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Empathy: Cornerstone of Effective Physician Patient Communication

It is well established that the medical care experience is enhanced by effective communication between physicians and their patients. Byproducts of this enhanced communication include improved health outcomes, better patient compliance, reduction in medical-legal risk, and improved satisfaction of physicians and patients. Of all the elements involved in effective communication, expressions of empathy seem to be the component of communication most frequently neglected.

What exactly is empathy in the medical context? Traditionally, empathy was viewed as "bedside manner,” with the tacit acknowledgment that some simply had “it” and others did not. The concept of empathy dates from the early years of the last century, when discussions of the topic were restricted to psychotherapists' analyses of their interactions with patients. The origin of the word empathy actually dates back to the 1880s, when German psychologist Theodore Lipps coined the term "einfuhlung" (literally, "in-feeling") to describe the emotional appreciation of another's feelings.

No longer restricted to the psychiatrist’s couch, we can define empathy as an intellectual identification with, or vicarious experiencing of, the feelings, thoughts, or attitudes of another. Importantly, this differs from sympathy which implies feelings are shared with the sufferer as if the pain belongs to both persons. When we sympathize with other human beings, we share and suffer with them. In contrast, empathy is a tool used by skilled clinicians to enhance communication and delivery of care. Sympathy can be burdensome, emotionally exhausting and can lead to burnout. Empathy on the other hand has been described as the clinician's most basic and most powerful diagnostic and therapeutic tool. A patient who feels rapport with his clinician will be more likely to reveal important information; similarly, a strong relationship can help motivate important behavior changes and potentiate other therapeutic interventions.

Even when physicians believe they are sensitive to their patients’ emotional needs, studies have shown that opportunities to demonstrate empathy are frequently missed. Such opportunities arise from a patient's emotion, either directly expressed or implied during the course of the clinical interview. Visits characterized by missed opportunities to express empathy tended to be longer and more frustrating for both physician and patient. Conversely, demonstrations of empathy often save time and expense and are a cost-effective method of facilitating early diagnosis and proper treatment.

In a study by Levinson, 116 office visits to primary care and surgical physicians were audiotaped and transcribed to examine the frequency of empathy opportunities or "clues." More than half of visits in each setting included one or more clues. In more than half of cases, patients presented these clues not overtly but in more subtle ways. Unfortunately, physicians responded to those clues in only 38% of surgical cases and in only 21% of primary care cases as physicians frequently missed opportunities to adequately acknowledge a patient's feelings.

Such clues are often hidden in the fabric of discussion about medical problems and thus may be easily overlooked by physicians who are busy attending to biomedical details of diagnosis and management. In fact, when opportunities for empathy are missed by physicians, patients tend to offer them again, sometimes repeatedly. This phenomenon can lead to longer, more frustrating visits.

Physicians have cited numerous barriers to discussing emotions with patients, from the impersonal office setting to the disinclination of both physician and patient to address particularly sensitive topics. Nonetheless, appropriate skilled communication can break through these barriers.

• It takes too much time - Recent studies suggest that interviews in which physicians respond to emotions may actually be shorter than those in which they do not. An explanation of this finding is that it may be more time-consuming to deal with the indirect effects of unaddressed emotions during the rest of the interview.
• It's too draining - While it is unrealistic to expect all physicians to be emotionally available at all times to all their patients, physicians sometimes exert a tremendous amount of energy avoiding emotions in the belief that dealing directly with them will be draining. To the contrary, it can be far more efficient to make an emotional connection, since so much energy goes into resisting it.
• The interview will get out of control - Although many doctors worry that addressing emotions will cause feelings to escalate, the opposite is often true -- addressing emotions helps diffuse them.

Empathy need not be awkward or emotionally exhausting. Unlike sympathy, empathy does not require emotional effort on the part of the clinician. An appropriate statement or gesture of empathy takes only a moment and can go a long way to enhance rapport, build positive relationships, and even improve difficult ones. Rather than extending the patient encounter as many physicians fear, an expression of empathy facilitates the clinical interview, increases efficiency of gathering information, and honors the patient. The American Academy on Physician and Patient’s Barry Enger MD explains:

• “Understanding the feelings, attitudes, and experience of the patient is the first step toward a more potent therapeutic alliance. Although empathy is not generally considered a therapeutic tool, discussion of emotional issues can be therapeutic. A premise of this discussion is that biomedical aspects of disease cannot be effectively addressed without considering their emotional consequences. Emotions, whether related to physiologic dysfunction or psychosocial issues, color the discussion in the examining room and may be so distracting that the patient cannot fully concentrate on other issues until the emotions are addressed. A few simple skills can demonstrate empathy and contribute to a mutually beneficial physician-patient relationship.“

Enger goes on to recommend these practical approaches:

• Reflection - refers to naming the emotion the doctor sees and reflecting it back to the patient. Reflection communicates the physician's understanding of the patient's experience. It also has the effect of making the feelings behind the patient's behavior or words explicit, where they can be dealt with directly. For example, when a patient greets a doctor who is 20 minutes late with, "My time is as valuable as yours," the doctor might say, "I'm sorry I'm late. You seem pretty angry with me." After reflecting an emotion, the doctor should stop talking and see how the patient responds. Although the patient will usually elaborate, if the physician keeps talking the exploration may be prematurely ended.
• Validation - informs the patient that you understand the reason for the emotion. This has the effect of normalizing the emotion and making the patient feel less isolated. You don't have to agree with patients to express understanding of their feelings. For example, to a somatizing patient who has been to several doctors who have been unable to find a cause for her abdominal pain, you might say," I can understand how frustrating it's been, to be no better after seeking so much help."
• Support - An expression of support shows patients that the physician cares about them and is willing to be present to their emotion. The expression can be verbal or nonverbal. An example of nonverbal expression would be handing the tearful patient a tissue. A verbal expression of support might be "It's pretty normal to get angry with children when they act out."
• Partnership - implies a team approach in which the patient and doctor work together. An advantage of partnership is that it may help motivate patients to take an active role in their improvement and may lay the foundation for a contract for behavior change. For example: “Congestive heart failure is a tough disease; we’re going to have to work very hard together to keep you out of the hospital.”
• Respect - This skill honors the emotional resources within a patient. The doctor might say "You've been through a lot," or "I'm impressed with how well you're holding up under the circumstances."

These skills can be used in any order and at different points in an interview. Ideally, after hearing the clinician's statement of empathy, the patient expresses agreement or confirmation ("You got it, Doc!" or "Yeah, that's exactly how I feel"). If this type of response is not received, you may not have understood the patient's experience exactly and should allow the patient to correct the perception. It’s okay if a concern arises for which there seems no answer. Physicians are used to "fixing" things, but feelings simply exist-and can't be "fixed." Patients do not expect that their feelings will be eliminated; they just want them to be acknowledged.

To Learn More
Although many medical schools have developed curricula with a strong focus on physician-patient communication and empathy, most physicians were trained in the world of "Find it and Fix it" medicine where empathetic communication was only an afterthought. More recently, empathy is the cornerstone of several communication models being taught to practicing physicians across the country, including "The Four Habits" model (Invest in the Beginning, Elicit the Patient's Perspective, Demonstrate Empathy, Invest in the End) developed by The Permanente Medical Group's Terry Stein with Richard Frankel; "The 4 E's" (Engage, Empathize, Educate, and Enlist) model used by the Bayer Institute for Health Care Communication; the "PEARLS" (Partnership, Empathy, Apology, Respect, Legitimization, Support) framework adopted by the American Academy on Physician and Patient; and others. MICA workshops and enduring materials feature important information from these and other useful frameworks. Physicians are encouraged to take advantage of training on this important topic.

In closing, empathy is a powerful, efficient communication tool when used appropriately during a medical interview. Empathy extends understanding of the patient beyond the history and symptoms to include values, ideas, and feelings. Benefits of improved empathetic communication are substantial for both physician and patient.

Reference List:

Coulehan JL, Platt FW, Enger B, et al. "Let me see if I have this right ...": words that help build empathy. Ann Intern Med 2001 Aug 7;135(3):221-7.