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Review  |   November 2017
Measuring Multidimensional Empathy: Theoretical and Practical Considerations for Osteopathic Medical Researchers
Author Notes
  • From the Department of Psychology at The New School for Social Research in New York, New York (Ms Martingano), and the Department of Obstetrics & Gynecology at the NYU Langone Hospital - Brooklyn in New York. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Daniel Martingano, DO, NYU Langone Hospital - Brooklyn, 150 55th St Brooklyn, NY 11220-2508. E-mail: daniel.martingano@nyumc.org
     
Article Information
Imaging / Medical Education / Neuromusculoskeletal Disorders / Pain Management/Palliative Care / Professional Issues / Psychiatry
Review   |   November 2017
Measuring Multidimensional Empathy: Theoretical and Practical Considerations for Osteopathic Medical Researchers
The Journal of the American Osteopathic Association, November 2017, Vol. 117, 697-704. doi:10.7556/jaoa.2017.136
The Journal of the American Osteopathic Association, November 2017, Vol. 117, 697-704. doi:10.7556/jaoa.2017.136
Abstract

Osteopathic physicians are increasingly recognizing the importance of empathy for improving patient satisfaction and clinical outcomes. This review advocates for a multidimensional perspective of empathy, encompassing both affective and cognitive empathy, and highlights situational and dispositional factors relevant to the curtailment of empathy. A review of the utility of self-report, behavioral, and physiological measures that researchers may use to quantify empathy in further research is also provided. The authors encourage members of the osteopathic medical profession to embrace a fuller understanding of empathy.

Osteopathic physicians and other health care professionals are increasingly recognizing the importance of empathy. Research has demonstrated that physician empathy is associated with increased patient satisfaction,1,2 improved diagnostic and clinical outcomes,3,4 and enhanced overall well-being for the physician.5-8 However, there may also be negative consequences to empathizing with patients—empathy may overwhelm physicians as they perform life-saving operations, invasive procedures, and emergency interventions.9 The complex role of empathy may be due, at least in part, to its multidimensional nature. By understanding the subcomponents of empathy, as well as the factors leading to its curtailment, health care professionals can establish how best to use empathy in their field. 
The present review outlines the theoretical and practical components of empathy measurement. Incorporating these components in research designs will potentially lead to a more nuanced understanding of the role of empathy in osteopathic medicine. 
Multidimensional Empathy
Outside the field of medicine, empathy is considered a complex multidimensional construct. Since the 18th century, at least 2 different types of empathy have been proposed: Smith10 differentiated between one's emotional reactions to others and one's ability to recognize these emotional states free of emotional experience. Smith's distinction persists today under the nomenclature of affective and cognitive empathy, respectively. 
Affective empathy refers to the extent to which a person experiences emotion in response to another person's expression of an emotion. Within this affective response, theorists distinguish between emotional resonance (feeling as another person feels) and empathetic concern (feeling for another)11 (Figure 1). Cognitive empathy, on the other hand, refers to the understanding of what another person is experiencing, and that understanding is normally achieved through perspective taking. This cognitive component has been emphasized in the medical field, often to the near exclusion of affective empathy.12 Physicians are expected to maintain emotional distance from their patients to ensure objectivity and limit their exposure to adverse emotions.12 This expectation has led to the teaching and practice of “detached concern,” a practice so ingrained that the very definition of empathy used by a leading group13 from the Society for General Internal Medicine is “the act of correctly acknowledging the emotional state of another without experiencing that state oneself.”14 
Figure 1.
The 4 psychological states called empathy.11
Figure 1.
The 4 psychological states called empathy.11
The exclusion of affective empathy in medical research is particularly troubling because mounting psychological research suggests that cognitive empathy alone is not enough to ensure compassion. For a dramatic example, consider that psychopaths are characterized by a lack of affective empathy and cognitive empathy levels that are equal or even superior to the general population.15 Simply, psychopaths understand, but do not care about, another's pain. Indeed, research demonstrates that both cognitive and affective components are necessary as they interact in the experience of empathy.16 To capture the importance of this interaction, Zaki and Ochsner17 suggested an additional third facet to their multidimensional definition of empathy: prosocial concern. This concern results from using the other facets to appreciate the emotions another is feeling. In light of this research, it seems reasonable to suggest that any attempt to increase physician empathy should be a comprehensive intervention aimed at improving all facets of empathy. 
To date, researchers have attempted to cultivate empathy in physicians using a variety of methods, including, but not limited to, communication skills training, role-play, and the use of cultural products such as literature, visual arts, and theater.18 Whether these interventions improve all facets of empathy is difficult to determine because their outcomes are typically measured using unidimensional self-report measures or total empathy scores that merge cognitive and affective empathy into a single concept. Interventions are generally considered a success if they elicit improvements on any component of empathy. 
However, perhaps there are some aspects of empathy that are not beneficial in the medical field. As mentioned earlier, affective empathy can come in 2 forms: emotional resonance (mirroring the same emotion) and emotional concern (feeling compassion). If a patient is highly distressed, it may be ineffective for a health care professional to mirror the patient's emotions but useful for them to respond with a more appropriate compassionate emotional response. For example, Newton et al19 demonstrated a decline in emotional resonance throughout the course of medical school. This decline may be adaptive in the case of general or orthopedic surgeons, who are required to curtail empathy to provide effective surgical treatment.9 
Some measures of empathy have attempted to capture this counterproductive aspect of empathy. The widely used Interpersonal Reactivity Index (IRI)20 includes a measure of Personal Distress, which measures feelings of fear, apprehension, and discomfort at witnessing the suffering of others. This self-focused aspect of empathy may lead to overwhelmingly negative feelings, leaving individuals with few resources to help and may motivate withdrawal from the situation.21 Therefore, it is reasonable to predict that, unlike other facets of empathy, a tendency to display emotional resonance would be detrimental for health care professionals. 
Dispositional and Situational Constraints on Empathy
When considering the virtues of empathy, it is important to distinguish between dispositional and situational empathy: some people are more likely to be empathetic than others, and some situations are more likely to elicit empathy than others. 
Dispositional Empathy
Low levels of dispositional empathy can arise from biological and neurological deficiencies22 as well as from poor socialization and rearing practices.21-27 The overwhelming majority of physicians, however, have a great capacity for empathy. Recent research suggests that medical students start school with average or above-average empathy levels for their age.28 However, empathy significantly declines over the course of medical school,9,19,29 and the extent of this decline varies across students. A longitudinal study by Hojat et al29 found 2 distinct groups of medical students: (1) those students who demonstrated a significant decline in empathy over their 4 years of medical school (70%) and (2) those students who seemingly had a disposition that prevented the erosion of empathy over this time (30%). 
Hojat et al29 discussed 2 variables that appear to predict resistance to empathy decline: a respondent's sex and specialty. Women demonstrated higher levels of empathy throughout medical school and showed a smaller magnitude of decline than men. This finding is consistent with evidence outside the medical field, which reliably finds a difference by sex in empathy physiologically,30 behaviorally,31 and through self-reports.32 Specific to the medical field, Hojat et al29 demonstrated that individuals in “people-oriented specialties” (eg, family medicine, internal medicine, pediatrics, emergency medicine, psychiatry, obstetrics-gynecology) showed less decline in empathy than those in “technology-oriented specialties” (eg, anesthesiology, pathology, radiology, surgery, orthopedic surgery). This difference across specialties could be because medical students with dispositions that protect against empathy erosion self-select into the “people-focused” specialties, or because a people-focused training process encourages the maintenance of empathy. Also, the difference by specialty was proposed as an artifact of preexisting sex differences if “people-orientated” specialties are female dominated. However, this possibility was not examined by the authors and thus remains speculative. 
Situational Empathy
Failure to experience empathy is not unique to individuals with low dispositional empathy. It can also result from learning when and toward whom to experience empathy. Although the building blocks of empathy are automatic, ubiquitous processes,33,34 we have the ability to curtail this natural empathetic response. This capacity is courtesy of the enhanced cognitive control exerted by the prefrontal cortex, which can inhibit empathetic responses. In a host of contexts, this ability is advantageous. For example, in emergency medical situations, empathetic arousal may not only be detrimental for the physician but also for the patient, as it may interfere with the physician's ability to conclude effective diagnoses and perform essential medical interventions. 
Functional magnetic resonance imaging findings have demonstrated the usefulness of situational empathy for routine medical procedures. When control participants were presented with visuals of needles being inserted into another person, activation occurred in brain areas involved in empathy for pain (anterior cingulate cortex, insula); however, physicians who practiced acupuncture did not demonstrate such activity.35,36 In this example, curtailment of a specific empathetic response may have had beneficial consequences by freeing up cognitive resources necessary for the effective completion of treatment and expression of concern.12 
Despite the possible benefits of empathy curtailment in certain situations, there are a variety of contexts where this learned ability would lead to poor patient care. One particularly concerning example is the selective curtailment of empathy to certain groups. Humans are adept at creating social boundaries, and we seem to automatically categorize our social world: men and women, cashiers and doctors, Muslims and Jews, etc. Avenanti et al37 demonstrated that these social categories are not simply banal descriptive heuristics but are meaningful at a neurological level. Using transcranial magnetic stimulation, they measured the neural activity of black and white participants in response to others’ pain. When participants witnessed a member of their own group (in this case, skin color) getting pricked with a needle, they exhibited sensorimotor empathetic brain responses. However, when participants saw a member of another group getting pricked, their brain responded more slowly and less intensely. One of the most remarkable things about this research is that Avenanti et al37 also looked at participants’ response to a violet hand—that is, a hand that had been dyed purple so that it did not fit into any racial category. Participants’ responses to this hand were more similar to an in-group response than an out-group response, suggesting that empathy is our default reaction and that curtailing it toward others requires humans to first place them firmly in the “other” category. As humans, we have no category for purple hands, thus allowing our default empathy to kick in. 
This tendency to curtail empathy toward certain social groups has important implications for physicians and other health care professionals who are expected to offer compassionate care to all patients regardless of their group membership. Despite this laudable goal, physicians of all races are susceptible to learned empathetic biases, which may explain why physicians underestimate minority patients’ pain38 and systematically undertreat black39-41 and Hispanic42,43 patients for pain relative to the treatment of white patients. Future research, both in the medical field and outside, should urgently address ways to unlearn or prevent this group-based empathetic bias. 
Measuring Empathy
Many measurement tools are available for the quantification of empathy, which can be grouped into self-reports, behavioral measures, and physiological measures. Each group, and each individual measure, can focus on widely disparate aspects of empathy. Researchers should carefully select an instrument depending on their interest. Multidimensional measures, or the use of multiple measures, may be the safest choice for exploratory research without a clear theoretical definition of empathy. 
Self-report Measures
A variety of self-report measures are available to measure empathy. The first measure to achieve widespread use was Hogan's Empathy Scale.39 This scale was widely used to measure cognitive empathy,39 but psychometric analysis of the scale demonstrated questionable test-retest reliability, low internal consistency, and low factor-structure stability.49 It has now been supplanted in popularity by the Interpersonal Reactivity Index (IRI).17 The IRI contains 4 subscales: empathetic concern, personal distress, perspective taking, and fantasy, which together tap both affective and cognitive components of empathy. Another popular multidimensional measure of empathy is the Basic Empathy Scale (BES), which measures emotional contagion, emotional disconnection, and cognitive empathy.50 Both the IRI and BES have been validated in various languages and age groups.51-54 
Many researchers may be motivated to use a measure of empathy developed specifically for medical populations. The Jefferson Scale of Physician Empathy (JSPE) was developed to measure empathy in physicians and other health professions (HP-version), medical students (S-version), and health professions students (HPS-version). The authors define empathy as “A predominantly cognitive attribute that involves an understanding of experiences, concerns and perspectives of another person, combined with a capacity to communicate this understanding.”55 This definition and the scale itself deliberately omit measurement of affective components of empathy, instead measuring “perspective taking,” “compassionate care,” and “standing in the patient's shoes.” None of these factors correlates with the personal distress subscale of the IRI (correlations of 0.01, 0.02, and 0.13, respectively),56 indicating that the JSPE fails to capture this aspect of affective empathy. Researchers who use the JSPE should do so only if they intend to solely measure cognitive empathy. 
Exploratory research on the effects of empathy interventions would be advised to use a multidimensional measure of empathy or a cognitive and affective measure together. Failure to measure all dimensions of empathy might risk developing interventions that have unintended negative consequences on the arousal of personal distress, which would go unnoticed by the researchers. This occurrence may not be uncommon as researchers regularly fail to measure all facets of empathy.18 
Researchers looking to measure only affective empathy may find that the Toronto Empathy Questionnaire (TEQ)57 or the Questionnaire Measure of Emotional Empathy58 suits their needs. 
Behavioral Measures
Self-report measures of empathy are generally treated with caution because such surveys are fairly transparent in their goals and therefore may tell us more about a participant's response style than their empathetic tendencies. For this reason, researchers may choose to use one of several behavioral measures of empathy. The classic behavioral measure of cognitive empathy is the false-belief task, which measures one's ability to recognize that others may hold beliefs that are different from their own. Numerous versions of the false-belief task have been developed based on the initial task developed for children by Wimmer and Perner.59 Although subsequent false-belief tasks have been created for adults,60 performance on false-belief tasks often endures ceiling effects as all participants succeed in their completion. The Yoni test is a more sensitive measure of cognitive empathy. It is a validated tool61-63 that assesses a person's ability to judge mental states based on verbal cues, eye gaze, and facial expression, and it has the advantage of assessing both cognitive and affective empathy. 
Behavioral measures of affective empathy are more widely used than cognitive measures. For example, the Reading the Mind in the Eyes Test64 is a measure of advanced affective empathy that has been translated into more than a dozen languages.65 This task asks participants to identify the emotion that a person is expressing from only a picture of their eyes. Alternatively, the Diagnostic Analysis of Nonverbal Accuracy test asks participants to identify emotion in full faces66 or from standing and sitting postures.67 
Despite being widely used as measures of empathy, research suggests that at least some behavioral measures of empathy may tap entirely different constructs from their self-report counterparts. Melchers et al68 found that the RMET barely correlated with the IRI and other self-report measures of empathy, suggesting it measures a distinct endophenotype of empathy. For this reason, care should be taken when generalizing from behavioral measures, and multimodal methods are encouraged. 
Physiological Measures
Emotional resonance, the subset of affective empathy, can be assessed by the concordance of physiological measures between 2 people. Marci et al69 demonstrated that similarities in skin conductance between 2 people indicated empathetic arousal, and the authors noted that this measurement technique could employ additional physiological measures (eg, heart rate, respiratory rate). 
Neuroscientists have used a variety of neuroimaging techniques to measure the many dimensions of empathy. Affective empathy is related to activation in the brainstem, amygdala, and sensory cortices, as well as the hypothalamus, insula, and somatosensory cortex, whereas the cognitive aspects of empathy are related to processes in the medial prefrontal cortex, dorsolateral prefrontal cortex, and temporoparietal junction.69 Finally, the neural underpinnings of the ability to feel concern and care for others are found in subcortical neural areas, such as the hypothalamus and orbitofrontal cortex.70 
The physiological measurement techniques presented here are by no means comprehensive and simply serve to highlight the variety of choices available to researchers interested in quantifying empathy. Individual researchers must carefully select the methods best suited to answer the research question at hand. 
Conclusion
As osteopathic physicians increasingly recognize the importance of empathy in care, a more nuanced understanding of the subcomponents of empathy, as well as the factors leading to its curtailment, are needed to better understand the role of empathy within the various osteopathic medical subspecialties. The understanding and use of empathy will vary greatly between specialties. Each subspecialty field is presented with different challenges, which are likely and uniquely unbalanced. For the osteopathic surgeon, it would potentially be more useful to briefly curtail empathy to focus cognitive resources on effectively carrying out life-saving and technically challenging surgical procedures. For the osteopathic family physician, the cognitive resources used by empathetic processes would provide the greatest benefit to the patient by developing rapport and understanding how medical concerns relate to each patient's situation. 
The theoretical relationship between empathy and clinical outcomes is seductive in its simplicity: physicians who show more empathy will have better patient outcomes. However, this simplistic understanding is under strain as more nuanced measures of empathy are introduced. Empathy is not a unitary construct, and different facets may be related in very different ways to patient outcomes. Further research into empathy in the osteopathic medical field requires cognizance of the multidimensional nature of empathy. 
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Figure 1.
The 4 psychological states called empathy.11
Figure 1.
The 4 psychological states called empathy.11