GUJHS. 2006 March; Vol. 3, No. 1
The average duration of a female physician’s interview is ten minutes and forty-five seconds, compared to the seven minute and thirty-eight second average interview conducted by her male colleague (Meeuwesen, et al., 1991). It has been found that there is no difference in the amount of biomedical information provided by the average male and female physician (Roter and Hall, 2004). What behavioral differences between male and female physicians could account for this discrepancy? Published evidence suggests that female doctors are generally more empathic than male doctors when relating to their patients (Hojat, et al., 2004; Roter and Hall, 2004).
I will begin by describing a cognitive conception of empathy put forth by a recent study in the American Journal of Psychiatry, which has “perspective taking” as its leading factor (Hojat, et al., 2002). I will then highlight the inadequacies of this model and suggest a richer notion of empathy that combines both cognitive and affective domains. My proposed conception of empathy consists of three main components: perspective taking, compassionate care, and what I will call experiential engagement. I will argue that empathic communication is important because it provides the best medical outcome and because it is the most morally-appropriate model of physician-patient communication. I will then suggest that the communication styles of female physicians foster a more empathic doctor-patient relationship.
I do not mean to suggest that every female physician acts more empathically than every male physician, nor do I claim that all male and female physicians communicate in the styles that I will present. The empirical data regarding physician communication styles are based on a large cohort of subjects, and therefore reflect trends among groups rather than individual behaviors. Many of the behaviors that I will describe apply to more than one component of empathy, and some apply to none at all. My purpose is merely to demonstrate that the complex notion of empathy is best encompassed by these three factors, and that the documented communication styles of female physicians on average better promote an empathic physician-patient relationship.
In order to create a model of clinical empathy, one must first distinguish it from sympathy, which is a relationship between people or things in which whatever affects one correspondingly affects the other (http://www.dictionary.com). Applying this definition to the context of the doctor-patient relationship suggests that the sympathetic physician participates in an emotional exchange with his patient through which both participants are affected by the motions of the other. A sympathy-based doctor-patient relationship has potential dangers. The sympathetic physician must be concerned that he does not violate the professional nature of the doctor-patient relationship by revealing too much personal information. Also, a lifetime of deep emotionally engagement in the field of medicine, where death is often inevitable, may cause a physician to feel cynical, futile and burnt out. This is especially worrisome physicians who are regularly confronted with death, such as those who work in emergency medicine or critical care.
Dr. Mohammedreza Hojat and his colleagues published a study in the American Journal of Psychiatry in which they investigated the components of empathy and measured its properties among groups of physicians and patients. According to this study, empathy is the “cognitive attribute that involves an ability to understand the patient’s inner experiences and perspectives and a capability to communicate this understanding” (Hojat, et al., 2002). The authors make a point to distinguish empathy from sympathy; the former they define as a purely cognitive understanding between physician and patient, while the latter involves the sharing of emotions. Clinical empathy, according to the authors, should be modeled as “compassionate detachment” in which physicians keep “sympathy at a reasonable distance to maintain an emotional balance” (Hojat, et al., 2002). This empirical study found that the core component of empathy is “perspective taking” (Hojat, et al., 2002).
Dr. Jodi Halpern, who has written extensively on the notion of empathy, argues that the model of “compassionate detachment” rests on the faulty assumption that knowing how a patient feels is the same as knowing that the patient is in a particular emotional state. Empathy, she claims, is not about labeling states, but rather about recognizing what it is like to actually experience something (Halpern, 2003). Experiences are not merely cognitive happenings. For a physician to keep emotions at a “reasonable distance” is to deny the validity of the patient’s experience. If a physician does not attempt to identify with a patient’s emotions, she makes empathy “a form of theoretical reasoning rather than a form of experiential knowledge” (Halpern, From Detached Concern to Empathy 73).
Halpern proposes that we define empathy as an “experiential way of grasping another’s emotional states” (Halpern, 2003). By using the word “experiential,” Halpern suggests that a physician must not only understand the patient’s experiences and perspective, but also must enter into those experiences. By entering into a patient’s experience, a physician avoids mistakenly assuming to understand a patient’s emotional state based upon “their own storehouse of accrued emotional knowledge” (Halpern, From Detached Concern to Empathy 71). Experiential engagement allows the physician to function not as a predicting observer, but rather as the agent anticipating her own acts (Halpern, From Detached Concern to Empathy 73).
According to Halpern’s model, what is crucial for empathic communication is not the physician’s recognition of his patient’s emotional state, but “noticing what is salient for a patient from within her emotional perspective” (Halpern, From Detached Concern to Empathy 70). Halpern provides an example to underscore the importance of a physician’s ability to engage with a patient in order to understand how the patient feels about a specific situation, rather than presuming that she is in a particular emotional state through mere observation. A cancer patient, Halpern describes, may be angry because she feels that her doctor has made a trivial error that signifies that her doctor may also be making more serious mistakes that will result in the improper treatment of her disease. The patient’s anger with her doctor is not her resentment at his superficial mistake, but rather an emotional response that is grounded in her understanding of him as a serious threat to her health. If the physician does not make this important distinction, he may resent her lack of understanding instead of validating and subsequently relieving her fear (Halpern, From Detached Concern to Empathy 69).
A rich notion of empathy can be achieved if we combine both the cognitive and emotional components. I propose that the ideal model of empathy would consist of three main components: perspective taking, compassionate care, and experiential engagement. Perspective taking is the concept of viewing the world from the patient’s position. Compassionate care encompasses all types of emotional support, both verbal and nonverbal. Compassion can be defined as a “deep awareness of the suffering of another coupled with the wish to relieve it” (http://www.dictionary.com). This component of empathy can only be achieved if the physician first takes the perspective of the patient so as to understand his true concerns. Once this “deep awareness” is obtained, the empathic physician must display her understanding of her patient’s situation as one that deserves care, and then must attempt to provide that care. A physician’s empathy must include the “experiential way of knowing about another’s emotional states” in order to achieve a truly empathic physician-patient relationship (Halpern,From Detached Concern to Empathy 74). I will call this component of empathy that Halpern endorses and Hojat warns against “experiential engagement”.
The importance of empathy in the doctor-patient relationship was confirmed by the Association of American Medical Colleges, who, in a series of reports regarding medical school educational objectives, stated that medical schools are expected to train physicians who are “compassionate and empathetic in caring for patients” (Hojat, et al., 2002). Empathic communication is important for two reasons: it promotes the best possible health outcomes by increasing the exchange of relevant medical information, increasing patient compliance, and supporting the patient’s ability to make autonomous decision, and it also serves as the most morally-appropriate method of physician-patient communication, regardless of the health outcome.
Sung Soo Kim of Michigan State University and his colleagues studied the effects of physician empathy on patient satisfaction and compliance. They found that the cognitive component of empathy, which corresponds to Hojat’s notion of perspective taking, led to a better exchange of cognitive information, and the affective aspect of physician empathy, compassionate care, led to partnership. This partnership led to increased interpersonal trust and had a higher association with patient’s satisfaction than did cognitive information exchange (Kim, et al., 2004). Patient compliance may serve as an indicator of the health outcome of emphatic communication, and patient satisfaction suggests an appropriate moral interaction.
Empathic communication increases the amount of relevant biomedical information disclosed by the patient. In a study from the Journal of the American Medical Association, researchers observed interactions between physicians and patients and found that patients displayed nonverbal cues even before the physicians began to take their history. When physicians responded to these signals in a detached manner, the patients did not disclose emotional information. However, when physicians acknowledged these cues and showed themselves to be engaged, patients revealed emotional information, which allowed the physician to obtain a more accurate history (Halpern, From Detached Concern to Empathy 131).
By attempting to understand the patient’s world, which is the essence of “perspective taking,” a physician validates that world as a real place full of legitimate concerns and needs. If a patient feels that his physician does not believe his concerns to exist as the patient feels them, he is unlikely to express their true form, perhaps out of embarrassment or a feeling of futility. The pain must exist for a physician before she can relieve it.
Medical treatment is patient-specific; a thirty-five year old man who runs five miles a day and is in perfect mental health should not necessarily take the same asthma medication as a person of the same age and physical condition but who battles serious depression. Side effects of almost every medication vary among users. Therefore, the success of the treatment, is contingent on the physician’s ability to understand both the physiological and emotional state of her patient, which requires that she accurately interpret her patient’s verbal and nonverbal cues.
Physician’s empathy, as noted by Kim and his colleagues, increases patient compliance and in turn, improves health outcomes. Most patients have not been trained to understand medical terminology; some may be confident enough to ask for further explanation, but most are not. By asking a patient to put the physician’s recommendation into his own words, the physician can gauge the degree to which the patient understands his condition and how to accurately carry out the treatment regimen. While it may not be difficult to determine if English is a patient’s first language, it is much more challenging to assess a patient’s literacy. Literacy is a particularly sensitive and often embarrassing subject for many people, and the physician who merely asks if her patient understands the written instructions is not acting in her patient’s best interest. If a patient cannot understand the written instructions on his pill bottle, he may put himself in danger by taking too many pills. On the other hand, the patient may take none at all out of fear. A physician should err on the side of caution in order to ensure that her patient receives the best possible treatment.
Dignity, vulnerability, and heightened engagement are constitutive of the patient’s role in the doctor-patient relationship. The patient must reveal personal information, ranging from aches and pains to deep emotional traumas. She must take off her clothes so that her physician can better look at her, prod her, and judge her condition. A patient undergoing surgery is giving her body to her physician for it to be cut open and examined. The patient-physician relationship would appear violated if after surgery the physician did not communicate to his patient that he respected her dignity as a person rather than as a malfunctioning body in need of a well-trained mechanic. The vulnerability and deep engagement between a physician and his or her patient create a moral relationship, which is not fully described by the patient’s health outcome. The physician, as the patient’s partner in this fiduciary relationship, must demonstrate to his patient that he recognizes her dignity and vulnerability for the relationship to be a moral one. This can only be accomplished through the practice of empathic communication.
Numerous studies suggest that the female physicians employ communication techniques, which better promote an empathic physician-patient relationship. Debra Roter and Judith Hall, from the Johns Hopkins Bloomberg School of Public Health, published a review of research on physician gender and patient-centered communication. According to their analysis, the average female physician engages in a more active partnership with her patients. She encourages her patients to play an active role in the doctor-patient relationship by requesting the patient’s opinion and asking for the patient to paraphrase and interpret given information (Roter and Hall, 2004). When a physician requests her patient’s opinion about a particular treatment, the physician employs the patient-centered approach to medicine in which the entire person is treated as the one in need of care, rather than just the disease.
A verbal analysis of doctor-patient communication conducted by the Department of Clinical Psychology and Personality in the Netherlands found that on average female physicians display more “affiliative behavior” compared to the controlling behavior of male physicians (Meeuwesen et all, 1991). Female physicians tend to downplay their status in order to engage in a more equal partnership in conversation (Roter and Hall, 2004). Compared to their male colleagues, female physicians are less authoritative and presumptuous, and offer less interpretation and advisement. In this case, interpretation is defined as “explaining the other to him/herself” and includes evaluations, judgments, and labeling. “You are too anxious,” for example, is an interpretation. Advisement is an attempt to “guide other’s behavior: advice, suggestions, permission, prohibition”. A physician advises a patient when she tells him that he is not allowed to go to work for the next two weeks (Meeuwesen, et al., 1991). These methods of communication allow for a holistic approach to medicine, compared to the illness-centered approach, in which each patient is acknowledged as whole person, one with both physiological and emotional needs.
Female physicians tend to exhibit more positive talk, such as complements, approvals, agreements, and encouragements. Their speech is more emotionally-focused, and includes a greater degree of psychosocial questioning and counseling (Roter and Hall, 2004). Many health professionals believe that female physicians are more interested in “interpersonal relationships and better able to listen” to their patients. Research shows that male physicians interrupt their patients more frequently than do female physicians, and do so as a means to assert control. Female physicians, on the other hand, are found to interrupt their patients as often as they themselves are interrupted (Martin, et al., 1988). On average, female physicians disclose more information about themselves, and display a “warmer and more engaged style of nonverbal communication” through head nods and smiles. Using these verbal and nonverbal communication tactics, female physicians tend to facilitate their patients to talk more openly and intimately (Roter and Hall, 2004).
As previously noted, female physicians attempt to create a more equal relationship with their patients and disclose more information about themselves. These two methods of communication allow the physician and patient to engage in a conversation that is, itself, a shared experience. The warm environment that female physicians tend to create, full of signs of attentiveness and genuine interest, creates a “more intimate therapeutic milieu of heightened engagement, comfort and partnership” (Roter and Hall, 2004).
By demonstrating women’s superior abilities in empathic communication, one must face the danger that these skills may be misconstrued as innate, rather than the product of socialization. If this skill is inherent only in females, then men cannot learn it, and thus it becomes the responsibility of female physicians to transform medical communication into a more empathic practice. This “asks that women be admitted into public life and public discourse not because they have a right to be there but because they will improve them” (Pollitt, 1992). If empathy is seen as constitutive of femininity, then female physicians who do not exhibit better-developed skills in empathic communication may be “castigated as unfeminine” (Pollitt, 1992).
Acknowledging the superiority of female physicians in communicating empathy as a product of socialization has two important benefits: it gives credit where credit is due, and more importantly, it serves as a pedagogical tool. Once we recognize that the skills required for empathic communication must be developed, we raise them “from the level of instinct or passivity,” and therefore are able to applaud women for their well-deserved success (Politt, 1992). A skill that must be developed can be taught. When we recognize that the skills required for empathic communication are not innate, but instead that women may enter the medical field with these skills more developed, then expending effort to train both male and female physicians in empathic communication becomes a worthy endeavor. Not only does it make an empathic model of care the shared responsibility of male and female physicians, but it also creates a potential for empathic communication between every physician and his or her patients.
The purpose of demonstrating the empathetic superiority of female physicians in comparison to their male colleagues is a pedagogical one. By describing the role of empathy in both health outcomes and in promoting a moral physician-patient relationship, I hope to have proven the importance of communicating empathy. Identifying particular communication styles that promote an empathic physician-patient relationship can allow both male and female physicians to practice these styles of communication in order to enhance their ability to heal.
Halpern, Jodi. From Detached Concern to Empathy. New York: Oxford University Press, 2001.
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Hojat, Mohammedreza, et al. “Physician Empathy: Definition, Components, Measurement, and Relationship to Gender and Specialty.” Am J Psychiatry Sept 2002; 159:9:1563-1569
Martin, Steven C., Robert M. Arnold, and Ruth M. Parker. “Gender and Medical Socialization.” Journal of Health and Social Behavior Dec. 1998; Vol. 29: 333-343
Meeuwesen, Ludwein, Cas Schaap, and Cees van der Staak. “Verbal Analysis of Doctor-Patient Communication.” Soc. Sci. Med. Vol. 32, No. 10:1143-1150
Pollitt, Katha. “Are Women Morally Superior?” The Nation Dec 1991; 799-807
Roter, Debra L., and Judith A. Hall. “Physician Gender and Patient-Centered Communication: A Critical Review of Empirical Research.” Annu. Rev. Public Health 2004; 25:497-519