Teaching Empathy in Healthcare: from Mirror Neurons to Education Technology

While modern medicine is moving towards genetically based personalized treatment, we still marvel daily at the healing power of the therapeutic relationships with patients. We are now closer to understanding where in the brain lies our capacity to view the world from the perspective of other people. Empathy is the ability to identify another person’s feelings and experiences and to view the world from their perspective. In healthcare provider–patient interaction, empathy improves interpersonal communication, fosters therapeutic alliance, correlates with patient and provider satisfaction, and improves patient care outcomes. Although the importance of empathy in healthcare is widely accepted, further work is due in clarifying the dimensions of empathy that are amenable to teaching and defining the role of healthcare providers’ and patients’ perception of empathy in treatment outcomes. Herein we will (1) provide a brief overview of neurobiology of empathy, (2) discuss the dimensions and conceptualizations of empathy as they apply to healthcare professions, and (3) discuss the body of literature on empathy teaching interventions, including technology options, with focus on virtual patient technology for medical, nursing, and allied health professions education.

[1]  M. Hojat,et al.  Patient perceptions of physician empathy, satisfaction with physician, interpersonal trust, and compliance , 2010, International Journal of Medical Education.

[2]  N. Haslam Humanising medical practice: the role of empathy , 2007, The Medical journal of Australia.

[3]  Jennifer S. Mascaro,et al.  Compassion meditation enhances empathic accuracy and related neural activity. , 2013, Social cognitive and affective neuroscience.

[4]  Rodrigo Basilio,et al.  Voluntary Enhancement of Neural Signatures of Affiliative Emotion Using fMRI Neurofeedback , 2014, PloS one.

[5]  L. Lancia,et al.  Empathy in health professional students: A comparative cross-sectional study. , 2016, Nurse education today.

[6]  J. Pineda,et al.  Neurofeedback training produces normalization in behavioural and electrophysiological measures of high-functioning autism , 2014, Philosophical Transactions of the Royal Society B: Biological Sciences.

[7]  M. Hojat,et al.  The empathy enigma: an empirical study of decline in empathy among undergraduate nursing students. , 2012, Journal of professional nursing : official journal of the American Association of Colleges of Nursing.

[8]  M. Hojat,et al.  Physicians' Empathy and Clinical Outcomes for Diabetic Patients , 2011, Academic medicine : journal of the Association of American Medical Colleges.

[9]  T. Stickley,et al.  Empathy and nurse education. , 2010, Nurse education today.

[10]  James J. Gross,et al.  Hiding feelings: The acute effects of inhibiting negative and positive emotion. , 1997 .

[11]  Debra Nestel,et al.  Teaching communication skills using the integrated procedural performance instrument (IPPI): a randomized controlled trial. , 2009, American journal of surgery.

[12]  R. Lew,et al.  A Cross-sectional Measurement of Medical Student Empathy , 2007, Journal of General Internal Medicine.

[13]  Benjamin Lok,et al.  Using Virtual Patients to Teach Empathy: A Randomized Controlled Study to Enhance Medical Students’ Empathic Communication , 2016, Simulation in healthcare : journal of the Society for Simulation in Healthcare.

[14]  Steven J Durning,et al.  The Role for Virtual Patients in the Future of Medical Education. , 2016, Academic medicine : journal of the Association of American Medical Colleges.

[15]  H. Riess Biomarkers in the Psychotherapeutic Relationship: The Role of Physiology, Neurobiology, and Biological Correlates of E.M.P.A.T.H.Y. , 2011, Harvard review of psychiatry.

[16]  Bruce N Cuthbert,et al.  The RDoC framework: continuing commentary , 2014, World psychiatry : official journal of the World Psychiatric Association.

[17]  Laura Meyer-Junco Empathy and the new practitioner. , 2015, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[18]  M. Iacoboni Imitation, empathy, and mirror neurons. , 2009, Annual review of psychology.

[19]  Jennifer H. Pfeifer,et al.  Understanding emotions in others: mirror neuron dysfunction in children with autism spectrum disorders , 2006, Nature Neuroscience.

[20]  A. Bayliss,et al.  Measurement of Empathy Changes During a Physical Therapist's Education and Beyond , 2015 .

[21]  J. Barsuk,et al.  Does Simulation-Based Medical Education With Deliberate Practice Yield Better Results Than Traditional Clinical Education? A Meta-Analytic Comparative Review of the Evidence , 2011, Academic medicine : journal of the Association of American Medical Colleges.

[22]  T. Habermann,et al.  Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. , 2006, JAMA.

[23]  R. Charon Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust , 2001 .

[24]  G. Watt,et al.  General Practitioners’ Empathy and Health Outcomes: A Prospective Observational Study of Consultations in Areas of High and Low Deprivation , 2016, The Annals of Family Medicine.

[25]  A. Battistelli,et al.  Empathy in the emotional interactions with patients. Is it positive for nurses too , 2013 .

[26]  J. Kelley,et al.  Empathy Training for Resident Physicians: A Randomized Controlled Trial of a Neuroscience-Informed Curriculum , 2012, Journal of General Internal Medicine.

[27]  U. Vollmer-Conna,et al.  Empathy as a Function of Clinical Exposure - Reading Emotion in the Eyes , 2013, PloS one.

[28]  Kyle Johnsen,et al.  Evaluating a Script -Based Approach for Simulating Patient -Doctor Interaction , 2005 .

[29]  Peter Gallagher,et al.  Teaching empathy to undergraduate medical students: Translation to practice , 2016 .

[30]  M. Hojat Ten approaches for enhancing empathy in health and human services cultures. , 2009, Journal of health and human services administration.

[31]  M. Hojat,et al.  Medical Students' Self-Reported Empathy and Simulated Patients' Assessments of Student Empathy: An Analysis by Gender and Ethnicity , 2011, Academic medicine : journal of the Association of American Medical Colleges.

[32]  L. Mckenna,et al.  Levels of empathy in undergraduate emergency health, nursing, and midwifery students: a longitudinal study , 2014, Advances in medical education and practice.

[33]  Joann S. Olson,et al.  Clarification of conceptualizations of empathy. , 2001, Journal of advanced nursing.

[34]  P. Ekman,et al.  Facial signs of emotional experience. , 1980 .

[35]  Sylvia M Määttä,et al.  Closeness and distance in the nurse-patient relation. The relevance of Edith Stein's concept of empathy. , 2006, Nursing philosophy : an international journal for healthcare professionals.

[36]  Benjamin Lok,et al.  Understanding empathy training with virtual patients , 2015, Comput. Hum. Behav..

[37]  G. Rizzolatti The mirror neuron system and its function in humans , 2005, Anatomy and Embryology.

[38]  L. Deloney,et al.  The medical student as patient navigator as an approach to teaching empathy. , 2002, American journal of surgery.

[39]  Richard J Lilford,et al.  University of Birmingham A Systematic Review of Empathy Test in Medicine , 2022 .

[40]  Thomas J Nasca,et al.  Physician empathy: definition, components, measurement, and relationship to gender and specialty. , 2002, The American journal of psychiatry.

[41]  David Heaney,et al.  The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process measure. , 2004, Family practice.

[42]  Brent Rossen,et al.  Human-Centered Distributed Conversational Modeling: Efficient Modeling of Robust Virtual Human Conversations , 2009, IVA.

[43]  J. Pinto-Gouveia,et al.  Relationships between nurses' empathy, self-compassion and dimensions of professional quality of life: A cross-sectional study. , 2016, International journal of nursing studies.

[44]  M. Hojat,et al.  Empathic and Sympathetic Orientations Toward Patient Care: Conceptualization, Measurement, and Psychometrics , 2011, Academic medicine : journal of the Association of American Medical Colleges.

[45]  Sylvia D. Kreibig,et al.  Autonomic nervous system activity in emotion: A review , 2010, Biological Psychology.

[46]  Heidi Chumley,et al.  Eliciting the patient's perspective: does experience or type of case make a difference? , 2011, Patient education and counseling.

[47]  H. Critchley,et al.  A common role of insula in feelings, empathy and uncertainty , 2009, Trends in Cognitive Sciences.

[48]  L. Shulman,et al.  Educating Nurses: A Call for Radical Transformation , 2009 .

[49]  Kerrie E. Doyle,et al.  Reviewing Tribunal cases and nurse behaviour: putting empathy back into nurse education with Bloom's taxonomy. , 2014, Nurse education today.

[50]  Z. Neuwirth Physician empathy—should we care? , 1997, The Lancet.

[51]  Amy O. Stevens,et al.  Do medical students respond empathetically to a virtual patient? , 2007, American journal of surgery.

[52]  C. Marci,et al.  Physiologic Correlates of Perceived Therapist Empathy and Social-Emotional Process During Psychotherapy , 2007, The Journal of nervous and mental disease.

[53]  N. Hadjikhani,et al.  Anatomical differences in the mirror neuron system and social cognition network in autism. , 2006, Cerebral cortex.

[54]  R. Pedersen Empathy development in medical education – A critical review , 2010, Medical teacher.

[55]  B. Williams,et al.  Empathetic attitudes of undergraduate paramedic and nursing students towards four medical conditions: a three-year longitudinal study. , 2015, Nurse education today.

[56]  K. Martyn,et al.  Patient-Centered Participatory Research in Three Health Clinics , 2016, Western journal of nursing research.

[57]  Michael J. Vergare,et al.  The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School , 2009, Academic medicine : journal of the Association of American Medical Colleges.

[58]  Benjamin Lok,et al.  Utilizing Real-time Human-Assisted Virtual Humans to Increase Real-world Interaction Empathy , 2014 .

[59]  D. Nestel,et al.  Empathy levels among health professional students: a cross-sectional study at two universities in Australia , 2014, Advances in medical education and practice.

[60]  Amy Baernstein,et al.  Educating for empathy , 2006, Journal of General Internal Medicine.

[61]  R. Saper,et al.  Embodied health: the effects of a mind–body course for medical students , 2013, Medical education online.

[62]  Benjamin Lok,et al.  Exploring the Effects of Healthcare Students Creating Virtual Patients for Empathy Training , 2015, IVA.

[63]  D. Jeffrey A meta-ethnography of interview-based qualitative research studies on medical students’ views and experiences of empathy , 2016, Medical teacher.

[64]  M. Goldstein,et al.  Impact of communication training on physician expression of empathy in patient encounters. , 2009, Patient education and counseling.

[65]  Mark H. Davis Measuring individual differences in empathy: Evidence for a multidimensional approach. , 1983 .

[66]  Maria Luisa Gorno-Tempini,et al.  Structural anatomy of empathy in neurodegenerative disease. , 2006, Brain : a journal of neurology.

[67]  E. Herdman Nursing in a postemotional society. , 2004, Nursing philosophy : an international journal for healthcare professionals.

[68]  Benjamin C. Lok,et al.  The Use of Simulation to Teach Suicide Risk Assessment to Health Profession Trainees—Rationale, Methodology, and a Proof of Concept Demonstration with a Virtual Patient , 2015, Academic Psychiatry.

[69]  James F. Steed,et al.  The effect of surgeon empathy and emotional intelligence on patient satisfaction , 2011, Advances in health sciences education : theory and practice.

[70]  C. Mailloux Using The Essentials of Baccalaureate Education for Professional Nursing Practice (2008) as a framework for curriculum revision. , 2011, Journal of professional nursing : official journal of the American Association of Colleges of Nursing.

[71]  M. Stewart Effective physician-patient communication and health outcomes: a review. , 1995, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[72]  D. Cook,et al.  Virtual patients: a critical literature review and proposed next steps , 2009, Medical education.

[73]  M. A. Wagaman,et al.  The Role of Empathy in Burnout, Compassion Satisfaction, and Secondary Traumatic Stress among Social Workers. , 2015, Social work.

[74]  C. Lamm,et al.  Reduction of Empathy for Pain by Placebo Analgesia Suggests Functional Equivalence of Empathy and First-Hand Emotion Experience , 2015, The Journal of Neuroscience.

[75]  Benjamin Lok,et al.  Building Virtual Humans with Back Stories: Training Interpersonal Communication Skills in Medical Students , 2014, IVA.

[76]  Friedrich Edelhäuser,et al.  Empathy Decline and Its Reasons: A Systematic Review of Studies With Medical Students and Residents , 2011, Academic medicine : journal of the Association of American Medical Colleges.

[77]  Arne D. Ekstrom,et al.  Single-Neuron Responses in Humans during Execution and Observation of Actions , 2010, Current Biology.

[78]  J. Quaintance,et al.  Development of a Communication Curriculum for Emergency Medicine Residents , 2009, Teaching and learning in medicine.

[79]  J. Frijns,et al.  Concern for Others: A Study on Empathy in Toddlers with Moderate Hearing Loss. , 2017, Journal of deaf studies and deaf education.

[80]  Betty Chewning,et al.  Perception of empathy in the therapeutic encounter: effects on the common cold. , 2011, Patient education and counseling.

[81]  S. Baron-Cohen,et al.  The "Reading the Mind in the Eyes" Test revised version: a study with normal adults, and adults with Asperger syndrome or high-functioning autism. , 2001, Journal of child psychology and psychiatry, and allied disciplines.

[82]  Gregory Makoul,et al.  Empathic communication and gender in the physician-patient encounter. , 2002, Patient education and counseling.

[83]  Matthew A. Davis,et al.  A perspective on cultivating clinical empathy. , 2009, Complementary therapies in clinical practice.

[84]  A. Mills,et al.  Generational influences in academic emergency medicine: teaching and learning, mentoring, and technology (part I). , 2011, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[85]  C. Brazeau,et al.  Relationships Between Medical Student Burnout, Empathy, and Professionalism Climate , 2010, Academic medicine : journal of the Association of American Medical Colleges.

[86]  A. DiGioia,et al.  Patient and Family Shadowing: Creating Urgency for Change , 2011, The Journal of nursing administration.

[87]  Tania Singer,et al.  Empathy and compassion , 2014, Current Biology.

[88]  E. Friedrich,et al.  Brain–computer interface game applications for combined neurofeedback and biofeedback treatment for children on the autism spectrum , 2014, Front. Neuroeng..