Health care organizations are well aware that patient satisfaction will be an important and growing component of the formula used by the Centers for Medicare & Medicaid Services to calculate reimbursements, as stated in the Patient Protection and Affordable Care Act.
Where CMS goes, many private payers are likely to follow. In fact, some private payers already have begun experimenting with pay-for-performance contracts that include a patient satisfaction component.
And as payers start to factor patient satisfaction into their reimbursement rates, health care organizations are linking patient satisfaction with physician pay. Hay Group's 2011 Physician Compensation Survey revealed that more than 60 percent of health care organizations now are incorporating patient satisfaction scores when calculating physician incentive payments.
So hospitals and physicians alike face a critical question: How can we improve patient satisfaction?
The Empathy-Satisfaction Connection
There is no magic bullet here. Hospitals and providers will have to do many things right to get strong satisfaction ratings on the Hospital Consumer Assessment of Health Providers and Systems surveys, but there is solid evidence that physician empathy plays an important role in forging strong patient-physician relationships and boosting patient satisfaction. For example, a classic study of empathy among senior medical students found that doctors who were rated most empathetic by their patients also succeeded in making patients feel comfortable and important (J.A. Colliver et al., "Assessment of Empathy in a Standardized-Patient Examination," Teach Learn Med 1998; 10:8–10).
It appears as though physician empathy has many other benefits for both doctors and patients. University of Melbourne Professor Nick Haslam summarized a number of these benefits in a 2007 article for the Medical Journal of Australia ("Humanising Medical Practice: The Role of Empathy," 187(7): 381–82). The studies cited by Haslam suggest that patients have better treatment adherence and suffer from fewer major medical errors while under the care of empathetic doctors.
Two other recent studies, one in Academic Medicine (M. Hojat et al., "Physicians' Empathy and Clinical Outcomes for Diabetic Patients," March 2011, 86(3): 359–64) and the other in Patient Education and Counseling (D. Rakel and B. Barrett et al., "Perception of Empathy in the Therapeutic Encounter: Effects on the Common Cold," E-pub Feb. 5, 2011; Dec. 2011, 85(3):390-7), have shown that health benefits were greater for diabetes patients (better cholesterol and blood-sugar scores) and flu patients (faster recovery times) who were under the care of empathetic doctors. Furthermore, neuroscientific research supports the idea that expressions of empathy in a health care setting by high-status individuals, such as physicians or nurse managers, can lead to "emotional contagion" that improves morale, motivation and satisfaction throughout the organization (D. Goleman et al., Primal Leadership, 2002; see Chapter 1).
Defining Empathy in a Medical Context
How can physicians and other health care providers express empathy in a medical setting?
Daniel Goleman, Hay Group research partner and co-founder of the Consortium for Research on Emotional Intelligence in Organizations, provides a clear, workable definition of empathy: (1) understanding the emotional makeup of people and (2) treating people according to their emotional reactions.
Being empathetic in a health care context means taking the time and interest to understand the emotional state of patients and other stakeholders, then finding ways to tailor communication methods and content according to these perceived emotional states.
Physicians may have another compelling reason to embrace empathetic medicine. In "Strategic Risk Management: Reducing Malpractice Claims Through More Effective Patient-Doctor Communication," first published in the American Journal of Medical Quality (July/Aug. 1999, 14(4): 153–59), Bernard Virshup and other researchers at the University of Southern California found that physicians who are able to understand and appropriately respond to the emotional needs of their patients (act empathetically) are less likely to be hit with malpractice lawsuits.
Demonstrating Emotional Intelligence
As Daniel Goleman has explained, empathy is one of the main components of emotional intelligence. For hospitals trying to raise the empathetic standards of their physicians, it makes sense to help doctors cultivate their emotional intelligence.
Some hospitals already have started down this path. As Helen Riess, M.D., director of the Empathy and Relational Science Program at Massachusetts General Hospital, says, "Contemporary physicians face incredible pressures in terms of the number of patients they are expected to see and the documentation requirements for each of those patients. It can be difficult for physicians to respond to those pressures while maintaining their empathy and compassion."
Her team is addressing these pressures by offering empathy training and emotional intelligence education to physicians and residents. A randomized controlled trial to test the results of Riess' empathy training showed statistically significant improvements in satisfaction among patients treated by residents who had undergone the training. The results have just been published in the Journal of General Internal Medicine.
Riess says the problem starts in medical school, where there is ample evidence that physicians-in-training become less empathic as they progress toward graduation. "Becoming less empathic is frequently a protective phenomenon," explains Riess. "You don't want to be flooded with personal distress every time you need to stick a patient with a needle, so you blunt your feelings of others' suffering in order to do procedures."
To counteract potential loss of empathy, the Partners HealthCare network (of which Massachusetts General is a member) has implemented a number of programs — group retreats for interns and house staff and individualized and group training for physicians. Additionally, Harvard Medical School requires a third-year course in which students reflect upon the process of becoming a physician.
"Many people think that empathy is either something you are born with, that either you have it or you don't," says Riess. "The exciting news from all our research is that empathy seems to be a mutable trait. Certain conditions can blunt expressions of empathy and, conversely, certain awareness-building and reflection activities seem to be able to up-regulate empathic behavior."
Riess says her empathy training at Massachusetts General is grounded in the neuroscience of emotions. Using a range of tools and methods including video simulation and role-playing, the training helps physicians cultivate self-awareness and self-management (both key components of emotional intelligence) to allow doctors to empathize with even the most challenging patients. "We try to show physicians that patients may act rudely or entitled because they feel afraid or powerless," explains Riess. "We try to teach physicians to empathize with the root emotions rather than reacting to the surface behaviors."
Riess notes that structural challenges create obstacles for even the most empathetic physicians. Doctors who would like to ask open-ended questions and spend time relating to the patient on a human level worry that such interactions will take 45 minutes when they have only 20 budgeted for each patient visit.
"I believe that we can help doctors become more empathic through training and coaching, and that this can even help clinicians become more efficient. Demonstrating empathy does not have to take more time. And by doing this, I think we should really be able to improve patient satisfaction," says Riess. "If we address all these issues and we still have problems, then we need to look at changing the system in ways that improve the physician-patient relationship and allow doctors to practice more empathic medicine."
A Virtuous Empathetic Circle
With emotional intelligence and empathy training, physicians can develop more empathetic relationships with their patients, improve their satisfaction scores and produce a cascade of positive outcomes throughout a health care system. Strong satisfaction scores will help hospitals perform well on the HCAHPS survey and earn more in reimbursements while winning a word-of-mouth reputation for quality care within their communities. Physicians who get high satisfaction scores will earn higher incentive payments, reduce their malpractice risks and improve patient communication in ways that could yield valuable medical insights.
Of course, patients themselves benefit by having empathetic caregivers whom they can trust to listen to their concerns. This trust encourages patients to give physicians all the information they need to make an accurate diagnosis, and it fosters a relationship where patients are more likely to comply with recommended treatment plans. This, in turn, will lead to the better long-term health outcomes that all stakeholders wish to achieve.
Ruth Malloy, Ph.D., is the managing director and global head of leadership and talent at Hay Group; she is based in Boston. Jim Otto is a senior principal in Hay Group's U.S. health care practice; he is based in Atlanta.
