Ten approaches for enhancing empathy in health and human services cultures.

Hojat, Mohammadreza

"A problem that is well understood is a problem that is half solved."

(cited in Hojat, 2007, p. xix).

Empathy is an ambiguous concept with a history that is marked by uncertainty in its conceptualization and measurement. The notion of empathy has been described as "elusive" (Basch, 1983) and "slippery" (Eisenberg & Strayer, 1987). Some suggest that empathy means so much that it really "means nothing" (Pigman, 1995); thus, it has been concluded that empathy "does not mean any thing at all" (Reik, 1948). Because of these anomalies, it has been proposed that the word empathy should be "eliminated" or replaced by a less ambiguous term (Levy, 1997). Because of the aforementioned confusion, empathy has been viewed as a concept that is difficult to define and hard to measure (Kestenbaum, Farber & Srouf, 1989).

I have described elsewhere that "an undefined concept can never be measured, and a well define concept is half measured." (Hojat, 2007, p. 202). Thus, the definition and measurement of a concept are intertwined: One depends on another. Despite a lack of consensus on the definition of empathy, there are many descriptions or characterization of the term in the literature (see for example Chapter 1 in Hojat, 2007). Based on those characterizations of empathy, I proposed the following definition of empathy in the context of patient care:

"Empathy is a predominantly cognitive (rather than emotional) attribute that involves an understanding (rather than feeling) of experiences, concerns and perspectives of the patient, combined with a capacity to communicate this understanding." (Hojat, 2007, p. 80).

The three key terms in this definition are italicized for two reasons: 1. to underscore their importance in the construct of empathy in the context of patient care, and 2. to distinguish between empathy and sympathy. An intention to help and alleviate pain and suffering is another feature of empathy in health and human services cultures. Sympathy, as opposed to empathy, is predominantly an affective or emotional attribute that involves intense feelings of a patient's pain and suffering. Despite the differences in conceptualization, the two notions are not entirely independent (Hojat, Mangione, Nasca, Cohen, Gonnella, et al., 2001).

The two concepts of empathy and sympathy are usually tossed into one terminological basket. The interchangeable use of these concepts may be inconsequential in social psychology, but it is important to separate the two in the context of patient care. The reason for making such a distinction is that the two concepts lead to different and sometimes opposite outcomes in patient care. In the context of social psychology, both empathy and sympathy can lead to a similar outcome (e.g., prosocial behavior), although for different behavioral motivations. For example, empathically induced prosocial behavior is more likely to be elicited by a sense of altruism, and sympathetically induced prosocial behavior is more likely to be triggered by egoistic motivation (Hojat, 2007).

It is also important to notice that in the context of patient care, empathy, as defined above, almost always leads to positive clinical outcomes, while sympathy in excess will be detrimental to objectivity in clinical decision making (for more detail discussion, see Hojat, 2007). Nightingale, Yarnold, and Greenberg (1991) have shown that empathic physicians, compare to their sympathetic counterparts, ordered fewer laboratory tests (cost containment by avoiding unnecessary tests), had less preference for patient intubation (needless attempt to inflict pain), and performed cardiopulmonary resuscitation for a shorter period of time before declaring their efforts unsuccessful (helpless effort to resuscitate). Based on these findings, one can assume that empathy, as opposed to sympathy, can lead to lower cost of medical care and saving more resources. In this article empathy is treated entirely differently from sympathy.

It has been reported that empathic interpersonal engagement in the clinical environment leads to greater patient satisfaction (Beckman, & Frankel, 1984; Bertakis, Roter, & Putman, 1991; Francis & Morris, 1969; Zachariae, Pedersen, Jensen, Ehrnrooth, Rossen, et al., 2003), better compliance (DiMatteo, Sherbourne, Hays, Ordway, Kravitz, et al., 1993; DiMatteo, Hays, & Prince, 1986; Eisenthal, Emery, Lazare, & Uden, 1979; Roter, Hall, Merisca, Nordstrom, Cretin, et al., 1998; Squire, 1990), and lower rates of malpractice litigation (Avery, 1985; Beckman, Markakis, Suchman, & Frankel, 1994; Hickson, Clayton, Githens, & Sloan, 1992; Hickson, Clayton, Entman, Miller, Githens, et al., 1994; Levinson, Roter, Mullooly, Dull, & Frankel, 1997; Shapiro, Simpson, & Lawrence, 1989; Moore, Adler, & Robertson, 2000; Steward, Brown, Boom, Galajda, Meredith, et al., 1999).

It has also been reported that higher cognitive empathy was associated with more positive well-being among therapists (Linley & Joseph, 2007) and among internal medicine residents (Shanafelt, West, Zhao, Novotny, Kolars, et al., 2005). In contrast, lower empathy was associated with professional burnout in medical students (Thomas, Dyrbye, Huntington, Lawson, Novotny, et al., 2007). Also, lower empathy among medical residents was associated with self-perceived medical errors (West, Huschka, Novotny, Sloan, Kolars, et al., 2008). Patients at Mayo Clinic identified empathy as one of the important ingredients in the ideal physician (Bendapudi, Berry, Frey, & Parish, 2006). Because of the effect of empathy on patient outcomes and physician well-being, enhancement of empathic understanding is considered one of the major tasks of medical education (Marcus, 1999).

In addition to the controversies surrounding the conceptualization of empathy, measurement of the concept in the context of health care has also been questioned. A few instruments have been developed for measuring empathy in the general population (for a description of these instruments see, Chapter 5 in Hojat, 2007). Based on the contents of these instruments, it is difficult to confirm their face validity for use with health care professionals. Moreover, it is not clear if these instruments intend to measure empathy, or sympathy, or both. None of these instruments is specific enough to capture the essence of empathy in the context of patient care.

A few years ago, our research team at Jefferson Medical College recognized the need for an instrument to measure empathy in the context of patient care. In response to this need, we developed the Jefferson Scale of Physician Empathy (JSPE), which specifically targeted medical students, physicians, and other health professionals (for a brief history of the JSPE's development and its measurement properties, see Chapter 7 in Hojat, 2007). Extensive data in support of the psychometrics (validity, reliability) of the JSPE have been reported for samples of physicians (Hojat, Gonnella, Mangione, Nasca, Veloski, et al., 2002a, Hojat, Gonnella, Nasca, Mangoine, Veloski, et al., 2002b; Hojat, Gonnella, Nasca, Mangione, Vergare, et al., 2002c), medical students (Hojat, Mangoine, Nasca, Cohen, Gonnella, et al., 2002; Hojat, Mangoine, Nasca, & Gonnella, 2005) nursing students (Ward, Schaal, Sullivan, Bowen, Erdmann, et al., in press), and nurses (Fields, Hojat, Gonnella, Mangione, Kane, et al., 2004; Hojat, Fields, & Gonnella, 2003). The JSPE has already been translated into 25 languages and is being used by researchers in the United States and abroad (for more information about the JSPE, visit the following website: www.tju.edu/jmc/crmehc/medu/jspe.cfm).

Changes are occurring in the health care system in the United States and abroad that have rippling effects on the education of health professionals, the delivery of health care services, administration roles in academic medical centers, and managerial function in health care institutions and assisted-living organizations. Therefore, it is important and timely to pay serious attention to promoting and improving empathy in the health care environment, and in all sectors of human services.

SELECTED APPROACHES TO ENHANCE EMPATHY IN THE CLINICAL ENVIRONMENT

Empathy is amenable to positive (Stepien & Baersntein, 2006), and negative changes (Hojat, Mangione, Nasca, Rattner, Erdmann, et al., 2004; Mangione, Kane, Caruso, Gonnella, Nasca, et al., 2002), and can be taught (Spiro, 1992). A number of approaches to enhance empathy have been developed by social and developmental psychologists, counselors, and nursing and medical educators (for a review see, Hojat, 2007). In the following section, I briefly described 10 approaches that are more specific to health professions education, practice, and management. Consistent with our definition of empathy, the common goal of all of these approaches is to enhance the understanding of health care professionals and administrators about patients' concerns and experiences. In addition, improving skills to convey this understanding to the patient is another goal of most of these approaches.

Improving Interpersonal Skills:

Interpersonal skills development is considered as an essential prerequisite to demonstrate empathic behavior (Book, 1991). Researchers in the health professions have attempted to enhance empathy by offering educational programs to improve students' interpersonal skills that implicitly imply enhancement of the capacity for empathy (Evans, Stanley, & Burrows, & Sweet, 1993; Kramer, Ber, & Moore, 1989; Poole, & Sanson-Fisher, 1980).

Suchman, Markakis, Beckman and Frankel (1997) developed an interpersonal model of empathic communication in the medical interview. Emphasis in this method is placed on the development of three basic communication skills namely, "recognition" of patient's negative emotions, concerns, and inner experiences; "exploration" of these emotions, concerns, and experiences; and "acknowledging" them to generate a feeling in the patient of being understood. These three skills correspond, respectively, to the keywords of "cognition," "understanding," and "communicating" in the definition of empathy in the context of patient care.

The goal of this training is to form an empathic engagement in the care-giver-care-receiver relationship by the care-giver recognizing an "empathic opportunity" when the care-receiver directly or implicitly expresses emotions or concerns. The care-giver responds empathetically by explicitly expressing understanding of the care-receiver's concerns, and communicating to the care-receiver that his or her concerns are understood.

In responding to the empathic opportunity, many untrained physicians may disregard the patient's concerns thus missing or terminating an opportunity rather than taking advantage of it. The training focuses on capturing the empathic opportunities that provide the caregiver with "windows of opportunities" (Branch & Malik, 1993), and avoiding pitfalls in missing or terminating them. A caregiver can form and maintain the empathic communication dynamics by continuing the conversation about the patient's concerns (so called continuer). This can be done by simply nodding the head to reflect understanding and using simple statements such as: "I understand your concern; let's work on it together." In addition to verbal cues, sensitivity to nonverbal cues is an important skill in establishing an empathic clinician-patient relationship. Nonverbal communication in clinical settings can be taught by understanding nonverbal expressions of affect. Such nonverbal expressions include: changes in tone of voice, eye contact, gaze and aversion of gaze, silence, laughter, teary eyes, facial expressions, hand and body movements, trembling, touch, physical distance, leaning forward or backward, sighs, or other signs of distress or uncomfortableness. These are important nonverbal cues in clinical encounters (Mehrabian, 1972; Wolfgang, 1979).

Psychological effects of nonverbal cues such as folded arms (more likely to indicate defensiveness, coldness, rejection, or inaccessibility) or moderately open arms (more likely to convey acceptance and warmth) can also be taught in interpersonal skills training programs (DiMatteo, 1979). Also, teaching clinicians to try to mirror patients' postures, gestures, respiration rates, tempo and pitch of speech, and language pattern can contribute to forming an empathic engagement (Matthews, Suchman, & Branch, 1993).

Winefield and Chur-Hansen (2000) reported that 81% of medical students who participated in two brief sessions on effective communication with patients felt more prepared to engage in empathic interviews. Yedidia and colleagues (2003) reported that practicing communication skills and engaging medical students in self-reflection on their performances improved students' overall communication competence as well as their skills in building relationships in patient care.

A 5-day communication skills workshop offered to medical students and medical residents in Spain significantly increased scores of participants' empathy (measured by the JSPE) compared to a non-participant control group (Fernandez-Olano, Montoya-Fernandez, & Salinas-Sanches, 2008).

In a randomized clinical trial conducted at the Johns Hopkins University School of Hygiene and Public Health, 69 physicians were assigned to one of three groups: two experimental groups and one control group (Roter, Hall, Kern, Baker, Cole, et al., 1995). Physicians in the experimental groups received eight hours of training designed to increase their communication skills and reduce their patients' emotional distress. The patients in one group were actual patients and those in the other group were simulated patients. During the training, the physicians asked patients about their concerns and expectations, reassured them, and acknowledged their psychosocial struggles. The results showed that the empathic skills of the physicians who participated in either training course improved significantly without increasing the time spent with individual patients.

Audio- or Video-Taping of Encounters with Patients:

A review and analysis of audio- or video-taping of patient encounters with physicians, nurses, hospital and office administrators to identify positive and negative interviewing factors is a valuable learning experience for enhancing empathic engagement.

Using the interpersonal empathic communication method (Suchman, et al., 1997) described above, Pollak, Arnold, Jeffrey, Alexander, Olsen, and their colleagues (2007), audio-recorded 398 interviews between advanced cancer patients and their oncologists. They found that oncologists responded with empathy to patients concerns only 27% of the time. Physicians either missed or prematurely terminated the conversation about patients' concerns 73% of the time. In a similar study, Morse, Edwardsen, and Gordon (2008) reported that only 10% of physicians responded to empathic opportunities in their communication with lung cancer patients.

Sanson-Fisher and Poole (1978) of the University of Western Australia Medical School, exposed 112 medical students to eight audio-taped empathy training sessions, and compared them with 23 students without such exposure. The empathy scores of the first group improved significantly compared to the latter group.

Audio-taped conversations between patients and physicians can help identify the empathic opportunities and physicians' positive responses, as well as demonstrate missed opportunities, or cases in which the concern-related part of the conversation was terminated. This can have valuable educational benefits for enhancing empathy.

By analyzing videotapes of interviews of 87 first-year medical students with simulated patients at Michigan State University School of Medicine, Werner and Schneider (1974) showed improvement in medical students' empathy. After each tape-recorded interview, the students joined in a group and their faculty instructors to discuss and analyze different sections of the interview. The videotape could be paused, forwarded, and rewound during the analysis. Werner and Schneider (1974) used an affective sensitivity measure and concluded that analysis of the videotape replay made students increasingly aware of their behavior in communicating with patients, and improved students' ability to empathize with patients. They also concluded that the videotape had its greatest impact on students who had the least developed skills for communication.

Exposure to Role Models:

Some investigators have suggested that faculty in undergraduate and graduate medical education can serve as role models or mentors to improve students' capacity for empathy (Campus-Outcalt, Senf, Watkins, & Bastacky, 1995; Ficklin, Browne, Powell, & Carter, 1988; Skeff & Mutha, 1998; Wright, 1996). Shapiro (2002) interviewed primary care physicians to find out how empathy can be enhanced in medical students and residents. Role modeling was endorsed by almost all research participants as the most effective approach to teach empathy. Quill (1987) reported that the practice behavior of the ambulatory preceptors, viewed as role models, exerted a broad influence on the residents. A study of medical students in South Africa (Mclean, 2004) found that as the students progressed through medical school, they selected more faculty members as role models.

Despite the fact that exposure to role models is an important factor in the enhancement of empathy, the results of a mailed survey of medical students at four different medical schools in Canada (Maheux, Beaudoin, Berkson, Des Marchais, & Jean, 2000) raised a question about students' exposure to appropriate role models: 25 percent of the second-year students and 40 percent of the seniors said they did not agree that their medical school faculty behaved as humanistic physicians and teachers.

Role Playing (Aging Games):

About 30 years ago, Hoffman and Reif (1978) described a role playing game to simulate problems perceived by elderly people. McVey, Davis, and Cohen (1989) adapted the technique and developed the "aging game" to increase the understanding of medical students about elderly people's sensory deficits and functional dependency.

The game generally consists of three stages. In the first stage, students are instructed to imagine that they are old (e.g., 70 to 99 years old) and use earplugs to simulate hearing loss.

The second stage begins with simulation that represents independent living in one area, then proceeds to semi-dependent living in another area, and finally to the third area that simulates dependent living where they are confined to wheelchairs and stretches. In each area they are confronted with facilitators who played the role of administrators, physicians, or nurses. As they progress through different game levels, the behaviors of the facilitators become more disrespectful.

Stage 3 is a group discussion of the participants' experiences during the previous stages of the game. Results of the original aging game experiment with 112 medical students at Duke University Medical School showed the medical students gained an increased understanding and sensitivity to the physical and psychosocial problems of the elderly (McVey, et al., 1989).

It is suggested that role playing results in the development of awareness and increased understanding of elderly patients (Hoffman, Brand, Beatty, & Hamill, 1985; Menks, 1983). Because understanding is the key ingredient in the definition of empathy, it is expected that improvement in understanding leads to enhancement of empathy. Such a link has been reported by Holtzman and colleagues (Holtzman, Beck, & Coggin, 1978; Holtzman, Beck, & Ettinger, 1981) among medical and dental students and nurses (Marte, 1988).

Pacala, Boult, Bland, and O'Brien (1995) presented a three-hour workshop of a modified version of the aging game to 39 medical students in an ambulatory medicine rotation at the University of Minnesota Medical School. They were then compared with 16 non-participating students. Students were asked to assume the identity of elderly persons and used earplugs to simulate hearing loss, heavy athletic stockings to simulate pedal edema, and unpopped popcorn seeds in their shoes to simulate the discomfort of arthritis pain. Students were labeled uncooperative by facilitators if they expressed their dissatisfaction with care. Protesters were restrained, and obedient students were ignored. Scores of a 2-item empathy scale (developed by the study authors) increased significantly among participants after completing the workshop.

Varkey, Chutka, and Lesnick (2006) used a variation of the aging game (e.g., students wore heavy rubber gloves to simulate decreased manual dexterity and goggles with films over the lenses to simulate cataract) with all 84 medical students in 2 first-year classes. They reported statistically significant increase in empathy. After ten years offering the aging game workshop at the University of Minnesota Medical School, Pacala, Boult, and Hepburn (2006) concluded that despite the burden of required personnel and resources to run the aging game workshops, students benefited greatly from their role playing experiences by developing a long lasting awareness and understanding of key issues in elderly patients and geriatric medicine.

In a study with students at Purdue University School of Pharmacy (Chen, LaPopa, & Dang, 2008), students were assigned to simulate the life of an underserved patient with multiple chronic medical conditions who had an economic burden (e.g., homeless), cultural differences (e.g., Hispanic), and communication barrier (illiterate or hearing-impaired). Participation in this experiment increased students' empathy scores. An examination of remarks by students showed that they grew to become more sensitive to patients' conditions they simulated and developed an understanding of the challenges faced by the patients after "walking in a patient's shoes" (Chen, LaPopa, & Dang, 2008).

Shadowing a Patient (Patient Navigator):

The patient navigation program was originally developed at the Harlem Cancer Education and Demonstration Project to help medically underserved cancer patients (Freeman, Muth, & Kerner, 1995). It has been reported that a trained patient navigator, who shadows the patients and offering help contributed to increased satisfaction and decreased anxiety among patients (Ferrante, Chen & Kim, 2007).

Using the patient navigator paradigm, researchers at the University of Arkansas for Medical Sciences, conducted a project in which first-year medical students "shadowed" a patient (with the patient's permission) during visits to a surgical oncologist and observed the patient throughout treatment (Henry-Tillman, Deloney, Savidge, Graham, & Klimberg, 2002). Participants reported that they learned to see patients as people, not as numbers or diseases. Seventy percent of the students said they experienced feeling of empathy while participating in the program.

Hospitalization Experiences:

Sharing common experiences can influence empathic understanding of the patient. The tendency of health professionals to empathize with those whom they share common experiences has been described as the "wounded healer effect." (Jackson, 2001). Clinicians who have experienced pain have a better understanding of their patients' pain (Gustafson, 1986). Therefore, painful hospitalization experiences can increase one's understanding of the hospitalized patient.

At the University of California-Los Angeles Medical School, healthy second-year medical students who had completed their training in the basic sciences and had no previous history of hospitalization participated in a program designed to examine whether the experience of being hospitalized would increase empathy for hospitalized patients (Wilkes, Milgrom, & Hoffman, 2002). The students were admitted to the hospital under an assumed name. They reported that the pseudo-hospitalization experience was useful because it enhanced students' understanding of patients' problems. Interestingly, the students acting as "new patients" gave the nursing staff more favorable patient encounter ratings than they gave to physicians! (Wilkes et al., 2002). Because of the effect of hospitalization on a physician's understanding of patients, Ingelfinger (1980) suggested that actual hospitalization experiences can be used as a criterion for admission to medical schools!

On their first day in the Emergency Medicine Department at the University of Florida Health Sciences Center, 25 residents participated in a study in which they were instructed to register as patients (the admission staff and nurses were not aware of the experiment) (Seaberg, Godwin, & Perry, 1999, 2000). Although the study was brief and ended when the emergency room physician entered the examination room, the results suggested that the experience enhanced residents' empathy, as indicated by their reports that the experiment improved their attitude toward patients in the emergency room.

The Study of Literature and the Arts:

Some researchers have proposed that reading literature, stories, novels, poetry; watching movies, plays, photographs, paintings, sculptures; and listening to music and songs expose medical students, physicians, and health professionals to a rich source of knowledge and insights about human emotions, pain and suffering, and perspectives of other human beings which improves the capacity for forming empathic connections (Acuna, 2000; Charon, Trautman Bank, Connelly, Hunsaker Hawkins, et al., 1995; Herman, 2000; Jones, 1987; McLellan & Husdon Jones, 1996; Kumagai, 2008; Montgomery Hunter, Charon, & Coulehan, 1995; Peschel, 1980; Szalita, 1976) (for an annotated bibliography see Montgomery Hunter, Charon, & Coulehan, 1995).

The emotions manifested in novels, short stories, poems, plays, films, painting, sculptures, and music enable students, practitioners, and administrators in the health professions to learn how feelings are expressed (Oatley, 2004). Thus, the study of literature and the arts provides students, practitioners, and administrators in the health care and human services with values and experiences in areas of concern such as aging, death, disability, and dying (Montgomery Hunter et al., 1995). The study of literature and the arts can also aid the development of otherwise abstract clinical competencies, such as accurate interpretation, imagination, ethical issues, and moral reflection (Montgomery Hunter et al., 1995) that are difficult to teach by means of conventional teaching methods.

Some authors have suggested that health professionals can gain new insights into the moral and ethical issues posed by their profession through the lens of literature, poetry and the arts (Calman, Downie, Duthie, & Sweeney, 1988; Charon et al., 1995; Coles, 1989; Flagler, 1997; Marshall & O'Keefe, 1994; Radley, 1992). The thoughts, feelings, sensations, and intuitions influenced by immersing oneself in literature can serve as a powerful impetus toward understanding the human mind (Schneiderman, 2002), and discovery of others that can lead to the development of self (Kumagai, 2008).

Literature can enrich students' moral education, increase their tolerance for uncertainty, and give them a rich grounding for empathic understanding of patients.

Lancaster, Hart, and Gardiner (2002) offered a one-month course in which medical students read stories, such as Tolstoy's The Death of Ivan Ilych. When the course ended, the students assigned their highest rating to the enhancement of empathy as a result of their participation in the course. Shapiro, Morrison, and Boker (2004) noticed a significant improvement in first-year medical students' empathy and attitudes toward humanities after participating in a short course in reading and discussion of poetry, skits, and short stories. Despite the importance of the humanities and arts in enhancing empathy, many medical schools have not incorporated these subjects in their curriculum. It is reported that only a third of all the medical schools in the United States had incorporated literature into their curriculum as of the mid-1990s (Charon et al., 1995; Jones, 1997; Montgomery Hunter et al., 1995). The development of professionalism in medicine, according to Wear and Nixon (2002), requires an imaginative immersion into others' stories that can be attained by studying literature and the arts.

Improving Narrative Skills:

Narrative defined as "someone telling someone else that something happened" (Smith, 1981, p. 228) is the royal road to the patient's world. It is physicians' attentive listening to their patients' narratives of illness rather than "clinical interrogation" (Klienman, 1995) that opens a window of opportunity to empathic engagement. Narrative, according to Wear and Nixon (2002) is a medium which seduces others into the world it portrays. In clinician-patient encounters, listening to the patient's stories of illness with a third ear and viewing their concerns in the mind's eye is a narrative skill that not only has diagnostic value but has therapeutic benefit as well (Adler, 1997). The narrative account of the patient's illness is the beginning of the healing process as well as a pathway to a correct diagnosis (Adler & Mammett, 1973). Patients often carefully monitor the clinician's attentiveness to their illness narrative, detect the signs of the clinician's empathic receptiveness, and feel better when the clinician appears to be in tune with the narrative themes (Brody, 1997).

Because the feelings and experiences of others are captured in their narratives, patients' narratives can convey how they view their illness (Bruner, 1990). According to Steiner (2005), clinical stories can be used to inform, share, inspire, educate, and persuade. Such narrative communication has implications not only for forming empathic engagement, but also for health research (to find a common theme) and health policy (to formulate compassionate policies). Evidence suggests that participating in programs on reflective writing can improve clinicians' empathic understanding (DasGupta & Charon, 2004; Lancaster et al., 2002). Understanding of patients will improve by adopting their perspectives through their stories, and by narrative skills to reflect the nature of patients' concerns and experiences. According to Kumagai (2008), narratives of illness provide an insight into subjective experience of others, which fosters perspective taking ability, and identification with patients.

According to DasGupta and Charon (2004), the ability to elicit, interpret, and translate the patients' narrative accounts of their illness is the key to empathic communication. Reflective writing and narrative competence offer opportunities for empathic and nourishing medical care (Charon, 2001). In a study involving 11 second-year medical students, nine of them reported that reflective writing (e.g., writing about a personal illness or about another person's illness) could enhance their understanding of patients and improve their ability to care for patients (DasGupta & Charon, 2004).

Theatrical Performances:

Dramatic performances by real or simulated patients, or by professional actors portraying patients have been used to enhance empathy among medical students and practitioners in the health professions. For example, Shapiro and Hunt (2003) presented medical students at the University of California-Irvine College of Medicine with performances by two patients. One patient chronicled his experiences with AIDS through narrative and song. The other patient, a survivor of ovarian cancer, described her experiences on hearing the diagnosis, undergoing treatment, and coping with the psychological effects of the ordeal and the spiritual journey on which she embarked while dealing with the illness. After the theatrical presentations, the students reported that watching the theatrical performances increased their empathic understanding of patients with AIDS or ovarian cancer.

The performing arts also have been used to increase medical students' understanding of patients' grief (Stokes, 1980) and of death and dying (Holleman, 2000).

Dramatic and tragic theatrical performances can generate insights in the observer that arise from climactic intellectual, emotional, or spiritual enlightenment (Golden, 1992). Empathy can arise from the cathartic effects of other peoples' tragedies.

Balint Method:

The Balint training program was developed by Michael Balint at the Tavistock Institute in London for general practitioners. It is based on the notion that medical trainees often spend their entire training in the laboratory and the hospital ward, without sufficient opportunity to develop skills in interpersonal aspects of patient care (Balint, 1957). The program provides opportunities to enhance understanding of patients' experiences and concerns.

Activities in the original Balint method included one to two hours unstructured, open, and supportive small group meetings every one to three weeks, for one to three years. The primary focus in these meetings was on behavioral, cognitive, and emotional issues related to communication between patients, physicians, and other personnel. The discussions (often coordinated by a psychoanalyst or psychologist) focused on the patient as a person rather than his or her disease as a case, and on difficulties experienced in patient-resident encounters. In addition to patient-physician communication, participants were also encouraged to discuss issues related to interprofessional collaboration and hospital administration.

The Balint method, and particularly shorter variations of it have been receiving attention in some residency programs in the United States, particularly in family medicine (Brock & Salinsky, 1993; Cataldo, Peeden, Greesey, & Dickerson, 2005). In a study of family medicine residents in the United States, no significant difference on the scores of the JSPE was observed between those who participated in a Balint training program and those who did not (Cataldo, et al., 2005).

The major premise of all of the aforementioned approaches is the improvement of understanding which is the key ingredient in the definition of empathy. Therefore, at a conceptual level, it makes sense to assume that all of these approaches can lead to the cultivation of empathy. However, in their review of the literature on effects of educating for empathy in medicine, Stepien and Baernstein (2006) concluded that most studies that attempted to provide empirical evidence in support of improving empathy, suffer from methodological limitations, uncertainty about conceptualization and measurement of empathy, and small non-representative samples. More convincing empirical evidence is needed to confirm the short- and long-term effects of these programs on medical education and practice, as well as on the administration of the health care centers, and on health insurance company's policies. This sets the agenda for future research.

CONCLUSION

Empathy has been considered as far too important to be taught only to health professionals (Ivey, 1971; 1974). Others have suggested that the capacity for empathy in people in general can serve as a foundation for building interpersonal relationships that have a buffering effect against stress and can be an essential step in conflict resolution (Kremer & Dietzen, 1991). As the author has noted "empathy can be viewed as a remedy for the psyche and soul of human kind...And may be it can serve as a means of achieving a global peace here, there, everywhere on earth." (Hojat, 2007, p. 214).

To enhance empathic understanding in health and human services, we need not only a broad reform in the health and human services education at undergraduate and graduate levels, but also in training the hospital staff, staff of the assisted-living environment, as well as health services administrators and executives. Clinical and organizational managers in health care institutions and human services organizations should develop well-designed and effective institutional-wide programs to retain, cultivate, and enhance a culture of empathic understanding based on approaches described in this article and other innovative approaches.

According to Hafferty (1998), there is a "hidden curriculum" in training of health professionals that must be uncovered. There seems to be a hidden culture of commercialism and financial preferences in health care education, practice, administration, and management of the health care system that must be replaced by a new culture of caring and professionalism. This cultural revolution in health care education, practice, and administration is not certainly a trivial task. Such profound changes should be considered as a mandate, not an option, if the public is to be served in the best possible manner. Most of us in medical education advocate empathy, but the effect of simply advocating empathy in health care and human services professions without using it, spreading it, or living with it (www.EmpathySymbol.com), or without implementing targeted programs to enhance it, would be analogous to singing a lovely song, but only in one's mind without others ever enjoying it!

ACKNOWLEDGMENTS:

I would like to thank Dorissa Bolinski for her editorial assistance.

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MOHAMMADREZA HOJAT

Thomas Jefferson University