Abstract
Empathy
is a powerful communication skill that is often misunderstood and
underused. Initially, empathy was referred to as "bedside manner";
now, however, authors and educators consider empathetic communication
a teachable, learnable skill that has tangible benefits for both clinician
and patient: Effective empathetic communication enhances the therapeutic
effectiveness of the clinician-patient relationship. Appropriate use
of empathy as a communication tool facilitates the clinical interview,
increases the efficiency of gathering information, and honors the
patient.
Introduction
That
the medical care experience is enhanced by effective communication
between clinicians and their patients is a well established fact.
Byproducts of this enhanced communication include improved health
outcomes,1 better patient compliance,2 reduction
in medical-legal risk,3-5 and improved satisfaction of
clinicians and patients.6,7 Of all the elements involved
in effective communication, empathy seems to be the component that
is most powerful yet is easily overlooked--and some commentators have
asserted that in medical practice the importance of empathy cannot
be overemphasized.8
What is Empathy?
The
origin of the word empathy 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. Empathy has further been described as the process
of understanding a person's subjective experience by vicariously sharing
that experience while maintaining an observant stance.9
Empathy is a balanced curiosity leading to a deeper understanding
of another human being; stated another way, empathy is the capacity
to understand another person's experience from within that person's
frame of reference.10
Even
more simply stated, empathy is the ability to "put oneself in
another's shoes." In an essay entitled "Some Thoughts on
Empathy," Columbia University psychiatrist Alberta Szalita stated,
"I view empathy as one of the important mechanisms through which
we bridge the gap between experience and thought." A few sentences
earlier in her essay, she had emphasized that ... "[empathy is]
consideration of another person's feelings and readiness to respond
to his [or her] needs ... without making his [or her] burden one's
own."11:p151
Can Empathy Be Taught?
Unfortunately,
many physicians were trained in the world of "Find it and Fix
it" medicine, a world where empathetic communication was only
an afterthought--if this behavior was considered at all. Empathy was
known as "bedside manner," a quality considered innate and
impossible to acquire--either you were born with it or you weren't.
More recently, greater emphasis has been placed on empathy as a communication
tool of substantial importance in the medical interview, and many
experts now agree that empathy and empathetic communication are teachable,
learnable skills.12,13 As we might therefore expect, empathy
is the cornerstone of several communication models, 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;14
"The 4 E's" (Engage, Empathize, Educate, and Enlist) model
used by the Bayer Institute for Health Care Communication;15
the "PEARLS" (Partnership, Empathy, Apology, Respect, Legitimization,
Support) framework adopted by the American Academy on Physician and
Patient;16 and other models.17,18
Many
medical schools have developed curricula with a strong focus on physician-patient
communication and empathy. Delivery of these curricula begins early
in the students' training. At the University of Colorado Health Sciences
Center, this curriculum is known as the "Foundations of Doctoring"
program, a curriculum whose teaching staff includes several physicians
and trainers from the Colorado Permanente Medical Group (CPMG). CPMG
has also developed an eight-hour clinician-patient communication course
based on The Four Habits model which is offered to all newly hired
physicians in the Kaiser Permanente (KP) Colorado Region. In this
course, plenty of time is set aside to explore empathy and to practice
empathetic communication with patients selected according to standard
criteria.
Practical Empathetic
Communication
Making
practical use of an otherwise esoteric concept such as empathy requires
division of the concept into its simplest elements. As outlined by
Frederic Platt,19 key steps to effective empathy include:
-
recognizing presence of strong feeling in the clinical setting (ie,
fear, anger, grief, disappointment);
-
pausing to imagine how the patient might be feeling;
-
stating our perception of the patient's feeling (ie, "I can
imagine that must be ..." or "It sounds like you're upset
about ...");
-
legitimizing that feeling;
-
respecting the patient's effort to cope with the predicament; and
-
offering support and partnership (ie, "I'm committed to work
with you to ..." or "Let's see what we can do together
to ...").
Being
a psychiatrist or mental health expert is not necessary for using
empathetic communication; the only requirement is an awareness of
opportunities for empathy as they arise during the interview with
a patient. This type of opportunity arises from a patient's emotion
(either directly expressed or implied): This emotion creates the opportunity
for an empathetic response by the physician. In a study by Wendy Levinson
et al,20 116 office visits to primary care and surgical
physicians were audiotaped and transcribed to look at 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 and frequently
missed opportunities to adequately acknowledge a patient's feelings.20
Clues are often hidden in the fabric of discussion about medical problems
and thus may be easily missed 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 interviews, return visits, and "doctor shopping"
by patients who feel dismissed or alienated.
After
an opportunity for empathy has been presented, the clinician should
consider offering a gesture or statement of empathy. Statements that
facilitate empathy have been categorized as queries, clarifications,
and responses.21 Examples of each are as follows:
- Queries
"Can
you tell me more about that?"
"What has this been like for you?"
"How has all of this made you feel?"
- Clarifications
"Let
me see if I've gotten this right ..."
"Tell me more about ..."
"I want to make sure I understand what you've said ..."
- Responses
"Sounds
like you are ..."
"I
imagine that must be ..."
"I
can understand that must make you feel ..."
Ideally,
after perceiving the clinician's statement of empathy, the patient
expresses agreement or confirmation ("You got it, Doc!"
or "Yeah, that's exactly how I feel"). When we have not
understood the patient's experience exactly, we must allow the patient
to correct our perception. Use of the Hypothesis-Test-Feedback Loop
allows the patient to clarify his or her experience and thus allow
the physician to restate an empathetic statement that originally missed
its mark. The following exchange is an example of this Hypothesis-Test-Feedback
Loop used in the doctor-patient encounter:
Patient:
I am sick and tired of living with these headaches. No one has been
able to help me, and none of the medications are working.
Doctor
(stating the hypothesis): I can see that you are frustrated
by the lack of improvement in your symptoms.
Patient
(giving feedback): Yeah, but I'm really more worried that we're
missing something serious. I've got a wife and kids who are depending
on me.
Doctor
(correcting the hypothesis): So, it sounds like you're really
more concerned that something serious could be going on that is
causing these headaches.
Patient
(closing the empathy loop): Yes, exactly.
In this
example, the physician makes an empathetic statement (hypothesis)
about what he or she surmises is the chief aspect of the patient's
experience: frustration about an unrelenting headache. When the hypothesis
is tested, the patient clarifies that although frustrated, he is mainly
experiencing worry about the situation. Armed with this feedback,
the physician restates the hypothesis back to the patient, who lets
the physician know that he or she "got it exactly right."
Barriers to Giving Empathy
Because
empathy is such a powerful communication skill, we might suppose that
clinicians would scramble to learn about and use it at every available
opportunity. However, this is not necessarily the case. Clinicians
have many reasons for not offering empathy to patients. An informal
survey of practicing clinicians participating in a recent clinician-patient
communication course revealed misgivings (and misconceptions) about
empathetic communication. Concerns mentioned included:
- "There
is not enough time during the visit to give empathy."
- "It
is not relevant, and I'm too busy focusing on the acute medical
problem."
- "Giving
empathy is emotionally exhausting for me."
- "I
don't want to open that Pandora's box."
- "I
haven't had enough training in empathetic communication."
- "I'm
concerned that if I use up all my empathy at work I won't have anything
left for my family."
In our
experience, empathy facilitates the clinical interview, increases
efficiency of gathering information, and honors the patient. Empathy
need not be awkward nor 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. Studies have shown that when opportunities
for empathy were repeatedly missed, visits tended to be longer and
more frustrating for both physician and patient.18,20 Conversely,
empathy may save time and expense and often is a cost-effective method
of facilitating early diagnosis and proper treatment.10
Conclusion
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 tangible for both
physician and patient.
|
Empathy Versus
Sympathy (and Versus Pity)
Despite
some divergent opinion on the matter, we may propose a subtle
but important distinction between empathy and sympathy.
Whereas
empathy is used by skilled clinicians to enhance communication
and delivery of care, sympathy can be burdensome and emotionally
exhausting and can lead to burnout. Sympathy implies feeling
shared with the sufferer as if the pain belonged to both persons:
We sympathize with other human beings when we share and suffer
with them. It would stand to reason, therefore, that completely
shared suffering can never exist between physician and patient;
otherwise, the physician would share the patient's plight and
would therefore be unable to help.
Empathy
is concerned with a much higher order of human relationship
and understanding: engaged detachment. In empathy, we "borrow"
another's feelings to observe, feel, and understand them--but
not to take them onto ourselves. By being a participant-observer,
we come to understand how the other person feels. An empathetic
observer enters into the equation and then is removed.
Harry
Wilmer22 summarizes these three emotions--Empathy,
Sympathy, and Pity--as follows:
- Pity
describes a relationship which separates physician and patient.
Pity is often condescending and may entail feelings of contempt
and rejection.
- Sympathy
is when the physician experiences feelings as if he or she
were the sufferer. Sympathy is thus shared suffering.
- Empathy
is the feeling relationship in which the physician understands
the patient's plight as if the physician were the patient.
The physician identifies with the patient and at the same
time maintains a distance. Empathetic communication enhances
the therapeutic effectiveness of the clinician-patient relationship.
|
Acknowledgments
Ilene
Kasper, MS, and Andrew M Lum, MD of Kaiser Permanente Colorado;
and Brian Dwinnell, MD, and Frederic W Platt, MD, FACP, of the University
of Colorado Health Sciences Center, reviewed the article.
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