Empathy across cultures - one size does not fit all: from the ego-logical to the eco-logical of relational empathy.

Empathy is extolled in Western healthcare and medical education as an exemplary quality to cultivate in trainees and providers. Yet it remains an elusive and inadequately understood attribute. It posits a "one size fits all" unidimensional attribute applicable across contexts with scant attention given to its multifaceted dimensions in intercultural contexts. In this article, we uncloak the shortcomings of this conventional empathy in intercultural settings, and instead propound an expanded "relational empathy".

The science of trust: future directions, research gaps, and implications for health and risk communication.

'Trust is among the most important factors in human life, as it pervades' all domains of society [1] and related decision-making processes. This includes people's trust in science, and in clinical and public health solutions. Unequivocally, community and patient trust are foundational to the adoption and maintenance of health-related behaviors, social norms, and policies. Yet, trust has to be earned and developed over time and through multiple interactions. Trust is about dialogue and human connection. It's about listening and knowing that one interaction will not be enough to build trust. It is also influenced by a variety of social, economic, cultural, and political factors, past experiences, and the history of specific communities and patient groups. It should be at the core of the health and social systems with which people interact. More recently, trust in evidence-based information has also been affected by misinformation, not only on social media but also in a variety of community, institutional, and patient settings. Ultimately, we are in the midst of a global trust crisis that precedes the COVID-19 pandemic and is often rooted in the health, racial, and social inequities many groups experience [2].

Institutional Resilience: The Foundation for Individual Resilience, Especially During COVID-19.

In the protracted healthcare crisis that the COVID-19 pandemic has become, healthcare professional wellness and resilience are a national concern. Physicians, nurses and medical staff have been profoundly negatively affected due to the inability of institutions to prepare for this pandemic. Institutional fixed point standards such as Eudaemonics, Inherent Value, and Amplifying Assumptions are essential to make it possible to steer an organizational course during a crisis. Fixed point standards must be embedded in hospitals and systems so they are positioned to do the most good. Employees must feel safe, valued and cared for always, so they can be resilient when crises strike. The best way to do that is by viewing the healthcare professionals through the lens of empathy. Institutional values of safety, access to accurate and caring information, human connection, and emphasis on mental health, are hallmarks of resilient organizations and will result in resilient individuals.

The Science of Empathy.

Empathy plays a critical interpersonal and societal role, enabling sharing of experiences, needs, and desires between individuals and providing an emotional bridge that promotes pro-social behavior. This capacity requires an exquisite interplay of neural networks and enables us to perceive the emotions of others, resonate with them emotionally and cognitively, to take in the perspective of others, and to distinguish between our own and others' emotions. Studies show empathy declines during medical training. Without targeted interventions, uncompassionate care and treatment devoid of empathy, results in patients who are dissatisfied. They are then much less likely to follow through with treatment recommendations, resulting in poorer health outcomes and damaged trust in health providers. Cognitive empathy must play a role when a lack of emotional empathy exists because of racial, ethnic, religious, or physical differences. Healthcare settings are no exception to conscious and unconscious biases, and there is no place for discrimination or unequal care afforded to patients who differ from the majority culture or the majority culture of healthcare providers. Much work lies ahead to make healthcare equitable for givers and receivers of healthcare from all cultures. Self- and other-empathy leads to replenishment and renewal of a vital human capacity. If we are to move in the direction of a more empathic society and a more compassionate world, it is clear that working to enhance our native capacities to empathize is critical to strengthening individual, community, national, and international bonds.

Empathic nonverbal behavior increases ratings of both warmth and competence in a medical context.

In medicine, it is critical that clinicians demonstrate both empathy (perceived as warmth) and competence. Perceptions of these qualities are often intuitive and are based on nonverbal behavior. Emphasizing both warmth and competence may prove problematic, however, because there is evidence that they are inversely related in other settings. We hypothesize that perceptions of physician competence will instead be positively correlated with perceptions of physician warmth and empathy, potentially due to changing conceptions of the physician's role. We test this hypothesis in an analog medical context using a large online sample, manipulating physician nonverbal behaviors suggested to communicate empathy (e.g. eye contact) and competence (the physician's white coat). Participants rated physicians displaying empathic nonverbal behavior as more empathic, warm, and more competent than physicians displaying unempathic nonverbal behavior, adjusting for mood. We found no warmth/competence tradeoff and, additionally, no significant effects of the white coat. Further, compared with male participants, female participants perceived physicians displaying unempathic nonverbal behavior as less empathic. Given the significant consequences of clinician empathy, it is important for clinicians to learn how nonverbal behavior contributes to perceptions of warmth, and use it as another tool to improve their patients' emotional and physical health.

Culture and nonverbal expressions of empathy in clinical settings: A systematic review.

OBJECTIVE: To conduct a systematic review of studies examining how culture mediates nonverbal expressions of empathy with the aim to improve clinician cross-cultural competency. METHODS: We searched three databases for studies of nonverbal expressions of empathy and communication in cross-cultural clinical settings, yielding 16,143 articles. We examined peer-reviewed, experimental or observational articles. Sixteen studies met inclusion criteria. RESULTS: Nonverbal expressions of empathy varied across cultural groups and impacted the quality of communication and care. Some nonverbal behaviors appeared universally desired and others, culturally specific. Findings revealed the impact of nonverbal communication on patient satisfaction, affective tone, information exchange, visit length, and expression decoding during cross-cultural clinical encounters. Racial discordance, patients' perception of physician racism, and physician implicit bias are among factors that appear to influence information exchange in clinical encounters. CONCLUSION: Culture-based norms impact expectations for specific nonverbal expressions within patient-clinician dyads. Nonverbal communication plays a significant role in fostering trusting provider-patient relationships, and is critical to high quality care. PRACTICE IMPLICATIONS: Medical education should include training in interpretation of nonverbal behavior to optimize empathic cross-cultural communication and training efforts should accommodate norms of local patient populations. These efforts should reduce implicit biases in providers and perceived prejudice in patients.

EMPATHY MATTERS: STUDY SHOWS THAT TEACHING EMPATHY CAN IMPROVE PATIENT SATISFACTION.

Contemporary physicians are facing tremendous pressures in terms of the number of patients they are expected to see, the short amount of time in which they have to see them, the complexity of the health problems, and increasingly burdensome documentation requirements. Empathy is challenged and to some extent driven down by many of the factors that are beleaguering health care today.

Physician burnout: coaching a way out.

Twenty-five to sixty percent of physicians report burnout across all specialties. Changes in the healthcare environment have created marked and growing external pressures. In addition, physicians are predisposed to burnout due to internal traits such as compulsiveness, guilt, and self-denial, and a medical culture that emphasizes perfectionism, denial of personal vulnerability, and delayed gratification. Professional coaching, long utilized in the business world, provides a results-oriented and stigma-free method to address burnout, primarily by increasing one's internal locus of control. Coaching enhances self-awareness, drawing on individual strengths, questioning self-defeating thoughts and beliefs, examining new perspectives, and aligning personal values with professional duties. Coaching utilizes established techniques to increase one's sense of accomplishment, purpose, and engagement, all critical in ameliorating burnout. Coaching presumes that the client already possesses strengths and skills to handle life's challenges, but is not accessing them maximally. Although an evidence base is not yet established, the theoretical basis of coaching's efficacy derives from the fields of positive psychology, mindfulness, and self-determination theory. Using a case example, this article demonstrates the potential of professional coaching to address physician burnout.

E.M.P.A.T.H.Y.: a tool to enhance nonverbal communication between clinicians and their patients.

There is a gap in the medical education literature on teaching nonverbal detection and expression of empathy. Many articles do not address nonverbal interactions, instead focusing on "what to say" rather than "how to be." This focus on verbal communication overlooks the essential role nonverbal signals play in the communication of emotions, which has significant effects on patient satisfaction, health outcomes, and malpractice claims. This gap is addressed with a novel teaching tool for assessing nonverbal behavior using the acronym E.M.P.A.T.H.Y.-E: eye contact; M: muscles of facial expression; P: posture; A: affect; T: tone of voice; H: hearing the whole patient; Y: your response. This acronym was the cornerstone of a randomized controlled trial of empathy training at Massachusetts General Hospital, 2010-2012. Used as an easy-to-remember checklist, the acronym orients medical professionals to key aspects of perceiving and responding to nonverbal emotional cues. An urgent need exists to teach nonverbal aspects of communication as medical practices must be reoriented to the increasing cultural diversity represented by patients presenting for care. Where language proficiency may be limited, nonverbal communication becomes more crucial for understanding patients' communications. Furthermore, even in the absence of cultural differences, many patients are reluctant to disagree with their clinicians, and subtle nonverbal cues may be the critical entry point for discussions leading to shared medical decisions. A detailed description of the E.M.P.A.T.H.Y. acronym and a brief summary of the literature that supports each component of the teaching tool are provided.

The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To determine whether the patient-clinician relationship has a beneficial effect on either objective or validated subjective healthcare outcomes. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Electronic databases EMBASE and MEDLINE and the reference sections of previous reviews. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Included studies were randomized controlled trials (RCTs) in adult patients in which the patient-clinician relationship was systematically manipulated and healthcare outcomes were either objective (e.g., blood pressure) or validated subjective measures (e.g., pain scores). Studies were excluded if the encounter was a routine physical, or a mental health or substance abuse visit; if the outcome was an intermediate outcome such as patient satisfaction or adherence to treatment; if the patient-clinician relationship was manipulated solely by intervening with patients; or if the duration of the clinical encounter was unequal across conditions. RESULTS: Thirteen RCTs met eligibility criteria. Observed effect sizes for the individual studies ranged from d = -.23 to .66. Using a random-effects model, the estimate of the overall effect size was small (d = .11), but statistically significant (p = .02). CONCLUSIONS: This systematic review and meta-analysis of RCTs suggests that the patient-clinician relationship has a small, but statistically significant effect on healthcare outcomes. Given that relatively few RCTs met our eligibility criteria, and that the majority of these trials were not specifically designed to test the effect of the patient-clinician relationship on healthcare outcomes, we conclude with a call for more research on this important topic.

Empathy training for resident physicians: a randomized controlled trial of a neuroscience-informed curriculum.

BACKGROUND: Physician empathy is an essential attribute of the patient-physician relationship and is associated with better outcomes, greater patient safety and fewer malpractice claims. OBJECTIVE: We tested whether an innovative empathy training protocol grounded in neuroscience could improve physician empathy as rated by patients. DESIGN: Randomized controlled trial. INTERVENTION: We randomly assigned residents and fellows from surgery, medicine, anesthesiology, psychiatry, ophthalmology, and orthopedics (N=99, 52% female, mean age 30.6 ± 3.6) to receive standard post-graduate medical education or education augmented with three 60-minute empathy training modules. MAIN MEASURE: Patient ratings of physician empathy were assessed within one-month pre-training and between 1-2 months post-training with the use of the Consultation and Relational Empathy (CARE) measure. Each physician was rated by multiple patients (pre-mean=4.6 ± 3.1; post-mean 4.9 ± 2.5), who were blinded to physician randomization. The primary outcome was change score on the patient-rated CARE. KEY RESULTS: The empathy training group showed greater changes in patient-rated CARE scores than the control (difference 2.2; P=0.04). Trained physicians also showed greater changes in knowledge of the neurobiology of empathy (difference 1.8; P<0.001) and in ability to decode facial expressions of emotion (difference 1.9; P<0.001). CONCLUSIONS: A brief intervention grounded in the neurobiology of empathy significantly improved physician empathy as rated by patients, suggesting that the quality of care in medicine could be improved by integrating the neuroscience of empathy into medical education.

Biomarkers in the psychotherapeutic relationship: the role of physiology, neurobiology, and biological correlates of E.M.P.A.T.H.Y.

Emerging biomarker research could powerfully influence the practice of psychotherapy, a standard treatment that is as strongly rooted in brain plasticity as are psychopharmacologic interventions. Psychotherapy is associated with measurable changes in central and peripheral neurophysiology. These markers could be harnessed to aid informed, personalized recommendations for specific psychosocial treatments, to guide a course of treatment, and to predict treatment outcomes, in lieu of relying on costly, trial-and-error approaches. Psychotherapy and empathy research also demonstrate that the patient-doctor relationship has important neurophysiological correlates that can be salient to treatment outcomes, as illustrated in a case example. These correlates include autonomic nervous system arousal manifested by heart rate, respiration rate, muscle tension, and galvanic skin resistance; electroencephalography; and brain-imaging markers. While additional biomarker research is unfolding, there are specific neurobiologically based clinical and subclinical observations, organized by using the E.M.P.A.T.H.Y. mnemonic, that may guide and enhance psychotherapy. Empathic attunement to patients is equally relevant for psychopharmacologic interventions and psychotherapy, and for all patient-doctor relationships.

Improving empathy and relational skills in otolaryngology residents: a pilot study.

Physician empathy and relational skills are critical factors predicting quality of care, patient safety, patient satisfaction, and decreasing malpractice claims. Studies indicate that physician empathy declines throughout medical training, yet little is published about methods to enhance empathy, especially in surgical residency training. The Accreditation Council for Graduate Medical Education requires competencies in 6 areas, including interpersonal skills and communication. To address this important problem, the first author developed an innovative empathy-relational skills training protocol focusing on the underlying neurobiological mechanisms of empathy and the interpersonal processes that positively affect the patient-doctor relationship. The authors tested the effectiveness of this protocol in a pilot study with 11 otolaryngology residents. Results showed that a brief series of 3 empathy training sessions can significantly improve physicians' knowledge of the neurobiology and physiology of empathy, as well as their self-reported capacity to empathize with patients. A trend toward increased patient satisfaction was observed.

Patient and practitioner influences on the placebo effect in irritable bowel syndrome.

OBJECTIVE: To determine whether placebo responses can be explained by characteristics of the patient, the practitioner, or their interpersonal interaction. METHODS: We performed an analysis of videotape and psychometric data from a clinical trial of patients with irritable bowel syndrome who were treated with placebo acupuncture in either a warm empathic interaction (Augmented, n = 96), a neutral interaction (Limited, n = 97), or a waitlist control (Waitlist, n = 96). We examined the relationships between the placebo response and a) patient personality and demographics; b) treating practitioner; and c) the patient-practitioner interaction as captured on videotape and rated by the Psychotherapy Process Q-Set. RESULTS: Patient extraversion, agreeableness, openness to experience, and female gender were associated with placebo response, but these effects held only in the augmented group. Regression analyses controlling for all other independent variables suggest that only extraversion is an independent predictor of placebo response. There were significant differences between practitioners in outcomes; this effect was twice as large as the effect attributable to treatment group assignment. Videotape analysis indicated that the augmented group fostered a treatment relationship similar to a prototype of an ideal healthcare interaction. CONCLUSIONS: Personality and gender influenced the placebo response, but only in the warm, empathic, augmented group. This suggests that, to the degree a placebo effect is evoked by the patient-practitioner relationship, personality characteristics of the patient will be associated with the placebo response. In addition, practitioners differed markedly in effectiveness, despite standardized interactions. We propose that the quality of the patient-practitioner interaction accounts for the significant difference between the groups in placebo response.

Teaching the teachers: a model course for psychodynamic psychotherapy supervisors.

OBJECTIVE: There are no standard training programs for teaching psychotherapy supervisors effective, ethical, and legal aspects of supervision. This article describes an eight session training course containing essential information for supervisors. METHODS: The literature on psychotherapy supervision was reviewed and an evening seminar series was offered to veteran supervisor. The seminars were then translated into a course for faculty supervisors and trainees interested in becoming supervisors. RESULTS: Participants completed a postcourse survey and ranked as high the quality and content of the course and course satisfaction on Likert scales. Participants felt well prepared and reported increased confidence in going forward in their supervisory roles. CONCLUSION: While current Residency Review Committee guidelines do not define standards for competency in psychotherapy supervision, the authors suggest that a course containing these principles of psychodynamic psychotherapy supervision be a prerequisite for those supervising residents. New and veteran supervisors reported learning essential aspects of supervision unknown before their course enrollment.

The clinical relevance of psychophysiology: support for the psychobiology of empathy and psychodynamic process.

Psychophysiologic measures, such as skin conductance and heart rate, have been used in both psychotherapy process research and clinical practice. We present a case report of a patient and therapist who participated in a process-oriented psychotherapy research protocol using simultaneous measures of skin conductance. Data from the research protocol were used to broaden an empathic understanding of the patient, which facilitated insight and enhanced the exploration of conscious and unconscious processes that originated in the past and have come to dominate the present--the core of psychodynamic theories of change. The case illustrates the clinical relevance of psychophysiology and its use as a potential bridge between psychotherapy research and the theory and practice of psychotherapy. The implications of the case in support of the role of empathy in psychotherapy are discussed.