Otolaryngology—Head and Neck Surgery
Short Scientific Communication
Improving Empathy and Relational Skills in
Otolaryngology Residents:  A Pilot Study
Helen Riess, MD1, John M. Kelley, PhD1,2, Robert Bailey1,
Paul M. Konowitz, MD3, and Stacey Tutt Gray, MD3
Sponsorships or competing interests that may be relevant to content are
disclosed at the end of this article.
Abstract
Physician empathy and relational skills are critical factors
predicting quality of care, patient safety, patient satisfaction, and
decreasing malpractice claims. Studies indicate that physician
empathy declines throughout medical training, yet little is
published about methods to enhance empathy, especially in
surgical residency training. The Accreditation Council for
Graduate Medical Education requires competencies in 6
areas, including interpersonal skills and communication. To
address this important problem, the first author developed an
innovative empathy-relational skills training protocol focusing
on the underlying neurobiological mechanisms of empathy and
the interpersonal processes that positively affect the patient-
doctor relationship. The authors tested the effectiveness of
this protocol in a pilot study with 11 otolaryngology residents.
Results showed that a brief series of 3 empathy training
sessions can significantly improve physicians’ knowledge of
the neurobiology and physiology of empathy, as well as their
self-reported capacity to empathize with patients. A trend
toward increased patient satisfaction was observed.
Keywords
patient-doctor relationship, empathy, relational skills, patient-
doctor communication, otolaryngology
Received June 23, 2010; revised August 13, 2010; accepted August 31,
2010.
Background
Empathy and relational skills are critical factors in predicting
quality of care, patient safety, patient satisfaction, and
decreasing malpractice claims.1 Physician empathy has been
shown to significantly improve health care outcomes, and
physicians who express empathy receive higher patient satis-
faction ratings. Despite its importance, physician empathy
Otolaryngology–
Head and Neck Surgery
144(1) 120­–122
© American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2011
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DOI: 10.1177/0194599810390897
http://otojournal.org
declines throughout medical training. The Accreditation
Council for Graduate Medical Education (ACGME) man-
dates competency in 6 areas, including interpersonal and
communication skills, which are defined as effective teaming
with patients, families, and other health professionals. In
addition to mandating interpersonal skills training, the
ACGME also mandates evaluation and assessment of these
skills. To address this need, the first author developed a novel
empathy training protocol based on the neurobiological and
physiological mechanisms and interpersonal processes that
improve empathy.
Methods
Eleven otolaryngology residents (43% female; mean age, 31)
completed three 90-minute empathy and relational skills
training modules, presented at 0, 4, and 6 weeks. On the basis
of recent mirror neuron research, the first author developed an
empathy and relational skills protocol focusing on the neuro-
biology and physiology of emotions, including videos that
portray difficult patient-physician interactions. These videos
display real-time physiological responses for both members
of the dyad, allowing observers to see the degree to which
patient and physician are physiologically concordant or dis-
cordant with one another. By integrating biometrics, the train-
ing aims at deeper levels of physiological awareness and
regulation that promise to be more effective than traditional
didactic teaching. This neuroscience approach may be partic-
ularly effective for training surgical subspecialties as it aug-
ments the concept of “being nice” by demonstrating the
1
Psychiatry Department, Massachusetts General Hospital/Harvard Medical
School, Boston, MA, USA
2
Psychology Department, Endicott College, Beverly, MA, USA
3
Department of Otology and Laryngology, Harvard Medical School and
Department of Otolaryngology, Massachusetts Eye and Ear Infirmary,
Boston, MA, USA
Corresponding Author:
Helen Riess, MD, Psychiatry Department, Massachusetts General Hospital/
Harvard Medical School, Massachusetts General Hospital, Wang ACC Suite
812, Boston, MA 02114, USA
Email: hriess@partners.org
Riess et al 121

Table 1. Pre and Post Means (SD) on Empathic and Relational

Skills Measures

Effect Size d
Measure Pre Post P Value (95% CI)
Balanced 45.2 (25.4) 50.2 (25.2) .26 0.20
Emotional (−0.74 to 1.11)
Empathy Scale
Jefferson Scale 110.1 (10.8) 114.3 (10.7) .19 0.39
of Physician (−0.56 to 1.30)
Empathy
Ekman Facial 6.7 (1.4) 8.1 (2.0) .10 0.81
Decoding Test (−0.19 to 1.73)
Patient-rated 37.7 (9.6) 40.0 (9.4) .31 0.25
Consultation (−0.24 to 0.72)
and Relational
Empathy
Measure
(CARE)

Figure 1. Pre- and posttraining mean scores on physician-rated
Consultation and Relational Empathy (CARE) measures. Paired
t test showed a significant improvement from baseline. Error bars
represent standard errors.
Paired t tests were used to compare pre and post scores for the first 5
measures. Because of missing data, we did not have pre and post measures
for all residents for the patient-rated CARE measure. Therefore, we com-
puted an independent samples t test using all available pre (n = 27) and post
(n = 45) training CARE measures. CI, confidence interval.

specific physiological and ameliorative effects on autonomic
nervous system activity produced by empathic skills.
At baseline and at study completion, residents completed 5
self-report measures: (1) the Balanced Emotional Empathy
Scale (BEES)2; (2) the Jefferson Scale of Physician Empathy3;
(3) the Neurobiology of Emotions Assessment (developed by
our team) to assess knowledge of the neurobiology and physi-
ology of emotions; (4) the Ekman Facial Decoding Test,
assessing accuracy in identifying emotions revealed by subtle
facial cues4; and (5) the Consultation and Relational Empathy
(CARE) measure.5 In addition, patients rated the physicians
on the CARE measure at baseline and training completion. In
addition to statistical tests, we also computed standardized
effect sizes (d), which are computed by dividing the difference
between 2 group means by the pooled standard deviation.
Conventional benchmarks for effect sizes are small (d = .2),
medium (d = .5), and large (d = .8). The research protocol was
approved by the Partners Institutional Review Board. Detailed
information about our measures and a description of the empa-
thy training protocol are available online.
Results
Pre-post changes on all self-report measures were in the pre-
dicted direction, and even with the small sample size, paired
t tests indicated that 2 of the changes were statistically signifi-
cant. Figure 1 and Supplemental Figure S1 (online) show sta-
tistically significant improvements in residents’ knowledge of
the neurobiology and physiology of empathy (P = .008) and in
self-reported empathy with patients (P = .01). Standardized
effect sizes for these differences were small to medium (d = .35)
for physician-rated empathy for patients (CARE) and very large
(d = 1.38) for knowledge of the neurobiology and physiology of
empathy. For example, there was an increase in endorsement of
specific items on the CARE measure, such as “I am interested
in my patients as whole people” and “I fully understand my
patients’ concerns.”5 Table 1 shows that residents’ ability to
decode subtle facial expressions of emotion (Ekman Test), their
self-reported ability to empathize with their patients (Jefferson
Scale) and with other people (BEES), and patients’ ratings of
physician empathy (CARE) all increased in the predicted direc-
tion, but none of these effects achieved statistical significance.
As shown in Table 1, observed effect sizes were small for the
BEES and the patient-rated CARE, medium for the Jefferson
scale, and large for the Ekman facial decoding test.
After the training was completed, residents reported agree-
ment with the following statements: (1) I found this training to
be interesting (83%), (2) I found this training to be helpful
(100%), (3) I will be able to apply the concepts and skills I
learned to clinical practice (100%), and (4) I am motivated to
try some of the techniques I learned (83%).
Discussion and Conclusions
This pilot study showed that our empathy training protocol
significantly improved surgeons’ knowledge of the neurobiol-
ogy and physiology of empathy, as well as their self-reported
capacity to empathize with patients. The residents also
showed nonsignificant improvements in their ability to use
subtle facial cues to identify emotions and to empathize with
others in general. Although not significant, patient ratings of
residents’ empathy were also in the predicted direction.
This empathy training program was incorporated into a
newly implemented educational curriculum in the Harvard
122 Otolaryngology–Head and Neck Surgery 144(1)
Otolaryngology Residency Program, entitled Quality, Human-
ism and Professionalism. The evaluative component of this
program could be used in the future as a reliable measure to
assess residents’ competence in the ACGME requirements.
The small sample size and lack of a control group limit gen-
eralizability. Nevertheless, this pilot study strongly suggests
that empathic and relational skills can be taught to resident
physicians. We are currently conducting a randomized con-
trolled trial at Massachusetts General Hospital of the training
protocol with a larger sample size and adequate controls. If this
larger trial is successful, it will demonstrate that physicians can
be trained to improve their empathic and relational skills. We
expect that such improvements would increase patient satisfac-
tion, decrease malpractice claims, and improve medical out-
comes. Future research could address each of these questions.
Acknowledgments
We are grateful to the foundations whose generous support made this
research possible: Arnold P. Gold Foundation, David Judah Fund,
Josiah Macy Jr. Foundation, and Risk Management Foundation.
We also thank the otolaryngology residents who participated in
the study and their patients. Finally, we thank Dr Michael Cunningham
for inviting the otolaryngology residents to participate in this research.
Author Contributions
Helen Riess, conception and design, implementation of intervention,
acquisition of data, analysis and interpretation of data, drafting and
revising the manuscript for important intellectual content, final
approval of the version to be published; John M. Kelley, conception
and design, analysis and interpretation of data, drafting and revising
the manuscript for important intellectual content, final approval of
the version to be published; Robert Bailey, acquisition of data,
revising the manuscript for important intellectual content, final
approval of the version to be published; Paul M. Konowitz, acquisi-
tion of data, revising the manuscript for important intellectual
content, final approval of the version to be published; Stacey Tutt
Gray, acquisition of data, revising the manuscript for important
intellectual content, final approval of the version to be published.
Disclosures
Sponsorships: Massachusetts Eye and Ear Infirmary (MEEI) and
Massachusetts General Hospital (MGH). MEEI and MGH had no
role in the study design and conduct; collection, analysis, and inter-
pretation of the data; and writing or approval of the manuscript.
Funding sources: Arnold P. Gold Foundation, David Judah Fund,
Josiah Macy Jr. Foundation, and Risk Management Foundation. The
foundations had no role in the study design and conduct; collection,
analysis, and interpretation of the data; and writing or approval of the
manuscript.
Supplemental Material
Additional supporting information may be found at http://oto.sage
pub.com/content/by/supplemental-data
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