person might be thinking or feeling and tries to mirror that thought or emotion. With repetition, the observer actually begins to appreciate the other person’s feelings and exhibits true empathy. The observers fake it until they become it.
The amount of emotional labor it takes to achieve empathy depends on the situation. For most people, it’s not difficult to empathize with someone who is a lot like oneself. For example, a white middle-class emergency physician may find it easier to empathize with a bicycle commuter who was struck by a car while riding home from her job than with a homeless man who was hit by a car while walking on the same street.
Larson and Yao describe two types of emotional labor: surface acting and deep acting. The first has more in common with developing communication skills such as making eye contact, repeating the patient’s statements, and responding appropriately. The second requires imagin
ing the patient’s emotional reaction and recalling a similar emotional experience of one’s own. In a sense, surface acting is faking an emotional display by imitating facial expressions and the like. Deep acting involves drawing on one’s own experiences to understand the emotions of another person.
For example, that doctor in the emergency department may never be able to fully grasp what it means to be homeless but can try to recall situations in which he felt desperate and without options even if the contexts are trivial in comparison with homelessness (e.g., how it felt to be stranded in an airport at night when every flight was canceled and every hotel room was booked). The goal is to capture some sense of the other person’s experience to the maximum extent possible.
Deep acting brings greater rewards by generating a feedback loop of empathy from patients. Caregivers who are able to generate a virtuous cycle of empathy are more likely to feel compassion satisfaction. They are nourished by their work rather than exhausted by it.
Comparing empathy to acting may seem cynical. Moreover, the suggestion that clinicians should strive for superficial acting first and work toward deep acting is an ambitious goal that may not be achievable with every patient. My actor friends would say that skeptics don’t fully grasp the nature of acting; it is not the same thing as pretending.
But the true major message I took home from this paper was that empathy is work. It takes energy and motivation to focus on every patient, to understand every patient’s needs, and to convey that understanding. Clinicians need the training to deliver empathic care, but they also need support so that they can muster the energy and the motivation to deliver it not just when they feel like it but for every patient.
