Empathy-the Secret Sauce in #physicaltherapy?


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.



21 responses to “Empathy-the Secret Sauce in #physicaltherapy?

  1. Great article with terrific references. Dr. Helen Riess, director of the Empathy and Relational Science Program in the department of psychiatry at the Massachusetts General Hospital in Boston has done a lot of research in this area. Here’s a link to a New York Times article summarizing her work: http://well.blogs.nytimes.com/2012/06/21/can-doctors-learn-empathy/

  2. Jason Silvernail DPT, DSc says:

    Outstanding post, Larry. I think the lack of empathy in many healthcare settings is not getting enough attention and I love this initiative!
    Thank you for bringing up this important issue!

  3. Thanks for bringing this important topic forward Larry. You are absolutely right that the combination of a high level of clinical competence linked with appropriate “science of caring” is an unbeatable combination. As an all cash clinic, people readily pay for the combination as it represents the 3rd leg of “patient values” in EBP. Back in ’06 I co-opted the old APTA logo when I led a “Future of PT” theme at the AZ state APTA meeting. Appreciate your efforts now to raise awareness in the profession.
    Here’s the old logo altered to reflect the shift from “either/or” to a “both/and” of science/art of healing and caring. Continued success, matt

  4. Larry says:

    Thanks for the feedback and comments. More to come! The links are helpful and we are adding them to our resources in an evidence based course on the integration of the science of caring into the practice of PT. The NY Times article should be mandatory reading for all PT’s. Matt, you have captured this so succinctly-it is not an either or phenomenon.

  5. Kory Zimney, PT, DPT, CSMT says:

    Larry, great stuff!!!!

    I recently viewed this TED-MED video which speaks to this as well (I think it is worth the 16 minute investment to watch it)


  6. Larry,
    Thanks for this post, now mandatory reading for my DPT students. Also thanks for a shout out to one of my favorite movies, The Fisher King.

  7. Derek Clewley, PT, DPT says:


    Thanks for the well written and inspiring post. I am also looking forward to disseminating this out to colleagues. Thanks for bringing this to the attention of many!


  8. Karen Litzy, MSPT says:

    Great post Larry. Thank you for sharing this topic. I talk about it all the time! Here is a link to a video from the Cleveland Clinic: http://www.youtube.com/watch?v=cDDWvj_q-o8

  9. Diana Echert says:

    Outstanding article. Thanks for keeping us grounded, reminding me why I became a physical therapist. I plan to share with my peers…over and over.


  10. Blair Green says:

    Larry, this is a great article. I will be sending to my staff to read. We so often get caught up in the “evidence” of what we do that we forget that patients are people too. We need to treat with compassion and empathy, understanding and support. I’m glad to see there is some evidence to support this as well.

  11. Dr. Carol Davis, professor at University of Miami and physical therapist at the Polestar Pilates center is the best example of an empathic physical therapist. My heart swells just thinking of her influence on me as a person and practitioner. She wrote a book called Patient Practitioner Interaction that explores this multi-faceted approach to healthcare. She did a doctoral thesis on empathy but it really is the way that connects with her patients and co-workers putting her heart into her work and relationships that brings her patients (and everyone around her) to a much greater level of healing.Here is a link to Dr. Davis speaking about integrity as a practitioner. http://www.youtube.com/watch?v=e0AUrAYvd9w Thank you very much for this post. I am grateful that this is an important part of being a physical therapist in today’s technology-filled world!

  12. As a physical therapist who became a psychotherapist (and sex therapist) I am thrilled to see this discussion of empathy in physical therapy practice.
    I continue to teach this skill to PTs in the pelvic floor courses I instruct in,
    Talli Rosenbaum

  13. Venise Mule Glass, PT,DPT,OCS says:

    Great article and great topic. Well needed especially now with all the extra documentation requirements, EBP, and decreased reimbursement, leading to burn out, lack of empathy and, in the end, poor outcomes. This should be a requirement in ALL health related fields’ programs!

  14. I am a PT who went back to school to pursue a degree in counseling for this very reason. Early in my profession, I quickly saw how you cannot separate the emotional and spiritual from the physical. Patients who are dealing with chronic pain and other life altering conditions need someone who will not only help them physically meet goals of improved function, but someone who will also provide them with hope and encouragement along the way!

  15. Jeff Daly says:

    Larry, great post. I have recently begun work with compliance and EMR within our organization and am very aware of doing my best to not get in the way of the clinician care. I am very interested in possibly incorporating these concepts into my role. Thank you!

  16. Luke McManus says:

    This is very true, Larry.
    Particularly in any chronic pain setting, an empathetic approach is so important in firstly giving the patient the space to tell their story. Without this, it’s hard to get an understanding of patients thoughts and beliefs around their pain.

  17. I applaud this effort to increase the awareness of empathy. Empathy and the humanities IMO should not be looked as adjuncts to an already robust physical therapy curriculum; they should be foundational.

    In its current state many of the mechanical conceptualizations are euphemisms that expurgate empathy from the practitioners mind. These terms create conceptual barriers. Barriers that prevent the therapist from living in the shoes of their patients. To truly accept empathy as a foundational principle within PT we are going to have to move past simplistic outcomes that reimburses want us to achieve. We have to accept that some of our patients will get better, and some won’t. That perhaps the best we can do for our more challenging folks is support them in thinking well about their painful and disabling conditions. Then help them cope so they come to peace with the life, body and mind they have.

    Trying to lump our patients into categorical boxes, boxes that are based simply based on outdated or invalid biomedical theories stands directly in between the therapist and a truly empathetic relationship.This is the true challenge for our physical therapy programs. To embrace empathy not simply as an adjunct subordinated by biomechanical constructs but truly the foundation with which we apply our hands and offer prescriptive instruction.

    When PT programs do this, such questions come up:
    Where does empathy fit along side using a dry needle (a treatment with a substantial chance of increasing their pain)?
    How prone are we to prejudice our patients for their less than salutary lifestyles i.e. smoking, sedentary etc?
    How to those prejudice’s effect how we talk to them, make them feel, and treat them?

    Answering the humanitarian side of these questions (and many more) would go just as far if not farther than obtaining the latest and greatest treatment fad.

    1. It should say humanistic and not humanitarian in the last sentence. ;)

    2. Larry says:

      Eric: completely agree. Thanks for those thoughts and reminders. Counter-acting our pre-judgements and judgements comes with maturity-and with a focus on empathy.

  18. Dee Daley says:

    Thanks for the great post Larry,

    It doesn’t matter if it is the patient interaction or the therapist learning interaction, the Affective Domain can be the most challenging to impact and I agree it should be something we consider in all “skill sets” if we look at the 3 foundations of learning/professional development. Empathy is likely at the higher levels of the domain at/above the responding/valuing/organizing level.

    Cognitive Domain- Knowledge, Comprehension, Application, Analysis, Synthesis, Evaluation
    Psychomotor Domain- Perception, Set, Guided Response, Mechanism, Complex Overt Response, Adaptation, Origination
    Affective Domain- Receiving, Responding, Valuing, Organizing, Characterizing

    Affective experiences are so often informal and can be tough to organize for formal learning- but that domain is known for being powerful as you noted. Sometimes our lives/learning experiences are so hectic, it can be tough to remember…. but it is an element of mindfulness that fits in with a holistic practitioner.

  19. Nice post Larry – knowing your passion for customer service, empathy is a significant part of that and an opportunity for a competitive advantage – the “I” in VRIO you shared with us in the EPPM course.

    Hard to relate to a professional association like the one we have here in California that cares so little about patients that they would endorse healthcare fraud and patient abuse in exchange for direct access.

Leave a Reply

Your email address will not be published. Required fields are marked *