Patients of empathetic doctors are more satisfied, less anxious, better able to understand and cope with their illness, and more likely to have good outcomes, a systematic review of primary care studies has found.¹

Seven studies from the UK, US and the Netherlands, published between 1995 and 2011, met the inclusion criteria. Empathy was assessed either by questionnaires or analysis of video consultations. Patient outcomes were measured by questionnaires, laboratory tests and consultation analysis using audio and video tapes.

One study, by Hojat and colleagues from the US, found a high degree of correlation between patient satisfaction scores and perception of physician empathy, measured using a five item rating scale. Another US study observed that patients of doctors who showed more interest in psychological and social aspects of their condition were offered more information about their psychosocial issues and were more satisfied with their care. A third study, from the Netherlands, found that patients who perceived their GP to have been more empathetic reported lower levels of anxiety.

A pilot study in Scotland, by Mercer and colleagues in 2008, suggested an association between patients’ perceptions of GP empathy and enablement i.e. the extent to which they felt empowered to cope with, understand and manage their illness. The full scale study, published in 2012, has confirmed this association: full enablement never occurred when GP empathy was low, whereas 63% of full enablement consultations occurred when GP empathy was high.²

Hojat and colleagues asked 29 family doctors to complete the Jefferson Scale of Physician Empathy (a 20 item questionnaire). Their scores were categorised as high (top third), medium (middle third) and low (bottom third). They found that diabetes patients of doctors with high empathy scores were significantly more likely to have good diabetic control (HbAlc < 7.0%) than patients of doctors with low empathy scores (56% and 40% respectively, P < 0.001).³

A further US study found that patients who gave their doctor an empathy score of 50/50 recovered one day sooner from viral upper respiratory tract infections than those who did not consider their doctors to be perfect! There was also objective evidence of more rapid recovery (change in interleukin-8 and neutrophil levels).

The paucity of studies is likely to reflect the difficulty of conducting research on empathy, not its importance. Problems include lack of an agreed definition or research measure and lack of agreement between patients, healthcare professionals and observers when asked to rate empathy within a consultation; only the patients’ ratings correlate with outcomes.³

Uncertainty regarding the direction of causation,⁴ confounding variables,³ and publication bias towards studies with positive findings may also be factors.

Empathy is not easy to define: it involves an understanding of the patient’s experiences, feelings and perspective, an ability to identify with their emotional experience and the communication of that understanding.⁵

Empathy may improve outcomes in several ways:

• There may be a direct therapeutic benefit from feeling understood and valued

• Patients may be more likely to adhere to their treatment and attend follow-up appointments

• The placebo effect of the treatment may be enhanced

The Quality and Outcomes Framework for 2013/14 has replaced the current requirement to complete an assessment of severity at the time of depression diagnosis with the requirement to carry out a biopsychosocial assessment which considers the family context, social and occupational issues.6 If approached

in a positive way, this has the potential to enhance therapeutic empathy through a deeper shared understanding of the origins of the patient’s problems. However, it may have the opposite effect due to a conflict between the doctor’s need to tick the boxes and the patient’s need to feel understood.