Could Health Reform Correct America’s “Empathy Deficit”?

On June 22, 2006, then Senator Barack Obama had this to say at Northwestern’s 148th Commencement (1):

“There’s a lot of talk in this country about the federal deficit. But I think we should talk more about our empathy deficit — the ability to put ourselves in someone else’s shoes; to see the world through those who are different from us — the child who’s hungry, the laid-off steelworker, the immigrant woman cleaning your dorm room.

As you go on in life, cultivating this quality of empathy will become harder, not easier. There’s no community service requirement in the real world; no one forcing you to care. You’ll be free to live in neighborhoods with people who are exactly like yourself, and send your kids to the same schools, and narrow your concerns to what’s going on in your own little circle.

Not only that — we live in a culture that discourages empathy. A culture that too often tells us our principal goal in life is to be rich, thin, young, famous, safe, and entertained. A culture where those in power too often encourage these selfish impulses.

They will tell you that the Americans who sleep in the streets and beg for food got there because they’re all lazy or weak of spirit. That the inner-city children who are trapped in dilapidated schools can’t learn and won’t learn and so we should just give up on them entirely. That the innocent people being slaughtered and expelled from their homes half a world away are somebody else’s problem to take care of.

I hope you don’t listen to this. I hope you choose to broaden, and not contract, your ambit of concern. Not because you have an obligation to those who are less fortunate, although you do have that obligation. Not because you have a debt to all of those who helped you get to where you are, although you do have that debt. It’s because you have an obligation to yourself. Because our individual salvation depends on collective salvation. And because it’s only when you hitch your wagon to something larger than yourself that you will realize your true potential — and become full-grown.”

The legion failings of the American Healthcare System have been well publicized. And while these deficiencies have received more then their share of space in public and professional journals, one far more troubling problem has received little or none – the “empathy deficit” that accumulates each and every year in doctors and nurses during their training.

The emotional cornerstone of the practice of medicine over the past century has been the patient-physician relationship. In studies conducted in the late 1990’s in the US, Germany, South Africa, the UK, Canada, and Japan, I was able to establish broad agreement among physicians and their patients that this relationship involved three core elements – compassion, understanding and partnership. Further, the study demonstrated that this relationship was evolving away from individual care toward team approaches, away from paternalism and toward partnerships, and away from “doctor says, patient does” and toward mutual decision making. (2,3)

The Association of American Medical Colleges on the Medical School Objectives Project has stated that medical schools are expected to educate altruistic physicians who “must be compassionate and empathetic in caring for patients.” (4) Expressions of caring, concern, and empathy—are among the listed educational objectives. But over the years definitions of these attributes and ways to measures their levels have been elusive.

How do we define empathy? In 2002, my co-authors and I had this to say: “Empathy has been described as a concept involving cognitive as well as affective or emotional domains. The cognitive domain of empathy involves the ability to understand another person’s inner experiences and feelings and a capability to view the outside world from the other person’s perspective. The affective domain involves the capacity to enter into or join the experiences and feelings of another person.” (5)

Can you “teach empathy”? To this question we replied in 2004:

“Studies are inconsistent about how amenable empathy is to educational intervention among medical students and physicians. Some researchers believe that empathy is a personality state that can decline during medical education but can also be improved by targeted educational activities. Others report that empathy is a personality trait that cannot be easily taught….Despite the mediating role empathy can play in improving clinical outcomes, there is a dearth of empirical study on the topic in the medical literature. One reason cited for this scarcity is the absence of an operational measure of empathy that is specific to the physician-patient relationship.” (6)

To address this need, we developed the Jefferson Physician Empathy Scale (JPES), and went about validating it as a reliable and predictable instrument to measure empathy focused on three major components – perspective taking, compassionate care and standing in the patient’s shoes. A wealth of studies have followed – comparing different specialties, identifying downward scores in empathy beginning in the third year of medical school and extending through residency, comparing men and women, comparing doctors and nurses. (7,8,9,10,11,12)

But the study I am most engaged in presently is a three year, double blind, prospective multi-center (18 sites) study exploring whether a single high impact home visit by 2nd year Family Medicine residents can reverse the downward trend line in JPES scores in these clinicians. As part of the intervention created by the 501c3 non-profit Rocking Chair Project (13), each participating 2nd year resident is asked to identified the single economically disadvantaged expectant mother under their care who would most benefit from a home visit and a gift of nurturing. Within two weeks of the birth, the resident makes a home visit, and along with the parents, assembles an upholstered glider rocking chair and ottoman. Prior to the visit, the resident is shown how to assemble the chair and familiarized with key supportive messaging prepared by the early childhood advocacy organization, Zero To Three (14).

While the study will not be completed until June, 2012, preliminary qualitative research suggests that the experience is highly formative and profoundly meaningful.(15) Here are three examples:

Putting the “family” back in Family Medicine

“A wonderful opportunity and experience to make someone’s wish come true and interact with them outside of the office/hospital setting. It really puts the “family” into “Family Medicine”. Thanks.”

Family Medicine resident, University of Connecticut Family Medicine

Helping a Military Family

“It was a wonderful feeling helping this particular family out as her husband is serving our country overseas. They were extremely grateful for all the care we provided for them. It certainly put a huge smile on not only their faces but mine as well.”

Family Medicine Resident, Southern Colorado Family Medicine

Mommy’s friend and doctor – (before she wouldn’t even look me in the eye)

“It was a great experience for both of us. I choose a mom that had a very hard childhood and continues to have a difficult time as an adult. She would not even look me in the eye for the first several times that I saw her in the office. I told her I wanted her to have something nice happen to her for a change. She has opened up to me and when I arrived at her home she told her daughter who is 18 months “this is mommy’s friend, and doctor”. We had a great time putting the chair together and I have never seen her smile so much. I wish I could do this for more of my patients.”

Family Medicine Resident, University of Missouri Family Medicine

Few would disagree with the goal of advancing professionalism by reinforcing empathy. But the issue, which I have raised in prior publications under the banner of “Advanced Professionalism”, is that values may not be able to be “put into practice” if obstructed either by a dysfunctional health care system or a geographic location that is inherently dehumanizing to both health care professional and patrient. (16)

If the AAMC wants to educate altruistic physicians who are compassionate and empathetic in caring for patients, I would suggest they encourage high impact, formative and transformative experiences as close to their patients real lives as possible. You must live where they live.

Finally, President Barach Obama had it right four years ago when he acknowledged our financial deficit, but shined a light on this nation’s “empathy deficit”. The ensuing financial crises and near financial disaster would make it easy for Americans to ignore the later and focus on the former. But that would be a mistake. Rather he should make the case that true health reform is the very best way to teach America how to care for each other and address this country’s “empathy deficit”.

References:

1. Obama B. 148th Commencement Address. Northwestern University. June 22, 2006. http://www.northwestern.edu/observer/issues/2006/06/22/obama.html

2. Magee M. Relationship Based Health Care in the United States, United Kingdom, Canada, Germany, South Africa and Japan: A Comparative Study of Patient and Physician Perceptions Wordwide. The Journal of Biolaw and Business, Vol. 7, 2003. http://web.me.com/drmikemagee/Site/Blank.html

3. Magee M. “Relationship-Based Care: Strengthening The Patient – Provider Relationship” in Connecting With The New Healthcare Consumer, D. Nash et al, Eds. McGraw Hill, 1999.

4. Association of American Medical Colleges (AAMC) Medical School Objectives Project.http://www.aamc.org/meded/msop

5. Hojat M, Gonnella, JS, Nasca TJ, Mangione S, Vergare M, Magee M. Physician Empathy: Definition, Components, Measurement, and Relationship to Gender and Specialty. Am J Psychiatry 159:1563-1569, September 2002. http://ajp.psychiatryonline.org/cgi/content/full/159/9/1563

6. Hojat M, Mangione S, Nasca TJ, Rattner S, Erdmann JB, Gonnella JS, Magee M. An empirical study of decline in empathy in medical school. Med. Educ. 2004 Sep;38(9):916-8. http://www.ncbi.nlm.nih.gov/pubmed/15327674

7. Hojat, M.; Mangione, S; Nasca, T; Cohen, M; Gonella, J; Erdmann, J; Veloski, J; Magee, M. “The Jefferson Scale of Physician Empathy”, Educational and Psychological Measurement, 61:2; April 2001; pp. 349-365. http://epm.sagepub.com/cgi/content/abstract/61/2/349

8. Fields SK, Hojat, M, Gonnella JS, Mangione S, Kane G, Magee M: Comparisons of nurses and physicians on an operational measure of empathy. Evaluation and the Health Professions, 2004, 27:1, 80-94 http://ehp.sagepub.com/cgi/content/abstract/27/1/80

9. Hojat M., Magee M. “Empathy in Medical Students as Related to Specialty Interest, Personality, and Perceptions of Mother and Father” Personality and Individual Differences, Nov.2005: vol 39, 1205-1215.http://bit.ly/9u2kba

10. Magee M., Hojat M., Mangione, S., Nasca, T., Gonnella, J., Empathy Scores in Medical School and Ratings of Empathic Behavior in Residency Training Three Years Later. Journal of Social Psychology, 2005, 145(6):663-72 http://www.ncbi.nlm.nih.gov/pubmed/16334513

11. Magee, M.; Hojat, M. “Personality Profiles of Male and Female Positive Role Models in Medicine,” Psychological Report, 1998; 82:547-59. http://www.ncbi.nlm.nih.gov/pubmed/9621729

12. Hojat, M.; Nasca, T.; Magee, M. et al “A Comparison of The Personality Profiles of Internal Medicine Residents, Physician Role Models, and the General Population,” Academic Medicine, 1999; 74:12; 1327-1333. http://bit.ly/aldX8f

13. www.rockingchairproject.org

14. www.zerotothree.org

15. Gagliardi A. Theoretical Assumptions and Evidence To Date. June, 2008. http://rockingchairproject.org/Yale_Research_Paper.pdf

16. Magee M. Under-visioning Professionalism: Deming, Berwick & Sensemaking. https://www.healthcommentary.org/?page_id=1867