John L. Coulehan

“Let Me See If I Have This Right …”: Words That Help Build Empathy

Consider these two physicianpatient dialogues: 1. Patient: You know, when you discover a lump in your breast, you kind of feelwell, kind of(her speech tapers off; she looks down; tears form in her eyes). Dr. A: When did you actually discover the lump? Patient: (absently) I dont know. Its been a while. 2. Patient: (same as above) Dr. B: That sounds frightening. Patient: Well, yeah, sort of. Dr. B: Sort of frightening? Patient: Yeah and I guess Im feeling like my life is over. Dr. B: I see. Worried and sad too. Patient: Thats it, Doctor. Dr. As patient may well go home feeling unheard and misunderstood. Dr. Bs patient, while equally distressed about the possibility of having breast cancer, may leave the office believing that her doctor understands her. One of the most widespread and persistent complaints of patients today is that their physicians dont listen. For their part, physicians complain that they no longer have sufficient time to spend with patients, and they often blame economic pressures imposed by managed care (1, 2). Nonetheless, they acknowledge that personal encounters with patients constitute the most satisfying aspect of their professional lives. They recognize that empathy, the ability to connect with patientsin a deep sense, to listen, to pay attentionlies at the heart of medical practice (1, 3, 4). In clinical medicine, empathy is the ability to understand the patients situation, perspective, and feelings and to communicate that understanding to the patient. The effective use of empathy promotes diagnostic accuracy, therapeutic adherence, and patient satisfaction, while remaining time-efficient (5-11). Empathy also enhances physician satisfaction (12). As with any other tool, clinical empathy requires systematic practice to achieve mastery (13, 14). Certain well-timed words and sentences facilitate empathy during the clinical encounter. These words that work are the subject of this paper. Empathy in Theory Tichener coined the term empathy in 1909 from two Greek roots, em and pathos (feeling into) (15). For some 50 years thereafter, empathy was discussed in the psychological and psychoanalytic literature as a type of vicarious emotional response (16-23). For example, Katz (24) wrote when we experience empathy, [it is] as if we were experiencing someone elses feelings as our own. We see, we feel, we respond, and we understand as if we were, in fact, the other person. Lief and Fox (25) diluted this strong sense of identification when they used the word to designate the vector for detached concern. They wrote that empathy involves an emotional understanding of the patient, while maintaining sufficient separation so that expert medical skills can be rationally applied to the patients problem (25). In practice, emotional understanding has to be tested by checking back with the patient, and its accuracy is enhanced through iteration. The concept of empathy has three important implications. First, empathy has a cognitive focus. The clinician enters into the perspective and experience of the other person by using verbal and nonverbal cues, but she neither loses her own perspective nor collapses clinical distance. Second, empathy also has an affective or emotional focus. The clinicians ability to put herself in the patients placeor walk a mile in his moccasinsrequires the experience of surrogate or resonant feelings (26). Finally, the definition requires that clinical empathy have an action component. One cannot know without feedback. The practitioner communicates understanding by checking back with the patient, using, for example, statements such as Let me see if I have this right or I want to be sure I understand what you mean. This gives the patient opportunities to correct or modulate the physicians formulation. At the same time it expresses the physicians desire to listen deeply, thereby reinforcing a bond or connection between clinician and patient. Empathy is sometimes confused with sympathy, or emotional identification with the patients plight. Sympathetic responses include a physicians feeling sad and becoming teary eyed when his patient starts crying, or a physicians experiencing righteous anger when her patient recounts an injustice. Sympathy also applies to feelings of loss that people experience in response to anothers loss. When present, sympathy often contributes to the physicianpatient relationship, yet physicians may not always exhibit sympathy because some patients are disagreeable, culpable, or unlikable. Empathy, by contrast, does not depend on having congruent feelings and thus may be more versatile. A physician can be empathic even when he or she cannot be sympathetic (27, 28). Numerous investigators have demonstrated the importance of empathy in the medical encounter. Empathy allows the patient to feel understood, respected, and validated. This promotes patient satisfaction, enhances the quantity and quality of clinical data, improves adherence, and generates a more therapeutic physicianpatient relationship (5-11, 29-31). To achieve these goals, medical educators conceptualized empathy as a set of teachable and learnable skills and developed a new focus on communication skills in the medical curriculum (13, 14, 32-36). More recently, some educators have explored the roles of narrative and literature in teaching clinical empathy (37-39), and others have emphasized the importance of reflection and self-awareness in maintaining ones empathic skills (40-44). Empathy in Practice Clinical empathy can be visualized as a positive feedback loop, or a neurologic track with afferent and efferent components (45, 46). The afferent arm includes verbal and nonverbal cues that lead to the practitioners initial appraisal or understanding of the patients message. The efferent arm includes the practitioners responsesqueries such as Tell me more or statements such as I can imagine how difficult it is. Such responses elicit additional information. While it is impossible for the clinician to understand exactly how the patient feels, in clinical empathy successive cycles may lead to a clearer, more accurate fix on the patients perspective and feelings. Thus, empathic communication includes the following components. Active Listening This requires nonverbal and paralanguage skills, such as appropriate position and posture; good eye contact; mirroring of facial expression; and facilitative responses, such as nodding and minimal expressions (for example, Hmmm and Uh-huh). It also demands that the physician remain silent and focus her attention on the patients story (47, 48). Framing or Sign Posting Clinicians often initiate an empathic response when they pick up a suggestion or indication that the patient is experiencing concern, conflict, or emotion. Because accurate understanding is not commonly attempted in ordinary conversation, patients may be unaccustomed to empathic responses. Clinicians may need to disclose their intent, providing a frame or signpost for the patient (35). Lengthy warning may be inefficient and exhausting, so we usually abbreviate it in these ways: Lets see if I have this right. Sounds like what youre telling me is Or simply Sounds like Reflecting the Content An empathic response accurately identifies the factual content of the patients statement, as well as the nature and intensity of the patients feelings, concerns, or quandaries. A reflection of content (symptoms or ideas) might sound like the following: So you were fine until this morning when you woke up with pain in your belly, and its been growing more severe ever since. Sounds like you think that you have appendicitis and that you might need to go into the hospital. The physician may also mirror the patients interests and values: So, if Im hearing you right, what you really enjoy is going out at night with your friends and having a few drinks. Identifying and Calibrating the Emotion Clinical empathy often entails responding to the patients expressed (or suggested) feelings. This means identifying the emotion and calibrating its intensity. Sometimes emotional content is evident, but the nature of the emotion is unclear. In such cases the patient will often reveal the feeling, if given an opportunity. Tell me how youre feeling about this. I have the sense that you feel strongly, but Im not sure I understand exactly what the feeling is. Can you tell me? The following are examples of empathic responses to patient statements that express sadness, fear, anger, distrust, and ambivalence. Sadness: That must have been a pretty painful experience for you, you sound like it was very sad. Fear: Sounds like you were really frightened when you discovered that lump. Anger: That situation really got to you, didnt it? I can imagine how angry Id feel if that happened to me. Distrust: It seems youre not sure whether you should trust me further after I didnt get that test result back to you last week. Ambivalence: It seems to me that youre caught in a bind about whether to stop smoking or not. Feelings vary markedly in intensity; often, clinicians tend to sanitize or dilute them. Consider this example: Patient: Most days the pain is so terrible that I just want to stay in bed. I just stare at the ceiling whats the point of it all? Doctor: So youre frustrated about the pain? In this case, the physician identified an emotion (frustration) but failed to capture the patients profound sense of helplessness. Weak affective words such as bother, annoy, upset, uneasy, and apprehensive are sometimes appropriate. At other times, red-blooded adjectives such as infuriated, enraged, tormented, overwhelmed, and terrified are more in order. This patient feels so depressed and helpless that he asks, Whats the point of it all? By hearing only annoyance or frustration in the statement, the physician missed a diagnostic cue and perhaps a useful path of inquiry and has distanced herself from the patient. An alternative an

“Tell Me about Yourself”: The Patient-Centered Interview

The following article initiates a series on Words That Make a Difference. Developed under the sponsorship of the American Academy on Physician and Patient, the series will focus on the language physicians use when they talk with patients. Although clinicians understand how important it is to communicate effectively with patients, they often have difficulty knowing exactly what the best words are for making the most of each patient interaction. Drawing on careful observation and research results, the authors of this series of articles have identified words and expressions that have proven particularly powerful as tools for understanding patients and helping them manage their illnesses effectively. We are interested in knowing what readers think of the series, and in learning about other uses of language that readers have found important and helpful. The Editors Patient: That specialist you sent me to is probably a pretty good doctor, but you cant talk to him. Physician: What do you mean? Patient: Well, he just didnt seem interested in what I had to tell him. He might know about kidneys but he didnt want to know what I was worried about. This disgruntled patient is not the first to wish that his physician would focus more attention on his concerns, feelings, and ideas. Many patients complain similarly, identifying a critical weakness in the medical interview and subsequent treatment. Unfortunately, patients may feel this way even about physicians who are highly experienced and very skilled technically. Inattention to the person of the patient, to the patients characteristics and concerns, leads to inadequate clinical data-gathering, nonadherence, and poor outcomes (1-14). Because each patients experience of illness is unique, the best patient care includes attention to the patients motivation, values, and desires; to her thoughts and feelings; and to the way she experiences her illness. Growing evidence suggests that physicians who focus on the patient as well as the disease obtain more accurate and thorough historical data, increase patient adherence and satisfaction, and set the stage for more effective patientphysician relationships (15-32). Although concerns are often raised that practice conditions may not allow clinicians the time to give attention to these issues, clear evidence indicates that interviews that attend to patients feelings, ideas, and values actually save time (33, 34). Physicians can refine their existing skills in ways that allow them to attend better to the person of the patient as well as the patients disease. The resultant patient-centered interview increases both patient and physician satisfaction. Recommendations to focus on the person of the patient are not new. Osler (35) urged that physicians care more particularly for the individual patient than for the special features of the disease, and Smyth (36) provided this suggestion for effective doctoring: To know what kind of person has a disease is as essential as to know what kind of a disease a person has. Despite knowing this, physicians find it difficult to go beyond disease-centered clinical encounters. Current social and economic constraints on practice, along with medical training that does not equip physicians to deal with the patients expression of values, ideas, or feelings, lead to clinical interviews that focus on understanding only the patients disease. Even well-motivated clinicians may find that they are uncomfortable with and untrained to respond to the person of their patient. The spoken language is the most important diagnostic and therapeutic tool in medicine, but physicians-in-training as well as experienced clinicians report that even when they wish to focus on the patient, they lack the words to do so. Because they do not know what to say, they avoid the challenge (37). Developing a repertoire of carefully refined words is useful, and such mastery of language plays a recognized role in educating physicians to interview patients. Clinicians all learn, for example, to define a patients physical pain with questions such as Where does it hurt?, Where else?, and Have you noticed anything that seems to increase the pain? In this article, we suggest language for conducting a patient-centered interview, offering words and phrases to help the physician who desires a more effective relationship with patients and who wants to communicate that patients are understood and valued. Of course, not all the questions cited should be used in any one interview. Often one request to the patientTell me about yourselfwill suffice. No one phrase works equally well for all physicians or all patients, and a skilled interviewer will titrate the language to the patient and the circumstances. A reader who wants to try these questions and directions might best choose a few favorite lines and try them out in clinical encounters. What Do Physicians Need To Know about the Person of a Patient? In getting to know the person of a patient, there are five main areas of concern: 1. Who is this patient? What constitutes that persons life? What are the patients interests, work, important relationships, major concerns? 2. What does this patient want from the physician? What are his values and fears? What does he hope to accomplish here today or in the long run? 3. How does this patient experience this illness? Specifically, what has it done to her functionally; how has it affected relationships; and what symbolic meaning does it hold for her? 4. What are the patients ideas about the illness? What is his understanding and perception of the disorder and its cause? What would seem to him to be reasonable treatment for it? 5. What are the patients main feelings about the illness, with special attention to the five common responses: fear, distrust, anger, sadness, and ambivalence? Physicians may touch on these areas of concern in routine medical encounters but seldom explore them fully. To do so lays the groundwork for a relationship based on understanding and trust, a mutual dedication to the patients health that is truly therapeutic. How To Say It 1. Who Is This Patient? According to Stoeckle (38), Patients bring not only their bodily complaints but also the circumstances of their everyday liveswho they are and might hope to be Elicitation of this psychosocial information about the patient is useful for relationship building, diagnosis, and the tasks of management. Some clinicians like to begin an interview with a new patient by asking about the person himself: Before we get to the medical problems, Id like you to tell me a little about yourself as a person. Those who prefer to get right down to the biomedical facts can make room for such an inquiry later: Now that Ive heard a little about this illness, and before we go on to review all your other health issues, Id like to learn about you as a person. In either case, most patients will provide a capsule summary, seldom longer than 30 seconds, of their lives and interests. Occasionally a patient will hesitate and ask, Like what? If so, the physician can reply, Well, your work, whos at home, what goes on in your lifethat sort of thing. Sometimes the most open inquiry works best: Tell me about yourself. How would you describe yourself? If you had to describe yourself in 50 words or less, what would you say? What if you wanted to expand on that? Once the reluctant patient responds, the interviewer can ask for more details: Tell me about that. Sometimes the physician may offer to trade information: We should take a little time to get to know each other since we will be working together now. Lets start by my asking you to tell me about yourself, and later Ill be glad to answer your questions about me. Sometimes, of course, the physician is the new kid on the block: Youve been coming here a long time, but Im new. Tell me a bit about yourself. With returning patients, one can ask for interim reports: Whats new in your life lately? Any changes in your life since your last visit here? Or, if the physician knows about a big event in the patients life: How did that trip to Chicago go? 2. What Does This Patient Want from the Physician and the Medical Team? Physicians often assume that their patients goals are exactly the same as the clinicians. But especially at the beginning of a relationship, it pays to inquire more fully: Since were new to each other, it would help me to understand what youre most hoping for in a relationship with a new doctor. Sometimes the patient has left a previous physician because of some dissatisfaction, perhaps a communication problem: Since you told me that you left Dr. X because the two of you werent communicating very well, can you tell me what works best for you in communicating with a doctor? What can we do to avoid having another communication problem like the one you experienced with Dr. X? Or, in the currently more common scenario of change: I can imagine that it is a real loss for you to have to leave Dr. Y just because your insurance changed. Can you tell me what worked well for you in your relationship with Dr. Y? Parenthetically, one should note that a question such as Can you tell me is theoretically answerable with a yes or a no and thus appears to be a closed-ended query, the sort physicians are urged to avoid. But most patients would take this question to be an invitation to tell more and would respond with an appropriate story, not a one-word answer. Sometimes physicians will discover that patient expectations contrast strongly with the physicians own view of the patients role and possibilities. Physicians may have to uncover that difference in their conversation with the patient: I see. It sounds as if what you expect from me is A, B, and C. But the difficulty Im having is that the way I see my role is to do D, E, and maybe F. So we have different ideas about what I can do for you. How can we best proceed? Do you see any place where we can g

Major Depression in Primary Care Practice: Clinical Characteristics and Treatment Implications

Major depression is thought to be underdiagnosed and undertreated in primary medical care facilities. The authors conducted a clinical trial that included a three-phase assessment so only ambulatory medical patients judged eligible for treatment of this disorder in medical settings were recruited. In addition to administering the Center for Epidemiologic Studies-Depression scale and the Diagnostic Interview Schedules (DIS) Depression section, the psychiatrists evaluated the DIS-positive patients. This third assessment determined that clinical characteristics of DIS-positive patients were such that 70% of the patients could be treated for major depression in a primary care setting, 13% should probably be referred to a mental health facility, and 17% were experiencing conditions other than major depression.

Clinical trials of primary care treatments for major depression: issues in design, recruitment and treatment

The objective of this article is to consider whether randomized clinical trials (RCTs) are able to determine the validity of transferring treatments for major depression from the psychiatric to the primary care sector. This clinical issue is of growing concern in the United States since both governmental and professional bodies are establishing guidelines for the treatment of medical patients with the affective disorder. The articles method involves analysis of how the competing aims of rigorous scientific methodology (internal validity) and generalization of study findings (external validity) are best balanced within the RCT. Experiences in recruiting medical patients with major depression and providing pharmacologic, psychotherapeutic, and usual care interventions compatible with the sociotechnical characteristics of ambulatory medical centers are described to illustrate the complexities of investigating transferability of treatments for major depression with RCT methodology.

Symptom Patterns of Depression in Ambulatory Medical and Psychiatric Patients

The failure of primary care physicians to recognize depressive disorders in medical patients has been attributed to the differing clinical syndromes presented by these persons in comparison with psychiatric patients. Earlier British studies have found inter sector difference in the prevalence and severity of somatic, affective, and cognitive symptoms. Our investigation with American patients did not replicate these findings. The need for further research along these lines is discussed, as are the implications for assessing depression in generalist and specialist practices.

Medical students' perceptions of racial diversity and gender equality

Objectivesu2002 To assess attitudes of medical students toward issues of racial diversity and gender equality and to ascertain changes in these attitudes during the pre‐clinical curriculum.

Teaching the Difficult Interview in a Required Course on Medical Interviewing.

A module dealing with the difficult patient interview is part of a required medical interviewing course for second-year students. Using a classification of difficult doctor-patient interactions, students identify what goes wrong during interviews with simulated patients and then learn techniques to remedy these problems in order to obtain reliable medical histories. Skills taught to the students include identifying the specific problem within an interview and recognizing and using their own feelings as information about the patient. Attitudes encouraged in students include recognizing that the source of the problem may be the patient, the interviewer, or both; that the physician rather than the patient may be the so-called poor historian; and that the goal of managing a difficult patient interview is not counseling but rather the acquisition of accurate and precise information.

The Word Is an Instrument of Healing

The word can be a powerful instrument of healing. One of the major themes in volume 8 of Literature and Medicine, The Cultures of Medicine, is that words—poetry and narrative, image and metaphor—have the power to relieve illness and reduce suffering when they are employed in an appropriate healing context.1 Several essays in The Cultures of Medicine Ulustrate and discuss such semantic heaUng as it occurs in various cultures and reUgions. Another theme of The Cultures of Medicine is the potential for sharp conflict when two different health-care cultures coexist among people of the same society—for example, traditional healing practices and scientific medicine among twentieth-century Chinese Americans (Alfred S. Wangs essay), or secular and reUgious heaUng among Emile Zolas contemporaries in nineteenth-century France (Barbara Corrado Popes essay). In this paper I want to consider therapy of the word as it occurs in our own biomedical culture and in ordinary physician-patient encounters. Because the predominant view in our culture is naà ̄ve realism, we tend to overlook symboÃ1⁄4c healing as a feature of scientific medicine. Our empiricist model of clinical reasoning holds that symptoms of illness are nothing more than reflections or manifestations of underlying disease.2 In this view, medical practice ought to focus exclusively on disordered somatic processes (i.e., the real causes of illness), and not concern itself with the personal or cultural meanings that people attach to symptoms. Such meanings may, of course, influence physician-patient encounters. For example, a patients belief system may color the words he or she uses to describe a symptom or determine whether or not that patient will adhere to therapy. However, these meanings are not, strictly speaking, medical issues. Susan Sontag articulated the strictest form of this empiricist model when she wrote that the most truthful way of regarding illness—and the healthiest. . . —is one most purified of, most resistant to, metaphoric