A price tag on clinical empathy? Factors influencing its cost-effectiveness

Abstract

Introduction

Good communication is a pillar of medical professionalism.¹ As such, it is required independently of its economic cost. Yet, faced with scarce resources, it is useful to know the extent to which devoting resources to ensure or enhance high-quality communication is cost-effective. The benefits of enhancing one particular type of communication, namely empathic positive communication, have been studied in a number of randomised trials.² These trials suggest that compared with ‘usual care’, empathic positive communication can reduce pain, improve patient satisfaction and increase quality of life. Observational studies suggest that empathic care has benefits ranging from reducing mortality³ and practitioner burnout⁴ to increasing safety.⁵ On the other hand, these very same studies reveal that additional time is required to undertake empathy training and to treat patients in the clinic; both of these can be costly. Unfortunately, with a few notable exceptions,⁶ empathy’s cost-effectiveness has not been rigorously evaluated. A definitive answer to whether practitioner empathy is cost-effective requires sufficiently powered trials or decision models that measure relevant outcomes, and this is starting to happen.⁶ In this overview, we consider the factors that might be weighed in future trials of empathy’s cost-effectiveness (see Table 1).

Table 1.

Factors that potentially influence the cost-effectiveness of empathy.

	Factors likely to improve cost-effectiveness		Factors likely to worsen cost-effectiveness
Direct benefits from randomised trials	Reduced pain^15–17	Direct costs	Additional time often required by practitioners²
	Improved quality of life^6,7
	Improved patient satisfaction^16,18–20

Direct benefits from observational studies	Reduced mortality by 50% among diabetic patients³
	Improved wellbeing^6,21
	Reduced hospital duration of stay and readmission rates²²
Indirect benefits	Improved diagnosis¹¹	Indirect costs	Training empathy^7,15
	Improved medication adherence¹³
	Reduced hospital admissions and psychiatric hospitalisation
	Reduced patient stress.²³ Lowered stress, in turn, may reduce pain, depression and anxiety and even lower the risk of heart disease¹²
	Improved trust²⁴ and subsequently medication adherence¹³
Benefits to practitioners	Reduced practitioner burnout⁴
	Reduced medico-legal risks²⁵

Benefits of empathy (likely to favourably influence cost-effectiveness)

We are aware of two trials that measured the impact of enhanced empathic care on quality of life. The first measured participant-assessed quality of life, using the 34-question Irritable Bowel Syndrome Quality of Life score.⁷ In a sample of 262 patients, empathic care seemed to improve quality of life by a small, statistically significant amount (standardised mean difference 0.43 [95% confidence interval 0.13–0.73]). In another trial with 152 patients, a complex intervention which included empathy (as well as longer consultations, continuity of care and additional support to treat multimorbid patients) found that the quality of life was improved. In this study, quality of life measured over the 12-month period was higher in the intervention group (p = 0.002), and the intervention was highly cost-effective over the 12-month period. Modelling suggested that cost-effectiveness would continue.⁶

Pain (which enhanced empathy can reduce) strongly influences the quality of life measures commonly used to evaluate cost-effectiveness. Three trials (1067 patients) within a systematic review of empathic care found a small, non-statistically significant benefit (standardised mean difference −0.05 [95% confidence interval 0.32–0.22]).²

We found four trials (including 955 patients) reporting satisfaction as an outcome which suggested that this was improved by a small amount (standardised mean difference 0.26 [95% confidence interval 0.02–0.54]).²

Observational studies report (among other things) that enhanced empathy reduces mortality by 50% among diabetic patients,³ reduces symptom burden and improves wellbeing,⁶ increases patient enablement,⁸ increases patient safety,⁵ improves self-efficacy and adherence⁹ and reduces practitioner burnout.⁴

The mechanisms by which enhanced empathic care produces beneficial results are currently somewhat speculative. First, empathy can be helpful to make a correct diagnosis, as without it, patients may not share details of symptoms, especially embarrassing ones. They are also more likely to remain engaged.¹⁰ By contrast, doctors perceived to be unfriendly are less likely to get enough information from patients to make the right diagnoses or prescribe the right treatment. One study even showed that unempathic doctors could cause harm by scaring patients away from medical care when they need it.¹¹ Next, an empathic doctor will help put a patient at ease and reduce their stress; lowered stress, in turn, may reduce pain, depression, anxiety and even lower the risk of heart disease.¹² Being positive (which is part of empathic care) also activates the patient’s endogenous opioid system, further reducing pain. In addition, empathy seems to facilitate trust¹⁰ and subsequently medication adherence.¹³ Adherence, in turn, is linked to better clinical outcomes, with one study showing that up to 62% of patients were more likely to adhere to treatment based on the quality of physician communication.¹⁴ Anecdotally, those of us who are practitioners (SM, SWM and JoH) find that the benefits of enhanced empathic care could reduce hospital admissions and psychiatric hospitalisation. Patients seem more likely to visit empathic practitioners who can prevent more serious events like hospital admissions and also reduce fears about issues such as medication shortages and medical tests.

Costs of empathy

The main way in which enhanced empathic care would increase healthcare costs is the potential additional time often required by practitioners to treat patients.² However, the extent to which enhanced empathy requires more time is not clear. Some trials of enhanced empathy do not increase the consultation time by focusing on non-verbal communication.¹⁹

Another cost is the time and money spent training practitioners to enhance empathy. Some trials that trained practitioners to enhance their empathy required a team of professionals, video consultations and two days.¹⁵ However, trials that had much less (4 hours) training did not result in smaller patient benefits when compared with trials involving doctors that had more extensive training.² While this training period amounts to a one-off cost whose marginal cost approaches zero, it nonetheless has the potential to be substantial.

Other considerations for measuring cost-effectiveness

Better communication (which includes empathic communication) reduces medico-legal risks, which represents a further benefit.²⁵ Some worry that a potential cost is increased practitioner burnout caused by the alleged increased emotional labour caused by empathic care. The evidence in this area, however, is mixed, with a growing consensus that therapeutic empathy reduces practitioner burnout and increases job satisfaction.⁴ Few things are likely to be more costly than losing physicians due to burnout and having to replace them. These long-term human resource outcomes are rarely included in cost-effectiveness analyses but may prove relevant in the evaluation of empathic interventions.

Technology and the future of empathy’s cost-effectiveness

The costs in training and additional time spent in empathic care will be subject to change as technology and artificial intelligence becomes increasingly involved in healthcare.²⁶ While it is unlikely that humanoid robots will be able to express empathy as well as real humans, the opportunity cost of training artificially intelligent robots (should they ever move out of the laboratory²⁷) will be close to zero. They have to be trained in some way, so choosing to train them to be more empathic does not seem to represent an additional cost. Likewise, the growth of digital online learning (catalysed radically during the COVID-19 era) has the potential to reduce the marginal cost of empathy training, as online courses are highly scalable.

Limitations to measuring cost-effectiveness

Measures of empathy’s cost-effectiveness will be as accurate as the underlying studies measuring its effects. The main problems with randomised trials of empathy are difficulty in blinding practitioners and subsequent contamination. Practitioners who are randomised to the control group of a trial of enhanced empathy know which group they are in, and their knowledge could affect the results. For example, the fact that they are aware that their empathy will be measured could lead them to be more empathic than they would usually be, thus decreasing the apparent benefits of empathy training. With that in mind, it is important to take the observational evidence into account, because contamination is not a confounder of observational studies.

To be sure, the results of observational studies have their own biases. A particularly salient potential problem with observational studies is selection bias. Patients who are healthier to begin with are more likely to be more sociable, less angry, easier to empathise with and more likely to do better over time than those who are less healthy to begin with. Still, the fact that all the observational studies reveal a large effect with a consistent direction is suggestive of a real effect.

The next main problem with trials of empathy is definition and measurement. One study identifyed 36 distinct ways to measure empathy within healthcare.²⁸ In spite of this, there is an emerging consensus that within healthcare, clinical empathy has three components: understanding; demonstrating understanding; and therapeutic action.²⁹ Relatedly, the two scales of clinical empathy that are most widely used – the Consultation and Relational Empathy (CARE) measure³⁰ and the Jefferson Scale of Physician Empathy (JSE)³¹ – are compatible with the definition of clinical empathy.

Discussion and recommendations

Beyond being a professional requirement, enhanced empathy has been proven in randomised clinical trials to serve two of the most important goals of medicine – decreasing pain and improving quality of life, by a small amount. Observational studies consistently show that empathy improves adherence to treatment, which is an important determinant of the cost-effectiveness of healthcare. Enhanced empathic care may also increase healthcare costs with resources required to encourage empathic care and additional time spent with patients. Our analysis found that there appear to be more potential benefits than costs.

Ultimately, whether empathy is cost-effective will depend on how robust all of its effects are, relative to all of its costs, over time. This can only be measured in comprehensive systematic cost-effectiveness analyses that take the factors listed here into account. Such analyses can weigh the factors listed in this paper. We recommend that a decision analytic model be used to evaluate potential cost-effectiveness using existing evidence, informing the design of future interventions and trials.

Footnotes

Declarations

Acknowledgements

None.

Provenance

Not commissioned; peer-reviewed by John Abramson and Francisco Javier Carrera-Hueso.

ORCID iD

J Howick

References

World Medical Association. World Medical Association International Code of Medical Ethics. Ferney-Voltaire: WMA, 1949.

Howick

Moscrop

Mebius

, et al. Effects of empathic and positive communication in healthcare consultations: a systematic review and meta-analysis. J R Soc Med 2018; 111: 240–252.

Dambha-Miller

Feldman

Kinmoth

Griffin

. Association between primary care practitioner empathy and risk of cardiovascular events and all-cause mortality among patients with type 2 diabetes: a population-based prospective cohort study. Ann Fam Med 2019; 17: 311–318.

Sturzu

Lala

Bisch

Guitter

Dobre

Schwan

. Empathy and burnout – a cross-sectional study among mental healthcare providers in France. J Med Life 2019; 12: 21–29.

Doyle

Lennox

Bell

. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open 2013; 3: E001570–E001570.

Mercer

Fitzpatrick

Guthrie

, et al. The CARE Plus study – a whole-system intervention to improve quality of life of primary care patients with multimorbidity in areas of high socioeconomic deprivation: exploratory cluster randomised controlled trial and cost-utility analysis. BMC Med 2016; 14: 88–88.

Kaptchuk

Kelley

Conboy

, et al. Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ 2008; 336: 999–1003.

Mercer

Jani

Maxwell

Wong

Watt

. Patient enablement requires physician empathy: a cross-sectional study of general practice consultations in areas of high and low socioeconomic deprivation in Scotland. BMC Fam Pract 2012; 13: 6–6.

Flickinger

Saha

Roter

, et al. Clinician empathy is associated with differences in patient-clinician communication behaviors and higher medication self-efficacy in HIV care. Patient Educ Couns 2016; 99: 220–226.

10.

Halpern

. Gathering the patient’s story and clinical empathy. Perm J 2012; 16: 52–54.

11.

Butler

Pill

Stott

. Qualitative study of patients' perceptions of doctors' advice to quit smoking: implications for opportunistic health promotion. BMJ 1998; 316: 1878–1881.

12.

Benson

. The Relaxation Response, New York: Morrow, 1975.

13.

Riess

. The science of empathy. J Patient Exp 2017; 4: 74–77.

14.

Zolnierek

Dimatteo

. Physician communication and patient adherence to treatment: a meta-analysis. Med Care 2009; 47: 826–834.

15.

Chassany

Boureau

Liard

, et al. Effects of training on general practitioners’ management of pain in osteoarthritis: a randomized multicenter study. J Rheumatol 2006; 33: 1827–1834.

16.

Vangronsveld

Linton

. The effect of validating and invalidating communication on satisfaction, pain and affect in nurses suffering from low back pain during a semi-structured interview. Eur J Pain 2012; 16: 239–246.

17.

White

Bishop

Prescott

Scott

Little

Lewith

. Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture. Pain 2012; 153: 455–462.

18.

Fujimori

Shirai

Asai

, et al. Effect of communication skills training program for oncologists based on patient preferences for communication when receiving bad news: a randomized controlled trial. J Clin Oncol 2014; 32: 2166–2172.

19.

Little

White

Kelly

, et al. Randomised controlled trial of a brief intervention targeting predominantly non-verbal communication in general practice consultations. Br J Gen Pract 2015; 65: e351–e356.

20.

Soltner

Giquello

Monrigal-Martin

, et al. Continuous care and empathic anaesthesiologist attitude in the preoperative period: impact on patient anxiety and satisfaction. Br J Anaesth 2011; 106: 680–686.

21.

Mercer

Higgins

Bikker

, et al. General practitioners’ empathy and health outcomes: a prospective observational study of consultations in areas of high and low deprivation. Ann Fam Med 2016; 14: 117–124.

22.

Trzeciak

Gaughan

Bosire

, et al. Association between medicare summary star ratings for patient experience and clinical outcomes in US hospitals. J Patient Exp 2016; 3: 6–9.

23.

Weiss

Vittinghoff

Fang

, et al. Associations of physician empathy with patient anxiety and ratings of communication in hospital admission encounters. J Hosp Med 2017; 12: 805–810.

24.

Halpern

Clinical empathy in medical care. In: Decety

(ed). Empathy: From Bench to Bedside, Cambridge, MA: MIT Press, 2012.

25.

Moore

Adler

Robertson

. Medical malpractice: the effect of doctor-patient relations on medical patient perceptions and malpractice intentions. West J Med 2000; 173: 244–250.

26.

Pealing

Tempest

Howick

, et al.

Technology: a help or hindrance to empathic healthcare?

J R Soc Med 2018; 111: 390–393.

27.

Giannopulu

Terada

Watanabe

. Emotional empathy as a mechanism of synchronisation in child-robot interaction. Front Psychol 2018; 9: 1852–1852.

28.

Hemmerdinger

Stoddart

SDR

Lilford

. A systematic review of tests of empathy in medicine. BMC Med Educ 2007; 7: 24–24.

29.

Howick

Bizzari

Dambha-Miller

, et al. Therapeutic empathy: what it is and what it isn’t. J R Soc Med 2018; 111: 233–236.

30.

Mercer

Maxwell

Heaney

, et al. The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process measure. Fam Pract 2004; 21: 699–705.

31.

Hojat

Gonnella

Nasca

, et al. The Jefferson Scale of physician empathy: further psychometric data and differences by gender and specialty at item level. Acad Med 2002; 77: S58–S60.