August 21, 2019
First, let’s clarify our terminology. Many experts distinguish empathy as having two components:
1) affective (experiencing or sharing the other’s feeling) and
2) cognitive (imagining what the other person is feeling yet not experiencing that feeling yourself).
Kathleen Bonvicini, EdD, MPH, CEO of the Institute for Healthcare Communication in New Haven, CT advocates for a third empathic component, behavioral empathy, which is necessary to create an emotional connection between individuals. Thus, cognitive empathy moves us as clinicians to notice what our patient may be feeling (e.g., anxious, scared, confused, etc.) and through behavioral empathy, to expressly acknowledge the experience to them.
For instance, “Mary, I can see that the idea of having another surgery so soon is very upsetting to you.” This is empathic communication. Remember empathy is not the same as sympathy. Sympathy is feeling sorry for something that has occurred and not validating the impact upon the patient.
The link between empathic communication and improved patient outcomes is strong. Many studies have shown improved outcomes with effective communication, with regard to symptom control, function, pain control, and adherence (as opposed to “compliance”) with a treatment plan.
Multiple studies have shown a strong connection between clinician empathy and patient satisfaction. A study of physician empathy in a hand surgery clinic showed that nearly two-thirds of the variation in patient satisfaction was due to physician empathy. In a study of CAHPS “Physician Communication” scores in a large multispecialty clinic, patients identified “treated with respect” as the most important factor in communication with their physicians.
Integrating Empathy Into Clinical Practice
WARNING: WORK REQUIRED!
Part of effective communication with patients is mindfulness, self-awareness, or other awareness on the part of the clinician. Knowing and compensating for factors such as distraction, illness, sleep deprivation and so on is part of our job. Often, it’s easier said than done.
Patients communicate with us verbally, but the non-verbal aspects of their communication are often even more telling. It is important to be vigilant for verbal and non-verbal clues, and to note the congruence between the two. For instance, a patient may verbally say “okay” to your treatment recommendation, but also be avoiding eye contact, or shaking their head, or tapping their foot, etc. Recognizing these behaviors requires clinicians to be focused on the patient (and family), and to watch and listen attentively. In this example, an empathic response that describes what you are seeing and hearing is appropriate, and can invite the patient to share his or her thoughts and concerns.
For instance, “Mr. Johnson, I hear you say that you are okay with (…….) yet I’m wondering if you have any concerns you want to share.” This communicates that you are indeed paying attention. Another approach might be to use the 3rd person to normalize. “You know Mr. Johnson, lots of patients that I care for have hesitations about (…….). I’m wondering if that might be what you are experiencing.” Normalizing is a form of empathy that is quite effective in inviting the patient to share thoughts and feelings. Listening intently and maintaining eye contact helps us appreciate clues such as facial expressions (grimacing, eye-rolling, tearing up), gestures, posture and other forms of body language that build trusting connections with our patients.
Further, listening for the patient’s words, as well as vocal tone and cadence, are additional forms of nonverbal communication and can also reveal clues that are relevant to the patient’s inner thoughts and feelings. Mention of a person who is not present is a clue – that person probably has an important stake in the patient’s well being (a boss, a significant other, a dependent). If these clues aren’t acknowledged, the behavior will likely be repeated, costing time, and giving the patient the impression that the provider isn’t listening or doesn’t care.
So, how does one express empathy?
Empathy makes patients feel that they have been seen, heard, and accepted. This speaks to the importance of communicating respect – in our verbal and nonverbal communication.
Acknowledgment can be non-verbal, such as “mirroring” the patient’s facial expression. Or in response to a non-verbal clue such as the patient tearing up, providing a box of tissues. Both of these are examples of empathy, and can be viewed as acts of compassion. Adding, “take your time” sends a message of comfort and support.
Verbal expressions of empathy take several forms. Reflective statements are a form of “teach back,” expressing your understanding of what the patient has said:
“So, I hear you saying that….”; “It sounds to me like….”
When making a reflective statement it’s important to let the patient correct you if you have misunderstood. It’s a sign of respect.
Strong emotion must be acknowledged. A reflective statement might sound like this:
“That must have been (frightening, frustrating, etc.) for you.
This is one of the rare cases when you might use a negative response:
“I can’t imagine……”
Patients may be embarrassed or apologetic when they are unable to recall details. A normalizing statement, such as one of those below, meets the patient halfway:
“It’s hard to keep all of this straight…”
“I’ve given you a lot of information that would be hard for anyone to remember.”
“Many people don’t remember…”
“Anyone would have been frightened by this…”
If the patient has a complex history, it’s important to acknowledge both the complexity and the challenges the patient has faced, as well as the patient’s effort:
“You have really been through a lot with this…”
“You have tried everything you knew to deal with this.”
A powerful form of empathy is a partnership statement:
“Let’s work on this together….”
This emphasizes that the patient and clinician both have important roles to play in treatment.
Empathy is needed both at the “front end” and in follow up visits. If all is going well, acknowledging the patient’s adherence is respectful and empowering. If there are problems with adherence or things just aren’t going as expected, empathy is crucial for maintaining the therapeutic relationship:
“So, following the medication schedule is more difficult than you thought it would be…”
Beware of “Blocking Behaviors”
Some of the tactics clinicians utilize when communicating with patients actually are counterproductive. These have been called “blocking behaviors” and include:
-Offering advice and reassurance before the main problems have been identified
-Explaining away distress as normal
-Attending to physical aspects only
-Switching the topic
-“Jollying” patients along
(from Maguire, BMJ 2002;325:697–700)
Although we think we’re being empathic, some phrases we use have the opposite effect. Here are some things it’s best NOT to say:
“I know how you feel”
“It’s nothing to worry about”
“It could have been worse”
There’s work involved in empathic communication, but there’s a large pay off as well.
There are multiple opportunities to express empathy in any patient encounter; these are truly “low hanging fruit.” When we are mindful and focused on the patient, these opportunities help us make a strong human (and therapeutic) connection with our patients.
KZA offers workshops, in cooperation with the Institute for Healthcare Communication, in effective, empathic communication for clinicians. Experienced physician facilitators use proven teaching tools and techniques to help clinicians improve their communication skills.