Should we be testing doctors for empathy?

Should we be testing doctors for empathy?
Image: Fernando Molina for Quartz
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We all have a story about the time a doctor was cold and aloof during a sensitive, perhaps even life-altering exchange. My example: A few years ago, when I accompanied my elderly mother to an appointment, I witnessed the doctor interrupting her, with mild annoyance, as she described her distressing symptoms. “We’ve been through this before,” the doctor said. “It’s Alzheimer’s.” She uttered these words as though she were reading a weather forecast.

In fact, I thought we were still running more tests to rule out other possibilities, but my mother had forgotten to tell me that we weren’t, because she hadn’t remembered. She was blindsided. So was I. And my grief in that moment was matched only by my astonishment at the doctor’s callous delivery.

Fortunately, most of us can also remember at least one encounter with a highly competent doctor who put the lie to the idea that emotions have no place in the patient-physician relationship, and who stood out for listening attentively, answering queries with thoroughness, and asking questions about your habits or schedules to better understand how prepared you might be for change or treatments. This is what patients crave: some empathy for what one is going through, how an illness is disrupting your life or triggering panic or shock. After receiving care of this nature, we wonder why all doctors can’t make the same effort.

Researchers who have studied what empathy can do for patients are asking the same question, especially now that we know that doctors who are highly empathetic have better patient outcomes, and a stronger sense of personal wellbeing as physicians. They even may be less likely to be sued.

A movement to build more empathetic doctors has already inspired creative programs across the US, Canada, the UK, and elsewhere. In some cases, hospital physicians are invited to seminars on Tibetan Buddhism or theater training. At many medical schools, doctors in training are donning virtual reality headsets to experience the trials of arthritis, macular degeneration, and other common conditions they’re likely to encounter in their practices. To hone patient-centered instincts, some medical students in Detroit are invited to treat the homeless at a street clinic.

But one researcher believes the effort needs to begin even earlier in a doctor’s career— he believes empathy tests should be used to screen candidates when they first apply to medical school.

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A crusade for compassion

Mohammadreza Hojat, a research professor in psychiatry and human behavior at Thomas Jefferson University in Philadelphia, developed the Jefferson Scale of Empathy (JSE) tool in 2001. The test, a questionnaire that asks subjects to rank how strongly they agree or disagree with statements like “Patients feel better when their doctors understand their feelings” or “Doctors should try to understand what is going on in their patients’ minds by paying more attention to their nonverbal cues and body language,” has been used in dozens of countries around the world, and verified by several studies. It’s sold in three versions: there’s one for medical students, one for practicing physicians, and a third for all other health practitioners, including nurses or pharmacists.

The goal of the test is to see how much a doctor or student equates empathy with the best patient care. “We define empathy, in the context of patient care, as a kind of personality attribute that involves an understanding of patients’ pain, experiences, suffering, and views,” Hojat says. “In addition, there should be a capacity to communicate this understanding to the patient,” and, thirdly, “an intention to help,” he adds.

Hospitals and researchers often use the JSE to measure empathy in physician cohorts, usually as part of medical studies, but Hojat has bigger plans for it. He is three years into a seven-year study looking at the associations between a student’s empathy and other variables—including gender, age, career interests, and academic background—to trace patterns in empathy levels as the student progresses through medical school, and to explore ways of improving empathy through training. Hojat asserts, citing his research, that empathy can be enhanced or taught, though he says, it’s not clear how long the positive effects of an empathy-boosting class can be maintained.

Hojat and his team reached a milestone this year, establishing national norms for empathy scores using a sample size of 16,000 osteopathic medical students. These trainees go on to earn a Doctor of Osteopathic Medicine, or DO degree, which is equivalent to an MD, though osteopathic teachings emphasize treating patients with a more holistic approach. (Hojat’s study is sponsored by two major osteopathic associations.) These norm tables could now be used by Osteopathic medical schools to assess students’ empathy throughout their education, with a particular focus on applicants. With benchmarks, schools could determine how a candidate ranks compared to candidates everywhere. Do their empathy levels place them within the top percentile of people like them?

The professor would one day like to see similar norms tables developed for allopathic medical school students, the much larger population of students who earn MDs (Doctors of Medicine).

Currently, applicants to either stream of schools are not tested for empathy through any one specific test. Hojat notes that medical schools claim they can assess empathy during the series of mini interviews that are part of the application process, when a candidate may be asked hypothetical questions about an encounter with a patient or even invited to role play an interaction with an actor playing a patient. Letters of recommendations, many school administrators would argue, also provide hints about a candidate’s personality and emotional intelligence. And four years ago, the Medical College Admissions Test (MCAT) added questions about sociology and psychology to its standardized test, which is used for admissions to medical schools in the US and Canada.

Hojat doesn’t believe that these various snapshots add up to a clear enough picture. His ambition, he says, is not to replace these practices, but to give medical school gatekeepers additional information about a student’s profile.

The empathy score ought to be among the factors considered when a candidate is being accepted or rejected, he argues. His own work has suggested that an empathy score, compared to school grades or an MCAT score, is a better predictor of a student’s success during the last two years of medical school, when students begin clinical training, which is exactly when empathy starts to falter according to one of his oft-cited studies. Meanwhile, he says, no data has linked evidence of a compassionate mindset in recommendation letters or interviews with a clear demonstration of that trait later on.

“We suggest said that empathy is the most germane and relevant measurement we use in admission to medical school,” he tells Quartz at Work, but he also suspects it has promise as a way of evaluating doctors at other steps in their career. “I believe we should use it for applicants to residency training programs or maybe for finding a position. But we have data to support the predictive validity of empathy in medical school, at least.”

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Empathy’s big comeback

Hojat is partly motivated by a mission much grander than just changing the selection process to medical schools. What he ultimately wants to do, he says, is help restore and cement the public image of doctors as compassionate and trustworthy caregivers.

There are other advocates of empathy in patient care who are fueled by a similar goal, to regain the spirit of medicine of old—as in ancient—when doctors were judged by their intuitive understanding of other humans as people, not merely a collection of blood, bones, and tissue. In a recent essay for The Conversation, Jeremy Howick, director of the Oxford Empathy Programme at Oxford University, explains that historically, this ingredient in the healing process was not in question. “Pleasant words are a honeycomb, sweet to the soul, and health to the bones,” King Solomon wrote two millennia ago, Howick notes. Hippocrates himself believed that “it is more important to know what sort of person has a disease than to know what sort of disease a person has.”

But “empathy got squeezed out as medicine became more professional and scientific,” Howick writes.

By the 19th century, a paternalistic, doctor-knows-best model dominated western medicine—which wasn’t the worst thing when doctors worked in villages and knew about their patients’ lives, Howick proposes. But current structures typically don’t allow for that kind of familiarity. So the profession was set up for a fall: At the same time that our culture began to value objective data and procedures over instinct, our expanding medical system complicated the patient-doctor experience with layers of bureaucracy, phone menus, and insurance companies. All of this led to a crisis of trust when a scientific solution—Howick points specifically to the use of thalidomide in the 1960s to treat nausea in pregnancy—tragically failed.

The paternalistic model lost its shine in the second half of the 20th century, with the rise of awareness of personal and interpersonal psychology. Though it has gone by all kinds of names, the current push for better “bedside manners,” as it were, or patient-centered care, started some 50 years ago. Contemporary proponents of compassionate care, like the Harvard surgeon and acclaimed writer (and now healthcare executive) Atul Gawande, Howick argues, have helped keep the topic in the mainstream zeitgeist.

Medical school training, however, has not adjusted much. Here, too, professionalism and the triumph of scientific thinking has overshadowed the necessity for empathy, says Nicole Piemonte, assistant dean of medical education at Creighton University, in Phoenix. Even now, as medical schools inject lessons about communication and the human condition into their course offerings, the messages from what’s been called the “hidden curriculum”—the one that values time-managed solutions and scientific problem-solving over other ways of thinking or being— undermines teachings about what’s really being treated in a doctor’s office or hospital, she says.

Piemonte believes that suffering follows “when people perceive a threat to their intactness—when they perceive a potential destruction of their identities routines, futures, relationships, roles and so forth,” she writes in her book Afflicted: How Vulnerability Can Save Medicine (MIT Press, 2018), which chronicles her work and personal experience when her mother died from ovarian cancer. When people seek medical care, part of what they’re hoping for, she writes, is “a restoration of their way of being in the world.”

And yet our system for selecting and training doctors hasn’t changed much from an era when few saw medicine this way. In 1910, Abraham Flexner, an American educator and education scholar, was hired by the Carnegie Foundation to tour the US and shut down medical schools that were selling quackery, or taking people’s money and not training them, says Piemonte. Flexner also wrote an influential report endorsing the German system of educating doctors, which required that aspiring physicians enter medical school with a bachelor’s degree, then study science for two years before moving on to clinical training for another two years.

That’s when “you get this ideal of the master clinician being the scientist,” Piemonte says. But with improvements in technology and diagnoses, doctors soon ran into profound philosophical questions that science couldn’t answer. Says Piemonte, “When do you take someone off a ventilator? When are they dead? Who gets what organs? Who deserves renal dialysis, if it’s a finite resource?”

On matters of life and death, scientists were ill prepared. “So these philosophers and theologians get together and they’re like, ‘Well, we’ve got to help these guys ’cause they don’t want to answer these questions,” says Piemonte. “And that’s where we get the development of the medical humanities, and courses on empathy and ethical discernment,” she explains. Yet today, classes on the art of ethical reasoning or compassion remain add-ons, not foundational components of traditional medical education.

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Against empathy tests

It’s not totally clear that testing med school candidates for empathy, as Hojat proposes, would drastically improve the odds that schools will admit more caring humans, or that empathy tests, as a concept, even work. If you want to appear empathetic, it wouldn’t be difficult to guess whether you should agree with a sentiment like, “A health care provider’s sense of humor contributes to better outcomes.” (Hojat says that the test scores account for the possibility that someone is choosing the right answers to create a favorable impression.)

Jean Decety, a professor of psychology and psychiatry at the University of Chicago, says he doesn’t believe empathy, which he has studied, can be properly measured through tests. “Empathy, whatever it means, is a flexible ability, which is influenced by social context and interpersonal relationships,” he says. “Components of empathy can be assessed by self reports and more objective tasks,” he adds. However, “[t]he former measures aren’t very accurate, and the latter are not exactly what physicians will face in their practice.”

Decety, who has a PhD in neuroscience, says his work has shown that although empathy is important for certain types of physicians, like family doctors, there’s no need to evaluate this dimension in all prospective medical students. Radiologists and surgeons, for instance, only need to be skilled technicians, he suggests. Still, he isn’t arguing that existing empathy classes are futile or unnecessary. A requisite seminar “that explains the benefits and costs of empathy cannot hurt,” he says, because it will make students “more aware of what empathy is.”

Piemonte likewise doubts that empathy can be properly tested or even taught. She’s prone to see it as “an innate quality that can be either cultivated or diminished through experience,” she explains.

Unlike Decety, though, she believes it can be powerful in any corner of the medical world. “Do I trust my surgeon to make the best decisions for me in the operating room if he or she doesn’t care about me in some way? Does my empathic connection with them before my operation make me trust them more, make me follow their recommendations, post-surgery, more readily?” she asks. Or, she says, how does that person’s behavior with staff influence the physician’s work? Even if you don’t meet your surgeon in person, do you want that person to be the type who rebukes and barks at nurses and other hospital colleagues?

Piemonte suspects that the majority of medical students are in fact deeply sensitive, compassionate people, who are ultimately let down by a system that emphasizes the wrong skills. In her mind, it’s the entire system that needs a rethink.

“We want to interview and accept students who are going to be successful academically, absolutely,” she says. “But with such an emphasis on their performance on the MCAT and other standardized exams, I think we might be missing people who might do just fine in medical school, who may need some extra academic support, but have these really rich human qualities that we want to see in our physicians.”

Imagine if the reason some applicants were not star students in their undergraduate classes was because they were caring for a sick parent, or working three jobs to pay for school, she asks. “Those are the ones that we want,” she says, “because they can understand the plight of others who are suffering.”

Meanwhile, the malfunction in the selection system is further exacerbated by flaws in the sorting system that follows. Once someone is already in medical school, it is difficult to deal with them if they prove to be less understanding or less patient-focused, according to Piemonte. “If the behavior is egregious, it will be dealt with,” she says, but otherwise schools are incentivized to depict their graduates as naturally caring doctors—because otherwise it could hurt the school’s match rate for residencies and thus its reputation and ability to attract talented applicants. In the medical humanities world, she says, there is talk about the need for gracious off-roads that would allow someone who isn’t cut out to be a physician the opportunity to switch tracks without blowing up their lives and wasting the schooling they already have.

In the face of these multifaceted problems, an empathy test looks to her like another blunt tool for choosing a few thousand applicants out of tens of thousands or more. “If we are using it and someone is way off the bell curve, a sociopath, I’d be glad we did that test,” she says. Otherwise, she is conflicted.

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“True understanding has no limit”

One of the more common concerns that Hojat hears about his project is that it’s unfair to ask doctors to be empathetic, because of the risk of exhaustion. Instead, young physicians in training need to practice building those healthy boundaries to avoid taking on every patient’s pain and all of the complications of their lives.

This criticism he rejects, however, citing the difference between sympathy, which is actually experiencing the pain and suffering of the patient or feeling pity about it, and empathy, which is more about trying to see things from the patient’s perspective. “When you get involved in feeling a patient’s suffering, it can influence the physician’s decisions,” he says, and it can encourage patients to become too dependent on their doctors. So, yes, emotions in excess can lead to burnout and other problems, “but true understanding has no limit,” he argues. “You can try to understand a person as much as you can, and the more you understand, the better for the patient.”

Exactly how empathy leads to better patient outcomes may be complex, as Hojat recently told the Philadelphia Inquirer. But he theorizes that the magic may be in the openness that compassion invites. “When there is empathic engagement in patient care, this would lead to a trusting relationship. Because of it, the patient might reveal the narrative of his or her disease more completely, not try to conceal anything. They would be honest with their physician. That leads to a better diagnosis because the physician gets all the important information,” he said.

Will medical schools accept this premise and start adding empathy tests to their admissions processes? “That’s up to them,” says Hojat. “Everyone says this is important, very nice, it needs to be done. But when it comes to actually doing this, it’s difficult to break that old system.” And yet a fundamental shift is what it will take if schools genuinely aim to select “promising students who become good, caring physicians,” says Hojat, “rather than applicants who can successfully pass licensing examinations or memorize factual information.”

Ironically, his analog JSE test might soon face competition from advanced technology. Data scientists have already developed AI software they claim can measure empathy in a therapist. How long before they devise an algorithm to do the same thing for doctors, and those who dream of becoming one?