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(Hojat 2009)

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

"Empathy has been considered as far too important to be taught only to health professionals (Ivey, 1971; 1974).

 Others have suggested that the capacity for empathy in people in general can serve as a foundation for building interpersonal relationships that have a buffering effect against stress and can be an essential step in conflict resolution (Kremer & Dietzen, 1991). 

As the author has noted "empathy can be viewed as a remedy for the psyche and soul of human kind...And may be it can serve as a means of achieving a global peace here, there, everywhere on earth." (Hojat, 2007, p. 214).

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

Methods Outline

  • Improving Interpersonal Skills:

  • Audio- or Video-Taping of Encounters with Patients:

  • Exposure to Role Models:

  • Role Playing (Aging Games):

  • Shadowing a Patient (Patient Navigator):

  • Hospitalization Experiences:

  • Study of Literature 

  • Study of the Arts:

  • Improving Narrative Skills:

  • Theatrical Performances:

  • Balint Method:



Adler, H. M. (1997). The history of the present illness as treatment: Who's listening, and why does it matter? The Journal of the American Board of Family Practice, 10, 28-35.

Adler, H.M, & Mammett, V. B. O. (1973). The doctor-patient relationship revisited: An analysis of the placebo effect. Annals of Internal Medicine, 78, 595-598.

Acuna, L. E. (2000). Don't cry for us Argentina: Two decades of teaching medical humanities. Journal of Medical Ethics: Medical Humanities, 26, 66-70.

Avery, J.K. (1985). Lawyers tell what turns some patients litigious. Medical Malpractice Review, 2, 35-37.

Balint, M. (1957). The doctor, his patient and the illness. New York: International University Press.

Basch, M. F. (1983). Empathic understanding: A review of the concept and some theoretical considerations. Journal of the American Psychoanalytic Association, 31, 101-126.

Beckman, H. B., & Frankel, R. M. (1984). The effect of physician behavior on the collection of data. Annals of Internal Medicine, 101,692-696.

Beckman, H.B., Markakis, K. M., Suchman, A. L., & Frankel, R.M. (1994). The doctor-patient relationship and malpractice: Lessons from plaintiff depositions. Archives of Internal Medicine, 154, 1365-1370.

Bendaputi, N.M., Berry, L L. Frey, K.A., Parish, J.T. (2006). Patients' perspectives on ideal physician behavior. Mayo Clinic Proceedings, 81, 338-344.

Bertakis, K.D., Roter, D., & Putman, S.M. (1991). The relationship of physician medical interview style to patient satisfaction. Journal of Family Practice, 32, 175-181.

Book, H. E. (1991). Is empathy cost efficient? American Journal of Psychotherapy, 45, 21-30.

Branch, W.T., & Malik, T. K. (1993). Using "windows of opportunities" in brief interviews to understand patients' concerns. The Journal of American Medical Association, 269, 1667-1668.

Brock, C. D., & Salinsky, J. V. (1993).Empathy: An essential skill for understanding the physician-patient relationship in clinical practice. Family Medicine, 25, 245-248.

Brody, H. (1997). Placebo response, sustain partnership, and emotional resilience in practice. Journal of the American Board of Family Practice, 10, 72-74.

Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard University Press.

Calman, K., Downie, R. S., Duthie, M., & Sweeney, B. (1988). Literature and medicine: A short course for medical students. Medical Education, 22, 265-269.

Campus-Outcalt, D., Senf, J., Watkins, A. J., & Bastacky, S. (1995). The effects of medical school curricula, faculty role models, and biomedical research on choice of generalist physician career: A review and quality assessment of the literature. Academic Medicine, 70, 611-619.

Cataldo, K. P., Peeden, K., Geesey, M. F., & Dickerson, I. (2005). Association between Balint training and physician empathy and work satisfaction. Family Medicine, 37, 328-331.

Charon, R. (2001). Narrative Medicine: A model for empathy, reflection, profession, and trust. Journal of American Medical Association, 286, 1897-1902.

Charon, R., Trautmann Banks, J., Connelly, J.E., Hunsaker Hawkins, A., Montgomery Hunter, K., Hudson Jones,A., Montello, M., & Poirer, S. (1995). Literature in medicine: Contribution to clinical practice. Annals of Internal Medicine, 122, 599-606.

Chen, J.T., LaPopa, J., Dang, D.K. (2008). Impact of patient empathy modeling on pharmacy students caring for underserved. American Journal of Pharmaceutical Education, 72, 1-7.

Coles, R. (1989). Call of stories: teaching and moral imagination. Boston: Houghton-Mifflin.

DasGupta, S., & Charon, R. (2004). Personal illness narratives: Using reflective writing to teach empathy. Academic Medicine, 79, 351-356.

DiMatteo, M. R. (1979). A social-psychological analysis of physician-patient rapport toward a science of the art of medicine, Journal of Social Issues, 35,12-33.

DiMatteo, M.R., Hays, R. D., & Prince, L. M. (1986). Relationship of physicians, nonverbal communication skills to patient satisfaction, appointment noncompliance, and physician workload. Health Psychology, 5, 581-594.

DiMatteo, M. R., Sherbourne, C.D., Hays, R.D., Ordway, L., Kravitz, R. L., McGlenn, E.A., Kaplan, S., & Rogers, W. H. (1993). Physicians' characteristics influence patients' satisfaction from physicians' nonverbal communication skills. Medical Care, 17, 376-387.

Eisenberg, N., & Strayer, J. (1987). Empathy and its development. Cambridge, UK: Cambridge University Press.

Eisenthal, S.E., Emery, R., Lazare, A., & Udin, H. (1979). Adherence and negotiated approach in patienthood. Archives of General Psychiatry, 36, 393-398.

Evans, B. J., Stanley, R. O., Burrows, G.D., & Sweet, B. (1989). Lectures and skills workshops as teaching formats in a history-taking skills course for medical students. Medical Education, 23, 364-370.

Evans, B.J., Stanley, R.O., & Burrows, G. D. (1993). Measuring medical students' empathy skills. British Journal of Medical Psychology, 66, 121-133.

Fernandez-Olano, C., Montoya-Fernandez,J., & Salinas-Sanches, A.S. (2008). Impact of clinical interview training on the empathy level of medical students and medical residents. Medical Teacher, 30, 322234.

Ferrante, J. M., Chen, P.H., & Kim, S. (2007). The effect of patient navigation on time to diagnosis, anxiety, and satisfaction in urban minority women with abnormal mammograms: A randomized controlled trial. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 85, 114-124.

Ficklin, F.L., Browne, V. L., Powel, R. C., & Carter, J. E. (1988). Faculty and house staff members as role models. Journal of Medical Education, 63, 392-396.

Fields S.K., Hojat, M., Gonnella, J.S., Mangione, S., Kane, G, & Magee, M. (2004). Comparisons of nurses and physicians on an operational measure of empathy. Evaluation & The Health Professions. 27, 80-94.

Flagler, E. (1997). Narrative ethics: A means to enrich medical education. Annals of the Royal College of Physicians & Surgeons of Canada, 30, 217-220.

Francis, V, & Morris, M. (1969). Gaps in doctor-patient communication: Patients' response to medical advice. The new England Journal of Medicine, 280, 535-540.

Freeman H.P., Muth, B., & Kerner, J.F. (1995). Expanding access to cancer screening and clinical follow-up among the medically underserved. Cancer Practice, 3, 19-30.

Golden, L. (1992). Aristotle on tragic and comic mimesis. Atlanta, GA: Scholar Press.

Gustafson, J.P. (1986). The complex secret of brief psychotherapy. New York: W.W. Norton.

Hafferty, F.W. (1998). Beyond curriculum reform: Confronting medicine's hidden curriculum. Academic Medicine, 73, 403-407.

Henry-Tillman, R., Deloney, L. A., Savidge, M., Graham, C. J., & Klimberg, S. (2002). The medical student as patient navigator as an approach to teaching empathy. The American Journal of Surgery, 183, 659-662.

Herman, J. (2000). Reading for empathy. Medical Hypothesis, 54, 167-168.

Hickson, G.B., Clayton, E.W., Entman, Miller, C.S., Githens, P.B., Whethen-Goldstein, K, & Sloan, F.A. (1994). Obstetricians' prior malpractice experience and patient satisfaction with care. Journal of American Medical Association, 272, 1583-1587.

Hickson, G.B., Clayton, E. W., Githens, P.B., & Sloan, F. A. (1992). Factors that prompted families to file medical malpractice claims following perinatal injuries. Journal of the American Medical Association, 267, 1359-1363.

Hoffman, S. B., Brand, F.R., Beatty, P.G., & Hamill. L. A. (1985). Geriatrix: A role-playing game. Gerontologist, 25, 568-572.

Hoffman, T. L., & Reif, S.D. (1978). 'Intro aging': Simulation game. Thorofare, NJ: Charles B. Slack Inc.

Hojat, M. (2007). Empathy in patient care: Antecedents, development, measurement, and outcomes. New York: Springer.

Hojat, M., Fields, S.K., Gonnella, J.S. (2003). Empathy: An NP/MD comparison. The Nurse Practitioner, 28, 45-47.

Hojat, M., Gonnella, J. S., Mangione, S., Nasca, T. J., Veloski, J. J., Erdmann, J. B., Callahan, C. A., & Magee, M. (2002a). Empathy in medical students as related to academic performance, clinical competence, and gender. Medical Education,36,522-527.

Hojat, M. Gonnella, J.S. Nasca, T.J., Mangione, S., Veloski, J.J., & Magee, M. (2002b). The Jefferson Scale of Physician Empathy: Further psychometric data and differences by gender and specialty at item level. Academic Medicine (supplement), 77, S58 S60.

Hojat, M. Gonnella, J.S., Nasca, T.J., Mangione, S., Vergare, M. , & Magee, M. (2002c). Physician empathy: Definition, measurement, and relationship to gender and specialty. American Journal of Psychiatry, 159, 1563-1569.

Hojat, M., Mangione, S., Gonnella, J. S., Nasca T., Veloski, J. J., & Kane, G. (2001). Empathy in medical education and patient care. Academic Medicine, 76, 669.

Hojat, M. Mangione, S., Kane, G., Gonnella, J.S. (2005). Relationships between scores of the Jefferson Scale of Physician Empathy (JSPE) and the Interpersonal Reactivity Index (IRI). Medical Teacher, 27, 625628.

Hojat, M., Mangione, S., Nasca, T. J., Cohen, M. J. M., Gonnella, J. S., Erdmann, J. B., Veloksi, J. J., & Magee, M. (2001). The Jefferson scale of physician empathy: Development and Preliminary psychometric data. Educational and Psychological Measurement, 61, 349-365.

Hojat, M., Mangione, S. Nasca, T.J. &. Gonnella, J.S. (2005). Empathy scores in medical school and ratings of empathic behavior 3 years later. Journal of Social Psychology, 145 (6), 663-672.

Hojat, M., Mangione, S., Nasca, T.J., Rattner, S., Erdmann, J.B., Gonnella, J.S., & Magee, M. (2004). An empirical study of decline in empathy in medical school. Medical Education, 38, 934-941.

Holleman, W. L. (2000). The play's the thing: Using literature and drama to teach about death and dying. Family Medicine, 32, 523-524.

Holtzman, J.M., Beck, J.D., Coggin, P. G. (1978). Geriatric program for medical students, II: Impact of two educational experiences on students attitudes. Journal of American Geriatric Society, 26, 355-359.

Holtzman, J.M., Beck, J.D., & Ettinger, R.L. (1981). Cognitive knowledge and attitudes toward the aged dental and medical students. Educational Gerontology, 6, 195-207.

Ingelfinger, F. J. (1980). Arrogance. The New England Journal of Medicine, 303, 1507-1511.

Ivey, A. (1971). Microcounseling: Innovations in interviewing training. Springfield, Ill: Charles C. Thomas.

Ivey, A. (1974). Microcounseling and media therapy: State of the art. Counselor Education and supervision, 4, 173-183.

Jackson, S. W. (2001). The wounded healer. Bulletin of the History of Medicine, 75, 1-36.

Jones, A. H. (1997). Literature and medicine: Narrative ethics. Lancet, 349, 1243-1246.

Jones, A. H. (1987). Reflections, projections, and the future of literature-and-medicine. In D.Wear, M. Kohn, & S. Stocker (Eds.). Literature and medicine: A claim for a discipline (pp. 29-40). McLean, VA: Society for Health and Human Services.

Kestenbaum, R., Farber, E. A., Sroufe, L.A. (1989). Individual differences in empathy among preschoolers: Relation to attachment history. In N. Eisenberg (Ed.), Empathy and related emotional responses (pp.51-64). San Francisco: Jossey-Bass.

Kleinman, A. (1995). Writing at the margin: Discourse between anthropology and Medicine. Berkeley, CA: University of California Press.

Kramer, D., Ber, R., & Moore, M. (1989). Increasing empathy among medical students. Medical Education, 23, 168-173.

Kremer, J. F., & Dietzen, L. L. (1991). Two approaches to teaching accurate empathy to undergraduates: Teacher-intensive and self-directed. Journal of College Student Development, 32, 69-75.

Kumagai, A. K. (2008). A conceptual framework for the use of illness narratives in medical education. Academic medicine, 83, 653-658.

Lancaster, T., Hart, R., & Gardner, S. (2002). Literature and medicine: Evaluating a special study module using the nominal group technique. Medical Education, 36, 1071-1076.

Levinson, W., Roter, D., Mulloly, J. P., Dull, V.T., & Frankel, R. (1997). Physician-patient communication: The relationship with malpractice claims among primary care physicians and surgeons. Journal of American Medical Association, 277, 553-559.

Levy, J. (1997). A note on empathy. New Ideas in Psychology, 15, 179-184.

Linley, P. A., Joseph, S. (2007). Therapy work and therapists' positive and negative well-being. Journal of Social and Clinical Psychology, 26, 385-403.

Maheux, B., Beaudoin, C., Berkson, L. C., Des Machais, J., & Jean, P. (2000). Medical faculty as humanistic physicians and teachers: The perception of students at innovative and traditional medical schools. Medical Education, 34, 630-634.

Mangione, S. Kane, G.C., Caruso, J.W., Gonnella, J.S., Nasca, T.J., & Hojat, M. (2002). Assessment of empathy in different years of internal medicine training. Medical Teacher, 24, 371-374.

Marcus, E.R. (1999). Psychodynamic social science and medical education. Journal of Psychotherapy Practice & Research, 8, 191-194.

Marte, A.L., (1988). How does it feel to be old? Simulation game provides "into aging" experience. Journal of Continuing Education in Nursing, 19, 166-168.

Marshall, P. A., & O'Keefe, J. P. (1994). Medical students' first person narrative of a patient's story of AIDS. Social Science & Medicine, 40, 67-76.

Matthews, D. A., Suchman, A. L., & Branch, W. T. (1993). Making "connexious": Enhancing the therapeutic potential of patient-clinician relationships. Annals of Internal Medicine, 118, 973-977.

Mclean, M. (2004). The choice of role models by students at a culturally diverse South Africa medical school. Medical Teacher, 26, 133-141.

McLellan, M. F. & Husdon Jones, A. (1996). Why literature and medicine? Lancet, 348, 109-111.

McVey, L.J., Davis, D.E., Cohen, H.J. (1989). The 'aging game' an approach to education of geriatrics. Journal of American Medical Association, 262, 1507-1509.

Mehrabian, A. (1972). Nonverbal communication. New York: Aldine-Atherton.

Menks, F. (1983). The use of a board game to simulate the experience of old age. Gerontologist, 23, 565-568.

Montgomery Hunter, K., Charon, R., & Coulehan, J. L. (1995). The study of literature in medical education. Academic Medicine , 70, 787-794.

Moore, P. J., Adler, N. E., & Robertson, P.A. (2000). Medical malpractice: The effect of doctor-patient relations on medical patient perceptions and malpractice intentions. Western Journal of Medicine, 173, 244-250.

Morse, D.S., Edwardsen, E.A., Gordon, H.S. (2008). Missed opportunities for interval empathy in long cancer communication. Archives of Internal Medicine, 168, 1853-1858.

Nightingale, S.D., Yarnold, P.R., & Greenberg, M.S. (1991). Sympathy, empathy, and physician resource utilization. Journal of General Internal Medicine, 6, 420-423.

Oatley, K. (2004). Script, transformation, and suggestiveness of emptions in Shakespeare and Chekhov. Review of General Psychology, 8, 323340.

Pacala, J.T., Boult, C., Bland, C., & O'Brien, J. (1995). Aging game improves medical students' attitudes toward caring for elderly. Gerontology & Geriatrics Education, 15, 45-57.

Pacala, J. T., Boult, C., Hepburn, K. (2006). Ten years' experience conducting the Aging game workshop: was it worth it? Journal of American Geriatric Society, 54, 144-149.

Peschel, E.R. (1980). Medicine and literature. New York: Neale Watson.

Pigman, G. W. (1995). Freud and the history of empathy. International Journal of Psychoanalysis, 76, 237-256.

Pollak, I. K., Arnold, R. M., Jeffrey, A. S., Alexander, S. C., Olsen, M. K., Abernethy, A. P., Skinner, C.S., Rodriguez, .L., & Tulsky, J. A. (2007). Oncologist communication about emotions during visits with patients with advanced cancer. Journal of Clinical Oncology, 25, 5748-5752.

Poole, A.D., Sanson-Fisher, R.W. (1980). Long-term effects of empathy training on the interview skills of medical students. Patient Counseling and Health Education, 2, 125-127.

Quill, T. E. (1987). Medical resident education: A cross-sectional study of the influence of the ambulatory preceptor as a role model. Archives of Internal Medicine, 147, 971-973.

Radley, C. (1992). Imagining ethics: Literature and practice of ethics. Journal of Clinical Ethics, 3, 38-45.

Reik, T. (1948). Listening with the third ear: The inner experience of a psychoanalyst. New York: Farrar, Straus.

Roter, D. L., Hall, J. A., Kern, D. E., Baker, L. R., Cole, K. A., & Roca, R. P. (1995). Improving physicians' interviewing skills and reduction in patients' emotional distress: A randomized clinical trial. Archives of Internal Medicine, 155, 1877-1884.

Roter, D. L, Hall, J. A., Merisca, R., Nordstrom, B., Cretin, D., & Svarstad, B. (1998). Effectiveness of interventions to improve patient compliance: A meta analysis. Medical Care, 36, 1138-1161.

Sanson-Fisher, R.W., Poole, A.D. (1978). Training medical students to empathize: An experimental study. Medical Journal of Australia, 1, 473-476.

Seaberg, D.C., Godwin, S. A., & Perry, S. J. (1999). Teaching empathy in an emergency medicine residency. Academic Emergency Medicine, 6, 485.

Seaberg, D. C., Godwin, S. A., & Perry, S. J. (2000). Teaching patient empathy: The ED visit program. Academic Emergency Medicine, 7, 1433-1436.

Schneiderman, L. J. (2002). Empathy and the literary imagination. Annals of Internal Medicine, 137, 627629.

Shanafelt, T.D., West, C., Zhao, X., Novotny, P., Kolars, J., Habermann, T., Sloan, J. (2005). Relationship between increased personal well-being and enhanced empathy among internal medicine residents. Journal of General Internal Medicine, 20, 559-564.

Shapiro, J. (2002). How do physicians teach empathy in the primary care setting? Academic Medicine, 77, 323328.

Shapiro, J., & Hunt, L. (2003). All the world's a stage: The use of theatrical performance in medical education. Medical Education, 37, 922-927.

Shapiro, J, Morrison, E., & Boker, J. (2004). Teaching empathy to first year medical students: evaluation of an elective literature and medical course. Education for Health, 17, 73-84.

Shapiro, R. S., Simpson, D. E., & Lawrence, S. L. (1989). Survey of sued and non-sued physicians and suing patients. Annals of Internal Medicine, 149, 21902196.

Skeff, K. M., & Mertha, S. (1998). Role models: Guiding the future of medicine. New England Journal of Medicine, 339, 2015-2017.

Smith, B. H. (1981). Narrative versions, narrative theories. In W. J. T. itchell (Ed.). On narrative (pp. 209-232). Chicago: University of Chicago Press.

Spiro, H. (1992). What is empathy and can it be taught? Annals of Internal Medicine, 116, 843-846.

Squire, R.W. (1990). A model of empathic understanding and adherence to treatment regimens in practitioner-patient relationships. Social Science & Medicine, 30, 325-339.

Steiner, J. F. (2005). The use of stories in clinical research and health policy. Journal of the American Medical Association, 294, 2901-2904.

Stepien, K. A., Baernstein, A. (2006). Educating for empathy: A review. Journal of General Internal Medicine, 21, 524-530.

Stewart, M., Brown, J.B., Boon, H., Galajda, J., Meredith, L., Sangster, M. (1999). Evidence on patient-doctor communication. Cancer Prevention and Control, 3, 25-30.

Stokes, J. (1980). Grief and the performance arts: A brief experiment in humanistic medical education. Journal of Medical Education, 55, 215.

Suchman, A.L., Markakis, K., Beckman, H.B., & Frankel, R. (1997). A model of empathic communication in the medical interview. The Journal of American medical Association, 277, 678-682.

Szalita, A. B. (1976). Some thoughts on empathy: The eighteenth annual Frieda Fromm-Reichmann memorial lecture. Psychiatry, 39, 142-152.

Thomas, M. R., Dyrbye, L.N., Huntington, J.L., Lawson, K.L., Novotny, P.J., Sloan, J.A. Shanafelt, T.D. (2007). How do distress and well-being relate to medical student empathy? A multicenter study. Journal of General Internal Medicine, 22, 177-183.

Varkey, P., Chutka, D.S., & Lesnick, T.G. (2006). The aging game: Improving medical students' attitudes toward caring for the elderly. Journal of the American Medical Directors Association, 7, 224229.

Ward, J., Schaal, M., Sullivan, J., Bowen, M.E., Erdmann, J.B., Hojat, M. (in press). Reliability and validity of the Jefferson Scale of Empathy in undergraduate nursing students. Journal of Nursing Measurement.

Wear, D., Nixon, L.L. (2002). Literary inquiry and professional development in medicine: Against abstraction. Perspectives in Biology and Medicine, 45, 104-124.

Werner, A., & Schneider, J. M. (1974). Teaching medical students interactional skills: A research-based course in the doctor-patient relationships. The New England Journal of Medicine, 290, 1232-1237.

West, C.P., Huschka, M.M, Novotny, P.J., Sloan, J.A., Kolars, J.C., Habermann, T.M., Shanafelt, T.D. (2006). Association of perceived medical errors with resident distress and empathy. Journal of the American Medical Association, 296, 1071-1078.

Wilkes, M., Milgrom, E., & Hoffman, J. R. (2002). Toward more empathic medical students: A medical student hospitalization experience. Medical Education, 36, 528-533.

Winefield, H. R., & Chur-Hansen, A. (2000). Evaluating the outcome of communication skill teaching for entry-level medical students.: Does knowledge of empathy increase? Medical Education, 34, 90-94.

Wolfgang, A. (1979). Nonverbal behavior: Applications and cultural implications. New York: Academic Press.

Wright, S. D. (1996). Examining what residents look for their role models. Academic Medicine, 71, 290-292.

Yedidia, M. J., Gillespie, C. C., Kachur, E., Schwartz, M . D., Ockene, J., Chepaitis, A. E., Snyder, C. W., Lazare, A., & Lipkin, M. (2003). Effect of communication training on medical student performance. Journal of the American Medical Association, 290, 1157-1165.

Zachariae, R., Pedersen, C.G., Jensen, A.B., Ehrnrooth, E., Rossen, P.B., & von der Maase, H. (2003). Association of perceived physician communication style with patient satisfaction, distress, cancer-related self efficacy, and perceived control over the disease. British Journal of Cancer, 88, 658-665.