Empathy and Patient Outcomes

  • Mohammadreza Hojat


  • The theoretical link between empathy and positive patient outcomes is based on the following assumptions: When an empathic engagement is formed, then a trusting relationship will develop, the constraints of relationship will diminish, and this will lead to a more accurate diagnosis and greater compliance.

  • In an empathic engagement, the patient perceives the clinician as a helping member of a social support system with all the beneficial health effects of human connection. All of these should theoretically contribute to optimal patient outcomes, including patients’ greater satisfaction with their health care providers, a reduced likelihood of malpractice litigation, and more optimal clinical results.

  • Research findings, showing significant associations between scores of a validated measure of physician’s empathy and tangible patient outcomes in diabetic patients, present strong evidence in support of the link between the health care provider’s empathy and clinical outcomes, independent of patients’ subjective assessments.

  • The psychosocial and biophysioneurological factors involved in interactions between a clinician and the patient are described as the plausible underlying mechanisms that can explain the link between clinician’s empathy and patient outcomes.


Clinical outcomes Patient outcomes Clinician–patient relationships Patient satisfaction Adherence Compliance Malpractice 


  1. Avery, J. K. (1985). Lawyers tell what turns some patients litigious. Medical Malpractice Review, 2, 35–37.Google Scholar
  2. Bacharach, M. H. (1976). Empathy: We know what we mean, but what do we measure? Archives of General Psychiatry, 33, 35–38.CrossRefGoogle Scholar
  3. Barsky, A. J. (1981). Hidden reasons some patients visit doctors. Annals of Internal Medicine, 94, 492–498.CrossRefPubMedGoogle Scholar
  4. Beckman, H. B., & Frankel, R. M. (1984). The effect of physician behavior on the collection of data. Annals of Internal Medicine, 101, 692–696.CrossRefPubMedGoogle Scholar
  5. Beckman, H. B., Markakis, K. M., Suchman, A. L., & Frankel, R. M. (1994). The doctor-patient relationship and malpractice: Lessons from plaintiff depositions. Archives of Internal Medicine, 154, 1365–1370.CrossRefPubMedGoogle Scholar
  6. Bennett, J. A. (1995). “Methodological notes on empathy”: Further considerations. Advances in Nursing Science, 18, 36–50.CrossRefPubMedGoogle Scholar
  7. Bertakis, K. D., Roter, D., & Putman, S. M. (1991). The relationship of physician medical interview style to patient satisfaction. Journal of Family Practice, 32, 175–181.PubMedGoogle Scholar
  8. Blackwell, B. (1973). Drug therapy, patient compliance. New England Journal of Medicine, 289, 249–252.CrossRefPubMedGoogle Scholar
  9. Bohart, A. C., Elliot, R., Greenberg, L. S., & Watson, J. C. (2002). Empathy. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp. 89–108). Oxford: Oxford University Press.Google Scholar
  10. Bowers, M. R., Swan, J. E., & Koehler, W. F. (1994). What attributes determine quality and satisfaction with health care delivery? Health Care Management Review, 19, 49–55.CrossRefPubMedGoogle Scholar
  11. Burns, D. D., & Nolen-Hoeksema, S. (1992). Therapeutic empathy and recovery from depression in cognitive-behavioral therapy: A structural equation model. Journal of Consulting and Clinical Psychology, 60, 441–449.CrossRefPubMedGoogle Scholar
  12. Butow, P. N., Maclean, M., Dunn, S. M., Tattersall, M. H. N., & Boyer, M. J. (1997). The dynamics of change: Cancer patients’ preferences for information, involvement and support. Annals of Oncology, 8, 857–863.CrossRefPubMedGoogle Scholar
  13. Carmel, S., & Glick, S. M. (1996). Compassionate-empathic physicians: Personality traits and social-organizational factors that enhance or inhibit this behavior pattern. Social Science and Medicine, 43, 1253–1261.CrossRefPubMedGoogle Scholar
  14. Clearly, P. D., & McNeil, B. J. (1988). Patient satisfaction as an indicator of quality care. Inquiry, 25, 25–36.Google Scholar
  15. Cohen, J. (1987). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Erlbaum.Google Scholar
  16. Colliver, J. A., Willis, M. S., Robbs, R. S., Cohen, D. S., & Swartz, M. H. (1998). Assessment of empathy in a standardized-patient examination. Teaching and Learning in Medicine, 10, 8–10.CrossRefGoogle Scholar
  17. Comstock, L. M., Hooper, E. M., Goodwin, J. M., & Goodwin, J. S. (1982). Physician behaviors that correlate with patient satisfaction. Journal of Medical Education, 57, 105–112.PubMedGoogle Scholar
  18. Davis, M. S. (1968). Physiological, psychological and demographic factors in patient compliance with doctor’s orders. Medical Care, 6, 115–122.CrossRefGoogle Scholar
  19. Del Canale, S., Louis, D. Z., Maio, V., Wang, X., Rossi, G., Hojat, M., & Gonnella, J. S. (2012). The relationship between physician empathy and disease complications: An empirical study of primary care physicians and their diabetic patients in Parma, Italy. Academic Medicine, 87, 1243–1249. doi: 10.1097/ACM.0b013e3182628fbf.Google Scholar
  20. Di Blasi, Z., Harkness, E., Ernst, E., Georgiou, A., & Kleijnen, J. (2001). Influence of context effect on health outcomes: A systematic review. Lancet, 357, 757–762.CrossRefPubMedGoogle Scholar
  21. DiMatteo, M. R., Hays, R. D., & Prince, L. M. (1986). Relationship of physicians’ nonverbal communication skills to patient satisfaction, appointment noncompliance, and physician workload. Health Psychology, 5, 581–594.CrossRefPubMedGoogle Scholar
  22. DiMatteo, M. R., Prince, I. M., & Taranta, A. (1979). Patients’ perceptions of physicians’ behavior: Determinants of patient commitment to the therapeutic relationship. Journal of Community Health, 4, 280–290.CrossRefPubMedGoogle Scholar
  23. DiMatteo, M. R., Sherbourne, C. D., Hays, R. D., Ordway, L., Kravitz, R. L., McGlynn, E. A., … Rogers, W. H. (1993). Physicians’ characteristics influence patients’ adherence to medical treatment: Results from the Medical Outcomes Study. Health Psychology, 12, 93–102.Google Scholar
  24. DiMatteo, M. R., Taranta, A., Friedman, H. S., & Prince, L. M. (1980). Predicting patient satisfaction from physicians’ nonverbal communication skills. Medical Care, 17, 376–387.CrossRefGoogle Scholar
  25. Dubnicki, C. (1977). Relationship among therapist empathy and authoritarianism. Journal of Counseling and Clinical Psychology, 45, 958–959.CrossRefGoogle Scholar
  26. Eisenthal, S. E., Emery, R., Lazare, A., & Udin, H. (1979). Adherence and negotiated approach in patienthood. Archives of General Psychiatry, 36, 393–398.CrossRefPubMedGoogle Scholar
  27. Entman, S. S., Glass, C. A., Hickson, G. B., Githens, P. B., Whetten-Goldstein, K., & Sloan, F. A. (1994). The relationship between malpractice claims history and subsequent obstetric care. Journal of the American Medical Association, 272, 1588–1591.CrossRefPubMedGoogle Scholar
  28. Falvo, D., & Tippy, P. (1988). Communicating information to patients. Patient satisfaction and adherence as associated with resident skill. Journal of Family Medicine, 26, 643–647.Google Scholar
  29. Francis, V., & Morris, M. (1969). Gaps in doctor-patient communication: Patients’ response to medical advice. The New England Journal of Medicine, 280, 535–540.CrossRefPubMedGoogle Scholar
  30. Free, N. K., Green, B. L., Grace, M. C., Chernus, L. A., & Whitman, R. M. (1985). Empathy and outcome in brief focal dynamic therapy. American Journal of Psychiatry, 142, 917–921.CrossRefPubMedGoogle Scholar
  31. Freemon, B., Negrete, V. F., Davis, M., & Korsch, B. M. (1971). Gaps in doctor-patient communication: Doctor-patient interaction analysis. Pediatric Research, 5, 298–311.CrossRefGoogle Scholar
  32. Gallese, V. (2001). The ‘shared manifold’ hypothesis: From mirror neurons to empathy. Journal of Conscious Studies, 8, 33–50.Google Scholar
  33. Gladstein, G. A. (1977). Empathy and counseling outcome: An empirical and conceptual review. The Counseling Psychologist, 6, 70–79.CrossRefGoogle Scholar
  34. Goodchild, C. E., Skinner, T. C., & Parkin, T. (2005). The value of empathy in dietetic consultation: A pilot study to investigate its effect on satisfaction, autonomy and agreement. Journal of Human Nutrition and Diet, 18, 181–185.CrossRefGoogle Scholar
  35. Greenberg, L. S., Watson, J. C., Elliot, R., & Bohart, A. C. (2001). Empathy. Psychotherapy, 38, 380–384.CrossRefGoogle Scholar
  36. Hall, J. A., & Dornan, M. C. (1988). Meta-analysis of satisfaction with medical care: Description of research domain and analysis of overall satisfaction level. Social Science & Medicine, 27, 637–644.CrossRefGoogle Scholar
  37. Hall, J. A., Roter, D. L., & Katz, N. R. (1988). Meta-analysis of correlates of provider behavior in medical encounters. Medical Care, 26, 657–675.CrossRefPubMedGoogle Scholar
  38. Heinrichs, M., & Domes, G. (2008). Neuropeptides and social behavior: Effects of oxytocin and vasopressin in humans. Progress in Brain Research, 170, 337–350.CrossRefPubMedGoogle Scholar
  39. Hickson, G. B., Clayton, E. W., Entman, S. S., Miller, C. S., Githens, P. B., Whetten-Goldstein, K., & Sloan, F. A. (1994). Obstetricians’ prior malpractice experience and patients’ satisfaction with care. Journal of the American Medical Association, 272, 1583–1587.Google Scholar
  40. Hickson, G. B., Clayton, E. W., Githens, P. B., & Sloan, F. A. (1992). Factors that prompted families to file medical malpractice claims following perinatal injuries. Journal of the American Medical Association, 267, 1359–1363.CrossRefPubMedGoogle Scholar
  41. Hojat, M., Louis, D. Z., Maio, V., & Gonnella, J. S. (2013). Empathy and health care quality [Editorial]. American Journal of Medical Quality, 28, 6–7. doi: 10.1177/1062860612464731.CrossRefPubMedGoogle Scholar
  42. Hojat, M., Louis, D. Z., Markham, F. W., Wender, R., Rabinowitz, C., & Gonnella, J. S. (2011). Physicians’ empathy and clinical outcomes in diabetic patients. Academic Medicine, 86, 359–364. doi: 10.1097/ACM.0b013e3182086fe1.CrossRefPubMedGoogle Scholar
  43. Hojat, M., Louis, D. Z., Maxwell, K., Markham, F., Wender, R., & Gonnella, J. S. (2011). A brief instrument to measure patient’s overall satisfaction with primary care physicians. Family Medicine, 43, 412–417.PubMedGoogle Scholar
  44. Hojat, M., & Xu, G. (2004). A visitor’s guide to effect sizes: Statistical versus practical (clinical) importance of research findings. Advances in Health Sciences Education, 9, 241–249.CrossRefPubMedGoogle Scholar
  45. Kaplan, R. M., & Simon, H. J. (1990). Compliance in medical care: Reconsideration of self-predictions. Annals of Behavioral Medicine, 12, 66–71.CrossRefGoogle Scholar
  46. Kelman, H. C. (1958). Compliance, identification, and internalization: Three processes of attitude change. Conflict Resolution, 2, 51–60.CrossRefGoogle Scholar
  47. Kendall, P. C., & Wilcox, C. E. (1980). Cognitive behavioral treatment for impulsivity: Concrete versus conceptual training in non-self-controlled problem children. Journal of Counseling and Clinical Psychology, 48, 80–91.CrossRefGoogle Scholar
  48. Kenny, D. T. (1995). Determinants of patient satisfaction with the medical consultation. Psychology and Health, 10, 427–437.CrossRefGoogle Scholar
  49. Kim, S. S., Kaplowitz, S., & Johnston, M. V. (2004). The effects of physician empathy on patient satisfaction and compliance. Evaluation and the Health Professions, 27, 237–251.CrossRefPubMedGoogle Scholar
  50. Korsch, B. M., Gozzi, E. K., & Francis, V. (1968a). Gaps in doctor-patient interaction and patient satisfaction. Pediatrics, 42, 855–871.PubMedGoogle Scholar
  51. Korsch, B. M., Gozzi, E. K., & Francis, V. (1968b). Gaps in doctor-patient communication: I. Doctor-patient interaction and patient satisfaction. Pediatrics, 42, 855–871.PubMedGoogle Scholar
  52. Kurtz, R. R., & Grummon, D. L. (1972). Different approaches to the measurement of therapist empathy and their relationship to therapy outcomes. Journal of Consulting and Clinical Psychology, 39, 106–115.CrossRefPubMedGoogle Scholar
  53. Levinson, W. (1994). Physician-patient communication: A key to malpractice prevention. Journal of the American Medical Association, 272, 1619–1620.CrossRefPubMedGoogle Scholar
  54. Levinson, W., Roter, D., Mullooly, J. P., Dull, V. T., & Frankel, R. (1997). Physician-patient communication: The relationship with malpractice claims among primary care physicians and surgeons. Journal of the American Medical Association, 277, 553–559.CrossRefPubMedGoogle Scholar
  55. Luborsky, L., Chandler, M., Auerbach, A. H., Cohen, J., & Bacharach, H. M. (1971). Factors influencing the outcome of psychotherapy: A review of quantitative research. Psychological Bulletin, 75, 145–185.CrossRefPubMedGoogle Scholar
  56. Luscher, T. F., & Vetter, W. (1990). Adherence to medication. Journal of Human Hypertension, 4(Suppl. 1), 43–46.PubMedGoogle Scholar
  57. MacPherson, H., Mercer, S. W., Scullion, T., & Thomas, K. J. (2003). Empathy, enablement, and outcome: An exploratory study on acupuncture patient’s perceptions. Journal of Alternative & Complementary Medicine, 9, 869–876.CrossRefGoogle Scholar
  58. Meltzoff, J., & Kornreich, M. (1970). Research in psychotherapy. New York: Atherton.Google Scholar
  59. Mercer, S. W., Maxwell, M., Heaney, D., & Watt, G. C. M. (2004). The consultation and rational empathy (CARE) measure: Development and preliminary validation and reliability of an empathy-based consultation process measure. Family Practice, 21, 699–705. doi: 10.1093/fampra/cmh621.CrossRefPubMedGoogle Scholar
  60. Mercer, S. W., McConnachie, A., Maxwell, M., Heaney, D., & Watt, G. C. (2005). Relevance and practical use of the Consultation and Relational Empathy (CARE) measure in general practice. Family Practice, 22, 328–334.CrossRefPubMedGoogle Scholar
  61. Mercer, S. W., & Reynolds, W. J. (2002). Empathy and quality of care. British Journal of General Practice, 52, S9–S12.PubMedPubMedCentralGoogle Scholar
  62. Meyers, A. R. (1987). Lumping it: The hidden denomination of the medical malpractice crisis. American Journal of Public Health, 77, 1544–1548.CrossRefPubMedPubMedCentralGoogle Scholar
  63. Moore, P. J., Adler, N. E., & Robertson, P. A. (2000). Medical malpractice: The effect of doctor-patient relations on medical patient perceptions and malpractice intentions. Western Journal of Medicine, 173, 244–250.CrossRefPubMedPubMedCentralGoogle Scholar
  64. Moss, H. A. (1967). Sex, age, and state as determinants of mother-infant interaction. Merrill-Palmer Quarterly, 13, 19–36.Google Scholar
  65. Moyers, T. B., & Miller, W. (2013). Is low therapist empathy toxic? Psychology of Addictive Behaviors, 27, 878–884.CrossRefPubMedGoogle Scholar
  66. Neuwirth, Z. E. (1997). Physician empathy—Should we care? Lancet, 350, 606.CrossRefPubMedGoogle Scholar
  67. Nightingale, S. D., Yarnold, P. R., & Greenberg, M. S. (1991). Sympathy, empathy, and physician resource utilization. Journal of General Internal Medicine, 6, 420–423.CrossRefGoogle Scholar
  68. Ong, L. M., DeHaes, J. M., Hoos, A. M., & Lammies, F. B. (1995). Doctor-patient communication: A review of the literature. Social Science & Medicine, 40, 903–918.CrossRefGoogle Scholar
  69. Patterson, C. H. (1984). Empathy, warmth, and genuineness in psychotherapy: A review of reviews. Psychotherapy, 21, 431–438.CrossRefGoogle Scholar
  70. Peabody, F. W. (1984). The care of the patient. Journal of the American Medical Association, 252, 813–818.CrossRefPubMedGoogle Scholar
  71. Preston, S. D., & deWaal, F. B. M. (2002). Empathy: It’s ultimate and proximate bases. Behavioral and Brain Sciences, 25, 1–20.PubMedGoogle Scholar
  72. Rakel, D. P., Hoeft, T. J., Barrett, B. P., Chewning, B. A., Craig, B. M., & Niu, M. (2009). Practitioner empathy and the duration of the common cold. Family Medicine, 41, 494–501.PubMedPubMedCentralGoogle Scholar
  73. Rizzolatti, G., Fadiga, L., Gallese, V., & Fogassi, L. (1996). Premotor cortex and the recognition of motor action. Cognitive Brain Research, 3, 131–141.CrossRefPubMedGoogle Scholar
  74. Rogers, C. R., Gendlin, E., Kiesler, D., & Truax, C. B. (1967). The therapeutic relationship and its impact. Madison: University of Wisconsin Press.Google Scholar
  75. Roghmann, K. J., Hengst, A., & Zastowny, T. R. (1979). Satisfaction with medical care: Its measurement and relation to utilization. Medical Care, 17, 461–479.CrossRefPubMedGoogle Scholar
  76. Roter, D. L., Hall, J. A., Merisca, R., Nordstrom, B., Cretin, D., & Svarstad, B. (1998). Effectiveness of interventions to improve patient compliance: A meta-analysis. Medical Care, 36, 1138–1161.CrossRefPubMedGoogle Scholar
  77. Sackett, D. H., & Haynes, R. B. (1976). Compliance with therapeutic regimens. Baltimore, MD: Johns Hopkins University Press.Google Scholar
  78. Sanson-Fisher, R., & Maguire, P. (1980). Should skills in communication with patients be taught in medical schools? Lancet, 2, 523–526.CrossRefPubMedGoogle Scholar
  79. Shapiro, R. S., Simpson, D. E., & Lawrence, S. L. (1989). Survey of sued and non-sued physicians and suing patients. Annals of Internal Medicine, 149, 2190–2196.CrossRefGoogle Scholar
  80. Speedling, E. J., & Rose, D. N. (1985). Building an effective doctor-patient relationship: From patient satisfaction to patient participation. Social Science & Medicine, 21, 115–120.CrossRefGoogle Scholar
  81. Squier, R. W. (1990). A model of empathic understanding and adherence to treatment regimens in practitioner-patient relationships. Social Science & Medicine, 30, 325–339.CrossRefGoogle Scholar
  82. Staudenmayer, H., & Lefkowitz, M. S. (1981). Physician-patient psychological characteristics influencing medical decision-making. Social Science & Medicine, 15, 77–81.CrossRefGoogle Scholar
  83. Stein, M. D., Fleisman, J., Mor, V., & Dresser, M. (1993). Factors associated with patient satisfaction among HIV-infected persons. Medical Care, 31, 182–188.CrossRefPubMedGoogle Scholar
  84. Stewart, M. A. (1996). Effective physician-patient communication and health outcomes: A review. Canadian Medical Association Journal, 152, 1423–1433.Google Scholar
  85. Stiles, W., Putman, S., Wolfe, M., & James, S. (1979). Interaction exchange structure and patient satisfaction with medical interview. Medical Care, 17, 667–679.CrossRefPubMedGoogle Scholar
  86. Street, R. L., Makoul, G., Arora, N. K., & Epstein, R. M. (2009). How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient Education and Counseling, 74, 295–301.CrossRefPubMedGoogle Scholar
  87. Sultan, S., Attali, C., Gilberg, S., Zenasni, F., & Hartemann, A. (2011). Physicians’ understanding of patients’ personal representations of their diabetes: Accuracy and association with self-care. Psychology and Health, 18, 1–17.Google Scholar
  88. Taragin, M. I., Sonnenberg, F. A., Karns, M. E., Trout, R., Shapiro, S., & Carson, J. L. (1994). Does physician performance explain interspecialty differences in malpractice claim rates? Medical Care, 32, 661–667.CrossRefPubMedGoogle Scholar
  89. Thompson, B. M., Hearn, G. N., & Collins, M. J. (1992). Patient perceptions of health professional interpersonal skills. Australian Psychologist, 27, 91–95.CrossRefGoogle Scholar
  90. Wasserman, R. C., Inui, T. S., Barriatua, R. D., Carter, W. B., & Lippincott, P. (1984). Pediatric clinicians’ support for patients makes a difference: An outcome-based analysis of clinician-parent interaction. Pediatrics, 74, 1047–1053.PubMedGoogle Scholar
  91. Watts, D. (2012). Cure for the common cold. New England Journal of Medicine, 367, 1184–1185.CrossRefPubMedGoogle Scholar
  92. West, C. P., Huschka, M. M., Novotny, P. J., Sloan, J. A., Kolars, J. C., Habermann, T. M., & Shanafelt, T. D. (2006). Association of perceived medical errors with resident distress and empathy. Journal of American Medical Association, 269, 1071–1078.Google Scholar
  93. Wilmer, H. A. (1968). The doctor-patient relationship and issues of pity, sympathy and empathy. British Journal of Medical Psychology, 41, 243–248.CrossRefPubMedGoogle Scholar
  94. Yarnold, P. R., Greenberg, M. S., & Nightingale, S. D. (1991). Comparing resource use of sympathetic and empathetic physicians. Academic Medicine, 66, 709–710.CrossRefPubMedGoogle Scholar
  95. Zachariae, R., Pedersen, C. G., Jensen, A. B., Ehrnrooth, E., Rossen, P. B., & von der Maase, H. (2003). Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease. British Journal of Cancer, 88, 658–665.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Mohammadreza Hojat
    • 1
  1. 1.Sidney Kimmel Medical College Thomas Jefferson UniversityPhiladelphiaUSA

Personalised recommendations