Empathy is the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another, in either the past or present, without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner. Numerous studies confirm positive association between a provider’s level of empathy and favorable clinical outcomes (1-4). As such, it stands to reason that empathy should be considered integral to a provider’s established set of clinical competencies. Further, positive patient satisfaction and lower litigation rates are evidenced by patients who consider their providers as empathetic (5). However, it is not uncommon for clinical training programs to inadequately provide, or neglect completely, training in the development of empathy skills for use during the provider-patient encounter (6,7). It is important, and in the best interest of all parties involved, for training faculty, practicing professionals, and healthcare employers to raise the bar on awareness, education and the practice of empathy during provider-patient encounters.

Just as it is required of a provider to understand the structure and functioning of a body’s system in order to properly evaluate, diagnose and provide treatment, it is equally important for the provider to do so with respect to rendering empathy to the patient. Prerequisites for this include a clear and comprehensive understanding of what characterizes empathy, its origins, its various forms, and the most effective methods for communicating and exhibiting true empathy to patients based on their individual psycho-emotional constructs.

Characterizing empathy is a complex and difficult undertaking. Empathy involves, among other things, an understanding of another person’s emotions. In this, empathy is characterized as a derivative of the many characterizations of human emotional states. Recognizing and understanding these various states requires clear insight into the unique disposition of the individual, with unbiased acknowledgement of the cognitive, psychological and physical components associated with the emotional state. This is a form of “emotional proprioception” in which the provider attunes herself to the specific information expressed by the patient, including: the words being said, the inflection and tone of voice, facial expressions, eye contact and movement, gesturing, and body language to determine the emotional state of the patient. The ability of a provider to gauge a patient’s emotions through emotional proprioception has its foundation innate to the individual provider. However, this ability is not necessarily stagnant, given the evidence that studies have proven the skill capable of development through training (8).

Empathy is an heirloom of human evolution. It has served to provide life-sustaining behavior between parent and offspring, reproducing mates, kin groups, and disparate societies. The endocrine and neurological complexities of empathy have been well-researched over the years and demonstrate not just the benefit for survival, but the vital role empathy plays in the healing process (9,10). The implications of these facts extend to the viability of the healthcare system, where malpractice insurance is becoming prohibitive in some areas, driving providers away from communities in need of healthcare service. Providers who demonstrate empathy have less malpractice litigation, improved patient compliance, and higher levels of patient satisfaction (11).

There are various mechanistic explanations used to elucidate the positive effects of provider empathy on patients. Two non-mutually exclusive explanations proposed by Decety and Fotopoulou include the social baseline theory (SBT) and the free energy principle (FEP) (12).

The social baseline theory addresses the fundamental issue of energy conservation, or a subtext within the concept of life history theory in evolutionary medicine. In this theory, the presence of other people, perhaps family members and providers, assist patients to “conserve metabolically costly somatic and neural resources through the social regulation of emotion” (12). There is ample research supporting the positive effects of social support, and conversely, the negative effects of a lack of social support with respect to morbidity and mortality rates (13-15). Often referred to as “social buffering”, this social regulation of emotion engages stress-related activity in the autonomic nervous system and hypothalamic-pituitary-adrenal axis (16).

The free energy principle is a highly complex model that relies on the balance between the external, ambiguous, variable world, and the internal need for predictive organization and homeostasis (17). Bottom-up sensory input, such as empathy signals from a provider, coupled with top-down expectancies, such as anticipation of empathetic behavior by the provider, serve to support the predictive process and provide a foundation for healing. Further, this alignment signals to the patient that she is in a safe environment and is therefore able to conserve energy that would be otherwise dedicated to problem-solving and other stress-inducing activity.

There has been an increase in attention given the role and importance of empathy in clinical training in recent years. In greater numbers, clinical training programs that have not already done so, are beginning to introduce, or enhance, empathy-based training for provider-patient encounters. However, there is much work to be done in this area. Further, the training and practice of empathy-based healthcare should be a career-long pursuit. Using communication as an “entry point” for understanding and enhancing skills in empathy has been used effectively for many years (18). In particular, the Myers-Briggs Type Indicator (MBTI) has been found useful for clinical trainees, practicing providers, and preceptors for exploring concepts and techniques related to empathy as a clinical competency (18).

In summary, empathy has been found beneficial to patients, providers, educators, preceptors, and healthcare employers. This has been evidenced by better clinical outcomes, improved compliance, increased patient satisfaction, reduced malpractice complaints, and enhanced instructional-learning performance. All stakeholders in healthcare and healthcare education should take acute notice of these facts and work to foster empathy in training and practice. Perhaps empathy should be considered a clinical competency.


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