Sunday, April 6, 2014

Strategies for Expressing Empathy

"So you think you can actually teach empathy to doctors?"
This is a question I have been asked scores of times during my 30+ years as a a medical educator.

And my answer is:
"Yes, it is possible to teach empathy to clinicians, even doctors."
Though many students, and practicing clinicians, are naturally empathic, and express empathy consistently during encounters with patients, others need help identifying how to respond to patients' expressed emotions, values and concerns, both verbally and non-verbally. And many others, though fully capable of responding effectively, have learned to suppress their natural empathic responses, both consciously and unconsciously, during training. Researchers have shown that the rigors of training and its intense focus on acquiring biomedical knowledge and skills can erode humanistic attitudes and practices. (See Rabin MW, Remen RN, Parmaelee DX and Inui TS. Professional Formation: Extending Medicine's Lineage of Service into the Next Century. Academic Medicine: 2010; 85:310 - 317.

For those who need help in learning how to express empathy, research has shown that skill training and practice (with feedback) can help, even among "seasoned" practicing clinicians. (See Dwamena, FM, Holmes-Rovner, et al. (2012). "Interventions for providers to promote a patient-centred approach in clinical consultations." Cochrane Database Syst Rev 12: CD003267.

Though a single communications skills workshop is not a sufficient "dose" of training for most learners, providing opportunities for repeated learning and practice can help many clinicians to adopt and regularly employ empathic skills in their interactions with patients, especially if personalized feedback is offered in the context of a supportive learning environment.
So,how do you teach empathy?
In my teaching, I have found the following strategies to be particularly valuable. They can help clinicians "find the words" to use when opportunities arise in encounters with patients.
Open-ended questions help the clinician explore and elicit the patients feelings, concerns, values or beliefs. Here are some examples:
  • How are you holding up?
  • What has this been like for you?
  • Tell me more about how you are feeling.
  • What else have you been experiencing?
  • How has this impacted your…..(relationships, condition, work, school, life)
  • Tell me more about what this means to you.
When a patient expresses an emotion, value or belief, (either spontaneously, or in response to a query),  the clinician may respond with a "reflection" that reiterates what the patient has said, either in the patient's own words, or with an approximation. 

Reflections (with "stems" to help form the reflections)

  • I can see you are ..…(upset, sad, frustrated, worried, anxious, distressed, angry, etc.)
  • You seem ..…(upset, sad, frustrated, worried, anxious, distressed, angry, etc.
  • I hear you saying that you feel.(upset, sad, frustrated, worried, anxious, angry, etc.)
  • Sounds like it’s been ….(.upsetting, depressing, frustrating, worrisome, nerve- wracking,  distressing, maddening, awful, etc.)
Reflections (without stems)
  • You are…(upset, sad, frustrated, worried, anxious, distressed, angry, etc.)
  • It’s been…(upsetting, depressing, frustrating, worrisome, maddening, awful, etc.)
  • This is important to you…
After a reflection, WAIT to allow the person to correct, confirm, elaborate, continue. (This is challenging for many clinicians who want to follow a reflection with a question)
Affirmations (with genuineness) are a type of reflection that also recognizes the patient's efforts or achievements. Patients generally appreciate this. 
  • You put a lot of effort into this….
  • You have worked so hard on this….· 
“Non-verbal” responses·
  • Eye contact
  • Sitting down, leaning in, moving closer,
  • Nodding, verbal facilitation (“oh”, “hmm”, “uhh”, “gosh”)
  • Matching (reflecting non-verbal gestures, without mimicking)
  • Touch, when appropriate
These strategies are featured in Motivational Interviewing (MI), an evidence-based clinical method that promotes partnership, acceptance, compassion and an evoking (as opposed to directing style). See my favorite links or go directly to: for more information, tools and resources on using MI.

What are your favorite strategies for helping others to express empathy?