Today I am talking with Dr. Mohammadreza Hojat, professor of psychiatry and human behavior at Jefferson Medical College and author of the new book Empathy in Patient Care: Antecedents, Development, Measurement, and Outcomes. Hojat, thanks very much for agreeing to participate in my series of interviews of thinkers and practitioners who have ideas that are valuable for the legal profession.
How did you come to be interested in empathy in the medical profession? I always find the story behind the expertise an intriguing place to start.
As a psychologist by academic training, I was curious about why people behave as they do in making or breaking human connections. I started to engage in medical education research more than two decades ago with this question in mind: How can patient-doctor connection, as a mini social support system, lead to positive clinical outcomes?
I became convinced that the alleviation of human suffering would flourish by enhancing empathic engagement in the caregiver-care receiver relationships. This is true in medicine as well as in any other public service profession that requires one-to-one relationship, including legal services.
In addition, changes that evolved in the current market-driven health care system that are detrimental to patient-physician relationships, physicians attention to financial incentives, and cost containment regulations formulated by health insurance companies, and their rippling effects on medical education prompted me to empirical research of empathy in medical education and patient care. This research led to the publication of my book: Empathy in Patient Care: Antecedents, Development, Measurement, and Outcomes.
Thank you. I certainly appreciate what you tell us about the role of empathy both in today's health care system with its many competing tensions and in the alleviation of human suffering. How do you define empathy in the context of patient care?
I define empathy in the context of patient care as a predominantly cognitive (rather than affective) attribute that involves an understanding of experiences, concerns and perspectives of the patient, combined with a capacity to communicate this understanding to the patient.
Three key ingredients in this definition are cognition, understanding, and communication. In this definition, I placed the emphasis on cognition rather than affect to make a distinction between empathy and sympathy that are often mistakenly tossed into one terminological basket, and used interchangeably in the literature.
Empathy is a cognitive attribute, sympathy is an affective response. It is important to make this distinction between the two concepts in the context of patient care, because abundance of empathy in patient care is always beneficial, but abundance of sympathy can be detrimental to patient outcomes.
I think it would be very helpful to fully understand that difference, especially if too much sympathy can actually be detrimental. Please tell me more about how you distinguish between empathy and sympathy.
Well, in Chapter 1 of my book, I described in details the differences between these two concepts, and listed their specific features in a table. Empathy is associated with a preponderance of cognitive information processing, whereas sympathy is involved with a predominantly emotional mental processing. The aim of empathy is to understand another person's concerns whereas the aim of sympathy is to feel another person's emotions.
Empathy involves an effortful attempt to understand another person's experiences without joining them, whereas sympathy involves an effortless feeling of sharing or joining the patient's pain and suffering. Empathy is a nonspontaneous response influenced by the regulatory process of appraisal, whereas sympathy is an spontaneous response influenced by regulatory process of arousal.
Because of the emotional (affective) nature of sympathy, its overabundance, like any other emotion, can be overwhelming, thus impeding the physician's (or lawyer's) objective decision making process.
Similar to the relationship between anxiety and performance, a certain amount of sympathy can be helpful, but too much of it can be devastating in clinical and surgical decision making. Empathy is always an enabling factor, whereas sympathy, in excess, can be a disabling factor. May be it is because of these features of sympathy that physicians are discouraged to treat a close family member who is in a critical situation that requires objective clinical decisions.
Despite the aforementioned differences, empathy and sympathy cannot be completed independent from one another. In our research, we found about 20% overlap between the two concepts.
I am very grateful for the way you explained the difference. I know your explanation will be thought-provoking for many lawyers and mediators. I am interested in how you measure empathy, the helpful trait. How do you measure empathy?
There are a few instruments for measuring empathy in the general population, but none was specific to the context of medical education and patient care. A few years ago, we developed a brief instrument, Jefferson Empathy Scale, that contains 20 items and can be answered in less than 10 minutes. We provided strong psychometric support for this instrument that has been described in details in Chapter 7 of my book. This scale has already been translated into 15 languages and is being used by many researchers in the United States and abroad. [Questions from the Jefferson Empathy Scale are on page 4 of this article on physician empathy co-authored by Hojat.]
I am wondering if empathy is a result of nature or nurture, if we are born with it or can acquire it. Can we teach empathy, and, if so, can all physicians (or lawyers for that matter) benefit equally from learning empathy?
Yes, as I indicated in Chapter 11 of my book, empathy can be taught by interpersonal skills training, by being exposed to positive role models, by simulating patient's problems for better understanding of the patient's experiences (e.g., using ear-plugs to simulate hearing loss in geriatric patients), by shadowing a patient during diagnostic procedures, hospitalization, and phases of treatment, by studying literature and arts to better understand human pain and suffering, and even by improving narrative skills to communicate understanding.
However, empathic capability, like any other personality attribute, is unevenly distributed in the population. Some have this gift in abundance, some in a meager amount, depending upon many factors including genetic predisposition, quality of early relationship with a primary caregiver (the mother), family and social environment, attachment experiences, and of course learning and educational factors. Some have simply a larger window than others for the capacity for empathy.
How do physicians respond to learning about empathy? Do they recognize the need? I ask because some lawyers lack empathy yet are unconsciously incompetent. I am very curious to know about the motivation, if any, for learning empathy, in one of our sister professions.
Physicians responses to learning about empathy vary, depending on the factors I described in your previous question. Research has shown positive "group" improvement in empathy as a result of targeted educational programs, although some physicians benefit more than others, some may not benefit at all!
At least medical educators do recognize the importance of physician-patient relationships in: more accurate diagnosis, more patient satisfaction, more patient compliance, and less likelihood of taking legal action against physicians. Some physicians recognize the need more than others, some are more motivated to enhance their empathic capacity than others.
That list of four easily can be converted for the legal profession by substituting the words "case analysis" for "diagnosis," "client" for "patient," and "lawyers" for "physicians." I think "compliance" translates to "cooperation" or "collaboration." All four are extremely important to lawyers, too. Hojat, I want you to know how much I appreciate your enlightening us about the vital role empathy plays in achieving those four goals. Thank you.
As an added bonus, here's an article Hojat co-authored on the decline of empathy in medical school. Some of you looking at legal education may want to read it.
Read the other idealawg interviews here. Scroll down to see them all.