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MD Empathy: The Patient Perspective


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MD Empathy: The Patient Perspective

By Tom A. Augello, CRICO

Related to: Communication, Emergency Medicine, Primary Care, Nursing, Obstetrics, Other Specialties, Surgery

Physicians who express empathy get higher ratings by their patients on other care issues.

Guest Commentators

  • Ronald Epstein, MD; University of Rochester Medical Center; Rochester, NY

  • Wendy Levinson, MD; University of Toronto Department of Medicine; Toronto, Ontario

  • Debra Roter, DrPH; Johns Hopkins School of Medicine and School of Nursing; Baltimore, MD


Studies indicate that trust is a key factor in the physician-patient relationship that can improve patient adherence and even clinical outcomes. Trust has also been shown to be connected to patient decisions to pursue litigation after an adverse clinical outcome.

New research by Epstein and colleagues at the University of Rochester suggests that a physician's communication of empathy is an important element in trust and patient satisfaction. And the research hints at the kinds of communication training that could help physicians help their patients and avoid problems for themselves. In the Epstein study, the more ambiguous the symptoms and diagnosis, the higher the association between expressions of empathy and positive patient ratings of their care.

"The thing we were particularly looking at here was whether physicians try to reassure prematurely, whether they try to provide cogent explanations, whether they provide empathy or whether they really ignore the patients' concerns entirely."

Dr. Ronald Epstein, Professor of Family Medicine, Psychiatry and Oncology at the University of Rochester Medical Center, was the lead author.

"This has relevance because we know that if patients feel understood, they tend to, for example, follow treatment advice more readily. They tend to be more trusting of their physicians. And other people have shown that when patients feel understood, they are also less likely to seek litigation; they are less likely to sue their physicians. "

One hundred physicians participated, and 50 patients from each physician's practice were surveyed to measure interpersonal aspects of their care. The 5,000 patients rated their doctors on trust, physician knowledge of the patient, satisfaction, and patient involvement in care.

The physicians in the study also agreed to unannounced visits twice in a 12-month period by actors trained to present as standardized patients. The two actors had separate roles—to either present with symptoms of gastroesophageal reflux or a medically unspecific symptom ("a poorly characterized chest pain.")

During the encounter, the standardized patients would prompt the physician with a question of concern, such as "do you think this could be something serious?" and they secretly tape-recorded the interaction. Dr. Epstein's team found that the physicians expressed empathy in only 15 percent of the taped encounters. The study found an association between these expressions of empathy and better survey scores by the physician's real patients.

"One thing that we noticed was that if physicians didn't express empathy initially, they tended not to do so at all. So if a patient said something like, you know, 'I'm worried that this is something serious,' and the physician then started asking more questions or providing some reassurance, they never really dealt with the emotional aspect of the patient's concern. So one of the things we came out with from this study is to say, 'well, when patients are worried—and probably this is generally true in life, when someone's worried—first address the emotional aspects of the worry, and then address the facts and what you're going to do about it."

These results do not surprise other researchers in the field of physician-patient communication.

[new voice]

"I think that in any encounter, it's important to realize that patients are anxious."

Dr. Wendy Levinson is Chair of the Department of Medicine at the University of Toronto. Dr. Levinson has done extensive research into the role of interpersonal communication styles and techniques in the physician-patient relationship.

"A patient once said to me, 'don't doctors know that every patient they see is afraid?' They are worried what the diagnosis is, they are worried about the treatment, they are worried about being a good patient. So this patient wondered out loud, do doctors notice that? Do they know that? It really caught me off guard because I realized that as a physician, of course we don't think about that very often. We see patients all the time. We see many in a day, so I don't think we often pause at the beginning of the visit to think this patient is probably nervous about something, afraid about what we might tell them or about their condition. I should be aware of that when I go in to see this patient."

Patients don't always verbalize their fears, of course. But when they do, the difference between reassurance and empathy is significant. In the Epstein study, reassurance was associated with less trust, not more. Dr. Levinson says this makes perfect sense to her.

"Reassurance can feel dismissive: 'Mrs. Jones, don't worry about that.' Well, when you are worrying, it doesn't help you when someone says, 'don't worry; I'll take care of that.' It can feel like false reassurance. It's very different than saying, 'I recognize you're feeling anxious about this. Many people feel anxious in this situation. It's natural.' That's very different than saying don't worry."

Dr. Levinson has co-authored communication studies with Debra Roter, a professor at Johns Hopkins School of Medicine and School of Nursing. Roter is also a professor at Johns Hopkins Bloomberg School of Public Health in the Health, Behavior, and Society Department. Her primary research has been in physician-patient communication, and her methods of process analysis, using audiotapes of medical encounters, has been widely adopted internationally.

"Patients judge trustworthiness on a number of dimensions. And the contribution of affective dimensions, that is, judgments of emotional consideration, are a primary aspect of trust."

Roter explains that the content of communication is only one part of what a patient hears and understands. Patients judge how forthcoming and informative a physician is. But when it comes to empathy, the specific words are just one aspect of a patient's interpretation.

"You don't really hear an explanation unless you judge the source of that explanation to be trustworthy. You make that decision based on how much sense they are making, how meaningful the information is and also on how you assess the message behind the message, which is often the nonverbal communication that accompanies an explanation. And that message behind the message may be through vocal quality, how they sound or by watching their facial expressions and their body language."

Patients with non-specific symptoms may be especially sensitive to how physicians communicate. Roter says this is consistent with the higher association between empathetic statements and satisfaction in the Epstein study.

Both Roter and Dr. Levinson acknowledge that most physicians don't lack empathy. It's a quality that led them to their profession. However, being able to communicate the empathy they feel sometimes takes practice and training. Dr. Levinson's most recent work focuses on malpractice litigation and the delivery of bad news and medical error disclosure. As in her previous work, she too has used standardized patients.

"It's very anxiety provoking to tell a patient that you operated on the wrong breast. You left a sponge in the abdomen and have to reoperate, like really tough communication. One of the things that doctors find useful is trying to practice this with the standardized patient and getting feedback. So they can try it out—the patient is not one who is going to sue them for the error that they made; it is a standardized patient—and then the patient can say, 'gee, you know, when you said this, this is how it felt to me.' And of course you can try again if you don't like the way it went."

Dr. Levinson says that even simple techniques at an individual practice level can help, such as direct observation—asking a colleagues to watch a patient interview and give feedback. Or using a tape recorder during encounters and listening back later.

She also says that getting ideas for helpful language is useful. Although a physician wouldn't want to rotely repeat someone else's words without feeling, they can be incorporated into his or her own repertoire to communicate what they really already feel, so that patients can move on in the encounter from their sense of anxiety.

"It sounds incredibly simple and it's much harder to do in the heat of an emotional moment, but I think it is very powerful to say, 'I can see that this is a really stressful experience for you,' or 'you look sad. This seems painful and I understand.' Then even pausing and allowing silence, which can feel also difficult when people are distressed. But in the silence people can experience the feeling that they are having and say something back to the doctor about what they are experiencing. So it is like opening the bubble in someone's head by just a simple comment of 'I can understand that this is really painful. I can see that this is really painful for you,' and then being quiet."

Dr. Epstein:

"I think of communication skills training is in a way learning to play an instrument; that is, you need to learn scales and arpeggios and exercises in order to build up your technical proficiency, but scales and exercises really aren't music. They are just preparation to learn to play music. In the same way, communication skills courses for medical students or practicing physicians give you some of those building blocks to be able to communicate well. But then you need to adapt them and interpret them in terms of the situation that you're facing or your own personal style in order to make it meaningful or make it work."

March 1, 2008
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