This study explored physicians’ perceptions of what promoted and inhibited their empathy development, and what was influential in the course of their training and medical education. The respondents to our survey mentioned various factors related to the medical curriculum, including some of its subjects, regular contact with patients, interactions with other physicians, their own reflection and active self-development, and workplace organization and structure. We have summarized these main themes with specific examples in Figure 1.
From these results, we reach two hypothetical conclusions:
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The “complex, multi-dimensional concept” of empathy [1] is influenced by the similarly complex and broad range of factors described, and some of these factors are interrelated.
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A number of factors can be a starting point for the promotion of clinical empathy.
In the following subsections, we further elaborate on these conclusions.
Physician empathy in medical education and practice
A lack of empathy education in the formal curriculum
Medical education should aim to develop clinical empathy and professionalism [1, 3–6, 23, 24, 26–28]. However, our results show that this might not be happening, at least not explicitly. A substantial number of our respondents, 14 of 42, described a lack of positive influences, and one summarized it this way: “empathy was not included in medical education” (male, pediatrics).
Some physicians did mention positive aspects of the formal medical curriculum. Yet these were mainly located “on the fringe” of the curriculum, addressed as ways to teach communication between physician and patient and including a discussion of psycho-social issues. Examples are communication and attentiveness training, medical ethics, complementary and alternative medicine, and training in psychology/psychiatry/psychotherapy. Of the core medical subjects, general practice and palliative care were mentioned as positive influences on the development of empathy. The respondents did not mention other disciplines—e.g., internal medicine, surgery, or pediatrics—as either positive or negative, although we had asked them to consider any aspect of their medical education.
Qualitative research with medical students on factors influencing their empathy also found that some “fringe subjects” provided a positive influence—e.g., “classes on empathy and ethics” ([36], personal communication from the author), the behavioral sciences and medical humanities [37], and other subjects [35]. Quantitative studies confirm the positive role of training in communication skills [10, 32, 51] and show that a positive attitude towards psycho-social aspects of care are associated with more empathetic behavior [52]. These findings leave the impression that medical education does not currently pay enough attention to the development of clinical empathy or to subjects that promote it in the formal curriculum. This view is supported by the fact that medical students tend to perceive psycho-social aspects of care as less important than the main, formally graded subjects [39].
Although we explicitly asked respondents to think about the content of their formally endorsed medical curricula, the majority of their statements were about aspects of the working and learning environment and organizational culture [53], and about extracurricular activity. Physicians responded in a similar way to another question in our questionnaire, “What barriers to behaving in an empathetic manner do you experience in your daily professional life?” They referred to the workplace and organizational environment, patient characteristics—e.g., “difficult patients”— and their own personal attitudes as barriers to showing empathy to patients [38]. This might indicate that empathy is influenced far more by these latter aspects than by the formal curriculum, as has been argued elsewhere [6, 29]. Also, the fact that respondents had taken the initiative to pursue reflective practice and self-development and saw those activities as positive influences seems to indicate that these contribute to the development of empathy but are lacking in current curricula.
The influence of role models, practice-based training, and patient contact
A prominent aspect of the learning environment is the influence of role models [2, 6] who provide both positive and negative influences on the development of empathy (see Table 2). In the perception of medical students, the role modeling of empathy provided by physicians was a central influence [29, 33–37], and it has been discussed as one factor influencing the development of empathy [29]. Students viewed faculty who were empathetic towards them as influential in the students’ own development of empathy [2, 35]. Teachers in primary care share this view [19], which is mirrored by our respondents’ comments that teamwork and constructive professional exchange promoted empathy development and hierarchical structures inhibited it.
Another factor that touches on aspects of the “informal” and the “hidden curriculum” [53] is contact with patients, together with practice-based training. While most of our respondents described both of these as helpful for the development of empathy, and students have done so in some studies [35, 36], other investigations have reported a both positive and negative role of practice experience [33, 38] or even a predominantly detrimental effect: Two of this article’s authors and other colleagues showed in the review mentioned earlier that self-assessed empathy dropped statistically significantly after students began the clinical phase of training—i.e., after contact with patients had started or intensified [29]. They suggested that the decline in empathy might be an internal reaction against overwhelming exposure to sickness, suffering, and death on the one hand and growing responsibilities on the other. Burks and Kobus have described a similar mechanism [2]. One possible explanation of the different perceptions of the impact of clinical practice is that our respondents have learned how to acquire and maintain empathy, while students have not yet done so. Most of our respondents were middle-aged (see Table 1), so this could well be the case. Another explanation is that factors other than patient contact itself cause a decline in empathy during clinical practice training—for example, the lack of opportunities for reflection on clinical experiences, or interaction with patients under stressful circumstances and time pressure.
Physicians’ stress, well-being, and focus of attention
Stress has been identified as a significant factor in the decline in empathy during medical school and residency [29]. Neurobiology shows that the neuronal basis for empathy, mirror neurons, stop working in the presence of stress, fear, and tension [5].
On the one hand, in our study, some respondents mentioned factors that might cause such stress. For example, regarding working conditions, which respondents perceived rather negatively, the most prominent ones cited were lack of time and time pressure. These perceptions are in line with the students’, who also experienced time constraints as inhibiting empathy [33–37]. In addition, another study suggested that time pressure is a prominent barrier to physician empathy and that organizational changes could reduce this effect [11]. Other possible causes of stress mentioned in the present investigation were pressure to perform, rivalry, exhaustion, night duty, overwork, and over-fatigue. Taking social conditions among physicians into account, such as teamwork vs. hierarchy as mentioned above, our results are in line with medico-sociological findings. These show that stress and well-being in the workplace arise from organizational, psychological, and social factors [54]. Because stress not only diminishes empathy towards patients but also affects workers’ health [11, 29, 54], it probably has a dual detrimental effect on health care quality.
On the other hand, our respondents perceived extracurricular activities and experiences as positive for their development of empathy, which are in part identical to factors helping physicians to stay well during their professional lives [6, 55–57]. Also, they have been discussed as empathy promoters [2, 6, 58, 59]. These included personal and guided reflection, active self-development, and non-medical experiences. Respondents also mentioned aspects of professional interaction, such as working in an interdisciplinary team and professional mutual support. Physician well-being, in turn, has been associated with greater empathy and professionalism, while stress, distress, depression, and burnout have all been associated with impaired empathy and lower-quality patient care [6, 59–61]. Therefore it is possible that well-being and distress are major determinants of physician empathy—but also that the presence or lack of empathy can be a determinant of physician well-being and stress.
Some aspects of medical practice were mentioned as negative factors in the development of empathy. Physicians stated that the “pure focus on … diagnostics and therapy” (pediatrics, male), “too strict adherence to guidelines” (pediatrics, male), and the reduction of pain and suffering to scientific phenomena were negative influences. In contrast, education fostering a focus on physician-patient interaction and psycho-social aspects of care were described as promoting empathy. Could an exclusive focus on abstract facts rather than on specific patients be one way to lose an empathic connection to them? The evidence from our study alone is weak. However, neurobiological research has shown that “attention processes affect the level of empathy, with distraction reducing it” [62]. And a recent study indicates that physicians can improve empathic interactions with patients by focusing consciously, with curiosity, and with openness on the present encounter [58]. Medical students’ focusing and concentration on one patient was positively correlated with empathy in another study [21]. This could mean that empathy is not only something that just happens but also something that requires concentration and determination.
Limitations and strengths
There are a number of limitations to our study. First, the written, semi-standardized survey did not allow for the interpretation of hidden meanings, which would have required more in-depth data collection and analysis. Interviews would likely have produced more complex and nuanced results because they would have allowed us to explore the relationship between medical education and its impact on physician empathy in greater depth. However, the data produced by interviews would have exceeded the exploratory character of our study. For those reasons, our findings cannot be the basis for theory-building but instead produced hypothetical conclusions [40].
Also, our survey question was based on the assumption that physician empathy is influenced by specific elements during medical training in either a positive or a negative way. This limitation might have excluded other important influences on our respondents’ empathy. Still, many participants expanded in their responses on the factors they believed influenced the development of empathy.
A third limitation is the fact that our sample was generated from the researchers’ network and the respondents represented only four disciplines. On the one hand, this sampling procedure might have generated a generally positive self-selection bias towards clinical empathy and excluded vital experiences of other types of physicians.
On the other hand, it elicited responses from physicians in both in-patient and out-patient institutions, and it achieved a good response rate of 67%, which certainly broadened the scope of our study.
A second advantage was collecting the data anonymously; anonymity encourages respondents to answer questions honestly, rather than in ways that are deemed “socially acceptable” [42].
Third, our study seems to be the first that explicitly asked physicians for their view on the determinants of empathy development during their medical education. In addition, while many studies have treated physician empathy as completely separate from the biomedical side of medicine, or have focused on the influence of the “informal” or “hidden curriculum,” or on negative influences within the formally endorsed medical curricula [30, 53], we included these relations through the openness of our qualitative design.
Finally, our results show parallels with existing research, and our hypothetical conclusions are valuable as an empirical basis for future research and possible implications for practice.
Implications for practice and research
In what ways might our conclusions be incorporated into ideas about medical training in order to improve physician empathy? Certainly the elements of the curriculum that are intended to foster good physician-patient interaction and to include psycho-social aspects of care should be used more extensively. (A complete list of those elements mentioned in our study is included in the coding scheme in the Additional file 1: Appendix.) Also, communication skills training seems to be effective in providing patient-perceived [10, 63] and observer-perceived aspects of empathy [64]. Another important approach could be to include reflective practice lessons and self-development opportunities into the medical curriculum, which some respondents had pursued as extracurricular activities that fostered their empathy.
However, when considering specific interventions to enhance empathy development, it might be wise to include learners’ individual needs in such approaches and base them on experiential learning [1, 2]. For example, the hospitalization of healthy medical students has been found to have a positive effect on their empathy, as has being a patient companion during a hospital stay; both experiences emphasize the importance of patient contact [32]. A “hands-on workshop” in clinical empathy can include reflection and creative elements such as photography and role play as well as theoretical background when required. The workshop concept is based on the assumption that each health care provider develops an individual concept of empathy during the course of their lives so that the application of empathy as an interpersonal skill is the result of each actor’s experiences. The effect of such an intervention on the development of empathy measures, however, is yet to be investigated [65].
Practice-based training is very likely to have an important influence on the development of empathy, too. Special attention could be given to longitudinal care for the chronically ill and the disabled [66, 67], in order to establish better relations with patients that help to develop empathy [19]. For students, practice experiences expose them to potential role models; for physicians, exposure to role models is ensured through collaboration with colleagues in their daily practice. In this context, it would seem valuable to raise physicians’ awareness that they are role models for each other and that they actively shape the organizational culture by the way they interact [68]. Because the circumstances of clinical practice might either promote or hinder the development of empathy, as was explained earlier, it is important to emphasize guidance and supervision in a clinical setting, which can be realized in a number of ways. For example, Balint groups, “meaningful experiences and reflective practice discussions”, and reflective writing sessions have been reported to help physicians deal with their experiences [5, 29, 69].
Such approaches, together with self-awareness training, the especially well-researched mindfulness-based stress reduction, and coaching/mentoring on a personal level could also be promoted to reduce stress and its detrimental effect on physician empathy [2, 5, 6, 29, 58, 67, 70]. For stress reduction, and from an organizational-structural point of view, special attention should be given to involvement in decision-making processes and the individual physician’s control over his or her practice [54]. Organizational culture and the social environment also influence stress levels. Leaders, especially, are in a position to create teamwork and mutual appreciation and support. However, “everyone in an organization … can foster a healthy organizational culture by thoughtful attention to communication, relationships, self-awareness, and the … significance of policies and behaviors” [54, 68].
There is still a need for more empirical research to define the ways in which empathy can be promoted and how we can create a “culture of care” [6]. Both theory-based quantitative investigations and in-depth qualitative methods can be used, and one task for future investigations is to validate or disprove our hypothetical conclusions. However, we would like to repeat the call for more extensive use of qualitative research [31, 33], because the subject is still “under researched” [31], especially from the “point of view of the person[s] concerned” ([71], p. 17).
