High physician empathy could offer patients with lower back pain lasting benefits, study shows

Amid the many demands of practicing medicine, doctors can have less time and energy for their patients, and those relationships can suffer. Yet research has shown that when physicians show empathy, that can generally lead to better clinical outcomes, at least over the near-term. Now, a new study, published Thursday in JAMA Network Open, demonstrates that those benefits can extend longer and be even more effective than some clinical therapies in dealing with lower back pain, which affects half of the U.S. population in any given year.

Researchers at the University of North Texas Health Science Center at Fort Worth, observing patients with lower back pain over the course of 12 months, found that treatment by a “very empathic” physician was associated with better outcomes at the end of that year than treatment by a “slightly empathic” physician. And those positive outcomes were greater than those associated with nonpharmacological treatments (exercise therapy, yoga, massage therapy, spinal manipulation, acupuncture, cognitive behavioral therapy), opioid therapy, and lumbar spine surgery.

“Nobody’s done any real long-term studies, such as the one that we’ve done here for 12 months,” said John Licciardone, Regents professor of family medicine at University of North Texas Health Science Center and the first author of the study. What he found most surprising is that “empathy is associated with better outcomes, but they’re also outcomes that really appear to last for a long period of time.”

Lower back pain is a very common condition, with 619 million people affected globally in 2020 according to the World Health Organization. In the U.S., up to 85% of people experience some form of back pain during their lifetime, and 50% have recurrent episodes within a calendar year. Licciardone and his colleagues turned to data from the nationwide Pain Registry for Epidemiological, Clinical and Interventional Studies and Innovation (PRECISION) and employed an empathic scoring system known as CARE, or Consultation and Relational Empathy. Run through the University of North Texas Health Science Center, the registry enrolls volunteers with chronic lower back pain between 21 to 79 years old.

“I think that it’s elegant,” Shiqian Shen, a pain management physician at Massachusetts General Hospital and Harvard Medical School, said about the study. He added that while it might seem like common sense, “real patient contact with compassionate or passionate care is something that is not being emphasized enough.” 

Focusing on people with lower back pain made sense, he added. “I think that’s part of one reason this patient population is being studied because it’s easier to gather enough patients to see a signal,” said Shen, who was not involved in the study.

Researchers used the data from 1,470 study participants drawn from the PRECISION registry who answered a set of 10 questions focused on patients’ opinions about their doctors. For example, did their doctor make them feel at ease? Did they explain things clearly and show care and compassion? From those questions, the researchers rated a doctor as “very empathic” or “slightly empathic.” 

After looking at patient-reported outcomes based on their level of pain and their ability to function, researchers found that, across the board, patients who had very empathic doctors had scores that reflected that they had less pain, were less likely to feel depressed, and less likely to have anxiety or other conditions that might interfere with their quality of life.

While Licciardone said that the data suggests a strong correlation between having a physician with high levels of empathy and experiencing better outcomes, Shen pointed out that there was only a moderate effect on improved health outcomes in the study. He said, nonetheless, that practicing empathy is  “something that we ought to do anyway, so we still have to improve on that aspect.”

Shen added that the results of this research suggest that physicians should look beyond the biological underpinnings of disease. Sometimes there are psychological factors and social factors that contribute to how a patient interprets their pain. “So, if we address only the biological aspect, by putting needles, doing the surgeries, … we might actually miss some opportunities to improve patient care.”

Lisa Hanrahan, a patient at the Pain Management Center at Mass General who leads the medical assistants team at the hospital, receives an injection every six months for her lower back pain. She told STAT that she feels comfortable because her medical team makes sure that she’s OK and not feeling pain, and she appreciates how they carefully explain procedures to her with the help of models and diagrams. Shen is one of Hanrahan’s providers. 

Licciardone and Shen believe that this study can be generalized to patients suffering from chronic pain and other chronic conditions. Ted James, chief of breast surgery at Beth Israel Deaconess Medical Center in Boston who was not a part of this study, stressed that the physician-patient relationship can be important across all specialties. Licciardone said one limitation of the study is that patients’ thoughts about their physicians didn’t really change over the course of 12 months. This means that patients who had very empathic physicians always started out with better outcomes than those who had slightly empathic physicians. Designing a randomized controlled study would have been difficult, but Licciardone and his colleagues hope to conduct a new type of study called a target trial emulation study, which imitates a clinical trial.

James, who has written about building physician empathy, added that while it’s hard to control for things in this type of observational study, it still shows the importance of the initial rapport that a physician has with their patient. He added that “empathy goes beyond being nice” — it is a skill that should be developed and a tool that clinicians should use.

Licciardone noted that researchers only conducted the study in English, which limited the diversity of the respondents. While this study did not look at sociodemographics, Licciardone said a 2022 study published in JAMA Network Open, showed that Black patients actually reported their doctors had higher empathy levels than white patients reported for their doctors, which he said he found a bit surprising.

All physicians who STAT spoke with mentioned that physicians should take more time to treat their patients as human beings, and that empathy should be emphasized while students are learning and throughout their professional careers.

“I feel very lucky … thankfully this was really emphasized by the majority of my teachers and so I think that really got ingrained in me,” said Stephanie Van, an interventional pain management specialist at Johns Hopkins School of Medicine and an assistant professor. She added that she always tells her students to humanize their patients and to never forget to ask about what they do for a living or what their favorite hobbies are. Because then that person with back pain becomes the grandma who wants to get back to playing with her grandchildren and knitting. “That’s a simple practice change that can really help humanize someone’s patients and help them see them as a whole person,” she said. Van, who is also a disability advocate, hopes to see more questionnaire-based studies about how patients feel about their access needs.

Shen said that doctors who treat chronic conditions should take these results into consideration when interacting with patients. “Sometimes they’re not asking for a magic cure, magic needle, magic knife,” said Shen.  “What they care for is they want to be heard, and they want to be understood. And there was someone to help them along the way.”