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. http://www.ncbi.nlm.nih.gov/pubmed/20107361)

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. http://www.ncbi.nlm.nih.gov/pubmed/23235595)

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: http://www.motivationalinterview.org/ for more information, tools and resources on using MI.

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

More on the Brene Brown Empathy Video

My last post was about a brief video on expressing empathy that featured Brene Brown, PhD. You can find the video at:https://www.youtube.com/watch?v=1Evwgu369Jw

Many liked the video, though some colleagues who are experts in clinician-patient communication felt that Dr. Brown was off target in her conceptualization of sympathy. Dr. Dennis Novack, Professor of Medicine and Associate Dean of Medical Education at Drexel University College of Medicine, wrote:

"I like what she says about empathy, but disagree completely with her definition of sympathy, which really undermines the value of the video for me. Sympathy is derived from the Greek sympatheia which means "feeling with." In one sense it might be empathy on steroids. We send a sympathy card to someone because we feel the loss as well. We feel sorrow for and with another, though maybe not as deeply, and in some ways identify with the other. 

The classic studies of Nightengale et al show that physicians who adopt a more sympathetic stance toward patients’ emotional situations do too many tests and perform CPR longer – they lose their objectivity (Nightengale, S.D., et al. JGIM:1991; 6:420-23.)
Empathy is conceived as a more objective process. All the actions you listed are components of the empathic process, that allow the physician to feel for patients and communicate that understanding, while still being able to make good decisions about their medical care free of the effects of the emotions elicited.By the way, a recent study Suely Grosseman and I and others recently did suggests that another component of the empathic process is checking to ensure that the patient got the empathic communication. We found that residents’ self-assessment of their empathic communication to standardized patients in 5 OSCE stations had zero correlation with SP assessments of their empathic communication."

Richard Frankel, Professor of Medicine, Indiana University School of Medicine noted the value of focusing on the interactional dynamics of empathy and referred interested folks to Jodi Halpern's use of the concept of "attunement" in her 2003 Journal of General Internal Medicine article (Halpern J. What is clinical empathy? Journal of general internal medicine. Aug 2003;18(8):670-674.) He added:

"Our group in Rochester also published a paper in 1997 in which we described the interactional dynamics of empathy, (Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA: the journal of the American Medical Association.1997;277(8):678-682.).
The model was later validated by Hilde Eide (Eide H, Frankel R, Haaversen AC, Vaupel KA, Graugaard PK, Finset A. Listening for feelings: identifying and coding empathic and potential empathic opportunities in medical dialogues. Patient education and counseling. Sep 2004;54(3):291-297)

Rich also endorsed the empathy video created by the Cleveland Clinic, featured in my March 23 2013 post:

http://empathyworks.blogspot.com/2013/03/watch-this-wonderful-video-empathy.html

I agree with both Dennis and Rich about the importance of both the cognitive and interactional aspects of emapthy and I, too, have found Jodi Halpern's conceptualization of clinical empathy quite helpful. Her thoughtful and erudite book, From Detached Concern to Empathy: Humanizing Medical Practice (Oxford University Press, New York, 2001) is highly recommended for all those interested in promoting and studying clinical empathy.

For those interested in learning more about clinical empathy, I also recommend the book, Empathy Reconsidered, New Directions in Psychotherapy (Eds: Arthur Bohart & Leslie Greenberg. American Psychological Association, Washington, 1997) which provides further perspectives on the role of empathy in clinical encounters, particularly in psychotherapy. I especially recommend the introductory chapter by the editors, in which they describe 3 different types of therapeutic empathy:

1. "empathic rapport" - the clinician expresses understanding and acceptance of the client's feelings (this is closest to what Brene Brown was describing in the video);
2. "experience - near understanding of the client's world" - a deeper understanding of the client's experience or "world". This usually results from exploration of the client's perceptions and reactions, including how the client's past experiences may have shaped their current emotional response; and
3. "communicative attunement" - characterized by moment-moment attunement based on reflections or other attempts to understand what the client is trying to communicate.The therapist is actively trying to, not only understand what the client is saying, but also trying to "help the client make sense of their ever-emerging experience."

In a future post, I will share some simple strategies and approaches clinicians might use to enhance their capacity to develop empathic rapport.

A Short Video on Empathy Featuring Brené Brown

Sue Raffa, PhD, a colleague at Alpert Medical School, Brown University,  recently shared a wonderful animated video on empathy with me. The brief video was created by the Royal Society of the Arts (RSA) and features Brene Brown, PhD, LMSW, a research professor at the University of Houston Graduate Colleage of Social Work.

You can find the video at: https://www.youtube.com/watch?v=1Evwgu369Jw

The video offers a wonderful, quick,and amusing lesson on empathy and how if differs from sympathy. 

I particularly like Dr. Brown's  reference to the 4 key qualities of empathy:

1. perspective taking
2. staying out of judgement
3. recognizing emotion; and
4. communicating what you notice

I also like her idea that empathy "fuels connection", contrasted with sympathy, which "drives disconnection". Empathy, she states, can be operationalized as "feeling with" other and requires a "vulnerable choice". She adds, "To connect with you, I have to connect with something in myself that knows that feeling", which can be painful. Empathy, she notes, is not about trying to make things better, it's about being present and expressing understanding to a person who is struggling>

"Rarely can a response make something better....what makes something better is connection."

Awesome! 

Rachel Remen, The Healer's Art, and Healing Healers

Two recent columns in the New York Times by David Bornstein highlight the work of Rachel Remen, MD, a physician, healer, educator and writer whom I deeply admire and respect.

David Bornstein is a journalist who has chronicled the impact of social entrepreneurs (I love his book, How to Change the World).  David writes a blog for NYT called "Fixes". In his September 18, 2013 column, Medicine's Search for Meaning, he writes about burnout among physicians that results from the challenges of practicing medicine in the current environment, one that focuses on productivity and treatment outcomes, rather than on meeting the emotional and functional needs of patients. To paraphrase:

"....healing involves far more than knowledge and skill. The process by which a doctor helps a patient accept, recover from, adapt to, or endure a serious illness is full of nuance and mystery......Great doctors don’t just diagnose diseases, prescribe medications and treat patients; they bring the full spectrum of their human capabilities to the compassionate care of others....."

Bornstein also writes:

"As administrative and documentation burdens have exploded in the past three decades, doctors find themselves under pressures to work as quickly as possible. Many have found that what is sacrificed is the very thing that gives meaning to the whole undertaking: the patient-doctor relationship."

Bornstein quotes medical educators who note that these burdens produce high levels of distress, depression, loss of satisfaction, fatigue, and burnout, producing "medical errors, substance abuse, and doctors quitting" and asks,  "How could we help medicine overcome its own illness?"

Bornstein answers his own question by describing work of Rachel Remen, who, as I noted in my introduction, has been a source of inspiration and healing for me for many years. Rachel is a wonderful clinician, educator and writer who has dedicated her career to meeting the broad biopsychosocial and spiritual needs of her patients. Through her writings and trainings, she has also helped practicing clinicians, as well as clinicians in training, to recapture the core values...the "meaning" ... that often led them to choose medicine or nursing as a career.

The Healer’s Art course was developed by Rachel over 2 decades ago at the University of California, San Francisco medical school. As David writes, The Healer's Art:

"is predicated on the idea that medicine is an ancient lineage that draws its strength from its core values: compassion, service, reverence for life and harmlessness. When students  derive meaning and strength .....[from these values, they] can 'immunize' themselves against the assaults of the medical curriculum and even the health care system itself."

The Healer's Art has now spread to dozen's of medical and nursing schools in the US and to a growing list of professional schools around the globe.

A similar program for practicing clinicians,  Finding Meaning in Medicine (FMM), provides a supportive forum for exploring core values and sharing positive experiences related to working with patients. I was a member of a FMM group for a few years and found it highly enlightening, rewarding and satisfying. Though I left the group when I changed jobs, I am still longing for participating in a group years later.

There were so many poignant and heartfelt responses by clinicians to the Sept 18th column that David wrote a follow-up column, Who Will Heal the Doctors?. This produced even more responses, reflecting the need for more programs like The Healer's Art and FMM.

As I noted in my comment, my heart goes out to all my colleagues who continue to make daily sacrifices to care for their patients, providing every ounce of compassion they can in the few minutes they have with patients.

I have been planning to attend the Healer's Art training program at Commonweal for several years now so I might serve as a facilitator of the program at Brown University's medical school. Just yesterday, I made a commitment to apply to attend the 2014 course, with Rachel, at The Institute for the Study of Health & Illness (ISHI). I am already excited about attending and experiencing some healing myself.

See more on Rachel, The Healer's Art, FMM and ISHI at:

www.rachelremen.com 

www.ishiprograms.org

www.theheartofmedicine.org

Danielle Ofri's Reflections on Fear Triggered by Illness

Danielle Ofri's recent column on Slate, the online magazine, addresses the topic of fear that results from uncertainty and the risks associated with medical illnesses and procedures, even minor ones. Danielle shares the distress and acute fear she experienced as a mom when her young son required minor ear surgery. Even though, as a physician, she understood that the risk of the procedure was low, she nonetheless imagined the worst and became gripped with raw fear that  didn't abate till her son was fully recovered from his surgery.

Dr. Ofri's distress during that minor ordeal increased her awareness of the needs of her patients and their family for her  support, empathy and compassion during episodes of illness, especially when tough medical decisions need to be made. As Danielle points out, the process of shared decision making requires more than information sharing and collaboration. It also requires eliciting and responding to the emotions that are aroused by uncertainnty and risk. As she she beautifully writes, 

"When I sit with a patient now, deciding on a treatment, I still lay out the risks and benefits as systematically as I can. But then I take a moment to acknowledge the raw fear that cannot be assuaged by even the most convincing clinical data. This conversation can’t eliminate the necessary leap of faith. But at least there is some recognition of the stomach-plummeting sensation that occurs" when a decision has to be made.

Thank, Danielle for your enlightening column! I also highly recommend Dr. Ofri's well written memoirs, including her latest book, What Doctors Feel: How Emotions Affect the Practice of Medicine .

EmpathyWorks Has Had 10,000 Views!

On July 11, 2009, I wrote My First Post on EmpathyWorks (click on text to view).

In the 57 posts that have followed, I have shared links and comments about articles, books and research studies on empathy and related aspects of relationship building. Many of my EmpathyWorks posts were links to a column I wrote for MPNforum, an online magazine for people who, like myself, are self-managing, or helping a loved one manage a myeloproliferative neoplasm.

I have enjoyed writing and sharing these tidbits and hope they have provided readers with opportunities to become more aware of the ways in which empathy can be a tool for enhancing understanding and promoting compassion and caring, particularly in health care settings.

I look forward to continuing to continuing to write and reflect on the impact and value of empathy here.

It would be great to have more comments and dialogue with readers, so please feel free to share your thoughts or ideas, either in the comment section on the blog, or via e-mail at goldsteinm52@gmail.com.

Enjoy!

Michael

Don Berwick Urges UK's NHS to Emphasize Empathy

In a report commissioned by the British National Health Service (NHS) to address  concerns about recent slippage in NHS's patient safety and quality ratings, Dr. Donald Berwick  encouraged NHS leaders to focus on empathy, compassion and support for both patients and health care teams.

Helen Riess provides her perspective on the report in her blog post for The Huffington Post- http://m.huffpost.com/us/entry/3757483