The Neuroscience of Empathy

Podcast Transcript

Steph Bayer: Welcome to another episode of Studies in Empathy, a Cleveland Clinic Podcast exploring empathy and patient experience. I'm your host, Steph Bayer, senior director of the office of patient experience here at the Cleveland Clinic in Cleveland, Ohio. And I'm very pleased to have with me today Dr. Helen Riess. Dr. Riess, welcome to Studies in Empathy.

Dr. Helen Riess: Thank you for having me.

Steph Bayer: Dr. Riess is the author of The Empathy Effect, a book about transforming our way of life using seven neuroscience based keys. She's the founder and CEO of Empathetics, a company that provides innovative empathy and interpersonal skills training for medical professionals. Dr. Riess is also a part-time associate professor of psychiatry at Harvard Medical School and the director of the empathy program at Massachusetts General Hospital. We're so grateful to have you with us today.

Dr. Helen Riess: Thanks.

Steph Bayer: You are quite an empathy expert and empathy has been at the core of so much of what you do in all of your many roles. What made you interested in exploring and researching neuroscience as it relates to empathy?

Dr. Helen Riess: Well, it really started with just a strong interest in empathy to begin with. I've always been really moved and disturbed when I see people suffer. And when I went to medical school, I intended to go into physical medicine, but seeing people suffer from mental illness was even more disturbing to me. And the fact of seeing people being misunderstood and judged for things that they really couldn't control really drove my empathy for trying to want to do something about that, which led to my becoming a psychiatrist.

And once I became practicing psychiatrist, what became a tipping point for wanting to understand the neuroscience of empathy was seeing my patients trying hard to make really difficult changes like stopping smoking or losing weight or other lifestyle changes, staying on medication that didn't make them feel very good, but their medical doctors really were trying to get them to stick with a program so they wouldn't have seizures or other types of things.

And more times than I want to really recall, my patients were either criticized for being on psychiatric medication with comments like, what do you want all these psych meds for? Or a patient of mine who really tried to lose weight for the first time in her life and lost 15 pounds. And the next time she went to her doctor expecting to be praised, her doctors just threw up her hand and said, "When are you going to do something about this weight?"

And my patient felt so dejected. She just said, "I feel like throwing in the towel if my own doctor can't even see my progress." And it was these sort of mistakes that people were making by just not being really attentive and tuned into where the patients were that were really starting to make me feel like these mistakes were harming people and derailing them from making changes that they really needed to make.

And so at the same time, there were lots of headlines in the news media talking about patients wanting doctors to show more empathy. There was an article in the Wall Street Journal that said when the doctor is in, but you wish he wasn't and all about how patients were really feeling that doctors were so glued to the computer because that was a major change. And many doctors were never familiar with entering all this data in the computer.

So there really was a rift in how many of them wanted to practice and how they could because they had entered so much information in the EHR. But this collision of sorts led me to bring to my research team, do you think empathy can be taught? Because everyone seems to think it's an inborn trait, but it feels like people are losing it.

So at that time, neuroscience was exploding with studies on empathy. And so I got to do a fellowship at Harvard Medical School to really dive into that literature. And by understanding the brain, that really was the key to developing empathy interventions. And so that's what led to my wanting to answer this question and finally having the neuroscience to lead that journey.

Steph Bayer: It's a really powerful and human answer, putting people first is as you think of your research. So thank you for sharing that. As you've done some of these studies and this research, can you talk to me about some of the more impactful studies and what you discovered?

Dr. Helen Riess: Yes. So I guess the first impactful study was using an empathy training intervention that I developed based on neuroscience with a group of ENT surgeons at the Mass Eye and Ear infirmary. And we did this pilot with a small number just to see like a proof of concept, like did their empathy improve?

Because at the same time we were trying to get funding to do a randomized control trial of this training, which I'm sure you're aware is the gold standard for research if you really want to prove that an intervention is what makes the difference, you have to control the population and randomize the participants. So the publication of the pilot study was kind of the first bellwether that there was interest in this whole field.

Then the randomized control trial, I would say is the most impactful evidence that with brief training physicians and now we know nurses can improve their empathy as measured by patients, not just whether they think they're more empathetic because of training, but because patients are saying that. And then we did a follow-up study one year later with the ENT surgeons and we found that the measures were maintained.

And so it's not just a skill you learn for a few months that decays, but it is lasting. So that was really impactful. And then I can tell you about three other studies we did that are related and also I think really important if you'd like.

Steph Bayer: I would love to hear more.

Dr. Helen Riess: So when we did all this research on empathy and we showed that you could improve it, many people said to members of my team, "This probably improves patient outcomes, right?" And we wanted to say yes but we really didn't have the evidence to say that. So we got a grant from the Gold Foundation for Humanism in Medicine to conduct a systematic review and a meta-analysis of all the randomized control trials that showed that just by changing relationship factors, hard health outcomes improved.

And these were health outcomes in some of the most vexing healthcare challenges today like obesity, like lung infections, like asthma and unexplained medical illnesses which is almost 50% of what people come to their primary care physicians with, things that we just don't know. But with relationship factors, even those complaints get better because when people feel understood, their whole physiology relaxes. So that was a very huge breakthrough to show relationships, actually improve outcomes.

And we then wanted to test whether empathy training not just improves warmth, but does it also improve competence? So we did another randomized control trial with analog patients over a thousand of them and we showed them videos of doctors using nonverbal forms of empathy in communication versus doctors who were not. So they were not looking at the patient, they had a big barrier between themselves and the patient, they weren't showing any warmth in their facial expressions.

And so we expected that the warmth measurement would really be improved in the nonverbals of empathy. But what really was impactful was that ratings of competence also improved. And so when people say it doesn't really matter how you treat the patient as long as you know the technical skills and as long as you can get the right diagnosis and treatment it's okay, it's really not.

Steph Bayer: That's tremendous.

Dr. Helen Riess: Yeah. And we did also a cultural empathy study looking at intercultural factors in how empathy is displayed because it's not a one size fits all no matter where you go, there are different norms that people need to learn.

Steph Bayer: This is really interesting in that empathy can drive health outcomes, cultural competency, and just overall competency clinically from a patient perspective, yet it can take time. And I heard you say as you're describing these studies, that it's brief training. The barrier we often hear is that I don't have the time for that, we're so busy, we've got so many patients to care for. How long does it take for you to offer these empathy courses? How much time is really involved in the training?

Dr. Helen Riess: Our evidence based courses that are offered through Empathetics, the basic training is only three hours, but it's not delivered in one seat time. It is delivered with intervals. So we have an algorithm of when people get the different modules. And so the three hours are broken up into shorter, doable modules because we know everybody doesn't have time to sit even for one hour without interruption. And so these courses are presented over time which gives them the ability to reinforce what they learned and time for practice.

Steph Bayer: I think that's so great. We recently sat down and talked to Kelly Leonard from The Second City and he was talking about how you can use improv skills to improve communication relationship. And what we were doing at the Cleveland Clinic prior to the pandemic, we would teach relational communication in a one day full day setting. And we had some really great outcomes from that, but post pandemic, it's hard to find an entire day to pull a provider off patient care. So we need to think of it differently.

And Kelly said think of a professional baseball team. They're not out there doing a full scrimmage. Every practice they have hitting practice, they have bating practice. Just like with communication skills and empathy, you don't need to have a full game all the time, you can break it up into different sections. And I love that your studies have proven that to be true. That's really important for people.

Dr. Helen Riess: That's exactly right. Because many of these skills, when people just get reminded they can do them, but if we're busy or we're pressured, or we just had a bad encounter and we're distracted, or we're worried about our kids, that's when these skills can often just be challenged. But I think the whole point that you don't have to pull people out of work, that you can provide something they can do in a self-paced credit bearing way. Because our courses are accredited by the American Nurse Association and by Mass Medical Society for nationwide continuing medical education credits and risk management.

Steph Bayer: Kind pulling on that thread though of busy people and making sure that it fits into where their needs are so that they can continue to have a balanced and full life, we have a real problem right now with burnout in our healthcare providers. It's a real issue that we need to solve for. What do you suggest healthcare providers can do to keep their mental health well so that they can stay empathetic?

Dr. Helen Riess: Well, that is the most important question of the day because the burnout is actually leading to massive exoduses from the medical professions for both nurses and physicians. And so before I answer what healthcare providers can do, I first want to speak about what healthcare leaders need to do because you can not expect a workforce that has been so traumatized to just brush off.

And now that we hope the pandemic is easing, at least in intensity to like, "Okay, we're good, let's go back to business as usual," without first acknowledging what this workforce has been through. So in addition to many healthcare providers, doctors, and nurses and others on the team, PAs, NPs, many of them could not work at the top of their license because they didn't have the equipment. They were facing moral injury because they were providing the best care that they could, but it wasn't the care they wanted to be able to provide.

And then there was the emotional harm of letting patients know they couldn't see their loved one, that in some cases, patients' families couldn't be there when their parent or their spouse was dying. People don't get over this by just saying, "Okay, that's over. Let's keep going." So for leaders to take the pause and say, we need to acknowledge what these people have been through in a real way, in a way that is substantive and not just lip service.

So about a year ago, I realized that focusing on patient experience was really important but focusing on healthcare providers experience was what this moment needs. And I developed a special training called self empathy. And some people think self empathy, isn't that an oxymoron? Isn't that just selfishness? And it's really self preservation.

And I don't know any other profession where the training and the rigors of becoming a doctor or a nurse are less focused on the wellbeing of the students and the trainees and then subsequently the doctors. It's all about giving, being as perfect as you can, getting every diagnosis right. And there is such emphasis as there should be on being the best you can be for the patients without realizing that these people need replenishment and they need to know how to take care of themselves.

And so I try to see every crisis should not go to waste. So we needed self care a long time ago, but now it's undeniable that workers need to be acknowledged for what they've been through. And at Empathetics, we offer self empathy workshops where it's not, "Here's a pass to a yoga class," it's, "here are some skills you can learn every day to improve your wellness on a regular basis."

And also we're going to with my psychiatry background, you need to process what you've been through, you don't just hop over it. And when people do this in a group, there is the unintended consequence of community building and relationship formation and people become more vulnerable and they realize, do I need to see a counselor? Do I need to be on medicine? I think my bad mood might be depression, right?

So people are walking around at half their ability because in sometimes they haven't even had the chance to take their own pulse and realize like I'm not doing well. So this is something that healthcare leaders need to understand that if they don't have a healthy workforce, they have nothing of value to offer the patients.

Steph Bayer: I love that you made a point in saying it's not just a yoga class. It work and it takes time and it takes intention. And I think you're so right, that that has to be a focus. One of the things we realized too and we actually published on this a couple years ago right when the pandemic was hitting. So again, all this research is now in a different environment.

But when you have empathy training and you teach people the skills of relationships and the importance of relationship building, providers have actually shown three months post and a year post to be more resilient. And that's the power of needing other people and connecting to other people just as your self empathy course advises. I love that concept and it's so necessary.

Dr. Helen Riess: Yes. The idea that taking care of yourself is going to enable you to be like your ideal self. But if you keep on spending yourself and spending your energy without refueling, I mean, simple physics says at some point that car is going to grind to a halt because there's no gas in it. And our bodies need to be taken care of and our minds and our resilience need to be cultivated.

Steph Bayer: What are some of the obstacles that you see or that you've experienced that get in the way of a physician patient relationship and that might hinder it from improving?

Dr. Helen Riess: Well there are a few outstanding leaders that I've spoken with recently that really get this, like they understand that they are in a unique position to decide where the resource is going to go. And unfortunately, the vast majority think that the healthcare workers are going to somehow just take care of themselves and figure it out. But the ones who really want to have and lead a compassionate organization, understand that they need to look at their resources and they need to prioritize taking care of people, it's like a new imperative.

So one of the biggest obstacles we hear about is, oh, yes, this is so important, we really should do this. Maybe we can budget it into 2023 or 2024. And it's like, can you afford to wait another half year? If you just run the numbers on what it costs to rehire or try to get someone hired in a physician or nurse role, hiring a new physician and onboarding them is in the half million dollar range and getting a new nurse is probably about a fifth of that. So when they say we can't afford this, which is literally pennies on the dollar of what it's going to cost to try to attract new people because so many are quitting.

Steph Bayer: It's empathy at a macro level in some ways of how an organization can be empathetic to its people just as we want our people to be empathetic to our patients.

Dr. Helen Riess: You're exactly right. I wrote an article on organizational empathy as a leadership kind of priority and you're exactly right. Many people think it's just an interpersonal skill, but it's really like how do you create an organization that's empathetic? And it's not just about telling people how to act with the patients, it's how do you act with your people and how do leaders behave with the people who report to them even at the very top? So it's really an organizational transformation that we hope to be part of.

Steph Bayer: And it's time for this transformation to keep our teams going. The crisis of healthcare is real. One of the obstacles I hear that get in the way of being empathetic and showing up in that way is just time. I want to do it, I don't have the time to take, to show empathy. We've got so much on our plate. And certainly to take training or to hard wire it into an organization, conceptually is going to take time. What would you say back to someone who said I don't have the time to be empathetic or to take the training?

Dr. Helen Riess: My first question when I hear that is what do you mean by being more empathetic? What is it you think you don't have time to do? Because you'll get answers like I don't have 10 more minutes to hear about every patient's problem or what's going on in their family and that is not why they're there to see you. They're there for a chief complaint and a chief concern.

And if you can get to the chief concern and they feel heard, understood, and that you get the main problem, not just the broken leg, but what this means in terms of what they can do next summer or whatever, you've now shown empathy and it's taken very little time. And I also ask people, how long does it take to sit down? Just by sitting down, you're having a different interaction.

So I understand the time constraints. And most people today understand that the days of having an hour with your physician where you can talk about all your problems, those days are gone. It's about what are you here today for and how can I help you? But also how can I treat you like a human being? How can I meet you the way I would want to be treated, how my first degree relatives would like to be treated? I wouldn't just want to be rushed through, given a prescription and say, "Call me if you need me."

Steph Bayer: I love that because I think there's easier ways to earn a dollar than caring for other people in healthcare. People don't enter this field to not show empathy, to not care for others. Sometimes we get in our own way in our scheduling. Sometimes our organizational processes don't allow it to be as easy.

For instance, we found at one hospital we had a commit to sit program where we said during rounds, if you just sit down with the patient, it doesn't take any longer, but the patients perceive it as more time. But we found that we didn't have stools in the rooms. So we hung hooks and we put the stools in the rooms so when they can commit to sit, the provider actually has the resource needed to actually sit down.

Dr. Helen Riess: Yeah, that's a perfect example that I've heard in so many systems. Well, we can't sit on the bed and sometimes a family member is in the only chair. And so, okay, that might be an expense to get an inexpensive stool that you can hang on the wall. But really compared to all the medical equipment we're buying. I can't imagine that that's such a big expense and it makes a huge difference.

Steph Bayer: In going back to what you said earlier, it improves outcomes and that's really what we want, is we want to have a healthy patient. It's so important, it's worth a couple dollars. And it's important that our organizations and ourselves included look for those moments of where we can be the nudges to improve.

Dr. Helen Riess: Yeah. The other thing I think that is a myth is that with the empathy taking more time, it actually saves time because if you address a person's real concerns, they're less likely to call you and need a follow-up phone call or email you or message you somehow. Because patients, I think they all understand that everyone's pressed for time and they often forget unless they're asked like, what is your main concern?

And they'll walk out and they're like, "Oh, will I be able to play football in the fall?" And then there's a phone call or a follow-up, and then why not? And do I need a note? And so if you just address it in the moment, they leave satisfied. And they like their experience, they'll recommend your clinic or your practice or your hospital because they've had it's such a win-win. And so I think we're finally at an inflection point where all these things that are intuitively obvious are starting to become obvious to leaders of hospitals and health systems.

Steph Bayer: I hope we are. And I love that point that it saves time too, so that there's things in there for all of us.

Dr. Helen Riess: Definitely.

Steph Bayer: On that note, I guess I want to ask what are some things that you do on a daily or a weekly or a monthly basis to keep your empathy strong?

Dr. Helen Riess: That's a very important question because when you're doing research and writing papers and leading a company, there's always more you can do for all these responsibilities. But what I realized is I had to start really listening to what I was saying and apply it to myself and taking a moment in the morning.

And people think meditation is sitting on a cushion for 30 minutes, it's not. It's taking moments to just center your mind. I ask myself, what are my values and how do I show up today so that my values are obvious? And if I'm feeling really good, I think about who in my life today do I just need to do a text, maybe a note or something to say I'm here? And some days it's a text to one person, other days I have a little more time, but that makes me feel so good.

So I start filling my tank by reaching out to at least one person. And if I'm having a conflict with somebody which used to be a way to start the day in a state of agitation or defensiveness, or just negative feelings, taking some time to think, what would this person be saying about what's happening? Like what would be their story? How would this look from their perspective and how can I show up with curiosity instead of judgment?

Because it's so easy to judge when somebody appears to be crossing you or not listening or not following through. But I've learned just by asking, I had somebody on my team years ago who was just always not meeting a deadline and the team would just kind of seethe in silence. And it was always like, "I'm so sorry. I'm really..." So many apologies.

But I finally called up this team member and I said, "Can you just share with me what's going on?" And she said, "I haven't wanted to burden the team with my medical problems." And then she had this really significant medical problem that once I understood that it made total sense. But it was a disconnect between her feeling she was burdening the team with the team just not understanding why this really high functioning and formerly very on time person wasn't being on time. So there's an example.

Steph Bayer: That's a great example of how curiosity is empathy.

Dr. Helen Riess: Yes.

Steph Bayer: I love the intentionality you're putting to center in yourself to start your day. That's a great tip that I'm going to steal from you. That's wonderful.

Dr. Helen Riess: Steal away. It makes your life happier.

Steph Bayer: It sure would. As we wrap up here, is there anything that I didn't ask or that you think we should keep front of mind as a take home message on why empathy matters so much?

Dr. Helen Riess: Well, I am really pleased to see that empathy is being described in the mass media as a leadership superpower. Like it's showing up in Forbes, in Accenture, in Citibank. The CEO of Citibank recently said it was one of the four competencies she looks for when she's hiring people. So I think empathy is surfacing in our culture because we all know there is a massive empathy deficit at every level of society right now. And so I want to encourage leaders to be the leader on having and creating an empathic organization. It will make your organization flourish, and I deeply believe that.

Steph Bayer: That's a perfect point to leave it on. It's a superpower. And thank you for being one of our superheroes with empathy. It's been a pleasure to talk to you today.

Dr. Helen Riess: Thank you for having me. It's been really lovely to speak with you.

Steph Bayer: This concludes the Studies in Empathy Podcast. You can find additional podcast episodes on our website, my.clevelandclinic.org/podcast. Subscribe to the Studies in Empathy on iTunes, Google Play, SoundCloud, Stitcher, or wherever you get your podcast. Thank you for listening. Join us again soon.