A 68-year-old man presented with weakness and a 30-lb weight loss over the past three months. Chest radiograph shows a large left hilar mass. CT scan shows a 12 cm left hilar mass with multiple bilateral pulmonary nodules, concerning for metastatic disease. The emergency department (ED) is full with boarding and critical patients, and 25 patients are in the waiting room. How should this information be communicated to the patient and family? What is the emergency physician’s role?

Evidence for Empathy

The medical literature includes numerous commentaries and opinions about the importance of compassion and empathy in the practice of medicine. More than 100 years ago, Sir William Osler said, “To serve the art of medicine as it should be served, one must love his fellow man.”¹ According to the ACEP Code of Ethics: The physician-patient relationship is the moral center of medicine and the defining element in clinical ethics.²  Is compassion merely a touchy-feely perspective? Is there scientific evidence supporting compassion in emergency medicine?

A recent systematic review found that greater empathy and communication was associated with improved patient outcomes, including reduced pain and shorter duration of hospital stays.³ Other studies have found that greater empathy is associated with improved health care outcomes, including patient satisfaction, pain, adherence to therapy, and reduced litigation.^4-10    

Empathy among physicians is highly variable.^11,12 There is a well-documented decrease in empathy during medical school.¹³ Although disturbing, the reasons for this decrease in empathy are not well understood. Several factors have been implicated, including work environment, stress levels, and lack of leadership.¹⁴

Improving Empathy

What then can be done to improve empathy? Educational interventions and improvements in the hidden curriculum have demonstrated benefit in demonstrated empathy.¹⁵ 

Some specific interventions to improve communication in the ED include a seated position, eye contact, reflective listening, and physician self-disclosure.^16-20 Most importantly, caring about the patient is paramount. The Golden Rule—do unto others as you would have them do unto you—is a valued perspective in many cultural and religious traditions. Recently, authors have proposed The Platinum Rule, where we should do unto patients as they would want done unto themselves.²¹ This standard requires communication and knowledge of patient-centered values in addition to empathy.

Knowing and applying evidence-based medicine may seem easier than taking the time and effort to show empathy, compassion, and kindness in a busy ED. It may be a more tangible reward to obtain return of spontaneous circulation after cardiac arrest, than to hold a hand and show empathy during a challenging time. As emergency physicians, we are constantly stressed by patient volumes and acuity. We may be tempted to think, “I don’t have time for a compassionate counseling session. Isn’t that the oncologist’s job?” Empathy may be driven to the back burner by the ED environment. It is up to each of us to bring empathy to the forefront, despite the challenges that the ED brings.

Case Discussion

In the challenging ED environment with the stress of patient volumes and acuity, we may view empathetic communication as a lower priority than life-saving interventions. However, we must remember the significance of communication to each individual patient. Just as we would find the time to perform an emergent intubation, we must take the time in any circumstance to provide empathetic communication, compassion, and caring to every patient.

Dr. Marco is professor of emergency medicine at Penn State Health-Milton S. Hershey Medical Center and associate editor of ACEP Now.

References

1. Nickson C. Lessons from Osler 004. https://litfl.com/lessons-from-osler-004/. Accessed February 17, 2025.
2. ACEP: Code of Ethics for Emergency Physicians. https://www.acep.org/siteassets/new-pdfs/policy-statements/code-of-ethics-for-emergency-physicians.pdf. Accessed February 17, 2025.
3. Howick J, Moscrop A, Mebius A, et al. Effects of empathic and positive communication in healthcare consultations: a systematic review and meta-analysis. J R Soc Med. 2018;111(7):240–252. 
4. Crawford MJ, Rutter D, Manley C, et al. Systematic review of involving patients in the planning and development of health care. BMJ. 2002;325(7375):1263.
5. Kelley JM, Kraft-Todd G, Schapira L, et al. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2014;9(4):e94207.
6. Haverfield MC, Tierney A, Schwartz R, et al. Can patient-provider interpersonal interventions achieve the quadruple aim of healthcare? a systematic review. J Gen Intern Med. 2020;35(7):2107-2117.
7. Trzeciak S, Roberts BW, Mazzarelli AJ. Compassionomics: hypothesis and experimental approach. Med Hypotheses. 2017;107:92-97.
8. Wang H, Kline JA, Jackson BE, et al. Association between emergency physician self-reported empathy and patient satisfaction. PLoS One. 2018;13(9):e0204113.
9. Zhang X, Li L, Zhang Q, et al. Physician empathy in doctor-patient communication: a systematic review. Health Commun. 2024;39(5):1027-1037.
10. Levinson W, Roter DL, Mullooly JP, et al. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277(7):553-559.
11. Howick J, Steinkopf L, Ulyte A, et al. How empathic is your healthcare practitioner? A systematic review and meta-analysis of patient surveys. BMC Med Educ. 2017;17(1):136.
12. Andersen FA, Johansen AB, Søndergaard J, et al. Revisiting the trajectory of medical students’ empathy, and impact of gender, specialty preferences and nationality: a systematic review. BMC Med Educ. 2020;20(1):52.
13. Howick J, Dudko M, Feng SN, et al. Why might medical student empathy change throughout medical school? a systematic review and thematic synthesis of qualitative studies. BMC Med Educ. 2023;23(1):270.
14. Kang ES, Di Genova T, Howick J, Gottesman R. Adding a dose of empathy to healthcare: what can healthcare systems do? J Eval Clin Pract. 2022;28(3):475-482.
15. Winter R, Issa E, Roberts N, et al. Assessing the effect of empathy-enhancing interventions in health education and training: a systematic review of randomised controlled trials. BMJ Open. 2020;10(9):e036471. Erratum in: BMJ Open. 2021;11(7):e036471corr1.
16. Swayden KJ, Anderson KK, Connelly LM, et al. Effect of sitting vs. standing on perception of provider time at bedside: a pilot study. Patient Educ Couns. 2012;86(2):166-171.
17. Johnson RL, Sadosty AT, Weaver AL, Goyal DG. To sit or not to sit? Ann Emerg Med. 2008;51(2):188-93, 193.e1-2.
18. Kobayashi M, Katayama M, Hayashi T, et al. Effect of multimodal comprehensive communication skills training with video analysis by artificial intelligence for physicians on acute geriatric care: a mixed-methods study. BMJ Open. 2023;13(3):e065477.
19. Braillon A, Taiebi F. Practicing “reflective listening” is a mandatory prerequisite for empathy. Patient Educ Couns. 2020;103(9):1866-1867.
20. Zink KL, Perry M, London K, et al. “Let Me Tell You About My…” Provider self-disclosure in the emergency department builds patient rapport. West J Emerg Med. 2017;18(1):43-49.
21. Chochinov HM. The Platinum Rule: a new standard for person-centered care. J Palliat Med. 2022;25(6):854-856.