MEDICAL TEACHER, 2017

VOL. 39, NO. 2, 164–173

http://dx.doi.org/10.1080/0142159X.2016.1248925

Empathy in medicine: Neuroscience, education and challenges

Eve Ekmana and Michael Krasnerb
a
Osher Center of Integrative Medicine, University of California San Francisco, San Francisco, CA, USA; bSchool of Medicine, University of
Rochester, Rochester, NY, USA

ABSTRACT
Empathy is a multifaceted skill and asset for health care providers. This paper uses current neuroscience literature of
empathy to generate nuanced theory of how empathy can be blocked by personal stress and aversion among health care
professionals. Current training approaches for educating sustainable empathy are reviewed in depth. The final part of the
paper provides suggestions on how to spread empathy education farther and wider across medical education.

Introduction
Empathy in the medical setting includes the appreciation
of the patient’s emotions and the expression of that aware-
ness to the patient. The American Association of Medical
Colleges calls empathy an essential learning objective and
it is believed to significantly influence patient satisfaction,
adherence to medical recommendations, clinical outcomes,
and professional satisfaction (AAMC 1998). Yet, health pro-
fessional educators struggle with how to cultivate empathy,
especially at a time of increasing professional burnout
among its trainees and graduates.
The growing interest in empathy, wellness and resilience
for medical professionals lead to the first international con-
ference to promote resilience, empathy and well being in
health care professions at Georgetown University in the fall
of 2015. Both authors of this paper gave presentations at
the conference and were inspired to expand on the confer-
ence theme of empathy in medical education. This paper
intends to integrate some key research and theory on the
study of empathy, and to review educational and training
approaches for health professionals. Rather than a compre-
hensive review, it intends to cover broad themes and share
useful examples in order to encourage further conversation
and inspire action.
Background
Empathy research and medicine
Empathy in medicine is complex. As medical ethicist and
philosopher Jodi Halpern chronicles in her pivotal work,
From Detached Concern to Empathy; Humanizing Medical
Practice, there is a longstanding fear that physicians who
over-identify with patients will lose objectivity and/or
experience sympathetic distress (Halpern 2001). Empathy
was, and to some extent still is, considered a liability for
the logical reason that it could lead to burnout. This
empathy-aversion influenced decades of medical education
and promoted an emotionally removed stance of “detached
concern” which bypasses the shared experience of the
patient (Halpern 2001). Halpern argued for the adoption of
Practice points

Neuroscience of empathy provides insights for
empathy education.

Different facets of empathy require different train-
ing approaches.

Medical Education should include training in vari-
ous aspects of empathy.
a professional empathy with emotional-based reasoning
instead of the detached concern. In 2015 Ekman and
Halpern suggest that skillful application of professional
empathy provides valuable connection for patients and
also supports a sense of connection and meaning for pro-
fessionals (Ekman & Halpern 2015).
Empathy describes both an affective “feeling with” the
suffering of the patient and a cognitive ability to take the
perspective or “to put oneself in the shoes of the patient”
(Reiss 2010). It is a skillset valued by health training institu-
tions for program candidates (Riess et al. 2012). Empathy is
a stated core competency among academies of medical
training across health professions (ACGME Home 2016).
Research demonstrates that physicians with greater
empathy practice with improved patient experience of care,
improved medical outcomes (Shapiro et al. 1989; Shanafelt
et al. 2002; Mercer et al. 2016) and experience greater pro-
fessional satisfaction (Shanafelt et al. 2012).
The combination of research demonstrating the value of
empathy and recent emphasis on wellness in medical train-
ing programs has made empathy training for health profes-
sionals an area of growing interest (Hojat et al. 2004;
Krasner et al. 2009; Riess et al. 2012). Basic research in
social psychology, neuroscience and the burgeoning field
of contemplative science offer important insights on under-
standing empathy, including how it can contribute to burn-
out or compassion, and how to teach sustainable empathy
(Shanafelt et al. 2002; Vachon 2016). Contemplative science,
central in these efforts, refers to interdisciplinary scientific
approaches to the mind and mental training based in

CONTACT Eve Ekman eve.ekman@ucsf.edu 1545 Divisadero, San Francisco CA 94114, USA
ß 2016 Informa UK Limited, trading as Taylor & Francis Group

traditional Eastern contemplative methods and philosophy.
Much of the current contemplative science research focuses
on how to reduce personal distress and improve wellbeing
through various forms of meditative practices (Kemeny
et al. 2012; Wallace & Shapiro 2006). These approaches
have been woven into evidenced-based trainings for the
general public and medical education, as explained in the
training descriptions that follow.
Importantly, the neuroscience referenced in this paper is
from laboratory functional neuro-imaging studies in which
empathy is experimentally induced, as opposed to natural-
istic observations of empathy in the real world. Laboratory
induction of empathy uses clearly distressing images and
sounds from a specially chosen emotionally stimulating
library. This makes this research on empathy specific to
when struggle and suffering is clear. Although empathy
practiced in medicine often involves an open stance or
curiosity to what is presenting, this paper focuses on the
empathic response to explicit distress and blatant suffering.
Empathy in neuroscience
Neuroscientist James Decay provides a succinct definition
of empathy that dovetails with Halpern’s theoretical work:
“The psychological construct of empathy refers to an inter-
subjective induction process by which positive and nega-
tive emotions are shared, without losing sight of whose
feelings belong to whom. Empathy can lead to personal
distress or to empathic concern” (Decety & Meyer 2008).
This definition hits three critically important points for
defining empathy: (1) there is a subjective felt experience
of another’s emotions, (2) empathy does not mean losing
oneself in the other persons’ experience and (3) empathy is
the precursor to feeling distress, or of caring, concern or
helping. Implicit in this definition, and explicit in other neu-
roscientifically-based definitions, is the role of cognition in
the empathy process. Other research by Decety, and
empathy/compassion neuroscientist Tania Singer, have
Figure 1. Empathy Appraisal: Compassion, Distance and Distress.
MEDICAL TEACHER 165
demonstrated that the affective emotional resonance is
faster than the appraisal which helps distinguish and iden-
tify the target of empathy (Decety & Jackson 2004; Singer
& Klimecki 2014). The teaching of empathy in medicine is
often challenged by a lack of clear distinction between
these important aspects of empathy which may require dif-
ferent teaching approaches. Through the four schematics
shown in Figure 1, we will review the felt experience and
biological underpinnings of different ways empathy can
unfold.
Resonance and affective empathy
Figure 1 illustrates the key components of empathy in tem-
poral order. We are hardwired for our first, and nearly auto-
matic, emotional resonance (Zaki et al. 2009). This
emotional resonance, sometimes called affective sharing or
emotion contagion, is believed to develop very early as evi-
denced by the contagion among crying newborn cries
(Fabes et al. 1994). This occurs in a bottom-up fashion,
meaning instantiated by external stimuli, and grounded in
what Decety calls perception–action coupling, our auto-
matic ability to perceive the actions in front of us (Decety
& Jackson 2004; Decety & Meyer 2008; Decety et al. 2014).
This is believed to involve our mirror-neuron system in
which neural networks in our minds “mirror” are activated,
as though we were experiencing what we are witnessing
(Iacoboni 2009; Iacoboni & Dapretto 2006). There is evi-
dence for mirror neuron activation when witnessing phys-
ical pain as well as seeing pain in facial expression (Preston
& De Waal 2002). The key aspect of resonance is automati-
city, this is the emotional poignancy, the affective aspect of
empathy.
Perspective taking, cognitive empathy
The second component is empathy appraisal and perspec-
tive taking. Perspective taking develops later in the course
166 E. EKMAN AND M. KRASNER
of early childhood development than emotional resonance,
it is found around three years of age (Zahn-Waxler et al.
1992). This is when we become aware of, and can consider,
a distinct and separate mind from our own. This ability to
have what is called a “theory of mind” is subserved by the
prefrontal cortex and is considered more of a top–down
process, relying on metacognition, a reflective experience
of our mind. This top–down process, less automatic than
resonance, is influenced by conscious thought. This is cog-
nitive empathy. As shown by the arrows going both ways,
the affective resonance can be moderated by this cognitive
aspect which can in turn influence the initial affective
response (Decety & Meyer 2008).
Enactive compassion
This cognitive aspect of empathy can moderate our emo-
tional responses to be caring or lead us to distancing and
distress. The top right box shows cognitive appraisal lead-
ing to empathic concern and enactive compassion. Enactive
compassion is a term drawn from the contemplative science
literature and elaborated on in a schematic model by con-
templative teacher Roshi Joan Halifax. Halifax teaches com-
passion to health care professionals who work with the
dying. Halifax begins with the concept of an enactive mind,
a mind which does not merely perceive the world, but is in
an emergent and contingent process of sense making with
the world and the surrounding environment (Thompson &
Stapleton 2008). Applying this conception to compassion,
compassion is not a discreet activity but part of a process
of perception and engagement (Halifax 2012). Enactive
compassion is not a blanket approach of caring, rather it is
a nuanced response to our emotional resonance, cognitive
appraisal, intention and somatic experience (Halifax 2011,
2012)
Intention and somatic experience are both skills which
are cultivated via contemplative training. Briefly, compas-
sionate intention is the cultivation of a core motivation and
aspiration that others be free from suffering. For many in
medicine their intention is already compassionate: “to be of
service, and reduce suffering”, however this intention can
become lost amid everyday stress and business. Intention
setting practices help us keep a compassionate motivation
in mind. Clearly, setting a compassionate intention can
increase our benevolence towards others (Dahl et al. 2016).
Somatic experience of compassion refers to the felt som-
atic correlates of our emotional experiences. Enactive com-
passion is our engaged response to the distress of our
patient. This is not always active or even kind. Because
enactive compassion begins with empathy, seeing the
patient, this can require responses such as firm boundary
setting or not doing, and simply witnessing. Enactive com-
passion is an active stance which can mitigate feelings of
inefficacy, powerlessness and distress when a professional
is unable to instrumentally “help” a patient due to limita-
tions in the system, expertize, or patient capabilities.
Aversion
The bottom left box represents cognitive appraisal without
an intention of compassion, one which is almost transac-
tional (Yagil 2006). In this version of empathy, automatic
emotional resonance to the suffering of another person is
followed by a distancing logic towards the person for their
suffering, such as “It is their fault they are sick, they don’t
take care of themselves”. This could be technically accurate,
as they could be a heavy drug abuser, or irresponsible with
their diet despite diabetes. This appraisal then leads to
aversion, and may result in responses of anger, blaming,
avoidance or ignoring. It is important to note here that the
very same patient, the drug abuser, could be appraised as
deserving of our enactive compassion because they are suf-
fering—the difference being perception, which is directly
shaped by our intention and/or our feelings of efficacy and
ability. For many health professionals, not being able to
help or treat a patient creates extremely difficult feelings of
inefficacy, and this inefficacy can shape our perception
towards feeling aversion to the patients we can not help
(Ekman & Halpern 2015). This aversion is a key feature of
burnout, measured through questions about cynicism and
depersonalization (Maslach et al. 2001). Burnout has been
frequently attributed as a cause of declining empathy
among health professionals (West et al. 2006).
Sympathetic distress
The final box on the lower right demonstrates what hap-
pens when we act ‘mindlessly’ without top-down aware-
ness of our emotional resonance. Here, we feel the
suffering of another as though it were our own and
devolve into self-related concerns (Halpern 2001; Decety
et al. 2014). When we feel too distressed, we attempt to
avoid emotional resonance. Because emotional resonance
occurs nearly automatically, avoidance requires effortful,
total suppression. This strategy has two downsides. One is
that we miss important clinical information which is com-
municated through the patient’s affect, such as fear from a
patient who experienced domestic violence which we have
not screened for. The second downside is that suppression
of emotions is effortful, and physiologically taxing on our
system, resulting in more, rather than less, emotional
exhaustion over time (Gross & Levenson 1997; Gross 2002;
Gross & John 2003; Goldin et al. 2008).
Here is an illustrative example of how these different
forms of empathy unfold in a patient encounter: A pri-
mary care professional is seeing a female patient in her
late 40s whom the professional has known for a year.
She often has bruises and broken bones and also often
misses her follow-up appointments. During this visit, the
patient appears very nervous and badly bruised on her
face and right forearm. She is tearful and tells the profes-
sional she is afraid to go home because of abuse from
her husband. In the case of enactive compassion, the
professional would resonate with the fear of the patient,
provide supportive communication and enact compassion
through assisting the patient to come up with a safety
plan. In the case of distancing, the professional would
resonate with the fear of the patient and then recall how
the patient does not make follow up appointments and
decide that the patient should have to find a solution to
her fears elsewhere. The professional communicates
options for DV counseling or a shelter on a piece of
paper but acts in a transactional way creating distance.
In the distressed form of empathy, the professional

over-resonates with the fears and sadness of the patient
and loses a sense of efficacy or ability to help her.
Although moved by the struggle of the patient, the pro-
fessional is emotionally overwhelmed which in the short
term results in some engagement, but prevents an ability
to develop a clear actionable plan, and in the long run
contributes to professional aversion and burnout. This
same patient, without the verbal vocalization of her fear,
could be effectively engaged with if the professional is
empathically connected and has an open and curious dis-
position as a default approach with patients. However,
the distanced and distressed professional could easily
miss or avoid the nonverbal cues of the patient’s fears.
Mindfully managing emotions
How then do we manage our appraisals to promote com-
passionate responses and avoid negative or maladaptive
empathy? Contemplative science has demonstrated some
impressive applications of compassion and attention-based
meditation training which can specifically help shift our
appraisals. The most in-depth studies of prolonged medita-
tion from the neuroscience laboratory of Clifford Saron and
colleagues demonstrate the efficacy of developing sus-
tained attention for managing our emotional resonance to
suffering (MacLean et al. 2010). Participants in one such
study were shown distressing film clips of a solider in
Afghanistan describing his emotional difficulties as well as
scenes of war and death. Before attention and compassion
training, these participants displayed sadness and anguish
in their facial muscles, described feeling sadness in their
self-reports and were physiologically over-aroused by these
clips. After the training these same participants exhibited
similar, albeit reduced, facial displays of sadness. They
reported feeling sad but were less physiologically aroused.
In other words, they remained aware of and understood
their emotions, but were not as distressed or exhausted by
these emotions (MacLean et al. 2010). This fits with
Decety’s model of empathy where the affective experience
can be modulated by the cognitive appraisal (Decety &
Jackson 2004).
Research from the labs of Richard Davidson and Tania
Singer, among others, have demonstrated that compassion
and loving kindness meditation trainings increase positive
emotions related to others, and observed a rise in helping
activity and brain activations of kindness (Davidson et al.
2003; Klimecki et al. 2012; Flook et al. 2013; Singer &
Klimecki 2014). Some of these studies show changes in
brain responses associated with compassion after only five
days of training.
As shown in Figure 1, there are a number of ways
empathy can be blocked or can lead to difficult experien-
ces. Managing these blocks and difficulties speaks to the
various aspects of the of cognitive empathy and affective
empathy definitions of Decety referred to previously.
These include working with the subjective felt experience
of another’s emotions, not losing oneself in the other per-
son’s experience and supporting appraisals that can help
one avoid feeling distress and aversion, leading one
instead to caring, concern or helping. Teachable empathy
skills include effective communication (both what is said
and how, and what is understood), increasing emotional
MEDICAL TEACHER 167
awareness compassion, loving kindness and attention
based mediation, mindfulness and managing stress.
Cultivating empathy in medical/health professional
education
Empathy, as discussed above, begins with hard-wired
affective emotional resonance that is modulated by “top-
down” or “bottom-up” responses, and is moderated by
intention and awareness. This results in intra-personal and
interpersonal actions, some compassionate in nature which
involve perspective taking and curiosity, and others less
sympathetic, involving aversion, projection, avoidance and
over-arousal.
One can appreciate how some actions coming from
empathy enhance the clinical encounter, and others detract
from it. Exploring empathy in health professional education
includes examining the ways in which empathy benefits
the patient as well as the professional. It also involves
inquiry into enhancing the professional’s capacity for
empathy in ways that enrich the therapeutic relationship.
Finally, it should explore avenues to protect the profes-
sional and patient from the potentially harmful effects of
the negative or maladaptive empathic response.
Empathy benefits and burdens
Despite an emphasis on empathy in medicine and its rec-
ognition as a core competency, investigators point out a
lack of empiric evidence connecting empathy with patient
outcomes. Nevertheless, a 2002 meta-analysis of medical
interactions in primary care found that physician empathic
appreciation was linked to increased patient satisfaction,
adherence, patient comprehension and perception of a
good interpersonal relationship. Evidence also demon-
strates that higher empathy levels increase not only patient
satisfaction and compliance, but also health status (Hojat
et al. 2004). For example, clinical outcomes in patients with
diabetes were improved under the care of physicians who
measured higher on a validated scale of physician empathy.
In a study investigating patient satisfaction with surgeons,
empathy indirectly affected patient satisfaction through its
positive effect on health outcomes. Health professional
empathy, especially if compassionate, curious, and with
perspective taking improves patient outcomes through its
capacity to build trust, improve communication and
enhance mutual understanding, resulting in improved
patient compliance and engagement in the medical care
plan.
Empathy also benefits the health professional. Empathic
communication yields improved physician as well as patient
satisfaction, and has been correlated with fewer malpractice
claims. Lower empathy may impact medical errors as well as
increase the distress experienced by health professionals.
Among a group of medical residents training at the Mayo
Clinic, perceived errors was associated with greater personal
distress and lower levels of empathy. The kind of distress
experienced by health professionals who value empathic
connection, but are untrained in how to engage with it fully,
is poignantly captured in this narrative description:
In general, I think that I am a pretty good listener. I will spend
extra time with my patients if they need it, but I felt in some
168 E. EKMAN AND M. KRASNER
ways that it was kind of sucking me dry. I would be so
empathetic, and then I would feel frustrated, like what else can
I do? … I would think about patients at home, in the shower,
thinking she can’t get to her appointment, maybe I should pick
her up and drive her … . I would empathize to the point of
where I would be so in their shoes. I would start to feel the
way that they felt and I mean, you know, take four of those in
a row in a day, and I would be just wiped out … and, they
don’t really want to hear about me and my processes … .
Shifting from distress to clinical empathy with emo-
tional-based reasoning as referenced earlier (Halpern 2001),
this same physician now understands and describes
empathy differently:
It’s not that I don’t empathize with them anymore, but [now] I
feel OK just to listen and be present with them … and I think
that in some ways that helps them more … and that is a
wonderful thing that you can do for patients … . I just needed
to learn that myself, I guess.
Despite these benefits, experiences highlighting the
more challenging empathic responses are familiar to the
medical professional as well as student. It is easy to become
overwhelmed by suffering or to recoil into self-protection. It
is tougher to “lean into” the difficulty especially without
educational experiences that reinforce the positive effects of
enacting compassion. Therefore, the challenge for empathy
in health professional education remains one of creating
conditions that enrich the therapeutic relationship bi-direc-
tionally. Empathy’s root – “em” or “in/with” and “pathos” or
“feeling, emotion, suffering” reflects its bidirectional nature.
This marvelous aspect of human consciousness, to feel the
state of another, was movingly described by Henry David
Thoreau: “Could a greater miracle take place than for us to
look through each other's eye for an instant?”.
Obstacles and challenges
Cultivating the “hard-wired” quality of empathy among
health professional trainees raises a number of challenges.
First, can empathy be taught? German phenomenologist
Edith Stein maintains that empathy can be facilitated, inter-
rupted and blocked, but cannot be forced to occur, and
that when it occurs, we find ourselves experiencing it,
rather than directly causing it to happen. Rather than instil-
ling empathy in students, the challenge remains to facili-
tate without interrupting or blocking it. This “allowing” of
students to experience empathy occurs at the intersection
of the humanity of the professional, the suffering of the
patient, and the relationship between the two.
True education has always reflected this kind of facilita-
tion. Educere, the Latin root translated as to “bring out,
lead forth” suggests the teacher’s active participation in the
educational interchange, rather than an implanting into the
student. It is the calling forth of what is already inherent,
nascent, but cultivatable (Dictionary 2016). Hindrances to
drawing forth empathy include the intrapersonal-those aris-
ing mainly from within the learner, interpersonal-those aris-
ing between the learner and others, and cultural/
institutional—those arising from values, behaviors and tra-
ditions within the health professional educational context.
Intrapersonal challenges to cultivating empathy include
the depersonalizing effects of burnout, developmental and
culturally acquired norms of turning away from, rather than
leaning into difficulties, and genetic and epigenetic
influences upon empathic expression. Personal distress can
interfere with empathic connecting, and is worth exploring
further.
There exists a well-documented connection between
empathy and burnout. Health professionals who experience
the suffering of others can shut down emotionally as a
result, making it difficult to attend to the needs of others,
especially for those who regularly witness suffering. Granek
poignantly illustrates this in a quote from an oncologist:
I go through weeks where it’s very difficult to come into work. I
come in and I don’t
really want to be here at all. It’s an effort to drag myself down
to clinic … because
I know that I’m going to see patients who are going to do
badly.
Perhaps different kinds of empathy elicit different out-
comes in the health professional. What is called clinical, or
professional empathy may be a more optimal approach,
preventing over-identification and internalizing the dis-
tress, without ignoring the emotional responses and feel-
ings of the patients (Ekman & Halpern 2015). Clinical
empathy is primarily a cognitive quality that “involves an
understanding of the inner experiences and perspectives
of the patient as a separate individual, combined with a
capability to communicate this understanding to the
patient” (Hojat et al. 2004). This is described in Decety’s
brain based understanding of empathy: our ability to
apply an understanding and reflection which can moder-
ate our affective resonance (Decety & Meyer 2008).
Consider the following exchange:
1. Patient: You know, when you discover a lump in your breast,
you kind of feel—well, kind of— (her speech tapers off; she
looks down; tears form in her eyes).
Dr. A: When did you actually discover the lump? Patient:
(absently) I don’t know. It’s been a while.
2. Patient: (same as above) Dr. B: That sounds frightening.
Patient: Well, yeah, sort of. Dr. B: Sort of frightening? Patient:
Yeah … and I guess I’m feeling like my life is over. Dr. B: I see.
Worried and sad too. Patient: That’s it, Doctor.
Interpersonal challenges in cultivating empathy arise
from difficulties in recognizing the self in the other. This
includes cultural diversity where culturally and linguistic-
ally diverse patients experience powerlessness, vulnerabil-
ity, loneliness and fear when undergoing health care, and
where students encounter difficulty in identifying and
understanding these issues. Contemporary educational
approaches improve knowledge about the care of cultur-
ally diverse patients, but are not found to change discrim-
inatory attitudes or enhance culturally competent
behaviors. Nonetheless, educational approaches which
attempt to place students “in the “shoes” of particular
patient groups have shown promise.
Common cognitive dispositions can be a barrier to
empathy and interfere directly with quality patient care.
These include the fundamental attribution error where dif-
ferential care is based on a clinician blaming the illness on
the patient or the patient’s behavior, and the affective
heuristic where the clinician’s affect, with regard to a
patient, influences the care rendered (Croskerry 2003).
Encouragingly, contemplative educational approaches
effectively address the roots of these biases through the

cultivation of metacognition and de-biasing, and provide a
model for further study (Sibinga & Wu 2010).
Finally, institutional and medical culture influences the
cultivation and expression of empathy. There is perhaps no
greater influence on the cultivation of empathy than the
hidden curriculum within medical education—all those
behaviors and events that students observe and experience
that may be at significant variance with what they have
been taught (Hafferty & Franks 1994). Medical sociologist
Renee Fox gave this account in a lecture:
As they struggle, individually and collectively, to manage the
primal feelings, the questions of meaning, and the emotional
stress evoked by the human condition and uncertainty aspects
of their training, medical students and housestaff develop
certain ways of coping with them. They distance themselves
from their own feelings and from their patients through
intellectual engrossment in the biomedical challenges of
diagnosis and treatment, and through participation in highly
structured, in-group forms of medical humor. By and large,
medical students and housestaff are left to grapple with these
experiences and emotions on their own … . They are rarely
accompanied, guided, or instructed in these intimate matters of
doctorhood by mature teachers and role models. Generally
their relations with clinical faculty and attending physicians are
too sporadic and remote for that.
As Coulehan describes, “today’s culture of medicine tends
to be hostile toward altruism, compassion, integrity, fidelity,
self-effacement, and other traditional qualities. In fact, hos-
pital culture, and the narratives that support it, implicitly
identify a very different set of professional qualities as ‘good’,
and sometimes these qualities are diametrically opposed to
the virtues that we explicitly teach” (Coulehan, 2005).
Despite these intra-personal, interpersonal, and institu-
tional/cultural impediments to compassionate empathy, a
number of approaches should be considered. These
include, but are not limited to: Professional Role-Modeling,
Communication Skills, Cultural Humility, Emotional Self-
Awareness, Meaning-Making, Meditation on Loving
Kindness, Compassion and Attention, Mindfulness, Social
support, and Narrative Medicine. Several will be explored
further below.
Educating for empathy: self awareness
Cognitive appraisal of the affective emotional resonance is
subject to conditioning, automatic reactions and influenced
by conscious thought, such as intention, somatic, emotional
and cognitive awareness and metacognition. Therefore, a
central task in cultivating compassionate empathy is to
address cognitive appraisal through enhancing self-aware-
ness. Even though empathy itself cannot be directly
“taught”, self-awareness as a skill can be cultivated in many
ways. These include somatic, emotional and cognitive
approaches in different combinations and with different
emphases. Educational activities that promote self-aware-
ness, nonjudgmental positive regard, and listening skills are
important in developing empathic clinicians.
Educating for empathy: communication skills,
cultural humility, emotional self-awareness,
meaning-making
Promoting self-awareness, self-reflection, communication
and relationship-centeredness, are educational models that
MEDICAL TEACHER 169
take a holistic approach to professional formation and
empathy. The stated goal of professional formation is to
anchor students to foundational principles while helping
them navigate the inevitable moral conflicts in medical
practice (Rabow et al. 2010). Several examples of these hol-
istic efforts include the Healer’s Art course taught in med-
ical schools in the United States and worldwide (Remen
et al. 2008), and health care institutional change initiatives
such as at the Indiana University School of Medicine based
on institutional-wide engagement of stakeholders through
an Appreciative Inquiry process (Suchman et al. 2004).
Likewise, communication skills training may assist health
professionals to build empathy. In a randomized controlled
study of a communication training intervention using
didactic and experiential teaching methods, coaching and
skills practice sessions, physicians significantly improved
empathic expression during patient interactions (Bonvicini
et al. 2009). Another approach used the review of taped
interviews of patient encounters, demonstrating that the
majority of empathic opportunities were missed by surgical
trainees, and that such review may improve resident phys-
ician core competencies.
Educating for empathy: mindfulness-based
approaches, compassion, narrative medicine
Contemplative approaches such as Mindfulness-Based Stress
Reduction, Mindful Self-Compassion, and Cultivating
Emotional Balance can help cultivate empathy in ways that
enrich the therapeutic relationship. As in the discussion of
Saron’s work, health professionals encounter suffering on a
regular basis, and by doing so are challenged to engage in
ways that minimize the negative effects of vicarious trauma,
depersonalization, and the affective heuristic on medical
decision-making (Slovic et al. 2005). Specific guided, brief
uses of Loving Kindness, Compassion and Attention medita-
tions can serve to help students tolerate distressing emo-
tions and increase feelings of benevolence. In SPRUCE, an
abbreviated contemplative training for residents, loving
kindness is taught to residents through identifying and
reflecting of their core values or intention of benevolence
towards their patients and themselves. Compassion is taught
as a practice to use “on the spot” when they encounter suf-
fering. Attention training can be easily taught as an “on the
spot” practice to use in the elevator or between charting
notes to focus the attention completely on awareness of the
breath through specific parts of the body for a couple of
minutes. Mindfulness, an open attention to what is happen-
ing in the present moment, can be applied throughout the
day to increase awareness of feelings and thoughts and
reduce ruminative anxiety.
Contemplative approaches can increase the capacity for
the clinician to remain empathically connected, while at
the same time minimizing the physiologic, emotional and
cognitive toll. This outcome defines resilience—“the ability
of an individual to respond to stress in a healthy, adaptive
way such that personal goals are achieved at minimal psy-
chological and physical cost; resilient individuals not only
‘bounce back’ rapidly after challenges but also grow stron-
ger in the process” (Epstein & Krasner 2013).
For example, a resilience-building year-long training pro-
gram of mid-career practicing primary care physicians
170 E. EKMAN AND M. KRASNER

based on mindfulness, narrative medicine and appreciative
inquiry resulted in significant improvements in empathy,
psychosocial orientation, burnout, and mood states. These
changes were strongly correlated with measures of mind-
fulness, supporting the mediating effect of contemplative
training (Krasner et al. 2009).
This educational intervention utilized the sharing of clin-
ical narratives about challenging clinical themes, such as
grief, suffering, errors, teamwork and uncertainty. Sharing
clinical narratives has been described by Charon as part of
practicing medicine with narrative competence, an ability
with which “physicians can reach and join their patients in
illness, recognize their own personal journeys, through
medicine, acknowledge kinship with and duties toward
other health care professionals, and inaugurate consequen-
tial discourse with the public about. Narrative competence,
she maintains, includes the necessity of clinician to have
the generosity and courage to tolerate and bear witness to
tragedy and loss.
Central to narrative competence is the capacity for self-
reflection, awareness and interpretation of emotional
responses, and the development of insight and wisdom to
enact what is required in the care of the suffering. The
relief of suffering, the central task of the health profes-
sional, demands an ability to identify, through the
empathic connection, with human suffering. Awareness of
self, awareness of other and awareness of the relational
space between the two are key objectives for contempla-
tive approaches to cultivate empathy.
Educating for empathy: skills, competencies and
trainings
The table below integrates the themes presented through-
out this paper, the obstacles to empathy, and opportunities
for training alongside the competencies from the
Accreditation Council for Graduate Medical Education and
American Association of Medical Colleges and a selection
of training programs.
The obstacles to empathy include cognitive and affect-
ive aspects of empathy covered earlier in this paper
(distress, aversion, suppression) as well as a lack of self-
care, missing emotional cues and structural inequalities. A
lack of self-care may have various etiologies. Taking time
for oneself may be limited due to work schedules, espe-
cially for residents, or lacking from an inability to feel
deserving to take time for self-care when patients need so
much more. Structural inequalities stem from over bur-
dened public health care setting where many professionals
work. Missing empathy cues could be a lack of training to
tune in to the faces of others, or a fear of tuning in to
empathy.
Table 1 lists skills in empathy trainings which can be
used to address different obstacles and include:
Communication Skills, Cultural Humility, Emotional Self-
Awareness, Meaning Making, Meditation on Loving
Kindness, Compassion and Attention, Mindfulness, Social
Support, Narrative Medicine. These skills require different
investments of time. For example, social support is time
costly as it is inherently a group activity, whereas some
meditations can be practiced remotely through online
guidance.
The competencies drawn from the ACGME, in italics
below include Patient Care
Professionalism, Interpersonal Skills and Communication.
The AAMC competencies which map on to trainings
include Social Skills, Team Work, Resilience and
Adaptability, Cultural Competence, Service Orientation,
Resilience and Adaptability.
The training programs described in Tables 1 and 2 are
by no means exhaustive but are representative of programs
either specifically designed for, or adapted for health care
professionals. These trainings have a number of distinct
qualities. Some trainings are based in contemplative prac-
tice as seen in Table 2: #4,5,7,10,11,12,13. Many of these
trainings have been delivered in medical education set-
tings, some as mandatory and others elective, and several
are delivered in retreat format intended more for post-
graduate continuing education or as part of medical educa-
tion curriculum.
Additional aspects to consider are the dosage of training
(how often and how much) and methods of training (live,
on-line, synchronous, asynchronous, group, one-on-one,

Table 1. Obstacles, Skills, Competencies and Training.

Obstacles to empathy
Empathic Distress, Stress,
Depression, Overidentification
(Affective Empathy)
Aversion, Blaming, Distancing,
Cynicism (Cognitive Empathy)
Missing Empathy Cues, (Affective
Empathy)
Emotional Suppression (Cognitive
and Affective Empathy)
Lack of Self Care, Giving too much
Structural Inequalities of Care
Skills
Emotional self awareness Meaning
making, Mindfulness, Meditation,
Loving Kindness, Compassion,
Narrative Medicine, Social
support
Compassion, Emotional Self
Awareness, Cultural Humility,
Communication, Narrative
Medicine,
Emotional Self Awareness, Emotion
identification, Mindfulness,
Meditation, Attention practices,
Communication skills
Emotional Self Awareness,
Mindfulness, Meditation,
Attention practices,
Communication skills
Emotional Self Awareness, Social
support, Mindfulness, Meditation
Compassion, Loving Kindness
Institutional Cultural Shift
Professional Role Modeling
ACGME/AAMC competencies
Patient Care Professionalism
Social Skills Team Work
Resilience and Adaptability
Patient Care Interpersonal Skills and
Communication
Service Orientation Social Skills
Ethical Responsibility
Patient Care Interpersonal Skills and
Communication
Service Orientation Social Skills
Cultural Competence
Professionalism Interpersonal Skills
and Communication
Social Skills Oral Communication
Professionalism
Service Orientation Social Skills
Resilience and Adaptability
Professionalism
Social Skills, Cultural
Competence
Training programs
Balint, CCT, CEB, GRACE, Healers
Art, MBSR, Mind Body Medicine,
Mindful Practice, MBSC
CCT, CEB, Empathetics, GRACE,
Mind Body Medicine, MBSR,
Mindful Practice, MBSC, Non
Violent Communication,
Motivational Interviewing, Facial
Expression of Emotion Training,
Empathetics,
CCT, CEB, Mind Body Medicine,
MBSR, Mindful Practice, MBSC,
Balint, CCT, CEB, GRACE, Healers
Art, MBSR, Mind Body Medicine,
Mindful Practice, MBSC
Appreciative Inquiry, CREW
 MEDICAL TEACHER 171

Table 2. Empathy education.

Training Delivery Population
1 Appreciative Inquiry is a model that seeks to engage stakeholders in self determined Live, Iterative Business, Healthcare
change, and has been used with teams, organizations and health care settings. A
strength-based focus on information, collected from employees is used in the creation
of organizational development strategy and implementation of organizational effect-
iveness tactics (Whitney and Trosten-Bloom 2010)
2 A Balint group is a group of physicians or other clinicians who meet regularly and pre- Live, Group, Ongoing Healthcare
sent clinical cases in order to better understand the clinician-patient relationship. A
Balint group usually has two leaders (often a physician and a psychologist, psych-
iatrist, clinical social worker or counselor) who facilitate the process.) (Johnson et al.
2016)
3 CREW, Civility, Respect, Engagement at Work, offers workgroups an intensive process to Live, Group, Varied Healthcare, Business
improve their level of civility and respect. CREW operates through a series of conver- time
sations, exercises, and role-plays designed to put relationship issues on the work-
group’s problem-solving agenda (Leiter et al. 2012)
4 CCT, Compassionate Care Training combines traditional contemplative practices with con- Live, Group, 2hours for General Public,
temporary psychology and scientific research to lead a more compassionate life. 8 weeks Healthcare
Instruction, daily meditation, mindfulness, and in-class interaction strengthen the qual-
ities of compassion, empathy, and kindness (Jazaieri et al. 2013)
5 CEB, Cultivating Emotional Balance, teaches skills of emotional self awareness and CEB: Live 42 hours, CEB; General Public
empathy through psychology based techniques of investigation along side contempla- SPRUCE: live & SPRUCE: healthcare
tive practices to strengthen attention and transform difficult emotions. A shorter online 8-12 hours
health care specific CEB focusing on reducing burnout and supporting empathy is
Supporting Provider Resilience by Upping Compassion and Empathy SPRUCE (Ekman
2015; Kemeny et al. 2012)
6 Empathetics offers scientifically based empathy education proven to optimize interper- Online, 1-3 hours Medical Trainees,
sonal engagement. Using self-paced, online education, participants learn the basic sci- Health care
ence of emotional connections with others (Riess et al. 2012) professionals
7 GRACE, Gathering attention, Recalling intention, Attuning to self and other, Considering Live, Group, Weekend Health Care
what will serve, Engaging, enacting, ending. This scientifically grounded, weekend Professionals
intensive training is for health care professionals who work with individuals suffering
from stress, trauma, life-threatening illness or chronic conditions. The training was cre-
ated to provide caregivers with a powerful method for fostering compassion (Vachon
2016)
8 Healers Art curriculum offers a safe learning environment for a personal, in-depth explor- Live, Group, Semester Medical Trainees,
ation of the time honored values of service, healing relationship, reverence for life length course Health care
and compassionate care. It is a Discovery Model curriculum in values clarification and professionals
professionalism for first and second year medical students (Remen et al. 2008)
9 Micro Expression Training Tool teaches you to detect micro expressions of emotion. By Online, 75 minutes General public
spotting micro expressions, you can better understand the differences between emo-
tions and identify concealed emotions of those around you.
10 Mindful Practice programs are organized around common challenges faced by health pro- Live, 3-5 day retreat Health care professio-
fessionals, such as responding to suffering, bad outcomes, conflicts with patients and workshop, brief nals, medical stu-
staff, errors, lapses in professionalism, burnout, and grief. It involves the sharing of seminars, year-long dents, other health
clinical narratives on challenging themes, with appreciative inquiry influencing the intensives professions
resulting dialogs, all within a container of mindfulness practice (Krasner et al. 2009)
11 Mind Body Medicine takes medical, and graduate students through a series of exercises Live, 8 sessions of Medical Trainees,
used to promote overall well-being, stress management, empathy, self-awareness and 2 hours Faculty
self-care. In addition, an annual professional training program in Mind-Body Medicine
is offered (Saunders et al. 2007)
12 MBSC, Mindfulness Based Self Compassion an 8-week program designed to cultivate self- Live, 8 sessions of General public,
compassion skills for daily life. MSC is an experiential journey—an adventure in self- 3hours healthcare
discovery and self-kindness—offering periods of instruction and periods of practice
(Neff & Germer 2013)
13 MBSR, Mindfulness Based Stress Reduction Dr. Jon Kabat-Zinn developed the Mindfulness Live, 8 sessions of Patients, Health Care
Based Stress Reduction (MBSR) program is an 8-week intensive training in mindfulness 3hours Professionals and
meditation, based on ancient healing practices. Since its inception, MBSR has evolved more
into a common form of complementary medicine addressing a variety of health prob-
lems (Kabat-Zinn 1982)
14 Motivational Interviewing is a method that works on facilitating and engaging intrinsic Live, group, individual, Clinicians
motivation within the client in order to change behavior. MI is a goal-oriented, client- class series,
centered counseling style for eliciting behavior change by helping clients to explore coaching
and resolve ambivalence (Miller 2004)
15 NVC, Nonviolent Communication is based on the principles of nonviolence– the natural Live, group, individual, General Public, Health
state of compassion when no violence is present in the heart. Through its emphasis class series, Care professionals
on deep listening—to ourselves as well as others—NVC helps us discover the depth coaching
of our own compassion (Rosenberg & Chopra 2015)

etc). These and other details are often problematic for med- Conclusions
ical education. The existent constraints of a specific medical
Albert Einstein said that Empathy is patiently and sincerely
setting may often dictate how these trainings are intro-
seeing the world through the other person’s eyes. It is not
duced, but as the trainings are woven in over time more
learned in school; it is cultivated over a lifetime (Kadlec
scheduling flexibility may be found.
Regional Medical Center). The importance of empathy as a
172 E. EKMAN AND M. KRASNER
quality of the health professional’s way of being cannot be
overstated. It is as critical to quality patient care as it is to
the well-being of the professionals who deliver that care.
Its cultivation requires not just personal embodiment devel-
oped through the process of self-exploration and self-
awareness. It also requires intelligent, emphatic, committed,
and embodied leadership of our medical educational insti-
tutions and medical centers, the training ground for the
health professions.
The successful implementation of empathy in health sci-
ences education requires that student literally live and
breath within an environment that values and engages
empathically. It cannot be successfully cultivated by simply
inserting courses on empathy or skills sessions on empathic
techniques, unless the qualities contained therein are
reflected throughout the curriculum, integrated horizontally
across contemporaneous courses as well as vertically from
year to year. It will be successful only when the hidden cur-
riculum mirrors the importance of relationship, of standing
in another’s shoes, and of perspective taking.
Further suggestions include using the information in this
article as a starting point, and reflecting upon the history,
culture, and human resources found within one’s own insti-
tution. Engaging in this important reflection is critical
toward identifying not only areas for improvement, but
more importantly strengths and assets that already exist,
that may be utilized as sources of inspiration and leverage
in transforming institutional culture, creating more
empathic, relational, resilient, and effective institutions. As
this process unfolds, we should embrace investigation into
the effects of these initiatives on patients, those who work
within medical institutions, the students, and the health
professionals themselves, as well as support research that
deepens our understanding of empathy.
Glossary
Enactive compassion: is a term drawn from the contemplative
science literature and elaborated on in a schematic model by
contemplative teacher Roshi Joan Halifax. An enactive mind, is
a mind which does not merely perceive the world, but is in an
emergent and contingent process of sense making with the
world and the surrounding environment. Applying this concep-
tion to compassion, compassion is not a discreet activity but
part of a process of perception and engagement. Enactive com-
passion is not a blanket approach of caring, rather it is a
nuanced response to our emotional resonance, cognitive
appraisal, intention and somatic experience.
Professional empathy: may be a more optimal approach to car-
ing, preventing over-identification and internalizing the distress,
without ignoring the emotional responses and feelings of the
patients. Clinical empathy is primarily a cognitive quality that
involves an understanding of the inner experiences and perspec-
tives of the patient as a separate individual, combined with a
capability to communicate this understanding to the patient.
Disclosure statement
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of this article.
Notes on contributors
Eve Ekman, PhD, MSW, is a postdoctoral fellow at the UCSF Osher
Center for Integrative Medicine, where her research focuses on
developing and evaluating live and online training to develop emo-
tional awareness for sustainable empathy and compassion for resi-
dents. Eve is the teacher trainer for the evidenced based Cultivating
Emotional Balance emotion and contemplative skills training along
side Buddhist scholar Alan Wallace.
Michael Krasner, MD, is a specialist in Internal Medicine Practicing
Primary Care, Rochester School of Medicine. Dr. Krasner has been
teaching Mindfulness-Based Stress Reduction to patients, medical stu-
dents, and health professionals for more than 13 years, and co-directs
the Mindful Practice program to train health professionals in mindful
practices at the University of Rochester and around the world.
Funding
This work was supported by the National Center for Complementary
and Integrative Health, 10.13039/100008460 [T32].
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