How Empathy Improves the Patient and Provider Experience - Dr. Helen Riess, CEO of Empathetics, Inc.

Shiv Gaglani: Hi, I'm Shiv Gaglani. If you were to list the skills leaders need to foster an innovative, engaged, and high-performing workforce, would empathy immediately come to mind? Well, multiple studies have concluded that the answer to that is an emphatic yes, and today's Raise the Line guest would agree. 

Dr. Helen Riess is the founder and CEO of Empathetics Inc., part-time professor of psychiatry at Harvard Medical School, and author of the book, The Empathy Effect. 

Empathetics provides evidence-based training that has proven to improve the patient experience, employee wellness and retention, and has trained thousands of clinicians and frontline staff. Trained as a psychiatrist, Dr. Riess developed her empathy training courses based on the neuroscience of emotions and directed a research team at Mass General Hospital to study the impact of clinician empathy on patient experience and outcomes. She's here to talk today about the importance of empathy in leadership in healthcare. 

So, Helen, thanks for taking the time to be with us today. 

Dr. Helen Riess: Thanks for having me. 

Shiv: So, I always like to start by asking our guests to, in their own words, describe what got them interested in a career in medicine and then ultimately, in your case, in psychiatry. 

Dr. Riess: My career in medicine, I think, was just drawing from a desire to help people. I come from a family where there was a lot of World War II trauma, and just hearing the stories and how people really needed to be understood and healed. I think that was a powerful motivator. 

I chose psychiatry, obviously, because it is the best way to actually get to know patients and hear their stories and to help them heal and recover from their own challenges in life. My work was really inspired by the psychoanalyst Heinz Kohut, who really broke away from Freudian theory and regarded empathy as the component of care without which there could be no cure. He really challenged many of the assumptions about what motivated people to do what they did, and he clearly laid out a foundation that made a lot of sense to me: that even with great technique, if you didn't actually understand people and see the world through their eyes, it would be very difficult to connect in a way that made them heal and recover.

Shiv: Yeah, that very much resonates. Having gone through some medical school education myself and now back in medical school, it seems to be the thing that differentiates those attendings who are loved by their patients from those who maybe are not. 

I know you've given a great TED Talk on empathy, you have this book as well, The Empathy Effect. What should our audience know about the neuroscience and study of empathy? Feel free to go into as much or as little detail as you'd like. 

Dr. Riess: So, I love that question, because as much as I believed and practiced psychiatry with an empathic focus, it wasn't until really about the early 2000s that the neuroscience of empathy

started to be even given any kind of attention. I was immediately drawn to learn about this, because I knew,  in my heart, that empathy was such a powerful way to motivate people to connect with people, and to really just help them move through whatever challenges that they were dealing with. 

So, when the neuroscience of empathy started to get published, it was really the first evidence that this was not just a kind of soft skill that's such a nice thing to have, and where people would sort of pat you on the head and say, “Oh, that's so good that you care about empathy.”  It was actually showing that humans are hardwired for this, and that our very survival depends on it.  Neuroimaging studies actually revealed that our own pain centers are activated when we see others in pain. The saying, “I feel your pain” is not just a figure of speech. We actually do feel other people's pain. 

The reason for that, of course, is to motivate us to help them. It's also to teach us what not to do to, you know, to get the same pain. If you see somebody stepping on a piece of glass, you quickly learn why this is such a survival technique, because you learn,  “Oh, that's really painful. I better not step on any glass.” But you also are hurting in a way just by having observed this happening to another person. So, that's a bit of the neuroscience. I don't know if you want to go into a whole lot more, but…

Shiv: No, that's fascinating. I love the evolutionary angles of that. Because why does altruism exist, and the evolutionary biology of that is because if you think about not the individual, but the level of the gene, genes pass on more successfully if the tribe winds up caring for each other being altruistic or empathetic and the pain fMRI studies that you mentioned are very interesting. 

How did you take all that interest and empathy and then ultimately turn it into this company Empathetics, and then we'll go into how it actually works and the actual offering that you guys have. So, maybe take us through the origin story of Empathetics.

Dr. Reiss: Well, Empathetics was quite distal to starting to investigate empathy. I did a medical education fellowship at Harvard Medical School, and I got to choose whatever topic I wanted so I really dove into the neuroscience of empathy because I really wanted to understand, is this something you can teach people to do? Or is it really true that you either have it or you don't? Because that was really the belief. Before I started on this sort of empathy journey, people would just say, like, you either have it or you don't. You can't instill empathy into people that don't have it. 

I observed so many physicians, particularly nurses, who I knew had a lot of empathy. And as the landscape of medicine was changing with the EHR and productivity requirements -- and as medicine was getting to be more and more of business -- I would hear things from my own psychiatry patients about things that were said to them, or ways that their concerns were dismissed. That made me realize you can definitely beat it out of people. 

So, if you can downregulate something, doesn't it stand to reason that you can upregulate it? And so I just didn't buy the fact that, you know, if you don't have empathy, you're sort of a lost cause. So in this fellowship, by studying the neuroscience and understanding how our brains perceive the emotions and thoughts of others, I came up with an intervention that I believed would help recalibrate this deficit. 

It was a long process. I developed this intervention that I believed would work. It took about a year to get funding to do a research study. I felt that unless we did a randomized control trial, no one was going to listen to this, because everyone would just say, “Oh, it's just an observational study. We're not going to give it any credibility.” So, it took a long time to get funding to do this study and then it took another year to get enough program directors to allow basically three hours of empathy training into their curricula.

 

We were lucky to get into some programs at Mass General that included surgery, orthopedic surgery, medicine, psychiatry, anesthesia, and ophthalmology, so we had a nice cross-section of both medical and surgical programs. Once we got that permission, then we implemented this training and had patients rate the doctors before they got exposed to any training -- a computer randomized who got the training and who didn't -- then we had patients rate them on this empathy scale at the end of four to six weeks after the empathy training and there was a big jump in patient experience scores.

Another question people asked was, well, does it stick? It's one thing to just, you know, get a change in behavior a few weeks later. So, we went back to our initial pilot group and studied them one year later, and their experience scores were virtually identical so that was powerful data to dispel the myth that you can't do anything about empathy.

Shiv: Well, that's fantastic. That's really good research. And I'm sure we'll want to link to some of those studies or your talk as well in the show notes. So, you had this intervention, you do this study, what does the intervention comprise of, if you can kind of give our audience a little bit of a sense? And frankly, for some of our audience, they may be interested in just asking the question, how do I improve my own empathy? If you have any tips or tricks for them to maintain or improve their own skills or empathy baseline, I think that'd be very valuable.

Dr. Reiss: Yeah. You asked initially how we got to Empathetics, so I'm just going to finish that thought. This study was published in the Journal of General Internal Medicine and it was the first study at that time to actually say that empathy could be taught. To our great surprise, it got a lot of press, and so it was not just the Northeastern hospitals that were suffering from a lack of empathy, this was starting to be kind of a pervasive complaint that was international. I got a lot of international invitations to give talks.

At first, it was very exciting and after a while, it got very draining to like, run around and talk about this topic all over the place, and the New York Times picked it up and the demand for the training just kept accelerating. An e-learning executive approached me who had been following this, not to my knowledge, but knew a whole lot about it and said, “I want to form a company with you. I'll take care of the business side. You're only going to reach a few hundred people doing this yourself. But if you commit this to an e-learning program, you could reach thousands of people.”

It took a little arm twisting because that really wasn't where I was going with this, but after a while, it made sense that if you really want to be part of a healthcare transformation innovator, it's got to get to scale and so that's why Empathetics got started. I don't think it was going to happen by doing a lot of grand rounds -- and I've done probably hundreds of grand rounds and it's always wonderful to see the interest -- but I always wonder what's the long-term impact, you know, when people hear about the case for why we need to improve empathy?

Shiv: Yeah, no, totally. I resonate with that one hundred percent because that's essentially why we left med school to start Osmosis, and ultimately, I think if you realize you're creating all this value -- and there's this motive to continue doing it and continue improving the learner experience and aligning their outcomes with your outcomes -- that seems to be a very powerful way to reach scale. 

So, maybe go to the question of, like, how do you teach empathy? What's in the program? Any tips for our audience about improving their own empathy skills? And then we'll transition into talking more about where you're at with Empathetics. Like how big is it? What are your goals this year, etc?

Dr. Reiss: Well, first of all, I really want to commend you because you picked up on something that was so needed, which was how can people do self-paced learning. Because all this time in lecture halls that you know, the audiences were getting thinner and thinner, but finding an evidence-based way to ensure that people are getting information was just a brilliant idea and I just commend you so much for everything you've accomplished. 

I think it comes from people who just really want to see a change, and if you don't start doing something about it, it's probably not going to happen. So, the training is multi-layered. There's a lot to it, but basically, it is enhancing perception skills about emotion detection. If you watch most doctors and nurses, they are so glued to technology. Computer screens and imaging and everything that is so helpful about healthcare is also drawing attention away from the patient. 

I used to shadow scores of doctors with low patient experience scores. Most of them were not making eye contact with the patient. There's no way that they could actually perceive the emotion because you actually have to look at someone's face to determine whether they're sad, confused, angry, disgusted or disappointed. And so there was this whole roadmap of information right in front of everybody's face that was not being accessed. Going through the review of systems like chest pain, shortness of breath, edema, swelling, but nothing about connecting with the human being that these symptoms belong to.

It's really fascinating that in medical school, we don't really learn much about emotion at all and yet it is the most powerful driver to whether you're going to have trust in a therapeutic relationship. 

So, much of the training is about enhanced perception. We have proprietary software that trains on emotion detection and it really works. It's very hard to go through our training and not know the difference between sadness and disgust, for example. As you can imagine, the way you would respond to a patient who is expressing sadness, but not really saying it verbally, versus someone who's expressing disgust...like, the way you reply to that could be so off, you know, that the patient's going to be like, “That person just doesn't get me.” So, these are just incredibly important ways to foster the therapeutic relationship.

We also teach that a key ingredient to empathy is the ability to take someone else's perspective because empathy is both cognitive and affective or emotional. Many people think empathy is just about a feeling. “I felt so bad, I felt so sad.” That's really kind of sympathy, just a shared feeling. Empathy goes much deeper than just knowing what the feeling is. It is really about the ability to understand what I call the whole person. You know, not just the broken wrist, but what does the broken wrist mean for a sixty-five-year-old woman who is the only caretaker for her grandchild? It means a lot. But if a person is only being treated for the fractured wrist and not ‘how are you going to take care of do your job’ you're really only doing half the job. 

So, it's a lot about just using curiosity to learn about what people are facing, who they're taking care of, who's there to take care of them. You know, why are they not taking their medicine? Maybe they can't afford it. Maybe they don't have transportation or can't get to a pharmacy. Medicine is full of assumptions about why people are doing what they're doing, and often attributing poor motives or apathy to the patient when they're actually facing true challenges.

Shiv: Thanks for the clarification. That nuance is really important. I personally would be interested in going through the programs myself again, now that I'm back on the clerkship. Can you tell us a little bit about the size and scale of Empathetics? Like, what are your main goals for the rest of the year or going into the next couple years? Some of our audience may be interested in getting involved, whether as learners themselves or bringing it to their programs, or maybe with the company itself.

Dr. Reiss: Well, one of the really wonderful things about getting clients who are really interested in tracking progress is that they start to do their own analytics on your product. So, we have some clients who have reported some really exciting results that are making Empathetics really grow right now. One of them is -- we obviously improve patient experience -- but some of them got into like the 90th percentile within three months. So, the skills are learnable, and they make a difference almost immediately.

But beyond that, one client we've had for four years -- and they've tracked not only patient experience but also levels of burnout, wellness, and retention of staff -- that client has had an 83% improvement in retention of staff, even during the pandemic in Empathetics trained cohorts. We think it's because people get aligned back to their sense of purpose and what they like about healthcare jobs as opposed to only looking at the myriad challenges and things that have made healthcare jobs really difficult in the last few years.

This alignment of purpose and meaning in your profession is an unintended consequence. I'm sure you know that the attrition rates of doctors and nurses right now are massive. It's one of the biggest headaches for CEOs right now, is just retaining staff. So, the fact that something like empathy can reinvigorate people to love their jobs again...hearing that from a few providers, “I feel like I like my job again,” was the best thing.

So, that, and also we've had significant improvement in the number of fewer communication breakdowns, and communication breakdowns are actually the cause of most malpractice suits. It's not whether you do the wrong procedure, or did the wrong thing. It's that something wasn't communicated well that resulted in something poor happening. Or even if something was done incorrectly, if there's not a heartfelt apology and a true sense of trying to make things right, you're much more likely to get a claim filed against you. It has so many benefits in the interpersonal domain for patients and for providers. There are fewer breakdowns.

One client has had a significant improvement on the “Mini Z” which is the American Medical Association’s burnout scale. A higher score means you have less burnout. It's really a scale of wellness. So, on these four metrics, our adoption has become, I would say almost exponentially higher than before the pandemic, because people are looking for solutions now and they realize not only do they have to take better care of their patients, but they have to take better care of their staff, and Empathetics has a program that is built for staff recovery as well.

Shiv: Wow, that's incredible and that definitely is a theme we've been highlighting on the Raise the Linepodcast...moral injury and burnout and the challenges health systems are facing. From the Osmosis angle, we come in and help train more clinicians. That's our goal and keeping them informed with continuing education, etc. But it's one thing to get more people into the bucket and then another thing to have such a leaky bucket that you can't keep them in practice for as long. So, I'm really glad to hear that you're seeing positive results on that side.

One thing I did want to touch upon, regular listeners to the podcast know that two of the very exciting areas that I love to cover are AI and psychedelics, so let's take these one at a time. I would love to get your thoughts as a psychiatrist and the founder of Empathetics on both of those. There's a lot of excitement about AI helping actually bring clinicians and patients more closely together because a lot of the documentation could be automated, so hopefully technology becomes more of an enabler as opposed to a distraction.

But then but then conversely, there's evidence that maybe AI chatbots could be more empathetic because they're infinitely patient. They've studied all the empathetic clinician text messages, so they know what an empathetic person sounds like. Where do you fall on AI as far as augmenting empathy, replacing clinicians with empathy? Would just love to hear your thoughts on that.

Dr. Reiss: So, first of all, I think AI is going to make the job of being a physician exponentially easier because workflows will get worked out. Information will appear when you need it so I think there's a great place for AI in making healthcare work more smoothly. I read the JAMA article about how the machine was able to come up with better and more empathetic statements than a doctor and I had to say those statements were right on. They took the perspective of the patient. They were kind, caring, showed curiosity. But then, it's ‘so what?’ Like, are you going to have an AI machine giving these answers to a patient? Or do you want a human being learning these skills to give those kinds of answers to a patient? Because having a machine learn it, for me, is not good enough. It's really about having the physicians and nurses and PAs and the whole medical team learn how to make these statements, how to recognize the emotion when an empathic communication needs to take place. So, I don't see this as threatening anything, except if people start wanting to relate to a robot and have a robot come in and do the interview with you and hope that it comes out with these responses. 

Ultimately, I think the communication has to come from your human doctor. And if anything, it has pointed out the need for empathy training more than ever because some of the comments that we read were so deficient in really listening to what the real question was, or what kind of reassurance the person needed. So, I think it's going to be a powerful tool but it's not going to substitute a human. That's my opinion.

Shiv: Yeah, I tend to agree with the powerful tool aspect, and for the second part, ultimately I think it will be the patient’s preference. I’m in Utah right now and teenagers -- especially female teenagers who are going through these conversations about premarital sex or things like that -- tend to want to talk to people who, you know, look like them -- female OBGYNs or even avatars and chatbots, right? They grew up on Snapchat. They're used to talking to these interfaces versus maybe some other people who want to be in person and see eye to eye. So, I think the patient's choice will matter. 

But I think this validates and accentuates the need for Empathetics, because humans in general need to become better at empathy and I love what you're building, because it's not just applicable to healthcare, but really anyone. I mean, if you're running a company or joining a company there's so much deficiency and empathy between managers and direct reports or between customers and customer success representatives. So, I love what you're doing in general for those applications.

Dr. Reiss: And I've even worked in law enforcement because there's a much greater need for people in law enforcement to show empathy for the people in their communities whose safety they're responsible for. So, there are just so many applications.

Shiv: Totally. It's a fundamental human need and then for the second part, psychedelics, we've had a lot of researchers and clinicians involved in psychedelic-assisted therapy on the podcast. Earlier this year, we had on Rick Doblin, who runs the Multidisciplinary Association for Psychedelic Studies, which came out with the second phase three clinical trial showing MDMA therapy has had very positive results for severe PTSD. The mechanism of action emotionally is MDMA is called an empathogen. It helps improve empathy during the treatment window and potentially beyond that. We'd just love to hear again -- you're a psychiatrist at Harvard, you run Empathetics -- what are your thoughts on MDMA or psychedelics and the promise for improving empathy?

Dr. Reiss: Well, I think that it's opened up a door to some therapeutics that were shut down for all kinds of political reasons back in the 60s and a lot of bad press and it is actually exciting to see how many really prominent health care research institutions are exploring this. I've had a few of my own patients, you know, seek out this kind of treatment and it really works for some and it doesn't work for everybody. But I think it gets some people into a state of openness and a lack of defensiveness that just opens up realms of new experience for them.

I'm really interested in the interface of psychedelics and psychotherapy. I do think that some people really need a guide. I've actually heard this from some of my own patients. I see the need for a guide to help them unlock or uncover certain things where they feel really stuck. So, I think just the medicines in and of themselves are really interesting and then that interface with a therapeutic or empathetic guide, I think, could be incredibly powerful.

Shiv: Yeah, I agree and hopefully, that guide has gone through empathetic training as well to make it even more effective. I know we're coming up on time so I only had two other questions for you. The first is, what advice would you give to our audience of early-stage health care professionals about meeting the challenges of the moment and approaching their careers in healthcare?

Dr. Reiss: I think that I have a lot of empathy for people who are starting their careers in healthcare right now. I mean, coming out of this pandemic, I think it is one of the most challenging times to get into healthcare and also one of the most exciting and promising. My worry is that there's so much talk about burnout and disenchantment and quitting and not following through on your career that I do worry that people are missing out on really the most positive, fulfilling aspects of having a career in healthcare. I just don't think we're hearing enough about that today. You know, when you meet a dedicated doctor or nurse who is filled up every day by some kind of interaction because they cared, because somebody was grateful, because they brought just the right thing at the right time... there is no job on the face of the earth where you feel as appreciated as when you're helping someone through a health issue or a health crisis. 

So, I would love to start changing the narrative about how hard and terrible and difficult and burned out everybody is to tell me about a job where you get to go home to your family and say, “I saved a life today” or this person made a life change that is going to make them live, you know, ten years longer, or this kid got into treatment. I don't know, there's just something so amazing about the impact we can have that we have to start looking for these moments of...I call them filling the piggy bank with these moments that fill your tank with, “that was amazing,” or “that was great” and that's, I think, part of what keeps people feeling connected to their job, and enjoying their job. But if we discount these moments and just focus on all the documentation and all of this, I think all of that is going to get so much better.

And I think AI is going to take care of so much of this administrative burden. I think it can't happen fast enough. But I do think we've got to get back to the calling that makes most people pick this profession. 

So, I want to say stick with it and look for the moments that really fill you up, because there'll be so many if you care about the people that you're in charge of.

Shiv: That's awesome. That's wonderful advice and I agree with you. Changing the narrative, I think, would be very powerful. And having clinicians like yourself, who are obviously filled up with their work, is good for our audience to learn from and hear from. 

The last question, is there anything else about you, empathy, Empathetics, or psychiatry, that you'd like to leave our audience with? It's sort of an open mic.

Dr. Reiss: I'm so very confident and proud of the team -- and I include this my research teams that help us prove this in the first place -- and the teams working with me at Empathetics that we really can transform healthcare. We're not the only answer. I think we're one of the best answers, but there are many good answers out there. I think people need to have a real open mind about what it's going to take to transform the cultures of healthcare, because they're really hurting. And I think institutional empathy is the message I want to leave you with that it has to start at the top. It has to start with leadership, it has to start with how are we treating our employees and our workers so that we can get the care that all of our mission statements claim that you're going to get when you come here. 

Let's align the mission with how we treat the people who work here and then we won't need all this unionizing and all this other stuff. I think institutional empathy is the answer.

Shiv: I love that. Yeah, that's a really wonderful message to end on and I hope that some of our audience members who are in positions now or in the future to change institutional cultures, take that to heart. Obviously, they start with themselves and hopefully become more empathetic but then bring it to their entire organization. 

So, with that, Dr. Riess, thanks for taking the time to be with us on the Raise the Line podcast, and more importantly, for the work that you've been doing to raise the line itself and strengthen our healthcare system.

Dr. Reiss: Thank you. And thank you for all the work you're doing. It's really inspiring.

Shiv: Appreciate that. And with that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show and remember to do your part to raise the line and strengthen our healthcare system. We're all in this together. Take care.