Many observers have argued that medical practice is increasingly dehumanised, dominated by impersonal technologies and economic imperatives.1 A solution that is sometimes offered is to cultivate empathy in doctors.2 Many doctors may be sceptical, wondering whether empathy is too ill-defined to make a difference in the pressured arena of clinical work. Perhaps it can be safely left to essay-writing medical humanists or to the nursing staff . . .

Such scepticism is unwarranted. Empathy can be defined as the capacity to take the perspectives of others, to be sensitive to their inner experience and to engage with them compassionately, rather than simply sharing their emotions (sympathy). In the medical context, empathy can be defined as “appreciation of the patient’s emotions and expression of that awareness to the patient”.3 More importantly, an emerging body of research indicates that empathy is associated with a variety of positive clinical outcomes.

Much of the evidence linking doctors’ empathy to patients’ outcomes is indirect. Large bodies of research show that positive outcomes are associated with the quality of the doctor–patient relationship and doctor–patient communication, and that empathy enhances both. Direct links between empathy and clinical outcomes have also been established. More empathic medical students received higher ratings of clinical competence and performed better on history-taking and standardised physical examinations.4,5 More empathic medical students and doctors received higher patient satisfaction ratings.5 Patients judge empathy to be very important in consultations,6 and show better treatment adherence and greater enablement with more empathic doctors.7 When doctors report a loss of empathy they subsequently show an increase in their rate of major medical errors.8 Doctors’ communication skills are associated with a variety of positive outcomes for patients9 and with reduced risk of malpractice claims, and patients judge their doctors’ empathy on the basis of such skills (eg, being reassuring, showing understanding, explaining procedures, not ignoring their concerns).10

If empathy promotes positive clinical outcomes, then we should want doctors to be empathic. This aim could be achieved by promoting empathy in medical training, and by using empathy as a selection criterion for entry to medical training. These two approaches reflect the reality that empathy is a disposition or quality, but also one that is malleable. Many ways of promoting empathy have been proposed, ranging from training in communication skills, to education in the medical humanities, through to complete overhaul of the medical curriculum. A review of intervention studies suggests that communication skills workshops have the greatest impact on medical students’ empathy.3

Assessing empathy as a criterion in medical school admission is more controversial, and there is as yet little direct evidence that it would produce better doctors. Nevertheless, several studies make an indirect case for supplementing traditional selection procedures, which are based heavily on educational attainment and cognitive ability, with measures of empathic traits. First, measures of empathy are generally unrelated to indices of attainment and ability, but capture non-redundant information that is relevant for selection. For example, one study found that empathy correlated highly with selection interview scores,11 but not with academic grades or a standardised aptitude test. Second, psychometric measures of empathy have been shown to predict real-world empathic behaviour, and should therefore be able to identify applicants who are especially likely to interact empathically with patients. Finally, including empathy assessment in the selection process is likely to increase access to medical training for less socially privileged applicants. Such students tend to fare less well on traditional criteria, but perform equally well or better on assessments of empathic traits.12 The possibility that broadened selection criteria might tend to favour female applicants, given evidence of sex differences,2 must also be entertained.

Even if doctors’ empathy can be enhanced by medical education or selection, it is at least as important to prevent the erosion of empathy over the course of professional training and practice. There is now considerable evidence that levels of empathy tend to decline during medical school and beyond.13 This decline has been attributed to the growing reliance on technology, and to economic and time constraints imposed by health care systems. Others identify psychological dynamics beneath the loss of empathy, such as creeping cynicism, a self-protective disengagement from people’s suffering and a sense of hopelessness in the face of therapeutic failure. Research indicates that the loss of empathy is linked to burnout — notably, feelings of emotional fatigue and a tendency to depersonalise patients. Trainees who make major medical errors subsequently experience a decline in empathy.8 Similarly, doctors who feel less in control of patient outcomes tend to engage in styles of closed, impersonal and inattentive communication that lead patients to see them as unempathic.10

There is a positive side to all of this. Empathy can be lost, but it can also be gained. If doctors lose empathy because of burnout, unhappiness and a loss of a sense of control over their work, then remedying these conditions should indirectly increase empathy. Indeed, doctors who report higher levels of wellbeing and a greater sense of personal accomplishment also report higher levels of empathy,14 and increases in wellbeing among residents are accompanied by increases in empathy.15 If empathic doctors are indeed better doctors, then improving doctors’ wellbeing should benefit patients.