by Janice Fisher
Before Robert DiTomasso, PhD, ABPP, professor and chairman, School of Professional and Applied Psychology, came to 黑料传送门 about 20 years ago, he taught in a family medicine residency in a University of Pennsylvania affiliated program. Part of his job was to observe encounters between doctors and patients. 鈥淚 watched the residents and coached them about how to be more empathetic, how to paraphrase, how to be supportive and accept patients 鈥榳here they are,鈥欌�夆�� he recalls. 鈥淭he doctors who came to discuss their cases with me might be angry or frustrated with a patient; you can鈥檛 help patients that way. If you鈥檙e not present in the moment with patients and don鈥檛 convey a true sense of understanding to them, they feel less satisfied and less connected to you and may not have as good an outcome as they might otherwise.鈥�
The lessons learned about empathy resonate for Dr. DiTomasso today in his teaching and mentoring at 黑料传送门.
Citing the work of psychologist Carl Rogers, who developed the model of person-centered therapy, Dr. DiTomasso describes the importance of seeing the world through the patient鈥檚 eyes. 鈥淲e think that empathy exerts its power by positively impacting the physician-patient relationship and providing opportunities for patients to learn. When we feed information and reflect feelings back to patients, more self-understanding is stimulated; patients get more meaning out of their experience, and we can help them look at how they are perceiving things. For example, if a patient says, 鈥業鈥檓 never going to be able to lose weight鈥� or 鈥業鈥檒l never be able to get my blood pressure down,鈥� that鈥檚 a pretty powerful statement. We want them to know we understand why they feel that way, and that there are strategies that can help.鈥�
Practitioner empathy鈥攏ot only for their patients, but for their colleagues鈥攊s another area of interest. 鈥淭he big initiative of the College today is interprofessional education,鈥� says Dr. DiTomasso. 鈥淎 significant proportion of people who come to see family doctors are having some psychological distress, so it鈥檚 been a great opportunity to train students together and teach integrated care.鈥� 黑料传送门 2020, the strategic vision initiated by Jay S. Feldstein, DO 鈥�81, president and chief executive officer, 黑料传送门, calls for the College 鈥渢o create a model for training practitioners of the future who can effectively collaborate,鈥� says Dr. DiTomasso. 鈥淧atients benefit by having an interdisciplinary team. A biomedical鈥損sychological鈥搒ocial approach is what integrated care work and patient-centered medical homes are all about.鈥�
Patient satisfaction measures play an increasingly prominent role in health care, and 鈥渁 significant component of patient satisfaction has to do with patient trust in the physician,鈥� says Dr. DiTomasso. Under the Affordable Care Act, patient satisfaction scores are used to calculate Medicare reimbursement. And more than 70 percent of hospitals and health networks use such scores in determining how to compensate physicians. 鈥淚s the physician seen as dependable, warm, friendly and understanding?鈥� asks Dr. DiTomasso. 鈥淒oes she respect me? Am I able to speak to her about anything? In the end, it鈥檚 鈥業 can talk to my doctor. The doctor is interested in and able to hear what I鈥檓 saying.鈥� You want to produce practitioners who not only have a great deal of knowledge but also know how to communicate with a patient.鈥�
Patients who are not satisfied with medical care, Dr. DiTomasso says, 鈥渁re more likely to 鈥榙octor shop鈥� and delay seeking care, even if they have a serious medical condition. Satisfied patients are more adherent, seek out their doctors and stay with them, and are less likely to engage in malpractice suits.鈥� He adds, 鈥淧atients change for their own reasons, not the doctor鈥檚. If you tell a patient what to do, without eliciting their own barriers to change and reasons for change, you鈥檙e missing the boat.鈥� Here Dr. DiTomasso invokes Carl Rogers鈥檚 concept of 鈥渦nconditional positive regard,鈥� which invites practitioners 鈥渢o accept patients for who they are and where they are without judging.鈥�
Dr. DiTomasso鈥檚 student Jennifer K. Olivetti, MS/Psy 鈥�13, PsyD 鈥�15, wrote her dissertation on the Professionalism Assessment Rating Scale (PARS), a scale developed by 黑料传送门 to assess the quality of DO students鈥� interpersonal and communication skills. Standardized patients (SPs) rate the students on eight criteria that have been linked in the literature to patient outcomes, patient adherence, patient satisfaction and malpractice. Besides demonstration of empathy, the criteria items cover rapport, confidence, appropriate body language, effective eliciting of information, active listening, timely feedback, and a thorough and careful exam or treatment. Dr. Olivetti鈥檚 research showed not only that students鈥� PARS scores improved over their three years at 黑料传送门, but that all of the PARS criteria correlated strongly with a single underlying factor or dimension: perceived quality of the provider-patient interaction. 鈥満诹洗兔� puts a lot of focus on training students in interpersonal skills,鈥� says Dr. DiTomasso, 鈥渁nd that will carry us into the future. In the end, let鈥檚 face it: When you refer a patient to your own personal physician, you judge your doctor鈥檚 caring, understanding, genuineness.鈥�
Samantha Welsh (PsyD 鈥�19), one of Dr. DiTomasso鈥檚 students, is planning on studying burnout in PCPs, who face the challenges of increasing patient volume as well as managing patients with psychological distress. Christina Pimble, MS/Psy 鈥�14, (PsyD 鈥�18), a student of Barbara Golden, PsyD, professor of psychology and director of the Center for Brief Therapy at 黑料传送门, has studied burnout in psychologists. 鈥淲hen we talk about burnout,鈥� says Dr. DiTomasso, 鈥渨e鈥檙e talking about role stress in the workplace. People experience emotional exhaustion, pessimism, depersonalization, less of a sense of personal accomplishment. 鈥� If you start getting burned out, you start to potentially undermine your effectiveness with the patient. If you鈥檙e emotionally drained, you may not listen as intently, making clinical judgments as you normally would. You may feel less sense of professional accomplishment. You can lose focus and empathy.鈥� Moreover, studies have linked empathy to decreased physician burnout.
Can you teach people to be more empathetic? The leading researcher in the field, Jefferson University鈥檚 Mohammadreza Hojat, PhD, says yes鈥攖hat while some people may find it easier than others to be empathetic, empathy is a cognitive attribute rather than a personality trait. Dr. DiTomasso was a fellow graduate student at Penn with Dr. Hojat. When Adam McTighe, Ms/Psy 鈥�12, PsyD 鈥�14, MBA, undertook a dissertation on 鈥淓ffect of Medical Education on Empathy in Osteopathic Medical Students,鈥� Dr. DiTomasso asked Dr. Hojat to join him as a member of the dissertation committee, along with Stephanie H. Felgoise, PhD, ABPP, professor, vice-chair and director, PsyD Psychology program, 黑料传送门.
Dr. McTighe, who completed his fellowship at UCSF Benioff Children鈥檚 Hospital Oakland and is now a clinical and forensic psychologist at Georgia Regional Hospital Atlanta in the Department of Behavioral Health and Developmental Disabilities, notes that 鈥渆mpathy doesn鈥檛 teach people to feel more, but rather to understand the right questions that help others verbalize what鈥檚 going on.鈥� His dissertation concludes with a call for more research on 鈥渨hat can be done to maintain empathic attitudes during the critical transition from the classroom to the exam room.鈥�
At Georgia Regional Hospital, Dr. McTighe is responsible for criminal forensic evaluations on individuals admitted to an inpatient state forensic psychiatric unit. In this setting, he notes, Dr. Hojat鈥檚 distinction between 鈥渃ognitive empathy鈥濃�攁n understanding of experiences, concerns and perspectives of the patient and the ability to communicate that understanding鈥攁nd sympathy鈥攖he emotional response that a physician might experience in response to a patient鈥攊s especially germane. Since these patients have 鈥渟erious persistent mental issues,鈥� Dr. McTighe鈥檚 goal is 鈥渃onnecting to them and understanding their norms, treating individuals with respect and dignity, which they may not have experienced.鈥�
For 12 of his 15 years as a mental health practitioner, Dr. McTighe reflects, he primarily worked with children and families when he had no children of his own. He recalls the first time he saw a mother and her little girl, and wondering how he could help them. 鈥淵ou try to be attuned to what they are going through; you don鈥檛 pretend you have that experience. You鈥檙e human, and sometimes you have to be willing to say you don鈥檛 understand.鈥�
Dr. McTighe, after being the first 黑料传送门 psychology student to join the DO/MBA program with St. Joseph鈥檚 University, received an MBA in 2012, which affords him insight into aspects of organizational culture including the teaching and modeling of empathy. For example, administrators 鈥渦nderstand the bottom line, but may not understand the assessments you need to pay for, or the need to train the staff that would benefit from enhanced empathy.鈥� He is also attuned to the possible barriers to empathy created by what Dr. Hojat and colleagues have called 鈥渟tudents鈥� gradual overreliance on computer-based diagnostic and therapeutic technology [, which] limits their vision for the importance of human interactions in patient encounters.鈥�* Dr. McTighe says, 鈥淚f technology seems to be taking you in the opposite direction from empathy, you can鈥檛 fight it; you have to get ahead of it, while practitioners are still in school. Urgent care can cut ER costs in half, for example. What might that model look like for mental health? Telehealth, for example, is an exciting new possibility for a practitioner and client to connect via videochat while still providing meaningful relationship opportunities.鈥�
In the long term, Dr. McTighe hopes to combine his clinical expertise with a business management role so that he can work on a broader scale, especially to enable community outreach at a higher level so that individuals have a better chance to get the help they need. Most recently, Dr. McTighe has helped create course materials for the company Help Each Other Out (Helpeachotherout.com), a nonprofit organization that 鈥渁ddresses community needs through education on simple, yet effective, strategies to empower, support and empathize with people in need.鈥� Another project is a grant proposal to better understand patient satisfaction and patient perceptions of osteopathic distinctiveness and physician empathy. He stresses that DOs already 鈥渉ave been doing things differently for 125 years! This is their bread and butter, the core of the osteopathic identity.鈥�
鈥淓mpathy is integrated into all medical disciplines鈥� at 黑料传送门, says Kenneth J. Veit, DO 鈥�76, MBA, provost, senior vice president for academic affairs and dean, 鈥渁nd into all steps of the four-year process (didactic and clinical).鈥� Dr. Veit points out that students especially learn empathy in Anatomy (showing respect for the cadaver and attending a postdissection ceremony), in Family and Internal Medicine, in Geriatrics/Palliative Care, in working with standardized patients and with real patients in the Healthcare Centers, and from modeling faculty, staff and clinical mentors. 鈥淪tudents also learn empathy in the way they are treated by faculty and staff,鈥� he says, 鈥渁nd students are selected by Admissions (in part) for their empathetic potential.鈥� Adds Robert G. Cuzzolino, EdD, vice president, graduate programs and planning, 鈥淓mpathy is essentially a component of the patient-physician relationship that centers on communication. Much of that material is in the Primary Care Skills courses and their corresponding patient simulation, particularly in the first year. Community-based Medicine also deals with the patient-physician relationship, along with ethics, patient rights and end-of-life decisions.鈥�
At 黑料传送门 School of Pharmacy 鈥� Georgia Campus, the required Pharmacy Communications course (PHAR 119G) is taught by Jennifer Elliott, PharmD, CDE, assistant professor of pharmacy practice. About half of the course involves communicating with patients, she says, and that鈥檚 where empathy comes in.
Empathy is conceived in the course as a teachable, learnable skill with tangible benefits for both healthcare provider and patient. These benefits include improved health outcomes, better patient compliance, reduction in medical-legal risk, and improved satisfaction of clinicians and patients. In contrast to sympathy, characterized by the notion of 鈥渟haring鈥� a patient鈥檚 emotion (which could lead to a lack of objectivity and emotional fatigue), empathy is a kind of 鈥渃ompassionate detachment,鈥� in which a professional can 鈥渋magine鈥� a patient鈥檚 emotion. Empathy is also distinguished from pity, 鈥渁 relationship which separates physician and patient鈥and] is often condescending and may entail feelings of contempt and rejection.鈥�
Dr. Elliott makes the course as practice-based as possible, with students working in groups through a variety of patient scenarios in class. The biggest challenge for the students, she says, is 鈥渄ealing with things they haven鈥檛 seen or dealt with before, such as a patient who is dying鈥攁nd there鈥檚 no one right answer.鈥�
A student in the course last year, Hilda Alvarez (PharmD 鈥�18), presented with colleagues on 鈥淪howing Empathy to a Diverse Group of Patients in Various Pharmacy Settings,鈥� which discussed how to convey empathy in such pharmaceutical settings as retail, free clinics, ambulatory care, hospitals, long-term care facilities, VA hospitals and hospices. Ms. Alvarez covered long-term care: both independent living/partially supervised apartments or senior housing, and nursing homes with 24-hour medical care/supervision. The most prevalent disease states in such settings are Alzheimer鈥檚 disease or other dementias, and depression. The best practices Ms. Alvarez recommended, based on her research, were to communicate compassionately and consistently, to be patient and supportive, and to not make assumptions about patients鈥� conditions.
Ms. Alvarez notes that for any number of reasons, patients may not be eager to come into a pharmacy to get a medication; if the pharmacist takes account of that reality, and builds trust with patients, 鈥渉opefully they鈥檒l come back and ask for advice and recommendations.鈥� She adds, 鈥淩egardless of the setting, you need to realize where you are working鈥攚hat type of patients you鈥檙e seeing, their economic status, their literacy level. Even within the same city, you must be able to adapt to different patient populations and be able to empathize with them.鈥�
In 1998, Gary L. Saltus, DO 鈥�73, underwent two neck surgeries, followed by heart surgery in 1999. 鈥淚 could no longer be a heart surgeon,鈥� he says. 鈥淚 lost my identity鈥攁nd my immortality. But I had a wonderful opportunity to find out who am I and what I want to do with life.鈥� Dr. Saltus found his passion: trying to get members of the healthcare community to come together empathically. 鈥淚鈥檓 a far better executive coach than I ever was a heart surgeon,鈥� says Dr. Saltus, 鈥渂ecause I鈥檓 open to the world and what the world will offer itself up to me.鈥�
Dr. Saltus describes his coaching work as 鈥渕ore transformational than oriented toward performance.鈥� Rather than change behavior, he says, his job when working with a client is to find out who that client is; then 鈥渂ehavior will automatically change.鈥� In the healthcare arena, Dr. Saltus works with departments and other groups to develop an empathetic cooperative culture, using the 鈥渙utward mindset鈥� model promulgated by the Arbinger Institute as well as his osteopathic empathetic philosophical core. Arbinger (www.arbinger.com) 鈥減rovides training, consulting, coaching, and implementation tools that move individuals, teams, and organizations from the default self-focus we call an inward mindset to the results focus of an outward mindset.鈥�
鈥淚n an inward mindset,鈥� continues Dr. Saltus, 鈥渕y focus is on how others are impacting me personally, and whether I think they can help me with my objectives. In contrast, in an outward mindset, the focus is on what others are able to achieve as a result of my efforts.鈥� In the realm of health care, providers with an outward mindset focus on what can be achieved by their patients, peer caregivers and staff and administrators. By shifting to an outward mindset, healthcare providers can work as a collaborative team, yielding better patient outcomes and sustained empathy.
鈥淏ehavior yields results,鈥� says Dr. Saltus, 鈥渂ut mindset drives behavior. So empathetic behavior is really an outward mindset. I鈥檓 more interested in supporting another person鈥檚 success, understanding another鈥檚 perspective without judgment.鈥� Dr. Saltus recalls his 鈥渉eart surgeon鈥� outlook: 鈥溾�業 can understand everyone鈥檚 perspective, but they are wrong.鈥� The inward mindset focuses on the self, so as a surgeon, I asked, 鈥楬ow can everyone help me obtain my objectives and meet my challenges?鈥欌��
鈥淲e call ourselves a team,鈥� says Dr. Saltus of healthcare professionals, 鈥渂ut we鈥檙e all doing our individual objective tasks, thinking 鈥業 am all alone.鈥� How do you empathically create a collaborative culture, where each individual is focused on the success of others?鈥� Take, for example, discharge instructions, which Dr. Saltus describes as 鈥渄own to a science in clinical pathways.鈥� If patients fail to comply with the instructions, 鈥渨e say, 鈥榃hy didn鈥檛 you follow them?鈥� instead of the team asking itself, 鈥榃hat are we missing?鈥欌�� What if we came together and tried to find out how we need to tweak discharge instructions? We have a silo culture. The silos would break down if everyone was invested in everyone else鈥檚 success.鈥�
Dr. Saltus was far from uncaring as a heart surgeon.
鈥淚 did a good job of sitting with my patients, for 45 minutes or an hour. I鈥檇 ask them if they鈥檇 like to see their imaging films; I would go through complications, mortality and morbidity; I鈥檇 review what we had to watch out for after surgery鈥擨 would try to win their trust so that we got to know each other. If I could have them on my side, that was a lot of the battle.鈥� But in the operating room, on the floors, in surgical intensive care, 鈥淚 feared failure,鈥� says Dr. Saltus. 鈥淚 was afraid of change if I went into the ER. Now I look forward to disruption. I used to be afraid of controversy. Now I know that something different will give me an opportunity to learn. 鈥� Fear of change is fear for myself, a very inward mindset. Empathy requires that we experience vulnerability, which is very difficult for healthcare workers even though we require our patients to do it whenever they come into a healthcare setting.鈥�
It鈥檚 estimated that over 400,000 deaths occur annually as a result of preventable hospital errors. Dr. Saltus asks, 鈥淛ust think about what would happen to sentinel events鈥濃�� unexpected occurrences involving death or serious physical or psychological injury鈥斺�渋f the system offered a reward for helping the other members of the team be successful? Creating an empathetic collaborative culture is the answer.鈥�
Dr. Saltus says that Arbinger 鈥済ave me the language that helps me describe empathy and the osteopathic philosophy鈥攂ecause they are one and the same. Osteopathic philosophy is holistic; we鈥檙e taking care of the whole patient. With external forces, we鈥檝e drifted away from our osteopathic empathetic core. I鈥檓 inviting people to come back. We need a rebirth of empathy.鈥�
*M. Hojat et al. (2009). The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Academic Medicine, 84(9):1182-1191.