patient care perspectives

Maintaining Empathy in Rheumatology

by Leonard H. Calabrese, DO


Global assessments of disease activity often differ between patients and providers. Applying empathic communication skills can help narrow the discordance gap and improve the quality of care.

Expert Commentary

Leonard H. Calabrese, DO

Professor of Medicine
RJ Fasenmyer Chair of Clinical Immunology
Director, RJ Fasenmyer Center for Clinical Immunology
Vice Chair, Department of Rheumatic and Immunologic Diseases
Cleveland Clinic Foundation
Cleveland, OH

“This is an evolving science in the world of rheumatology, and I am excited about it. It is important for rheumatologists to recognize positive role models who have empathic communication skills. These skills are teachable, and the vast majority are nonverbal.” 

Leonard H. Calabrese, DO

Because we have such incredible therapies now, rheumatologists often focus on precision medicine. But we often forget that many patients with rheumatoid arthritis are discordant in their clinical response with the provider, meaning that the patient and doctor differ in their perception of how well things are going. Often, the doctor thinks that the patient is doing better than the patient thinks that they are doing. This is because patients have dimensions of wellness other than those that relate directly to their joints. It is an important role of the healer to recognize that patients do not experience the disease in a vacuum. There are signs, symptoms, and immunobiology going on, but the disease is experienced at an entirely personal level.

Empathy is the capacity that all providers, rheumatologists, and advanced practitioners must apply effectively in a healing relationship. It is primarily a cognitive attribute that allows us to feel and experience, to a degree, what the patient is actually going through and then to communicate that back to the patient, with an intention to help them. The value is that this allows patients to be heard. There are data to suggest that patients with rheumatoid arthritis who are discordant often feel that they are not being heard or not being listened to. Buffering our empathy, being present, and applying empathic communication skills can help narrow this gap and improve the quality of care, regardless of how the drugs are working. True empathy comes when you are whole. That is, a burned-out person who has become jaded and loses perspective is, by definition, going to be losing empathy.

This is an evolving science in the world of rheumatology, and I am excited about it. There is exciting work going on in placebo science supporting that rituals or the relationship between the provider and the patient has the power to affect a variety of outcomes, particularly surrounding quality of life (ie, pain, fatigue, general well-being). These are outcomes where our highly effective targeted therapies often fall short. It is important for rheumatologists to recognize positive role models who have empathic communication skills. These skills are teachable, and the vast majority are nonverbal. While we all have time constraints, empathy is not time limited. It has been shown that you can have effective empathic communications during a brief visit. It is just that we often go through this in a very nonmindful fashion. We miss all of the empathic cues that are occurring during the patient encounter. That is where empathic communication skills can be taught. The key is to pay attention to people, how they are reacting, what their mood is like, and what their concerns are, rather than just their complaints. We now try to work with our fellows and trainees to demonstrate this. I am giving a major session talk on the role of empathy in rheumatology at the American College of Rheumatology annual meeting this year, and I am very excited about it. 


Carayon P, Cassel C, Dzau VJ. Improving the system to support clinician well-being and provide better patient care. JAMA. 2019;322(22):2165-2166. doi:10.1001/jama.2019.17406

Hojat M, DeSantis J, Shannon SC, et al. The Jefferson Scale of Empathy: a nationwide study of measurement properties, underlying components, latent variable structure, and national norms in medical students. Adv Health Sci Educ Theory Pract. 2018;23(5):899-920. doi:10.1007/s10459-018-9839-9

Hojat M, Shannon SC, DeSantis J, Speicher MR, Bragan L, Calabrese LH. Does empathy decline in the clinical phase of medical education? A nationwide, multi-institutional, cross-sectional study of students at DO-granting medical schools. Acad Med. 2020;95(6):911-918. doi:10.1097/ACM.0000000000003175

Kvrgic Z, Asiedu GB, Crowson CS, Ridgeway JL, Davis JM III. “Like no one is listening to me”: a qualitative study of patient-provider discordance between global assessments of disease activity in rheumatoid arthritis. Arthritis Care Res (Hoboken). 2018;70(10):1439-1447. doi:10.1002/acr.23501

Smolen JS, Strand V, Koenig AS, Szumski A, Kotak S, Jones TV. Discordance between patient and physician assessments of global disease activity in rheumatoid arthritis and association with work productivity. Arthritis Res Ther. 2016;18(1):114. doi:10.1186/s13075-016-1004-3

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