Leadership and Empathy

Leadership and Empathy
By Benjamin Zigun, MD, JD, MBA, Chair of Psychiatry, Griffin Hospital, Derby, CT

Benjamin Zigun photoThis article is part one of a two-part series. Part II will run in April.

There seems to be ever-increasing focus on empathy in the healthcare space.   We can speculate as to the reasons, but empathy is nothing new. Hippocrates directed Primum No Nocere, “First Do No Harm,” probably while teaching his students under a Planetree. Because healthcare can be intrusive if not invasive, the interviewing, examining and treating of patients without regard to empathy, in my view, can and does create harm. During a healthcare crisis, patients and their families are typically in their most vulnerable states and we find that empathy emerges as a critical component to their care.

In this first of a two-part series, we will focus on empathy broadly, and particularly how it relates to interactions between providers and patients/families. In Part 2, we will focus on the topic of healthcare leadership broadly and specifically on the interaction between healthcare leadership and empathy, which arguably is dynamic and very complex.  There we will explore empathy between providers and their peers, supervisors and employees, and a healthcare facility and its community.

Technical Excellence Must Not Come at the Expense of Empathy

I attended the 2014 Planetree International Conference in Chicago and was deeply impressed by a quote by Alexandra Drane, a keynote speaker and thought-leader in healthcare. She said, “Empathy is the single biggest missing ingredient in the healthcare space.” The Griffin Hospital cohort that attended the conference held a debriefing meeting shortly after returning to Connecticut, and we reviewed lessons learned. We reached a consensus that Ms. Drane’s comment was profound, as it was both disturbing and accurate, and it merited follow up. We subsequently convened several sessions of an empathy strike force to explore ways to amplify empathy at Griffin Hospital as part of our Planetree journey.

If a healthcare provider wonders whether a patient/family member/staff member is listening, watching and reflecting on everything that is being done, they are. When we think empathetically, we need to anticipate and consider what might be going on inside the patient’s/peer’s/staff’s/boss’s head (or heart). One tenet of Planetree is, “We create memories by everything we do.” As we think back on our own experiences at the receiving end in healthcare, we can recall vividly how we were treated emotionally, not just technically. Technical excellence must remain the norm. But a high degree of empathy must be delivered as well. Patients demand and deserve the best care, and there should not be a trade-off between technical excellence and empathy.   If one thinks that the emotional component doesn’t really matter, consider Maya Angelou’s quote, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

What Empathy Is and Isn’t

As we focus on empathy, let’s consider what empathy is and isn’t. Empathy is an affirmative, active behavior. It seems to be borne out of compassion, emanating from our humanity. It may also relate to a sense of obligation, out of social contract, out of justice, fairness and equity, and it can be prescribed by corporate culture. Empathy, however, is not sympathy, which I would define as getting into the same boat of problems with the patient with a concomitant loss of objectivity. Healthcare staff must strive to maintain good boundaries and to take good care of themselves both physically and emotionally, as it can be difficult to be empathic and compassionate towards others when not treating oneself well.

The Griffin Hospital empathy strike force spent several hours exploring the metes and bounds of empathy. We considered empathy to be expressed warmth and understanding that includes tact and timing, and seeing things from another’s perspective. Empathy may include reflective listening. Empathy may not be so much what is said, but how it is said. The strike force felt there is really no how-to guide for empathy and that perhaps empathy is best learned by modeling and example. Most importantly, we recognized that for empathy to be experienced, the receiver’s perception is key. A provider can attempt to transmit empathy, but if the receiver does not perceive it, the opportunity will have been lost.

Routes to Empathy

Routes to Empathy
Routes to Empathy

Our strike force concluded there are many routes to empathy, as diverse as the individuals who provide healthcare. But it is the phenotypic expression of empathy (what the patient or family member experiences) not the “genotypic” route that matters.

Though empathy is difficult to define, it remains critically important. One knows it when one sees it; but even more so, one recognizes it when it is missing. Empathy seems difficult for healthcare organizations to roll out as a core value. It is difficult to measure and to survey. And it is difficult to maintain. For an organization to promote a culture of empathy system-wide, the challenge is to attain consistency: empathy must be expressed by many (providers) to many (patients and families) on an individualized, customized basis, hopefully repeatedly. While this is a tall order, it should not keep us from doing the necessary, hard work.

Even before starting to bolster the positive, empathy, facilities should reduce and eliminate any negative behaviors towards patients and their families, specifically antipathy and apathy. Callousness and wanton disregard of the needs of others should never be tolerated in the healthcare setting and should trigger appropriate disciplinary action.

Empathy Virtues and Vices

Our strike force compiled lists of Empathic Virtues and Empathic Vices. We also considered factors that might drive one towards Empathic Vices rather than Empathic Virtues. By reviewing the list of Empathic Vices and recognizing factors that might cause them, a healthcare worker can take purposeful actions to overcome negative counter-transferences and compensate, thereby producing more empathic responses.

The strike force explored patients’ or family members’ behaviors that could interfere with staff’s ability to feel and express empathy (Figure 4). We also considered possible drivers of these “difficult behaviors” (Figure 5).

Figure 4: Difficult Behaviors Staff May Face
Figure 4: Difficult Behaviors Staff May Face
Figure 5: Possible Drivers of Difficult Behaviors
Figure 5: Possible Drivers of Difficult Behaviors

Here too, we hope that by raising staff’s consciousness about maladaptive patient/family behaviors and potential drivers of these behaviors, staff will find it easier to overcome negative counter-transferences and be able to yield more empathic responses.

Broadly speaking, expressed empathy towards patients and their families should be a net positive; there is little cost to it and great potential benefit. There are limits to empathy, however, and we will explore these in Part 2. We will also explore empathic relativism as it applies to leadership and staff-staff interactions.

The Challenge

The dilemma, the challenge, or the opportunity will be to deliver emotionally-sensitive, high-quality, individualized population health (sounds oxymoronic?). That is to say, excellent, evidence-based care must be delivered to one patient at a time, in an empathic, humanistic way. We cannot mass-produce empathy or standardize its expression. There will be multiple touch points where empathy can flourish or fail. Ideally, we as healthcare providers will express empathy consistently across all touch points. Due to the heterogeneity of providers, patients and clinical situations, we cannot guarantee that patients will consistently perceive and value the empathy that staff expresses. This should not thwart our focus on empathy.   Despite challenges in maintaining consistency, we hope that our efforts will be rewarded as evidenced by better patient outcomes, improved satisfaction scores, increased referrals and improved institutional reputation.

As we consider empathy, we should remember that 1) it is the right thing to do, 2) it is a differentiator in a competitive market, 3) it may begin as a project to be managed or as a strategy to be launched, but it needs to become part of the organizational culture and 4) it must be demonstrated by example.

Quoting Buddha, “A generous heart, kind speech, and a life of service and compassion are the things which renew humanity.”

The author wishes to acknowledge the other members of the Griffin Hospital Empathy Strike Force: Daun Barrett, Johanne Cayer, Katy Christian, Martha Denstedt, Cormac Levenson, Eunice Lisk and Carrie O’Malley.