After taking a mild break with a few other posts, I want to re-visit the Cares More posts (here and here) where I describe our Called to Care initiative that we have started and demonstrated empirically that you can shift physical therapists behavior that enhances compassion, kindness, positivity and empathy in the care of their patients. It is my contention that care excellence coupled with clinical and service excellence are the pillars necessary in creating the best clinical outcomes. Part of Care excellence includes in part positivity, empathy, compassion, and shaping patient expectations (this specific topic Tim Flynn and I elaborated on in this month’s JOSPT editorial). In the second post, I put a framework around the background state of healthcare which necessitates this change which provides physical therapists unprecedented opportunity to really distinguish ourselves from other providers. After an impromptu twitterfest with some other PT’s, the subject of empathy arose with vigor thus the topic of this post. Is empathy the secret sauce for PT’s? Can it really be taught or is inherent? For answers to these and other questions, we have to go to the literature and evidence.
Within a clinical context, empathy is a predominantly cognitive (rather than emotional) attribute that involves an understanding (rather than feeling) of experiences, concerns and perspectives of the patient, combined with a capacity to communicate this understanding (Hojat, 2007, p. 80). A lack of empathy is believed to contribute to burnout or attrition rates of healthcare providers, particularly those who work with traumatized clients (Harrison & Westwood, 2009). There is a prevailing belief or assumption that provider detachment could lead to less burnout, the thought being that if I don’t overly feel for my patients, I won’t get consumed. In fact, it is likely the opposite. Mental health workers with “exquisite empathy” (Harrison & Westwood, 2009, p. 213)—defined as being highly present, sensitively attuned, with clear boundaries and heartfelt empathic engagement—were found to be invigorated, rather than depleted by their intimate professional connections with traumatized clients, and thus protected against compassion fatigue and burnout. Medical providers who make more time for caring learn to love even their difficult patients, and they actually become better providers with more successful medical outcomes (Figley, 1995; Weininger & Kearney, 2011). Empathy, when viewed as a measured strength from Gallup’s Strengthsfinder (Rath, 2009), is not as prevalent in healthcare as I had anticipated. In fact, our extensive internal studies and profiling of PTs most frequently places empathy in the bottom five (of the 34 strengths measured). Perhaps the definition of empathy from Strengthsfinder (“the empathy theme can sense the feelings of other people by imagining themselves in others’ lives or situations”) (Rath, 2009, Chapter 7, Section 2, para 1) is not encompassing enough to be transported in a healthcare environment. Regardless of the degree of empathy, many licensed medical providers actually lose their empathic skills the longer they stay in practice, which should be considered to be part of the dehumanization process in an age and culture where internally, there is too much focus on acquisition and status more than values, and externally, a healthcare environment of daunting regulations and compliance pressure. Yes, in healthcare we actually unlearn empathy (Hojat et al., 2002; Hojat et al.; 2011; Youngson, 2012)!
But can one regain or enhance empathy? This has also been studied extensively (Hojat, 2009; Krasner, et al., 2009), and methods include mindfulness, cognitive methods, and integration of humanities. We found the latter method more practical for implementation of this initiative. Shapiro and Rucker (2004, p. 445) have coined the phrase, “the Don Quixote effect” to denote a gain in empathy, and the technique to create this gain in empathy is watching movies. It’s not Don Quixote himself who is the role model for medical students in training, but his practical servant Sancho Panza, who influences Don Quixote to be a more honorable, compassionate, and tender person. This influence is similar to the effect imparted by viewing movies.
An example of how the Don Quixote effect can be triggered is found in the 2001 film, Wit (Nichols & Nichols, 2001). This movie explores the struggle of Vivian Bearing, a scholar and specialist in Donne’s poetry of irony who is dying of ovarian cancer. Ovarian cancer and its treatment produce agonizing effects on patients. Because of its low survival rate, it is a difficult diagnosis to deliver and more difficult to receive. Watching the movie, students generally feel empathy toward Emma Thompson in the title role, even when she is vomiting, bald, and clearly dying. In one of the final scenes, Vivian’s mentor comes to visit her. Shocked at the suffering of her former student, the old professor doesn’t try console Vivian with words but simply crawls into bed with her and reads her a children’s book about enduring and unconditional love.
According to Shapiro and Rucker (2004), many students are moved to tears by this scene. Discussion enables the students and medical providers to move from the level of concrete reality to that of idealism. They report feeling not only empathy, but sorrow, care, and compassion. They admire the experience behind the old professor’s spontaneous gesture. The image of Vivian Bearing, dying and embraced, becomes fixed in their minds as a representation of all that they want to realize in their treatment of patients. Other movies that have been shown to help build empathy are The Fisher King, (Gilliam & LaGravenese, 1991), Terms of Endearment, (Brooks & Brooks, 2005), and Philadelphia (Demme & Nyswanger, 1993). A reasonable plan for every physical therapy clinic is to incorporate training by watching movies, scenes, and recommendations that promote empathy-essentially crowd-sourced from physical therapy and healthcare professionals.
Literature can likewise provide significant benefit for healthcare providers, including an increase in tolerance for uncertainty and enhanced grounding for empathic understanding of patients (Hojat, 2009, p. 427). Lancaster, Hart, and Gardiner (2002) offered a one-month course for medical students in which they would read stories such as Tolstoy’s 1960, The Death of Ivan Ilych. In the evaluation at the end of the course, the students assigned their highest rating to the enhancement of empathy. Shapiro, Morrison, and Boker (2004) noticed significant improvement in first-year medical students’ empathy and their attitudes toward humanities after participating in a short course in which they read and discussed poetry, skits, and short stories.
Despite the importance of the humanities and arts in enhancing empathy, many medical schools and most physical therapy programs have not incorporated these subjects in their curriculum. It is reported that only a third of all the medical schools in the United States had incorporated literature into their curriculum as of the mid-1990s (Charon et al., 1995; Jones, 1997; Montgomery Hunter, Charon, & Coulehan, 1995). Physical therapists that are part of the Called to Care initiative will incorporate empathy training. Empathy just might be the strategic competitive advantage that really differentiates physical therapists in the evolving healthcare delivery.