by Janice Fisher
Before Robert DiTomasso, PhD, ABPP, professor and chairman, School of Professional and Applied Psychology, came to PCOM 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. “I watched the residents and coached them about how to be more empathetic, how to paraphrase, how to be supportive and accept patients ‘where they are,’ ” he recalls. “The doctors who came to discuss their cases with me might be angry or frustrated with a patient; you can’t help patients that way. If you’re not present in the moment with patients and don’t 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.”
The lessons learned about empathy resonate for Dr. DiTomasso today in his teaching and mentoring at PCOM.
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’s eyes. “We 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, ‘I’m never going to be able to lose weight’ or ‘I’ll never be able to get my blood pressure down,’ that’s a pretty powerful statement. We want them to know we understand why they feel that way, and that there are strategies that can help.”
Practitioner empathy—not only for their patients, but for their colleagues—is another area of interest. “The big initiative of the College today is interprofessional education,” says Dr. DiTomasso. “A significant proportion of people who come to see family doctors are having some psychological distress, so it’s been a great opportunity to train students together and teach integrated care.” PCOM 2020, the strategic vision initiated by Jay S. Feldstein, DO ’81, president and chief executive officer, PCOM, calls for the College “to create a model for training practitioners of the future who can effectively collaborate,” says Dr. DiTomasso. “Patients benefit by having an interdisciplinary team. A biomedical–psychological–social approach is what integrated care work and patient-centered medical homes are all about.”
Patient satisfaction measures play an increasingly prominent role in health care, and “a significant component of patient satisfaction has to do with patient trust in the physician,” 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. “Is the physician seen as dependable, warm, friendly and understanding?” asks Dr. DiTomasso. “Does she respect me? Am I able to speak to her about anything? In the end, it’s ‘I can talk to my doctor. The doctor is interested in and able to hear what I’m saying.’ You want to produce practitioners who not only have a great deal of knowledge but also know how to communicate with a patient.”
Patients who are not satisfied with medical care, Dr. DiTomasso says, “are more likely to ‘doctor shop’ 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.” He adds, “Patients change for their own reasons, not the doctor’s. If you tell a patient what to do, without eliciting their own barriers to change and reasons for change, you’re missing the boat.” Here Dr. DiTomasso invokes Carl Rogers’s concept of “unconditional positive regard,” which invites practitioners “to accept patients for who they are and where they are without judging.”
Dr. DiTomasso’s student Jennifer K. Olivetti, MS/Psy ’13, PsyD ’15, wrote her dissertation on the Professionalism Assessment Rating Scale (PARS), a scale developed by PCOM to assess the quality of DO students’ 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’s research showed not only that students’ PARS scores improved over their three years at PCOM, but that all of the PARS criteria correlated strongly with a single underlying factor or dimension: perceived quality of the provider-patient interaction. “PCOM puts a lot of focus on training students in interpersonal skills,” says Dr. DiTomasso, “and that will carry us into the future. In the end, let’s face it: When you refer a patient to your own personal physician, you judge your doctor’s caring, understanding, genuineness.”
Samantha Welsh (PsyD ’19), one of Dr. DiTomasso’s 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 ’14, (PsyD ’18), a student of Barbara Golden, PsyD, professor of psychology and director of the Center for Brief Therapy at PCOM, has studied burnout in psychologists. “When we talk about burnout,” says Dr. DiTomasso, “we’re talking about role stress in the workplace. People experience emotional exhaustion, pessimism, depersonalization, less of a sense of personal accomplishment. … If you start getting burned out, you start to potentially undermine your effectiveness with the patient. If you’re 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.” 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’s Mohammadreza Hojat, PhD, says yes—that 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 ’12, PsyD ’14, MBA, undertook a dissertation on “Effect of Medical Education on Empathy in Osteopathic Medical Students,” 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, PCOM.
Dr. McTighe, who completed his fellowship at UCSF Benioff Children’s 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 “empathy doesn’t teach people to feel more, but rather to understand the right questions that help others verbalize what’s going on.” His dissertation concludes with a call for more research on “what can be done to maintain empathic attitudes during the critical transition from the classroom to the exam room.”
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’s distinction between “cognitive empathy”—an understanding of experiences, concerns and perspectives of the patient and the ability to communicate that understanding—and sympathy—the emotional response that a physician might experience in response to a patient—is especially germane. Since these patients have “serious persistent mental issues,” Dr. McTighe’s goal is “connecting to them and understanding their norms, treating individuals with respect and dignity, which they may not have experienced.”
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. “You try to be attuned to what they are going through; you don’t pretend you have that experience. You’re human, and sometimes you have to be willing to say you don’t understand.”
Dr. McTighe, after being the first PCOM psychology student to join the DO/MBA program with St. Joseph’s 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 “understand 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.” He is also attuned to the possible barriers to empathy created by what Dr. Hojat and colleagues have called “students’ gradual overreliance on computer-based diagnostic and therapeutic technology [, which] limits their vision for the importance of human interactions in patient encounters.”* Dr. McTighe says, “If technology seems to be taking you in the opposite direction from empathy, you can’t 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.”
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 “addresses community needs through education on simple, yet effective, strategies to empower, support and empathize with people in need.” 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 “have been doing things differently for 125 years! This is their bread and butter, the core of the osteopathic identity.”
“Empathy is integrated into all medical disciplines” at PCOM, says Kenneth J. Veit, DO ’76, MBA, provost, senior vice president for academic affairs and dean, “and into all steps of the four-year process (didactic and clinical).” 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. “Students also learn empathy in the way they are treated by faculty and staff,” he says, “and students are selected by Admissions (in part) for their empathetic potential.” Adds Robert G. Cuzzolino, EdD, vice president, graduate programs and planning, “Empathy 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.”
At PCOM School of Pharmacy – 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’s 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 “sharing” a patient’s emotion (which could lead to a lack of objectivity and emotional fatigue), empathy is a kind of “compassionate detachment,” in which a professional can “imagine” a patient’s emotion. Empathy is also distinguished from pity, “a relationship which separates physician and patient…[and] is often condescending and may entail feelings of contempt and rejection.”
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 “dealing with things they haven’t seen or dealt with before, such as a patient who is dying—and there’s no one right answer.”
A student in the course last year, Hilda Alvarez (PharmD ’18), presented with colleagues on “Showing Empathy to a Diverse Group of Patients in Various Pharmacy Settings,” 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’s 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’ 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, “hopefully they’ll come back and ask for advice and recommendations.” She adds, “Regardless of the setting, you need to realize where you are working—what type of patients you’re 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.”
In 1998, Gary L. Saltus, DO ’73, underwent two neck surgeries, followed by heart surgery in 1999. “I could no longer be a heart surgeon,” he says. “I lost my identity—and my immortality. But I had a wonderful opportunity to find out who am I and what I want to do with life.” Dr. Saltus found his passion: trying to get members of the healthcare community to come together empathically. “I’m a far better executive coach than I ever was a heart surgeon,” says Dr. Saltus, “because I’m open to the world and what the world will offer itself up to me.”
Dr. Saltus describes his coaching work as “more transformational than oriented toward performance.” Rather than change behavior, he says, his job when working with a client is to find out who that client is; then “behavior will automatically change.” In the healthcare arena, Dr. Saltus works with departments and other groups to develop an empathetic cooperative culture, using the “outward mindset” model promulgated by the Arbinger Institute as well as his osteopathic empathetic philosophical core. Arbinger (www.arbinger.com) “provides 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.”
“In an inward mindset,” continues Dr. Saltus, “my 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.” 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.
“Behavior yields results,” says Dr. Saltus, “but mindset drives behavior. So empathetic behavior is really an outward mindset. I’m more interested in supporting another person’s success, understanding another’s perspective without judgment.” Dr. Saltus recalls his “heart surgeon” outlook: “‘I can understand everyone’s perspective, but they are wrong.’ The inward mindset focuses on the self, so as a surgeon, I asked, ‘How can everyone help me obtain my objectives and meet my challenges?’
“We call ourselves a team,” says Dr. Saltus of healthcare professionals, “but we’re all doing our individual objective tasks, thinking ‘I am all alone.’ How do you empathically create a collaborative culture, where each individual is focused on the success of others?” Take, for example, discharge instructions, which Dr. Saltus describes as “down to a science in clinical pathways.” If patients fail to comply with the instructions, “we say, ‘Why didn’t you follow them?’ instead of the team asking itself, ‘What are we missing?’ 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’s success.”
Dr. Saltus was far from uncaring as a heart surgeon.
“I did a good job of sitting with my patients, for 45 minutes or an hour. I’d ask them if they’d like to see their imaging films; I would go through complications, mortality and morbidity; I’d review what we had to watch out for after surgery—I 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.” But in the operating room, on the floors, in surgical intensive care, “I feared failure,” says Dr. Saltus. “I 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. … 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.”
It’s estimated that over 400,000 deaths occur annually as a result of preventable hospital errors. Dr. Saltus asks, “Just think about what would happen to sentinel events”— unexpected occurrences involving death or serious physical or psychological injury—“if the system offered a reward for helping the other members of the team be successful? Creating an empathetic collaborative culture is the answer.”
Dr. Saltus says that Arbinger “gave me the language that helps me describe empathy and the osteopathic philosophy—because they are one and the same. Osteopathic philosophy is holistic; we’re taking care of the whole patient. With external forces, we’ve drifted away from our osteopathic empathetic core. I’m inviting people to come back. We need a rebirth of empathy.”*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.