Empathic Communication Coding System Research Articles

Empathic Communication and Implicit Bias in the Context of Cancer Among a Medical Student Sample

ABSTRACT Oncology clinicians often miss opportunities to communicate empathy to patients. The current study examined the relationship between implicit bias (based on cancer type and ethnicity) and medical students’ empathic communication in encounters with standardized patients who presented as Hispanic (lung or colorectal) individuals diagnosed with cancer. Participants (101 medical students) completed the Implicit Association Test (IAT) to measure implicit bias based on cancer type (lung v. colorectal) and ethnicity (Hispanic v. non-Hispanic White). Empathic opportunities and responses (assessed by the Empathic Communication Coding System; ECCS) were evaluated in a mock consultation (Objective Structured Clinical Examination; OSCE) focused on smoking cessation in the context of cancer. Among the 241 empathic opportunities identified across the 101 encounters (M = 2.4), 158 (65.6%) received high empathy responses from the medical students. High empathy responses were most frequently used during challenge (73.2%) and emotion (77.3%) opportunities compared to progress (45.9%) opportunities. Higher levels of implicit bias against Hispanics predicted lower odds of an empathic response from the medical student (OR = 3.24, p = .04, 95% CI = 0.09–0.95). Further work is needed to understand the relationship between implicit bias and empathic communication and inform the development of interventions.

Using Virtual Patients to Support Empathy Training in Health Care Education: An Exploratory Study.

Empathy is essential for effective patient care. Yet, research shows suboptimal empathy in patient-practitioner interactions. Intelligent virtual patient simulations may offer an effective educational tool for empathy training. This observational study explored the quality of speech pathology of students' empathy responses in virtual patient simulations. Using the 7-point Empathic Communication Coding System (ECCS), we examined 72 students' empathic communication during a 12-week virtual patient interview series as part of their standard curriculum across 4 cohorts (a total of 388 empathic responses). The ECCS data were tallied and graphically displayed. We compared year groups (cohorts from 2015 to 2018), changes over semester, and differences between virtual patients. Median ECCS scores were 4 of a maximum of 6 (interquartile range, 3) across all interviews. Most students (89%) scored between a level 2 (implicit recognition) and level 5 (confirmation) with only a few responses scoring at the lowest 2 levels of empathy (0: denial, 0.5%; 1: automatic recognition, 2%) or the highest level of empathy (6: shared feeling or experience, 9%). Students consistently acknowledged patients' feelings and often offered an action, solution, or reassurance. However, shared feelings or experiences were infrequent. Although virtual patient simulations do not replace experiential learning such as simulation, standardized patients, and clinical practicum, they offer a safe environment to practice skills. This article provides support for designing larger controlled clinical trials and provides insights for educators on how to design virtual patient empathic opportunities of varying complexity for students.

Empathic communication between clinicians, patients, and care partners in palliative care encounters

ObjectivePalliative care encounters often involve empathic opportunities conveyed by patients and their care partners. In this secondary analysis, we examined empathic opportunities and clinician responses with attention to how presence of multiple care partners and clinicians shapes empathic communication. MethodsWe used the Empathic Communication Coding System (ECCS) to characterize emotion-focused, challenge-focused, and progress-focused empathic opportunities and responses in 71 audio-recorded palliative care encounters in the US. ResultsPatients expressed more emotion-focused empathic opportunities than did care partners; care partners expressed more challenge-focused empathic opportunities than did patients. Care partners initiated empathic opportunities more frequently when more care partners were present, though they expressed fewer as the number of clinicians increased. When more care partners and more clinicians were present, clinicians had fewer low-empathy responses. ConclusionThe number of care partners and clinicians present affect empathic communication. Clinicians should be prepared for empathic communication focal points to shift depending on the number of care partners and clinicians present. Practice implicationsFindings can guide development of resources to prepare clinicians to meet emotional needs in palliative care discussions. Interventions can coach clinicians to respond empathically and pragmatically to patients and care partners, particularly when multiple care partners are in attendance.

The co-construction of empathic communication in interpreter-mediated medical consultations: A qualitative analysis of interaction

Current interpreter training programs pay increasingly more attention to the intricacies of the clinical context, such as doctors and patients’ communicative goals. However, to date, the conduit model remains influential when it comes to interpreters dealing with other participants’ emotions and their own emotions in interpreter-mediated consultations (IMCs). Consequently, establishing a good doctor-patient relationship by means of empathic communication (EC) might be jeopardized in IMCs. During EC, patients express their emotional or illness experiences to which doctors convey their empathic understanding. This study aimed to assess how doctors, patients, and interpreters verbally co-construct EC and the interpreter’s effect on this process. We analyzed 7 authentic IMCs using the Empathic Communication Coding System, as previously adapted for IMCs. We identified empathic opportunities (EOs) and empathic responses (ERs) as expressed by patients/doctors, and as rendered by interpreters. Our results showed that EC is the result of an interactive and collaborative process among all participants in IMCs. That is, the interplay between participants’ communicative actions determines how patients’ expressed lived experiences are addressed in IMCs. Our findings suggest that interpreters hold a central position in this process as they initiated EC about the patient’s illness experience and exerted control over the ways in which statements were rendered (e.g., interpreters omitted and altered original statements). In addition, our results indicated that EC in IMCs might be compromised by doctors and interpreters’ communicative actions.

Is Sociodemographic Status Associated with Empathic Communication and Decision Quality in Diabetes Care?

ObjectiveTo assess the relationship between empathic communication, shared decision-making, and patient sociodemographic factors of income, education, and ethnicity in patients with diabetes.Research Design and MethodsThis was a cross-sectional study from five primary care practices in the Greater Toronto Area, Ontario, Canada, participating in a randomized controlled trial of a diabetes goal setting and shared decision-making plan. Participants included 30 patients with diabetes and 23 clinicians (physicians, nurses, dietitians, and pharmacists), with a sample size of 48 clinical encounters. Clinical encounter audiotapes were coded using the Empathic Communication Coding System (ECCS) and Decision Support Analysis Tool (DSAT-10).ResultsThe most frequent empathic responses among encounters were “acknowledgement with pursuit” (28.9%) and “confirmation” (30.0%). The most frequently assessed DSAT components were “stage” (86%) and knowledge of options (82.0%). ECCS varied by education (p=0.030) and ethnicity (p=0.03), but not income. Patients with only a college degree received more empathic communication than patients with bachelor’s degrees or more, and South Asian patients received less empathic communication than Asian patients. DSAT varied with ethnicity (p=0.07) but not education or income. White patients experienced more shared decision-making than those in the “other” category.ConclusionsWe identified a new relationship between ECCS, education and ethnicity, as well as DSAT and ethnicity. Limitations include sample size, heterogeneity of encounters, and predominant white ethnicity. These associations may be evidence of systemic biases in healthcare, with hidden roots in medical education.

Empathic communication in dignity therapy: Feasibility of measurement and descriptive findings.

Dignity therapy (DT) is a guided process conducted by a health professional for reviewing one's life to promote dignity through the illness process. Empathic communication has been shown to be important in clinical interactions but has yet to be examined in the DT interview session. The Empathic Communication Coding System (ECCS) is a validated, reliable coding system used in clinical interactions. The aims of this study were (1) to assess the feasibility of the ECCS in DT sessions and (2) to describe the process of empathic communication during DT sessions. We conducted a secondary analysis of 25 transcripts of DT sessions with older cancer patients. These DT sessions were collected as part of larger randomized controlled trial. We revised the ECCS and then coded the transcripts using the new ECCS-DT. Two coders achieved inter-rater reliability (κ = 0.84) on 20% of the transcripts and then independently coded the remaining transcripts. Participants were individuals with cancer between the ages of 55 and 75. We developed the ECCS-DT with four empathic response categories: acknowledgment, reflection, validation, and shared experience. We found that of the 235 idea units, 198 had at least one of the four empathic responses present. Of the total 25 DT sessions, 17 had at least one empathic response present in all idea units. This feasibility study is an essential first step in our larger program of research to understand how empathic communication may play a role in DT outcomes. We aim to replicate findings in a larger sample and also investigate the linkage empathic communication may have in the DT session to positive patient outcomes. These findings, in turn, may lead to further refinement of training for dignity therapists, development of research into empathy as a mediator of outcomes, and generation of new interventions.

Compassionate and Clinical Behavior of Residents in a Simulated Informed Consent Encounter.

Compassionate behavior in clinicians is described as seeking to understand patients' psychosocial, physical and medical needs, timely attending to these needs, and involving patients as they desire. The goal of our study was to evaluate compassionate behavior in patient interactions, pain management, and the informed consent process of anesthesia residents in a simulated preoperative evaluation of a patient in pain scheduled for urgent surgery. Forty-nine Clinical Anesthesia residents in year 1 and 16 Clinical Anesthesia residents in year 3 from three residency programs individually obtained informed consent for anesthesia for an urgent laparotomy from a standardized patient complaining of pain. Encounters were assessed for ordering pain medication, for patient-resident interactions by using the Empathic Communication Coding System to code responses to pain and nausea cues, and for the content of the informed consent discussion. Of the 65 residents, 56 (86%) ordered pain medication, at an average of 4.2 min (95% CI, 3.2 to 5.1) into the encounter; 9 (14%) did not order pain medication. Resident responses to the cues averaged between perfunctory recognition and implicit recognition (mean, 1.7 [95% CI, 1.6 to 1.9]) in the 0 (less empathic) to 6 (more empathic) system. Responses were lower for residents who did not order pain medication (mean, 1.2 [95% CI, 0.8 to 1.6]) and similar for those who ordered medication before informed consent signing (mean, 1.9 [95% CI, 1.6 to 2.1]) and after signing (mean, 1.9 [95% CI, 1.6 to 2.0]; F (2, 62) = 4.21; P = 0.019; partial η = 0.120). There were significant differences between residents who ordered pain medication before informed consent and those who did not order pain medication and between residents who ordered pain medication after informed consent signing and those who did not. In a simulated preoperative evaluation, anesthesia residents have variable and, at times, flawed recognition of patient cues, responsiveness to patient cues, pain management, and patient interactions.

The professional interpreter’s effect on empathic communication in medical consultations: A qualitative analysis of interaction

ObjectiveTo investigate how empathic communication is expressed in interpreter-mediated consultations (IMCs) and the interpreter's effect on it. MethodsWe coded 20 authentic video-recorded IMCs by using the Empathic Communication Coding System (ECCS). We compared patient-initiated empathic opportunities (EOs) and doctors' responses as expressed by patients and doctors and as rendered by interpreters. ResultsWe identified 44 EOs. In 2 of the 44 EOs there was a close match in the way the EOs were expressed by the patient in the first place and in the way they were rendered by the interpreter. Twenty-four of the 44 EOs that were passed on by the interpreter to the doctor and presented the doctor with an opportunity to respond, came with a shift in meaning and/or intensity. Twenty of the 44 EOs were not passed on by the interpreter to the doctor. ConclusionIn IMCs, EOs are subject to the interpreter's renditions and the doctor's actions during interaction. Practice implicationsDoctors and interpreters require skills to detect patient cues, assess them correctly, render them completely and in an appropriate manner (interpreters) and display communicative behaviours that take into account the intricacies of interpreter-mediated clinical communication and facilitate each other’s communicative goals.

Investigating empathy in interpreter-mediated simulated consultations: An explorative study

ObjectiveTo explore i) the ways in which empathic communication is expressed in interpreter-mediated consultations; ii) the interpreter's effect on the expression of empathic communication. MethodsWe coded 9 video-recorded interpreter-mediated simulated consultations by using the Empathic Communication Coding System (ECCS) which we used for each interaction during interpreter-mediated consultations. We compared patients' empathic opportunities and doctors' responses as expressed by the patients and doctors and as rendered by the interpreters. ResultsIn 44 of the 70 empathic opportunities there was a match between the empathic opportunities as expressed by the patients and as rendered by the interpreters. In 26 of the 70 empathic opportunities, we identified 5 shift categories (reduced emotion, omitted emotion, emotion transformed into challenge, increased challenge/progress, twisted challenge) in the interpreter's rendition to the doctor. These were accompanied by changes in the level of empathy and in the content of the doctors' empathic responses. ConclusionThe interpreters' renditions had an impact on the patients' empathic opportunities and on the doctors' empathic responses in one third of the coded interactions. Practice implicationsCurricula with a focus on intercultural communication and/or empathy should consider the complexity of interpreter-mediated interaction and the interpreter's impact on the co-construction of empathy.

Using Virtual Patients to Teach Empathy: A Randomized Controlled Study to Enhance Medical Students' Empathic Communication.

Physician empathy is a complex phenomenon known to improve illness outcomes; however, few tools are available for deliberate practice of empathy. We used a virtual patient (VP) to teach empathic communication to first-year medical students. We then evaluated students' verbal empathy in a standardized patient (SP) interaction. Seventy medical students, randomly assigned to 3 separate study groups, interacted with (1) a control VP portraying depression, (2) a VP with a backstory simulating patient shadowing, or (3) a VP able to give immediate feedback about empathic communication (empathy-feedback VP). Subsequently, the students interviewed an SP portraying a scenario that included opportunities to express empathy. All SP interviews were recorded and transcribed. The study outcomes were (1) the students' verbal response to the empathic opportunities presented by the SP, as coded by reliable assessors using the Empathic Communication Coding System, and (2) the students' responses as coded by the SPs, using a communication checklist. There were no significant differences in student demographics between groups. The students who interacted with the empathy-feedback VP showed higher empathy in the SP interview than did the students in the backstory VP and the control VP groups [mean (SD) empathy scores coded on a 0-6 scale were 2.91 (0.16) vs. 2.20 (0.22) and 2.27 (0.21), respectively). The difference in scores was significant only for the empathy-feedback VP versus the backstory VP group (P = 0.027). The SPs rated the empathy-feedback and the backstory VP groups significantly higher than the control VP group on offering empathic statements (P < 0.0001), appearing warm and caring (P = 0.015), and forming rapport (P = 0.004). Feedback on empathy in a VP interaction increased students' empathy in encounters with SPs, as rated by trained assessors, whereas a simulation of patient shadowing did not. Both VP interventions increased students' empathy as rated by SPs, compared with the control VP group.

Greater professional empathy leads to higher agreement about decisions made in the consultation

ObjectiveTo examine the relationship between professional expression of empathy and agreement about decisions made in the consultation. MethodsConsultations between 86 individuals with diabetes and four dieticians were audio-recorded. Immediately following consultations patients and dieticians independently reported decisions made in a booklet. Audio-recordings were coded directly for empathy using an amended version of the empathic communication coding system (ECCS). ResultsEmpathy correlated significantly with patient and professional agreement about decisions made in the consultation (τ=.283, p=.0005). Multiple regression analysis indicates that for each dietician the greater the empathy the higher the level of agreement about decisions (p<.0005). Professional empathic response to patients statements of challenge was a significant factor in increasing agreement about decisions (p=.008). ConclusionResults support the hypothesis that greater professional empathy will result in greater agreement about decisions made in consultations. Practice implicationsFindings have implications for empathy training and provide guidance on the communication skills needed to support expression of empathy. Patient and professional agreement about decisions made provides a simple marker of effectiveness and highlights the importance of empathy as a seminal component of professional communication skills during a patient consultation.

Conveying empathy to hospice family caregivers: Team responses to caregiver empathic communication

ObjectiveThe goal of this study was to explore empathic communication opportunities presented by family caregivers and responses from interdisciplinary hospice team members. MethodsEmpathic opportunities and hospice team responses were analyzed from bi-weekly web-based videoconferences between family caregivers and hospice teams. The authors coded the data using the Empathic Communication Coding System (ECCS) and identified themes within and among the coded data. ResultsData analysis identified 270 empathic opportunity-team response sequences. Caregivers expressed statements of emotion and decline most frequently. Two-thirds of the hospice team responses were implicit acknowledgments of caregiver statements and only one-third of the team responses were explicit recognitions of caregiver empathic opportunities. ConclusionAlthough hospice team members frequently express emotional concerns with family caregivers during one-on-one visits, there is a need for more empathic communication during team meetings that involve caregivers. Practice implicationsHospice clinicians should devote more time to discussing emotional issues with patients and their families to enhance patient-centered hospice care. Further consideration should be given to training clinicians to empathize with patients and family caregivers.

Self-assessment and observer rating of empathetic communication in pharmacy students

Methods First year pharmacy students enrolled in a communications course completed the empathic concern and perspective taking scales from the Interpersonal Reactivity Index (IRI) and participated in a video recorded patient interaction focusing on initial medication use. Students used the Empathic Communication Coding System (ECCS) to rate the first empathic opportunity in their video recording. Two researchers separately rated the video recordings using the ECCS for the empathic opportunity identified by the students and discrepancies were discussed until consensus was reached. Description statistics, correlations, and T-tests were used as appropriate to analyse the data. Results Analyses were performed on 63 students (class of 131) who consented and had complete data. Students rated themselves higher on the ECCS (3.6, SD=1.4) when compared with observers (2.6, SD=1.1) (T-test, p<0.05). There were no statistically significant correlations between the IRI self-report and either student or observer ECCS ratings. Male students rated themselves lower on the ECCS (3.2, SD=0.3) than females (3.8, SD=0.8) while there were no gender differences in observer ECCS scores (male: 2.7, SD=1.5; female: 2.6, SD=1.3). Discussion Pharmacy students were not able to accurately assess their own empathic communication. Our results indicate that students’ self-report empathy was not correlated with behaviour. Observers found no difference between male and female empathetic communication; although males has lower self-assessment than their female colleagues. Further work is required to find appropriate methods for evaluating student empathy and developing accurate self-assessment of empathic communication.

Examining Empathy in Medical Encounters: An Observational Study Using the Empathic Communication Coding System

Educators, researchers, clinicians, and patients often advocate empathy in the physician–patient relationship. However, little research has systematically examined how patients present opportunities for physicians to communicate empathically and how physicians respond to such opportunities. The Empathic Communication Coding System was used to investigate empathic opportunity–response sequences during initial visits in a general internal medicine clinic. This study focuses on 100 visits during which patients created at least 1 explicit empathic opportunity. Overall, patients presented 249 empathic opportunities in these 100 visits; physicians most often responded by acknowledging, pursuing, or confirming the patient's statement. The mean length of empathic opportunity–response sequences was 25.8 sec; sequences tended to be longer in duration when the physician used a more empathic response. Positively valenced empathic opportunities generated a more empathic response than did negatively valenced empathic opportunities. However, there was no relation between the emotional intensity of empathic opportunities and the level of empathy in subsequent physician responses. Further research should examine patient preferences and outcomes associated with varying levels of empathic responses.

The value of empathy in dietetic consultations. A pilot study to investigate its effect on satisfaction, autonomy and agreement

Forty individuals with diabetes and three dietitians completed a questionnaire concerning their consultation. Empathy was examined using the Empathic Communication Coding System (ECCS) (Bylund & Makoul, 2002). The more empathic the professionals' response to emotional opportunities, the more satisfied patients were with their consultations (r = 0.41, d.f. = 15, P = 0.05). There was a nonsignificant trend that the more empathic opportunities that arise during a consultation, the higher the agreement between patient and dietitian on what was discussed (r = 0.28, P = 0.07). The data also suggest that patients reported more autonomy support when they created more empathic opportunities during their consultation (r = -0.29, P = 0.07). This preliminary study suggests that professionals' responses to empathic opportunities may be a useful component of dietetic consultations.

Empathic communication and gender in the physician–patient encounter

Although empathy in the physician–patient relationship is often advocated, a theoretically based and empirically derived measure of a physician’s empathic communication to a patient has been missing. This paper describes the development and initial validation of such a measure, the Empathic Communication Coding System (ECCS), which includes a method for identifying patient-created empathic opportunities. To determine the extent to which empathic communication varies with physician and patient gender, we used the ECCS to code 100 videotaped office visits between patients and general internists. While male and female patients created a comparable number of empathic opportunities, those created by females tended to exhibit more emotional intensity than those created by males. However, female patients were no more likely than male patients to name an emotion in their empathic opportunities. Physician communication behavior was consistent with the literature on gender differences: female physicians tended to communicate higher degrees of empathy in response to the empathic opportunities created by patients. The ECCS appears to be a viable and sensitive tool for better understanding empathy in medical encounters, and for detecting modest gender differences in patients’ creation of empathic opportunities and in physicians’ empathic communication.