Empathy and clinical reasoning in consultations

The intern has fifteen minutes and a list of questions. The patient answers each one, but always comes back to the same point: the fear of losing his job if he stays in the hospital. The intern takes notes, follows the list, and only at the end of the consultation, when the patient finally feels heard, discovers that he stopped taking his medication a month ago. The information that changed the reasoning was stored behind a worry that no one had asked about.

NEXO is a daily medical diagnosis game: one clinical case a day, six progressive clues, and ICD-10 proximity feedback across five levels.

Empathy is often treated as kindness, separate from diagnosis. Studies suggest something else: it is also a way of collecting data. This guide explains what clinical empathy is, how it connects to reasoning, what research shows about its association with outcomes and with training, and how to train it.

Key points

• Clinical empathy involves understanding the patient's perspective, communicating that understanding and acting on it.
• The literature separates a cognitive and an affective dimension, and some authors propose a more integrated view, called empathic concern.
• In a study with outpatients, perceived empathy was associated with satisfaction and adherence through information exchange, trust and partnership.
• Studies with family physicians found an association between measured empathy and better clinical outcomes, in a design that indicates association, not cause.
• Empathy tends to fall during training, especially in the clinical phase, and can be trained.

What clinical empathy is

Cognitive and affective

The debate on clinical empathy often divides the concept into two parts: cognitive empathy, which is understanding what the other person experiences, and affective empathy, which is feeling with them (Guidi and Traversa, 2021). This division has consequences. Those who emphasize only the cognitive part risk a cold, almost technical empathy; those who emphasize only the affective part risk the exhaustion of someone who gets involved without limits.

Empathic concern

To move away from this dichotomy, a review proposed the notion of empathic concern: a genuine interest in welcoming, recognizing and responding to the emotions of those who suffer (Guidi and Traversa, 2021). The authors also discuss the detachment that medical culture teaches and point to narrative medicine as a path to train this attitude (Guidi and Traversa, 2021). Narrative medicine has its own guide in this series.

Empathy is different from sympathy

Sympathy is feeling sorry or agreeing. Empathy is understanding the other person's experience without needing to agree with it and without confusing your own emotion with theirs. In the consultation, the difference shows in the response: sympathy says "how awful"; empathy says "it seems this has been keeping you awake, is that it?".

Why empathy enters reasoning

Empathy as data collection

In a study with 550 outpatients at a university hospital in Korea, the empathy perceived in the physician influenced satisfaction and adherence through intermediate factors: information exchange, perception of competence, trust and partnership (Kim et al., 2004). The first of these factors is the one that matters to reasoning. A patient who trusts tells more, and tells it better.

A review on empathy in general medicine included, among the effects studied, diagnosis linked to information exchange (Derksen et al., 2013). The idea is intuitive: hypotheses depend on data, and much of the data comes from the history, as the guide on signs, symptoms and history shows.

When emotion enters the wrong place

Empathy also has risks for reasoning. Liking a patient very much, or disliking them, can pull the diagnosis to one side: this is affective bias, the subject of its own guide. Stereotypes about groups of patients, implicit bias, also change what the physician asks and what they hear. The empathy useful to reasoning is attentive to the patient's emotion and to the physician's own.

What changes in practice

An empathic consultation usually has three movements that feed reasoning:

1. Open space: open questions at the start, before the list.
2. Name the emotion: say out loud what you notice, and check.
3. Ask about context: what the patient fears, what they think they have, what they expect.

The third move often reveals information that changes the list of hypotheses in the differential diagnosis, such as the medicine the patient stopped taking or the concern that explains the return to the emergency department.

What the studies show

Satisfaction, anxiety and sense of control

The general medicine review screened 964 studies and included seven after quality assessment (Derksen et al., 2013). The authors found a good correlation between physician empathy and patient satisfaction, a positive relationship with patient enablement to manage their own health, and a reduction in anxiety and distress (Derksen et al., 2013).

Clinical outcomes

Two studies with primary care physicians, one in the United States and one in Italy, found an association between physicians' empathy measured by a validated scale and clinical outcomes measured in their patients (Hojat et al., 2011; Del Canale et al., 2012). Both are correlational: they show that empathy and good outcomes go together, but other differences between physicians may explain part of the result, and neither proves cause. Even so, the association is enough to take the topic seriously in training.

Empathy throughout training

A frequent decline

A systematic review included 18 studies on the empathy of students and residents, 11 with medical students and 7 with residents (Neumann et al., 2011). Most showed a significant drop in empathy during medical school and during residency, and the authors pointed to the clinical practice phase and the distress produced by the formal, informal and hidden curricula as the main reasons (Neumann et al., 2011).

The size of the decline varies

A cross-sectional study with 10,751 students from osteopathic medical schools in the United States found a statistically significant drop between the preclinical phase and the clinical phase, but of negligible magnitude, with an effect size of 0.13 (Hojat et al., 2020). In the comparison with students from allopathic medical schools, the pattern of decline was similar, though less pronounced among osteopathic students (Hojat et al., 2020).

The authors raise as a possible explanation the emphasis of osteopathic schools on patient-centered care (Hojat et al., 2020). If the teaching environment influences the decline, it can also help prevent it.

Fatigue and empathy

The decline connects with another theme in the series, burnout during training. An exhausted student has less room to perceive the other person's emotion, and the empathy that remains tends to be cognitive, more by the book.

How to train empathy in the consultation

Practice phrases, not just intentions

Empathy is learned like any communication skill: with models, practice and feedback. A few base phrases help at the start:

• "It seems this has been worrying you a lot."
• "What do you think is happening?"
• "What else has been weighing on you in this situation?"
• "Let me see if I understand: you are afraid of..."

Over time, the phrases stop being a script and become a way of listening.

Practice in simulation

The consultation simulation, with an actor or a colleague, allows you to train the response to emotion without risk to a patient. The consultation simulation guide shows how to organize these sessions, and empathy can be included as one more item of observation.

Ask for feedback on listening

After an observed consultation, ask the preceptor at what moment the patient seemed to open up and at what moment they closed off. The guide to feedback in clinical cases helps turn that feedback into something concrete.

Review your own reasoning

At the end of a consultation, ask yourself what information appeared only because the patient felt heard and which of your emotions may have pulled the diagnosis. It is an exercise in metacognition in medicine applied to the consultation. During the internship, where time is short, the guide to clinical reasoning in the internship helps fit this review into the routine.

The reasoning behind the story in NEXO

In NEXO, the case of the day arrives in up to six clues, and many of them bring details from the patient's history that only make sense when read carefully. The cases are fictional with a real clinical presentation. With each guess, the proximity in ICD-10 across five levels shows how far off the hypothesis was, which helps you notice when a clue from the history was ignored.

The game trains the part of reasoning that uses the data; the empathic collection of that data happens in the consultation. The guide what NEXO is explains the whole match, and how the modes are unlocked is on the NEXO economy page.

If you coordinate a medical school, a student league or a residency and want to discuss cases in a group, meet NEXO Closer. Researchers in medical education can propose studies through NEXO Researcher. Physicians who review cases take part through NEXO Curator, and those who create health content on social media can take part through NEXO Creators.

Frequently asked questions

What is clinical empathy?

It is the ability to understand the patient's perspective, communicate that understanding and act on it in the consultation.

What is the difference between cognitive and affective empathy?

Cognitive empathy is understanding what the other person is going through; affective empathy is feeling with them. Some authors propose integrating the two in the idea of empathic concern (Guidi and Traversa, 2021).

Does empathy help with diagnosis?

It improves the exchange of information and trust (Kim et al., 2004), and more quality information better feeds reasoning.

Does empathy decline during medical school?

A review found a decline in most studies, especially in the clinical phase (Neumann et al., 2011).

Can empathy be trained?

Yes, with sentence templates, simulated consultations and feedback from preceptors on listening.

Is empathy the same as sympathy?

Sympathy is feeling sorry or agreeing; empathy is understanding the other person's experience without confusing your own emotion with theirs.

Empathy checklist in the consultation

1. Start with an open question before the list.
2. Name the emotion you perceive and check it.
3. Ask what the patient fears and what they think they have.
4. Record the context that may change the hypotheses.
5. Notice your own emotion and how much it weighs.
6. Practice in simulation and ask for feedback on listening.
7. Review the consultation looking for the detail that only came up through trust.

Want to train reasoning with the patient's history? Play the case of the day on NEXO.

References

1. Guidi C, Traversa C. Empathy in patient care: from 'Clinical Empathy' to 'Empathic Concern'. Med Health Care Philos. 2021. https://pubmed.ncbi.nlm.nih.gov/34196934/
2. Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient satisfaction and compliance. Eval Health Prof. 2004. https://pubmed.ncbi.nlm.nih.gov/15312283/
3. Derksen F, Bensing J, Lagro-Janssen A. Effectiveness of empathy in general practice: a systematic review. Br J Gen Pract. 2013. https://pubmed.ncbi.nlm.nih.gov/23336477/
4. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians' empathy and clinical outcomes for diabetic patients. Acad Med. 2011. https://pubmed.ncbi.nlm.nih.gov/21248604/
5. Del Canale S, Louis DZ, Maio V, Wang X, Rossi G, Hojat M, et al. The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med. 2012. https://pubmed.ncbi.nlm.nih.gov/22836852/
6. Neumann M, Edelhäuser F, Tauschel D, Fischer MR, Wirtz M, Woopen C, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011. https://pubmed.ncbi.nlm.nih.gov/21670661/
7. Hojat M, Shannon SC, DeSantis J, Speicher MR, Bragan L, Calabrese LH. Does Empathy Decline in the Clinical Phase of Medical Education? A Nationwide, Multi-Institutional, Cross-Sectional Study of Students at DO-Granting Medical Schools. Acad Med. 2020. https://pubmed.ncbi.nlm.nih.gov/31977341/