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Erosion and Enhancement of Empathy

  • Mohammadreza Hojat
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Abstract

  • Empathy is viewed as an important element of professionalism in medicine; however, a few obstacles to the development and implementation of empathy exist in medical education and practice.

  • Health professions education and the health care system have become very reliant on computer-based diagnostic and therapeutic technology that may limit students’ and practitioners’ vision about the importance of human connection and empathic engagement in patient care.

  • Given the findings that medical students tend to develop a certain cynicism as they progress through their medical education and empathy erodes in medical school and postgraduate medical education, it is timely and important to pay serious attention to enhancing and sustaining empathy in the health professions education and patient care.

  • Enhancing and sustaining empathy in health profession education and practice should be considered a mandate that must be acted upon by leaders and educators in the health professions academic centers and heath care institutions.

  • Research shows that empathy is an attribute that is amenable to change as a result of targeted educational programs and educational experiences.

  • Some approaches used to enhance empathy in the health professionals-in-training and in-practice are described, including improving interpersonal skills, audio- or video-taping of patient encounters, exposure to role models, role playing (e.g., aging game), shadowing a patient (patient navigator), hospitalization experiences, studying literature and the arts, improving narrative skills and reflective writing, theatrical performances, and the Balint method.

  • More empirical research is needed to confirm the effectiveness of programs designed to enhance empathy, to examine the long-term effects of such programs, and to develop strategies to sustain enhancement in empathy for a longer period of time.

Keywords

Enhancement of empathy Professionalism Patient care Cynicism Health care system Amenability to change State versus trait Helping professions Interpersonal skills Audio- or video-taping Role models Aging game Role playing Shadowing a patient Patient navigator Hospitalization experiences Theatrical performance Balint method Narrative skills Reflective writing Studying literature Studying the arts 

Introduction

This chapter begins with a discussion of professionalism in medicine and describes some factors that hamper the development of empathy among students and practitioners in the health professions. I also present results of findings of empirical research that suggest that empathy tends to erode during medical and some other health professions education. Then, I describe some of the approaches that psychologists and researchers in health professions education have used to enhance empathy, including ten specific approaches used in undergraduate and graduate medical education to improve and sustain empathy among physicians-in-training.

Professionalism in Medicine

Professionalism in medicine is defined as an array of personal qualities beyond the requisite medical knowledge and procedural skills that health care professionals must possess to deliver high-quality health care to their patients that leads to positive clinical outcomes (Veloski & Hojat, 2006). Medical educators currently are encouraged to make every effort to foster professionalism in medicine by offering programs at the undergraduate, graduate, and continuing education levels.

Although no consensus exists regarding the number and nature of personal qualities required for professionalism in medicine, compassionate care and empathy have frequently been mentioned as its key components (Arnold, 2002; Barondess, 2003; Linn, DiMatteo, Cope, & Robbins, 1987). In his book Humanism and the Physician , Edmund Pellegrino (1979) described the empathic way of helping patients as an important aspect of the physician’s humanistic attributes. Senior residents at Laval and Calgary Universities in Canada listed empathy, respect, and competence as the three most important elements of professionalism in medicine (Brownell & Cote, 2001).

Cultivating humanistic values, including empathy, is among the important goals of education in the health care professions. The Medical Schools Objectives Project of the Association of American Medical Colleges (2004) includes enrichment of empathy among the educational objectives of medical schools, emphasizing that the schools should strive to produce altruistic physicians who provide compassionate care to patients and demonstrate empathy by conveying their understanding of the patient’s perspective. In a position paper, the American Board of Internal Medicine (1983) recommended that humanistic attributes, including empathy, should be instilled in and assessed among residents as an essential part of their medical training.

Despite the consensus regarding the healing potential of empathic encounters in patient care, insufficient attention has been given to enhancement of the capacity for empathy in the design of medical education curriculum. As a result, the concept of empathy in patient care, according to Novack (1987), seems to be fading away in modern medical education. The current system of medical education does not seem to be seriously concerned about physicians’ losing their healing touch, treating it instead “as if it were a relic of an unscientific past” (Novack, 1987, p. 346).

The lack of attention to empathy in patient care is partially the result of overreliance on computer-based diagnostic and therapeutic technology and partially the result of changes in the health care system with its ripple effect on medical education and practice. In the biotechnologically advanced atmosphere of patient care, what computers spit out seems to receive more attention from some practitioners who trust the machines more than their skills in detecting clinical signs of disease or their patients’ narrative accounts of illness.

Although the pathophysiology of disease may be detected by examining computer output and electronic images, an accurate diagnosis of illness is possible by listening to the patient and conducting physical examinations in clinical encounters (Spiro, 1986). Today, the public pleads desperately for physicians who are more communicative and empathic in their encounters with patients (Fishbein, 1999). Despite the current emphasis on the development of professionalism, enhancement of empathy in the education of health care professionals has not yet received systematic and sufficient attention. According to Girgis and Sanson-Fisher (1995), although most physicians are well equipped to provide high-quality technical services, they are often ill equipped to provide empathic care.

Obstacles to Empathy in Patient Care

Some of the factors that impede the development and implementation of empathy in in-training and in-practice health professionals are described in the following sections.

Cynicism

Most medical students embark on a journey to become physicians with idealism and enthusiasm for curing disease and preventing infirmity. Despite the intention of medical school faculty to nurture these qualities, it is ironic that some have noticed a decline in humanitarianism, enthusiasm, and idealism among students during medical training (Kay, 1990; Maheux & Beland, 1989; Sheehan, Sheehan, White, Leibowitz, & Baldwin, 1990; Silver & Glicken, 1990; Wolf, Balson, Faucett, & Randall, 1989; Zeldow & Daugherty, 1987). This observation has been supported by empirical research showing that students’ empathy tends to erode in medical school (Hojat et al., 2004, 2009) and in postgraduate medical education (Bellini, Baime, & Shea, 2002; Bellini & Shea, 2005).

The effects of medical education on personal qualities were addressed empirically more than five decades ago with some disturbing results (Becker & Geer, 1958; Eron, 1958). One longitudinal study conducted in the 1950s (Eron, 1958) found that medical students became more cynical and less humanitarian as they progressed through medical school, whereas this pattern was not observed among law students! In that study, a typical question used to measure cynicism was “If you don’t look out for yourself, nobody else will,” and a typical question for measuring humanism was “When I hear about the suffering of a particular individual or group, I want very much to help.”

A similar concern about medical students’ progression toward cynicism during medical school was raised in the early 1980s (Silver, 1982). Another study found that as many as three-fourths of medical students became more cynical about academic life and the medical profession as they progressed through medical school (Sheehan et al., 1990). This metamorphosis in the character of medical students was likened to the “battered child syndrome” and was attributed to inappropriate treatment of students by the medical schools (Rosenberg & Silver, 1984; Silver & Glicken, 1990). The terms “dehumanization” (Edwards & Zimet, 1976) and “traumatic deidealization” (Kay, 1990) were also used to describe the cynical transformation occurring during medical education.

Several additional studies conducted in the 1980s reported other disturbing findings. A study at the University of Texas Health Science Center in San Antonio found that medical students underwent a significant hedonistic change in personality between the freshman and junior years of medical school: They became less inhibited and more self-indulgent (Burnstein et al., 1980). In a longitudinal study conducted at the same medical center, a decline in students’ scores on the “need to understand” scale of a personality inventory also raised concern about the negative influence of medical education on students’ personalities (Whittemore, Burstein, Loucks, & Schoenfeld, 1985). Students in the senior year at the Louisiana State University School of Medicine reported that the top two changes in attitude during medical school were more cynicism (76 %) and more concern about making money (60 %) (Wolf et al., 1989).

The alarm bells became even louder in 2002 when a nationwide study found that 61 % of residents in American residency training programs believed that they had become more cynical during their medical education (Collier, MaCue, Markus, & Smith, 2002). Cynicism was more prominent among female residents than it was among male residents (63 % versus 56 %, respectively). Interestingly, however, residents with children reported less cynicism and more humanistic feelings during their medical education (Sanson-Fisher & Maguire, 1980).

In an atmosphere of declining humanism, the emphasis by some modern medical educators placed on “detached concern” and “affective distance” for the purpose of increasing objectivity in clinical decision making is accelerating the dramatic metamorphosis occurring in medical education and patient care (Coulehan & Williams, 2001; Evans, Stanley, & Burrows, 1993; Farber, Novack, & O’Brien, 1997). Although well intended, the advice of those educators can be misinterpreted, thus adding to the factors contributing to the ultimate depletion of empathy’s importance in medical education and practice (Ludmerer, 1999; Starr, 1982). Among other factors fueling increased cynicism in medical education are lack of role models (Diseker & Michielutte, 1981; Kramer, Ber, & Moore, 1987) and lack of dedicated educational programs for nourishment of humanistic qualities in patient encounters.

Paradigmatic Shift in the Health Care System

As Gonnella et al. (1993, 1993) suggested, in addition to factors related to physicians and patients, the environment of health care delivery exerts a significant influence on physicians’ interpersonal behavior and patient outcomes. Recent developments in the organization, financing, and delivery of health care, notably in the expansion of managed care, cost containment, and the restriction of physicians’ autonomy, pose challenges that contribute to physicians’ discontent with the practice of medicine and a lack of opportunity for empathic engagement in clinical encounters (Burdi & Baker, 1999; Magee & Hojat, 2001).

Anecdotal reports suggest that financial incentives and insurance regulations in the current environment of health care have forced a number of physicians to trade off their patients’ interest against their will. The golden principle that the patient’s best interest must be the primary consideration in patient care has lost its priority in such a market-driven health care environment. According to a survey of physicians, the significant decline in the time physicians spent with patients and their inability to control the length of patients’ hospital stays and their own work schedules exacerbated their dissatisfaction with the current atmosphere of the health care environment (Burdi & Baker, 1999). When Burdi and Baker (1999) compared a sample of physicians surveyed in 1991 with another cohort-matched sample of physicians surveyed in 1996, they found that the number of physicians who said that they would have chosen medicine if they had been college students declined by 10 % during the 5-year period. This decline reflects the evolving changes in the health care system leading to physician dissatisfaction.

In a survey of 2608 physicians conducted in 2004, 58 % of them said that their enthusiasm for medicine had declined in the past few years, and 87 % said that their morale had declined because of changes in the health care system (Zuger, 2004). The discontent of physicians is an inevitable outcome of the restrictions on their autonomy and use of resources imposed by hospital administrators, the health care system, and the health insurance industry (Hojat, Gonnella, Erdmann, Veloski et al., 2000; Kassirer, 1998; Magee & Hojat, 2001). Physicians’ discontent with the practice of medicine, especially among those who have been “wounded” by malpractice allegations, matters because it influences the interpersonal quality of care and empathic engagement in clinical encounters. An analysis of how physicians are depicted in the movies showed that their portrayal as positive figures has declined in recent years. In current films, they are often depicted as greedy, egoistic, uncaring, and unethical (Flores, 2002).

The “time” factor is another impediment caused by the growing emphasis on cost containment that has contributed to shortening the duration spent in clinical encounters, thus hindering the formation of empathic relationships. The medical profession, once the most respected of all professions (Thomas, 1985), is now under siege, and physicians are frequently blamed, often mistakenly, for the problems created by nonphysician managers of health insurance organizations. These structural and functional shifts in the health care delivery system can hamper the potential benefits of forming empathic clinician–patient relationships. The ripple effect of changes in the American health care system has also had a profound effect on medical students (Hojat, Veloski et al., 1999) and nurses (Steinbrook, 2002).

Research shows that physicians’ discontent leads to patients’ noncompliance with treatment (DiMatteo et al., 1993) and dissatisfaction with their health care providers (Hass et al., 2000; Linn, Yager, Cope, & Leake, 1985). Such discontent among physicians can be reflected in pessimism manifested in their communication with patients. Furthermore, research suggests that pessimism is significantly associated with mortality among physicians as well as their patients (Hollowell & De Ville, 2003).

As a result of the paradigmatic shift described earlier, the health care delivery system has been transformed into a profit-driven enterprise with less emphasis on clinician–patient interactions and more emphasis on financial efficiency (Merlyn, 1998). Diminished prestige, loss of autonomy, and deep personal dissatisfaction are among the outcomes of paradigmatic shifts in health care systems. Research shows a widespread “professional malaise” among physicians who are caught between the desire to provide high-quality care to their patients on the one hand and the need to satisfy the insurers and regulators on the other hand (Zuger, 2004).

According to psychoanalytic theories, this type of approach-avoidance psychic conflict (e.g., a desire to help patients and avoid conflicts with insurers at the same time) can lead to frustration and neurotic-type distress that threatens physicians’ physical, mental, and social well-being. Poor clinical management and substandard medical care resulting from a system that restricts physicians’ autonomy in dealing with patients inevitably lead to hostile reactions by the public, often directed toward physicians, who themselves are victims of the system’s crippling effects.

Added to this paradigmatic shift in the health care delivery system is the dramatic rise in the number of malpractice suits. The inevitable result is greater discontent with medicine among practitioners and even greater dissatisfaction with health care services among patients (Mello et al., 2004). In an atmosphere in which the physician–patient relationship resembles an encounter between consumer and retailer, little room obviously is left for compassion and empathy.

The primary concern of powerful players in the health care system—notably, nonphysicians employed by government agencies, hospital administrators, and the health insurance industry—is cost containment. The new arrangements created by this shift of emphasis have intruded in the clinical autonomy of physicians, led to the inability of physicians to preserve their altruistic image, and eroded the public’s trust and support (Schlesinger, 2002). In a hostile atmosphere where physician–patient encounters are based on fear of allegations of malpractice, rather than on trust, the physician–patient relationship is likely to be shaken at best and violated or broken at worst (Thom, Hall, & Pawlson, 2004). As a result of all the changes occurring in the health care system, the adverse effects on the physician–patient relationship are more threatening to the outcomes of care than ever before (Simpson et al., 1991). Needless to say, an empathic relationship is highly unlikely to form in an atmosphere in which physicians view each patient as a potential adversary for malpractice litigation (Mello et al., 2004), while patients view their physicians as uncaring and greedy individuals who cannot be trusted.

In 2002, the American Board of Internal Medicine, the American College of Physicians, the American Society for Internal Medicine, and the European Federation of Internal Medicine jointly published a report titled Medical Professionalism in the New Millennium: A Physician Charter (Sox, 2002). The report not only confirmed the existence of the problems described here but also underscored their severity by concluding that the “changes in the health care delivery systems in countries throughout the industrial world threaten the values of professionalism” (p. 234). These trends in medicine, with their ripple effect on medical education, have resulted in brief consultations, the goal of which is to identify one physical problem as the “chief complaint” (Shorter, 1986), thus shifting the attention from the patient as a “whole person” to a disease as a “case.” One hopes that the recent attention to professionalism in medical education and practice will bring empathic engagement between physician and patient to the forefront of health care once again.

Overreliance on Biotechnology, Computerized Diagnostic and Therapeutic Procedures

The new millennium offers either the best or the worst clinical care, depending on whether one views the “glass” as half-full or half-empty. The glass is half-full, given the fact the biotechnological developments can certainly help to prevent many diseases worldwide at a rapid pace, to make more accurate diagnoses much earlier than before, and to treat patients more aggressively. The glass is half-empty, however, given the fact that computerized medicine is gradually replacing “the laying on of hands,” trivializing the importance of face-to-face encounters between clinician and patient and reducing opportunities to form empathic engagement as a result. Even telephone calls to family physicians (who made home visits in the good old days) are answered by automatic messages instructing desperate patients to call back during office hours, or go to the nearest hospital emergency room for help. Obviously, these trends are not conducive to empathic engagement in patient care.

During visits to a physician’s office, patients are often required to undergo a series of laboratory tests, unnecessarily in some cases (Divinagarcia, Harkin, Bonk, & Schluger, 1998; Sandler, 1980), and wait until the physician receives the results and makes a diagnosis, overlooking the clinical signs and symptoms that have been used successfully by physicians for hundreds of years. In this era of overreliance on biotechnology, many physicians tend to view the results of laboratory tests and computerized diagnostic procedures as the holy script—despite the well-known errors associated with the sensitivity and specificity of tests—rather than paying more attention to the patients’ clinical signs and illness narrative. Thus, patients are treated as objects for technical services (Coulehan & Williams, 2001) rather than as subjects for human care. This style of dealing with patients defies Peabody’s stated purpose of patient care: “The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal” (Peabody, 1984, p. 814). In a survey of patients who either changed their physicians or were thinking of changing their physicians, the following comment made by a patient deserves serious attention in medical education: “Students should be taught to use technology as a backup and not as the primary factor of the examination of the patient” (Cousins, 1985, p. 1423).

The strain in the physician–patient relationship caused by the shift from the patient’s trust in the physician’s healing touch to the physician’s trust in computerized diagnostic and therapeutic procedures has led to the public’s perception that physicians have become too “detached” to be concerned about their patients (Mangione et al., 2002). As a result, the medical profession is increasingly faced with the criticism that physicians are losing their human touch (Johnston, 1992). Indeed, a number of studies have supported this view by confirming that medical students, residents, and practicing physicians have become more cynical and less compassionate during medical training and practice (Feudtner, Christakis, & Christakis, 1994; Hojat et al., 2004; Kay, 1990; Lu, 1995; Maheux & Beland, 1989; Self, Schrader, Baldwin, & Wolinsky, 1993; Sheehan et al., 1990; Silver & Glicken, 1990; Wolf et al., 1989; Zeldow & Daugherty, 1987).

The abovementioned issues are only some of the challenges facing medical education and practice today. However, despite all the bad news, the good news is that it is possible to enhance empathy through dedicated educational programs and through demonstrations of its beneficial effects on patient outcomes.

The Amenability of Empathy to Change

A number of studies have shown that during the course of medical education, a students’ capacity for empathy can undergo positive, negative, or no change. Although the inconsistent research findings are troublesome and may reflect issues involving conceptualization, measurement, and methodology, the fact that most of the recent studies have noted a change in empathy, either positive as a result of implementing targeted interventions (Hojat, Axelrod, Spandorfer, & Mangione, 2013; Van Winkle, Bjork, et al., 2012; Van Winkle, Fjortoft, & Hojat, 2012) or negative as a result of negative educational experiences and a lack of positive role models (Hojat et al., 2009), indicates that this attribute is amenable to change—welcome news for medical educators.

The State-Versus-Trait Debate

The idea of enhancing empathy during education for the health professions depends heavily on the belief that the capacity for empathy is amenable to change. Thus, it is important to address this issue at the outset because, if empathy proved to be a stable personality trait that cannot be easily changed, discussion of educational programs designed to enhance empathy would be pointless.

Psychologists have long been concerned about the possibility of changing people’s motivations, attitudes, values, personality, and behavior. It is generally believed that some human attributes are more resistant to change than others. In the behavioral and social sciences, personal qualities, such as excitability, that are highly stable and difficult to change, are often called traits, whereas relatively unstable personality attributes, such as moods, that are easy to change are called states (Cole, Martin, & Steiger, 2005). The findings of longitudinal research concerning the stability of the so-called traits are inconsistent. For example, some findings suggest that traits can change over time (Roberts & DelVecchio, 2000), and other findings indicate that traits continue to show stability over a period of 15 years (Caspi & Silva, 1995).

The notion that empathy has an evolutionary root (Chap.  3) suggests that under ordinary circumstances, normal individuals are naturally programmed to demonstrate empathy. The extent to which the potential for empathy can be actualized or enhanced in a particular person depends on the interaction of several factors, including the person’s constitutional makeup, early life experiences, motivation, and a facilitating environment as well as exposure to specific educational programs. Therefore, empathy, in my view, is neither a highly stable personality trait nor a state that can be changed without effort. In a sense, empathy resembles the notion of attachment that is rooted in evolutionary, genetic, developmental, experiential, situational, and educational ground, and its deficit can be improved by therapeutic or interventional approaches.

Changes in Empathy During Health Professions Education

Positive Change

Some studies that offered a targeted educational program reported an improvement in empathy. For example, residents who participated in a comprehensive interpersonal skills training course demonstrated greater use of empathy when dealing with patients (e.g., they asked more open-ended questions and provided emotion-related responses) (Kause, Robbins, Heidrich, Abrassi, & Anderson, 1980).

A study of Israeli medical students found that a clerkship in psychiatry improved their scores on Mehrabian and Epstein’s Emotional Empathy Scale (Chap.  5) and that the students retained the effect of the program for at least 6 months (Elizur & Rosenheim, 1982). In another study, the investigators noticed that medical students and physicians who participated in an interpersonal skills workshop demonstrated improved empathic engagement, as determined by their increasing use of supportive behaviors, such as listening, responding empathically, and calming patients (Kramer, Ber, & Moore, 1989).

At the University of Missouri School of Medicine in Kansas City, empathy training offered to students in the early years of medical school resulted in increased scores on Carkhuff’s Empathic Understanding in Interpersonal Processes Scale (Feighny, Arnold, Monaco, Munro, & Earl, 1998). However, the students’ scores on Davis’s Interpersonal Reactivity Index (IRI, see Chap.  5) did not increase, probably because of its lower sensitivity in the clinical context. Finally, over the years, training in communication skills provided in various formats (lectures, workshops, and audio- or videotapes) has proven to be useful in improving empathy-related skills (Evans et al., 1993; Fine & Therrien, 1977; Kramer et al., 1989; Sanson-Fisher & Poole, 1978; Winefield & Chur-Hansen, 2000).

Stepien and Baernstien (2006) reviewed articles on empathy education programs in medical schools and found that many of the articles reported an improvement of empathy. However, these authors suggested that research on enhancement of empathy in medical education poses challenges because of the lack of consensus about the conceptualization and definition of empathy, the lack of adequate research designs and control groups, and variation among the instruments used to measure empathy. These limitations may not apply to more recent studies in which a validated measure of empathy (JSE) was used which relies on an operational definition of empathy in the context of patient care which was described in Chaps.  1 and  6 (e.g., Brazeau, Schroeder, Rovi, & Boyd, 2011; Chen, LaLopa, & Dang, 2008; Hojat, Axelrod et al., 2013; Van Winkle, Fjortoft et al., 2012, see also  Appendix A).

Negative Change

Another group of studies showed a decline in empathy among medical students and residents during the course of their medical education in the absence of a targeted educational program. For example, after a period of clinical experience, medical students at the Bowman Gray School of Medicine in North Carolina showed a slight decrease in scores on Hogan’s Empathy Scale (Diseker & Michielutte, 1981). Another study reported that a sample of medical students developed a hedonistic personality pattern during medical school that contributed to the decline in empathy (Whittemore et al., 1985).

In a study of changes in empathy, humanism, and professionalism during medical education at a major academic center, Marcus (1999) analyzed approximately 400 dreams reported by healthy medical students and house staff and traced the development of empathy and humanistic attitudes in different years of medical education. Marcus reported that identification with cold and uncaring role models; increasing reliance on the technological aspects of treatment, rather than on the humanistic side of patient care; and development of a sense of elitism or of belonging to a privileged group were some of the factors that became noticeable among students in the third year of medical school, as inferred from dream analyses.

At the University of Pennsylvania Hospital, Bellini et al. (2002) administered the IRI (see Chap.  5) to first-year residents in internal medicine and reported a decline in the residents’ scores on the Perspective Taking and Empathic Concern scales of the IRI. Conversely, the residents’ scores increased on the IRI Personal Distress scale—a result that was not conducive to empathic patient care. A follow-up study 3 years later showed that the decline in scores on the Empathic Concern scale remained throughout the 3 years of the residency program (Bellini & Shea, 2005).

Similar patterns of decline in empathy were found in most of the other studies in which the JSE was used. For example, in a longitudinal study of 456 medical students at Jefferson Medical College, an erosion in empathy was found in the third year of medical school (Hojat et al., 2009). In an earlier longitudinal study of 125 third-year medical students, we also noticed a statistically significant decline in JSE scores from the beginning to the end of the third academic year (Hojat et al., 2004). In a study of residents in internal medicine in three different years of residency at Thomas Jefferson University Hospital, we noticed a progressive decline in JSE scores as the residents progressed from one level of training to the next (Mangione et al., 2002). Although systematic, the observed decline did not reach the conventional level of statistical significance (p < 0.05) in this study. Sherman and Cramer (2005) also observed a significant decline in dentistry students’ scores on the JSE as the students progressed through dental school.

A number of other researchers have also noticed a statistically significant decline in the JSE scores as medical and other health profession students progress through their education in different cultures (see  Appendix A). The unfortunate transformation of health professional students to less empathic beings as they progress through health professions education resembles the notion of the “Lucifer effect” described by Zimbardo (2007) about why good people turn bad as a result of environmental condition he noticed in his well-known Stanford Prison Experiment (see Chap.  8). (Lucifer was a mythological angel who fell from grace to become a Satan.)

In a review article, it is claimed that findings on erosion of empathy among medical and other health profession students have been exaggerated (Colliver, Conlee, Verhulst, & Dorsey, 2010a, 2010b). However, such criticism has not been left unchallenged (Newton, 2010; Hojat, Gonnella, & Veloski, 2010; Sherman & Cramer, 2010). Empirical research findings from a number of studies that have confirmed a decline in empathy during health professions education are deeply troubling and should not be viewed as a trivial matter. To restore respect to the medical profession, the most humanistic profession in existence, the factors that contribute to the decline of empathy and other humanistic values must be investigated seriously. A medical education system that produces physicians who are unable to apply the science of medicine in conjunction with the art of healing represents, in my view, an “unfinished business.” The physician who has learned the science of medicine, but has no sense of the art of healing, is, in the words of Saadi (the twelfth-century Persian poet), like “a man who ploughs, but sows no seed.”

No Change

There is yet a third group of studies showing no change in empathy during medical education. For example, a course in behavioral science offered to medical students did not change the students’ orientation toward viewing the patient as a person (Markham, 1979).

Zeldow and Daugherty (1987) reported that they observed no significant changes in medical students’ empathy measured with the Empathic Concern and Perspective Taking subscales of the IRI. A study in which the IRI was administered to nursing students during their third year of nursing education found no change in the students’ empathy during the 9-month training period (Becker & Sands, 1988). There are also a number of studies with different health professions students in various cultures who reported no significant changes in the JSE scores as a result of implementation of their educational programs aimed at improving empathy (see  Appendix A).

In general, the majority of findings reported in the previous sections indicate that empathy is amenable to either positive or negative changes during professional education. Even the negative findings can be viewed optimistically because if empathy can decline in the absence of appropriate educational programs, it has the potential to increase if appropriate educational remedies are implemented. The possibility of teaching empathy (Spiro, 1992) and other human virtues (Shelton, 1999) during medical and other health professions education has already been discussed. However, do we all agree that educators in the health professions must assume responsibility for improving students’ personality, including personal attributes, such as empathy, in addition to imparting knowledge to them and developing their clinical and procedural skills? Although this question may generate some debate concerning the applications of behavioral modification with students and practitioners in the health professions, my own answer is an affirmative one because of my belief that medicine (and all other health professions for that matter) is a public service endeavor and therefore must produce professionals who are fully equipped to better serve the public (Hojat, Erdmann, & Gonnella, 2014). Consequently, in addition to opportunities to acquire up-to-date knowledge and develop fine clinical and procedural skills, medical and all other health professions educational programs should provide students with opportunities to develop personal qualities that lead to optimal patient outcomes (Knight, 1981; Shelton, 1999). That, I believe, must be considered as a mandate not a luxury, not only in health professions education, but also in all other educational programs in any public service disciplines.

As the research findings just described attest, assuming that students in the health professions will automatically develop empathic understanding and other humanistic qualities during their professional education obviously is unrealistic (Hornblow, Kidson, & Ironside, 1988). Therefore, because not everyone develops the capacity for empathy by default, enhancement of empathy among health professions students and practitioners will require targeted educational programs, appropriate experiences, and exposure to humanistic role models.

Approaches to the Enhancement of Empathy

Many approaches have been used to enhance empathy, most of them by social psychologists and some by medical and nursing educators. Among the many approaches to improving empathy are parental training (Gladding, 1978; Therrien, 1979), skill-development workshops (Black & Phillips, 1982; Hatcher et al., 1994; Kremer & Dietzen, 1991; Pecukonis, 1990), perspective-taking exercises (Coke, Batson, & McDavis, 1978), role taking and role playing (Kalisch, 1971; Moser, 1984), communication or interpersonal skill training (Kause et al., 1980; Yedidia et al., 2003), films and videos (Gladstein & Feldstein, 1983; Simmons, Robie, Kendrick, Schumacher, & Roberge, 1992; Werner & Schneider, 1974), role modeling (Dalton, Sunblad, & Hylbert, 1976; Gulanick & Schmeck, 1977; Shapiro, 2002), or a combination of these and other approaches (Beddoe & Murphy, 2004; Benbassat & Baumal, 2004; Erera, 1997; Kipper & Ben-Ely, 1979).

Although didactic teaching methods are effective for improving beginners’ empathic communication skills (Gladstein et al., 1987), more advanced techniques, such as role playing, simulation, and audiovisual methods, are useful for advanced training in empathy. In the following sections, I briefly describe some of the approaches used to enhance empathy in the fields of social and counseling psychology and then discuss some of the methods used among students and practitioners in the health care professions.

Social and Counseling Psychology

In early laboratory experiments, social psychologists used the classical conditioning paradigm to demonstrate that empathic responses could be elicited. For example, two studies indicated that watching others who appeared to be receiving electric shocks followed by a warning signal could cause observers to form empathic reactions to the warning signal (Berger, 1962; DiLollo & Berger, 1965). The observers terminated the electric shocks more quickly when they believed that they were able to help (Weiss, Boyer, Lombardo, & Stich, 1973). These studies suggest that the empathic response can be elicited by classical and operant conditioning.

An empathy enhancement program called Parent Effectiveness Training , which included lectures, tape recordings, role playing, and role modeling, was also implemented for parents who wished to improve their parent–child communication (Therrien, 1979). The results showed that parents who participated in the program were able to function at a higher level of empathy, as measured by the Accurate Empathy Scale of Truax and Carkhuff’s Relationship Questionnaire. The improvement was maintained over a period of 4 months.

In a series of studies on the use of imagination, Stotland and colleagues demonstrated that when an observer was instructed to “stand in another person’s shoes” by simply imagining the pain experienced by a person whose hand was strapped to a machine generating painful heat, the observer exhibited a more intense empathic response than did other observers who passively watched the distressed person’s actions and appearance (Stotland, 1969; Stotland, Mathews, Sherman, Hansson, & Richardson, 1978). This finding suggests that a cognitive process of perspective taking or imagining the other person’s experience (i.e., standing in the other person’s shoes) can elicit empathic responses reflected in the role taker’s behavior, heartbeat, and skin conductance.

Imagination has also been used as a method of inducing an empathic response. Two kinds of imagination have been used. One kind was imagining another person in a specific situation (e.g., a person whose parents have been killed in an automobile accident). The question is what the other person might feel and experience (third-person experience). The other kind was imagining oneself experiencing another person’s concerns, feelings, and experiences as vividly as possible (first-person experience). Empathic behavior determined by physiological responses or self-reports can be generated by such imaginings.

Since prejudice against specific groups can lead to psychological distance, some psychologists have attempted to reduce prejudice and improve prosocial behavior by enhancing empathy. If an important ingredient of empathy is the ability to understand other people’s concern, pain, and suffering, such an understanding can reduce prejudice and bridge the gap between people. Efforts to understand others will diminish hatred toward them, and helping behavior presumably would follow when empathic understanding is formed (Batson, 1991; Batson & Coke, 1981; Davis, 1994).

One approach to understanding others is to read about them—their values, culture, concern, pain, and suffering. Most programs designed to increase cultural sensitivity focus on the simple principle that understanding different cultures reduces prejudice and increases the sense of common identity. When people were asked to read stories about a particular group of sufferers, such as patients with AIDS, homeless people, or prisoners on death row, they developed more positive attitudes toward these groups as their awareness improved (Batson, Polycarpou et al., 1997).

Those who read vignettes about racial discrimination and were instructed to empathize with the victims (by standing in the other person’s shoes) improved their attitudes toward the victims (Stephan & Finlay, 1999). When college students participated in a “dialogue group” to discuss diversity, race, and ethnic issues, the researchers observed both short- and long-term improvements in the students’ empathic understanding of minority groups (Gruin, Peng, Lopez, & Nagda, 1999; Lopez, Gurin, & Nagda, 1998). Such dialogues concerning people’s similarities and differences can create a sense of a common identity that reduces prejudice and increases helping behavior. Research has also demonstrated that people who participate in multicultural educational programs, read relevant materials, watch videos, and engage in conversation with people from other racial, ethnic, and cultural groups increase their insight and their empathic understanding of the views held by those groups (Banks, 1997).

More than three decades ago, Bridgman (1981) suggested that prosocial behavior could be measured by cognitive developmental processes through role taking. In a study based on this suggestion, children from different groups who took the role of a person from another group in specially designed educational programs worked cooperatively together and improved their empathic understanding of each other. These findings have implications for education in the health professions with regard to not only improving practitioners’ understanding of patients and other staff members from diverse sociocultural backgrounds and experiences but also promoting collaboration and teamwork as well. Our studies have shown that when medical students and nurses work together, the students’ understanding of the importance of nursing services to patient care increases and their attitudes about collaborative relationships improve significantly (Hojat et al., 1997; Hojat & Herman, 1985).

Krebs (1975) and Stotland and colleagues (Stotland, 1969; Stotland et al., 1978) indicated that taking another person’s perspective can lead to increased intensity of the motivation to help and, consequently, to an empathic response. Batson and colleagues reported that empathic behavior could be developed in a two-stage model of training (Batson, Coke, & Pych, 1983; Coke et al., 1978). In Stage 1, adopting the perspective of another person, such as a patient, increased empathic concern. The motivation to help was elicited in Stage 2 as a result of adopting another person’s perspective.

Crabb, Moracco, and Bender (1983) developed a training program for lay helpers (church volunteers) based on the micro counseling interviewing technique (Ivey, 1971) and the skilled-helper training method (Egan, 1975) and offered the program to a large group of church volunteers. After administering Carkhuff’s Empathic Understanding in Interpersonal Processes Scale to the participants, the authors reported that a large-group format for teaching the skills of empathy can be effective (Crabb et al., 1983).

In another study, undergraduates were taught active listening skills (e.g., identifying expressions of emotion and communicating this understanding verbally) either through training tapes (the self-directed method) or through highly intensive programs presented by teachers (Kremer & Dietzen, 1991). Although both approaches improved the students’ empathy skills, the investigators concluded that empathy skills could be taught effectively in a large-group format without intensive programs and with direct contact with a teacher as a necessary component.

Another important finding was that an observer’s empathic responses could be demonstrated more vividly when the person observed was involved in a distressing, not pleasant, situation (Stotland et al., 1978). In other words, human beings tend to empathize with people who need help to reduce their pain and suffering, rather than empathize (rejoice) with people who want to share their joy and ecstasy. This finding is relevant to clinician–patient encounters, where there is always a patient in pain and in need of help and a clinician in a position to offer help. Such is the condition in which an empathic relationship is waiting to form.

The Health Professions

Since the 1970s, a number of researchers have argued that empathy is far too important to be taught only to health professionals (Ivey, 1971, 1974). Egan (1975) and Therrien (1979) recommended that everyone should receive empathy training to improve human relationships in general and to face crises of life more effectively. Others have suggested that the capacity for empathy 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), regardless of professions.

Researchers in the health professions have attempted to enhance empathy by offering educational programs. Most of the programs address the broader goal of improving students’ interpersonal skills and understating which implicitly means enhancement of the capacity for empathy. It is assumed that the capacity for empathy is an essential prerequisite to demonstrate empathic behavior (Book, 1991). The following studies are examples of the training programs designed to enhance empathy among students and practitioners in the health professions.

Helping Professions

In a study at the University of Haifa, social work students participated in an empathy training program developed and implemented for service professionals (Erera, 1997). Designed to enhance participants’ sensitivity, the program consisted of four activities: (a) recording students’ interviews with clients, (b) reviewing the interviews for the purpose of developing hypotheses or speculating about statements clients made during the interviews, (c) developing hypotheses about the students’ statements, and (d) verifying the hypotheses or speculations by analyzing possible reasons for the statements students made during exchanges with clients. For example, “What did the client try to convey by using a specific statement?” or “What did the student infer from the client’s statement?” A statistically significant improvement in scores on Mehrabian and Epstein’s Emotional Empathy Scale was observed among the students who participated in the program.

Sensitivity to nonverbal cues is an important skill in establishing an empathic clinician–patient relationship. When a group of mental health professionals was exposed to a 90-min program designed to increase their ability to interpret nonverbal cues, the results demonstrated that such skills could be learned (DiMatteo, 1979; Rosenthal, Hall, DiMatteo, Rogers, & Archer, 1979). The brief presentation included information about the importance of nonverbal communication in clinical settings, demonstrations of how one can understand nonverbal expressions of affect by noting changes in tone of voice, and practice in judging emotions by observing facial expressions, bodily movements, and postures. The participants had no difficulty learning the apparent meaning of certain nonverbal cues.

Nursing

In a study designed to improve empathy among nursing students, the students underwent didactic training that involved role playing and exposure to a role model (Kalisch, 1971). Although the investigator noticed an increase in the students’ self-reported empathy on Barrett-Lennard’s Relationship Inventory, no increase occurred in patients’ ratings of the nurses’ empathy.

LaMonica, Carew, Winder, Haase, and Blanchard (1976) developed an empathy training program for hospital nursing staff based on Carkhuff’s human relationship model (1969). During the brief program, nurses learned to interpret patients’ nonverbal behaviors and expressions of anger, engaged in empathic role playing, and practiced responding empathically. Despite a significant increase in the nurses’ empathy scores, the authors reported that the majority of participants needed more training.

Layton (1979) attempted to enhance nursing students’ empathy by conducting an experiment based on Bandura’s observational social learning theory (Bandura, 1977). The students observed interviews with simulated patients that consisted of three components: (a) a modeling component demonstrating the interviewers’ empathy (positive modeling) or lack of empathy (negative modeling); (b) a labeling component in which segments of the modeling component were played back, followed by a narrative explaining the presence or absence of empathy depicted on the videotapes; and (c) a rehearsing component, during which the videotapes were stopped briefly after each verbal and emotional expression shown by the patient. During each pause, the students were asked to construct their own responses to the patient’s expressions. When the experiment ended, Layton found that the junior-year students’ scores on Carkhuff’s Empathic Understanding in Interpersonal Processes Scale had improved, whereas the scores of the senior students had not. Layton speculated that one explanation for the disparate results was that the modeling approach may have been more effective for less advanced students.

As a result of extensive work in nursing education and research in the 1960s and 1970s, Orlando (1961, 1972) developed a model of therapeutic encounters proposing that when nurses interacted with patients, they should validate their perceptions to ensure that they had an accurate understanding of the patients’ experiences. More than two decades later, Olson and Hanchett (1997) adopted Orlando’s model as a suitable method of studying empathy and patient outcomes and hypothesized that if nurses understood their patients’ needs accurately and shared that understanding with patients, who in turn confirmed its accuracy, patient outcomes would improve. Accordingly, Olson and Hanchett initiated a study involving 70 staff nurses and 70 patients to test the hypothesis that nurses’ empathy would reduce patients’ distress and overlap with the patients’ perceptions of the nurses’ empathy, as measured by the Empathic Understanding subscale of Barrett-Lennard’s Relationship Inventory. At the end of the study, the authors reported a moderate but statistically significant relationship between the nurses’ self-reported empathy and the patients’ perceptions of the nurse’s empathy: i.e., the hypothesis was confirmed.

In another study, Beddoe and Murphy (2004) exposed nursing students to an 8-week “mindfulness-based stress reduction” program to explore the program’s effects on stress and empathy. At the end of the 8 weeks, the authors reported favorable changes in the students’ scores on the Personal Distress and Fantasy subscales of the IRI.

Ten Approaches to Enhance Empathy in Health Professions Education and Practice

In this section, I have selected ten approaches that are more specific to medical (and all other health professions) education and practice (Hojat, 2009). Consistent with our definition of empathy, the common goal of all of these approaches is to improve the understanding of students and practitioners in the health professions in regard to patients’ concern, pain, suffering, and experiences.

Improving Interpersonal Skills

Interpersonal skill development is considered as an essential prerequisite to demonstrate empathic behavior (Book, 1991). Researchers in the health professions have attempted to enhance empathy by designing educational programs to improve students’ interpersonal skills that implicitly imply enhancement of the capacity for empathy (Evans et al., 1993; Kramer et al., 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: “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 our definition of empathy in the context of patient care. The goal of this training is to form an empathic engagement in the caregiver–care-receiver relationship by the caregiver recognizing an “empathic opportunity” when the care receiver directly or implicitly expresses emotions or concerns. The caregiver 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) while 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 discomfort. 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 skill 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 et al. (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 skill workshop offered to medical students and medical residents in Spain significantly increased scores of participants’ empathy (measured by the JSE) compared to a non-participant control group (Fernandez-Olano, Montoya-Fernandez, & Salinas-Sanchez, 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 the three groups: two experimental groups and one control group (Roter 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 experimental 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 compared to the control group 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, and 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 et al. (2007) audio-recorded 398 interviews between advanced cancer patients and their oncologists. They found that oncologists responded with empathy to patient 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. After the training, students’ scores on the Accurate Empathy scale of Truax and Carkhuff’s Relationship Questionnaire increased significantly compared with the scores of a control group of students who did not participate in the program. Audio-taped conversations between patients and physicians can help identify 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) used a variation of a technique called “Interpersonal Process Recall” to enhance medical students’ interviewing skills and awareness of patients’ affective messages. The students were videotaped as they interacted with simulated patients with various problems. The videotapes were then played back so the students could view interactions with patients and receive critical analyses from instructors and other students about their interactions with the patient. After each tape-recorded interview, the students joined in a group with 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) 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 discern 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 teaching 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. However, the role models they selected most often were their own parents, and notably their mothers who were described as caring, sympathetic, and self-sacrificing mentors. These findings are consistent with the notion I describe in Chap.  4 that mothers are key figures in the development of a child’s capacity for empathy.

Despite the fact that exposure to role models is important 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 % of the second-year students and 40 % of the seniors said that they did not agree that their medical school faculty behaved as humanistic physicians and teachers. In a study of decline in empathy in medical school, students in response to a question about factors that had negatively influenced their views on patient-physician relationships had indicated that inappropriate role models (faculty and attending physicians) was one of the major factors (Hojat et al., 2009).

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 medical students’ understanding of 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., 70–99 years old) and use earplugs to simulate hearing loss.

The second stage begins with a 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. In each area they are confronted with facilitators who play 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 that 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, Beck, and Coggin (1978) and Holtzman, Beck, and Ettinger (1981) among medical and dental students, and nurses (Marte, 1988).

Pacala, Boult, Bland, and O’Brien (1995) presented a three hours 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 nonparticipating 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 un-popped popcorn in their shoes to simulate the discomfort of arthritis pain. Scores of a two-item empathy scale (developed by the study authors: “I believe I can truly empathize with older patients” and “I believe I understand what it feels like to have problems associated with aging”) 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 cataracts) with all 84 medical students in two first-year classes. They reported a statistically significant increase in empathy. After 10 years of 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 et al., 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), or a 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 whose conditions they simulated, and developed an understanding of the challenges faced by the patients after “walking in a patient’s shoes” (Chen et al., 2008). In another study, medical and pharmacy students participated in a workshop which included a theatrical play performed by their classmates who were coached to enact problems and concerns of elderly patients (a variation of the “aging game”). Statistically significant improvement in the JSE scores was observed among students (Van Winkle, Fjortoft, et al., 2012). I will describe this study in more detail in the “Theatrical Performances” section of this chapter.

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 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 that they experienced feelings of empathy while participating in the program.

In another study, 12 first-year emergency medicine residents at Thomas Jefferson University Hospital were randomly divided into experimental and control groups (Forstater, Chauhan, Allen, Hojat, & Lopez, 2011). Each resident in the experimental group shadowed one patient in the emergency department in the first month of residency training. The control group did not participate in shadowing and followed a routine training schedule. The JSE was completed by all residents 2 and 9 months after the shadowing experiment. No substantial difference was observed on the JSE scores between the two groups 2 months after the experiment (effect size = 0.02); however, a larger decline in empathy scores was noticed in the control group compared to the experimental group (effect size = 0.58), suggesting that the erosion of empathy may be prevented to some extent by shadowing experiences.

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) (see Chap.  8). 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. Investigators 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 could 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

In his book, A History of Medicine, Castiglioni (1941) quoted Hippocrates as saying, “Where there is a love for man, there is also a love for the arts.” The statement indicates that there is a bridge connecting the human heart and the arts together. Numerous authors have proposed that in addition to reading the medical literature, medical students and physicians should read literature unrelated to medicine because it would expose them to a rich source of knowledge and insights about the emotions, pain, and suffering, and perspectives of human beings and would improve their capacity for forming empathic connections (Acuna, 2000; Charon et al., 1995; Herman, 2000; Jones, 1987; Kumagai, 2008; McLellan & Husdon Jones, 1996; Montgomery Hunter, Charon, & Coulehan, 1995; Peschel, 1980; Szalita, 1976) (for an annotated bibliography of works in medical and nonmedical literature, see Montgomery Hunter et al., 1995). In support of the impact of physicians’ familiarity with literature and the arts on patient outcomes, Mandell and Spiro (1987, p. 458) suggested that “the humanities will not improve the technical care of our patients, but they may help to civilize that care.”

Borrowing from Jungian concepts, Knapp (1984) suggested that by studying classical literature, the reader can develop insight into the “collective unconscious” of the human mind and better understand the archetypal images in myths, legends, literature, and the arts. The simulated worlds presented by famous novels, short stories, poems, plays, paintings, sculptures, music, and films enable us to learn how emotions are expressed in human relationships (Oatley, 2004). Thus, the study of literature and the arts can provide students and practitioners in the health professions with values and experiences in areas of concern in clinical practice, 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 hard-to-teach clinical competencies, such as accurate observation, interpretation, imagination, ethical issues, and moral reflection (Montgomery Hunter et al., 1995).

In addition, studying literature and reading poetry not only facilitate clinicians’ understanding of other people’s feelings and expressions of their inner world but also can be used as an ancillary tool through which both clinician and patient can find different meanings in and ways of expressing emotion, pain, and suffering (Lerner, 1978, 2001). Furthermore, literature and the arts provide clinicians with the ability to use metaphor in encounters with patients that can help them to enhance mutual clinician–patient understanding (Blanton, 1960; Lerner, 2001).

Charon et al. (1995) indicated that in addition to increasing one’s understanding of human suffering and ability to use metaphor, studying literature and the arts can help health professionals to “contextualize” and “particularize” the ethical issues in patient care. Other authors have indicated 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), and recognize that the discoveries of others can lead to the development of self (Kumagai, 2008). The quandaries and decision-making processes of characters in literary narratives are useful for teaching ethical guidelines to students and practitioners in the health professions (Coles, 1989). 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).

Reading literature can result in higher mental processes leading to greater imagination and better interpretive skills that reinforce empathic understanding (Calman et al., 1988; Charon et al., 1995; Clouser, 1990; Downie, 1991; Radley, 1992; Starcevic & Piontek, 1997; Younger, 1990). Literature can enrich students’ moral education, increase their tolerance for ambiguity, and give them a rich grounding for empathic understanding of their patients. Lancaster, Hart, and Gardner (2002) offered a 1-month course in which medical students read works, such as Tolstoy’s The Death of Ivan Ilych, which improved their narrative skills. 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.

Although it is assumed that engagement with literature can deepen medical students’ understanding of illness experiences, increase their capacity for self-reflection, and enhance their capacity for empathy, resistance among medical students to a course on literary inquiry has been observed (Wear & Aultman, 2005). Denying the relevance of studying literature to medicine, discounting the value of literary inquiry to patient care, and distancing the arts from science are among the reasons for medical students’ resistance to studying literature and improving their narrative skills (Wear & Aultman, 2005). Students’ motivation can be improved by convincing them of the link between literary inquiry and medicine. Despite the importance of humanities in enhancing empathy, only a third of all the medical schools in the USA had incorporated literature into their curriculum as of the mid-1990s (Charon et al., 1995; Jones, 1997; Montgomery Hunter et al., 1995). Other medical schools should be encouraged to follow their lead. 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 and Reflective Writing

It is said that human beings are storytelling animals (Hurwitz, 2000), that the universe is made of stories (Feldman & Kornfield, 1991), and that physicians are immersed in patients’ stories (Steiner, 2005). Humans are described by Dawes (1999, p. 29) as “the primates whose cognitive capacity shuts down in the absence of a story.” It is suggested that the human brain is evolved to process stories better than any other forms of input (Newman, 2003). Narrative, defined by Smith (1981, p. 228) as “someone telling someone else that something happened,” is the royal road to a patient’s world.

It is physicians’ attentive listening to their patients’ narratives of illness (narrative skills), rather than “clinical interrogation,” (Kleinman, 1995) that opens a window of opportunity to empathic engagement. In clinician–patient encounters, listening to the patient’s stories of illness with the third ear while taking the history of the patient’s current illness is described as a “narrative communication” that, when skillfully performed, 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 & Hammett, 1973). Patients often carefully monitor the clinician’s attentiveness to their illness narrative, detect signs of the clinician’s empathic receptiveness, and feel better when the clinician appears to be in tune with the narrative themes (Brody, 1997). In his article “Power of Stories over Statistics,” Newman (2003) suggests that narrative skills enable physicians to make empathic connections with their patients.

Clinicians are often witnesses to their patients’ pain and suffering: they listen to the patients’ stories, and they prepare short narratives of the patients’ experiences after taking their history and interviewing them. The clinicians’ task, according to Kleinman (1988, p. 50), is “to witness a life story, to validate its interpretation, and to affirm its value.” Because the feelings and experiences of others are captured in patients’ narratives, their narratives can convey how they view their illness (Bruner, 1990). Evidence suggests that participating in programs on reflective writing and improving narrative skills can improve clinicians’ empathic understanding (DasGupta & Charon, 2004; Lancaster et al., 2002; Shapiro & Hunt, 2003). The understanding of patients will improve by adopting their perspectives through their stories, and by narrative skills allowing health care provider to reflect on the nature of patients’ concerns and experiences. According to Kumagai (2008), narratives of illness provide an insight into subjective experiences of others, which fosters perspective taking ability, and identification with patients. According to Steiner (2005), clinical stories can be used to inform, share, inspire, educate, and persuade, with implications not only in forming empathic engagement but also in health research (to find a common theme) and in health policy (to formulate compassionate policies).

Clinicians’ narrative skills gained by engaging with stories in literature is pivotal when thinking about case histories in ethics (Charon & Montello, 2002). Rita Charon (2001b) has written extensively about narrative medicine and physicians’ narrative competence in recognizing and interpreting the predicaments of their patients. She believes that a bridge exists between narrative skills and the capacity for empathy (Charon, 1993) and that the effective practice of medicine requires narrative competence that includes the ability to understand, absorb, interpret, and act based on the stories and plights of patients (Charon, 2000, 2001a).

Narrative competence in medicine can be acquired by reading, writing, studying the arts, and recognizing that all human beings are vulnerable to illness and death (Charon, 1993). According to DasGupta and Charon (2004), the ability to elicit, interpret, and translate 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, 2001a). In a study involving 11 second-year medical students, 9 reported that reflective writing (e.g., writing about a personal illness or another person’s illness) could enhance their understanding of patients and improve their ability to care for patients (DasGupta & Charon, 2004).

Narrative competence is beneficial not only for the clinicians who write the patients’ stories of illness to make accurate diagnoses and select appropriate treatments but for the patients as well. For example, patients with mild or moderately severe asthma or rheumatoid arthritis who wrote about their stressful experiences achieved a significantly better clinical outcome (Smyth, Stone, Hurewitz, & Kaell, 1999). Branch, Pels, and Hafler (1998) suggested that small-group discussions about medical students’ narrative reports of critical incidents during encounters with patients could enhance the students’ understanding of the clinician–patient relationship.

In another study, 40 staff physicians at the Cleveland Clinic were assigned into the experimental and two control groups (Misra-Hebert et al., 2012). Those in the experimental groups participated in a six-session program on narrative medicine and engaged in guided reflective writing. Physicians in one control group received the assigned course reading materials (which were given to the experimental group) but did not participate in the course sessions (control group 1), and those in the second control group neither received the reading materials nor participated in the course sessions. Quantitative analysis showed improvements in the experimental group compared to the two control groups (using the JSE). Qualitative analysis of physicians’ reflective writings in the intervention group showed compassionate solidarity and empathic concern and more exploration of negative rather than positive emotions.

Theatrical Performances

Dramatic performances by real or simulated patients, or by professional actors portraying patients or by health professions students playing a role, have been used to enhance empathy. For example, Shapiro and Hunt (2003) presented medical students at the University of California-Irvine College experiences with AIDS through narrative and song. Another 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.

In another study with 370 medical and pharmacy students at Chicago College of Osteopathic Medicine and at Chicago College of Pharmacy of Midwestern University (Van Winkle, Fjortoft et al., 2012), students participated in a workshop which included a 10-min theatrical play performed by their classmates who were coached to enact problems and concerns of elderly patients (a variation of the “aging game”). Subsequent to watching the play, students discussed in small groups their perceptions/feeling about issues of elderly people depicted in the play. Statistically significant increases in the JSE pretest-posttest mean scores were found in both groups of medical and pharmacy students. However, follow-up assessments showed that the improvement in empathy scores did not sustain for a longer time after the workshop.

The performing arts have also 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 into the observer that arise from climactic intellectual, emotional, or spiritual enlightenment (Golden, 1992). Empathy can arise from the cathartic effects of other peoples’ tragedies. In his theory of catharsis, Aristotle explained that observing the hero’s tragic experiences can generate a calming effect (a catharsis) that serves to separate the observer from the hero’s suffering while understanding the hero’s pain. A healthy society needs the performing arts, and students and practitioners in the health care professions need them for the same reason—because they learn about the experiences of others and can experience catharsis by being drawn into their patients’ tragic stories while remaining separate from patients (Trautmann Banks, 2002). In other words, empathy can arise from the cathartic effects of these stories.

Another explanation for the beneficial effects of the performing arts on empathy is the involvement of the human mirror neuron system. As I described in Chap.  13, when a person observes another person performing an act, the mirror neuron system is activated in the observer’s brain and contributes to empathic understanding of the observed person. It is also well known, particularly from studies involving hypnosis and imagery, that imagination can produce real physiological effects (Wester & Smith, 1984). These neurological and physiological activities may explain how watching theatrical or cinematic performances can induce neurophysiological effects leading to a greater empathic understanding.

There is a new notion of teaching health professions students performing arts to cultivate empathic skills. It is assumed that developing skills to act and think like another human being (e.g., doctors, patients) can improve understanding of those whose acts and thoughts are simulated. The idea seems to be similar to Gestalt-Therapy technique introduced by Frederick Perls (1969/1992). The basic principle in this therapeutic technique is to teach therapists and clients phenomenological awareness (being in the here and now) by placing oneself in another person’s shoes, but simultaneously retaining one’s own sense of identity. Acting nonjudgmentally as if one is another person, without losing the “as if” condition (Rogers, 1959, 1975), is the guiding acting role to experience another person’s feelings and concerns. Based on premises from theater and performing arts education, a technique, called “Facilitated Simulation Education and Evaluation,” has recently been introduced to improve interpersonal communication skills and enhance empathic understanding in physicians-in-training (Eisenberg, Rosenthal, & Schlussel, 2015). Currently Dr. Salvatore Mangione and his team at Sidney Kimmel Medical College are undertaking a study to teach different roles to medical students and residents by professional performers and faculty of performing arts to examine if role-performing skills can enhance empathy and tolerance.

Balint Method

The Balint training program was developed by Michael Balint at the Tavistock Institute in London for general practitioners. Balint designed a program to counteract a problem that Houston (1938) had described nearly two decades earlier. It is based on the notion that medical trainees often spend their entire training in the laboratory and the hospital ward where they do not have sufficient opportunity to develop skills in interpersonal aspects of patient care. To compensate for deficits in interpersonal communication and awareness of psychosocial aspects of illness, Balint suggested that they meet in small groups of ten to discuss cases they felt were difficult, particularly in relation to physician-patient relationship (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 of unstructured, open, and supportive small group meetings every 1–3 weeks, for 1–3 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, has received attention in some residency programs in the USA, particularly in family medicine (Brock & Salinsky, 1993; Cataldo, Peeden, Geesey, & Dickerson, 2005). In a study of family medicine residents in the USA, no significant difference on the scores of the JSE was observed between those who participated in a Balint training program and those who did not (Cataldo et al., 2005).

Other Approaches to Enhance Empathy in Health Professions Students and Practitioners

There are other innovative approaches used to sustain and enhance empathy among health professions students and practitioners. For example, in an experimental study of 248 second-year medical students at Jefferson (currently Sidney Kimmel) Medical College (Hojat, Axelrod et al., 2013), students were divided into experimental and control groups and participated in a two-phase study. In phase 1, students in the experimental group watched and discussed video clips of patient encounters (selected from commercial movies) meant to enhance empathic understanding; those in the control group watched a documentary film. Ten weeks later in phase 2 of the study, students who were in the experimental group were divided into two groups.

One group attended a lecture on the importance of empathy in patient care, and the other plus those in the control group watched a movie about racism. The JSE was administered pre-post in phase 1 and posttest in phase 2. Results showed a statistically significant increase in the JSE mean scores for the experimental group in phase 1. No significant change in the JSE scores was found in the control group. In phase 2 of the study, the JSE mean score improvement was sustained in the group who attended the lecture on importance of empathy in patient care, but not in the experimental group who watched a movie about racism in this phase of the study. Also, no significant change of empathy was observed in the control group in the second phase of the study. It was concluded that enhancement of empathy in medical students can be sustained by additional educational reinforcements.

In another study 57 residents from 16 family medicine programs (Magee & Hojat, 2010) were offered the opportunity in the second year of their training to choose one of their indigent pregnant patients who was in the second trimester of pregnancy, to receive the free gift of a glider rocking chair. Shortly after the baby was born, ten of the residents agreed to make a prearranged home visit to the mother of the newborn to assist in assembling the chair while talking with the mother in a friendly manner about child care and well-being. Compared to the residents who did not make such a home visit, the simple home visit experience contributed to an impressive increase in posttest JSE scores among those residents who made such a home visit.

In a study conducted at the University of Missouri-Kansas City School of Medicine, medical students participated in a three-stage multidimensional training program on empathy (Feighny et al., 1998). In Stage 1, the students developed a clinical presentation of an illness, such as diabetes, from a patient’s perspective (cognitive empathy). In Stage 2, the students tried to experience the situation as if they were patients (emotional empathy). In Stage 3, the students were provided with corrective feedback about their communication skills (behavioral empathy). The investigators noted that the students’ scores improved significantly on Carkhuff’s Empathic Understanding in Interpersonal Processes Scale but did not change significantly on the IRI. The investigators attributed the discrepancy to the IRI’s lack of sensitivity in the context of patient care. In her doctoral dissertation at Iowa University, Stebbins (2005) reported that exposure to interactive interpersonal communication enhanced empathy among second-year osteopathic medical students.

Platt and Keller (1994) developed a program to enhance empathic communication among physicians facing difficult encounters with patients who expressed strong negative emotions (e.g., anger, fear, sadness) and were unwilling to assume responsibility for their own health. During the program, the participants attempted to increase their awareness of a patient’s emotional clues by trying to understand the emotion, naming the emotion for the patient to insure that they had identified the emotion correctly, acknowledging and justifying the patient’s emotion, and affirming the patient’s behavior and offering help. The authors concluded that empathic communication is a teachable and learnable skill.

In summary, 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 Baernstien (2006) concluded that most studies that attempted to provide empirical evidence in support of improving empathy suffer from inappropriate design, methodological limitations, uncertainty about conceptualization and measurement of empathy, and small nonrepresentative samples. More convincing empirical evidence is needed to confirm the short- and long-term effects of these programs on health professions education and practice, as well as on the administration of the health care centers, and on health insurance company’s policies.

Effectiveness of the Programs

Although some studies cited in this chapter indicate that empathy can be enhanced, some clues suggest that the improvement cannot be sustained without practice or reinforcement (Engler et al., 1981; Hojat, Axelrod et al., 2013). Thus, the popular saying “Use it or lose it” may be applicable to empathy that has been enhanced as a result of an educational program. Furthermore, it is also important to bear in mind that when assessing any educational program designed to enhance empathy, it is desirable to examine not only the short-term but also, more importantly, the long-term effects of the program. Although some studies have indicated that educational training programs designed to enhance empathy may have a relatively long-term effect (Kramer et al., 1989; Poole & Sanson-Fisher, 1980), the long-lasting effect of empathy training programs awaits more empirical scrutiny.

At a conceptual level, it makes sense to believe that targeted educational programs can cultivate empathy. However, Skelton, Macleod, and Thomas (2000) are not satisfied with empirical evidence to verify the truth of this assumption. With regard to this challenge, McManus (1995) suggested that investigators who attempt to conduct empirical assessments of the humanities’ contribution to medical outcomes must “bite the bullet” of definition and measurement. However, recent research subsequent to the development of the JSE (Chap.  7) can relieve us, to some extent, of the need to bite that bullet (see  Appendix A).

Recapitulation

Although the current emphasis on professionalism in medicine places a high value on enhancement of empathy in patient care, most students in the existing medical education system in the USA do not routinely acquire the skills needed to demonstrate empathy. However, research shows that empathy can be effectively enhanced by targeted educational programs. Counteracting current trends in medical education and practice that are not conducive to empathic engagement in patient care requires a mandate for the development and implementation of educational programs at all levels of training (undergraduate, graduate, and continuing education) in all health professions academic centers and hospitals. Only then will the public be better served and will all health professionals regain the utmost respect they rightly deserve.

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Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

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

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