BY Victor S. Sierpina, MD, ABFM, ABIHM Director, Medical Student Education Program, WD and Laura Nell Nicholson Family Professor of Integrative Medicine, Professor, Family Medicine University of Texas Distinguished Teaching Professor

Empathy is the ability to detect, understand, and relate to another’s emotions. It is the basis of deep interpersonal relationships, including therapeutic relationships such as between a healer and a client or patient. Much of empathy is a non-verbal process.

Empathy is different from compassion. Compassion is a positive trait embraced by all major faith traditions. Compassion literally means “to suffer together.” It is defined as the feeling that arises when you are confronted with another’s suffering and the feeling you have motivating you to relieve that suffering. You can imagine how you might feel in a similar situation and conceive of how you might support and help the other person either physically, emotionally, metaphysically, or even spiritually. This is compassion.

Empathy refers to our ability to take the perspective of and feel the emotions of another person directly rather than interpreting them as we can do with compassion. Empathy is something that comes naturally to some people but can be developed and improved in others. A recent article in Academic Medicine describes an evidence-based acronym (E.M.P.A.T.H.Y.) developed at Massachusetts General, the Harvard teaching hospital to improve patient perception of clinician empathy. They analyzed body language, neurological signaling, facial expressions, and neural substrates of empathy.

Learning empathy is highly important in training health professionals. Patients expect and deserve attentive, understanding care from a provider who makes a skilled attempt to understand their perspective. Indeed, without such a connection, the therapeutic relationship and quality of care suffers. Factors such as adherence to prescribed therapy, patient anxiety, and loss of trust may result. Many factors can affect this process including cultural and language barriers, inaccurate projection of one’s own feelings on another person, or inattentiveness and lack of sympathy because of time constraints or other factors.

Even malpractice rates may be affected in the healthcare setting. A study that analyzed the tone, but not the content of surgeons’ conversations with patients found a significant higher malpractice rate in those whose tone was rated as domineering, nonempathic, and thus created dissatisfaction among their patients. Imagine as an example someone in an adjacent room hearing the soothing, caring tonalities of a mother calming her infant. Compare this to the surgeons’ tones which sounded harsh, confrontational, and dismissive. This is a lawsuit waiting to happen, especially if there were surgical complications.

So here are some things to remember when you are with others and wish to create a feeling of empathy, which is probably most of the time!

Eye contact, Muscles of facial expression, Posture, Affect, Tone of voice, Hearing the whole person, Your response. These are the seven steps to empathy as described in a recent article based on research from Harvard’s teaching hospital. (1)

The E.M.P.A.T.H.Y. approach to better communication and connection with patients:

E. Eye Contact.
This is so essential to connection, and engagement, and even the neurobiology of relation, that we need to attend to it. Be aware that some cultures find prolonged eye contact intrusive, seductive, or even rude. As a physician, it seems harder to maintain good eye contact throughout an encounter because of the ever-present electronic record which requires us to document, review results, write orders, refills, write work or jury excuses, etc. Early, late, and as often as possible eye contact is what I recommend to my students and colleagues despite the intrusion of the electronic environment and a busy clinic schedule with short office visits. Also, I recommend patients shut off their phones during visits as the precious time we have can be interrupted by frequent calls and texts.

M. Muscles of Facial Expression.
Empathy is enhanced when we are able to notice and interpret others’ facial signals, and likewise, by consciously making our own expressions evoke and reflect caring, involvement, emotional alignment, compassion. Such subtle messages of body language require awareness, mindfulness, and sensitivity to subtle messaging. The facial muscles are unique in being attached to the skin giving the human face an enormous range of expressions and emotions. Pay attention to it as you endeavor to communicate empathically with others.

P. Posture.
Leaning forward with attentiveness is a powerful message that what a person is saying counts. Think about how you sat talking to the love of your life when you first met him or her. UTMB has a “Commit to Sit” program which encourages our clinicians to sit at the bedside, eye-to-eye with patients rather than towering over them while conversing. Evidence has shown that the simple act of sitting down creates a patient impression of more time, more attention being given by their doctor, even if the actual time spent is less than during the standing conversation.

A. Affect.
This term describes the appearance of a person which reflects their emotional state. Someone may appear angry, agitated, distracted, anxious, or upset. Rather than presuming we understand what this affective state means, an effective strategy is to ask them what they are feeling like. For example, “It seems to me that you are upset. Can you tell me if that is true and if so, what is going on?”

T. Tone of Voice.
This is vital, as s earlier described in the case of recorded conversations with surgeons. The counterpoint was that other surgeons whose tones conveyed warmth and anxiety about the patient’s health had never been sued. Practice listening to your own tone and not just the content. Tone creates an powerful subconscious opportunity for increased empathy and connection.

H. Hearing the Whole Person.
This goes beyond non-verbal cues, affective cues, and listening skills. It means understand the context of the person’s life and how what they are saying relates to that. This is easier for those you know well. For others, asking a question like, “How is that for you?” may elicit a deep and meaningful response that the story so far may not have revealed.

Y. Your Response.
This may be the critical point in any attempt to empathize. How we reflect back and respond to someone’s deeply expressed feelings and situation can make or break the bond of empathy. Callous, superficial, or indifferent responses remove bonds of trust and willingness to share both now and in the future. If you do not know how to respond, silence is a good thing. Uncertainty expressed as, “I am not sure how to respond, but this is what I understand about what you are saying….” can be an honest, open response inviting further conversation. Practicing empathy can enhance not only patient satisfaction, it can improve clinical outcomes, patient safety, adherence to therapy, reduce law suits, reduce burnout, and improve professional satisfaction.

1. Riess H, Draft-Todd G. E.M.P.A.T.H.Y.: A tool to enhance nonverbal communication between clinicians and their patients. Acad Med. 2014:89-1108-1112