‘A potent medicine’: In matters of pain and trust, empathy may make all the difference
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Physician empathy has long been recommended — but not required — in the doctor-patient relationship.
However, for a growing number of rheumatology researchers and providers, a healthy dose of empathy has become not just an essential aspect of one’s bedside manner, but also key to improving outcomes like pain and fatigue, and maximizing the impact of pharmacotherapeutic and non-pharmacotherapeutic interventions alike.
“Empathy is an active process in which we engage with another person’s suffering without judgment or stigma,” Luana Colloca, MD, MPower distinguished professor and director of the Placebo Beyond Opinions Center, at the University of Maryland, in Baltimore, told Healio Rheumatology. “It is a primordial ability of humans, and it is so essential to our life, health and well-being.”
According to Colloca, empathy may impact the interplay between stress, immune system dysfunction and disease processes. Meanwhile, in recent years, researchers have begun to establish connections between empathy, general health and well-being, and material clinical outcomes.
However, these neurobiological relationships are not easily explained, and myriad questions remain.
“The issue now is that the mechanisms of how empathy can improve pain and fatigue are still being debated,” Leonard H. Calabrese, DO, professor of medicine at the Cleveland Clinic Lerner College of Medicine, of Case Western Reserve University, and RJ Fasenmyer chair of clinical immunology at the Cleveland Clinic, said in an interview.
According to Mohammadreza Hojat, PhD, research professor in the department psychiatry and human behavior at Thomas Jefferson University, in Philadelphia, these mechanisms may be explained by psychosocial factors and people’s neuro-biological responses to those factors, specifically — in this case — the connections they make with their physicians and health care providers.
“Mechanisms involved in connecting clinical empathy and clinical outcomes can be described by psychosocial factors and neurobiological responses that are usually evoked when interpersonal attunement is formed,” Hojat, who is also director of the Jefferson Longitudinal Study of Medical Education, at the Asano-Gonnella Center for Research in Medical Education and Health Care, told Healio Rheumatology. “The interpersonal attunement lays the foundation for a trusting relationship between the clinician and the patient, which is the key mechanism that leads to positive patient outcomes.”
This type of trusting relationship can tear down barriers to communication and allow patients to tell the story of their condition honestly and openly, without concealment, according to Hojat.
“This will lead to achieving a more accurate diagnosis and greater compliance, thus helping improve overall wellness,” he said.
Many patients with rheumatic diseases require more than just improved wellness. They hope to end, or at least mitigate, their chronic pain. Additionally, as important and effective as empathy may be, most patients with chronic pain resulting from a rheumatic condition require medication. That said, understanding how empathy can improve the efficacy outcomes of those medicines could signal a new phase of treatment in the rheumatology space.
“It is not possible to separate the action of pharmacotherapeutics from the actions of the body and the brain,” Colloca said.
Meanwhile, the wider rheumatology community has taken notice of these connections.
“EULAR has come out with official guidelines for use of integrative medicine, a series of points to consider and policy positions regarding management of chronic pain and fatigue,” said Calabrese, who is also the chief medical editor for Healio Rheumatology. “But there are still unmet needs in the specialty in this regard. Nonpharmacologic interventions like empathy are still under-used and under-appreciated. We need to increase recognition of their effectiveness and share this information with our colleagues.”
‘An Essential Element’ of Competence
In a 2023 paper published in Discover Health Systems, Hojat and colleagues reported on the Jefferson Clinical Empathy Project, which led to the development of the Jefferson Scale of Empathy (JSE). They described the tool as “the most frequently used instrument for measuring clinical empathy in health profession students and health care practitioners.”
A critical component of the score pertains to “relationship building” between patient and practitioner, according to the paper. However, the study also features potentially broader implications for this tool and its use in clinical practice.
Specifically, the findings suggest that empathy “must be placed in the realm of evidence-based medicine,” and “considered an essential element” of professional competence, according to the researchers. This includes its consideration in admission decisions to medical schools and postgraduate training programs, and use in professional development for all health professionals, whether in training or currently in practice.
“Our conceptualization of clinical empathy implies that empathic engagement in patient care revolves around communication, reciprocity, and mutual understanding, all of which pave the road to interpersonal attunement and ultimately to positive patient outcomes,” Hojat said.
Like Colloca, Karen McKerihan, MSN, NP-C, director of infusion services at Articularis Healthcare, based in South Carolina, and president of the Rheumatology Nurses Society, stressed that empathy takes effort.
“In my 37 years of nursing, I have learned that attentive, intentional, focused listening is the foundation of building trust with patients,” she told Healio Rheumatology. “This type of listening is not just a passive activity. It is really hearing the patient and their support persons, and giving them the opportunity to express themselves, regardless of whether it is about their ailments or their frustrations.”
Physicians who ask clarifying and relevant questions, listen without interruptions and can keep their own biases in check may be more likely to build trusting relationships with patients, according to McKerihan.
“As your patient-provider relationship develops on this initial layer of empathy and trust, it becomes easier to communicate with the patient,” she said.
It is worth noting that every health care provider should be aiming to improve communication and trust in the clinic. However, rheumatologists are most commonly tasked with the more daunting challenge of minimizing chronic pain. Recent findings demonstrate that empathy may have a role in this process, as well.
A Question of ‘Subjective Perception’
In a 2024 study published in JAMA Network Open, John C. Licciardone, DO, and colleagues studied data from 5,943 encounters among 1,470 adults with chronic low back pain, from the national Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation.
The results of their multivariate analysis demonstrated that greater physician empathy carried an inverse association with pain intensity (β = –0.014; P < .001), back-related disability (β = –0.062; P < .001), and health-related quality of life (HRQOL) deficits on each measure.
Additionally, in a comparison of outcomes among patients treated by “slightly” empathic physicians vs. “very” empathic physicians, those in the latter group experienced lower mean pain intensity (difference on the numerical rating scale = 0.4; P < .001), less mean back-related disability (difference = 1.9; P < .001), and fewer HRQOL deficits on each measure.
“This is a really important study,” Calabrese said.
In an interview with Healio Rheumatology, Licciardone, a regents professor of family medicine and at the University of North Texas Health Science Center-Texas College of Osteopathic Medicine, in Fort Worth, discussed why rheumatologists should be aware of these findings.
“In our study, patients with chronic pain who had a very empathic physician reported that pain less often interfered with their activities and enabled them to lead more active lifestyles, including participating in social roles and various activities that were important to them,” he said.
These results may illuminate how to proceed in the clinic, and represent a step in the right direction for health care providers. However, understanding the actual mechanism by which empathy connects with pain remains a whole other question — and one that remains poorly understood.
According to Hojat, the answer lies in the in how empathetic connections and communication can help build trusting relationships, which in turn may trigger “psychological and neurobiological responses” in the patient.
“The plausible explanation is the development of mechanisms of trust in empathic engagement that evokes psychological and neurobiological responses, both leading to positive patient outcomes,” Hojat said. “Of course, it is desirable to examine a physician’s level of clinical empathy, and a patient’s perception of pain and fatigue, which are common features of rheumatologic and autoimmune conditions, given that both pain and fatigue are also a function of a patient’s own subjective perception of psychological/neurophysiological mechanisms.”
Although researchers continue to investigate the neurophysiology of pain, Colloca suggested that there may also be simpler explanations at hand.
“Treating only pain intensity can be misleading,” she said.
For example, two patients may both report an eight out of 10 on a numerical pain scale. However, one may not be able to sleep, exercise or perform regular activities, while the other may still be able to cope and have quite a normal life.
It is possible that the empathy the latter patient receives from her provider and caretakers may play a role in their ability to function, according to Colloca.
“Understanding how this works is the main challenge in pain medicine,” she said.
To complicate things even further, chronic pain is far from the only complaint reported by patients with rheumatic and autoimmune diseases that appears under the sway of empathy in the clinic. In fact, rheumatology patients are commonly beset with a panoply of comorbidities that could also be targets for empathic intervention.
‘Better Outcomes Pertaining to Anxiety, Depression’
In a 2012 paper published in Academic Medicine, Del Canale and colleagues assessed metabolic complications in 20,961 patients with type 1 or type 2 diabetes mellitus, and compared outcomes with 284,298 control individuals. According to the researchers, patients who were treated by physicians with high empathy scores, as assessed by the JSE, experienced acute metabolic complications at a rate of 4 per 1,000 patients, while patients treated by physicians with low or moderate scores on the Jefferson scale demonstrated higher rates of these complications (7.1 and 6.5 per 1,000 patients, respectively; P < .05). This trend persisted through logistic regression analysis.
“These results suggest that physician empathy is significantly associated with clinical outcome for patients with diabetes mellitus and should be considered an important component of clinical competence,” the researchers wrote.
Licciardone drew a direct line between these data and his own study of patients with chronic pain. In addition, far from being limited to impacting just chronic pain, he argued that empathy may also affect a host of symptoms and comorbidities, including depression and fatigue.
“When looking more closely at health-related quality of life, we found that patients with chronic pain who were treated by very empathic physicians also reported better outcomes pertaining to anxiety, depression, fatigue, and sleep disturbance,” Licciardone said.
However, it is not just physicians who can improve outcomes in this way. According to McKerihan, nurses can play a vital role in deploying empathy when caring for a patient’s needs.
“From a training perspective, nurses are taught from a patient-centered model while physician assistants and physicians are taught from a disease-centered model,” McKerihan said. “For example, a patient who is in the hospital for brain surgery needs to have their ambulation, bathroom, skin, cleanliness and pulmonary functions all assessed and addressed, not just the brain.”
Addressing these basic needs often falls to nurses. This is perhaps why data often show that nurses are viewed as more empathetic than doctors.
For example, findings from Otsuka and colleagues published in the Journal of General Internal Medicine in 2024 showed that among health care providers in Japan, physicians scored significantly lower on the JSE than nurses.
However, McKerihan stressed that a result like this may be more a function of logistics than level of empathy.
“Because nurses are the ones who are typically left to answer questions after a provider has left the room, or are the ones to answer questions on the phone, they can be seen as more empathetic,” she said.
Ultimately, all members of the care team are responsible for whatever comorbidities a patient may be experiencing. And although empathy from doctors and nurses alike may improve these outcomes, medication often, at the end of the day, will also play a role. However, examining how these tools available to providers interplay and impact each other may provide some clues regarding empathy’s mechanism of action.
‘A Potent Medicine’
The mechanism by which empathy can augment pharmaceutical interventions is not fully understood, but experts have plenty of opinions on the subject.
“A good amount of research has also been published in which clinical empathy of students in pharmacy schools have been studied,” Hojat said.
In a 2021 paper published in Psychoneuroendocrinology, Barchi-Ferreira and Osorio conducted a systematic review analyzing the association between empathy and patients’ response to oxytocin.
“Taken together, the results of the studies reviewed support the existence of a relationship between oxytocin and empathy that is complex and multifaceted,” the researchers wrote.
However, they noted that “robust evidence is still needed” to fully understand these potential links.
“Based on research findings, I would always remind pharmacy and all other health professions students and practitioners that empathy in patient care is a potent medicine without any adverse effect,” Hojat said.
Further data from the Licciardone paper underscore this point.
“Our research has shown that physician empathy and supportive communication provide additional health benefits that extend beyond those attributable to the other treatments often prescribed for patients with chronic pain,” he said.
For Licciardone, the ability of empathy to improve on pharmacological outcomes is related to the act of listening.
“This may augment the benefits of drug therapy by better assessing patient response to treatment, including consideration of necessary dosage alterations or drug discontinuation owing to early detection of related adverse events,” he said.
An empathic physician can also impact broader quality of life factors, according to Colloca.
“When a person has a feeling of well-being and being understood, they may be more likely to desire to move, exercise or engage in activities that are enjoyable,” she said.
It is additionally critical to understand that although empathy can elicit these positive responses, a lack of empathy can have the opposite effect.
“If you speak to your patient with empathy, the benefits of even medications like NSAIDs can reduce pain intensity from a seven out of 10, to five out of 10,” Colloca said. “But if you speak to the patient with judgment or stigma, you might not see that benefit.”
Some providers may not be aware that their communication with patients contains judgment and stigma. Consideration of both verbal and nonverbal interactions can help improve the level of empathy patients feel in the clinic.
‘Third Ear, Mind’s Eye’
Kraft-Todd and colleagues hypothesized that perceptions of physician competence could correlate with perceptions of physician warmth and empathy. In their study, published in 2017 in PLoS One, they asked participants to rate physicians on nonverbal behaviors to communicate empathy — such as eye contact — and on cues that may signify competence — such as a white coat. Results showed that physicians who demonstrated warmth and empathy also were rated as more competent than those who demonstrated unempathic nonverbal behavior.
“Given the significant consequences of clinician empathy, it is important for clinicians to learn how nonverbal behavior contributes to perceptions of warmth, and use it as another tool to improve their patients’ emotional and physical health,” the researchers wrote.
According to McKerihan, the personalities of the provider and the patient, the care setting, the emotions involved, the roles of participants and the news being delivered all feed into the in-the-moment perceptions of empathy in the clinic.
“A doctor may say the same words that a nurse says but the tone, setting, situation and other factors impact how the patient perceives and understands it,” she said.
Although it is important for caregivers to exhibit nonverbal cues of empathy, it is equally important that they read those nonverbal cues in their patients, McKerihan added.
“Some patients need the ‘warm and fuzzy’ type of empathy, which may include hand holding, direct eye contact or more physical reassurance,” she said. “Others may want clinical information. ‘Show me the data and talk me through the guidelines.’ They still have questions but may not be as emotional.”
According to Hojat, nonverbal clinical communication involves quite a bit of listening.
“It is necessary to hear patients not only with the anatomical ear but also with the ‘third ear,’ to get beyond the spoken words,” he said. “A clinician must also hear what the patient does not say, or hesitates to say, by hearing with the third ear.”
Similarly, clinicians should attempt to see the patient’s “inner world,” Hojat added.
“We can see this not only with anatomical eyes, but also with the mind’s eye,” he said. “Clinicians must see what the patient does not show, or conceals, some of which could be reflected in and inferred from the patient’s nonverbal behavior.”
Understanding these nuances of interpersonal communication does not come naturally to every health care provider. Most experts agree that some type of training is necessary to equip rheumatologists with the tools to provide this level of empathic care.
‘Intentional Process of Healing’
Reiss and colleagues aimed to quantify exactly that type of training in a 2012 paper published in the Journal of General Internal Medicine. The researchers implemented an empathy training protocol in a study that included 99 residents and fellows from a cross-section of health care specialties. Participants were assigned to receive either standard post-graduate medical education or education augmented with three 60-minute empathy training modules. Results were assessed via patients rating participant empathy using the Consultation and Relational Empathy (CARE) measure.
According to the researchers, those in the empathy training group demonstrated greater changes in this metric compared with controls (difference = 2.2; P = 0.04). In addition, those in the empathy training group also demonstrated greater changes in knowledge of the neurobiology of empathy (difference = 1.8; P < 0.001), and in ability to decode facial expressions of emotion (difference = 1.9; P < 0.001).
As subsequent generations of providers become more facile with these tools, the experts who spoke to Healio Rheumatology offered some immediately actionable strategies beyond simply listening to patients.
“Providing clear explanations and answers to questions can help patients take control of their health,” Licciardone said.
Meanwhile, empathy does not always have to come from the provider, according to McKerihan.
“The next step is to have good tools available to give to the patients, including printed materials with answers to common questions, websites they can visit and support groups that meet in the area,” she said.
Hojat warned that an over-reliance on computer and artificial intelligence technology should not replace deep listening and seeing a patient’s inner world.
“We seriously need to place an emphasis on these ingredients of empathic communication in the current curriculum of health professions education for enhancing them,” he said.
For Colloca, it is all about collaboration.
“Empathy involves this intentional process of healing where we become a team and alliance with our patients,” she said.
- References:
- Barchi-Ferreira AM, Osorio FL. Psychoneuroendocrinology. 2021;doi:10.1016/j.psyneuen.2021.105268.
- Del Canale S, et al. Acad Med. 2012;doi:10.1097/ACM.0b013e3182628fbf.
- Hojat M, et al. Discov Health Systems. 2023;doi:10.1007/s44250-023-00020-2.
- Kraft-Todd GT, et al. PLoS One. 2017;doi:10.1371/journal.pone.0177758.
- Licciardone JC, et al. JAMA Network Open. 2024;doi:10.1001/jamanetworkopen.2024.6026.
- Otsuka T, et al. J Gen Intern Med. 2024;doi:10.1007/s11606-024-08620-1.
- Reiss H, et al. J Gen Intern Med. 2012;doi:10.1007/s11606-012-2063-z.
- For more information:
- Leonard H. Calabrese, DO, can be reached at 3500 Euclid Ave., Cleveland OH, 44195; email: calabrl@ccf.org.
- Luana Colloca, MD, can be reached at 655 W Lombard St., 733 21201 Baltimore, MD; email: colloca@umaryland.edu.
- Mohammadreza Hojat, PhD, can be reached at 1015 Walnut St., Curtis Building, 3rd Floor, Suite 320B Philadelphia, PA 19107, USA; email: mohammadreza.hojat@jefferson.edu.
- John C. Licciardone, DO, can be reached at 3500 Camp Bowie Blvd., Fort Worth, TX 76107; email: john.licciardone@unthsc.edu.
- Karen McKerihan, MSN, NP-C, can be reached at 2015 Second Ave., Suite 204, Summerville, SC 29486; email: karen.mckerihan@rns-network.org.
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