Empathic Statements Research Articles

What do displays of empathy do in palliative care consultations?

Empathy is an important way for doctors to demonstrate their understanding of patients’ subjective experiences. This research considers the role of empathy in 37 doctor–patient palliative or end-of-life care consultations recorded in a hospice. Specifically, it focuses on four contexts in which there is a disparity between patients’ displayed experience of their illness and the doctor’s biomedical, expertise-driven perspective on their illness. These include cases in which the patient is sceptical of the medical perspective, cases in which the patient’s expectations exceed what can realistically be provided and cases in which patients have an overly pessimistic view of their condition. The analysis shows how doctors can use empathic statements to display that they are attentive to the patient’s subjective experience even when the task at hand is, ostensibly, an expertise-driven, biomedical one. It thus demonstrates that empathy is of importance throughout palliative care consultations, even in those phases which might seem biomedical or task-driven.

Efficacy of a Novel Communication Skills Intervention for Practicing Oncologists (S735)

•Describe a novel communication skills intervention aimed at practicing oncologists.•Evaluate the efficacy of a GoC discussion training session for practicing oncologists. Oncologists routinely have opportunities for goals of care (GoC) discussions with patients and their families. GoC discussions increase the likelihood that patients receive care consistent with their wishes and values. However, studies indicate oncologists often feel uncomfortable or ill-equipped to discuss end-of-life care with their patients. To evaluate the efficacy of a communication training and coaching intervention for oncologists to increase utilization of key communication skills (eliciting values, empathic statements, etc.) during GoC discussions. We randomized solid tumor oncologists to participate in communication skills training using a coaching model at four hospitals. After attending a 1-hour lecture on GoC discussions, oncologists were randomized to intervention (INT) or usual care (UC). INT oncologists participated in an interactive 2-hour training session and conducted four joint GoC visits with communication coaches in their actual practice environment. We recorded GoC discussions before and after the intervention to assess communication skill utilization. Three blinded coders evaluated skill ascertainment using a validated assessment tool. Oncologists (n=22) were 67% male, average 46 years of age (range 34-68) and 20 years (range 8-42) in practice, and 59% reported training in GoC. Sixty-nine percent were White, 23% Asian, and 8% Hispanic. At baseline, there was no difference between the number of GoC skills employed by the INT group (mean 6.64 ± 3.88) and the UC group (mean 5.45 ± 2.58) (p = 0.41). Post intervention, the INT group utilized significantly more skills in their GoC discussion (mean 8.27 ± 3.64) than the UC group (mean 5.36, ± 2.25) (p = 0.035). A training and coaching communication model resulted in a significant increase in skill utilization during GoC discussions led by practicing oncologists.

Serious Illness Conversations: Paving the Road with Metaphors.

Discussions with patients about serious illness concerns are especially challenging for the oncologist. This article provides guidance for preparing for such conversations, including examples of the use of metaphors to personalize and improve communication.

Nurses' Communication of Safety Events to Nursing Home Residents and Families.

Although communication is an essential part of the nursing process, nurses have little to no formal education in how to best communicate patient safety event (PSE) information to nursing home (NH) residents and their family members. The current mixed-methods study tested an intervention aimed at educating nurses on how to communicate a PSE to residents/family members using a structured communication tool. Nurse participants improved their knowledge of PSE communication, especially about the cause of the event, what they would say to the resident/family member, and future prevention of the PSE. Through qualitative subgroup analysis, an increased number of empathic statements were noted post-intervention. The tool tested in this study provides structure to an important care process that is necessary for improving the culture of safety in NH settings. [Journal of Gerontological Nursing, 44(2), 25-32.].

Effects of Minimal Versus Intensive Intervention to Enhance Motivational Interviewing in HIV Care.

We conducted a randomized trial comparing the effect of two different levels of motivational interviewing training on clinician communication behaviors and patient experiences. We enrolled 12 HIV clinicians who attended a one-day MI workshop focusing on behavior change counseling skills. We then randomized clinicians to receive (or not) 3-5 rounds of personalized feedback from the MI trainer. We compared outcomes before and after the interventions and between the intervention groups. We tested time-by-study arm interactions to determine if one group improved more than the other. For all analyses, we used generalized estimating equations to account for clustering of patients within clinicians, with Gaussian or negative binomial distributions as appropriate. Patients of clinicians in both intervention groups rated their visits as more MI consistent (6.86 vs. 6.65, p=0.005) and audio-recording analysis revealed that visits were more patient-centered (1.34 vs. 0.96, p=0.003) with a more positive patient affect (22.36 vs. 20.84, p<0.001) after versus before the intervention, without differences between intervention arms. Several specific clinician behaviors such as empathic statements, asking patient opinions and open-ended questions improved more in the workshop+feedback versus the workshop-only intervention arm. A few specific communication behaviors increased (total and complex reflections) after versus before the intervention, without differences between intervention arms. The workshop alone was as effective as the workshop plus feedback in improving patient experiences and overall communication measures. Certain communication behaviors improved more with the more intensive intervention, but these additional benefits may not warrant the extra financial and logistical resources required.

Interprofessional Teamwork When Meeting with a Family in the Pediatric Cardiac Intensive Care Unit (FR441A)

•Identify the recommended roles of team members in conducting family meetings as presented in the literature and identify patterns of team behavior in the pediatric critical care unit.•Identify what constitutes empathic opportunities and responses in a family meeting, how to assess parental understanding and understand the difference between open and closed ended questions. Parents of children in the pediatric cardiac intensive care unit (CICU) report inadequate communication and a lack of empathy during conversations with their clinicians. To evaluate communication behaviors and inter-professional team interactions during family meetings in the pediatric CICU. Meetings of family members and CICU clinicians were audio recorded. We used quantitative case-coding to compare the duration of contributions made by attendees, and used the SCOPE codebook to measure assessment of parental understanding, closed and open-ended questions, and empathic statements in response to opportunities. Qualitative coding identified major themes regarding content discussed in the meetings. In the 10 meetings, CICU attendings spoke for an average of 64% of each meeting (SD=17%), parents 17% (SD=12%), registered nurses 7% (SD=6%), social workers 3% (SD=5%), and nurse practitioners 1% (SD=1%). In two meetings, parental understanding was assessed at the beginning of the meeting; in no meeting was this assessed at the end. Clinicians asked parents 132 closed-ended questions (86%) and 21 open-ended questions (14%). The team missed empathic opportunities seven out of 17 (41%) occasions. CICU attendings had the highest number of expressions of empathy at 12 (57%), followed by social workers at 2 (10%). Social workers were the team member most likely to initiate discussions about parents’ worries or concerns. Nurses’ contributions were largely to clarify a CICU attending’s statement or to elicit any questions about nursing from the parents. Clinical information is often given without checking for parental understanding but empathic opportunities were responded to frequently. Team members seem to serve different roles in the meetings, with physicians speaking for two-thirds of the time.

Development of the LaComm 1.0, A French medical communication analysis software: A study assessing its sensitivity to change

ObjectiveTo test and compare the sensitivity to change of a communication analysis software, the LaComm 1.0, to the CRCWEM’s using data from a randomized study assessing the efficacy of a communication skills training program designed for nurses. MethodsThe program assessment included the recording of two-person simulated interviews at baseline and after training or 3 months later. Interview transcripts were analyzed using the CRCWEM and the LaComm 1.0 tools. ResultsOne hundred and nine oncology nurses (mainly graduated or certified) were included in the study. The CRCWEM detected 5 changes out of 13 expected changes (38%) (e.g., more open directive questions after training) and the LaComm 1.0, 4 changes out of 7 expected changes (57%) (e.g., more empathic statements after training). For open directive question, the effect sizes of the group-by-time changes were slightly different between tools (CRCWEM: Cohen’s d=0.97; LaComm 1.0: Cohen’s d=0.67). ConclusionsThis study shows that the LaComm 1.0 is sensitive to change. Practice implicationsThe LaComm 1.0 is a valid method to assess training effectiveness in French. The use of the Lacomm 1.0 in future French communication skills training programs will allow comparisons of studies.

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.

Anger Proneness and Prognostic Pessimism in Men With Prostate Cancer

Anger is a common reaction to cancer diagnosis which may impact patients' perceptions of their prognosis and goals of care. This study tested the hypothesis that men with prostate cancer who are anger prone are pessimistic regarding their cancer prognosis. Two hundred and twelve men with a history of prostate cancer completed measures of personality traits, their prostate cancer prognosis, and their perception of their doctor's assessment of their prognosis. Anger proneness was operationally defined by the presence of high levels (ie, above the medians) of neuroticism and disagreeableness. One in 4 men with prostate cancer disagreed with their doctor about prognosis. Anger-prone participants endorsed more pessimistic perceptions of prognosis ( P = .041). This significant association was maintained after accounting for potential confounders. Greater attention paid to patient anger regulation style and pessimistic perceptions will improve discussions about prognosis and goals of care among men with prostate cancer. Given recent calls for wider distress screening and earlier palliative care intervention in cancer settings, providers have an unprecedented opportunity to assess and respond to anger in the clinical setting. Communication could be improved through empathic statements that convey realistic optimism when appropriate, a commitment to the patient-provider relationship and a willingness to explore and address patient needs.

You think you are an empathic coach? Maybe you should think again. The difference between perceptions of empathy vs. empathic behaviour after a person-centred coaching training

ABSTRACTWhile empathy in effective coaching is widely accepted, it is yet under researched. Following the call for process research, we assessed 19 coaching dyads regarding their processes with a multi-method research design. We (1) assessed the perception of coaches’ expressed (cognitive) empathy by questionnaires, observed and analysed the communication (interaction analysis) of (2) coaches’ empathic statements (paraphrasing and addressing counterpart's feelings) and (3) the clients’ reaction to these kinds of empathic behaviour. Results show that coaches and clients perceptions of coaches’ expressed (cognitive) empathy differ. Hence, we focused on the client as recipient and analysed the influence of the coach's empathic statements on the client. Only coaches’ empathic paraphrasing led to a higher client rating of the coaches’ empathy. Sequential analysis showed the immediate positive reaction from the client on coaches’ empathic behaviour of paraphrasing and addressing counterpart's feelings. Findings regarding perceived empathy are discussed, and future lines of research are delineated.

Response to Letter to the Editor in Response to “The link between perception of clinical empathy and nonverbal behavior: The effect of a doctor’s gaze and body orientation”

We thank Dr. Charaf for her interest in our study and for bringing under the attention an important research field [1]. More research is indeed needed on the effects of keeping up the electronic health care record (computer screen engagement) during consultations on nonverbal communication and specific patient outcomes. Concern for any unwanted effects of computer use in the medical office was one of the reasons we conducted our research. In our study, we researched the effect of a doctor’s gaze and body orientation on respondents’ perception of sincerity, engagement and empathy by using standardized video vignettes in which actors performed as doctors. In the video vignettes, four conditions were determined: (1) patient-centered gaze and body orientation, (2) averted gaze and body orientation, (3) patient-centered gaze and averted body orientation and (4) averted gaze and patientcentered body orientation. In condition 2 and 3, the actor’s body was turned toward the computer. To make these conditions more realistic, all actors were instructed to use the computer as if they were entering data into an electronic health care record before expressing the standardized empathic statement. In condition 2, the actor kept looking at the computer (averted gaze), in condition 3, the actor stopped typing and looked in to the camera (patientcentered gaze) while maintaining the body orientation toward the computer screen. In other words, through our design, we did not explore the effect of computer use as such but rather focused on the effect of different nonverbal cues. Although we did not discuss this in our article, we expected that the use of a computer is of less influence than the effect of gaze; technology does not influence the patient if the doctor is mindful of maintaining eye contact to the patient. From our results it can be concluded that condition 2 (averted gaze, averted body orientation) was rated lowest out of the four with respect to the

PI-REAL: A study of informed consent (IC) communication in real-time during phase I clinical trial encounters.

22 Background: Advanced cancer patients (ACP) in phase I clinical trials are unable to recall significant elements of IC, yet the actual verbal and non-verbal content of trial discussion between oncology fellows and ACP consenting in real time to such trials has not been well described. Methods: Phase I Communication in Real Time Fellow-ACP Encounters (PI-REAL) study is an evidence-based intervention designed to improve communication about phase I clinical trial IC. ACP completed follow-up questionnaires after new patient visits to assess understanding of IC elements, such as research purpose. Video recordings were analyzed using CanCode for verbal and non-verbal skills associated with IC elements. Results: To date, 61 ACP-fellow clinical encounter video recordings were available for analysis. Average length of encounters: 45.4 min (range: 5.7-87.8 min). ACP demographics included: median age 60y (33-83); 55% male; 89% Caucasian; 55% median income &gt; $60,000. Fellows were coded as verbally disclosing: 1. Purpose of phase I trial as dose-determining in 49% of encounters; 2. Physical risks of trial in 75% of encounters; 3. Potential benefits (e.g. improved QOL) gained by ACP participation in trial in 70% of encounters; 4. Alternatives to trial entry (e.g. other trials, palliative/supportive care) in 55% of encounters. A significant association existedbetween coded fellow empathic statements and ACP subsequently recalling the purpose of the trial as dose-determining, with 72% of subjects who heard empathic statements identifying “dosage” compared to 10% of subjects who did not (72% v. 10%, p &lt; 0.05). Regarding non-verbal skills, fellows: leaned toward ACP in 64% of encounters; observed ACP face directly in 72% of encounters; had relaxed body posture in 55% of encounters; and displayed responsive facial expressions in 77% of encounters. Conclusions: Empathic statements by fellows appear to be associated with improved ACP understanding of Phase I trial research purpose as dose-determining. Additional encounters continue to undergo video recording and analysis.

Commentary on “Shared Truth”

Commentary on “Shared Truth”

“Isn't There Anything More You Can Do?”: When Empathic Statements Work, and When They Don't

The query, "Isn't there anything more you can do?" represents a classic informational question with an emotional subtext. In our previous work we have emphasized the value of noticing the emotional cue implicit in this question, and responding with an empathic statement. Yet responding explicitly to patients' emotions is not the best initial communication strategy for all patients. In this paper we discuss four different opening communication strategies--verbalize empathy, exchange information, contain chaos, respect searching--for patients who ask, "Isn't there anything more you can do?"

Evidence for the Utility of a Photovoice Task as an Empathic Skill Acquisition Strategy Among Counselors‐in‐Training

An instructional technique derived from photovoice was compared with a didactic approach for empathic skill acquisition among 38 master's‐level counselors‐in‐training. Participants in the photovoice condition demonstrated marked improvements in quality of empathic statements compared with those receiving didactic lecture. Considerations for implementing this educational approach are provided.

Providing support to patients in emotional encounters: A new perspective on missed empathic opportunities

ObjectiveStudies have repeatedly found that providers miss 70–90% of opportunities to express empathy. Our study sought to characterize provider responses to patients’ emotions, with the overall goal of better understanding reasons for lack of empathic response. MethodsWe analyzed 47 visits between patients and their providers. We defined empathic opportunities as instances where patients expressed a strong negative emotion. We then developed thematic categories to describe provider response. ResultsWe found a total of 29 empathic opportunities within 21 visits. Provider responses were categorized as ignore, dismiss, elicit information, problem-solve, or empathize. An empathic statement occurred at some point in the response sequence in 13/29 opportunities (45%). When problem-solving was the initial response, empathic statements rarely occurred in subsequent dialogue. Among the 16 instances with no empathic statements, providers engaged in problem-solving in 8 (50%). ConclusionSimilar to other studies, we found providers missed most opportunities to respond empathically to patient emotion. Yet contrary to common understanding, providers often addressed the problem underlying the emotion, especially when the problem involved logistical or biomedical issues, as opposed to grief. Practice implicationsWith enhanced awareness, providers may better recognize situations where they can offer empathy in addition to problem-solving.

Enhancing communication between oncologists and patients with a computer-based training program: a randomized trial.

Quality cancer care requires addressing patients' emotions, which oncologists infrequently do. Multiday courses can teach oncologists skills to handle emotion; however, such workshops are long and costly. To test whether a brief, computerized intervention improves oncologist responses to patient expressions of negative emotion. Randomized, controlled, parallel-group trial stratified by site, sex, and oncologic specialty. Oncologists were randomly assigned to receive a communication lecture or the lecture plus a tailored CD-ROM. (ClinicalTrials.gov registration number: NCT00276627) Oncology clinics at a comprehensive cancer center and Veterans Affairs Medical Center in Durham, North Carolina, and a comprehensive cancer center in Pittsburgh, Pennsylvania. 48 medical, gynecologic, and radiation oncologists and 264 patients with advanced cancer. Oncologists were randomly assigned in a 1:1 ratio to receive an interactive CD-ROM about responding to patients' negative emotions. The CD-ROM included tailored feedback on the oncologists' own recorded conversations. Postintervention audio recordings were used to identify the number of empathic statements and responses to patients' expressions of negative emotion. Surveys evaluated patients' trust in their oncologists and perceptions of their oncologists' communication skills. Oncologists in the intervention group used more empathic statements (relative risk, 1.9 [95% CI, 1.1 to 3.3]; P = 0.024) and were more likely to respond to negative emotions empathically (odds ratio, 2.1 [CI, 1.1 to 4.2]; P = 0.028) than control oncologists. Patients of intervention oncologists reported greater trust in their oncologists than did patients of control oncologists (estimated mean difference, 0.1 [CI, 0.0 to 0.2]; P = 0.036). There was no significant difference in perceptions of communication skills. Long-term effects were not examined. The findings may not be generalizable outside of academic medical centers. A brief computerized intervention improves how oncologists respond to patients' expressions of negative emotions. National Cancer Institute.

Electrodermal activity in response to empathic statements in clinical interviews with fibromyalgia patients

Objective To study patients’ electrodermal response (1) to an interviewer's empathic statements vs. inattention to emotional concerns and (2) to the emotional content in clinical interviews. Methods Patients with fibromyalgia ( n = 48) were given a clinical interview in a randomized 2 × 2 design, in which interviewer empathic or inattentive behavior (scenario A) and the emotional or neutral content of the interview (scenario B) were manipulated. Electrodermal activity (EDA) was measured during the interview. The patients’ affective state (PANAS) and patient satisfaction were also assessed. Results In scenario A a significant main effect of empathy was found, indicating an increased tonic EDA (skin conduction level, SCL) during the empathy condition ( p < .05). In scenario B there was a main effect of empathy ( p < .01) and a significant empathy × content interaction effect ( p < .01). There was a strong positive association between empathy and patient satisfaction ( p < .0001). Conclusions Empathic statements by the interviewer were associated with increased SCL in patients, most so in interviews with emotional content. Practice implications Psychophysiological variables such as EDA may be applied in clinical communication research on emotional communication, but the limitations of such measures should also be recognized.

How do non-physician clinicians respond to advanced cancer patients’ negative expressions of emotions?

Patients with advanced cancer often experience negative emotion; clinicians' empathic responses can alleviate patient distress. Much is known about how physicians respond to patient emotion; less is known about non-physician clinicians. Given that oncology care is increasingly provided by an interdisciplinary team, it is important to know more about how patients with advanced cancer express emotions to non-physician clinicians (NPCs) and how NPCs respond to those empathic opportunities. We audio recorded conversations between non-physician clinicians and patients with advanced cancer. We analyzed 45 conversations between patients and oncology physician assistants, nurse practitioners, and nurse clinicians in which patients or their loved ones expressed at least one negative emotion to the NPC (i.e., an empathic opportunity). Empathic opportunities were coded three ways: type of emotion (anger, sadness, or fear), severity of emotion (least, moderate, or most severe), and NPC response to emotion (not empathic, on-topic medical response, and empathic response). We identified 103 empathic opportunities presented to 25 different NPCs during 45 visits. Approximately half of the empathic opportunities contained anger (53%), followed by sadness (25%) and fear (21%). The majority of emotions expressed were moderately severe (73%), followed by most severe (16%), and least severe (12%). The severity of emotions presented was not found to be statistically different between types of NPCs. NPCs responded to empathic opportunities with empathic statements 30% of the time. Additionally, 40% of the time, NPCs responded to empathic opportunities with on-topic, medical explanations and 30% of the responses were not empathic. Patients expressed emotional concerns to NPCs typically in the form of anger; most emotions were moderately severe, with no statistical differences among types of NPC. On average, NPCs responded to patient emotion with empathic language only 30% of the time. A better understanding of NPC-patient interactions can contribute to improved communication training for NPCs and, ultimately, to higher quality patient care in cancer.

Empathy and Life Support Decisions in Intensive Care Units

Although experts advocate that physicians should express empathy to support family members faced with difficult end-of-life decisions for incapacitated patients, it is unknown whether and how this occurs in practice. To determine whether clinicians express empathy during deliberations with families about limiting life support, to develop a framework to understand these expressions of empathy, and to determine whether there is an association between more empathic statements by clinicians and family satisfaction with communication. Multi-center, prospective study of audiotaped physician-family conferences in intensive care units of four hospitals in 2000-2002. We audiotaped 51 clinician-family conferences that addressed end-of-life decisions. We coded the transcripts to identify empathic statements and used constant comparative methods to categorize the types of empathic statements. We used generalized estimating equations to determine the association between empathic statements and family satisfaction with communication. There was at least one empathic statement in 66% (34/51) of conferences with a mean of 1.6 +/- 1.6 empathic statements per conference (range 0-8). We identified three main types of empathic statements: statements about the difficulty of having a critically ill loved one (31% of conferences), statements about the difficulty of surrogate decision-making (43% of conferences), and statements about the difficulty of confronting death (27% of conferences). Only 30% of empathic statements were in response to an explicit expression of emotion by family members. There was a significant association between more empathic statements and higher family satisfaction with communication (p = 0.04). Physicians vary considerably in the extent to which they express empathy to surrogates during deliberations about life support, with no empathic statements in one-third of conferences. There is an association between more empathic statements and higher family satisfaction with communication.