Clinical Empathy: A Neglected Force for Improving Care

When clinicians learn techniques that foster communication with patients, the results can be greater compliance, improved outcomes — and even increased physician satisfaction. 

Many physicians consider this the hardest procedure to master in order to treat patients successfully: empathy, with its essential component, communication.

“People think that there is a hard part of medicine and there is a soft part of medicine, and that communication is the soft, fuzzy part,” says Nirmal Joshi, MD, chief medical officer of Pinnacle Health System in Harrisburg, Pa. “In my opinion, effective communication is just as hard as knowing how to remove a gall bladder or knowing how to care for diabetes, because we are finding that if we don’t communicate as physicians, the incidence of noncompliance is extremely high.” Pinnacle Health instituted a physician training program in communication and empathy that greatly increased its patient satisfaction scores.

Few doctors have been trained in effective communication techniques, especially ones that will be effective in treating lifestyle-related conditions such as diabetes, according to Kathryn Pollak, PhD, professor in community and family medicine at Duke University. “What doctors have been taught to do is to give a lot of information and to give a lot of advice, but those methods do not change behavior. What we know that does work is to be empathic and curious, to try to put yourself in the shoes of the patient,” Pollak says.

Better Outcomes with Empathy

A Joint Commission on Accreditation of Healthcare Organizations report found that communication failures were a root cause of more than 70% of serious adverse health outcomes in hospitals.

And conversely, studies have shown that clinical empathy is clearly associated with better patient outcomes. In two studies of diabetes patients, researchers administered the Jefferson Scale of Empathy to physicians and grouped them according to whether they scored high, medium, or low on empathy skill. The researchers studied diabetes because it has clear patient outcomes that can be tracked in electronic health records.

In a study of 29 family physicians and 891 diabetic patients, the patients of physicians with high empathy scores were significantly more likely to have good control of their hemoglobin A1C and LDL cholesterol compared with patients of physicians with low empathy scores. The second study included more than 240 physicians and examined the incidence of hospitalizations among 20,000 diabetic patients in Parma, Italy. “The rate of hospitalizations due to acute metabolic complications in diabetic patients was much lower for patients of physicians who scored high on empathy and was significantly higher for patients of physicians who scored low on empathy,” says Mohammadreza Hojat, PhD, research professor in the department of psychiatry and behavior at Sidney Kimmel Medical College, Thomas Jefferson University, in Philadelphia.

Success with Training

Dissatisfied with the patient ratings of doctor-patient communication at his institution, Joshi instituted a communication training program for physicians. His team created a one-hour training exercise that began with the physicians talking for 10 to 15 minutes to a patient-actor and the patient’s “family,” who were trained on a script. The actors then provided feedback on how well the physician performed on specific measures of communication. The physicians next viewed a 20-minute film on best practices to improve doctor-patient communication.

In addition to this training, Joshi made communication improvement an ongoing part of the hospital’s focus by hiring a coach who periodically sits in on patient encounters in order to give real-time advice on how physicians can improve.

About 350 physicians have now been through the training, and over two years patient satisfaction scores have increased a remarkable 40 percentile points. “In some disciplines, the scores are now in the 90th percentile, and in other instances they are between the 50th and the 90th percentile,” Joshi says.

Stacia Melenchek, M.Ed., has been Pinnacle Healthcare’s physician education coach for the past three years. She has a master’s degree in education and had little background in healthcare at the time she was hired, which was by design to bring a consumer perspective to her task.

Some of the procedures emphasized at Pinnacle seem simple: knocking on the door before entering, introducing yourself and explaining your role (because patients see a lot of doctors and others in a hospital), and sitting down rather than towering over the bedside.

But Melenchek also coaches clinicians on making an empathetic connection with the patient by listening carefully and reading their body language: “Being able to read the patient’s facial expression, being able to read the patient’s eyes. Are they raising their eyebrows, are they looking down at the ground, is there a blank stare, are they fidgeting?”  The patient may be feeling overwhelmed, and an overwhelmed patient can have trouble processing the information a clinician is eager to impart.

Melenchek also emphasizes giving medical information in plain English. “I educate them to use a fifth to eighth grade reading level,” she says.

“In my opinion, effective communication is just as hard as knowing how to remove a gall bladder or knowing how to care for diabetes, because we are finding that if we don’t communicate as physicians, the incidence of noncompliance is extremely high.” — Nirmal Joshi, MD, chief medical officer, Pinnacle Health System, Harrisburg, Pa.

Benefits for Physicians

The patients are not the only ones who benefit from improved communication, according to Esther Tucci Thoman, manager of physician training at Pinnacle. The physicians have noticed that if they listen carefully and communicate clearly, not only is the patient more likely to adhere better to the plan of care, but the result is less work for the physicians because they get fewer calls and questions from nursing later on.

Some of these tasks seem so simple that physicians are surprised to learn that they are not actually performing them, says Pollak, who also coaches physicians. She records patient-doctor encounters, and when she plays them back, physicians are surprised at the number of times they miss opportunities to respond empathetically.

“Part of the reason it is so hard to be a doctor is because patients don’t always do what we want them to, and that is frustrating,” Pollak says. Physicians frustrated by a patient’s failure to follow advice should try a different tack. “Try to put yourself in the shoes of the patient, to think about: why is this patient not taking their insulin, why does this patient continue to get sweet tea at Bojangles even though her A1C has been 9 for years?” Pollak says.

We all do things that are not good for our health — such as not getting enough sleep or exercise — and when physicians “realize that they themselves could be judged for their own behaviors, that helps them not judge the patient,” Pollak says. The physician who tries to understand what benefit the patient is getting out of the sweet tea might be able to find a substitute that meets some of the patient’s needs, but perhaps more important, that empathy increases rapport and makes the patient more likely to disclose information and work with the doctor to make changes.

More Acceptance, Less Judgment

And again, the patients aren’t the only ones who benefit. Pollak’s team trained the clinical staffs at a primary care clinic and a pediatric obesity-focused clinic in motivational interviewing — an empathetic approach featuring open-ended questions and reflective listening designed to address a patient’s ambivalence about making changes. Patient satisfaction scores improved in the intervention clinics compared with control clinics where clinicians did not receive training. But equally noteworthy, clinicians in the intervention clinics reported lower burnout scores and better staff cohesiveness.

“Accepting people for who they are, not judging them, and trying to be curious about why patients are doing what they are doing makes clinicians happier because they are not carrying that judgment around,” Pollak says.

Another aspect of empathy is noticing when a patient reacts in an emotional way to news, says Anthony Back, MD, professor of medicine at the University of Washington in Seattle: “If the physician doesn’t recognize that and stop for a moment, and say, it looks like this is a big thing for you, the physician will go droning on with medical information. And the patient is not going to hear any of it.”

Back is a founder of a nonprofit, VitalTalk, that has developed courses on communication, mostly based on the group’s many studies funded by the National Institutes of Health. A wealth of information — including videos of patient encounter situations and “cheat sheets” on how to talk to patients in various situations — is available for free at its website, www.vitaltalk.org.

Communication techniques can be challenging to learn and require practice, which is why Pollak encourages physicians to think of them as another procedure to learn. But the headline of an op-ed by Joshi in the New York Times gives a simple starting point: “Doctor, shut up and listen.”

Seaborg is a freelance writer based in Charlottesville, Va. He wrote about expanding the dangers of the dietary supplement biotin in the January issue.

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