Caring is not enough: How to develop a structured approach to empathetic communication

College of Physicians and Surgeons of Alberta CPSA, Messenger

By Dr. Cameron MacGougan

I am an emergency physician at the Royal Alexandra Hospital. For the past 12 years, I’ve tried hard to provide excellent care, but I‘ve struggled. I’ve watched colleague after colleague burn out at the end of their careers and I figured the writing was on the wall. I needed to figure out how to retire early, or get a new job.

Every so often, work would be great. I felt like I made a difference. I might have even received a thank you letter. But other days, patients were angry and frustrated. “You don’t care. You doctors are all the same!” were common refrains.

I thought I knew what empathetic care was: I thought you just had to care.

It wasn’t until I attended the Royal Alexandra Patient & Provider Experience Summit that I took a hard look at my practice. I began exploring what it meant to provide empathetic care and after some hard work, a lot of reading and some trial and error, things changed. My patients feel listened to and cared for and I feel like I have made a difference.

I want to share what I have learned. I’m not an expert and I still have a long way to go, but I hope I can get you interested in developing a structured approach to empathetic communication.

Practising with intent

To practise with empathy, it’s important to understand the difference between caring and empathy. You need to know that some patients will challenge your empathetic communication skills. You need to understand why empathy matters. You need to have a structured approach to communicating with empathy. You need to be aware of the five enemies of empathy so you can avoid them. Most importantly, you need to practice empathy as a communication skill – ideally with feedback.

Caring versus empathy

People often seem uncomfortable about addressing their empathetic communication. A common reaction is “I care… I’m already doing this.” I thought I was doing it too, but it was not until I examined my practice that I understood the difference between caring and empathy. Caring is to feel concern or interest in another person. Empathy (or more specifically, cognitive empathy) involves understanding someone’s experiences. Caring is not the same thing as empathy.

I work with some great people and I don’t believe the problem is a lack of caring. And yet, College complaints are on the rise and the majority of these complaints stem from communication issues7.

Why does empathy matter?

Empathetic communication is easy when the patient is someone you can easily relate to. But patients with disruptive behavior, drug-seeking behavior, chronic pain, somatization, unreasonable expectations or with a disease that is a consequence of self-inflicted behavior (like substance abuse) can be challenging. Delivering bad news or disclosing a medical error can also lead to tough conversations.

Empathy and empathetic listening involves understanding someone’s experiences and understanding – not necessarily fixing – a problem. We all have the ability to be empathetic; this ability is present from birth. Evidence shows that we are hard-wired for empathy17-19, a cooperative trait has likely helped us thrive as a species.

Unfortunately, empathy can erode throughout medical school and residency as we are exposed to the hidden curriculum of our training9-12. We need to teach learners to triage their time, but I think we also inadvertently teach them to thicken their skin, which can make it hard for them to re-connect with their empathy.

William Osler said, “The good physician treats the disease. The great physician treats the patient who has the disease.”

A medical evolution

Osler’s time was an era of bedside medicine. Physicians spent a lot of time trying to accurately diagnose disease, but had limited treatment options. Osler believed that immersion with patients was so important that he established the first live-in residency. He knew that sitting by the bedside to give emotional comfort was the best care a physician of his time could offer.

Today, we live in an era of curative medicine. The exponential growth of knowledge has forced us to specialize and resulted in fragmented care. We spend the bulk of our time away from the bedside and often focus on whether a patient has something that will benefit from what we do, not on what is wrong with the patient or what they need. We give patients labels like “non-cardiac chest pain” or “this is not an emergency.”  This is a reductionist approach focused on what is right for the organ, not what is right for the person. Curative medicine values technical excellence and efficiency, but do we still value empathy?

Empathetic communication is what you would want as a patient. It improves patient outcomes13, 20-21and decreases the risk of complaints and litigation23. It reduces the risk of burnout22 and creates meaningful joy at work. Patients will thank you, and your drive home from work will feel a lot better. It’s the right thing to do.

The truth about empathy

It is a myth that you can’t be technically excellent and empathetic. You don’t have to choose between competence and empathy. A good physician can accomplish both. It’s not easy, but it is important.

It is a myth that empathy is a character trait that can’t be altered. Just because you have the ability to be empathetic doesn’t mean you always communicate empathetically. Empathetic care requires you to choose to connect with another person in the moment, using communication skills that can be taught14-16.

It is a myth that you don’t have time for this. Empathetic communication requires more front-end time but reduces the tail-end time of the encounter. One study looking at insurance claims settled against primary care physicians found that doctors with no claims spent only three minutes longer per patient encounter than those with two or more lifetime claims24.

The Dalai Lama said, “If you want others to be happy, practise compassion. If you want to be happy, practise compassion.” Empathy, like compassion, is a trait that needs to be practised. And like most things in medicine, if we want to do something consistently, we need to develop a structured approach.

An eight-step approach to empathetic communication:1-6, 8

  1. Play the part.
  2. Use open-ended questions.
  3. Look for emotional cues and respond empathetically.
  4. Wait for the natural pause before you clarify your history.
  5. Smile.
  6. Set your agenda using shared decision-making.
  7. Explain the timeline of the patient’s care.
  8. Re-assess and update the patient.

Play the part

In Ancient Greece, the persona was a mask worn by actors to convey the personality of the part they were playing. As a medical practitioner, you need to put on your persona and choose how you want to portray yourself as a doctor.

When you walk into the room, your emotional connection with your patient may be weak. But you can recognize the patient as a person that deserves good care and your emotions will often feel real to you as the encounter progresses.

Communication is more than words. Verbal communication communicates data and non-verbal communication conveys the emotional tone. So remember, non-verbal communication matters. Pay attention to the posture, eye contact, facial expressions and tone of both yourself and your patient. To establish a connection:

  • Knock on the door.
  • Introduce yourself to everyone in the room.
  • Explain your role.
  • Consider diffusing initial tension and resetting the emotional clock with an apology (i.e., “I’m sorry you had to wait so long”).
  • Sit down.
  • Face your patient.
  • Make eye contact.
  • Smile.
  • Adopt an open, comfortable stance, making sure your arms are not crossed.
  • Lean in.
  • Try to match the patient’s emotional intensity with your own expressions.

To connect on a deeper level, try recalling a similar emotional experience of your own to help imagine a patient’s emotional reaction to their situation. This can be challenging, but it is also more rewarding:

  • Take a deep breath before you walk in to re-centre yourself.
  • Think about the issues your patient is facing.
  • Be curious.
  • Be present.

Use open-ended questions

Start with an open-ended question and do not interrupt. Something like “What brings you to the hospital today?”  Then demonstrate your interest and comprehension by nodding your head and saying “mmm hmm,” “uh huh” or “I see.”

The Chinese character for listen explains it best. You want to listen with your ears. You need to look for non-verbal communication with your eyes. You need to provide your undivided attention as you use your heart and mind to understand where your patient is coming from. Let the patient direct the conversation.

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The only time you should interrupt is if you notice verbal or non-verbal emotional cues. It’s easy to ignore emotional cues and just move along in your history, but instead  take a moment to acknowledge that an emotion has been shared and respond empathetically. Don’t worry about getting it wrong—the patient will still appreciate your engagement and will clarify the emotion for you if you are off the mark. When you name the emotion, try to use non-threatening language. Avoid statements that escalate an emotion, like “You seem angry.”  It is better to de-escalate with language like “You seem upset.”

Example of responding to a verbal cue:

“I live alone. My husband died six years ago.”

Empathetic response:

“I’m sorry to hear that.”

Example of responding to a non-verbal cue:

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Empathetic response:

“You look down.”

After you name an emotion, allow for a pause and wait for the conversation to evolve organically. Whatever you do, do not respond to an emotional cue with facts, advice or logic. When the patient’s emotional needs are dominant, it’s important to engage with their emotional brain. Empathetic listening is about understanding, not fixing a problem.

After the pause, be ready to address the emotional needs that may come up. Two useful communication tools to have ready are “I wish” statements from VITALtalk and the SAVE pneumonic from the Cleveland Clinic.

Example: A patient struggling with chronic pain

I wish statement (VITALtalk):

  • “I wish I could make your pain go away. But that is not possible.”

SAVE Pneumonic (Cleveland Clinic):

  • Support: “I’m going to look after you.”
  • Acknowledge: “Chronic pain is a terrible thing to live with.”
  • Validate: “I would be frustrated if I were in your position.”
  • Emotion naming: “You seem upset.”

Wait for the natural pause before you clarify your history

Open-ended questions rarely take more than three minutes. Wait for the natural pause before you switch from empathetic listening to medical questioning. A natural pause can look like a sigh, a change in emotional intensity or a shift in the focus of the conversation. Patients often take a circuitous route in telling their story. To incorporate it back into the medical model, you will often need to clarify the details and gather more information.

Summarize

Once you have gathered your data, summarize it back to your patient. Paraphrase their history while using language that is appropriate for your patient’s educational and cultural background. Your goal is to use simple and direct terms. Be willing to use some of the patient’s words, like a “zinging” headache. Be sure to include the emotional message you have heard. After you have completed your summary, ask the patient if there is anything else.

Set your agenda using shared decision-making

After you summarize, consider using shared decision-making to set the agenda. You want to provide information clearly and simply. For patients with low health literacy, focus on the most important points, use plain language and frequently check to ensure they understand.

You can’t always do what the patient asks. Explain the pros and cons of treatment options and try to come to an agreement, while realizing it is okay to disagree. You can’t give everyone opioids, antibiotics or MRIs—safety has to come first. Patient satisfaction is important, but it must always be trumped by safety.

Explain the timeline of the patent’s care

Explaining the process helps patients and families have a sense of control. We want to prevent unnecessary suffering from unanticipated delays, uncertainty or uncoordinated care. If a patient thinks they are only going to wait two hours and they wait six, they will be upset. The key is to manage patient expectations.

Re-assess and update the patient

After the initial encounter, your patient may be confused and overwhelmed. Consider offering written handouts to read while in the office. Let them know where they are in the maze by re-assessing and updating them. They need to know about any findings, mistakes or delays. Going back to visit your patient reinforces the message that you still care.

Beware of the five enemies of empathy

Distraction, work issues, personal issues, approach issues and erosion can all compromise your ability to provide empathetic care.

Distraction

Distraction can be external or internal. External distraction comes from things like pagers, cell phones or texts. Internal distraction comes from things like getting ahead of your patient and thinking about the differential diagnosis too soon rather than listening.

Work issues

Work issues include production pressure, dysfunctional culture and conflict.

Personal issues

Personal issues include bias, fatigue, relationship problems, drug/alcohol problems and mental health concerns. An important personal issue to be aware of is burnout. Burnout is characterized by a low sense of personal accomplishment, emotional exhaustion, cynicism and depersonalization.

Approach issues

Most people do not listen to understand. They listen with the intent to reply. Empathetic listening is about understanding, not fixing a problem. Judgment, criticism or advice are not empathy. If you use statements like “I went through the same thing, let me tell you about it…” you are not providing empathetic care.

Erosion

The last enemy of empathy is erosion. Empathy is a skill that can be practised and developed. It can also wither if not used regularly.

In summary

I needed something to help make my drive home from work feel better. I really liked my job but was worried I was burning out. As part of my journey to re-kindle meaningful joy at work, I needed to learn about empathy. A structured approach to empathetic communication has given me the tools I need to re-connect with my patients and understand their experiences.

Despite our curative model of medicine, a lot of problems still cannot be fixed. We don’t have to cure all problems, but we do have to care for all of our patients.

I saw one patient who was suffering from acute chronic back pain as a challenge when I picked up his chart—how could I help him feel listened to and cared for? I listened and was empathetic first, then I offered advice when he was ready to hear it.

He told me about how the pain had affected him, how he had lost his job, how he was worried about losing his house and being able to provide for his family. He didn’t want to be addicted to drugs—he wanted the pain gone. He just wanted his life back. Empathetic care helped diffuse his anger and frustration and helped me understand where he was coming from.

Once he was ready, we discussed the role of opioids, MRI and surgery and how while I wished otherwise, it was unlikely we could make his pain go away completely. But we talked about things we could do that might make his life better. By taking the time to understand and support my patient, I felt like I made a difference. Not every case is going to lead to a genuine thank you, but when you get one, it’s special.

A structured approach to empathy will help you provide better care too.

References

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