A Definition and Key Features of Empathy in Patient Care

  • Mohammadreza Hojat


  • Empathy in patient care is addressed in this chapter with regard to the World Health Organization’s (WHO) definition of health, consistent with the notion of a biopsychosocial paradigm of illness.

  • Empathy in the context of patient care is defined as a predominantly cognitive attribute that involves an understanding of the patient’s experiences, concerns, and perspectives, combined with a capacity to communicate this understanding and an intention to help. The importance of the four key features (cognition, understanding, communication, and an intention to help) used in the definition of empathy is elaborated and suggestion is made to make a distinction between cognition and emotion, between understanding and feeling, and between empathy and sympathy because of their different consequences in patient outcomes.

  • Because of its cognitive nature, an abundance of cognitively defined empathic engagement is always beneficial in the context of patient care, whereas excessive sympathetic involvement (akin to emotional empathy), because of its affective nature, can be detrimental to both the clinician and the patient, leading to exhaustion and burnout.

  • In the context of patient care, empathy bonds the patient and the health care provider together, whereas sympathy blinds them to objectivity and reason. Thus, efforts should be made to maximize empathy and regulate sympathy for optimal patient outcomes.

  • To achieve optimal patient outcomes, communication of understanding in empathic engagement between physician and patient must be reciprocal, confirming the patient’s significant role in the outcome of patient care.


Cognitive empathy Emotional empathy Clinical empathy Sympathy Healthy definition by WHO Biopsychosocial paradigm Cognition Understanding Intention to help Empathy versus sympathy 


  1. Aring, C. D. (1958). Sympathy and empathy. Journal of the American Medical Association, 167, 448–452.CrossRefPubMedGoogle Scholar
  2. Ayra, D. K. (1993). To empathize or to dissociate—A physician’s dilemma. Journal of the Royal Society of Medicine, 86, 3.Google Scholar
  3. Baron-Cohen, S. (2003). The essential difference: The truth about the male and female brain. New York: Basic Books.Google Scholar
  4. Bennett, M. J. (2001). The empathic healer: An endangered species. San Diego, CA: Academic Press.Google Scholar
  5. Blumgart, H. L. (1964). Caring for the patient. New England Journal of Medicine, 270, 449–456.CrossRefPubMedGoogle Scholar
  6. Borgenicht, L. (1984). Richard Selzer and the problem of detached concern. Annals of Internal Medicine, 100, 923–934.CrossRefPubMedGoogle Scholar
  7. Branch, W. T., & Malik, T. K. (1993). Using windows of opportunities in brief interviews to understand patients’ concerns. Journal of the American Medical Association, 169, 1667–1668.CrossRefGoogle Scholar
  8. Brody, H. (1997). Placebo response, sustained partnership, and emotional resilience in practice. Journal of the American Board of Family Practice, 10, 72–74.PubMedGoogle Scholar
  9. Bylund, C. L., & Makoul, G. (2005). Examining empathy in medical encounters: An observational study using the empathic communication coding system. Health Communication, 18, 123–140.CrossRefPubMedGoogle Scholar
  10. Carkhuff, R. (1969). Helping and human relations: Selection and training (Vol. 1). New York: Holt, Rinehart & Winston.Google Scholar
  11. Chessick, R. D. (1992). What constitutes the patient in psychotherapy: Alternative approaches to understanding humans. Northvale, NJ: Jason Aronson.Google Scholar
  12. Davis, M. H. (1983). Measuring individual differences in empathy: Evidence for a multidimensional approach. Journal of Personality and Social Psychology, 44, 113–126.CrossRefGoogle Scholar
  13. Davis, M. H. (1994). Empathy: A social psychological approach. Boulder, CO: Westview.Google Scholar
  14. Decety, J., & Jackson, P. L. (2006). A social-neuroscience perspective on empathy. Current Directions in Psychological Science, 15, 54–58.CrossRefGoogle Scholar
  15. DeKruif. (1926). Microb hunters. New York: Harcourt, Brace.Google Scholar
  16. Diseker, R. A., & Michielutte, R. (1981). An analysis of empathy in medical students before and following clinical experience. Journal of Medical Education, 56, 1004–1010.PubMedGoogle Scholar
  17. Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136.CrossRefPubMedGoogle Scholar
  18. Engel, G. L. (1990). The essence of the biopsychosocial model: From 17th to 20th century science. In H. Balner (Ed.), A challenge for biomedicine? (pp. 13–18). Amsterdam and Rockland, MA: Swets & Zeitlinger, Inc.Google Scholar
  19. Farber, N. J., Novack, D. H., & O’Brien, M. K. (1997). Love, boundaries, and the patient-physician relationship. Archives of Internal Medicine, 157, 2291–2294.CrossRefPubMedGoogle Scholar
  20. Figley, C. R. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York, NY: Brunner/Mazel.Google Scholar
  21. Frenk, J. (1998). Medical care and health improvement: The critical link. Annals of Internal Medicine, 129, 419–420.CrossRefPubMedGoogle Scholar
  22. Freud, S. (1958a). Recommendation to physicians practicing psychoanalysis. In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 12, pp. 109–120). London: Hogarth Press and the Institute of Psychoanalysis (original work published in 1912).Google Scholar
  23. Freud, S. (1958b). On beginning the treatment. In J. Starchey (Ed. & Trans.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 12, pp. 121–144). London: Hogarth Press and the Institute of Psychoanalysis (original work published in 1913).Google Scholar
  24. Friedman, E. (1990). The perlis of detachment. Health Care Forum Journal, 33, 9–10.PubMedGoogle Scholar
  25. Gianakos, D. (1996). Empathy revisited. Archives of Internal Medicine, 156, 135–136.CrossRefPubMedGoogle Scholar
  26. Gladstein, G. A. (1977). Empathy and counseling outcome: An empirical and conceptual review. The Counseling Psychologist, 6, 70–79.CrossRefGoogle Scholar
  27. Gleichgerrcht, E., & Decety, J. (2013). Empathy in clinical practice: How individual dispositions, gender, and experience moderate empathic concern, burnout, and emotional distress in physicians. PLoS One, 8(1–12), e61526. doi: 10.1371/journal.pone.0061526. Retrieved from: Scholar
  28. Greenson, R. (1967). The techniques and practice of psychoanalysis. New York: International University Press.Google Scholar
  29. Halpern, J. (2001). From detached concern to empathy: Humanizing medical practice. New York: Oxford University Press.CrossRefGoogle Scholar
  30. Hojat, M., Erdmann, J. B., & Gonnella, J. S. (2014). Personality assessments and outcomes in medical education and the practice of medicine (AMEE Guide 79). Dundee, UK: Association for Medical Education in Europe (AMEE). First published in 2013 in Medical Teacher, 35, e1267–e1301.Google Scholar
  31. Hojat, M., Gonnella, J.S., Mangione, S., Nasca, T.J., & Magee, M. (2003). Physician empathy in medical education and practice: Experience with the Jefferson Scale of Physician Empathy. Seminars in Integrative Medicine, 1, 25–41. Hojat, M., Gonnella, J. S., Nasca, T. J., Mangione, S., Vergare, M., & Magee, M. (2002b). Physician empathy: Definition, components, measurement, and relationship to gender and specialty. American Journal of Psychiatry, 159, 1563–1569.Google Scholar
  32. Hojat, M., Nasca, T. J., Cohen, M. J. M., Fields, S. K., Rattner, S. L., Griffiths, M., … Garcia, A. (2001). Attitudes toward physician-nurse collaboration: A cross-cultural study of male and female physicians and nurses in the United States and Mexico. Nursing Research, 50, 123–128.Google Scholar
  33. Hojat, M., Paskin, D. L., Callahan, C. A., Nasca, T. J., Louis, D. Z., Veloski, J. J., … Gonnella, J. S. (2007). Components of postgraduate competence: Analyses of 30 years of longitudinal data. Medical Education, 41, 282–289.Google Scholar
  34. Hojat, M., Samuel, S., & Thompson, T. L. (1995). Searching for the lost key under the light of biomedicine: A triangular biopsychosocial paradigm may cast additional light on medical education, research and patient care. In S. K. Majumdar, L. M. Rosenfeld, D. B. Nash, & A. M. Audet (Eds.), Medicine & health care into the 21st century (pp. 310–325). Easton, PA: Pennsylvania Academy of Science.Google Scholar
  35. Hojat, M., Spandorfer, J., Louis, D. Z., & Gonnella, J. S. (2011). Empathic and sympathetic orientations toward patient care: Conceptualization, measurement, and psychometrics. Academic Medicine, 86, 989–995. doi: 10.1097/ACM.0b013e31822203d8.CrossRefPubMedGoogle Scholar
  36. Hojat, M., Vergare, M., Maxwell, K., Brainard, G., Herrine, S. K., Isenberg, G. A., … Gonnella, J. S. (2009). The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Academic Medicine, 84, 1182–1191.Google Scholar
  37. Hojat, M., Vergare, M., Maxwell, K., Brainard, G., Herrine, S. K., Isenberg, G. A., … Gonnella, J. S. (2009). The devil is in the third year: A longitudinal study of erosion of empathy in medical school. Academic Medicine, 84, 1182–1191.Google Scholar
  38. Hudson, G. R. (1993). Empathy and technology in the coronary care unit. Intensive and Critical Care Nursing, 9, 55–61.CrossRefPubMedGoogle Scholar
  39. Jensen, N. (1994). The empathic physician. Archives of Internal Medicine, 154, 108.CrossRefGoogle Scholar
  40. Keysers, C., & Perrett, D. I. (2004). Demystifying social cognition: A Hebbian perspective. Trends in Cognitive Sciences, 8, 501–507.CrossRefPubMedGoogle Scholar
  41. Koenig, H. G. (2002). Spirituality in patient care. Philadelphia: Templeton Foundation Press.Google Scholar
  42. LaMonica, E. L. (1981). Construct validity of an empathy instrument. Research in Nursing & Health, 4, 389–400.CrossRefGoogle Scholar
  43. Larson, E. B., & Yao, X. (2005). Clinical empathy as emotional labor in the patient-physician relationship. Journal of the American Medical Association, 293, 1100–1106.CrossRefPubMedGoogle Scholar
  44. Lazarus, R. S. (1982). Thoughts on the relations between emotion and cognition. American Psychologist, 37, 1019–1024.CrossRefGoogle Scholar
  45. Levinson, W. (1994). Physician-patient communication: A key to malpractice prevention. Journal of the American Medical Association, 272, 1619–1620.CrossRefPubMedGoogle Scholar
  46. Lief, H. I., & Fox, R. C. (1963). Training for “detached concerns” in medical students. In H. I. Lief, V. F. Lief, & N. R. Lief (Eds.), The psychological basis of medical practice (pp. 12–35). New York: Harper & Row.Google Scholar
  47. Lief, H. I., Lief, V. F., & Lief, N. R. (Eds.). (1963). The psychological basis of medical practice. New York: Harper & Row.Google Scholar
  48. Linley, P. A., & Joseph, S. (2007). Therapy work and therapists’ positive and negative well-being. Journal of Social and Clinical Psychology, 26, 385–403.CrossRefGoogle Scholar
  49. Makoul, G. (1998). Perpetuating passivity: Reliance and reciprocal determinism in physician-patient interaction. Journal of Health Communication, 3, 233–259.CrossRefPubMedGoogle Scholar
  50. Makoul, G. (2001). Essential elements of communication in medical encounters: The Kalamazoo consensus statement. Academic Medicine, 76, 390–393.CrossRefPubMedGoogle Scholar
  51. McKinlay, J. B., & McKinlay, S. M. (1981). Medical measures and the decline of mortality. In P. Conrad & R. Kern (Eds.), The sociology of health and illness: Critical perspectives (pp. 12–30). New York: St. Martin’s Press.Google Scholar
  52. Mehrabian, A., & Epstein, N. A. (1972). A measure of emotional empathy. Journal of Personality, 40, 525–543.CrossRefPubMedGoogle Scholar
  53. Miller, K. (2002). Communication theories: Perspective, processes, and context. Boston: McGraw-Hill.Google Scholar
  54. Morse, J. M., & Mitcham, C. (1997). Coempathy: The contagion of physical distress. Journal of Advanced Nursing, 26, 649–657.CrossRefPubMedGoogle Scholar
  55. Nightingale, S. D., Yarnold, P. R., & Greenberg, M. S. (1991). Sympathy, empathy, and physician resource utilization. Journal of General Internal Medicine, 6, 420–423.CrossRefGoogle Scholar
  56. Novack, D. H. (1987). Therapeutic aspects of the clinical encounter. Journal of General Internal Medicine, 2, 346–355.CrossRefPubMedGoogle Scholar
  57. Novack, D. H., Epstein, R. M., & Paulsen, R. H. (1999). Toward creating physician-healers: Fostering medical students’ self-awareness, personal growth, and well-being. Academic Medicine, 74, 516–520.CrossRefPubMedGoogle Scholar
  58. Olinick, S. L. (1984). A critique of empathy and sympathy. In J. Lichtenbergh, M. Borenstein, & D. Silver (Eds.), Empathy I (pp. 137–166). Hillsdale, NJ: Analytic Press.Google Scholar
  59. Osler, W. (1932). Aequanimitas with other addresses to medical schools, nurses, and practitioners of medicine. Philadelphia, PA: Blakiston.Google Scholar
  60. Peabody, F. W. (1984). The care of the patient. Journal of the American Medical Association, 252, 813–818.CrossRefPubMedGoogle Scholar
  61. Raudonis, B. M. (1993). The meaning and impact of empathic relationships in hospice nursing. Cancer Nursing, 16, 304–309.CrossRefPubMedGoogle Scholar
  62. Ray, O. (2004). How the mind hurts and heals the body. American Psychologist, 59, 29–40.CrossRefPubMedGoogle Scholar
  63. Reynolds, W. J. (2000). The measurement and development of empathy in nursing. Burlington, VT: Ashgate.Google Scholar
  64. Rogers, C. R. (1975). Empathic: An unappreciated way of being. Counseling Psychologist, 5, 2–11.CrossRefGoogle Scholar
  65. Schneiderman, L. J. (2002). Empathy and the literary imagination. Annals of Internal Medicine, 137, 627–629.CrossRefPubMedGoogle Scholar
  66. Soenens, B., Duriez, B., Vansteenkiste, M., & Goossens, L. (2007). The intergeneration transmission of empathy-related responding in adolescence: The role of maternal support. Personality and Social Psychology Bulletin, 33, 200–311. doi: 10.1177/0146167206296300.CrossRefGoogle Scholar
  67. Solomon, R. C. (1976). The passion. New York: Anchor/Doubleday.Google Scholar
  68. Spiro, H. (1992). What is empathy and can it be taught? Annals of Internal Medicine, 116, 843–846.CrossRefPubMedGoogle Scholar
  69. Starcevic, V., & Piontek, C. M. (1997). Empathic understanding revisited: Conceptualization, controversies, and limitations. American Journal of Psychotherapy, 51, 317–328.PubMedGoogle Scholar
  70. Suchman, A. L., Markakis, K., Beckman, H. B., & Frankel, R. (1997). A model of empathic communication in the medical interview. Journal of the American Medical Association, 277, 678–682.CrossRefPubMedGoogle Scholar
  71. Sutherland, J. A. (1993). The nature and evolution of phenomenological empathy in nursing: An historical treatment. Archives of Psychiatric Nursing, 7, 369–376.CrossRefPubMedGoogle Scholar
  72. Tausch, R. (1988). The relationship between emotions and cognitions: Implications for therapist empathy. Person-Centered Review, 3, 277–291.Google Scholar
  73. Truax, C. B., & Carkhuff, R. (1967). Towards effective counseling and psychotherapy: Training and practice. Chicago: Aldine.Google Scholar
  74. White, K. L. (1991). Healing the schism: Epidemiology, medicine, and the public’s health. New York: Springer-Verlag.CrossRefGoogle Scholar
  75. Wispe, L. (1986). The distinction between sympathy and empathy: To call forth a concept, a word is needed. Journal of Personality and Social Psychology, 50, 314–321.CrossRefGoogle Scholar
  76. World Health Organization. (1948). World Health Organization Constitution: Basic documents. Geneva: Author.Google Scholar

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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