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Empathy for Patient Centeredness and Patient Empowerment | OMICS International
ISSN: 2329-9126
Journal of General Practice
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Empathy for Patient Centeredness and Patient Empowerment

Mudiyanse RM*
Faculty of Medicine, University of Peradeniya, SriLanka
Corresponding Author : Mudiyanse RM
Faculty of Medicine
University of Peradeniya
E-mail: [email protected]
Received: December 24, 2015 Accepted: January 06, 2016 Published: January 14, 2016
Citation: Mudiyanse RM (2016) Empathy for Patient Centeredness and Patient Empowerment. J Gen Practice 4:224. doi:10.4172/2329-9126.1000224
Copyright: © 2016 Mudiyanse RM. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Empathy involve internal process of experiencing what is perceived from the outside world through our senses leading to imaginations and projections, so that such experience will turn the belief of “I and you” in to “I am you” or at least “I might be you”. According to Hojat, empathy in clinical practice is predominantly a cognitive attribute that involves understanding and communicating this understanding with an intention to help by alleviating pain and suffering. Unlike sympathy, empathy is trainable through experiential learning that involves all 4 domains of learning; cognitive, psychomotor, affective and interpersonal domains. Intellectual understanding of the situations (cognitive),emotional feeling and motivation (affective) results in actions with commitment (psychomotor) leading to the expression of his/her intension to help others (interpersonal). Enhancing empathy is beneficial as a parallel improvement of the professional development and patient outcomes is expected. The relationship between the intensity empathy and its beneficial outcomes has a linear relationship. However the relationship of sympathy and its beneficial outcomes shows an inverted U shape, indicating beneficial effects of enhancing sympathy progress only up to a certain limit and after that it start declining. The affective nature of sympathy leads to spontaneous reactions causing distress and deterioration of the efficacy leading to confusions and vicarious trauma. Therefore sympathetic reactions are not productive for health care professional. Empathy is a trainable attribute that contributes to the efficacy in communication, therapeutic adherence and success of treatment and finally to the satisfaction of patients as well as health care professional. Empathetic doctors are less liable for malpractice suits. Empathy promotes feeling of sameness, parallel position and respect that is conducive for patient centered attitudes. However unlike egocentric sympathy, empathy demonstrates altruism and recognizes “separateness” while retaining the feeling of sameness. The health care provider understands that the healthcare receiver is not he or her but another independent individual. Therefore empathy promotes the view that “one needs to look after themselves”. This perception motivates health care professionals to another commitment, which is to empower their patients through deliberate practices like motivational counseling. Sympathetic health care professional will focus on patient satisfaction while empathetic health care professional will focus on patient empowerment. All the religions promote empathy; understanding, feeling and supporting others to alleviate pain. Perception of separateness while experiencing the suffering of the others that will prevent attachments and vicarious trauma is also probably embedded in all regions. I have quoted explicit in examples from Buddhist philosophy due limited knowledge about teaching in other religions regarding these concepts

Evolution of Empathy
Earliest notions of empathy surfaces from the German word “Einfuhlung” that describe “feeling in to’ to portray the feelings of the audience in a theatre, proposed by Robert Vischer who followed his father Friedrich [1]. According to Theodor Lipp and Violet, we people ‘lend our life” to what we perceive through our senses that result in a unification of self and others. Edward B Titchner coined the word empathy and describes the internal mental activity of experiencing the world, as we perceive events through our senses [1]. This experience, a mixture of understanding and feeling surpass the boundaries between individuals, and leads to imaginations and projections revolving the feeling of “I and you” in to “I am you” or at least “I might be you” [1,2]. Teaching by the Lord Buddha (623 BC-589 BC) recognizes value of understanding along with feeling that is leading to actions [3]. Rev Valpola Rahula presents Buddhists view about the understanding and feeling “According to Buddhism, for a person to be perfect there are two qualities that they should develop equally: compassion (karuna) on one side, and wisdom (panna) on the other. Here compassion represents love, charity, kindness, tolerance and such noble qualities on the emotional side, or qualities of the heart while wisdom would stand for the intellectual side or the qualities of the mind. If one develops only the emotional neglecting the intellectual, one may become a good-hearted fool; while to develop only the intellectual side neglecting the emotional may turn one into a hard-hearted intellect without feeling for others. Therefore, to be perfect one has to develop both equally. That is the aim of the Buddhist way of life: in it wisdom and compassion are inseparably linked together” [3]. The practice of Buddhism promotes actions and changes of behavior based on this ‘wisdom and compassion”.
Empathy and Sympathy
Empathy is not similar to sympathy. Empathy is an advanced, effortful, intellectual, and trainable attribute that involves cognition more than emotions and contribute for professional satisfaction and carrier development, whereas sympathy is a primitive and effortless reaction that mainly involves affective domain leading to anxiety and subsequent vicarious trauma [2,4]. Empathy involve neo cortex of the brain and the parasympathetic system that will conserve energy while sympathy involves the more primitive limbic system and the sympathetic system leading energy consumption [2]. Empathy is an appraisal and the response in non-spontaneous while sympathy is an arousal and the reaction is spontaneous. Empathy is altruistic behavior and recognizes separateness and while sympathy is an egoistic behavior that promotes attachment that leads to distress and vicarious trauma [2]. However in literature words empathy and sympathy are used interchangeably without discriminating. Therefore awareness about the context of using these two words should be taken in to consideration to avoid confusions.
Empathy in Medical Education and Clinical Practice
In the context of medical education and patient care, empathy is defined as predominantly a cognitive (as oppose to affective or emotional) attribute that involves understanding (as oppose to feeling) of patient’s experiences, concerns and perspectives combined with capacity to communicate this understanding with the intention of helping by alleviating pain and suffering [2,4]. Cognitive nature of empathy contributes for reasoning, appraisal and clinical judgement that lead to positive patient outcomes. On the other hand sympathy with overwhelming emotions can obscure objectivity in clinical judgement and impede optimal outcomes [2]. Being understood is a basic human need. Physicians’ understanding of the patient’s physical mental and social needs is fundamental for providing care. Communication of the understanding is vital in delivery of patient care. Patients’ understanding the physician’s empathy through verbal and nonverbal communication plays a significant role in patient outcomes [2]. This definition is practical and support the educational effort of teaching and training of healthcare professionals.
Hojat recommend 10 approaches to enhance empathy in medical education: improving interpersonal skills, analysis of audio or video taped encounters with patients, being exposed to role models, roleplaying, shadowing a patient, experiencing hospitalization, studying literature and art, improving narrative skills, watching theatrical performance and engaging in Balint method of small group discussions [4,5]. Methods of teaching empathy and communication skills involve experiential learning based on skills training [6]. Teaching doctor patient communication skills in the Calgary Cambridge model promote empathy building and adopt many approaches like role-playing, watching video/audio taped encounters and small group discussion that support to enhance empathy [7]. Building rapport, open ended questioning, facilitating and encouraging the patient tell his/her story, empathetic listening and responding, exploration of patient ideas, concerns, emotions and expectations and collaborative planning promoted in doctor patient conversation could enhance learners empathy [7] and inculcating such habits among learners could preserve lifelong learning and practice of empathy. However teaching sessions should be planned deliberately to avoid stress and role model empathy towards the learner. Method of giving feedback in Calgary Cambridge model of communication ensure minimal stress and defensive behavior of learners by encouraging them to reflect and express their learning needs while providing focused and specific feedback that helps the learner to enhance their skills. Expression of empathy by the facilitator towards the learner promoted as a guiding principle in giving feedback will set an example for the learners to follow [6,7].
Just like learning communication skills, learning empathy also should involve cognitive, affective, psychomotor and interpersonal domains of learning [8]. Learning about empathy for the purpose of recalling for examinations is of no use. Cognitions at higher levels of Bloom’s taxonomy such as comprehension, analysis and application of such knowledge [8] are vital to achieve a state of mind to support his own behavior and to understand behavior of others. Empathy involves psychomotor skills. Learners perceive the performance of facilitators and practice under supervision before they master those skills by practice to achieve a stage of autonomy. Change of behavior and attitudes involve affective domain. Learner’s initial compliance to what is instructed in teaching session in role-playing will gradually turn in to acceptance and internalization of such behaviors with positive experience with repeated practice. Here it is important to emphasize the need for positive reinforcement of the learning experience to achieve the final outcome, which is the change in behavior. Empathy and capacity to build relationship support each other. Interpersonal domain in learning will promote developing higher levels of relationship to share experiences, emotions and opinion rather than superficial exchanging information [8]. Building rapport in doctor patient communication is higher order relationship that will be conducive for exchange of ideas feelings emotions and collaborative planning in doctor patient encounters.
Empathy for Patient Centered Care
Empathy is a very valuable attribute for a doctor. Altruism, commitment, attitudes, communication, patient centeredness and ultimately overall performance of healthcare professionals depend on empathy [2]. In 1950s and 1960s with the advancement of science and the emphasis of the biomedical approach in medicine doctors were promoted to adopt factor analytic approach in communication with patients [9] that promoted the concept of non-engaged empathy or neutral empathy; doctors would be neutral in emotions so that they could make logical decisions about patient managements [10]. In fact neutralizing the emotions of medical students by engaging in dissection of cadavers was considered as valuable in training [11] However the artificial nature of neutral empathy was highlighted and engaged empathy was promoted as an essential attribute for a doctor [10] as the bio-psychosocial model of patient care was promoted in the twentieth century that promotes patient centered approaches [9]. Empathy is the basis of caring and sharing attitudes in patient centered care that recognizes the patient as a whole person rather than an organ or a disease [12]. Empathetic doctor will see the patient as someone similar to him and provide care and be prepared to share information with respect and parallel position.
Females tend to be more empathetic than male [13] probably too due to biological need of such attribute in childrearing. Doctors with empathy tend to be duty conscious [14] and committed for the benefit of the society [15]. Advantages of empathy in clinical care are numerous. Empathy contributes for patient satisfaction [16], as well as physician satisfaction [16] leading to better therapeutic adherence and relationships [17,18], and better therapeutic efficacy [19]. Empathetic doctors have better caring attitudes [20] and less likely to involve in conflicts or malpractice litigations with patients [16] and have better attitudes for elderly patients [20] perform better in history taking and physical examinations [21,22]. The doctor patient conversations with empathetic engagement become more accurate, supportive and efficacious [6,7]. Empathy ensures accuracy, as patients are likely to give correct and relevant information as they engaged in conversation that leads to feeling of supportiveness. Patient’s involvement in developing the agenda for consultation could avoid redundancies and contribute for time efficiency as well [6,7].
Empathy for Patient Empowerment
Empathy promotes patient empowerment rather than patient satisfaction. Altruism and the sense of separateness in empathy promote detachments while egoism in sympathy creates attachments that can have negative impact in professional pursuits [23]. Attachments are discouraged in Buddhist Philosophy [3] while promoting the self-reliance in looking after their problems. Bikku Dhammasami highlight the phrase “Attahi Attano Natho”(Pali), “Oneself is the refuge for one” (Buddhist quote from the Dhammapada). He further sates “The Buddha in many ways has shown us to have confidence in our own action and its results, and thereby encouraged us to depend on no one but ourselves. …. be dependent on the Dhamma, go for refuge to the Dhamma — the righteous principles’ [24]. Here Dhamma refers to truth, facts, knowledge and understanding.
Patient empowerment involves patient education and motivation in such a way that they will develop their own methods of managing their problem by internalizing the need for self-changes with guidance on the health care professional [25]. Models of communication that emphasis patient centeredness, respect and parallel positions with patients such as Calgary Cambridge model promotes patients empowerment as well as empathy by facilitating to play an active role in the in doctor patient encounters by asking open-ended questions, developing an agenda agreeable to patients, evaluation of patients perspective and collaborative planning. Asking patient perspectives and encouraging them to express their opinion and expectations would help empower patients [6,7].
Motivational interviewing is a counseling approach that focuses on patient empowerment by developing collaborative partnership and promoting patient set goal for self-management of their problems. The motivational interviewing involve expression of empathy for the challenges faced by the patients, promoting self-realization of the discrepancy of his/her behavior and what is expected and encouraging the patient to develop his own strategies of managing problems and finally supporting the self-efficacy by providing on-going encouragements and fostering the belief that patient can look after his problem [26]. Entire process requires patients, respect and empathetic interactions. Health care professional have a natural tendency to correct and fix patients problems by imposing solutions early in the conversation. They should resist this “righting reflex” and encourage patients to talk and come out with their own solutions. Reflective listening with restating, echoing and non-judgmental questions could facilitate patients to reflect on their behaviors and opinions leading to adopt more rational stand. Pursuing on asking open question promotes patients to come out with ideas and solutions. Adopting the strategy of ask-provide-ask encourage the patient to express what he knows before health professional share his knowledge or experiences. Finally affirm and summarizing is done through conversation [26,27].
Empathy and Education Environment
Education environment could be designed to inculcate empathy among students as much as poorly designed curricula could daunt empathy. Educational environment and role modeling by teachers can leads to deterioration of empathy [4,5] as well as patient centeredness [28]. Doctor centered approaches that focus on data gathering style of communication tends to foster attitude that marginalize feelings and emotions over facts. If the teachers focus on factual information over emotions and feelings students will gradually deviate from their emotional engagement with patients [4].
Evidence based education demands methods of assessments of empathy. The Empathy Test [26] Empathy Construct Rating Scale [29] the Empathic Understanding of Interpersonal Processes Scale [30] and the empathy subtest of the Relation Inventory [31] are some of the tools developed for assessment of empathy in nursing profession. Reactivity Index [33], the Hogan Empathy Scale [33], and Emotional Empathy [33] assess empathy in others. Jefferson’s Scale of empathy has three separate versions that assess medical students (S-Version) health professionals (HP – Version for physicians and other professionals) and students of other profession (HP – Version for students) [2].
Empathy is a valuable attribute for doctors. Educationists should invest on inculcating this valuable attribute to harness holistic benefits to patients, the profession as well as the society at large. Empathy will create an internal motivation among health professional to be patient centered and to engage and empower patient in health care. Health care professionals should exhibit their scholarship nit only by teaching and evaluating empathy but also by engaging in research in to empathy and methods of inculcating empathy among health care professionals.
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  1. Donna Blair
    Posted on Oct 18 2016 at 2:42 pm
    The topic is more psychological than clinical. The feeling of empathy and sympathy towards patients is discussed in the article. The information provides an insight into medical psychology.

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