a systematic review of research on empathy in health care

A systematic review of research on empathy in health care

Affiliations.

• 1 Health Care Management Department, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
• 2 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
• 3 Life Sciences and Health Care Practice, Deloitte Consulting, LLP, New York, New York, USA.
• PMID: 35765156
• PMCID: PMC10012244
• DOI: 10.1111/1475-6773.14016

Objective: To summarize the predictors and outcomes of empathy by health care personnel, methods used to study their empathy, and the effectiveness of interventions targeting their empathy, in order to advance understanding of the role of empathy in health care and facilitate additional research aimed at increasing positive patient care experiences and outcomes.

Data source: We searched MEDLINE, MEDLINE In-Process, PsycInfo, and Business Source Complete to identify empirical studies of empathy involving health care personnel in English-language publications up until April 20, 2021, covering the first five decades of research on empathy in health care (1971-2021).

Study design: We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

Data collection/extraction methods: Title and abstract screening for study eligibility was followed by full-text screening of relevant citations to extract study information (e.g., study design, sample size, empathy measure used, empathy assessor, intervention type if applicable, other variables evaluated, results, and significance). We classified study predictors and outcomes into categories, calculated descriptive statistics, and produced tables to summarize findings.

Principal findings: Of the 2270 articles screened, 455 reporting on 470 analyses satisfied the inclusion criteria. We found that most studies have been survey-based, cross-sectional examinations; greater empathy is associated with better clinical outcomes and patient care experiences; and empathy predictors are many and fall into five categories (provider demographics, provider characteristics, provider behavior during interactions, target characteristics, and organizational context). Of the 128 intervention studies, 103 (80%) found a positive and significant effect. With four exceptions, interventions were educational programs focused on individual clinicians or trainees. No organizational-level interventions (e.g., empathy-specific processes or roles) were identified.

Conclusions: Empirical research provides evidence of the importance of empathy to health care outcomes and identifies multiple changeable predictors of empathy. Training can improve individuals' empathy; organizational-level interventions for systematic improvement are lacking.

Keywords: empathy; health personnel; impact; intervention; patient experience; systematic review.

© 2022 Health Research and Educational Trust.

Publication types

• Systematic Review
• Research Support, U.S. Gov't, P.H.S.
• Cross-Sectional Studies
• Delivery of Health Care
• Health Personnel*

Grants and funding

• U18 HS016978/HS/AHRQ HHS/United States

• Open access
• Published: 16 July 2016

Empathy promoting interventions for health professionals: a systematic review of RCTs

• Vassilios N. Kiosses 1 ,
• Vassilios T. Karathanos 1 &
• Athina Tatsioni   ORCID: orcid.org/0000-0001-7652-6592 1 , 2  

Journal of Compassionate Health Care volume  3 , Article number:  7 ( 2016 ) Cite this article

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Authors assessed systematically the effectiveness of interventions aiming at health professionals’ increase of empathic responses.

Authors searched Pubmed, Cochrane Database of Clinical Trials, Scopus, and PsycInfo for randomized controlled trials (RCTs) (latest search on November 2012). They included trials in English that evaluated interventions, which may promote empathy in health professionals. Studies were categorized according to the type of the outcome on empathy (attitude or opinion, knowledge or skills, and behavior). Authors considered change in empathy as the main outcome. Standardized mean differences (SMD) with 95 % confidence interval (95 % CI) were calculated for the studies that provided adequate data. Primary analysis included all the studies that provided adequate data per outcome category. In addition, authors proceeded in subgroup analyses for the following groups (a) type of intervention (experiential vs. non-experiential; (b) training specifically for promoting empathy vs. other; (c) type of assessor (external observer, health professional participants, and patients); and (d) type of process used for empathy evaluation, (simulated interview, actual interview, and questionnaire completion without interview).

Out of 722 items, 17 articles were eligible. Trials were highly heterogeneous in terms of participants, interventions, and outcome measures. Interventions usually covered a broad training on communication skills. Thirteen studies used experiential while four non-experiential learning approaches. There were only two studies that evaluated interventions specifically aiming at promoting empathy; one of these trials reported significant increase in residents’ empathy related knowledge, skills, and behavior. Based on 13 trials with adequate data, health professionals in intervention group improved empathic behavior when compared to control group (SMD 0.8, 95 % CI 0.4, 1.2; P value <0.001). None of the trials assessed patients’ health care outcomes.

There are interventions, which may contribute to a significant improvement in empathic behavior among health professionals. However, the type of intervention that would be effective needs to be supported by future studies. Whether empathic behavior may last, or whether it may affect patients’ outcomes is yet to be defined.

Empathy is described sometimes as a cognitive attribute featuring understanding of experiences of others; at other times, as an emotional state of the mind featuring sharing of feelings; and at still other times as a concept involving both cognition and emotion [ 1 ]. People, who demonstrate it, identify with another’s feelings. The ability to empathize is directly dependent on a person’s ability to feel his/her own feelings and identify them [ 2 , 3 ]. Health professional—patient communication is the means to deliver care that is adapted to an individual’s emotional, cognitive, and biological needs. Clinical empathy includes understanding the patient’s situation, perspective and feelings as well as their attached meanings; communicating understanding and checking its accuracy; and acting on that understanding with the patient in a therapeutic way [ 4 ]. Medical and other health care professional schools have included educational interventions to maintain and enhance empathy in undergraduate students [ 5 ]. The reason for which clinical empathy has been introduced to health care curricula is related to empathy’s expected positive attributes, including dutifulness, prosaic behavior, moral reasoning, reduced malpractice litigation, improved history taking and physical examination, patient satisfaction, physician satisfaction, improved therapeutic relationships, and overall improved clinical outcomes [ 6 – 14 ]. However, to our knowledge there is no systematic approach to indicate whether interventions aiming at the improvement of health professionals’ empathy may contribute to any of the above outcomes. Limited evidence mainly from clinical studies with non-experimental design has supported the correlation of empathy with patient outcomes [ 5 , 15 ]. This may have led some researchers to question whether enhancing empathy would have any incremental beneficial effect on medical care [ 16 ]. Moreover, reduced empathy may sometimes allow physicians to complete clinical tasks more accurately [ 17 , 18 ]. In certain clinical contexts, such as surgery [ 14 ] or oncology, is argued that keeping an emotional distance from patients maintains clinical neutrality [ 19 ] while being empathic has a psychological cost for health care professionals [ 20 , 21 ], which can lead to ‘compassion fatigue’ [ 22 ].

The ambiguity associated with the definition of empathy obstructs investigators to clearly see what they intend to study, and hinders their ability of how to measure it in the context of patient care [ 1 ]. Social relationships may require both mutual understanding and feeling of emotions. However, for patient—physician relationships, health professionals need to be aware of patient’s concerns. Empathy in patient care has been introduced as a multidimensional concept involving at least three factors: “perspective taking,” “compassionate care,” and “standing in the patient’s shoe” [ 1 ]. The ability to capture all three dimensions in studies evaluating empathy has important implications not only for the conceptualization and measurement of empathy in patient care but also for the assessment of patient outcomes [ 1 ]. In addition, research findings on empathy can be subject to serious challenges if the conceptualization, definition, and measurement issues remain unsettled [ 1 ].

Previous work [ 1 ] presented studies with randomized and non-randomized designs that included a wide variety of interventions aimed at enhancing empathy either by evaluating an empathy-focused training, or by evaluating empathy training as part of a communication skills training program for health professionals. This extended work offered substantial insight on the professional groups that may receive the intervention, the type of interventions, and the type of measures for empathy. However, several issues remained unsolved including what type of interventions are effective, and which outcomes may actually be improved. Therefore, the authors of the present paper tried to systematically assess the extent to which interventions aiming at the improvement of health professionals’ empathy were evaluated in randomized controlled trials (RCTs). Authors focused on RCTs in order to capture the best quality information and to ensure the highest robustness of the results [ 23 ]. Developing an intervention for improving empathy may need additional methodological approaches, such as the use of theory of planned behavior. However, in order to support effectiveness and ensure reproducibility of the results among health professionals, the assessment of the developed intervention needs to be supported by well-designed RCTs [ 23 ]. In an effort to clarify what intervention might be promising for improving empathy and whether the evaluation mode for the intervention correlated with the results, authors considered a number of factors in their analyses, including the type of intervention, the type of assessors, and the type of process for assessing empathy. To address the challenges in the type of measures for empathy, they categorized outcomes on attitudes, knowledge, skills, and behavior. To increase generalizability, authors included interventions for all health professionals both at undergraduate and postgraduate level. For interventions specifically aiming at increasing empathy, authors also explored whether studies assessed the impact of these interventions on patients’ health care outcomes.

Search strategy

Authors searched Pubmed, Cochrane Database of Clinical Trials, Scopus, and PsycInfo (from inception to November 2012) using the following search algorithm: (“empathy”[MeSH Terms] OR “empathy”[All Fields]) AND (“Clinical Trials as Topic”[Mesh] OR “randomized controlled trial”[pt] OR “controlled clinical trial”[pt] OR randomized [tiab] OR placebo[tiab] OR randomly[tiab] OR trial[ti]) AND (“Clinical Trials as Topic”[Mesh] OR “randomized controlled trial”[pt] OR “controlled clinical trial”[pt] OR randomized[tiab] OR placebo[tiab] OR randomly[tiab] OR trial[ti]). Electronic searches were supplemented by perusal of the references of the retrieved papers as well as the references of review articles. Two independent investigators (VNK, VTK) screened abstracts and papers in full text. Discrepancies were resolved with consensus and the participation of an arbitrator (AT) where necessary.

This systematic review was performed according to PRISMA guidelines [ 24 ] .

Eligibility criteria

Authors included only randomized control trials (RCTs) irrespective of the type, i.e., parallel, crossover, cluster, and pragmatic design, which evaluated training interventions and included empathy change in health professionals, or health care students during their encounters with patients as an outcome. Authors included both trials that evaluated training for specifically promoting empathy and studies that assessed interventions aiming at communication or interpersonal skills. They considered as eligible both studies with a clear definition of empathy and articles that did not include any clarification. They did not set any exclusion criteria for the type of measures that investigators employed to assess change in empathy.

In case a trial was reported in multiple papers (duplicated publications), authors considered as eligible the paper including the most complete information. They excluded RCTs that were published at the protocol stage, RCTs that may have measured but did not report results on eligible outcomes, and studies that were not written in English.

Data extraction

Data were extracted in predefined forms. Two independent investigators (VNK, VTK) extracted all data. Discrepancies were resolved with consensus and the participation of a third arbitrator (AT) where necessary.

Extracted items included name of first author, year of publication, country, study design, sample size, description of the recruited population, and the number of centres that participated, the percentage of male, the mean age of the participants, and duration of the study. If a paper described empathy, authors recorded how empathy was defined. They also recorded the description of the intervention in the experimental group, including content and whether it was experiential or not, frequency, and duration as well as the intervention—if any—in the comparator group. During the experiential learning, trainees are involved in the learning process through experience. It is learning by doing and it is distinct from didactic learning.

In addition, authors reported the outcomes as described in each paper as well as the assessors and measures used by the investigators; and whether empathy was the primary endpoint. They recorded all primary and secondary outcomes in articles that assessed interventions for specifically promoting empathy. Based on the outcome categories provided by the MERSQI tool for assessing the quality of medical education studies [ 25 , 26 ] authors grouped reported outcomes in the four following types: (a) satisfaction /attitude /perceptions /opinions; (b) knowledge /skills; (c) behavior; and (d) patients /health care outcome. For trials that assessed interventions aiming at communication or interpersonal skills, authors only recorded empathy regardless of whether it was included as primary or secondary outcome. If an instrument was used to measure any of the outcomes, they recorded whether the article reported construct or content validity of the scale. Finally, authors captured the number of participants who were analysed for each measure. They also extracted the difference and the reported measure of dispersion, both for within group and between group comparisons, and the corresponding P- values. If a study reported multiple follow up points, authors recorded these values for each point separately.

Quality assessment of the studies

To assess the quality of reporting of the eligible RCTs, authors used the CONSORT statement [ 27 ] for reporting randomized controlled trials. Specifically, for each trial, they reported whether it described the mode of randomization, allocation concealment, blinding, and if yes, who were blinded, power calculations, the primary outcome, and the percentage of withdrawals. In addition, they recorded whether trials described the trainers—if any—for the interventions, and whether fidelity was evaluated for the intervention in each study. Authors also recorded whether potential adverse events of the intervention were reported.

Analyses /synthesis

To address the potential effectiveness of interventions, authors presented the results of the studies per outcome category. In case a primary study described results on empathy using multiple measures, authors calculated the combined estimate of empathy for the study by the inverse of variance fixed effects model (FEM) [ 28 ]. To combine effect estimates across studies, standardized mean differences (SMDs) and 95 % confidence intervals (CIs) were calculated from the changes in means (post—pre-intervention) and their standard deviations (SD). If the post—pre-intervention changes were not reported, post-intervention means were used for the synthesis of the results. Authors performed random effects model (REM) meta-analysis of standardized mean differences (SMD) [ 28 ]. Heterogeneity was evaluated with Cochran’s Q statistic (statistically significant for P <  0.10) and it was quantified with the I [ 2 ] metric (low, moderate, large, very large for values of <25, 25–49, 50–74, >75 %, respectively) [ 29 ]. Primary analysis included all the studies that provided adequate data to calculate SMD. Sensitivity analysis included also studies that part of their results had to be imputed to facilitate their inclusion in the meta-analysis, i.e., studies that provided median instead of mean values (in these studies median was assumed to equal the mean), and trials that provided the mean value but did not provide the SD (in these trials the missing SD was imputed by the largest SD that was recorded among the studies of the same outcome category). Studies that did not provide results on effect estimate and dispersion were excluded from the analyses. In addition, authors proceeded in subgroup analyses for the following groups (a) type of intervention (experiential vs. non-experiential; (b) training specifically for promoting empathy vs. other; (c) type of assessor (external observer, health professional participants, and patients); and (d) type of process used for empathy evaluation, (simulated interview, actual interview, and questionnaire completion without interview). Analyses were performed in STATA 10.0 (STATA Corp., College Station, TX, USA). P values were two tailed.

Eligible studies

Electronic searches yielded 722 unique items. Pubmed included 465, Cochrane Database of Clinical Trials included 52, Scopus included 1, and PsychInfo included 204. Authors excluded 621 items after screening the titles. Additionally they excluded 50 articles after screening the abstracts either because they were not written in English ( n =  7), or because the intervention was not relevant ( n =  43). Authors retrieved 51 publications in full text. They excluded 34 articles (one was duplicated; two papers were dissertations; and 31 were not RCTs). Searches of the reference lists of the retrieved articles and of review papers did not reveal additional eligible papers. Thus, the total number of the eligible papers included in our systematic review was 17 (Fig.  1 ).

Flow diagram of study selection process

Characteristics of eligible studies (Table  1 )

Eligible studies were published from 1979 to 2012. Thirteen out of the 17 studies were published after 2000 [ 30 – 42 ]. Almost half of them were conducted in USA; [ 30 , 31 , 35 , 36 , 39 , 43 – 45 ] seven in Europe [ 32 – 34 , 38 , 40 – 42 ] and one in Australia [ 37 ].. All studies were reported as parallel RCTs except for two [ 31 , 39 ] with a cross-over design.

Sample size ranged from 16 to 452 participants (median 79; IQR 48–133). Ten studies 30,31,33,34,36,-38,40–42 included health care professionals (physicians, residents, and nurses). Seven studies [ 32 , 35 , 39 , 43 – 46 ] included under-graduate or post-graduate students. There were 7 multicentre studies; [ 31 , 33 – 35 , 39 , 40 , 42 ] five studies [ 32 , 43 – 46 ] did not provide data on the number of centres. Two studies [ 34 , 42 ] included only females; three studies [ 32 , 44 , 45 ] gave no information about gender. Male proportion for the rest of the studies ranged between 15 % and 81 % (median 53 %; IQR 21 %-68 %). Mean age of the participants ranged from 21.2 to 49.3 years. Nine studies [ 30 , 32 , 34 , 40 – 45 ] provided no data on age. Duration of the studies varied from one month to 60 months (median 10.5 months; IQR 6–12 months).

Two [ 31 , 36 ] articles provided definition for empathy. Boncivici [ 36 ] referred to empathy as a ‘multidimensional concept and skill with cognitive, affective and behavioral components’. Riess [ 31 ] defined empathy as ‘a process with both cognitive and affective components, which enables individuals to understand and respond to others’ emotional states and contributes to compassionate behavior and moral agency’.

Type of interventions (Table  2 )

Fifteen studies described experiential interventions [ 31 , 32 , 34 – 46 ]. Two [ 31 , 39 ] out the 15 studies included interventions for specifically promoting empathy while the rest assessed interventions on communication or interpersonal skills. Experiential interventions included role-playing, self-awareness exercises, and feedback as well as group discussions where the participants are responsible for their own learning. Two studies [ 30 , 33 ] described non-experiential interventions including items such as audio-taped interactions between physicians and patients, CD-ROMs or Internet courses, where the participants had no active presence during learning process.

Frequency of intervention varied between studies (Table  2 ). Three papers—two referred to experiential and one to non-experiential interventions—did not specify the intensity of the interventions [ 33 , 40 , 41 ]. Experiential interventions lasted from 8 h to 6 months while non-experiential from 2 weeks to 3 months. In four studies [ 30 – 32 , 39 ] – two [ 31 , 39 ] of which included interventions for specifically promoting empathy - there were experiential interventions with duration less than 2 weeks. Eleven studies [ 31 , 32 , 34 , 35 , 37 , 39 , 41 – 43 , 45 , 46 ] with experiential interventions, and two [ 30 , 36 ] with non-experiential interventions reported no training for the comparison group. Three [ 30 , 36 , 38 ] of the remaining four studies provided a brief intervention. In one study [ 40 ], investigators gave written feedback to the control group.

Type of outcomes (Table  3 )

All studies evaluated change in physicians’ empathic behavior as an outcome. Riess [ 27 ] was the only study that also evaluated change in attitude towards empathy, knowledge, and skills using self-reported questionnaires.

To evaluate change in health professionals’ behavior, studies used interviews with simulated patients [ 32 , 37 ], or actual interviews [ 33 , 36 , 40 , 41 , 45 ], or both [ 38 , 42 ]. All these studies used external assessors; Tulsky [ 33 ] also used the patients as assessors for the actual interviews. There were six studies that used questionnaires completed by the health professionals to evaluate change in their behavior [ 30 , 31 , 34 , 44 – 46 ]. Shapiro [ 35 ] used an external observer who filled in the questionnaire. In three studies [ 31 , 34 , 43 ], patients completed the questionnaire.

Effectiveness of interventions (Table  4 )

Riess [ 31 ] did not find significant change in residents’ attitude towards empathy; however, this study showed a significant increase in physicians’ knowledge of the neurobiology and physiology of empathy ( P <  0.001) as well as in physicians’ skill at decoding subtle facial expressions of emotion ( P <  0.001).

Out of four studies that used simulated interviews to assess change in empathic behavior, there was only one [ 42 ] that reported a significant improvement in the use of emotional “distress” words by nurses ( P <  0.001 for frequency score and P =  0.04 for density score). However, the use of emotional “distress” words was not increased in the same study when investigators evaluated actual interviews. Out of the seven studies that used actual interviews, there were four trials that reported significant improvement in empathic behavior for health professionals. Specifically, Tulsky [ 33 ] showed a significant increase in the number of empathic statements per conversation ( P =  0.024), and in the number of continuer response to empathic opportunities ( P =  0.028) for oncologists. Bonvicini [ 36 ] reported significant increase in physicians’ empathic expression using Global Rating Score ( P <  0.01), and Hierarchical Empathy Communication Coding System ( P <  0.01). Fallowfield [ 40 ] supported improvement in the number of empathic expressions ( P =  0.005) for oncologists while Razavi [ 42 ] concluded that nurses increased the use of emotional “anxiety” words ( P =  0.028) in actual interviews.

Out of the nine studies that used questionnaires completed by the health professionals to evaluate change in their behavior, three trials reported a significant improvement for the intervention group. Specifically, Blair-Irvine [ 30 ] showed a significant increase in the psychosocial construct of empathy Likert scale ( P =  0.04); Daniels [ 44 ] supported a significant increase in Carkhuff index of communication ( P <  0.05) for nurses; while in Wolf [ 44 ], medical students exhibited greater ability to respond to patients’ emotional concerns in hypothetical scenarios using Medical Communication Index ( P <  0.001), and greater preferences for responses that addressed patients’ emotions using Helping Relationship Inventory ( P <  0.001). In addition, external observers who completed Staff-Patient Interaction Rating Scale in one trial [ 35 ], found an increase in expressed empathy for the medical students ( P =  0.04). Finally, out of the two studies that patients filled in the questionnaires, one [ 31 ] reported significant increase in residents’ empathy using Consultation and Relational Empathy Measure ( P =  0.04).

Three studies [ 39 , 40 , 43 ] did not provide numerical data on results; and therefore, they were excluded from further analyses. Delvaux [ 38 ] reported results for several measures of empathic behavior as relative risk (RR), and therefore this trial was also excluded from standardized mean difference (SMD) meta-analyses. It reported that intervention was not effective in improving empathic behavior (RR 1.5, 95 % CI 1.0, 2.3; P value 0.6). In Table  4 , the results of meta-analyses per outcome category as well as per subgroup were presented (additional information on the corresponding forest plots is available in Appendix ). Ten studies [ 30 – 36 , 42 , 44 , 46 ] provided adequate results and were combined showing that interventions were effective in improving empathic behavior (SMD 0.7, 95 % CI 0.3, 1.1; P value <0.001) (Table  4 ; see also Appendix ). After inclusion of three [ 37 , 41 , 45 ] additional studies for which part of their results had to be imputed, the interventions remained effective for improving empathy (SMD 0.8, 95 % CI 0.4, 1.2; P value <0.001) (Table  4 ; see also Appendix ). Similar results were supported by subgroup analyses for experiential interventions, non-experiential interventions, and for training health professionals on interpersonal /communication skills programs (Table  4 ; see also Appendix ). However, training on programs that specifically aimed at empathy was assessed by one study and did not yield a significant result. In addition, significant improvement for empathy was noted when an external observer or the health professional that participated was used as assessor but not when the patient assessed the health professional (Table  4 ; see also Appendix ). Finally, interventions were found effective regardless of the evaluation process that was used (Table  4 ; see also Appendix ).

Quality of reporting for eligible studies

Included studies were of fair to moderate quality. Randomization mode and allocation concealment were not reported in any of the studies. Eight of the seventeen studies [ 31 – 33 , 37 , 39 , 41 , 44 , 45 ] reported single, while three reported double [ 31 , 32 , 38 ] blinding. Three studies [ 31 , 35 , 36 ] used power calculations to determine the sample size and they reached the number of requested participants. However, none of the studies reported that they incorporated potential contamination between the intervention and the control group in their power analysis.

Out of the 15 trials that employed trainers for the intervention, seven [ 34 , 35 , 41 , 42 , 45 ] described the number and the experience of the trainers. Two trials [ 30 , 33 ] provided internet-based or computerized interventions without the need for trainers. Trials invariably did not report on whether researchers verified the accurate implementation of interventions. Potential adverse effects of the interventions were not reported in the studies.

All studies clearly stated primary outcomes; eight trials included empathy as primary outcome [ 30 , 31 , 33 , 36 , 39 , 42 , 43 , 46 ]. Out of the 13 studies that used a scale to assess their outcomes, eleven [ 30 – 32 , 34 – 36 , 38 , 39 , 43 , 44 , 46 ] reported the psychometric characteristics of the scales.

Nine studies [ 33 – 36 , 38 , 40 – 43 ] reported withdrawal rate, which ranged from 0 to 23 %. Jenkins [ 41 ] was the only trial that reported a withdrawal rate more than 20 %, i.e., 23 %.

Several trials assessed the change in empathic behavior among health professionals supporting a significant improvement; however, very few were well powered and assessed empathy as primary outcome. Interventions usually covered a broad training on communication skills based on experiential approach. There was a limited number of RCTs that evaluated interventions specifically aimed at promoting empathy; none of them evaluated patients’ outcomes.

Clinical trials that assessed changes in empathic behavior were highly heterogeneous in terms of participants, interventions and outcome measures. Interventions varied in terms of content and frequency; their duration was generally brief and did not exceed six months. Follow up did not exceed one year in any of the studies. Studies with significant results at the end of the intervention did not observe the improvement at a later stage when they followed participants for a longer period. Thus, it would be difficult to support even for potential effective interventions that changes in empathic behavior may last. Investigators applied a wide variety of modes, and measures to assess changes in empathic behavior among health professionals. This may reflect the complexity of measuring any change in behavior [ 47 ]. In this meta-analysis, patients did not perceive improvement on empathic behavior for health professionals. This may reveal the necessity for a validated, globally accepted process to assess empathy in research taking into consideration the assessment both from health professionals and patients. It may also reveal the lack of agreement on the definition of empathy in clinical practice [ 48 ]. In this review, authors found only two publications [ 31 , 36 ] that provided a definition for empathy. For the purpose of this study, authors considered the definition of empathy within the framework of the Person-Centered Approach as the ability to deeper understand other’s frame of reference and involves being able to put oneself in the other’s position [ 49 ].

A previous systematic review included training in empathy as a part of generalized communication skills training [ 50 ], and revealed improvement in outcomes such as trust in physicians, or patient’s satisfaction. However, the specific role for empathy as part of communication skills to achieve these results remained unknown. Another systematic review [ 51 ] referred to communication skills training for health care professionals working with cancer patients and their families. It identified three trials, one of which showed significant increase in the expression of empathy. In our review, several RCTs showed that training in communication skills might enhance empathic behavior. Effective communication skills training incorporated a number of brief experiential interventions including role-playing, self-awareness exercises, and feedback as well as group discussions; or brief non-experiential interventions including items such as audio-taped interactions between physicians and patients, CD-ROMs or Internet courses. However, most of these studies did not report power calculations. Therefore, their results need to be cautiously interpreted. Moreover, future studies are necessary to corroborate these results. In addition, there was a paucity of RCTs for interventions specifically aiming at empathy training. Whether such interventions may have an impact on patients’ health care outcomes as well needs to be investigated in the future. Effective interventions specifically aiming at enhancing empathy may be incorporated in general training programs. However, further research is needed in order to clarify the type of approach, the duration, and the frequency of empathy enhancing interventions within a generic program. There is still debate about whether it is feasible and sound to isolate empathy from general training or empathy has to be taught in the context of a communication skills training. In the present meta-analysis, interventions aimed specifically at empathy were not found effective; however, the number of the included trials was small. Until there is a definitive answer both approaches may complement each other. Thus, medical curricula may provide empathy training within the targeted training in each clinic, such as cardiology, internal medicine or orthopedics. Taking into consideration that empathy is a way of being; there is indeed no need to separate it from the general training. In addition specific communication skills training may provide students or health care professionals with the appropriate process and time in order to further enhance awareness about empathy.

The methodological quality of eligible studies in our review was compromised. They invariably failed to report important items for RCT design and several times did not provide details on interventions. This may increase the difficulty for these interventions for replication in future studies. However, it was encouraging that several recent studies showed better reporting. The current development of tools for reporting RCTs of behavior change and health education interventions [ 52 ] may explain this observation. Almost all studies that included a process with simulated or actual interview used an external rater, which may have attributed a higher objectivity in the measurements [ 25 , 26 ]. Studies with questionnaires requested health professionals to evaluate their own performance. Two trials used multiple types of assessors, i.e., an external observer and a patient [ 33 ], or a health professional and a patient [ 31 ], which did not yield concordant results within each study [ 31 , 33 ]. .

The present systematic review confirmed that empathy is an attribute that is amenable to change as a result of educational experiences [ 1 ]. Counteracting current trends in medical education and practice that are not conducive to empathic engagement in patient care requires a mandate for the development and implementation of targeted educational programs at all levels of training in all academic medical centers [ 1 ]. In order to develop an educational program for promoting empathy investigators need to take into consideration that the extent to which the potential for empathy can be actualized or enhanced in a particular person depends on the interaction of several factors, including the person’s constitutional makeup, early life experiences, motivation, and a facilitating environment [ 1 ]. The content of an educational intervention needs to address the variety of clinical contexts in which empathy may be communicated as well as the variety of verbal and non-verbal ways in which empathy may be communicated. This process requests for a methodological approach beyond the design of an RCT. It requires the contribution of other research fields, such as communication theory, planned behavior theory, and behavioral science. For example, an educational program for promoting empathy may be based on scientifically validated theories of behavior, such as the social cognitive theory, the theory of planned behavior, operant conditioning, implementation intentions, or stage theories. This will facilitate the theoretical understanding of the likely process of change among health professionals. However, once an educational program is developed its rigorous evaluation through RCTs is necessary. These RCTs demand the explicit reporting of additional design characteristics as compared to RCTs for pharmacological interventions. Empathy enhancing interventions may be complex interventions including multiple components that may be tailored to individual participants. Thus, these interventions need a detailed reporting including the procedures for tailoring them to individual participants, the mode through which they were standardized, the process through which the adherence of the providers with the protocol was assessed. In addition they need to report how these interventions were finally implemented and whether any blinding process was also attempted. Acknowledging that there would be factors –several of them unknown—that may not have been taken into consideration during the design of an empathy promoting intervention, randomization would be the way to control for these factors during the evaluation process. In addition, there are several barriers to maintain the results of a potentially effective educational intervention including time restriction, poor reimbursement, and decision-making about access to treatments by another provider. A pragmatic study design may facilitate addressing these issues; or RCTs may evaluate interventions specifically developed to confront these barriers and provide solutions for sustainability of empathic behavior among health professionals.

This review had several limitations. First, authors may have failed to identify additional studies in search strategy since certain investigators may have used different phrases or words to describe empathy. However, there were extensive searches in multiple electronic databases as well as hand searches of the retrieved articles to retrieve all RCTs that included the word “empathy”. Included studies used different instruments to measure the same construct, and therefore SMD was used in meta-analysis for combining continuous data. The use of SMD was helpful in generalizing the results; however, interpretability may be limited. Authors also provided a narrative synthesis of the results per outcome category to facilitate interpretation. Finally, authors cannot exclude the possibility of a publication bias.

As a conclusion, limited evidence suggested that certain interventions might effectively enhance empathic behavior among physicians, residents, nurses, or medical students for a brief period of time. However, the exact type of intervention that would be effective needs to be clarified. In addition, whether any improvement in health professionals’ empathic behavior may continue to be present after a longer period, or whether it may also affect patients’ outcomes is yet to be defined. Future research needs to clarify factors, which may contribute to the enhancement of empathy in patient care, and support a lasting effect of empathy training. In addition, future research is necessary to measure the impact of empathy promoting interventions on patient outcomes.

Abbreviations

CI, confidence Interval; CONSORT consolidated standards of reporting trials; FEM, fixed effects model; IQR, interquartile range; MERSQI, medical education research study quality instrument; PRISMA, preferred reporting items for systematic reviews and Meta-analyses; RCTs, randomized controlled trials; REM, random effects model; RR, relative risk; SD, standard deviation; SMD, standardized mean difference

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Acknowledgements

We thank Dr Dimitrios Mavridis, Assistant Professor in the University of Ioannina Department of Primary Education for discussing on the statistical analyses.

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The datasets supporting the conclusions of this manuscript are included in Tables  1 , 2 and 3 within the paper.

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Dr AT had the original idea, organised the study design, and performed the statistical analyses; Mr VNK and Dr VTK collected the data; all three authors evaluated and interpreted the data and the results; Mr VNK and Dr AT wrote the first draft of the manuscript, which was critically reviewed by Dr VTK; all authors approved the final version. Dr AT agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Meta-analysis including only the studies with adequate data to calculate standardized mean difference with 95 % confidence interval ( N =  10)

Meta-analysis including the studies with adequate data to calculate standardized mean difference with 95 % confidence interval and the studies with imputed values ( N =  13)

Meta-analysis of subgroups according to the type of intervention (experiential [ N =  11] vs. non-experiential [ N =  2]). Values represent standardized mean difference with 95 % confidence interval

Meta-analysis of subgroups according to the type of training (interpersonal skills programme [ N =  12] vs. empathy-only training [ N =  1]). Values represent standardized mean difference with 95 % confidence interval

Meta-analysis of subgroups according to the type of assessor (external observer [ N =  8] vs. health professional participant [ N =  6] vs. patient [ N =  3]). Values represent standardized mean difference with 95 % confidence interval

Meta-analysis of subgroups according to the type of evaluation process (simulated interview [ N =  3] vs. actual interview [ N =  5] vs. questionnaire [ N =  7]). Values represent standardized mean difference with 95 % confidence interval

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Kiosses, V.N., Karathanos, V.T. & Tatsioni, A. Empathy promoting interventions for health professionals: a systematic review of RCTs. J of Compassionate Health Care 3 , 7 (2016). https://doi.org/10.1186/s40639-016-0024-9

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Interventions to cultivate physician empathy: a systematic review

• Zak Kelm 1 ,
• James Womer 2 , 3 ,
• Jennifer K Walter 3 &
• Chris Feudtner 3  

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Physician empathy is both theoretically and empirically critical to patient health, but research indicates that empathy declines throughout medical school and is lower than ideal among physicians. In this paper, we synthesize the published literature regarding interventions that were quantitatively evaluated to detect changes in empathy among medical students, residents, fellows and physicians.

We systematically searched PubMed, EMBASE, Web of Science and PsychINFO in June of 2014 to identify articles that quantitatively assessed changes in empathy due to interventions among medical students, residents, fellows and physicians.

Of the 1,415 articles identified, 64 met inclusion criteria. We qualitatively synthesized the findings of qualified studies by extracting data for ten study metrics: 1) source population, 2) sample size, 3) control group, 4) random assignment, 5) intervention type, 6) intervention duration, 7) assessment strategy, 8) type of outcome measure, 9) outcome assessment time frame, and 10) whether a statistically significant increase in empathy was reported. Overall, the 64 included studies were characterized by relatively poor research designs, insufficient reporting of intervention procedures, low incidence of patient-report empathy assessment measures, and inadequate evaluations of long-term efficacy. 8 of 10 studies with highly rigorous designs, however, found that targeted interventions did increase empathy.

Conclusions

Physician empathy appears to be an important aspect of patient and physician well-being. Although the current empathy intervention literature is limited by a variety of methodological weaknesses, a sample of high-quality study designs provides initial support for the notion that physician empathy can be enhanced through interventions. Future research should strive to increase the sample of high-quality designs through more randomized, controlled studies with valid measures, explicit reporting of intervention strategies and procedures, and long-term efficacy assessments.

Peer Review reports

In their Learning Objectives for Medical School Education, the Association of American Medical Colleges states that, “physicians must be compassionate and empathetic in caring for patients” [ 1 ]. Similarly, the American Medical Association’s first principle of medical ethics asserts the following: “A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights” [ 2 ]. These statements illustrate that the field of medicine is not only committed to producing and upholding the most knowledgeable and skillful physicians possible, but also the most caring and empathic. Within the field of medicine, there is disagreement regarding the precise definition of empathy [ 3 , 4 ]. Some researchers define physician empathy as a “cognitive attribute that involves an ability to understand the patient’s inner experiences and perspective and a capability to communicate this understanding” [ 3 ]. Others describe four components of the empathy construct: 1) emotive, the ability to imagine and share a patient’s psychological state or feelings; 2) moral, the physician’s internal motivation to express empathy; 3) cognitive, the intellectual ability to identify and understand a patient’s perspectives and emotions; and 4) behavioral, the ability to communicate this understanding of the patient’s perspectives and emotions [ 5 ]. Most constructions of empathy have in common, however, an understanding of the emotional states of others and expression of this understanding.

While there is some disagreement regarding the exact components of empathy, there is wide consensus that physician empathy significantly affects patients in a variety of ways. Physician empathy has been associated with higher levels of patient satisfaction [ 6 – 12 ], adherence to medical recommendations or regimens [ 10 , 13 – 16 ], and improved clinical outcomes [ 6 , 16 – 20 ]. Moreover, empathy appears to positively influence physicians themselves, as empathy has been linked to lower burnout [ 21 ], higher well-being [ 21 – 23 ], higher ratings of clinical competence [ 3 ], and less medical-legal risk [ 24 – 26 ]. Physician empathy may even reduce health care costs, as patient centered communication styles have been associated with lower diagnostic test expenditures [ 27 ].

Despite considerable evidence demonstrating the benefits of physician empathy for patients and physicians, empathy is at a lower than ideal level in medicine. Studies indicate that physicians often overlook or miss empathic opportunities during patient encounters [ 28 – 32 ], and tend to spend significantly more time and energy on biomedical inquiry and offering medical explanations to patients [ 8 , 32 ]. In one study, physicians acknowledged or explored empathic opportunities only 10% of the time [ 32 ]. Patient reports also point to a shortage of physician empathy [ 33 ]. Yet, not only is there a shortage of empathy among medical students and physicians, numerous studies show that empathy declines throughout medical training, in both medical school and residency [ 34 – 39 ]. As trainees experience an increase in personal distress from burnout, higher rates of depression and decreased quality of life during their training, they are less likely to experience or demonstrate empathy. This distress is potentially promoted by deficiencies in several aspects of the medical curricula, including the formal (e.g. lack of formal empathy training), informal (e.g. inadequate mentors, shorter hospital stays, and inappropriate learning environments), and hidden (e.g. mistreatment of students and high workload) medical curricula [ 38 ].

The lack of empathy among physicians and the decline in empathy throughout medical training offer reasons for concern, especially given the relationship between physician empathy and patient health and well-being [ 6 – 20 ]. It is incumbent upon medical educators, and the field in general, to investigate methods to enhance medical student and physician empathy. Although studies have reviewed and examined interventions to increase empathy among medical students [ 40 ] and in health and human services [ 41 ], no review has been done on the full body of literature regarding interventions designed to quantitatively detect changes in medical student or physician empathy. Thus, the present study seeks to systematically review and synthesize the existing literature of quantitatively evaluated interventions aimed at cultivating empathy among medical students, residents, fellows, and attending physicians.

In June of 2014, we conducted a systematic review of the literature, searching the online databases PubMed, EMBASE, Web of Science, and PsychINFO (Figure  1 ). We collaborated with a librarian from the Biomedical Library at the University of Pennsylvania to discuss and refine our search strategy.

Study flow diagram. Illustration of database search process to identify studies that met inclusion criteria.

In PubMed, we used the following search terms as key words: (1) empathy or caring or compassion, (2) medical students or physicians, (3) medical education or clinical competence or training or workshop, and (4) communication. This search generated 574 articles. In EMBASE, the following search terms were used as descriptors: (1) empathy, (2) medical student or resident or physician, (3) medical education, (4) clinical competence, and (5) doctor patient relation or interpersonal communication. This search produced 359 articles. In Web of Science, we searched using the following key terms: (1) empathy, (2) medical students or physicians, and (3) education or training or workshop or intervention. This search generated 550 articles. Finally, in PsychINFO, we used the following descriptors: (1) empathy, (2) medical students or physicians, and (3) medical education or training. The PsychINFO search produced 145 articles.

Overall, our initial literature search generated 1,628 citations. Elimination of duplicate articles produced 1,400 citations, and an additional 15 articles were identified through references. In turn, 1,415 articles were screened by title and abstract. Of these, 1,303 articles were excluded from further review, including correlational studies, theoretical papers, articles that failed to assess empathy, and publications with non-medical populations. The full texts of the remaining 112 studies were retrieved and assessed for eligibility using the inclusion criteria outlined below, yielding 64 eligible studies.

Our inclusion criteria specified that each study: 1) elucidate that some type of intervention was used, 2) explicitly state that “empathy” was being evaluated or measured, 3) assess changes in empathy by reporting quantitative outcomes using statistical methods, and 4) examine empathy in medical students, residents, fellows or physicians. We considered only articles written in the English language. After reviewing the titles and abstracts of all articles retrieved through our initial database search, we obtained full texts of potentially eligible studies. We also reviewed the reference sections of these selected articles to obtain any additional studies not found through our initial database search.

Members of the research team (ZK, JW) independently examined the full texts of studies that passed title and abstract review and met inclusion criteria. Each article was assessed for a variety of metrics, including source population, sample size, type of intervention, duration of intervention, assessment strategy, type of outcome measure, and outcome assessment time frame. Data were extracted and finalized through discussion among the research team.

The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (see Additional file 1 ).

We identified 64 studies [ 42 – 105 ] that quantitatively assessed empathy interventions in our specified population (see Additional file 2 ). 50 of these 64 studies were published within the past ten years. We reviewed the findings from these articles by extracting data for ten major study metrics: 1) the study source population , 2) the study sample size , 3) the presence or absence of a control group , 4) whether or not random assignment was used, 5) the type of intervention , 6) the duration of the intervention , 7) the empathy assessment strategy , 8) the type of outcome measure , 9) the outcome assessment time frame post-intervention, and 10) whether or not a statistically significant increase in empathy was reported. This summary method allowed the research team to investigate similarities and differences among articles and to attain a more general appreciation for the strengths and weaknesses of the current literature regarding empathy interventions. Thus, the results are presented and organized around the ten metrics used to evaluate each study.

Source population

The source population assessment was divided into four major categories: medical students, residents, fellows and physicians. Of the 64 studies reviewed, 36 (56%) evaluated empathy interventions with medical students, 13 (20%) with residents, 2 (3%) with fellows, and 15 (23%) with attending physicians. In addition, six studies evaluated empathy in a “mixed” population, including three articles assessing both medical students and residents, two assessing residents and fellows, and one article assessing medical students and attending physicians.

Sample size

Sample sizes ranged from 11 participants to 439 participants. The mean sample size was approximately 89 participants, with a median of 78, Q1 of 28, Q3 of 125, and a standard deviation of 75. 21 studies (33%) exhibited sample sizes of 100 or more participants, while 24 studies (38%) reported sample sizes of fewer than 50 participants.

Control group

Of the 64 studies reviewed, 35 (55%) used a control or comparison group.

Random assignment

Of the 35 controlled interventions, 24 (69%) used random assignment.

Intervention type

A variety of intervention types were utilized. 20 studies (31%) employed “communication skills training” interventions. We classified an intervention as “communication skills training” if the study authors explicitly referred to their intervention as a communication skills training or workshop. Often, communication skills training interventions were comprised of a variety of features, including didactic sessions on effective communication and empathy, experiential learning, and skills or behavior-based workshops. For instance, Winefield and Chur-Hansen [ 103 ] used both didactic material (i.e., lecture, videotape and handouts) and training workshops in which medical students practiced their communications skills by interviewing standardized patients and receiving feedback. Tulsky et al. [ 99 ] used an audiotape CD-Rom training program that allowed physicians to observe the demonstration of an effective communication skill and review or reflect upon their own conversations and implementation of the skill.

Seven studies (11%) primarily used a “role playing” intervention, typically involving experiential learning in which study participants acted as a patient or family member. For example, Chunharas et al. [ 51 ] sought to build medical student empathy for patients receiving intramuscular or subcutaneous injection by asking medical students to take turns injecting each other with saline solution.

Six studies (9%) utilized some form of the “humanities,” including reflective writing, a literature course, and theater. For instance, Shapiro et al. [ 93 ] used a reflective writing intervention, in which medical students wrote essays from the point of view of either hypothetical or standardized patients.

In addition, two articles reported an intervention involving “motivational interviewing training,” a counseling approach aimed at patient behavior change. Three interventions used “balint training,” which entails small group discussions focused on patient emotions. Two studies emphasized mindfulness-based stress reduction (MBSR), a type of meditation characterized by nonjudgmental, moment-to-moment awareness. One intervention used problem-based learning sessions that focused on empathy and communication.

Finally, 23 studies (35%) were categorized as “other.” Those studies classified as “other” could not be logically organized into a more general category. Studies classified as “other” often used a variety of intervention types. For instance, Krasner et al. [ 69 ] constructed an intervention that involved MBSR and the humanities, particularly reflective writing, appreciative inquiry exercises, and other educational and experiential tasks. Riess et al. [ 82 ] created an empathy training protocol that included education in the neurobiology and physiology of empathy, real-time biofeedback during physician-patient encounters, and mindfulness exercises. In addition, many of the “other” type interventions exhibited similarities to “communication skills training” interventions, as various didactic, experiential or skills-based elements were utilized.

Duration of intervention

Duration of empathy interventions (i.e., amount of time spent on intervention activities) ranged from 40 minutes to approximately 96 hours, with a mean of 15 hours, median 12 hours, Q1 of 4 hours, Q3 of 18 hours, and a standard deviation of 74.4 hours. Interventions occurred over the course of days, weeks, months, and even years. 19 studies (30%) were regarded as “not explicit” (N/E) in their reporting of intervention duration, particularly the number of intervention hours.

Assessment strategy

Empathy assessment strategies were evaluated using two major categories: timing of the empathy assessment (pre- versus post-intervention) and overall study design evaluation (within-group versus between-group). 58 (91%) of the 64 studies assessed empathy both pre- and post-intervention. 15 studies (23%) used between-group comparison to evaluate empathy changes, 32 studies (50%) used within-group comparison methods, and 17 (27%) utilized both a within- and between-group assessment strategy.

Outcome measures

Among the outcome measures used to assess changes in empathy, 31 studies (48%) used self-report measures. 33 (52%) employed other-report measures where others (including patients) evaluated their perception of a medical practitioner’s empathy. Only six studies (9%) evaluated changes in empathy using patient reports. Four assessed empathy using more than one type of outcome measure.

Self-report measures involved a self-report survey or single question. A variety of self-report survey types were used, including the Jefferson Scale of Physician Empathy (JSPE), Empathic Tendency Scale (ETS), Empathic Skill Scale (ESS), Balanced Emotional Empathy Scale (BEES), Empathy Construct Rating Scale (ECRS), and Interpersonal Reactivity Index (IRI). The JSPE was the most commonly used self-report survey, appearing in 15 of the 31 studies employing self-report measures.

Other-report outcome measures varied as well. Typically, these measures involved assessments of participant behaviors during clinical encounters or medical interviews by trained observers. For instance, Bonvicini et al. [ 46 ] used trained observers and an empathy coding system to evaluate physician empathy during audiotaped recordings of physician-patient interactions. 24 of the 32 articles employing other-report measures evaluated empathy during real or staged patient encounters. Six studies assessed empathy based on medical students’ or residents’ written responses to hypothetical patient scenarios, and two studies used tests requiring decoding of emotional facial expressions.

Outcome assessment time frame

Outcome assessment time frames ranged from immediately following the intervention to 21 years post-intervention. We defined immediately following the intervention as studies that measured empathy within a day after the end of an intervention. 30 studies (47%) assessed empathy immediately following the intervention. 17 studies (27%) evaluated empathy at some time after immediate assessment. Of these studies, seven (11%) assessed empathy 1–4 weeks post-intervention, ten (15%) assessed empathy 1–6 months post-intervention, three evaluated 12 months post-intervention, one study assessed after 3 years, and one study assessed empathy between four and 21 years post-intervention. Nine studies evaluated empathy at multiple time points post-intervention. 20 studies (31%) were not explicit (N/E) about the outcome assessment time frame.

Significant increase in empathy reported

42 (66%) of the 64 reviewed studies reported a statistically significant increase in empathy. 14 studies (22%) showed no significant change in empathy. Finally, eight studies (12%) were classified as “mixed” because they reported some measure with no significant change in empathy and another measure with a significant increase in empathy. Cahan et al. [ 49 ] reported the results of two distinct pilot studies. Pilot 1 was a between-group study design that showed no significant result. Pilot 2 used a within-group study design that resulted in a significant increase in empathy. Both Chunharas et al. [ 51 ] and Norfolk et al. [ 76 ] reported a significant increase in empathy within groups, but no increase resulted from between-group comparison. Riess et al. [ 81 ] reported a significant increase in empathy on the Consultation and Relational Empathy (CARE) measure, but no change on the Balanced Emotional Empathy Scale (BEES), Jefferson Scale of Physician Empathy (JSPE), and Ekman Facial Decoding Test. Riess et al. [ 82 ] found a significant increase in empathy on the CARE measure, the Neurobiology and Physiology of Empathy Test and the Ekman Facial Decoding test, but no significant increase on the BEES and JSPE. Sanson-Fisher & Poole [ 87 ] reported no significant change in empathy when evaluated within the intervention group, but a significant increase resulted from between-group comparison. Shapiro et al. [ 92 ] found an increase in empathy on the BEES, but no change on the Empathy Construct Rating Scale (ECRS). Finally, Shapiro et al. [ 93 ] used a study-specific thematic coding system for writing samples of medical students and found an increase in empathy for physicians, but no change in empathy for the family or patient.

Study design quality assessment

Given that two thirds of included studies reported a significant increase in empathy (not including mixed results), we performed a qualitative assessment of study design quality (see Additional file 3 ). Study design quality was based on three metrics: 1) presence or absence of a control group, 2) whether or not random assignment was used, and 3) the reliability and validity of the outcome measure. Further, outcome measures were categorized into three types: 1) reliable and valid outcome measure (+), 2) reliable, but not valid outcome measure (+/−), and 3) neither reliable, nor valid outcome measure (−). If reliability or validity information was not available in published material, efforts were made to contact the authors to obtain this information.

The three quality metrics were used to establish a study design rating system composed of three tiers. 10 studies (16%) were classified as Tier 1. Tier 1 studies were the most rigorous, involving randomized, controlled interventions, along with reliable and valid outcome measures (+). 9 studies (14%) were categorized as Tier 2. Tier 2 studies were composed of one of two quality metric arrangements: 1) randomized, controlled interventions, along with reliable, but not valid outcome measures (+/−), or 2) controlled interventions devoid of random assignment, along with reliable and valid outcome measures (+). Finally, 45 studies (70%) were classified as Tier 3: all other study designs.

We compared study design quality to our significant increase in empathy metric (Figure  2 , Additional file 3 ). Of the ten studies classified as Tier 1, eight reported a significant increase in empathy, and two showed mixed results. Of the nine studies classified as Tier 2, six (66%) showed a significant increase in empthy and three (33%) exhibited no change in empathy. Of the 45 studies classified as Tier 3, 28 (62%) reported a significant increase in empathy, six (13%) showed mixed results, and eleven (24%) reported no change in empathy. Compared to the 80% of studies showing a significant increase in empathy in Tier 1, 63% (34/54) of studies in Tier 2 and Tier 3 reported a significant increase in empathy. Moreover, all 14 studies that reported no significant change in empathy were categorized into either Tier 2 or Tier 3.

Comparison of study design quality with significant increases in empathy. Number of studies exhibiting significant, non-significant and mixed effects among Tiers 1, 2 and 3.

Characteristics of tier 1 studies

Tier 1 studies were heterogeneous in their source populations: 50% involved medical students and 50% involved residents, fellows, or physicians, suggesting that empathy interventions may be effective during or after training. A variety of intervention types were used in Tier 1 studies: 30% had been classified as “communication skills training,” 40% were categorized as “other,” and “role playing,” “motivational interviewing,” and “humanities” interventions were each represented by a single study. Tier 1 studies also exhibited a relatively balanced array of outcome measure types, as 60% used other-report measures, 50% employed self-report measures, and 30% used patient-report measures. Furthermore, 50% of Tier 1 studies evaluated empathy 1–6 months post-intervention. Five Tier 1 studies reported effect size data; however, no two of those five used the same methodology to calculate effect size, leaving us unable to make meaningful comparisons based on those data.

The present study provides a novel synthesis and analysis of empathy interventions in medicine. Previous studies have systematically reviewed empathy measures and their relationship to patient outcomes in cancer care [ 106 ], emotion skills training for medical students [ 107 ], and empirical research on empathy in medical students and physicians [ 108 ]. This study, however, has systematically reviewed and synthesized interventions that quantitatively evaluate changes in empathy among medical students, residents, fellows, and physicians.

This review has generated a number of key findings. As previously mentioned, 66% of studies reported a significant increase in empathy. While this result was encouraging, we sought to further evaluate this trend by assessment of study design. Results of this assessment indicated that although the majority of studies (84%) lacked highly rigorous study designs (Tier 2 and Tier 3), all ten studies classified as Tier 1 exhibited either significant increases in empathy or mixed effects. Moreover, 80% of Tier 1 studies showed a significant increase in empathy (not mixed), while only 63% of studies in Tier 2 and Tier 3 reported significant increases. Despite the small number of studies, these findings generally support the hypothesis that intervention can increase empathy among physicians and medical students, not only because of the high incidence of significant increases in empathy in Tier 1, but also because Tier 1 studies included balanced assortments of other study metrics (e.g., study population, intervention type, outcome measure type, and outcome assessment time frame). Taken together, the Tier 1 results suggest that empathy can be enhanced through a variety of intervention types targeted toward medical students, residents, fellows and physicians, and that increased empathy may persist beyond the immediate post-intervention period.

Although these findings are encouraging, it is important to highlight the fact that only ten studies were classified as Tier 1. Further, only half of the Tier 1 studies explicitly reported effect sizes. These findings add uncertainty to our inferences about the cultivation of empathy among medical students and physicians, and also point to major limitations associated with the full body of physician empathy intervention literature: significant fractions of eligible studies lacked rigorous study designs, lacked control groups, and failed to use random assignment. Well-controlled and randomized studies are the most reliable way to account for, or minimize, potential confounding factors, and the fact that they are rare in the physician empathy intervention literature should be taken into account when examining the high incidence of significant outcomes. The overall literature was also marked by relatively small sample sizes and vague reporting of intervention durations and outcome-assessment time frames. While empathy interventions were classified into different categories, the literature was characterized by a wide array of intervention types that typically showed both similar and disparate underlying features. In some cases, articles lacked detailed descriptions of the intervention. If the ultimate goal is implementation of effective empathy-increasing interventions, the literature does not enable other institutions to replicate these outcomes.

Outcome assessment time frames, and particularly the high prevalence of studies only assessing empathy immediately following the intervention, should also be highlighted as a weakness of the current literature. While medical student or physician empathy may significantly increase immediately after an intervention, there is limited insight available about long-term efficacy. Just over a quarter of studies explicitly reported follow-up quantitative evaluations of empathy at some time (i.e., 1 week to 21 years) after an immediate assessment of the intervention.

The majority of empathy interventions were targeted toward medical students. Although this trend is not surprising given that medical school has an explicit curriculum, including communication skills training in a growing number of institutions, researchers and educators should be wary of the fact that these empathic skills degrade over time [ 34 – 39 ]. Therefore, interventions aimed at enhancing empathy among residents, fellows and physicians may be more important to ensure that patients consistently receive empathic care from their physicians. Little is known about the long-term efficacy of empathy interventions. Even if medical student empathy is enhanced through interventions, a lack of long-term efficacy could have serious consequences for arguably the most critical population – practicing physicians and their patients.

Another limitation of the literature involved outcome measure type. Empathy was measured in a variety of ways, but the vast majority of studies used self-report or other-report measures, and only six employed patient reports to measure physician empathy. Indeed, close to half of the reviewed studies used self-report measures to evaluate changes in empathy. Some of these self-report surveys are psychometrically reliable and validated, yet little is known about the relationship between self-report measures of empathy and behavioral or patient-report measures. It is also the case that measurements of empathy in a medical population may be subject to significant social desirability bias; therefore, particularly with self-report measures of empathy, it can be difficult to say whether interventions increase empathy, or awareness of the desirability of an empathetic physician. Self-report surveys can be an effective and reliable measure of physician empathy, but they must be validated against behavioral or patient-report measures.

A recent study indicated that a commonly used self-report measure, the Jefferson Scale of Physician Empathy (JSPE) [ 109 – 111 ], exhibited statistically significant correlations with a patient-report measure, the Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE) [ 112 ]. The strongest correlations have been demonstrated with real patients [ 113 ], although weaker correlations exist with standardized patients as well [ 112 ]. Further, a systematic review concluded that physician empathy is associated with beneficial outcomes based on patient-report measures in cancer care. However, little is known about the relationship between the reliable and valid patient-report measures examined in the cancer care study and physician self-report empathy measures like the JSPE [ 106 ]. In other words, there may be a misalignment between the outcome measure type (patient-report) most prevalent in studies investigating the association between physician empathy and patient outcomes, and an outcome measure type common to empathy interventions (self-report). It is worth noting that while only six studies overall used patient-report measures, three of these studies were categorized as Tier 1. Further, all three of these Tier 1 studies employed reliable and valid patient-report measures that have been associated with beneficial patient outcomes. These results may add confidence to the inference that targeted interventions may not only increase empathy, but also lead to beneficial effects for patients.

In addition to the weaknesses of the current empathy intervention literature, our study may have been marked by a number of limitations, such as that imposed by the availability of information in the published materials (e.g., intervention durations, procedures, outcome assessment time frames, and reliability and validity of measures). Our efforts to contact authors to obtain further information yielded mixed results. Our study may have also been limited by a ‘publication bias’, which could relate to the high incidence of studies reporting significant effects. Thus, the literature may contain a disproportionately small number of null results.

Overall, results of the study design quality assessment suggest that empathy can be enhanced in our study population. However, given the relatively small number of Tier 1 studies and limitations of the full body of literature, we suggest strategies to facilitate progress within empathy interventions for medical students, residents, fellows, and physicians: 1) Further determining the correlation between self-report, other-report (behavioral), and patient-report measures of physician empathy to ensure future studies are able to utilize reliable and validated measures that have an established connection between change in self-report and increase in patient perception of empathy; 2) Establishing consensus about which measurement types should be used to evaluate physician empathy so that smaller studies may be aggregated in the future in a meta-analysis; 3) Ensuring adequate and explicit reporting of intervention procedures and implementation to promote transparent and easily replicable studies; 4) Conducting more high-quality randomized controlled study designs to establish a larger sample of Tier 1 studies, and thereby evaluating their efficacy with a higher degree of confidence because confounding factors have been controlled for; 5) Given the degradation of empathy, recognizing the need to develop and test interventions at multiple time points in training and practice of medicine; and 6) Lengthening outcome assessment time frames to investigate the long-term efficacy of empathy interventions.

Although considerably more research must be undertaken, the present study provides valuable insight into the current state of the empathy intervention literature and suggests that targeted interventions may be able to cultivate physician empathy. The reported shortage of empathy and decline in empathy during medical training only amplifies the importance of finding reliable interventions for physicians and physicians-in-training. Indeed, heightened empathy among medical practitioners could not only lead to a more ethical healthcare system, but also to enhanced health and well-being for patients and practitioners themselves.

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Acknowledgements

We thank Melanie Cedrone, a Biology and Biomedical Graduate Studies Liaison at the Biomedical Library of the University of Pennsylvania, for her advice and collaboration during our initial database search process.

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ZK and CF conceived the paper. JW and ZK performed the title and abstract review and extracted the data. JKW, JW, and ZK performed the study design quality assessment and revised the manuscript during the review process. ZK, JW, JKW, and CW participated in the design of the study and interpretation of the data; performed the data analysis; drafted the manuscript; and revised the manuscript for key intellectual content. All authors read and approved the final manuscript.

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Additional file 1: PRISMA 2009 Checklist. Table reporting key PRISMA items by section and page number of the systematic review. (DOC 62 KB)

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Additional file 2: Table S1: Intervention studies evaluating quantitative changes in empathy. Table showing the results of all data extraction measures for the 64 qualifying studies. (DOCX 146 KB)

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Additional file 3: Table S2: Quality assessment of intervention studies. Description of Dataset: Table showing the quality assessment results of all 64 studies. (DOCX 114 KB)

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Kelm, Z., Womer, J., Walter, J.K. et al. Interventions to cultivate physician empathy: a systematic review. BMC Med Educ 14 , 219 (2014). https://doi.org/10.1186/1472-6920-14-219

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• Volume 10, Issue 9
• Assessing the effect of empathy-enhancing interventions in health education and training: a systematic review of randomised controlled trials
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• http://orcid.org/0000-0002-8775-2461 Rachel Winter 1 ,
• Eyad Issa 1 ,
• Nia Roberts 2 ,
• Robert I Norman 1 ,
• Jeremy Howick 3
• 1 College of Life Sciences , University of Leicester , Leicester , UK
• 2 Bodleian Health Care Libraries , University of Oxford , Oxford , UK
• 3 Faculty of Philosophy , University of Oxford , Oxford , UK
• Correspondence to Dr Rachel Winter; rw205{at}le.ac.uk

Objective To estimate the effect of empathy interventions in health education and training from randomised controlled trials (RCTs).

Methods MEDLINE, PsycINFO, EMBASE, CINAHL and Cochrane databases were searched from inception to June 2019 for RCTs investigating the effect of empathy-enhancing interventions in medical and healthcare students and professionals. Studies measuring any aspect of ‘clinical empathy’ as a primary or secondary outcome were included. Two reviewers extracted data and assessed the risk of bias of eligible studies using the Cochrane Risk of Bias Tool. Random effects meta-analyses of the impact of empathy training on participants’ empathy levels were performed.

Results Twenty-six trials were included, with 22 providing adequate data for meta-analysis. An overall moderate effect on participant empathy postintervention (standardised mean difference 0.52, 95% CI 0.36 to 0.67) was found. Heterogeneity across trial results was substantial (I 2 =63%). Data on sustainability of effect was provided by 11 trials and found a moderate effect size for improved empathy up until 12 weeks (0.69, 95% CI 0.23 to 1.15), and a small but statistically significant effect size for sustainability at 12 weeks and beyond (standardised mean difference 0.34, 95% CI 0.11 to 0.57). In total, 15 studies were considered to be either unclear or high risk of bias. The quality of evidence of included studies was low.

Conclusion Findings suggest that empathy-enhancing interventions can be effective at cultivating and sustaining empathy with intervention specifics contributing to effectiveness. This review focuses on an important, growing area of medical education and provides guidance to those looking to develop effective interventions to enhance empathy in the healthcare setting. Further high-quality trials are needed that include patient-led outcome assessments and further evaluate the long-term sustainability of empathy training.

Protocol registration number PROSPERO (CRD42019126843).

• medical education & training
• education & training (see medical education & training)
• statistics & research methods

Data availability statement

Data are available in a public, open access repository. Data sharing not applicable as no datasets generated and/or analysed for this study. All data relevant to the study are included in the article or uploaded as supplementary information. This is a systematic review of randomised controlled trials. No original datasets generated or analysed for this study.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2019-036471

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Strengths and limitations of this study

This is an up-to-date review that excludes non-randomised studies, follows a prepublished protocol and measures the longer term effects of empathy training.

The quality of the review was limited by the reporting quality of some of the included studies.

The studies in our review were heterogeneous, which we anticipated.

We found only four studies that followed-up participants for at least 3 months.

Introduction

Clinical empathy has multiple benefits for patient care 1–4 and practitioner health. 5 6 Indeed, person-centred and empathic care are central to all professional healthcare education. 7 Empathy in the clinical setting has been defined in various ways 8 and can be considered as a multidimensional construct incorporating affective, cognitive, behavioural and moral components. 9 A widely accepted definition of clinical empathy involves the ability to understand the patient’s situation, perspective and feelings, communicate that understanding to them and act on it in a helpful and therapeutic way. 10 There is still, however, little consensus on the precise nature of clinical empathy, not least reflected in the variety of tools and scales available to measure it. No guidance exists on how to select measures for assessing clinical empathy, and choice of tools is likely to be led by the definition of empathy used or specific domain being measured. 11 A recent systematic review 11 on empathy measurement tools for care professionals identifies certain measures as scoring highest for quality, but concedes even these had low scores in some of the criteria they used.

Although contested by some, 12 13 there is evidence that empathy in medical and healthcare students declines during undergraduate education. 14–16 Researchers agree that empathetic skills can be taught 17–20 and cultivating empathy to protect against a possible decline would seem sensible. No standard empathy curriculum for healthcare training currently exists and empathy-based training does not appear routinely in healthcare education. 14 Understanding what type of empathy training is most effective in healthcare at both cultivating and sustaining empathy would be a useful start in preparing one.

Four systematic reviews of empathy-promoting interventions have been conducted. 17 20–22 Kelm et al 17 conducted a qualitative synthesis of empathy-cultivating interventions for medical students or physicians. Their findings support the hypothesis that interventions can increase physician and medical student empathy. However, they also identified a lack of rigorous study design in most studies (such as lack of control groups). More recently, Kiosses et al 20 published a systematic review of randomised controlled trials (RCTs) of empathy-promoting interventions for health professionals. However, only 2 out of 17 included reported change in empathy as a primary outcome, focusing instead on general communication skills. Hence, the review did not provide robust evidence of empathy-enhancing interventions. In 2019, Patel et al 21 reviewed educational interventions aimed at enhancing both empathy and compassion. They included observational as well as randomised studies and looked only at physicians and physicians-in-training. They were not able to pool their results statistically and did not investigate whether potential benefits of empathy were sustained over time. With the most recent review, Fragkos and Crampton 22 conclude that empathy interventions significantly increase empathy, but limit their study population to medical students only. In addition, they do not explore whether any improvement in empathy is sustained over time.

These problems listed above present barriers for medical educators looking to implement empathy training into their curricula. It is unclear how large the effect size of effective empathy training is; whether the effect is sustained over time or how best to train students and continuing learners from various health backgrounds. It is important to measure the effect of empathy training, both postintervention and sustainability of effect over time. Arthur et al 23 found no effect of empathy training immediately after the training, but significant improvement 12 weeks after the end of the training. A delayed improvement in empathy could potentially be accounted for by participants only recognising the benefits of training once they are putting any lessons learnt into action.

In this systematic review and meta-analysis, we addressed these gaps, with an up-to-date synthesis of RCTs of interventions aimed at promoting empathy, delivered to both medical and healthcare students and professionals, with results that are generalisable to all healthcare contexts. In addition, we will consider both immediate and longer term impact of interventions on empathy.

The overarching objective of this systematic review and meta-analysis is to combine data from all available RCTs of empathy-enhancing educational interventions in health education and training. This was achieved with two subsidiary objectives:

To assess the effectiveness of empathy-enhancing interventions aiming to enhance empathy in undergraduate and postgraduate health education and training.

To assess any lasting effect of empathy training.

We also had three secondary aims:

To identify the intervention type (eg, communication skills training) that is most effective at enhancing empathy.

To identify the duration of training that is most effective.

To identify the tools used to measure empathy levels in participants to consider differences in self-reported and observer-reported measures.

Protocol and registration

In accordance with the Cochrane Handbook for systematic reviews of interventions, 24 we published a protocol for this systematic review, 25 registered with PROSPERO international prospective register of systematic reviews (registration number CRD42019126843). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 26

Eligibility criteria

RCTs investigating the effect of empathy-enhancing interventions on medical and other healthcare students’ and professionals’ empathy levels as a primary or secondary outcome were eligible for inclusion. Trials measuring empathy via self-reported and/or observer-reported measures were included. See online supplemental eMethods for further details.

Supplemental material

Information sources and search strategies.

The following databases were searched from inception to 6 June 2019: MEDLINE, PsycINFO, EMBASE, CINAHL and Cochrane. Search strategies are detailed within online supplemental eTable 1 . Electronic searches were supplemented by hand-searching the references of retrieved papers.

Study selection

All studies retrieved through the search strategy were stored using EndNote with duplicates removed. Two authors (RW and EI) reviewed titles and abstracts to identify those meeting inclusion criteria. Full text manuscripts were retrieved for potentially relevant articles. If the decision to include or exclude was unclear, the study was discussed with a third author (JH) to reach a consensus. Seven papers were discussed with the third author. A PRISMA flow chart recorded the screening and selection process.

Data collection

One reviewer (RW) extracted, summarised and recorded data to assess quality and synthesise evidence from included studies. A second author (JH) independently extracted a random sample (10%) of studies to ensure agreement on the information extracted and summarised. See online supplemental eMethods for details on information extracted. If data was not reported, study authors were contacted.

Risk of bias in individual studies

Risk of bias was assessed using the Cochrane Collaboration’s Tool for assessing the risk of bias in clinical trials (see online supplemental eMethods for further details). Using the criteria provided by Higgins and Green, 24 each item was scored as high, low or unclear risk of bias, and evidence from the study was used to justify each score given. Given that evidence increasingly suggests that sequence generation and allocation concealment are of particular importance in determining the overall risk of bias, 24 a study was classed as being at high risk of bias if it scored as high or unclear risk on either of these domains.

Synthesis of results

We calculated the overall effect size of empathy interventions using the standardised mean difference (SMD) and 95% CIs based on the data provided in the studies: postintervention sample size, mean and SD for experimental versus control group (except where only mean difference and SD between preintervention and postintervention for the experimental and control groups were provided). We used a random effects model (REM) to allow for likely different (though related) intervention effects. If a study had more than one intervention arm, we used the results for the most comprehensive training intervention. If a study provided measures of empathy using different tools, the primary tool to measure empathy was used. If it was unclear which was the primary measure, we used the first reported measure of empathy.

Heterogeneity was anticipated between studies and assessed using Cochran’s Q Statistic (heterogeneity was declared if p value <0.10) and quantified using the I 2 statistic, with an I 2 value of 50% or more being considered to represent levels of heterogeneity.

Primary analysis included all studies providing the data needed to calculate the mean and SD (or SE) of the postintervention control and intervention groups. Where studies provided more than one point for outcome assessment, the data closest to the end-point of the intervention was used. Studies that provided no numerical data on empathy-related outcomes or data from which it was not possible to calculate mean values and SD were excluded from the meta-analysis.

Additional analyses

We performed a sensitivity analysis excluding studies that were considered to be at high risk of bias (scoring unclear or high risk of bias for either sequence generation or allocation concealment, with evidence suggesting these domains are of particular importance in establishing risk of bias). 24

We conducted separate meta-analyses to look at: sustainability of the effects of the intervention; the intervention type that is most effective; the duration of intervention that is most effective; the outcome assessment tools (comparing objective and subjective outcome measures) and participant populations (effectiveness of interventions aimed at student populations compared with those aimed at professional populations). See online supplemental eMethods for further details.

Risk of bias across studies

Reporting bias was assessed qualitatively based on inspection of the characteristics of the studies included. A funnel plot was produced to investigate small study effects, which may indicate the presence of publication bias. The GRADE system was used to evaluate the overall quality of evidence for the primary outcome. 27

Patient and public involvement

This research was done without patient involvement. Patients were not invited to comment on the study design and were not consulted to develop patient-relevant outcomes or interpret the results. Patients were not invited to contribute to the writing or editing of this document for readability or accuracy.

The literature search resulted in 4904 citations with duplicates removed. Figure 1 provides an overview of the selection process (see online supplemental eResults for further details). Seventy-two articles were retrieved for full-text review. Forty-six studies were excluded (see online supplemental eTable 2 ). Twenty-six trials were included 23 28–52 (n=2900). Table 1 provides a summary of characteristics ( online supplemental eTable 3 gives further details).

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Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. RCT, randomised controlled trial.

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Summary of characteristics of included studies

Study characteristics

Study publication dates ranged from 1987 to 2019, with 15 out of 26 trials published in the last 5 years. 23 28 30 32 34–38 40 42 47 49 51 52 Thirteen were carried out in the USA and Canada, 29 32–34 40–43 45 46 48 50 seven in Europe, 23 30 36–38 47 51 three in Iran 35 39 49 and one each in Australia, 31 Ghana 28 and China. 52 Fourteen studies provided a definition of empathy. 30 32 34–37 40 43–47 51 52

Study design

Sample size ranged from 12 to 352 participants (median 90.5; IQR 49.25–154). Thirteen studies had 100 or more participants. 23 28 29 36–38 47 49–51 Seven had fewer than 50 participants. 31 32 40 41 43 46 48 Fifteen studies evaluated empathy interventions for student populations, 28 30 32–35 39 41–43 45 49–52 including seven that looked at medical students, 30 34 35 42 45 50 51 five with nursing students, 33 39 40 50 52 two with student pharmacists, 32 41 one with physiotherapy students 43 and one with a mixed nursing and midwifery student population. 28 Ten trials used professional/qualified populations, 23 29 30 36–38 44 46–48 with four of these focusing on physicians, 31 44 46 48 one on nurses 36 and five with qualified care staff, including healthcare assistants. 23 29 37 38 47 One study used a mixed student and professional population (nursing students and nurse practitioners). 40

Five trials used multiple sites, 23 30 36 37 40 and five were cluster RCTs. 23 36 37 49 52 Ten studies defined both inclusion and exclusion criteria for the study. 23 28 29 35 37 39 41 49 52 Thirteen defined inclusion criteria only 30–33 36 38 40 42 43 45–47 50 and in three studies inclusion/exclusion criteria were either not given or not clear. 34 48 51

Study interventions

While the aims of eligible trials in this review were to enhance empathy through an educational intervention, a range of intervention types were employed. The most commonly used approach was a communication skill-based training intervention, with eight studies 28 31 33 34 39 42 48 50 using this. Four studies used perspective-taking training, 23 40 41 49 two had a psychotherapy focus, 30 46 three used empathy skill-based training sessions, 35 44 51 two used an arts and humanities approach, 32 52 one used mindfulness-based training 45 and one a serious gaming intervention. 47 Five studies could not be classified and were described as ‘mixed’ interventions, using various elements of theoretical knowledge teaching and experiential learning sessions. 29 36–38 43 Seventeen were specifically designed to foster empathy 23 32 34–37 39–44 46–48 50 52 and the remainder used interventions not specifically designed to improve empathy but with the hypothesis that they would. For example, Buffel du Vaure et al 30 explored the impact of a psychotherapy-focused ‘Balint Group’ intervention on medical student empathy.

The most frequently used mode of delivery was face-to-face, with 18 interventions using this. 23 28 30 31 33 35–37 40–42 44–46 49–52 Six interventions were delivered online, 29 34 38 39 42 47 one employed a self-directed mode of delivery 32 and one a CD-ROM to deliver the intervention. 48

Studies ranged in duration of intervention (total time spent participating in the intervention) from 20 min to 42 hours. The mean duration was 10.2 hours (SD 8.8). Five studies did not explicitly state duration. 34 36 38 46 48 Training packages in six studies were considered to be ‘short duration’, lasting 3 hours or less 32 37 39 42 47 49 ; 10 were considered ‘medium duration’, lasting between 4 and 12 hours 23 28–30 35 39 43 44 50 51 ; and 5 were considered ‘long duration’, lasting more than 12 hours. 31 33 41 45 52 Timespan of the interventions ranged from 1 to 120 days, with a mean length of 38.5 days (SD 40.2).

Outcome measures

Studies used either self-report or other-(objective)report measures to assess a change in participants’ empathy. Objective measures included those completed by patients or experts (eg, faculty staff or trained actors playing simulated patients). Most studies (18) used only self-report measures. 23 28 29 32 33 35–39 41–43 45 47–50 52 Four used objective measures 31 34 46 48 and four used a combination of self-report and objective-report tools to measure empathy. 30 40 44 51

The Jefferson Scale of Empathy (JSE) 53 was the most frequently used self-reported outcome measurement tool, with 13 studies employing it. 23 28 29 32 35 36 39 41–44 49 51 53 Other self-report tools used included the Balanced Emotional Empathy Scale (BEES), 54 the Ekman Facial Decoding test, 55 and the Toronto Empathy Questionnaire (TEQ). 56 The Consultation and Relational Empathy Scale (CARE) 57 was the most frequently used objective measure of empathy, with three studies employing it. 30 40 44 Other objective outcome measures included the Carkhuff Empathy Rating Scale. 58 In addition, some studies developed their own measures of empathy, for example, Tulsky et al 48 used a Likert scale with 10 items to assess perceived oncologist empathy. Butow et al 31 created a manual to code transcripts of videoed patient interactions to assess empathic behaviour, in addition to using the CARE scale. 57 All studies except three 29 31 48 employed a validated tool to measure empathy.

Outcome assessment strategy

Timeframes for measuring outcomes varied. Fifteen studies did not specify a timeframe for postintervention measurements or were unclear. 31–33 35–38 40 41 43–52 For example, Hastings et al 37 reported measuring empathy 6 weeks post-randomisation but were not clear how long after the intervention had ended that this measurement was taken. For studies that were explicit, postintervention measures varied between 2 days and 6 months, with the majority of measures taken within 2 weeks of the intervention. 23 28–30 32 41 48 Eleven studies measured the effects at one or more follow-up points (in addition to the postintervention measurement), 23 28 29 31 33 35 37 39 41 49 52 which varied between 4 weeks and 18 months.

Risk of bias within studies

In total, 11 studies 23 28 31 36–39 43 45 47 48 were considered to be at low risk of bias overall (low risk of bias for sequence generation and allocation concealment). 24 Thirteen were considered to be low risk for random sequence generation 23 28 31 43 47 48 and 11 were low risk for allocation concealment. 6–23 23–28 28–31 31–39 43 44 47 48 Blinding was not possible in the majority of studies due to the nature of the interventions (often described to participants as empathy-promoting) and the method of outcome assessment (eg, self-report questionnaires, making explicit what is being measured, such as the JSE). Full details of the risk of bias assessment are reported in the online supplemental eResults with online supplemental eFigure 1 illustrating the overall findings.

Results of individual studies

The majority of studies (19/26) found that the tested intervention significantly improved empathy on at least one outcome measure. 29 30 33–35 38–41 43–52 Seven studies did not find any significant increase in empathy. 23 28 31 32 36 37 42 Of the studies that reported a significant improvement in empathy on at least one outcome measure, 11 were aimed at student populations (representing approximately 73% of student population studies) 30 33–35 41 43 45 49–52 and 7 were aimed at professionals (representing 70% of professional population studies). 29 38 39 44 46–48 Fifteen studies reported a significant improvement in empathy using a self-rated outcome measure (this represents 68% of studies (15/22) using a self-report outcome tool). 29 30 33 35 38–41 43 45–47 49 50 52 Four studies reported an increase in empathy when using an objective measure (representing 50% (4/8) of studies using an objective outcome measure). 34 44 48 51 Seventeen studies employed an educational intervention that had been specifically designed to foster empathy. 23 32 34–37 39–44 46–48 50 52 Of these, 12 (70%) were successful. 5 34 39–44 46–48 51 52 Four out of five studies that were classed as ‘long duration’ (lasting >12 hours) reported a significant improvement in empathy postintervention 33 41 45 52 ; 50% of ‘medium duration’ studies (between 3 and 12 hours) reported a significant increase in empathy 29 35 39 50 51 and 33% of ‘short duration’ studies (<3 hours) reported a significant improvement. 47 49

Of the 26 studies included in this review, 4 were excluded from meta-analysis as they did not provide adequate data from which to calculate the SMD and SD. 31 36 46 51 For the studies that were excluded from the primary analysis, Butow et al 31 reported a positive but not statistically significant effect and Gould et al 36 found no significant difference between control and intervention groups. Wündrich et al 51 reported no significant influence of the intervention as measured by the JSE (student version) but did report a positive and statistically significant effect on the observer-assessed outcome. Sripada et al 46 also reported a statistically significant positive effect. Of the 22 studies that had adequate data for pooling, all but one (Arthur et al 23 ) showed a benefit of intervention. The primary analysis identified that the overall effect of empathy interventions in terms of improving participant empathy was statistically significant (SMD 0.52, 95% CI 0.36 to 0.67) ( figure 2 ). The Q value indicated significant heterogeneity, with p equal to 0.0001 and I 2 equal to 63%. A summary of findings is presented in table 2 .

Meta-analysis of eligible studies providing adequate data to calculate standardised mean difference with 95% CI.

Summary of effect sizes for studies included in meta-analyses

Sensitivity analysis

For the sensitivity analysis of the least biased studies ( table 2 ), 11 were judged to have low risk of bias for random allocation or allocation concealment 23 28 31 36–39 43 44 47 48 and 9 of these provided sufficient data to be included in a meta-analysis ( figure 3 ). 23 28 37–39 43 44 47 48

Meta-analysis of eligible studies, excluding those considered to be at high risk of bias.

Sustainability of improved empathy analysis

Eleven studies provided follow-up data assessing sustainability of changes to empathy, in addition to postintervention measurement. 23 28 29 31 33 35 37 39 41 49 52 Eight were eligible for inclusion in a subgroup analysis 23 29 35 37 39 41 49 52 (see online supplemental eResults 1 for further details), which found a moderate effect size for sustainability up to 12 weeks and a smaller, but still significant effect size for sustainability of impact of training at 12 weeks or later ( figure 4 and table 2 ).

Meta-analysis of studies that provided follow-up observation points to determine long-term effectiveness of intervention.

Type of intervention analysis

A meta-analysis comparing subgroups of different types of intervention (see online supplemental eFigure 2 in the online supplemental eResults for further details) found the greatest effect was with empathy training that was communication skill-based ( table 2 ). The smallest effect reported was for interventions that were described as ‘mixed educational programmes’ and ones based in the arts and humanities ( table 2 ). It is worth noting however that only two studies used arts and humanities interventions (compared with seven in the communication skill group) and this may well impact on the effect size.

Duration of intervention analysis

Interventions of medium and longer duration ( online supplemental eFigure 3 ) were most effective. Interventions of short duration had the smallest effect size ( table 2 ).

Participant population analysis

Studies using healthcare student participant populations appeared to have a larger effect size than those directed at professional/qualified populations ( online supplemental eFigure 4 ). Studies included in a subanalysis of interventions for students showed a moderate effect size of training compared with a smaller but still significant effect size for training directed at professional/qualified populations ( table 2 ).

Outcome assessor analysis

Studies using a self-assessment outcome scale showed a moderate and significant benefit to empathy for the intervention tested ( online supplemental eFigure 5 ) compared with a small and statistically not significant effect size for observer-assessed outcome studies ( table 2 ).

A funnel plot used in the primary meta-analysis (22 studies) did not reveal evidence of publication bias ( figure 5 ). An evaluation of evidence using GRADE software found the quality of evidence was low ( online supplemental eTable 4 ). This was due to a high or uncertain risk of bias based on random sequence generation and/or allocation concealment in a number of studies and a high degree of heterogeneity across studies.

Funnel plot of effect sizes and SEs. SMD, standardised mean difference.

Summary of evidence

Training healthcare practitioners and trainees improved their empathy by a modest amount. The effect of training seemed to diminish, but lasts to beyond 12 weeks.

Comparison with other evidence

Our review supports the evidence of previous similar reviews, finding benefits of empathy training 17 20–22 and that practitioner empathy training makes a difference to patients. 59 Our study adds to this evidence by providing an estimate of empathy training from higher quality (randomised) trials and by showing that the effect lasts well beyond the intervention.

Strengths and limitations

This review, to the best of our knowledge, is the first systematic review and meta-analysis limited to RCTs of clinical empathy training for all healthcare students and professionals. This is an up-to-date review that excludes non-randomised studies, follows a prepublished protocol and assesses both the immediate and longer term effects of empathy training. Our broad study population with both healthcare students and professionals means findings are generalisable to all areas of healthcare education and training.

We chose to include only the results of the primary measure of empathy reported by each study. Where it was unclear which was the primary measure, we used the measure that was reported first. We recognise that this might have been biased, as authors may have chosen to report the most positive outcomes first. However, we found that this was not necessarily the case. For example, the first measure of empathy reported by Buffel du Vaure et al 30 (who did not specific which measure was primary) had a smaller effect than the second.

We recognise the heterogeneity of the studies in our review and anticipated this. This means that further research is required to identify the most effective empathy training methodology. Also, the strength of findings in this review may be limited by the reporting quality of some of the included studies. A sensitivity analysis of studies of highest quality found a slightly smaller but still significant effect size. Another limitation in reviewing the evidence in this field is the multiple tools used by investigators to measure clinical empathy. With the lack of a definitive definition of clinical empathy and a range of tools measuring different aspects of empathy, the impact of an intervention may vary depending on the measurement tool used. This is demonstrated by Riess et al 44 who found a statistically significant improvement in empathy when measured using the CARE scale but no significant changes using the JSE. In contrast, Buffel du Vaure et al 30 reported the opposite. Perhaps because of the larger sample size or other factors, our review found a benefit of training independently of how it was measured. A further limitation with this review is that we only identified four studies that followed participants up for at least 3 months. The trials identified however found a positive effect. Lastly, we did not measure the qualitative experiences of participants in this review.

Implications for research and practice

Interventions for cultivating student and trainee empathy should be further developed and implemented. Optimising implementation will require additional qualitative research on the experiences of empathy teachers and learners. Also, the longer term effects (>12 weeks) of empathy training have not been studied adequately and future research should address this. With competition for time and space in both undergraduate and postgraduate healthcare curriculums, future research in this area needs to be robust. Designers of future trials of empathy training in healthcare can use the results of this review as a guide to their intervention development.

Teaching students and other learners how to enhance empathy is moderately effective over a sustained period of time and is likely to benefit present and future patients. Future research should focus on empathy interventions with patient-led outcome assessment and on assessing effectiveness of training over more sustained periods of time. Medical educators and curriculum designers can use this research to think of ways to integrate empathy training into busy curricula.

Ethics statements

Patient consent for publication.

Not required.

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1

Contributors All authors meet the criteria for authorship as described in the ICMJE recommendations. RW and JH are responsible for substantial contributions to the conception and design of the work including the acquisition of data and analysis and interpretation of data. They have both made substantial contributions to revisions of the draft. RIN has contributed to the conception, design and revising of the work for important intellectual content. EI and NR have made contributions to the acquisition, analysis and interpretation of the data. All authors have given final approval to the version to be published.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests All authors have completed the Unified Competing Interest form and declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

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• v.35(10); 2020 Oct

Improving Empathy in Healthcare Consultations—a Secondary Analysis of Interventions

Kirsten a. smith.

1 University of Southampton , Southampton, UK

Felicity L. Bishop

Hajira dambha-miller, mohana ratnapalan, emily lyness, jane vennik, stephanie hughes, jennifer bostock, leanne morrison, christian mallen.

2 Keele University , Keele, UK

Lucy Yardley

3 University of Bristol , Bristol, UK

Hazel Everitt

Paul little, jeremy howick.

4 University of Oxford , Oxford, UK

A recent systematic review of randomised trials suggested that empathic communication improves patient health outcomes. However, the methods for training healthcare practitioners (medical professionals; HCPs) in empathy and the empathic behaviours demonstrated within the trials were heterogeneous, making the evidence difficult to implement in routine clinical practice. In this secondary analysis of seven trials in the review, we aimed to identify (1) the methods used to train HCPs, (2) the empathy behaviours they were trained to perform and (3) behaviour change techniques (BCTs) used to encourage the adoption of those behaviours. This detailed understanding of interventions is necessary to inform implementation in clinical practice. We conducted a content analysis of intervention descriptions, using an inductive approach to identify training methods and empathy behaviours and a deductive approach to describe the BCTs used. The most commonly used methods to train HCPs to enhance empathy were face-to-face training ( n  = 5), role-playing ( n  = 3) and videos (self or model; n  = 3). Duration of training was varied, with both long and short training having high effect sizes. The most frequently targeted empathy behaviours were providing explanations of treatment ( n  = 5), providing non-specific empathic responses (e.g. expressing understanding) and displaying a friendly manner and using non-verbal behaviours (e.g. nodding, leaning forward, n  = 4). The BCT most used to encourage HCPs to adopt empathy behaviours was “Instruction on how to perform behaviour” (e.g. a video demonstration, n  = 5), followed by “Credible source” (e.g. delivered by a psychologist, n  = 4) and “Behavioural practice” ( n  = 3 e.g. role-playing). We compared the effect sizes of studies but could not extrapolate meaningful conclusions due to high levels of variation in training methods, empathy skills and BCTs. Moreover, the methods used to train HCPs were often poorly described which limits study replication and clinical implementation. This analysis of empathy training can inform future research, intervention reporting standards and clinical practice.

INTRODUCTION

Empathy is defined in numerous ways; however, in healthcare, there is emerging consensus that it involves therapeutic empathy, whereby a HCP (‘Healthcare Practitioner’: a medical professional, such as a nurse or surgeon) puts themselves in a patient’s position to acknowledge their feelings, concerns and expectations and behaves in a way to show that they understand. 1 , 2 These behaviours could be using verbal or non-verbal behaviours to convey empathic affect (e.g. saying ‘I understand how you are feeling’ or using eye contact) or behaviours that encourage empathic healthcare interactions so that the patient feels listened to and supported (e.g. explaining rationale for treatment, checking the patient understands). Understanding and compassion in healthcare is of global importance: the World Health Organization has identified person-centred care as a crucial component of healthcare, “measurably improving the quality of care, the success of treatment and the quality of life of those benefiting from such care” ( 3 P46). In the United Kingdom (UK), healthcare policy increasingly emphasizes the importance of “compassion, dignity and respect” in patient interactions. 4 This is relevant and timely as national data reports empathy levels among HCPs are decreasing. 5 In UK primary care, where over ten million HCP contacts occur annually, patient satisfaction reached an all-time low at 65% in 2017. 6 These findings are concerning given evidence that low empathy strongly correlates to low satisfaction and increased levels of anxiety, distress and pain. 1 Patient experiences of empathy have additionally been linked to other health outcomes including blood pressure, all-cause mortality and faster resolutions of self-limiting illness. 1 , 7 , 8 Moreover, empathy has been shown to be beneficial to HCPs in reducing stress and burnout. 9

While the benefits of empathic communication are broadly accepted, evidence of ongoing patient dissatisfaction with healthcare consultations 6 and the decline in HCP empathy over time 5 suggests that more needs to be done to translate this evidence and implement it in practice. A problem with the current literature is that there is no agreed method of training empathy, or consistent content to such training. A detailed description of the methods used to encourage empathic care could therefore move this field forward by making the evidence implementable. To achieve this, we selected Howick et al. 10 as the basis for our analysis as it provides recent high-quality RCT data with physical or psychological outcomes for the patient’s health. It also details only qualified HCP training, which has substantial differences to student training in time invested and setting. We aimed to extract the core details of the HCP empathy training from each included study to better understand these interventions and inform the development of successful implementable evidence-based empathy training for HCPs.

• Methods used to train HCPs,
• Empathy behaviours that HCPs were trained in and
• Behaviour change techniques (BCTs) used to train HCPs.
• To investigate which empathic behaviours are most effective for improving patient outcomes.

Howick et al.’s systematic review 10 contained seven randomised trials that compared outcomes in patients who had been treated by (a) HCPs trained to be more empathic and (b) HCPs who had not been trained. The review excluded non-randomised trials, and any study that did not compare the (downstream) effect on patients. Trials that measured change in practitioner empathic behaviour, but not patient outcomes, were excluded. The conditions and experiences included in these studies were chronic pain, 11 – 13 anxiety, 14 distress among cancer patients, 15 irritable bowel syndrome 16 and satisfaction after primary care consultations. 17 The average effect size was modest (SMD − 0.18 [95% CI, − 0.32 to − 0.03]), and study heterogeneity was medium ( I 2  = 55%). Topic experts were consulted to help identify additional papers, and a rapid search for more recent research matching Howick et al.’s inclusion criteria found no additional randomised trials (November 2018).

We used a qualitative content analysis approach 18 , 19 to describe and analyse the methods used to train HCPs in empathic communication, and the specific behaviours that the training intended to encourage. In this approach, text is searched for certain types of content, which is then extracted, categorized and summated. This approach was chosen as it allowed us to condense the data and potentially evaluate which empathy behaviours and empathy training methods are most effective.

First, papers were read in detail and systematically searched for all content about the training, which was then extracted into a spreadsheet (by JH and KS). An inductive approach was used to code (1) methods used to train HCPs, including the duration and deliverer of the training, and (2) empathy behaviours that the HCPs were trained in.

Interventions use many different approaches that aim to change a person’s behaviour, often involving many complex components. The Behaviour Change Technique Taxonomy was developed as a tool to extract the active ingredients in different interventions so that they could be replicated, synthesized and implemented. It covers typical teaching techniques like demonstration, but also other techniques to change behaviour, such as different types of reward, social support, feedback and habit formation. We are interested in not only how and what the HCPs were taught, but what was done to motivate them to implement and sustain the empathic behaviours.

A deductive approach was used to code the BCTs used to train HCPs. This involved reviewing descriptions of training to identify any use of the 93 BCTs defined and described in an established BCT taxonomy. 20 Finally, papers were evaluated according to whether they reported using each training method, empathy behaviour and BCT identified. At least two authors experienced in qualitative analysis (FB and KS) checked the coding for each of (a) empathy training methods, (b) empathy training content and (c) BCTs.

Effect sizes reported in Howick et al. 10 were then compared across components to explore qualitatively if there were any differences in training components between highly effective and less effective interventions.

Empathy Training Methods

Full details and characteristics of the included studies are presented elsewhere (Howick et al.). Table  1 presents a summary of the HCP training methods extracted from the papers included in the systematic review. All interventions took place at the HCPs’ place of work, including primary and secondary care settings.

Methods of HCP Training Extracted Using Content Analysis

We found that the core methods of training were:

• Face-to-face training ( n  = 5)
• Role-playing ( n  = 3)
• Videos of model consultations (n = 3)
• Videos of self in consultation (n = 3)
• Post-training material (hand-outs, reminders, feedback, meetings) ( n  = 4)
• Presentation/talk ( n  = 2)
• Discussion with peers ( n  = 2)

Training could include multiple methods—see Table ​ Table1 1 for the components described in each paper.

Training duration varied from 2 to 20 h. Three studies described training HCPs in groups of 4–36. Five studies described using face-to-face training. The types of trainer used were HCPs (e.g. psychiatrists, psychologists, oncologists, therapists) and a medical student. Role-playing was used for three of the studies. Videos were used extensively; three studies used videos of others as part of the training, and three studies required the HCPs to have videos made of themselves. Two studies described a lecture or talk being given to HCPs prior as part of their training. Two studies used discussion with other HCPs. Four studies described content or contact provided after the initial training session: reminders, feedback on their videos, a summary sheet and regular meetings with other trained HCPs. One study provided materials (an informational leaflet) to give to patients.

Empathy Training Content

Figure  1 summarises the different empathy behaviours that the HCPs were trained in. Between 3 and 9 (median = 7) empathy behaviours were identified in each reported training (see Table  2 ). The most common element that the HCPs were trained in was providing explanations of treatment ( n  = 5). Providing non-specific empathic responses (e.g. “I show my patient that I believe his/her pain is genuine” 11 ), a friendly manner (e.g. being friendly, warm or cordial to the patient) and non-verbal behaviours (e.g. nodding, leaning forward) were also popular ( n  = 4 each), followed by active listening (using body language and short responses like “hmm, ok” to show you are listening), eliciting questions from patients and reassurance ( n  = 3 each). Other empathy-related behaviours included using a consultation structure, unspecified conversations, more time ( n  = 2 each), discussion of lifestyle issues, checking patient understanding, describing the evolution of the disease, instructing the patient on how to quantify their symptoms, proposing a patient-practitioner partnership, complying with patient wishes and emphasizing comfort and well-being ( n  = 1 each).

Overview of training content in each study. ‘Other’ includes all content only reported in a single study; see Table ​ 2 for 2 for details.

Training Content of Empathy Interventions Extracted Using Content Analysis with Effect Sizes

While the descriptions used consistent terminology for describing components of the training, they were not specific in what that entailed. For example, ‘non-specific empathic responses’ and ‘friendly manner’ could include non-verbal behaviours such as nodding and smiling, or verbal reassurance. Better descriptions of the training components would be required to resolve this.

Behaviour Change Techniques

Table  3 summarises the BCTs evident from descriptions of the empathy training. Between 1 and 6 (media n  = 5) BCTs were identified in each empathy training. Due to the scant reporting of training in several of the papers (especially 12 – 14 ), it is likely that the training employed more BCTs, but there was insufficient evidence to code any others.

Behaviour Change Techniques Used to Train HCPs in Empathy Identified Using the Behaviour Change Technique Taxonomy. Effect Sizes Taken from Howick et al. with effect sizes

The most common BCT used was 4.1 Instruction on how to perform behaviour ( n  = 5), followed by 9.1 Credible source ( n = 4 ) and 8.1 Behavioural practice ( n  = 3). 2.2 Feedback on behaviour , 6.1 Demonstration of behaviour and 6.3 Information about others ’ approval were evident in two training descriptions. Additionally, Little 2015 employed 1.1 Goal setting , 1.4 Action planning , 2.3 Self-monitoring of behaviour (n.b. this was self-monitoring of a behaviour recorded at baseline, not monitoring of changes in behaviour) and 5.3 Information about social/environmental consequences ; Chassany 2006 used 7.1 Prompts and cues and 9.2 Pros and cons ; and White 2012 used 6.2 Social comparison .

Effect Sizes

The effect sizes for each intervention, as reported by Howick et al. (2018), are shown in Tables ​ Tables2 2 and 3. All interventions had a significantly positive effect on psychological outcomes, with the exception of White 2012, which was not statistically significant. Kaptchuk 2008 and Little 2015 demonstrated the greatest effect sizes. These trainings were quite diverse in training methods and BCTs used, with only Instructions on how to perform behaviour as a common BCT. Both used self-recording as part of training, though not exclusively to the dataset. The training content overlapped in several areas: they included elements of Friendly manner , Non-verbal behaviours ( gestures , looking , facial expression ), and Active listening . Due to the diversity of these features, and the paucity of reporting in other interventions, we do not feel that we can draw any strong conclusions from these commonalities. The studies with the highest effect sizes varied greatly in duration (up to 2 h10 17 versus 20 h 16 ), suggesting that empathy training does not need to be long to be effective.

In this paper, we identified the components of HCP training in empathic communication from seven empathy papers based on a recent systematic review, 10 with no additional papers found from further literature searches and discussions with topic experts. We found that training included a variety of methods that emphasized a spectrum of empathic behaviours and employed a range of BCTs. Face-to-face training, role-playing and videos were commonly used. The most frequent behaviours targeted were providing explanations of treatment, providing non-specific empathetic responses, displaying a friendly manner and using non-verbal behaviours. The most common BCT used to train HCPs was 4.1 Instruction on how to perform behaviour, followed by 9.1 Credible source and 8.1 Behavioural practice. There were some similarities in intervention components between the papers with high effect sizes, but also much diversity: the training methods and content varied greatly. Of particular relevance for the pressured environment of everyday clinical practice, there was little evidence that longer training was beneficial.

To the best of our knowledge, this is the first study to examine in detail the underlying methods and behaviours utilised to train HCPs in delivering empathy. Inadequate theoretical development and consideration of these underlying processes in delivering empathy interventions are likely to have hindered progress in the wider clinical application of empathy interventions. To some extent, this might have contributed to the findings of Howick et al.’s 10 review in which only small absolute effects were observed. More detailed consideration of these processes is critical and timely in delivering effective and cost-effective empathy interventions. At a time of unprecedented pressures and greater austerity in the UK and other health services, alongside declining patient satisfaction, practitioner empathy could provide a valuable additional tool given the previous evidence of its effect on patient satisfaction, trust, health outcomes and HCP well-being. Our findings highlight key areas that are promising in future development and application towards effective empathy interventions.

Our ability to investigate which empathic behaviours are most effective for improving patient outcomes (Aim 2) was hampered by the lack of reporting adequacy of empathy training methods. Empathy training and empathic behaviours were defined and described in different ways and were reported in varying degrees of detail. For example, Fujimori et al. 15 provided a detailed schedule of a 2-day workshop, while Soltner et al. 14 presented a calibration study to check the success of training, the content of which was not described. Furthermore, while some studies did not describe using particular training or behaviour change methods, this does not necessarily mean that such methods were not used. The papers also lacked information on the level of experience the trainers had in education, which could impact on the training’s effectiveness. While we were able to obtain additional information about one intervention by contacting the author (Little et al. 17 ), despite attempting contact we were unable to obtain any further details from the authors of the remaining papers. Although there has been recent attention to the better reporting of interventions, 21 there has been limited work on describing how people are trained to deliver the intervention. This is essential for interventions which deliver a complex behavioural interaction, such as conveying empathy in a clinical consultation. Without a complete description of this, empathy training trials cannot be accurately replicated, or the findings built upon. We recommend a checklist is developed for the reporting of intervention delivery training (perhaps as an extension to the TIDieR framework 21 for intervention descriptions) where the intervention has a complex behavioural component.

We also found that the seven studies presented in the systematic review were insufficient to draw conclusions about which (combinations of) components of training might have the largest effects on patient health outcomes. Although the studies chosen for Howick et al.’s review 10 were randomised trials, other reviews and individual trials on empathy may provide additional data (e.g. 22 , 23 ). These studies were excluded from the study because no patient outcomes were reported (e.g. Riess et al. reported patient-rated practitioner empathy but no health outcomes 24 ). However, the data from these excluded studies relating to how empathy is trained may be usefully examined to encapsulate current empathy training approaches. Qualitative studies may also be helpful for understanding the broader context and consequences of empathy training. 25

Another limitation is that the BCT Taxonomy 20 approach may have been inadequate for encapsulating the BCTs conveyed in the intervention. We found that the interventions applied the same BCTs in different ways—e.g. the 15 min PowerPoint presentation 17 from a medical student delivered in the workplace to one HCP and the 1-h lecture from an expert to a groups of HCPs 15 both demonstrated the BCT of “Instruction on how to perform behaviour”, but are not necessarily comparable. This somewhat reductive method erases important distinctions between the interventions. Furthermore, the taxonomy does not permit a BCT to be coded unless it meets strict criteria—therefore, we could not code ‘1.5 Goal Review’ for, 17 where the taxonomy assumes there must be ‘someone’ delivering the intervention, though self-directed goal reviewing was present.

The heterogeneity in HCPs, training methods and contexts of the studies examined may also contribute to our disparate findings. It is plausible that if a larger set of similar studies had been grouped together, our findings may have elicited different outcomes. Relatedly, the trials in our sample were all English language papers, which may impact upon the generalisability of our findings, and further to this, cultural differences in the HCP-patient relationship may preclude the application of our results in non-western cultures.

This study, like many, is limited by a likely selection bias within the primary studies. It is likely that people who were interested in becoming more empathic chose to participate in these studies. They were motivated to make changes to their practice. It is certainly possible that this effect would be weaker ‘in the wild’, and further work would be needed to explore it. Mitigating this bias, there may have been contamination in the control groups. HCPs in the control groups may have enhanced the way they expressed empathy although they were not trained to do so.

Our study is one of the first to examine the common elements of empathy training for HCPs. Findings suggest that HCPs wanting their practice to reflect current evidence can consider enhancing their friendly manner, empathic responses, non-verbal behaviour and explanations of treatments. However, specific techniques may be more or less appropriate depending on the clinical context. Furthermore, advice to enhance one’s friendly manner, empathic responses and non-verbal behaviour may be too generic to be meaningfully implemented. It is therefore imperative that future studies in this area provide comprehensive, detailed, descriptions of training content and training methods, including the application of any behaviour change techniques. Studies should conform to better intervention reporting standards such as TIDieR 21 when reporting any training undertaken as part of an intervention, taking care to clearly describe specific behaviours (e.g. nodding) rather than broader categories (e.g. friendly manner). Without this, the studies become impossible to replicate, and it is impossible to extrapolate what aspects of empathy training are effective.

Author Contribution

This manuscript is an honest, accurate and transparent account of the study being reported that no important aspects of the study have been omitted. JH provided the initial data, wrote the initial protocol and draft with KS and provided editorial comments on subsequent drafts. All authors agreed to the protocol. KS and FB performed the analyses and JH checked the final coding. HDM provided important background literature. KS wrote the initial draft of the paper with JH. All authors contributed to revision of the manuscript. PL, LY, HE, JH, CM and FB wrote the grant proposal for the project. JB wrote the lay summary, reviewed the manuscript and provided an ethical and public perspective.

Funding information

The EMPATHICA trial is supported by a National Institute for Health Research (NIHR) School for Primary Care Research (project number 389). The Primary Care Department is a member of the NIHR School for Primary Care Research and supported by NIHR Research funds. MR is an NIHR School for Primary Care Research funded ACF. HDM is funded through an NIHR Clinical Lectureship. CDM is funded by the National Institute for Health Research (NIHR) Applied Research Collaboration West Midlands, the NIHR School for Primary Care Research and an NIHR Research Professorship in General Practice (NIHR-RP-2014-04-026). The research programme of LY and LM is partly supported by the NIHR Southampton Biomedical Research Centre (BRC).

This paper presents independent research funded by the National Institute of Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, HEE or the Department of Health. The funders had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Compliance with Ethical Standards

The following were co-authors of papers in this analysis: PL and HE are authors of 17 ; PL and FB are authors of. 13

Lay Summary and Patient Perspective

Patients believe that ‘nice’ doctors and nurses make ‘better’ doctors and nurses. As patients, we want our healthcare professionals (HCPs) to be considerate, show us respect, listen to our concerns and show a degree of sensitivity. Colloquially speaking, we would call such communication ‘empathic’, and it is this style of communication that is being examined in this study.

While most healthcare practitioners are empathic, many can learn to enhance the way they express it. So, various training packages have been created to help HCPs communicate with their patients in an empathic way.

This study looked in detail at what methods were used to encourage HCPs to communicate with more empathy. We were looking at what methods were used to train people (such as video or role play) and what particular parts of the training worked best and led to better communication with patients. We found that face-to-face training was more common than video or online training. However, we were unable to identify what methods work best. We found that active listening and a friendly manner were the most common empathic behaviours that the training encouraged HPCs to have.

What we found was that there is a lack of strong evidence of what works best to train HCPs in empathic communication. This finding shows us that there is a gap in research. To ensure HCP training actually helps them communicate better with patients, and ultimately helps patients feel better, we recommend that future research looks to identify the best ways to train practitioners in empathy, and explore what type of empathy helps patients most. This current evidence suggests that HCP’s should try to enhance their friendly manner, empathic responses, non-verbal behaviour and explanations of treatments.

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Knowledge at Wharton Podcast

Why empathy in health care matters, may 23, 2023 •.

A new study co-authored by Wharton’s Ingrid Nembhard finds that patients who are treated with empathy have better health outcomes. She explains why empathy in health care delivery should become standard.

• Health Care Management

Listen to the podcast.

Patients who are treated with empathy by their doctors and other clinicians have better health care outcomes, according to a new study from Wharton health care management professors Ingrid Nembhard and Guy David . The paper is titled “A Systematic Review of Empathy in Health Care,” and it appears in the journal Health Services Research . The co-authors are Wharton undergraduate student Iman Ezzeddine, and David Betts and Jennifer Radin, both of Deloitte Consulting.

Nembhard spoke to Knowledge at Wharton about the study, which concludes with a call for more organizational-level interventions to ensure empathy for all patients, systematically.

How Do We Define Empathy in Health Care?

Angie Basiouny: Why is empathy in health care important? If my doctor is board certified and graduated at the top of her class, I know I’m going to get good care. What difference does it make if she doesn’t make me feel warm and fuzzy?

Ingrid Nembhard: You may get great clinical care, but that’s different from empathy. We assume that everyone is clear on what empathy is and what its role is in health care. Broadly speaking, empathy refers to understanding another person’s feelings and their thoughts, and feeling those congruent thoughts and states. In health care, empathy is defined as “understanding and feeling a patient’s emotions and perspective.” It’s also offering a response — for example, how you communicate with that patient — that reflects understanding and that actually aims to help them.

Why does empathy matter in health care? Well, when there’s insufficient empathy, there’s diminished understanding of the patient’s perspective. On the other hand, when there is higher empathy, there is understanding. In principle, that understanding matters because it cultivates efforts to better meet patient needs through both interpersonal choices, such as speaking with care, and operational choices, such as connecting patients with resources, whether they need mental health providers or transportation — things that can facilitate their care experience and their actual care and health.

We know now from looking at the research, and even if you thought about this theoretically, that the more that understanding is present, the more patient-centered care plans are likely to be made, the better the patient care experience will be, and the greater patient adherence to their plans will be. That all means that we can expect better patient, worker, and organizational outcomes, whether you think about clinical outcomes, or you think about worker job satisfaction, because they’re getting the information they need to be able to treat patients the way they should. And they’re getting better patient experience ratings.

So, why it matters is that it’s the beginning of a positive cascade, I think, for patients and health care, and even for workers.

Taking Stock of Empathy in Health Care

Basiouny: In the paper, you mention that there’s a great deal of disjointed information about empathy in health care, but that it’s emerging as its own research field. What were you and your co-authors hoping to contribute to the literature?

Nembhard: I do a lot of research on patient care experience in addition to understanding the organizational side of care. The data at this point is pretty robust that a lot of patients are having poor patient care experiences, and there has been this growing attention now to the relational side of health care. That has really led to a lot of investigation about what facilitates and what hinders empathy. What outcomes come from empathy? How best can we measure empathy? Who is likely to give you empathy, and who is unlikely to give empathy? Who is likely to get empathy? Who is unlikely to get empathy? And then how do you go about increasing it?

These kinds of investigations have been occurring for the last 50 years. We see that largely they’ve been occurring by individual researchers in independent investigations that have been published in a wide variety of journals. That means that we can now say that there is an actual research field of empathy, because there has been a lot of attention in this field, but it’s all disparate. You haven’t had yet the research that integrates all of that knowledge.

My colleagues and I thought we’ve reached a time now where we need to pause and take stock of the field. We need to see what lessons can be extracted from the 50 years of research, and we need to see if we can create clarity about the way empathy is operating in our health care system.

We can then start to identify where we need to do more research and where practice needs to change in order to achieve those goals. We decided to do a systematic review of 50 years’ worth of empirical, quantitative research on empathy. And our research covered 450 articles that met our criteria.

What Factors Predict Empathy in Health Care?

Basiouny: Let’s talk about the takeaways. You found that more empathy ends with better health care outcomes, and that five factors predict empathy. Can you take us through those factors?

Nembhard: Sure. The first is that provider demographics seem to matter. Those are things like the number of years a professional has been in their specialty. We also see that it varies by characteristics like gender and the specialty. Perhaps not surprisingly, studies suggest that primary care physicians and those in behavioral health tend to display more empathy than colleagues who are more on the surgical side or who have acute experiences with patients.

Other characteristics of Who is providing empathy can matter too. In that bucket, we find things like personality, whether somebody is an introvert or extrovert, their knowledge, their attitudes towards different people and the like.

The third category that we identified is how providers behave during their interactions. We pay attention to the fact that people talk in different ways and speak to people in different ways, and that certainly appears in the data. Providers vary in the way that they communicate, the tone they use, the words they use. They also vary in aspects like their body movement in the interaction. Are they closer to you or farther away? Do they create distance or not have distance? And whether they give adequate consultation.

The fourth bucket of things that we find are target characteristics. We’re referring largely to patients as the target of that empathetic interaction. It varies by the type of condition the person has or the disease that they’re battling. Some of the data would suggest that certain conditions are more likely to elicit an empathetic response than other conditions. Someone’s socioeconomic status — whether they have more income or less income — tends to influence the level of empathy that’s directed towards them.

The fifth category that we found in the literature is organizational context. Things that are organizational include how long is the visit that the patient has with their provider? In shorter visits, there’s less empathy typically found. The waiting time also is tied to perception of how much empathy there is.

The five categories are really interesting. I’m simply giving you the high-level [view]. Within each one of those categories, our research showed there are multiple factors.

What Interventions Increase Empathy in Health Care?

Basiouny: You also looked at some interventions that can increase empathy among health care givers. What are those interventions?

Nembhard: Once the field appreciated that empathy might matter, it started to think about ways to increase it. Most of those have been individual-level educational interventions, so things like training participants how to do a particular skill, like how to communicate well — in an empathetic way. We see some studies that focus on having a course, so a person goes through a series of lectures about how to be empathetic or what empathy behavior entails. Sometimes there are workshops where you’ll role play and get feedback on how you behave. Simulations, visuals, videos. The category that probably most caught my attention is treatment for empathy. There are studies that trial transcranial direct current stimulation — actually stimulating that part of the brain [associated] with empathy. There are a lot of options that are on the table for improving and increasing empathy, most of them educational interventions.

For us looking at the data, it was surprising that there were no studies of organizational interventions, because one of the factors that we found that was significant was organizational context. We know that organizations can matter. In some sense, the absence of organizational interventions may reflect the fact that we think of empathy as a human trait, so why make it part of the organization? You don’t need to be trained in empathy.

But if the provision of empathy benefits from having dedicated time and people and processes and leadership, then it totally makes sense that we need to direct greater attention to organizational interventions for improving empathy. My co-authors and I are now very much of the mindset that we need to have more empathetic systems and institutions that are structured in such a way that they create conditions for anybody to receive empathy, in a non-arbitrary way throughout their whole service of care.

We’ve seen that organizational interventions can work. We see it around patient safety. It used to be that you thought safety was the type of thing that a provider delivered to a patient. Innovation was the type of thing that an entrepreneur delivered. Yet now when we look at health care, it’s not unusual to see a chief patient safety officer or a chief innovation officer, or roles that are dedicated exclusively to ensuring those goals. Organizations are taking that route, rather than just training clinicians.

There are now role-based approaches centered on non-clinicians to deliver what is needed. We might want to move in that direction [for empathy too]. I think my colleagues and I would be excited to see more interventions that say, “OK, this is something that organizations need to be attentive to.”

How Empathy in Health Care Can Reduce Disparities

Basiouny: I want to ask you about two demographics, which are Black patients and Hispanic/Latino patients. We know those two groups have worse health care outcomes across a number of measures, whether it’s COVID-19, heart disease, or maternal mortality. Would greater empathy for those patients translate into better outcomes?

Nembhard: The simple answer is that it should. If you recall my earlier response to your first question about why does it matter, it’s largely about understanding people, their emotions, their needs, and where they are in their care in their state. If we were to have greater empathy, we would expect that there would be greater understanding such that the choices that are made and the conversations that happen in the course of care would be more attentive to the needs of the person. That means that they would get the communication they need, and it would be culturally competent.

If you need transportation, we would provide transportation, because we would understand the circumstances. We would understand and therefore make choices and make care plans that would allow people to be successful in their health care. I do think empathy is part of the process. If we want to reduce some of those disparities, we need to be better about understanding where people are.

Basiouny: This study is the first of its kind. What do you want to look at next?

Nembhard: The main motivation in taking on the last 50 years of research was that we wanted to be better prepared to do work that could make a difference. We’d love to be able to collaborate with a health system interested in trying and trialing a role-based organizational intervention. We think it’s time.

We’ve been doing the training of individuals for years, and we’re still not at the level we need to be. That appears to be insufficient to allow systematic empathetic health care. So, we would love to be able to study role-based organizational intervention. We’d love to see the field take off and other people think about other organizational interventions that might be used to build empathy.

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