The that they will always use the power they

fundamental quality of the healthcare professional-client relationship
is trust. Professions are professions because of the differential that exists
between them and those seeking their help. Such power, based in the
professionals’ knowledge and skills, requires that those seeking help trust
that they will always use the power they possess in their patients’ best
interest. This outcome requires an empathic dispositionon the part of the

who develop an empathic understanding towards the patient, may see them as more
real and perceive their needs and demands as more reasonable. Empathy is
related to understanding the patient’s feelings, and patients who feel
understood tend to fully explain their symptoms and to engage in a physician-patient

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associate empathy with improved physician-patient communication, trust,
treatment adherence, and clinical outcomes2,3,4.

Empathy is the ability to understand a
patient’s experiences and feelings accurately and respond to the patient in a
manner that exhibits understanding5.According to research in nursing, empathy is a
contested and complex concept to understand, experience, and teach6. In dental education, the role of
empathy in ethics is also subject to ongoing debate7,8.

Passik etal found that when trainees began
medical school, nursing school, and other allied health disciplines, one of
their primary motivations for choosing their career path was to help others,
but declines over the years8. In
an introductory course in practice administration for first-year dental
students, the students were asked why they chose dentistry over other possible
careers.  A desire to help others
consistently ranked the lowest of all of the reasons given by students for
entering dentistry. For these reasons, showing empathy for patients’ concerns
may not be immediately anticipated9.

the past half-century, there has been a paradigm shift in the ‘best practices’
of bedside conduct from a detached, paternalistic relationship towards a more
empathic, patient-centered model of care. The earlier literature on empathy in
medicine largely considered emotional interaction between physicians and
patients to be a taboo topic. Today, medicine is becoming a more empathic,
patient-centered profession—at least in policy if not in practice— and that the
standards of medical education and professional conduct have been adjusted to
meet this change10.

is a complex, multi-dimensional concept. Empathy involves the ability to:

understand the patient’s situation, perspective and feelings (and their
attached meanings)

communicate that understanding and check its accuracy and

act on that understanding with the patient in a helpful (therapeutic) way.

in consultation improves outcomes, and empathy can be improved by focused,
experiential teaching methods. The secret in the care of the patient is caring
for the patient.

An extensive review of the literature on empathy by
Morsesummarizes the components of empathy under four key areas11.

The ability to subjectively experience and share in another’s psychological
state or intrinsic feelings

Moral: An internal altruistic force that motivates the practice of empathy

 Empathy provides the basis
for the concept of morality. The Golden Rule, “Treat others as you would want
to be treated,” is the core to the moral code of essentially every culture or
religion in­cluding Greek
polytheism,Judaism,Christianity,Islam,Hinduism,Confucianism,and Buddism12-18. This demotes
ethics of reciprocity. It would not be possible to expect one to follow such a dogma
if the ability to conceive the other as if the other is absent.

3.Cognitive: The helper’s
intellectual ability to identify and understand another person’s feelings and
perspective from an objective stance.

Communicative response to convey understanding of another’s perspective

From this stance, clinical empathy can be seen as a form of
professional interaction, a set of skills or competencies, rather than a
subjective emotional experience, or a personality trait that one possess or not19.


literature on the concept of empathy is extensive. Lipps in1903 organized the
concept of Einfühlung20, which was referred to as the tendency of
perceivers to project themselves into the objects of perception which can be
considered a kind of animism. The word “empathy” first appeared in English in
1909 when it was translated by psychologist Titchener21 from the
German Einfühlung, which he defined as a “process of humanizing objects, of
reading or feeling ourselves into them.”


The mammalian evolution
has a long history of empathy.  Masserman
and Wechkin, in a study found that rhesus monkeys in a cage refused to pull a
chain that provided them with highly desirable food when they discovered that
doing so shocked another monkey in an adjoining cage22.The monkeys who were
familiar with one another had stronger desire not to inflict pain versus those
who were not. Empathic behavior have been documented in
animals in numerous other studies23,24.

Empathy probably evolved in the context of the paren­tal care that
is required for the development of all mammals, signaling their state through smiling and crying, human
infants urge their caregiver to take action25,26. Hence empathy has developed in hu­man evolution as an instinct
that has been naturally selected as a result of its ability to foster coopera­tive
behavior and thus improve the ability to survive and thrive. According to
Martin Hoffman, natural selection resulted in empathy27.

Studies have also shown that empathy like intelligence,
empathy has a genetic basis with an environmental overlay28,29. The
“empathy quotient” of a person is the result of the interaction of nature and
nurture. Neuroscientists have confirmed these findings through neurological
investigation.GiacomoRizzolatti et al., discovered a cluster of cells in the
brain known as mirror neurons. These cells mirror the movements of others. When
one sees another smile, the mirror neurons fire as if you were smiling, scowling,
grimacing, or crying30.

To summarize, the evolution of empathy has developed in humans as
a natural instinct to foster cooperative behaviour, thus improving the ability
to survive and thrive. There is an emotional/cognitive congruence, in which joy
is reciprocated with joy and distress with distress. When distress is
empathized, helping behaviours are elicited 31, 32 .

or Empathy

word “sympathy” has been used previously to refer to what we know today as
empathy. Goleman described sympathy as a state “where we feel sorry for the
person but do not taste their distress in the least, but empathy is distinct fromsympathy33,34.Empathy creates more
meaningful connections between patients and the healthcare professional.The
feeling of sympathy on the other hand develops from the acknowledgment that
another person – your patient – is suffering. It is /can be a genuine and
honest feeling. A sympathetic healthcare professional may feel sorry or pity
for their patients but can create a sense of inferiority and disempowerment. A
healthcare professional, at some point may need to put their own opinions and
issues away and comforting patients would need to take over as priority. On the
other hand, reacting in sympathy can compromise the ability to function as an
effective healthcare professional.

Empathy has shown to
decrease as an adaptive response of health professionals as they progress
through their careers. Studies among
nurses and physicians have suggested a relationship between age and different
levels of empathy; younger members show greater levels of empathy than older

According to a systematic by Neumann’s review,
self-perceived empathy declines significantly during medical school and
residency (particularly, in students who choose non-clinical specialties).36  The results were similar in other studies
among dental students whose empathy declined significantly in the clinical
phase of training.37 Many explanations have
been put forward for this phenomenon, the main being the coping mechanism.
These students associate humane treatment (display empathizing signals with
patients) with suffering and as an increasing source of potential distress and
thus to protect themselves applies a non-empathic caring style to protect
themselves from suffering.36,38

Other authors have suggested that the
unrealistic expectations of medical trainees (e.g. medicine can always cure) or
an increase in responsibility and demands under undesirable situations may lead
them to be non-empathetic in front of stress, thus finishing their work by
focusing on organs, systems and data instead of the patients to protect
themselves27. Another factor could be the deficiencies during
medical/nursing/ dental training where there is a recognized lack of exercise
to prepare students to support difficult situations. These decreased empathic
levels rarely improve in their future career. Thus, it is important that these
students learn coping techniques to confront their personal distress and work
disappointments, before they apply the unempathic manner and dehumanizing
caring style as coping methods.

Empathy has shown to
differ by gender and medical specialties.Different
people perceive and respond to emotional stimuli differently, although little
is known about the factors that influence clinicians’ response to the patient’s
concerns in medical interviews. 39 Higher empathy scores are shown in women
than men, and some studies confirm this gender distinction based on different
health settings.40,41

Regarding health professionals, female
physicians spent more time with their patients and render more preventive care.
40.Moreover, women were more likely than men to pursue primary care
disciplines where empathic and communicating skills are critical, unlike male
physicians who were more likely to pursue to surgical specialties with
prominent technical skills. 42

Skeptic and pragmatic health professionals
with less empathic attitudes may pay less attention to the emotional patients’
needs and tend to direct their skills towards the technical improvement of the
illness. Hence, medical students who planned to pursue “people-oriented”
specialties – primary care, obstetrics and gynecology, emergency medicine,
psychiatry and pediatrics) scored higher empathy levels than their counterparts
enrolled in “technology-oriented” specialties(hospital-based specialties,
surgery, surgical subspecialties, and radiology or pathology). 40,43
According to studies by Díaz-Morán et al,gender has shown to be a strong
predictor for empathic attitudes (women were associated with higher empathy).44
Explanation for this as some studies suggests could be that women have better
understanding of patients’ issues and concerns than men, due to their great
receptive ability to emotional signals.45It could be also due to
“gender-differences” related to pain awareness 46 and strategies to solve
emotional tasks 47: women seem to recruit more emotion-related regions of the
brain whereas men activate more cognitive-related areas.Health care
professionals, physicians and nurses particularly, have to deal quite commonly
with options and decisions which can be mediated by a patient’s religion: from
aggressive treatments in critically ill or terminal patients 48to crucial
advice on drugs, diets, customary habits and other health-related issues.49

As religion can work as a motivational factor
for positive attitudes, it seems reasonable to expect that professionals should
know how to assess spirituality needs.Studies have shownlinks between
agreeableness/conscientiousness and religiousness. Hence, personal dispositions
such as religion and an empathic caring style may interact with medical
settings to predict behaviors that are considered expressions of underlying
personality traits. Health professionals with altruistic concerns may have more
mental flexibility to understand and accept the needs of other people.


In healthcare profession, limiting factors on
clinical empathy is workload, thus resulting in less time to be available for
each clinical encounter. It may also because that empathy is undervalued and
under-taught. Studies have indicated that empathy skills can be significantly
increased by teaching empathy focusing on students experience with patients.
50-53 In general medicine and nursing, significantand sustained improvements
in empathy have been shown after an empathy training program based on Reynolds
empathy scale.6


Therefore a) students of
health professions (specially, medical, dental and nursing students) display
correct empathic levels during their training period and residency; b) their
empathic levels decrease throughout their professional career, a decrement that
might be caused by the absence of efficient coping skills to confront patients’
distress; c) currently, training curricula do not have enough alarm systems to
detect this empathic decline and to try to correct it; and d) the evaluation of
the patients’ satisfaction might be an important indicator for their emotional
needs and the quality of health assistanceMany philosophers consider it to be
mandatory for emotional intelligence to be a criterion for admission in dental
colleges. Intellectual empathy and Emotional empathy must be enhanced by
ethical training for better patient care. Although the current literature on
teaching empathy is hampered by conceptual confusion and methodological
weakness, a systematic studystates that empathy can be enhanced by teaching.
54Students and doctors can learn that empathy is neither detachment nor
immersion but an iterative relational process of emotional resonance,
reciprocity and curiosity about the meaning of the clinical situation for the
patient. 55

In many countries, medical educators are waking up to the value
of compassion in healing. In 2006, medical schools in Israel altered their
admission procedures to require the presence of compassion and empathy in every
entering medical student. High grades and intellectual skills continued to be
important, but they were judged insufficient to qualify one for admission.