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Empathic communication and gender in the physician-patient encounter
Abstract
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.
... This refers to sharing a similar emotion or life situation as the patient [9]. Sharing personal memories with others has been shown to increase empathy [10], and research on the hierarchy of empathic communication suggests that shared experience may convey more empathy than other types of empathic responses, such as validation or acknowledgment [11]. One reason for this may be that shared experience is a form of self-disclosure since it involves the provider sharing personal information or life experiences [12], which patients may perceive as creating interpersonal closeness. ...
... Provider variables were gender (0 = woman, 1 = man) and occupation (0 = chaplain, 1 = nurse). Gender was selected as a variable because previous empathic communication research found that when an empathic opportunity arose, female physicians responded with higher degrees of empathy [11]. While chaplain and nurse-led Dignity Therapy was found to be effective at improving patient dignity in older adult cancer patients [24], we wanted to examine if their use of ESD as an empathic communication strategy differed. ...
... Patient characteristic variables were gender (0 = woman, 1 = man), interview modality (0 = virtual, 1 = in-person), and a continuous variable of patient chronological age. Patient gender was selected as a variable because previous empathic communication research found that female patients had more emotional intensity in their empathic opportunities when compared to male patients [11]. Interview modality was selected as a variable because a systematic review on clinician telehealth behavior found varied results on the verbal communication between clinicians and patients; in some cases, physicians increased selfdisclosure and verbal behaviors in telehealth visits, while in other cases telehealth visits resulted in less verbal behavior and lower empathy [25]. ...
Objective
During Dignity Therapy a trained provider guides a patient to share their life story and legacy. Providers can demonstrate empathy through empathic self-disclosure (ESD), sharing something substantial and personal about themselves in response to the patient. The current study aims to identify the topics of ESDs and determine whether ESD frequency varied by patient and/or provider characteristics.
Methods
Two coders analyzed 203 audio-recorded, transcribed Dignity Therapy sessions of palliative care patients (M = 65.78 years; SD = 7.43 years, 65.69% women) for ESD. Topic modeling characterized themes of ESD and multilevel modeling examined ESD frequency based on several patient and provider characteristics.
Results
ESD occurred in 37% of interviews (M = 0.59, SD = 1.21). Topic modeling revealed five main themes: family, memory, school, geographical experiences, and values/beliefs. Multilevel modeling indicated patient-level differences, including greater rates of ESD when patients were men and older.
Conclusion
ESD seems to be dependent on the context of the patient rather than individual communication style differences. Providers may use ESD in multiple instances, including when similar and different from patients.
Innovation
This study introduces and defines the novel concept of ESD. It is among the first to examine patient-provider communication during Dignity Therapy, and the first to specifically examine self-disclosure.
... Empathic opportunities were deliberately incorporated into virtual patient interactions to evoke empathic reactions from users. Empathic opportunities were crafted based on Bylund and Makoul's definition, which describes them as "patient statements that present an explicit expression of emotion, progress, or challenge by the patient [16,17]". Bylund et al. proposed the Empathic Communication and Coding System (ECCS) to assess the level of empathy in responses to empathic opportunities [16,17]. ...
... Empathic opportunities were crafted based on Bylund and Makoul's definition, which describes them as "patient statements that present an explicit expression of emotion, progress, or challenge by the patient [16,17]". Bylund et al. proposed the Empathic Communication and Coding System (ECCS) to assess the level of empathy in responses to empathic opportunities [16,17]. Virtual patient interactions were used to enhance medical students' empathic communication skills [12,18,19]. ...
... We emphasized the structure of the APC scaffolding (Acknowledge, Pursue, Confirm) based on the ECCS scale for participants to formulate empathic responses [16,17]. In Cynthia's first empathic opportunity, participants were presented with a detailed explanation of APC, as shown in Fig. 2a. ...
Background
Clinicians working with patients at risk of suicide often experience high stress, which can result in negative emotional responses (NERs). Such negative emotional responses may lead to less empathic communication (EC) and unintentional rejection of the patient, potentially damaging the therapeutic alliance and adversely impacting suicidal outcomes. Therefore, clinicians need training to effectively manage negative emotions toward suicidal patients to improve suicidal outcomes.
Methods
This study investigated the impact of virtual human interaction (VHI) training on clinicians’ self-awareness of their negative emotional responses, assessed by the Therapist Response Questionnaire Suicide Form, clinicians’ verbal empathic communication assessed by the Empathic Communication and Coding System, and clinical efficacy (CE). Clinical efficacy was assessed by the likelihood of subsequent appointments, perceived helpfulness, and overall interaction satisfaction as rated by individuals with lived experience of suicide attempts. Two conditions of virtual human interactions were used: one with instructions on verbal empathic communication and reminders to report negative emotional responses during the interaction (scaffolded); and the other with no such instructions or reminders (non-scaffolded). Both conditions provided pre-interaction instructions and post-interaction feedback aimed at improving clinicians’ empathic communication and management of negative emotions. Sixty-two clinicians participated in three virtual human interaction sessions under one of the two conditions. Linear mixed models were utilized to evaluate the impact on clinicians’ negative emotional responses, verbal empathic communication, and clinical efficacy; and to determine changes in these outcomes over time, as moderated by the training conditions.
Results
Clinician participants’ negative emotional responses decreased after two training sessions with virtual human interactions in both conditions. Participants in the scaffolded condition exhibited enhanced empathic communication after one training session, while two sessions were required for participants in the non-scaffolded condition. Surprisingly, after two training sessions, clinical efficacy was improved in the non-scaffolded group, while no similar improvements were observed in the scaffolded group.
Conclusion
Lower clinical efficacy after virtual human interaction training in clinicians with higher verbal empathic communication suggests that nonverbal expressions of empathy are critical when interacting with suicidal patients. Future work should explore virtual human interaction training in both nonverbal and verbal empathic communication.
... We measured clinicians' verbal empathic communication during the virtual human interactions using the Empathic Communication Coding System (ECCS), a method extensively used by our group in prior research [15]. The ECCS is an interaction analysis system composed of two steps: identifying patient-generated empathic opportunities and evaluating clinicians' responses to those opportunities [17,26]. This instrument has been used to characterize empathy in real-patient, standardized-patient, and virtual-patient interactions [15,17,18,22]. ...
... After completing each virtual human interaction, at T1 and T2, and completing the TRQ-SF measure, participants in the intervention condition received emotional self-awareness feedback which included the three following components: an individual transcript of the interaction with the virtual patient; the scores obtained by the clinician on the TRQ-SF measure, to assess the clinician's self-reported negative emotional response toward the virtual patient [11]; and if the TRQ-SF score indicated high negative emotional response, participants were directed through online live feedback, in a supportive manner, to selfexamine possible negative emotional responses at the time of the virtual interaction, such as "anger or coldness triggered by anxiety," and the clinician's score for verbal empathic communication coded by ECCS [15,26], which reflects the level of verbal empathy, as well as suggestions for alternative empathic responses. ...
... The nature of these statements and their intense emotional features might explain why challenge opportunities are more likely to elicit empathic responses from the clinicians and, consequently, lead to a significantly higher ECCS average score. This response replicates the real clinician-patient interactions, coded via ECCS [18,26,38], underlining the likely correspondence with real-world clinical practice. ...
Working with suicidal patients can elicit negative emotional responses that can impede clinicians’ empathy and affect clinical outcomes. Virtual human interactions represent a promising tool to train clinicians. The present study investigated the impact of virtual human interaction training to enhance clinicians’ emotional self-awareness and empathy when working with suicidal patients.
Clinicians were randomly assigned into two groups. Both groups interviewed a virtual patient presenting with a suicidal crisis; clinicians in the intervention condition (n = 31) received immediate feedback about negative emotional responses and empathic communication, whereas those in the control condition (n = 33) did not receive any feedback. All clinicians interviewed a second virtual patient 1 week later. Clinicians’ emotional response to the two virtual patients and their empathic communication with each of them were assessed immediately after each interaction. Linear mixed models were used to assess change in clinicians’ emotional response and verbal empathy between the two interactions across conditions.
Clinicians’ emotional responses toward the suicidal virtual patients were unchanged in both conditions. Clinicians in the intervention condition presenting low empathy level with the first virtual patient showed higher empathy level with the second virtual patient than with the first (B = 1.15, SE = 0.25, p < 0.001, 95% CI [0.42, 1.89]).
This work demonstrates the feasibility of using virtual human interactions to improve empathic communication skills in clinicians with poor empathy skills. Further refinement of this methodology is needed to create effective training modules for a broader array of clinicians.
... They were created following the definition of an empathic opportunity described by Bylund and Makoul as "patient statements that include an explicit (i.e., clear and direct) statement of emotion, progress, or challenge by the patient [7]. " The empathy level of empathic responses was evaluated based on the Empathic Communication and Coding System (ECCS) proposed by Bylund et al. [6,13,21]. ECCS was used in our study to manually code the empathy level of users' responses. ...
... In the existing education intervention we used, statements from Bernie and Cynthia that can trigger an empathic opportunity have been coded by a Board-certified adult psychiatrist [36]. Bylund et al. proposed the Empathic Communication and Coding System (ECCS) to evaluate physicians' empathy levels during the medical interview [6]. Yao et al. utilized ECCS in their study to evaluate users' responses to empathic opportunities when interacting with virtual patients [36]. ...
... Yao et al. utilized ECCS in their study to evaluate users' responses to empathic opportunities when interacting with virtual patients [36]. The ECCS scale proposed by Bylund et al. defines seven empathy levels of responses [6,7]. The seven levels of responses can be categorized into three categories: 1) ignores or implicit recognizes the central issue in the empathic opportunity (corresponding to ECCS levels 0-2), 2) explicitly acknowledges the central issue in the empathic opportunity, with or without asking more questions to pursue the topic (ECCS levels 3-4), 3) legitimizes or validates the feelings or experiences expressed by patients (ECCS levels 5-6) [7]. ...
Virtual human interactions are increasingly used for empathy skills training in healthcare by providing feedback during or after the interaction. The post-interview feedback consists of evaluation results of users’ empathic responses and can be provided once without interfering with the interaction. However, this type of feedback is insufficient to engage trainees in obtaining a deeper understanding and insights into their learning. The scaffolded pingpong feedback consists of a multi-round of descriptions explaining how to formulate desired empathic responses to induce users to explore an understanding of how to respond empathically. To increase the training effectiveness to enhance users’ expressed empathy, we studied how to apply scaffolded ping-pong feedback in virtual human interactions to train users’ empathy skills. In this paper, we studied how different forms of feedback impact users learning how to express empathy to screen-based virtual humans. To evaluate the training effectiveness, we collected 638 empathic responses from 27 clinician participants in the interaction with two virtual patients integrated with scaffolded ping-pong feedback. We compared them with 809 empathic responses from 25 clinician participants in the post-interview condition. The result shows that the scaffolded ping-pong feedback helped clinician participants to provide a higher percentage of medium-empathy level and a lower percentage of low-empathy level empathic responses than the post-interview feedback. The scaffolded ping-pong feedback was perceived as more difficult to use but did not affect the overall interaction experience with virtual patients. This work demonstrates the applicability of integrating ping-pong feedback to strengthen the training effectiveness of virtual human education interventions.
... However, these tools do not allow for the study of interactional processes leading to the co-construction of empathy among patients and doctors in IMCs. At the time of this study, the only tool that allowed for this type of analysis capturing moment by moment the co-construction of EC and that had been adapted for IMCs (Krystallidou, Remael, et al., 2018) was the Empathic Communication Coding System (Bylund & Makoul, 2002. ...
... Since we wanted to investigate the interactional aspect of EC, we used the Empathic Communication Coding System (Bylund & Makoul, 2002 as previously adapted for IMCs (Krystallidou, Remael, et al., 2018). ...
... Progress is a "positive development in physical condition that has improved quality of life, a positive development in the psychosocial aspect of the patient's life, or a recent, very positive, life-changing event" (Bylund & Makoul, 2002, p. 209). The tool also distinguishes among different levels of doctors' ERs, ranging from Level 0 (doctor's denial of the patient's perspective) to Level 6 (doctor and patient share a feeling or experience) (Bylund & Makoul, 2002. Appendix A provides an overview of the Empathic Communication Coding System designed by Bylund & Makoul (2002. ...
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.
... They were created following the definition of an empathic opportunity described by Bylund and Makoul as "patient statements that include an explicit (i.e., clear and direct) statement of emotion, progress, or challenge by the patient [7]. " The empathy level of empathic responses was evaluated based on the Empathic Communication and Coding System (ECCS) proposed by Bylund et al. [6,13,21]. ECCS was used in our study to manually code the empathy level of users' responses. ...
... In the existing education intervention we used, statements from Bernie and Cynthia that can trigger an empathic opportunity have been coded by a Board-certified adult psychiatrist [36]. Bylund et al. proposed the Empathic Communication and Coding System (ECCS) to evaluate physicians' empathy levels during the medical interview [6]. Yao et al. utilized ECCS in their study to evaluate users' responses to empathic opportunities when interacting with virtual patients [36]. ...
... Yao et al. utilized ECCS in their study to evaluate users' responses to empathic opportunities when interacting with virtual patients [36]. The ECCS scale proposed by Bylund et al. defines seven empathy levels of responses [6,7]. The seven levels of responses can be categorized into three categories: 1) ignores or implicit recognizes the central issue in the empathic opportunity (corresponding to ECCS levels 0-2), 2) explicitly acknowledges the central issue in the empathic opportunity, with or without asking more questions to pursue the topic (ECCS levels 3-4), 3) legitimizes or validates the feelings or experiences expressed by patients (ECCS levels 5-6) [7]. ...
Virtual human interactions are increasingly used for empathy skills training in healthcare by providing feedback during or after the interaction. The post-interview feedback consists of evaluation results of users' empathic responses and can be provided once without interfering with the interaction. However, this type of feedback is insufficient to engage trainees in obtaining a deeper understanding and insights into their learning. The scaffolded ping-pong feedback consists of a multi-round of descriptions explaining how to formulate desired empathic responses to induce users to explore an understanding of how to respond empathically. To increase the training effectiveness to enhance users' expressed empathy, we studied how to apply scaffolded ping-pong feedback in virtual human interactions to train users' empathy skills. In this paper, we studied how different forms of feedback impact users learning how to express empathy to screen-based virtual humans. To evaluate the training effectiveness, we collected 638 empathic responses from 27 clinician participants in the interaction with two virtual patients integrated with scaffolded ping-pong feedback. We compared them with 809 empathic responses from 25 clinician participants in the post-interview condition. The result shows that the scaffolded ping-pong feedback helped clinician participants to provide a higher percentage of medium-empathy level and a lower percentage of low-empathy level empathic responses than the post-interview feedback. The scaffolded ping-pong feedback was perceived as more difficult to use but did not affect the overall interaction experience with virtual patients. This work demonstrates the applicability of integrating ping-pong feedback to strengthen the training effectiveness of virtual human education interventions.
... Participant characteristics are summarized in Supplemental Content 1. In total, the studies reviewed Bylund & Makoul, 2002;Campbell et al., 2007;Chesser et al., 2013;Cohen et al., 2002;Guimond et al., 2003;Hulsman et al., 2002;Lockyer et al., 2006;Menear et al., 2018; or models were identified (see Supplemental Content 2). The most prevalent theories or models were a "patient-centered approach" (n=4; 7%; Assis-Hassid et al., 2015;Chesser et al., 2013;Ellman et al., 2016;, the "Four Habits" approach (n=3; 5%; Karnieli-Miller et al., 2018;, "motivational interviewing" (n=2; 4%; Childers et al., 2012;Strayer et al., 2011), the "SKIPES" ( Most tools assessed physicians' communication competency during interactions with standardized (n=35; 61%) or real patients (n=18; 32%), which were coded by external raters (see below). ...
... From these records, 125 full text articles were identified, and 70 publications were put forward for data extraction and quality extraction. As seen inFigure 1, 57 articles fulfilled all inclusion criteriaAssis-Hassid et al., 2013;Assis-Hassid et al., 2015;Burt et al., 2014;Burt et al., 2018;Bylund & Makoul, 2002;Campbell et al., 2007;Caron et al., 2013;Chesser et al., 2013;Childers et al., 2012;Cohen et al., 2002;Dong et al., 2015;Ellman et al., 2016;Gallagher, Hartung & Gregory, 2001; Guimond et al., 2003;Gustin et al., 2016; Huang et al., 2010;Hulsman et al., 2002;Humphris & Kaney, 2001;Huntley et al., 2012;Joekes et al., 2011;Joshi et al., 2004;Karnieli-Miller et al., 2018;Kim et al., 2009;Kirk et al., 2013;LeBlanc et al., 2009;Makoul, 2001;Menear et al., 2018; Mortsiefer et al., 2014;Siminoff & Step, 2011;Simmenroth-Nayda et al., 2014;Strayer et al., 2011;Stubenrauch et al., 2012; Suojanen et al., 2018;Suzuki Laidlaw et al., 2006;Szmuilowicz et al., 2010;Teresi et al., 2005;Valverde et al., 2018;Wouda & van de Wiel, 2013;Wroe et al., 2017;Zabar et al., 2010;Zaidi et al., 2012) ...
... & Step, 2011;Stubenrauch et al., 2012;Teresi et al., 2005;Violato et al., 2006;Zabar et al., 2010). Other types included medical students (n=21 studies; n=10,333 ;Dong et al., 2015;Ellman et al., 2016;Gallagher et al., 2001; Huang et al., 2010;Humphris & Kaney, 2001;Huntley et al., 2012;Joekes et al., 2011;Karnieli-Miller et al., 2018;Kim et al., 2009;Kirk et al., 2013;LeBlanc et al., 2009;Makoul, 2001; Mortsiefer et al., 2014;Simmenroth-Nayda et al., 2014;Strayer et al., 2011; Suojanen et al., 2018;Zaidi et al., 2012) and medical residents (n=14 studies; n=623 ;Assis-Hassid et al., 2013;Caron et al., 2013;Childers et al., 2012;Huntley et al., 2012;Joshi et al., 2004;Suzuki Laidlaw et al., 2006;Szmuilowicz et al., 2010;Valverde Bolivar et al., 2018;Wouda & van de Wiel, 2013;Wroe et al., 2017).2.4.4 Tool CharacteristicsOnly 51% (n=23) of the tools mentioned the use of theories or models underlying the conceptualization and design of the toolAssis-Hassid et al., 2015;Burt et al., 2014;Burt et al., 2018;Bylund & Makoul, 2002;Chesser et al., 2013;Childers et al., 2012;Ellman et al., 2016;Gallagher et al., 2001; Guimond et al., 2003;Gustin et al., 2016;Karnieli-Miller et al., 2018;Kim et al., 2009;Kirk et al., 2013;Menear et al., 2018;Siminoff & Step, 2011;Strayer et al., 2011;Stubenrauch et al., 2012;Teresi et al., 2005;Zabar et al., 2010;Zaidi et al., 2012). Twenty different theories ...
... Empathic communication (henceforth EC) entails sequences in an interaction through which patients express empathic opportunities to which doctors express understanding in the form of an empathic response (Hojat, 2016). Patients' empathic opportunities can be summarized in three main verbal manifestations: emotion (e.g., I'm scared), challenge (e.g., I can't go to work because of my back pain) or progress (e.g., we got married) (Bylund & Makoul, 2002. If patients' need for empathy is met, their health outcomes and doctor-patient satisfaction can improve (Kerasidou, 2020;Yaseen & Foster, 2020). ...
... Level 1 Verbal interaction ECCS coding system (Bylund & Makoul, 2002 as adapted for IMCs Participants' verbal actions in the context of EC Level 2 Verbal and nonverbal interaction A.R.T. framework (Krystallidou, 2016) Participants' verbal and nonverbal actions and the way they relate to each other in interactions in the context of EC Level 3 ...
... The level 1 analysis draws on the ECCS coding system, which is a valid instrument for measuring EC in monolingual consultations (Bylund & Makoul, 2002 and was adapted for IMCs . It views EC as a transactional sequential process consisting of verbally patient-expressed empathic opportunities (EOs) expressed by patients, doctors' empathic verbal responses to those opportunities (Bylund & Makoul, 2005), and interpreters' renditions of those statements . ...
Empathic communication (EC) in healthcare occurs when patients express empathic opportunities, such as emotions, to which doctors respond empathically. This interactional process during which participants try to achieve specific communicative goals (e.g., seeking and displaying empathy) serves as a context in which doctors and patients perform verbal and nonverbal actions and collaboratively co-construct meaning. This applies to interpreter-mediated consultations (IMCs) too, where interpreters perform additional actions of a similar kind. However, there is a dearth of research on the ways in which participants perform these actions in the context of EC, and how these actions in turn help (re)shape the context of EC in IMCs (Theys et al., 2020). To date, any tools for studying EC investigate participants' actions in isolation, without studying them in the context of EC or in relation to the participants' awareness of their own and others' ongoing interactions. In this article, we present the Empathic Communication Analytical Framework (ECAF). The tool draws on valid, complementary analytical tools that allow for a fine-grained, three-level multimodal analysis of interactions. The first level of analysis allows for instances of EC in spoken language IMCs to be identified and for participants' verbal actions in the context of EC to be studied. The second level allows analysts to investigate participants' verbal and nonverbal actions in the previously identified context of EC. The third level of analysis links the participants' concurrent verbal and nonverbal (inter)actions to their levels of attention and awareness and shows how participants' actions are shaped and in turn help to reshape the context of EC in IMCs. In this article, we present the various levels of the ECAF framework, discuss its application to real-life data, and adopt a critical stance towards its affordances and limitations by looking into one excerpt of EC in IMCs. It is shown that the three distinct yet interconnected levels of analysis in the ECAF framework allow participants' concurrent multimodal interactions in the context of EC to be studied.
... Several psychologists have defined tiered levels of empathy for observational research. Observed empathy schemes are based on key phrases used by the listener [11], [12], extent of follow up questions [13], or emotions evoked [14]. Self-assessment empathy schemes rely on an individual's reflection of their own traits, habits, and perceptions. ...
... 3. Empathic opportunity -In the evaluation of behavioral empathy, an empathic opportunity is defined as a noun-verb phrase that addressed a user need or design requirement. 4. Behavioral empathy scale -Derived from scales developed in the literature [11], [13], [14] and from the empirical results of this study, we created a fourlevel behavioral empathy scale to classify content from student assignments related to the design process. a. Level 1 -No empathy -Student repeats verbatim the needs expressed by the user without further interpretation. ...
... The assignments and presentation transcripts from the three fully consenting teams were collected and anonymized for qualitative data analysis. To address RQ1 and empirically determine the presence or absence of behavioral empathy in the process, a behavioral empathy scale for design was developed by integrating scales from published empathy studies, summarized in Table 1: "These Things Called Empathy: 8 Related but Distinct Phenomena" [14], an exploration of psychological theory; Empathic Communication Coding System (ECCS) derived from an empirical study of recorded physician-patient interactions [13]; and an interpretation of the ECCS applied to medical student-virtual patient interaction [11]. ...
The objective of this paper is to develop a methodology to better understand behavioral empathy in the design process for the purpose of addressing user needs. To accomplish this, content analysis was conducted on undergraduate student assignments that documented group projects designing a consumer product. Using qualitative data analysis, the assignments and presentations were coded for their levels of behavioral empathy, using a scale that applied psychology and design theories. The Interpersonal Reactivity Index was administered to the students to assess their trait empathy. Results from these two analyses showed little connection between levels of behavioral empathy and self-assessed trait empathy of the student groups. The student assignments did reveal empathic waves that demonstrated comprehension and application of expressed user needs, evidenced by ascending and descending the empathy scale. These results indicate that is it not trait empathy that leads to empathic design, but rather applied empathy in the design process; developing internal empathy is not sufficient if it does not effectively translate user needs to technical requirements in the final design.
... In order to assess pain cues and responses by residents, we adapted the validated Empathic Communication Coding System (ECCS) (Bylund & Makoul, 2002, 2005. The ECCS is a coding system that provides rules for coders to rate the level of physician response to patient cues, specifically empathic opportunities (defined as moments when the patient expresses a clear and direct statement of emotion, progress, or challenge). ...
... To our knowledge, this is the first study that has examined anesthesiologists' responsiveness to verbal and nonverbal expressions of acute pain. By modifying the Empathic Communication Coding System (ECCS) (Bylund & Makoul, 2002, 2005, we were able to examine how frequently and in what ways anesthesiology residents responded to standardized patients' verbal and nonverbal expressions of acute pain. We also examined whether resident responsiveness was related to interaction length, more positive general impressions of the resident, and prescribing behavior. ...
... These findings suggest that there may be specific skills and behaviors that residents can learn to improve recognition, acknowledgement and treatment of acute pain, enhance patient satisfaction, reduce suffering, and allow for more efficient interactions, especially in the acute care context. Skills in noticing, interpreting, and responding appropriately to patients' pain cues are of course, just a manifestation of the array of interpersonal and clinical skills that have often been discussed as integral to patient-centered care (Bylund & Makoul, 2002, 2005Hall, 2011;Zimmermann et al., 2010). Of importance, because we coded from videotapes and were not able to interview the residents post-scenario, we are uncertain if the large number of pain cues the residents failed to respond to were really ignored by the resident (i.e., resident recognized pain, but consciously decided not to respond) or were missed (i.e., resident did not recognize or respond because they did not notice the pain cues). ...
Anesthesiologists must recognize and respond both verbally and nonverbally to their patients’ pain. The current study analyzed 65 videotaped interactions between anesthesiology residents, a standardized registered nurse, and a standardized male patient in pain awaiting urgent repair of a perforated gastric ulcer. Interactions were assessed using a modified version of the Empathic Communication Coding System to code verbal and nonverbal responses to pain cues. Nearly 60% of the time, residents responded with denial or disconfirmation of the pain, either completely ignoring or disconfirming that the patient’s pain was real or needed to be addressed. Only 29% of all responses verbally acknowledged the patient’s pain. Residents responded with more empathic verbal responses to verbal pain cues compared to nonverbal pain cues, and to more intense pain cues compared to less intense pain cues. Residents were more likely to respond when the nurse advocated for the patient’s pain rather than when the patient expressed his own pain. Residents who were more responsive nonverbally and had higher total responsiveness had shorter interactions with the patient. Residents who were more verbally responsive were more likely to prescribe pain medication and prescribe it earlier in the interaction, which was the appropriate clinical action in this scenario to reduce patient suffering. These findings suggest that there may be specific skills and behaviors that physicians can learn to improve recognition, acknowledgment, and treatment of acute pain, enhance patient satisfaction, reduce suffering, and allow for more efficient interactions, especially in the acute care context.
... Gricean maxims of communication 104,105 ; politeness theory. 32,63,92,93,107,108 Physicians should ensure patients feel comfortable sharing information that they may be worried is repetitive or irrelevant (e.g., "I know you talked to the nurse already, but I'd like you to start from the beginning and let me know what brings you in here today."). ...
... It is useful to consider concepts and theories that explain how individuals conceive of themselves, how they portray themselves to others, and the role of "normal" in health and illness to understand how role and identity can impact communication. Goffman's theory of facework is concerned with how individuals portray themselves in social interactions, [91][92][93] and it is important that physicians consider the face needs of their patients during interactions that may represent face-threatening acts (e.g., questioning a patient about risky behaviors); this will allow them to communicate in a way that is more sensitive to the identity of the patient. The concept of the voice of the lifeworld, contrasting with the voice of medicine, offers similar insight to help physicians understand the identity of the patient and its role in the health care setting. ...
... Politeness theory explains the ways in which interactive partners work to maintain their own face, as well as the face of others, by avoiding facethreatening acts such as direct conflict or challenges to authority. 32,63,92,93,107,108 Verbal communication tools like hedging ("I believe you may have a broken arm. ") are a common politeness strategy that allows interactants to speak with less certainty and authority, thereby mitigating face threats. ...
Objective:
Strong verbal communication skills are essential for physicians. Despite a wealth of medical education research exploring communication skills training, learners struggle to become strong communicators. Integrating basic science into the curriculum provides students with conceptual knowledge that improves learning outcomes and facilitates the development of adaptive expertise, but the conceptual knowledge, or "basic science", of patient-provider communication is currently unknown. This review sought to address that gap and identify conceptual knowledge that would support improved communication skills training for medical trainees.
Method:
Combining the search methodology of Arksey and O'Malley with a critical analytical lens, the authors conducted a critical scoping review of literature in linguistics, cognitive psychology, and communications to determine: what is known about verbal communication at the level of word choice in physician-patient interactions? Studies were independently screened by three researchers during two rounds of review. Data extraction focused on theoretical contributions associated with language use and variation. Analysis linked patterns of language use to broader theoretical constructs across disciplines.
Results:
The initial search returned 15,851 unique studies and 210 studies were included in the review. The dominant conceptual groupings reflected in the results were: (1) clear and explicit language, (2) patient participation and activation, (3) negotiating epistemic knowledge, (4) affiliative language and emotional bonds, (5) role and identity, and (6) managing transactional and relational goals.
Conclusions:
This in-depth exploration supports and contextualizes theory-driven research of physician-patient communication. The findings may be used to support future communications research in this field, and educational innovations based on a solid theoretical foundation.
... Comparing Bylund & Makoul, 2002). rated by observers using the videorecorded interactions. ...
... Preliminary literature indeed demonstrates the applicability of using virtual patients to train clinicians to increase empathy (Yao et al.,2020). Furthermore, clinicians' empathic responses to virtual patients have been found to mirror real-life patient interactions (Bylund and Makoul, 2002) "Bernie Cohen", a 53-year-old Caucasian single gay man with a history of generalized anxiety disorder, seeking treatment for depression with suicidal ideation, after unexpectedly losing his long-term partner. ...
Virtual Human Interaction (VHI) was utilized to train outpatient clinicians in emotional self-awareness which includes both recognition of one's own emotional responses, and ability to engage in verbal empathic communication with acutely suicidal patients. Namely, clinicians were provided a weblink that gave them access to the Virtual People Factory (VPF2), a platform specialized in web-based and conversation-specific virtual humans (VH; Rossen and Lok, 2012). On the platform, clinicians were asked to interview a virtual patient and to assess their suicidal risk level. The interactions were video-recorded. Then, each clinician participated in a training phase, during which they were provided an individualized feedback about the level of empathy they displayed with the virtual patient. Each clinician was also provided with suggestions to increase their verbal empathy. Following the reception of the feedback, clinicians interacted with a second virtual patient. The verbal empathy displayed by clinicians was assessed by trained observers, as described below. Clinicians were randomly assigned to two groups: Group A interacted with Cynthia Young at pre-training and with Bernie Cohen at post-training, while group B interacted with Bernie Cohen at pre-training and with Cynthia Young at post-training.
... Alternatively, three of the reviewed coding tools describe emotional expressions and their responses as the UoA and share a similar framework. The Empathic Communication Coding System (ECCS) [63] defines patient and physician's categories separately. Patient's EOs are a statement of emotion ('The surgery scares me'), a statement of progress ('I have been eating healthy'), or a statement of challenge ('I struggle to reach 10.000 steps'). ...
... Frequently, IRR was represented as an overall score for all the categories that ranged from 0.65 to 0.85 [51,54,61,62,64]. Others assessed HCP and patient categories coding reliability separately that ranged from 0.73 to 0.93 and from 0.70 to 0.91, respectively [59,63,65]. In three of the tools, authors calculated IRR for the form, function, and/or content of the utterance [55,56]. ...
Background
Although healthcare professionals (HCP) undergo communicative skills training, these are sometimes unsatisfactory for patients (empathy, discussion managing). Existing coding tools overlook the interaction and patients' responses. Meanwhile, remote consultations are redefining communication channels. While some researchers adapt those tools to telehealth, few investigate written interactions.
Objective
To identify and evaluate coding tools for healthcare interactions and examine their suitability for written interactions.
Methods
We conducted a meta-narrative review in PubMed, PsycINFO, Embase, Web of Science, CINAHL, and Scopus databases up to December 2022 with Communicati* AND Human* AND Linguistic* AND Professional-Patient Relation* as search terms. We extracted data regarding methodology, unit of analysis (UoA), coding categories, reliability, strengths, weaknesses, and inter-rater reliability (IRR).
Results
We identified 11 mixed-methods tools. Qualitatively, coding dimension was focused (n = 6) or comprehensive (n = 5). Main quantitative methods were descriptive statistics (n = 4) and cross-tabulations (n = 4). Main UoA was utterance (n = 7). Relevant categories were processes (n = 4), content (n = 3), emotional expressions and responses (n = 3), and grammatical format (n = 2). IRR ranged from 0.68 to 0.85 for coding categories.
Conclusion
Despite similarities, category terminologies were inconsistent, one-sided, and mostly covered conversation topics and behaviours. A tool with emotional and grammar categories could bridge the gap between a speaker's intended meaning and the receiver's interpretation to enhance patient-HCP communication. Furthermore, we need empirical research to determine whether these tools are suitable for written interactions.
Innovation
This review presents a comprehensive and state-of-the-art overview of healthcare interactions' coding tools and identifies their barriers. Our findings will support communication researchers in selecting appropriate coding tools for evaluating health interactions and enhancing HCP training.
... In the comparisons of intervention vs. assessment, three studies reached 100% consistency [18,37,48]. Interestingly, all three interventions were communication-associated workshops or educational courses, and all three corresponding measures involved the Empathy Communication Coding System (ECCS) [20]. Both interventions and measures fulfilled the category of the behavioral dimension. ...
... Similarly, when an intervention is chosen, it is recommended that a measure with the corresponding empathy dimensions and KAB aspects be employed. For example, an intervention of a communication-associated workshop or educational course, which fulfills the behavioral dimension of empathy and the behavior aspect of the KAB model, should be assessed with a measure involving both the behavioral dimension and the behavior aspect, such as the ECCS [20] or Consultation and Relational Empathy (CARE) [31], instead of a measure having different dimensions and aspects, such as the JSE [22,36]. ...
Various studies have examined the effectiveness of interventions to increase empathy in medical professionals. However, inconsistencies may exist in the definitions, interventions, and assessments of empathy. Inconsistencies jeopardize the internal validity and generalization of the research findings. The main purpose of this study was to examine the internal consistency among the definitions, interventions, and assessments of empathy in medical empathy intervention studies. We also examined the interventions and assessments in terms of the knowledge–attitude–behavior aspects. We conducted a literature search for medical empathy intervention studies with a design of randomized controlled trials and categorized each study according to the dimensions of empathy and knowledge–attitude–behavior aspects. The consistencies among the definitions, interventions, and assessments were calculated. A total of 13 studies were included in this study. No studies were fully consistent in their definitions, interventions, and assessments of empathy. Only four studies were partially consistent. In terms of knowledge–attitude–behavior aspects, four studies were fully consistent, two studies were partially consistent, and seven studies were inconsistent. Most medical empathy intervention studies are inconsistent in their definitions, interventions, and assessments of empathy, as well as the knowledge–attitude–behavior aspects between interventions and assessments. These inconsistencies may have affected the internal validity and generalization of the research results.
... Gender disparities in communication skills have been demonstrated in previous literatures. Female physicians typically demonstrate higher levels of empathy and utilize more positive language when engaging with patients [1]. Similarly, the study carried out by Holm and Aspegren [2] indicated that female students often exhibit superior communication competencies in training courses in communication skills. ...
Gender stereotypes are often discussed as potential explanations for disparities observed in communication, job satisfaction, and the treatment of individuals within workplace environments. This study aims to investigate the persistence of such gender differences and explore existing literature explanations. Utilizing an online questionnaire, 96 participants from diverse professional backgrounds in China were recruited for this research. The results indicate that by holding communication skill levels constant, female employees exhibit higher levels of job satisfaction. These findings underscore a significant gender disparity in how communication skills influence job satisfaction, emphasizing the importance of adopting gender-sensitive approaches to enhance workplace satisfaction and ensure equitable opportunities for all employees. Future research should delve deeper into the underlying factors contributing to these disparities and develop strategies to improve communication effectiveness and job satisfaction across diverse workforce demographics.
... Second, the perception of empathy by examiner or SP depends on several factors of their own, which were not analyzed in the study except for gender (Pavlova et al. 2022). Third, characteristics of the SP, like female gender, may be associated with a greater likelihood of eliciting physician empathy during a medical consultation (Bylund and Makoul 2002;Chen et al. 2020). ...
Purpose:
To assess the Consultation And Relational Empathy (CARE) measure as a tool for examiners to assess medical students' empathy during Objective and Structured Clinical Examinations (OSCEs), as the best tool for assessing empathy during OSCEs remains unknown.
Methods:
We first assessed the psychometric properties of the CARE measure, completed simultaneously by examiners and standardized patients (SP, either teachers - SPteacher - or civil society members - SPcivil society), for each student, at the end of an OSCE station. We then assessed the qualitative/quantitative agreement between examiners and SP.
Results:
We included 129 students, distributed in eight groups, four groups for each SP type. The CARE measure showed satisfactory psychometric properties in the context of the study but moderate, and even poor inter-rater reliability for some items. Considering paired observations, examiners scored lower than SPs (p < 0.001) regardless of the SP type. However, the difference in score was greater when the SP was a SPteacher rather than a SPcivil society (p < 0.01).
Conclusion:
Despite acceptable psychometric properties, inter-rater reliability of the CARE measure between examiners and SP was unsatisfactory. The choice of examiner as well as the type of SP seems critical to ensure a fair measure of empathy during OSCEs.
... Through empathic communication, individuals can consciously help others [71]. Extensive research has been conducted on the effectiveness of empathic communication in doctor-patient interactions [70,72,73]. However, the impact of empathic communication on fostering workplace relationships still needs to be verified. ...
Researchers have increasingly concentrated on loneliness in the workplace as a crucial factor influencing the mental health of employees and the viability of telework. In contrast, the current understanding of the strategies mitigating workplace loneliness and how leaders utilize their behaviors to impact followers’ loneliness remains limited. Since servant leadership values the emotional needs of followers and displays a high level of empathy, this study investigated the direct and indirect effects of servant leadership on workplace loneliness. In this study, 267 employees (mean age = 31.5 years) from 28 provinces in China were recruited to participate in this survey. We proposed that servant leaders motivate their own empathic communication and other followers’ empathic communication to reduce lonely followers’ workplace loneliness. This research further examined the relationship between the leader’s and colleagues’ empathic communication, and the two jointly mediate the connection between servant leadership and followers’ workplace loneliness. We constructed a serial mediation model to examine the relationships between servant leadership, leader’s empathic communication, colleagues’ empathic communication, and workplace loneliness. The results indicate that servant leadership creates a cycle of empathy and provides insights into building a culture of empathy to improve employee well-being.
... Empathic communication, speci cally empathic opportunities, is a robustly operationalized aspect of patient-centered communication in the cancer context [27][28][29]. Empathic opportunities refer to patient statements that express an emotion such as fear, worry, or relief and explicitly give the medical provider the opportunity to respond empathically [29]. We argue that empathic opportunities align with the rst two tenants above (communication that elicits patient perspectives and seeks to understand patients' unique psychosocial context). ...
Purpose: Effective communication between cancer patients and providers is critical for addressing psychological distress, reducing uncertainty, and promoting patient well-being. This is particularly relevant during medical appointments that may elicit uncertainty, such as surgical consultations for newly diagnosed women with breast cancer. This study aimed to evaluate how pre-appointment anxiety affects patient-provider communication in breast cancer surgical consultations and subsequent post-appointment well-being. Breast cancer patient anxiety has been studied as an outcome of provider communication, though less is known about the extent to which pre-existing anxiety acts as an antecedent to effective patient-provider communication.
Methods: This study analyzed videorecorded breast cancer surgical consultations (N = 51) and corresponding patient surveys to understand how pre-appointment anxiety influences pre-appointment patient uncertainty, patient-provider communication during the appointment, and subsequent post-appointment uncertainty.
Results: Overall, patients with elevated pre-appointment anxiety (n = 12) did not have more pre-appointment uncertainty but were interrupted by their provider at a higher rate than those without anxiety. The proposed model achieved good fit to the data such that more pre-appointment anxiety was associated with more pre-appointment uncertainty, more pre-appointment anxiety was associated with more empathic opportunities per minute, and more empathic opportunities were associated with less post-appointment uncertainty.
Conclusions: Results provide new understanding for how patient anxiety acts as an antecedent to effective patient-provider communication and how this affects patient uncertainty post-appointment. Assessing breast cancer patients’ psychological well-being is crucial for identifying those at higher risk of poor health outcomes and providing holistic cancer care.
... They use emphatic stress in their speech so the addressee does not take their words lightly and to emphasise the serious tone of the situation. It is used to intensify the speaker's utterances and emotional message (Bylund & Makoul, 2002;Palczewski et al., 2023). ...
The purpose of this study is to analyze the major features of women’s language used by the female characters in “Birds of Prey and the Fantabulous Emancipation of One Harley Quinn” movie. This study investigates the types of women speech features found in the movie. A qualitative approach employing a content analysis method was used in this study. The data were taken from female characters’ utterances. The data were then identified and analyzed based on the classifications of women’s speech features proposed by Lakoff (1975). Findings of this study indicate that six of the features are used by the female characters: lexical hedges/fillers, empty adjectives, tag questions, super polite forms, avoiding strong words, and emphatic stress. Rising intonation, precise color terms, intensifiers, and hypercorrect grammar have not been found in the current research data.
... This indicates that the women who desired Core specialties were better able to maintain their cognitive empathy skills, especially when comparted to their male classmates who preferred Non-Core specialties. This supports the research by Bylund and Makoul [26] and Roter et al. [27], who found that female physicians spend more time with their patients, engage in more communication with increased amounts of perceived empathy (n=249; p<0.05, and a meta-analytic review in which n=870; p<0.001, respectively). The current data show that CUSOM students, when compared to the POMEE cohort, have lower JSE-S scores than their counterparts across the United States. ...
Context
Establishing an empathic bond of trust with patients is a characteristic that physicians need, because patients feel that physicians are more caring if they sense that they are empathetic. Former cross-sectional studies have shown an erosion of cognitive empathy as medical students progress through their education.
Objectives
This study aims to measure the changes in student cognitive empathy as they progress through their undergraduate osteopathic medical education. Cognitive empathy scores are compared to the nationwide norms established by the Project in Osteopathic Medical Education and Empathy (POMEE) study by Mohammadreza Hojat, PhD, and colleagues.
Methods
During orientation to medical school, and at the beginning of each subsequent academic year, and just before graduation, the graduating classes of 2017–2019 participated in this longitudinal study by filling out the Jefferson Scale of Empathy-Student Version (JSE-S). A total of 345/459 Osteopathic Medical Student (OMS) I-IV students (75.2 % of the graduates) filled out the forms for all five time points. Desired specialty choice and sex were also collected. Specialty choice was divided into Core and Non-Core groups. Core specialties are “people-oriented” and have a large amount of patient contact and continuity of care, while Non-Core specialties are “technical- or procedure-oriented” and have little or no patient contact and/or continuity of care.
Results
Men selecting Non-Core specialties had significant drops in JSE-S scores (p=0.001); whereas men who selected the Core specialties did not have a significant decrease. For women, there was no significant drop in JSE-S scores for those selecting either Core or Non-Core specialties. When compared to POMEE norm data, none of the Campbell University School of Medicine students had JSE-S scores that were above the 50th percentile.
Conclusions
Students selecting Core specialties do a better job of maintaining their cognitive empathy, which aids their ability to establish an empathic bond of trust with patients, when compared to students who desire Non-Core specialties. JSE-S scores not above the POMEE 50th percentile is concerning and indicate either a curricular change to better enhance empathic communication skills and/or better applicant selection.
... Clinicians highlighted the importance of delivering knowledge with empathy and understanding. Consistent with principles of empathic communication in healthcare that encourage clinicians to acknowledge, validate, and normalize an individual's experience, 28,29 clinicians responded in language that indicated their compassion toward FCPs when providing education. Relatedly, multiple participants described the importance of recognizing that many FCPs want to hold on to hope for as long as possible, even when the PLwD is declining. ...
Introduction:
More than 35% of hospice care recipients 65 and older have a dementia diagnosis. Yet family care partners of persons living with dementia report feeling unprepared to address their hospice recipient's changing needs nearing end of life. Hospice clinicians may have unique insight into the knowledge needs of family care partners and strategies for end-of-life dementia caregiving.
Methods:
Semi-structured interviews were conducted with 18 hospice physicians, nurse practitioners, nurses, and social workers. Interview transcripts were deductively analyzed using thematic analysis to examine clinicians' perspectives on gaps and strategies related to family care partner knowledge about end-of-life dementia caregiving.
Results:
We identified 3 themes related to gaps in family care partners' knowledge: dementia is a progressive, fatal disease; end-of-life symptoms and symptom management in persons living with advanced dementia; and understanding hospice goals and guidelines. Three themes related to clinicians' strategies to increase knowledge included: providing education; teaching strategies to facilitate coping and preparedness for end-of-life care; and communicating with empathy.
Discussion:
Clinicians perceive gaps in knowledge specific to dementia and end of life among family care partners. These gaps include a lack of understanding of Alzheimer's symptom progression and strategies to manage common symptoms. Recommendations for approaches to reduce knowledge gaps include providing education and strategies delivered with empathy toward the family care partner experience.
Conclusion:
Clinicians who work with persons living with dementia receiving hospice care have valuable insights regarding family care partners' gaps in knowledge. Implications on the training and preparation of hospice clinicians working with this care partner population are discussed.
... Our study is consistent with previous work, which suggests that, when clinicians display empathy, families share more about their feelings and goals, the clinician-family relationship is enhanced, and families report feeling more supported. 9,42,43 Our findings differ from a previous study examining adult care conferences, which showed that clinicians express support less frequently when language interpretation is used. 18 There are few studies on interpreted care conference empathic expression (none in pediatrics), and the most recent adult study is from 2009. ...
Background and objectives:
Clinician empathy is associated with improved communication and clinical outcomes. We hypothesized that, when clinicians express empathy, families are more likely to deepen discussions, and that clinicians express less empathy in care conferences with language interpretation.
Methods:
Prospective, mixed methods cohort study of English and interpreted audio-recorded transcripts of care conferences for pediatric patients with serious illness hospitalized at a single urban, quaternary medical institution between January 2018 and January 2021. Directed content analysis identified empathic opportunities, clinician empathetic statements or missed opportunities, and family responses. Clinician empathic statements were "buried" if immediately followed by more clinician medical talk. Descriptive analyses summarized demographics and codes. χ2 analyses summarized differences among language interpretation and family responses.
Results:
Twenty-nine patient-family dyads participated. Twenty-two (81%) family members were female. Eleven (39%) used language interpretation (8 Spanish, 2 Vietnamese, 1 Somali). Families created 210 empathic opportunities. Clinicians responded with unburied empathy 80 times (38%, no differences for English versus interpreted care conferences, P = .88). When clinicians buried empathy or missed empathic opportunities, families responded with alliance (agreement, gratitude, or emotional deepening) 14% and 15% of the time, respectively. When clinicians responded with unburied empathy, families responded with alliance 83% of the time (P < .01).
Conclusions:
Our study suggests that clinician empathic expression does not differ when language interpretation is used in pediatric care conferences. Clinicians often miss opportunities to express empathy, or they bury it by medical talk. Although unburied empathy created opportunities for relationship-building and family-sharing, buried empathy negatively impacted these domains similarly to no empathic expression.
... Similarly, another study has shown how individuals raised within a lower socioeconomic background tended to show a greater frequency of empathic attitudes as compared to participants from the higher socioeconomic background (7). In medicine, factors such as age and gender have been shown to have a modulating effect on one's clinical empathic experience (8). ...
Empathy is a cognitive attribute that forms the cornerstone for good doctor–patient encounters. The formative period for the development of empathy toward patients begins with clinical encounters within medical school. An individual medical student's empathy levels may in part be a product of their resilience and perfectionist attitudes. A cross-sectional study with 320 medical students across all years of study was conducted to determine the correlation of perfectionism and resilience with clinical empathy in medical students. The JSE-S, CD-RISC 10, and APS-R scales were used to assess levels of empathy, resilience, and perfectionism, respectively. The study found that a positive correlation exists between resilience ( r = 0.174) and academic year with empathy, and a negative correlation exists between maladaptive perfectionism and empathy ( r = −0.138). The resilience score declined progressively as the year of study progressed with a statistically significant. Mean empathy scores were lowest in fifth-year students (96.8 ± 12.5) and highest in third-year students (107.8 ± 13.2). Further longitudinal studies are necessary to better understand the impact of resilience and perfectionism on empathy.
... For the semi-structured and structured templates, which contain prepopulated fields, there should be an accompanying "codebook" of definitions describing the parameters for each field.. For example, building on the previous example using Street et al's constructs, the code "responding to emotions" could identify instances where patients appear to be sad or worried and the provider responds to these emotions (also termed empathic opportunities and empathic responses) by eliciting, exploring, and validating the patients' emotions [24,25]. This process operationally defines each concept and facilitates more reliable data capture. ...
Objective
To provide health research teams with a practical, methodologically rigorous guide on how to conduct direct observation.
Methods
Synthesis of authors’ observation-based teaching and research experiences in social sciences and health services research.
Results
This article serves as a guide for making key decisions in studies involving direct observation. Study development begins with determining if observation methods are warranted or feasible. Deciding what and how to observe entails reviewing literature and defining what abstract, theoretically informed concepts look like in practice. Data collection tools help systematically record phenomena of interest. Interdisciplinary teams--that include relevant community members-- increase relevance, rigor and reliability, distribute work, and facilitate scheduling. Piloting systematizes data collection across the team and proactively addresses issues.
Conclusion
Observation can elucidate phenomena germane to healthcare research questions by adding unique insights. Careful selection and sampling are critical to rigor. Phenomena like taboo behaviors or rare events are difficult to capture. A thoughtful protocol can preempt Institutional Review Board concerns.
Innovation
This novel guide provides a practical adaptation of traditional approaches to observation to meet contemporary healthcare research teams’ needs.
... Females are also known for having more emotional intensity than males. [11] Thus, it is possible that dental care providers felt more emotional toward adult female patients with IDD and referred them to receive their dental needs under GA more than adult male patients with IDD. Lastly, it has been reported that female patients with IDD had a higher prevalence of dental caries when compared to male patients with IDD. ...
Aim: To investigate factors determining the need for general anesthesia (GA) to deliver dental treatment for adult people with intellectual and developmental disabilities (IDD).
Methods: This study involved a retrospective review of medical records of adult patients with IDD who received dental treatment under GA at Tabuk Specialist Dental Center, Saudi Arabia, between 2018 and 2020. Demographic characteristics and dental-related details, level of cooperation, and methods of delivering dental treatment were collected.
Results: A total of 86 adult patients with IDD were included. The mean age of the study participants was 34.8 years (standard deviation [SD] 6.5), and the majority were males (n = 47, 54.7%). Eighteen patients had aphasia (20.9%), 16 had epilepsy (18.6%), and 10 had cerebral palsy (11.6%). Most dental treatments delivered were complex dental treatments (n = 39, 45.3%) followed by dental extraction (n = 25, 29.1%), and non-surgical periodontal therapy (n = 22, 25.5%). Females had higher odds of undergoing GA compared to males (Odds ratio (OR) =6.79, 95% Confidence intervals (CI): 1.62–28.41). Furthermore, patients who had aphasia had higher odds of undergoing GA compared to patients who had no medical conditions (OR = 14.03, 95% CI: 1.05–186.7).
Conclusion: Being female or having aphasia are independent factors related to the need for GA to deliver dental treatment for Saudi adults with IDD.
... However, no such scenarios have been developed for or tested in the context of design. The valid definition of prosocial responding is context-dependent, with general mishaps and inflicting pain having been used to assess empathic responding in general (Rieffe et al., 2021), but expressions of emotion having been more common in medicine (e.g., Bylund & Makoul, 2002). Further work is needed to develop design relevant measures for prosocial responding. ...
In this research note, we bring clarity to the concept of empathy in design research by discussing issues in its conceptualization and operationalization. We review literature to identify and clarify the core concepts of empathy and to showcase its potential operationalizations, borrowing from closely related fields of social psychology and neuroscience. We identify five core concepts: empathic understanding, empathic design research, empathic design action, empathic orientation, and empathic mental processes. We also identify six potential operationalizations: empathic tendencies, beliefs about empathy, emotion recognition, understanding mental contents, shared feelings, and prosocial responding. By combining the core concepts and operationalizations, we provide a frame of operation for future empathy research in design.
... In studies evaluating empathy skills in the field of health sciences, researchers found that women are statistically or quantitatively more accomplished than men. [45][46][47][48][49][50][51][52][53][54][55][56] Two different studies comparing human-human and human-animal empathy levels concluded that empathy scores varied with gender, and women rated themselves more highly. 38,57 Women scored higher than men in regard to empathy in a recent experimental study conducted in Turkey with senior veterinary students. ...
İletişim becerileri, bir öğrencinin iletişim kurma yeteneği ile empati becerisini arttırabilmesi nedeniyle diğer klinik beceriler arasında önemli bir yere sahip olan öğretilebilir ve öğrenilebilir becerilerdir. Bu çalışmanın amacı, veteriner fakültesi son sınıf öğrencilerinin iletişim konusunda kendilerini nasıl değerlendirdiklerini ve cinsiyetin bu algı üzerinde bir etkisi olup olmadığını belirlemektir. Çalışma 128 gönüllü öğrenci ile 30 sorudan oluşan İletişim Yeterlilik Ölçeği kullanılarak gerçekleştirilmiş, bağımsız örneklemlerde t-testi ile istatistiksel değerlendirme yapılmıştır. Yapılan değerlendirmeye göre, tüm katılımcılar arasında erkeklerin en yüksek puanı, kadınlar en düşük puanı aldığı görülmüştür. Ancak kadın ve erkeklerin toplam puanları arasında istatistiksel olarak anlamlı fark bulunamamıştır (p=0.605). Kadın ve erkekler arasında sosyal yeterlilik, empati yeterliği ve uyum yeterliği açısından anlamlı fark bulunmuştur. Kadınlar empati yeterliğinde, erkekler ise sosyal yeterlilik ve uyum yeterliğinde daha yüksek puan almıştır. İletişim yeterlikleri algısı bakımından kadınlar kendilerini daha empatik, erkekler ise daha sosyal ve uyumlu bulmuştur. Bu çalışma Türk veteriner fakültesi öğrencilerinin iletişim yeterlikleri konusunda öz algılarını yansıtan ilk çalışma olması bakımından önemlidir. İletişim becerileri eğitimi Türkiye’de veteriner fakülteleri müfredatında daha güçlü hale gelecek ve bu konu ileri araştırmaların yapılmasını teşvik edecektir.
... An additional advantage of empathic validation as a means to convey empathy is that this approach does not assume that patients are responsible for inviting it. While studies based on the "empathic opportunities" framework measure the success of a physician's empathy by how well they respond to the empathic opportunities that patients create (Bylund & Makoul, 2002), in this article I show that physicians can express empathy quite effectively regardless of whether the patient has indicated that it would be appropriate to do so (e.g., by naming an emotion). Expressing concerns is already challenging for patients, and sensitive topics that could benefit from clinical empathy may be even more difficult for patients to raise. ...
Interest in systematic approaches to improving clinical empathy has increased. However, conceptualizations of empathy are inconsistent and difficult to operationalize. Drawing on video recordings of primary care visits with older adults, I describe one particular communication strategy for conveying empathy—empathic validation. Using conversation analysis, I show that the design of empathic validations and the context in which they are delivered are critical to positive patient responses. Effective empathic validations must (a) demonstrate shared understanding and (b) support the patient’s position. Physicians provided empathic validation when there was no medical solution to offer and within this context, for three purposes: (1) normalizing changes in health, (2) acknowledging individual difficulty, and (3) recognizing actions or choices. Empathic validation is a useful approach because it does not rely on patients’ ability to create an “empathic opportunity” and has particular relevance for older adults.
... Thus, female interns showed more empathy and communicated better with patients as we see in the overall communication skills competence. Similar findings were found in other studies [14] also showed that female interns have a tendency to communicate with higher degrees of empathy. There was also a recent meta-analysis that showed that female physicians displayed better patient-centered communication behaviors like empathy, collaborative communication skills and also gave more psychosocial information to the patients. ...
Background: Interns who would be the future doctors are not being observed for communication skills at their workplace. The Mini-clinical evaluation exercise (mini-CEX) can be used as a “Work Place Based Assessment” (WPBA) tool for the assessment of the communication skills of the interns and also for giving immediate feedback. This study was done to evaluate the acceptability, feasibility, and effectiveness of mini-CEX for improving the communication skills of interns in Pediatrics. Materials and Methods: It was a prospective interventional study which was conducted in the Department of Pediatrics. Forty interns and six faculty who volunteered participated in the mini-CEX encounters. The structured assessment mini-CEX form by the American Board of Internal Medicine was used. Each intern faced six assessment sessions on mini-CEX forms with each of the faculty. At the end of the internship rotation, the perceptions of the interns and faculty were gathered by an anonymous validated questionnaire containing both close-ended (using 5-point Likert scale) and open-ended questions. Statistical Analysis Used: The descriptive data were analyzed on the Statistical Package for the Social Sciences (SPSS) version 23. also done. Qualitative data of open-ended questions were done by thematic analysis. Results: Most interns (87.5%) and all faculty (100%) felt that mini-CEX helped them in achieving good communication skills. Comparison between the 1st and the 6th encounter of mini-CEX showed an increase in the mean score values for all skill competencies, and this improvement was statistically significant (P < 0.001). Conclusions: Mini-CEX is an acceptable, feasible, and effective WPBA tool for communication skills training of interns in pediatrics.
... In line with the goals of patient-centered care (Clayton et al., 2011), we propose empathic patient-provider communication as a potential interpersonal mechanism of effective DT. Empathic communication is an interactive process mutually constructed by patient and provider (Bylund and Makoul, 2002). The importance of empathy in clinical interactions, particularly in oncologic care, has been rigorously established (Neumann et al., 2009). ...
Objective
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.
Methods
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.
Results
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.
Significance of results
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.
... 10 Across multiple specialties, women physicians more frequently use patient-centered communication techniques, spend more time with their patients in an average clinic visit, and exhibit more empathy in patient encounters. 11,12 With these patterns in other specialties, retina patients would likely benefit from increased representation of women practitioners as well. In fact, female vitreoretinal surgeons have been shown to have a faster learning curve than their male peers in training for retinal detachment surgery. ...
Purpose
This work evaluates trends in achievement of women in the retina field, through an analysis of gender representation in the American Society of Retina Specialists (ASRS).
Methods
This retrospective, longitudinal study spans 1983 to 2020. Historical data classified by male or female gender were collected from ASRS's overall membership, board of directors and officers, and recipients of the 4 society awards. The proportion of each benchmark held by women was compared with prior decades since the founding of ASRS using the Fisher’s exact test.
Results
Women’s representation increased from 11% of ASRS members in 2007 to 19.7% in 2020. From 2010 to 2019, women received a higher proportion of society awards (21.1%) compared with membership prior to the start of that decade. In 2020, women were proportionally well represented in board of director positions (21.9%) and held a significantly higher proportion of board positions than in the period 1983 to 1989 ( P = .02). From 1983 to 2020, women held 4.3% (1 of 23) of presidencies.
Conclusions
Although the number of women in retina is increasing, women remain underrepresented in the leadership of ASRS. Interventions to increase exposure to female mentorship and improve childcare benefits are warranted to engage female ophthalmology trainees in retina and ultimately society leadership.
Background: Establishing an empathic bond of trust with patients is a trait that is important to learn during medical school. There are two types of empathy: affective and cognitive. Being able to partially blunt a detrimental affective response while maintaining cognitive empathy is beneficial for both the patient and the physician. AIM: To find those students who have partially blunted their affective empathy while maintaining or enhancing their cognitive empathic skills. Methods: Affective and cognitive empathy was measured using the Balanced Emotional Empathy Scale and the Jefferson Scale of Empathy, respectively. The survey instruments were given during entrance into medical school, at the start of years 3-4, and a final administration just before graduation. Students who fit the aim of the study, had blunted their BEES score by -0.5 to -1.5 s.d. below the male or female population norms, as well as being at or above the 75th percentile for JSE scores as established by the Project in Osteopathic Medical Education and Empathy study. Desired specialty choice and sex was also collected at each timepoint. Five specialties are “people-oriented” and have a large amount of patient contact and continuity of care, and include Family and Internal Medicine, Ob/Gyn, Pediatrics and Psychiatry. Most other specialties are more “procedure- or technical-oriented” and are those with little or no patient contact and/or continuity of care (e.g., Surgery, Emergency Medicine, Anesthesiology). Results: Only a small subset of students (n = 15/345) fell within the above parameters upon entering medical school. It was a different, small cadre (n = 13) that had these traits upon graduation. Ergo, there was no student who fell within the parameters for all four years of their undergraduate medical education. Conclusions: Few students had the ability to partially blunt their affective empathic response while maintaining the ability to give a reassuring cognitive empathic response to patients. This indicates an increased emphasis needs to be placed on teaching empathic skills during the basic science years of the curriculum. However, the onus needs to fall upon the physicians who are empathic role-models during the clinical rotation year.
Objective
To provide a scoping review of studies on empathy recognition in text using natural language processing (NLP) that can inform an approach to identifying physician empathic communication over patient portal messages.
Materials and methods
We searched 6 databases to identify relevant studies published through May 1, 2023. The study selection was conducted through a title screening, an abstract review, and a full-text review. Our process followed the PRISMA-ScR guidelines.
Results
Of the 2446 publications identified from our searches, 39 studies were selected for the final review, which summarized: (1) definitions and context of empathy, (2) data sources and tested models, and (3) model performance. Definitions of empathy varied in their specificity to the context and setting of the study. The most common settings in which empathy was studied were reactions to news stories, health-related social media forums, and counseling sessions. We also observed an expected shift in methods used that coincided with the introduction of transformer-based models.
Discussion
Aspects of the current approaches taken across various domains may be translatable to communication over a patient portal. However, the specific barriers to identifying empathic communication in this context are unclear. While modern NLP methods appear to be able to handle empathy-related tasks, challenges remain in precisely defining and measuring empathy in text.
Conclusion
Existing work that has attempted to measure empathy in text using NLP provides a useful basis for future studies of patient-physician asynchronous communication, but consideration for the conceptualization of empathy is needed.
The communication between animal patient, owner and veterinarian proves to be a point of outstanding importance, which can influence many real developments that affect the general quality of all involved. A relatively high risk of interaction was described between veterinarians, which produced impacts on the relationship of these mentioned individuals, demonstrating how important the study and comprehensive research is to prevent certain relationships that influence the professional action of the veterinarian, the guardian, and the main individual, which is the animal patient. Seeking to elucidate these aspects, this article explains, in the light of psychobiology and psychopedagogy, factors such as perceived stress, anxiety, depression, emotional suffering, emotional exhaustion, personal fulfillment, secondary traumatic stress and satisfaction through compassion, looking for associations between satisfaction of the client and measures of welfare of the veterinarians, under the action of the treatment of the animal patients. The need for greater attention to this topic, so important and so present in the life of the veterinary medical professional, is highlighted.
Introduction:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
Research indicates that patients consider empathy as a key factor contributing to the quality-of-care. However, ambiguities in the definition of this multidimensional construct complicate definite conclusions to-date. Addressing the challenges in the literature, and using a hypothetical physician-patient interaction which explored patient-perceived differences between expressions of affective empathy, cognitive empathy, compassion and no empathy, this study aimed to test whether lay participants' evaluations of the quality-of-care depend on the type of empathic physician behavior, and on the physician's gender. We conducted a randomized web-based experiment using a 4 (type of empathy) by 2 (physician gender) between-subjects design. Empathy was subdivided into three concepts: first, affective empathy (i.e. feeling with someone); second, cognitive empathy (i.e. understanding); and third, compassion (i.e. feeling for someone and offering support). Perceived quality-of-care was the primary outcome. Compared with non-empathic interactions, quality-of-care was rated higher when physicians reacted cognitively empathic or compassionate (d = 0.71; 0.43 to 1.00 and d = 0.68; 0.38 to 0.98). No significant difference was found between affective empathy and no empathy (d = 0.13; -0.14 to 0.42). The physician's gender was not related with quality-of-care. Aspects of participants' personality but not their age, gender or the number of physician visits were associated with quality-of-care. No interactions were observed. In showing that patients rated quality-of-care higher when physician reactions were described as cognitively empathic and compassionate, as compared with affectively empathic or non-empathic, our findings refine views about the kinds of empathy that are important in patient care with implications for clinical practice, education and communication trainings.
Objectives:
This study examined the degree to which breast cancer patients' psychological well-being is facilitated through empathic provider communication. We explored symptom/prognostic uncertainty reduction as a mechanism through which provider communication influences patient psychological adjustment. Additionally, we tested if treatment status moderates this relationship.
Methods:
Informed by uncertainty in illness theory, current (n = 121) and former (n = 187) breast cancer patients completed questionnaires about perceptions of their oncologists' empathy and their symptom burden, uncertainty, and adjustment to their diagnosis. Structural equation modeling (SEM) was conducted to test hypothesized relationships between perceived provider empathic communication, uncertainty, symptom burden, and psychological adjustment.
Results:
SEM supported the following: (1) higher symptom burden was associated with increased uncertainty and reduced psychological adjustment, (2) lower uncertainty was associated with increased adjustment, and (3) increased empathic communication was associated with lower symptom burden and uncertainty for all patients (χ2(139) = 307.33, p < .001; RMSEA = .063 (CI .053, .072); CFI = .966; SRMR = .057). Treatment status moderated these relationships (Δχ2 = 264.07, Δdf = 138, p < .001) such that the strength of the relationship between uncertainty and psychological adjustment was stronger for former patients than for current patients.
Conclusions:
Results of this study reinforce the importance of perceptions of provider empathic communication as well as the potential benefits of eliciting and addressing patient uncertainty about treatment and prognosis throughout the cancer care continuum.
Practice implications:
Patient uncertainty should be a priority for cancer-care providers both throughout and post-treatment for breast cancer patients.
Effective communication between the doctor and the patient is considered the core element within the clinical care setting, as it can contribute to greater understanding of medical information, resulting in a significant level of engagement, awareness, general competence, and empowerment of the individual, which is personally involved in the decision-making process. From this perspective, the doctor-patient relationship may have significant implications on health outcomes and medical care. Here, we begin by providing a brief overview of the main interpersonal communication skills and contexts in which the doctor-patient relationship occurs. We will continue by summarising the most significant changes in the doctor-patient relationship over the last few decades, as well as the main theoretical models implicated. The rest of the chapter will focus on social cognition (a complex set of mental abilities) with reference to the Theory of Mind (ToM) and Empathy, highlighting the human disposition to mentalize and the ability to attribute mental states to oneself and others, which is necessary at all stages of the care processes. Finally, we will discuss the brain areas activated and implicated in response to the patients’ needs and possible future directions.KeywordsDoctor-patient relationshipTheory of mindEmpathyCommunicationClinical care
Deel 3 behandelt de vragen die AIOS huisartsopleiding hebben over verschillende aspecten van empathie. In verschillende focusgroepen tijdens onze studie kwamen deze vragen aan de orde. Soms waren ze heel praktisch inhoudelijk, soms meer beschouwend. Elk onderdeel van dit hoofdstuk start met een quote van een AIOS, waarna de vraag die deze daarin stelt wordt beantwoord.
Doctors and patients rely on verbal and nonverbal resources to co-construct clinical empathy. In language-discordant consultations, interpreters’ communicative actions might compromise this process. We aim to explore doctors, patients, and professional interpreters’ perspectives on their own and others’ actions during their empathic interaction in interpreter-mediated consultations (IMCs). We analyzed 20 video stimulated recall interviews with doctors, patients, and interpreters using qualitative content analysis. Doctors and patients found ways to connect with each other on the level of empathic communication (EC) that is not limited by interpreters’ alterations or disengaged demeanor. Some aspects of doctors and interpreters’ professional practices might jeopardize the co-construction of EC in IMCs. The co-construction of EC in IMCs is not only subject to participants’ communicative (inter)actions, but also to organizational and subjective factors. These results provide evidence of the transactional process between the behavioral, cognitive, and affective components of clinical empathy in the context of IMCs.
OBJECTIVE
To determine if clinician experience influenced the euthanasia rate in 2 common surgical emergencies.
ANIMALS
142 dogs with nontraumatic hemoabdomen (NTH) due to suspected ruptured splenic mass and 99 dogs with gastric dilatation-volvulus (GDV) where the owner either elected surgery or euthanasia.
PROCEDURES
Medical records were reviewed for dogs that had either NTH or GDV. For each patient, the owner’s decision to pursue euthanasia versus surgery was recorded. The primary clinician was categorized as an intern, defined as a clinician with < 12 months experience, or a non-intern, defined as a clinician with more than 12 months experience. The euthanasia rates were compared used a Fisher exact, and the 95% CI was calculated for the risk of euthanasia if the primary clinician was an intern compared with a non-intern. If a difference was identified, subgroups comparing time of day, referral status, age, Hct, total solids, lactate, and heart rate were evaluated using a t test with a Bonferroni correction for the continuous variables and a Fisher exact for categorical variables.
RESULTS
For dogs with NTH, the euthanasia rate for cases primarily managed by non-interns (52%) was significantly lower than that of interns (76%; P = .005). The relative risk of euthanasia associated with NTH when the case was treated by an intern was 1.44 with a 95% CI of 1.1229 to 1.8567. For 99 dogs with GDV, the rate of euthanasia was not different between interns and non-interns.
CLINICAL RELEVANCE
The euthanasia rate for dogs with NTH may be impacted by the level of experience of the clinician. Support of new clinicians during challenging conversations should be provided.
The World Health Organization's (WHO) open‐source learning platform, OpenWHO, allows diverse audiences worldwide to access self‐paced, asynchronous online courses based on WHO technical expertise and guidance. In addition, the platform emphasizes equitable access to learning by aiming to remove barriers. All OpenWHO courses are therefore provided free of charge and in low‐bandwidth friendly, downloadable, and offline formats. This paper explores differences in access to online learning across learner demographics, namely gender, country income status, and preferred language. The evidence presented is derived from surveys and statistical data extracted from the OpenWHO platform. It advocates for the importance of offering courses in non‐time‐bound formats that address the relevant diseases, outbreaks, and challenges of affected communities. Doing so is vital to ensure the broadest possible and most equitable access to learning, according to learners' availability and preferred media, languages, and health topics.
Background:
Compassion in healthcare provides measurable benefits to patients, physicians, and healthcare systems. However, data regarding the factors that predict care (and a lack of care) are scattered. This study systematically reviews biomedical literature within the Transactional Model of Physician Compassion and synthesizes evidence regarding the predictors of physician empathy, compassion, and related constructs (ECRC).
Methods:
A systematic literature search was conducted in CENTRAL, MEDLINE, PsycINFO, EMBASE, CINAHL, AMED, OvidJournals, ProQuest, Web of Science, and Scopus using search terms relating to ECRC and its predictors. Eligible studies included physicians as participants. Methodological quality was assessed based on the Cochrane Handbook, using ROBINS-I risk of bias tool for quantitative and CASP for qualitative studies. Confidence in findings was evaluated according to GRADE-CERQual approach.
Results:
One hundred fifty-two included studies (74,866 physicians) highlighted the diversity of influences on compassion in healthcare (54 unique predictors). Physician-related predictors (88%) were gender, experience, values, emotions and coping strategies, quality of life, and burnout. Environmental predictors (38%) were organizational structure, resources, culture, and clinical environment and processes. Patient-related predictors (24%) were communication ease, and physicians' perceptions of patients' motives; compassion was also less forthcoming with lower SES and minority patients. Evidence related to clinical predictors (15%) was scarce; high acuity presentations predicted greater ECRC.
Discussion:
The growth of evidence in the recent years reflects ECRC's ongoing importance. However, evidence remains scattered, concentrates on physicians' factors that may not be amenable to interventions, lacks designs permitting causal commentary, and is limited by self-reported outcomes. Inconsistent findings in the direction of the predictors' effects indicate the need to study the relationships among predictors to better understand the mechanisms of ECRCs. The current review can guide future research and interventions.
Background and objectives:
The Women's Wellness through Equity and Leadership (WEL) program was developed as a collaboration between 6 major medical associations in the United States. The goal was to contribute to the creation of equitable work environments for women physicians. The purpose of the current study was to evaluate the pilot implementation of WEL.
Methods:
Participants included a diverse group of 18 early career to midcareer women physicians from across medical specialties, 3 from each partner organization. WEL was developed as an 18-month program with 3 series focused on wellness, equity, and leadership and included monthly virtual and in-person meetings. After institutional board review approval, a mixed-methods evaluation design was incorporated, which included postseries and postprogram surveys and in-depth telephone interviews.
Results:
Participants delineated several drivers of program success, including peer support and/or networks; interconnectedness between the topics of wellness, equity, and leadership; and diversity of participants and faculty. Areas for improvement included more opportunities to connect with peers and share progress and more structured mentorship. Regarding program impact, participants reported increased knowledge and behavior change because of their participation.
Conclusions:
This longitudinal, cohort initiative resulted from a successful collaboration between 6 medical associations. Evaluation findings suggest that providing opportunities for women physicians to connect with and support each other while building knowledge and skills can be an effective way to advance wellness, equity, and leadership for women in medicine.
This study examines concerns within the field of occupational therapy on the growing disconnect between the profession’s roots and espoused beliefs in empathic-centered care, and the modern realities of health care. In particular, the study examined whether the empathy levels of occupational therapy students would change after a course involving the close reading of literary narratives. Close reading of literary narratives has correlated with improved levels of empathy. Empathy is defined as a four-step dynamic process involving Theory of Mind (ToM), emotional resonance, emotional regulation, and empathy as a willful act. Initial study of the proposed curriculum found improved scores on the Jefferson Scale of Empathy (JSE) between pre and post-test class surveys, and no difference between pre and post-test surveys of the Reading the Mind in the Eyes Test (RMET). The JSE and RMET measures aspects of ToM, emotional resonance and empathic regulation. The outside factors of gender, education, GPA, and novels did not play a consequential role in the findings. Limitations in the study included mid-course changes in the curriculum design due to the COVID-19 pandemic. In particular, the change from in person to a strictly online recorded format. Another limitation was the potential influence of social desirability on student self-reported levels of empathy. Implications of the study are a call for an ongoing dialogue and proposed curriculum to meet occupational therapy’s espoused values within the modern demands of healthcare.
Background
Effective patient provider communication skills can be difficult and time‐consuming to teach. Deliberate practice of communication skills through improvisational theatre exercises, with structured debriefing, can provide a solution for teaching patient‐centred communication skills in time‐limited settings. The objective of this study was to determine if improvisational theatre exercises improved the ratings of patient satisfaction and empathetic communication by standardised patients.
Methods
This was a randomised controlled trial looking at the effect of improvisational theatre exercises on ratings of patient satisfaction and empathetic communication. Third‐year medical students (n = 188) participated in a formative team‐based standardised patient (SP) experience. Prior to the SP experience, teams of students were randomly assigned to receive a 45‐minute communication‐focused improvisation intervention (immediately before the SP experience) or to a control arm without intervention. All teams then participated in the SP experience; the SPs (blinded to team randomisation assignment) then assessed each team's empathetic communication and completed patient satisfaction questions focused on physician behaviours derived from Press GaneyTM and the Hospital Consumer Assessment of Healthcare Providers and System SurveysTM. Fifty teams of three or four students participated; 20 teams in the intervention arm and 30 teams in the control arm.
Results
Student teams in the improvisation intervention group had increased measures of empathetic communication (p = 0.04) compared to the control group. The intervention group had increased patient satisfaction survey ratings of ‘ability to listen carefully’ (p = 0.001) and of ‘physician skills’ compared to control groups (p = 0.03).
Discussion
Improv exercises with students increased students’ empathetic communication and patient satisfaction as assessed by standardised patients.
Communication skills are teachable and learnable skills, which have a vital position among other clinical skills because a student's ability to communicate can increase empathy. Empathy scores tend to be higher for women than for men. The focus of this article is to determine how senior students evaluate themselves regarding communication competence and whether gender has an impact on their perception. The study included 128 volunteering students, using the Communication Competence Scale, consisting of 30 questions, as a data collection tool and the independent samples t-test for statistical evaluations. The evaluation of all participants showed that male participants had the highest score, and female participants had the lowest. However, there was no statistically significant difference between female and male participants' total scores (p = 0.605). There was a statistically significant difference between female and male students in terms of the social competency, empathy, and adaptability. Female scores for empathy were statistically higher than those of males. Male students scored themselves higher than females in terms of social competency and adaptability. In the context of the students' perceptions of their communication competence, it was determined that women assessed themselves to be more empathetic and men perceived themselves to be more social and adaptable. This research is significant as it is the first study of Turkish veterinary students' self-perception of communication competence. Communication training may become more robust in veterinary curricula in Turkey, and further research will be affected by this issue.
Objective
To describe and evaluate a consensus finding and expert validation process for the development of patient-centred communication assessments for a national Licensing Exam in Medicine.
Methods
A multi-professional team of clinicians and experts in communication, assessment and role-play developed communication assessments for the Swiss Federal Licensing Examination. The six-month process, informed by a preceding national needs-assessment, an expert symposium and a critical literature review covered the application of patient-centred communication frameworks, the development of assessment guides, concrete assessments and pilot-tests. The participants evaluated the process.
Results
The multiple-step consensus process, based on expert validation of the medical and communication content, led to six high-stakes patient-centred communication OSCE-assessments. The process evaluation revealed areas of challenge such as calibrating rating-scales and case difficulty to the graduates’ competencies and integrating differing opinions. Main success factors were attributed to the outcome-oriented process and the multi-professional exchange of expertise. A model for developing high stakes patient-centred communication OSCE-assessments was derived.
Conclusions
Consensus finding was facilitated by using well-established communication frameworks, by ensuring outcome-orientated knowledge exchange among multi-professional experts, and collaborative validation of content through experts.
Practice implications
We propose developing high-stakes communication assessments in a multi-professional expert consensus and provide a conceptual model.
The relationship between physicians' b]ody movement and judgments of rapport was examined in this study. One-hundred eighteen observers rated physicians' b]ehavior on 14 bipolar scales assessing dimensions of empathy. Physicians' n]onverbal behavior was manipulated so that there were three levels of trunk angle (forward, straight, backward), two levels of arm position (open, folded), two levels of leg position (open, crossed), and two levels of head attitude (nodding, not-nodding). Significant effects were found for trunk angle, head attitude, and arm posture; physicians who leaned forward with open arm positions and nodded their head were judged more positively. Discussion focuses on the reinforcing valuc of nodding, judges' p]erceptions of physicians' a]ccessibility conveyed by trunk and arm postures, and expressions of dominance in physician-patient encounters.
Empirical studies on nonverbal communication in clinician—patient interaction are reviewed for both the psychotherapeutic and medical settings. Nonverbal behavior is considered both as the consequence of antecedent variables, such as individual or relationship characteristics, and as a predictor of clinical effectiveness and patient outcomes. The concept of rapport is considered in relation to nonverbal behavior, both theoretically and empirically. Also, the relevance of a patient's nonverbal behavior to the diagnostic goals of the clinical visit is demonstrated by research on nonverbal cues to psychopathology, Type A/B personality, and pain. Although the topic of nonverbal behavior and clinician—patient interaction has had a promising start, much research is still needed, especially that which experimentally manipulates either antecedent variables or nonverbal behavior itself to demonstrate cause and effect relations.
Empathic understanding in practitioner relationships is postulated as necessary for adherence to therapeutic regimens. It is considered to be one of the most important practitioner relationship skills leading ultimately to patient health benefit. Research literature from a wide-range of health disciplines including personality theory, social psychology, psychotherapy, psycho-analysis, and practitioner-patient communication highlights the key role of empathic processes in personal health care. A model of empathic understanding is described which attempts to integrate the substantive findings in the research literature and seeks to generate new ideas for further investigation. The model addresses theoretical relationships between practitioners' empathic understanding, patients' knowledge of their illness and motivation to get better, adherence to treatment advice, and outcome. Recent work on the selection and training of medical and nursing staff in empathic skills is reviewed. A number of areas for future research are outlined including the effect of individual practitioner differences in the components of empathy, empathic compatibility in practitioner-patient dyads, fluctuations in levels of practitioner empathy during long-term care, specific practitioner behaviours which communicate empathy, and the relationship between factors of patient satisfaction and the perception of empathic understanding.
The provision of high quality medical care and the insurance of patient satisfaction depend in part upon the ability and willingness of physicians to establish rapport with their patients and to develop effective physician-patient communication. In this study, patients' overall satisfaction with their physicians' care was assessed in relation to their perceptions of their physicians' (1) proficiency at communicating and listening to details of the illness and medical treatment, (2) capability of providing affective care, and (3) technical competence. Perceptions of physician behaviors were measured by a questionnaire administered to 329 patients of 54 residents in a family practice center. The relationship between the perceptions of patients and their satisfaction with medical care was examined both for the entire sample and among groups of patients with differing demographic characteristics. Results indicate an important link between patients' perceptions of socioemotional aspects of the physician-patient relationship and their reported satisfaction with medical care. Noticeable differences were found to exist in the importance that patients with different demographic characteristics placed on various aspects of their physicians' conduct.
The relation of physician and patient gender to verbal and nonverbal communication was examined in 100 routine medical visits. Female physicians conducted longer visits, made more positive statements, made more partnership statements, asked more questions, made more back-channel responses, and smiled and nodded more. Patients made more partnership statements and gave more medical information to female physicians. The combinations of female physician-female patient and female physician-male patient received special attention in planned contrasts. These combinations showed distinctive patterns of physician and patient behavior, especially in nonverbal communication. We discuss the relation of the results to gender differences in nonclinical settings, role strains in medical visits, and current trends in medical education.
The current literature does not provide an answer to the question, "What prompts patients to sue doctors or hospitals?" Not all adverse outcomes result in suits, and threatened suits do not always involve adverse outcomes. The exploration of other factors has been hampered by the lack of a methodology to contact plaintiffs and elicit their views about their experience in delivered health care. This study employed the transcripts of discovery depositions of plaintiffs as a source of insight into the issues that prompted individuals to file a malpractice claim.
This study is a descriptive series review of a convenience sample of 45 plaintiffs' depositions selected randomly from 67 depositions made available from settled malpractice suits filed between 1985 and 1987 against a large metropolitan medical center. Information extracted from each deposition included the alleged injury; the presence of the question, "Why are you suing?" and, if present, the answer; the presence of problematic relationship issues between providers and patients and/or families and, if present, the discourse supporting it; the presence of the question, "Did a health professional suggest maloccurrence?" and, if yes, who. Using a process of consensual validation, relationship issues were organized into groups of more generalized categories suggested by the data. Answers to the questions, "Why are you suing?" and "Who suggested maloccurrence?" are described.
Problematic relationship issues were identified in 71% of the depositions with an interrater reliability of 93.3%. Four themes emerged from the descriptive review of the 3787 pages of transcript: deserting the patient (32%), devaluing patient and/or family views (29%), delivering information poorly (26%), and failing to understand the patient and/or family perspective (13%). Thirty-one plaintiffs were asked if health professionals suggested maloccurrence. Fifty-four percent (n = 17) responded affirmatively. The postoutcome-consulting specialist was named in 71% (n = 12) of the depositions in which maloccurrence was allegedly suggested.
In our sample, the decision to litigate was often associated with a perceived lack of caring and/or collaboration in the delivery of health care. The issues identified included perceived unavailability, discounting patient and/or family concerns, poor delivery of information, and lack of understanding the patient and/or family perspective. Particular attention should be paid to the postadverse-event consultant-patient interaction.
To formulate an empirically derived model of empathic communication in medical interviews by describing the specific behaviors and patterns of interaction associated with verbal expressions of emotion.
A descriptive, qualitative study of verbal exchanges using 11 transcripts and 12 videotapes of primary care office visits to a total of 21 physicians.
An urban health maintenence organization (HMO), an urban university-based general medicine clinic, and an urban community hospital general medicine clinic. ANALYTIC METHOD: Individual review of transcripts by each research team member to identify instances of expressed or implied emotional themes and to observe the physicians' responses. Individual ratings were compared in group discussions to achieve consensus about the classifications. Similar consensus-based classification was used for review of videotapes.
We observed that patients seldom verbalize their emotions directly and spontaneously, tending to offer clues instead. If invited to elaborate, patients may then express the emotional concern directly, and the physician may respond with an accurate and explicit acknowledgment. In most of the interviews, the physicians allowed both clues and direct expressions of affect to pass without acknowledgment, returning instead to the preceding topic, usually the diagnostic exploration of symptoms. With emotional expression so terminated, some patients attempted to raise the topic again, sometimes repeatedly and with escalating intensity. We noted a parallel dynamic for encounters in which patients sought praise. We summarized the full interactional sequence in a simple descriptive model.
This empirically derived model of empathic communication has practical implications for clinicians and students who want to improve their communication and relationship skills. Based on our observations, the basic empathic skills seem to be recognizing when emotions may be present but not directly expressed, inviting exploration of these unexpressed feelings, and effectively acknowledging these feelings so the patient feels understood. The frequent lack of acknowledgment by physicians of both direct and indirect expressions of affect poses a threat to the patient-physician relationship and warrants further study.
To examine the association of physician sex, medical specialty, and year of graduation from medical school with attitudes and behaviours that define physician-patient relationships. Hypotheses tested are that women physicians, family physicians, and recent graduates spend more time discussing lifestyle and general health issues during patients' first visits; are more likely to report behaviours that are empathetic and that encourage communication with patients; are less likely to view their role as directive and problem-oriented; and are more supportive of patients' rights to information and participation in decision making.
A survey was mailed to a stratified random sample of physicians between February and June 1996.
Physician practices in Ontario.
Of 714 practising Ontario physicians, 405 (57%) responded.
Proportion of time and actual time spent discussing a patient's lifestyle during a first visit, communication style, attitudes regarding a directive approach to care, and attitudes regarding patients' rights.
Women physicians and family physicians spent significantly more time discussing lifestyle during a first visit. Women, family physicians, and recent graduates were significantly more likely to report an empathetic communication style. Women and recent graduates were significantly less likely to have a directive, problem-oriented approach to care. Family physicians were significantly less supportive of patients' rights than medical and surgical specialists were.
Physicians in this study reported empathetic communication styles and attitudes that support information sharing and patients' rights.
Patients often present clues (direct or indirect comments about personal aspects of their lives or their emotions) during conversations with their physicians. These clues represent opportunities for physicians to demonstrate understanding and empathy and thus, to deepen the therapeutic alliance that is at the heart of clinical care. A paucity of information exists regarding how physicians address the psychological and social concerns of patients.
To assess how patients present clues and how physicians respond to these clues in routine primary care and surgical settings.
Descriptive, qualitative study of 116 randomly selected routine office visits to 54 primary care physicians and 62 surgeons in community-based practices in Oregon and Colorado, audiotaped and transcribed in 1994.
Frequency of presentation of clues by patients during office visits, nature (emotional vs social) and content of clues, and nature of physician responses to clues, coded as positive or missed opportunity.
Fifty-two percent and 53% of the visits in primary care and surgery, respectively, included 1 or more clues. During visits with clues, the mean number of clues per visit was 2.6 in primary care and 1.9 in surgery. Patients initiated approximately 70% of clues, and physicians initiated 30%. Seventy-six percent of patient-initiated clues in primary care settings and 60% in surgical settings were emotional in nature. In surgery, 70% of emotional clues related to patients' feelings about their biomedical condition, while in primary care, emotional clues more often related to psychological or social concerns (80%) in patients' lives. Physicians responded positively to patient emotions in 38% of cases in surgery and 21% in primary care, but more frequently they missed opportunities to adequately acknowledge patients' feelings. Visits with missed opportunities tended to be longer than visits with a positive response.
This study suggests that physicians in both primary care and surgery can improve their ability to respond to patient clues even in the context of their busy clinical practices. JAMA. 2000;284:1021-1027
For everyday hurts and hassles, the informal communicative assistance one receives from the network of personal relationships can be effective at helping one overcome various forms of distress. This chapter discusses the features of more and less effective comforting messages; reviews the appraisal theories of emotion focusing particularly on how affective distress is conceptualized by appraisal theories; and then presents a reformulation of the comforting process from the perspective of appraisal theory, specifying how supportive conversations can assist distressed persons in coping with their emotions. Analyses of emotional distress, the comforting process, and, especially, psychological effects of comforting efforts can be developed most productively in the context of appraisal theories of emotion. Associated with each particular emotion is a core relational theme, a specific appraisal pattern, and a distinct action tendency. The chapter also describes how a variety of conversational behaviors and message strategies can help accomplish critical functions in constituting and conducting effective supportive interactions.
Context Patients often present clues (direct or indirect comments about personal
aspects of their lives or their emotions) during conversations with their
physicians. These clues represent opportunities for physicians to demonstrate
understanding and empathy and thus, to deepen the therapeutic alliance that
is at the heart of clinical care. A paucity of information exists regarding
how physicians address the psychological and social concerns of patients.Objectives To assess how patients present clues and how physicians respond to these
clues in routine primary care and surgical settings.Design, Setting, and Participants Descriptive, qualitative study of 116 randomly selected routine office
visits to 54 primary care physicians and 62 surgeons in community-based practices
in Oregon and Colorado, audiotaped and transcribed in 1994.Main Outcome Measures Frequency of presentation of clues by patients during office visits,
nature (emotional vs social) and content of clues, and nature of physician
responses to clues, coded as positive or missed opportunity.Results Fifty-two percent and 53% of the visits in primary care and surgery,
respectively, included 1 or more clues. During visits with clues, the mean
number of clues per visit was 2.6 in primary care and 1.9 in surgery. Patients
initiated approximately 70% of clues, and physicians initiated 30%. Seventy-six
percent of patient-initiated clues in primary care settings and 60% in surgical
settings were emotional in nature. In surgery, 70% of emotional clues related
to patients' feelings about their biomedical condition, while in primary care,
emotional clues more often related to psychological or social concerns (80%)
in patients' lives. Physicians responded positively to patient emotions in
38% of cases in surgery and 21% in primary care, but more frequently they
missed opportunities to adequately acknowledge patients' feelings. Visits
with missed opportunities tended to be longer than visits with a positive
response.Conclusion This study suggests that physicians in both primary care and surgery
can improve their ability to respond to patient clues even in the context
of their busy clinical practices.
Although considerable research indicates that both functional communication skills and prosocial behaviors increase across childhood and adolescence, relatively few studies have examined developmental and individual differences in the prosocial communication skill of comforting. The present study examines relationships among age, social‐cognitive development, and comforting skill and investigates how these relationships change over the course of development. Assessments of several social‐cognitive indices and the use of listener‐sensitive comforting strategies were obtained from 137 students enrolled in grades one through 12. All of the social‐cognitive indices were moderate to strong predictors of comforting skill, and remained moderate predictors even when controlling for the effects of age. Each of the indices made an independent contribution to the prediction of comforting skill. Moreover, the relationship between social‐cognitive ability and comforting skill apparently is contingent on age; social‐cognitive ability became an increasingly strong predictor of comforting skill with advancing age. Contrary to expectations, the relationship between age and comforting skill was found not to vary over the course of childhood and adolescence.
Background: Empathy has long been thought to be an important characteristic of a good physician, and a measure of empathy is needed to provide feedback to medical students, residents, and physicians on this important aspect of their clinical performance. The standardized-patient-testing format provides a simple but intuitively convincing approach to the assessment of empathy. Purpose: To determine the extent to which 4th-year medical students were checked "empathic" by standardized patients (SPs) on a performance-based examination, to evaluate the psychometric properties of this simple empathy measure, and to see whether empathy was related to clinical performance on history taking and physical examination. Method: Analyses were performed on examination data for 1,048 senior medical students in the 8 member schools of the New York City Consortium tested at The Morch and Center of Mount Sinai School ofMedicine. Results: The percentage of students who were checked "empathic" ranged from 59% to 98% (M = 79%) across the 7 SP cases. Of the 1,048 students, 268 (26%) were checked "empathic" on all 7 cases; however, 221 (21%)were checked on ≤4 cases, 90 (9%)on ≤3 cases, and 26 (3%)on ≤2 cases. The generalizability coefficient of the overall empathy scores was. 43; the dependability index with cutoff was. 81 for detecting students checked "empathic" on fewer than half of the 7 cases. The correlations of the empathy item with the other checklist items suggest that the empathy construct refers to behaviors that make the patient feel comfortable and important. Also, students who were checked "empathic" on fewer than half of the 7 cases performed lower on history taking and physical examination. Conclusions: Empathy appears to be reasonably acceptable in this sample of students, although it is of concern that, on average, more than 200 students per case were not seen as empathic, and more than 200 were checked "empathic" on ≤4 of the 7 cases. These results show the potential usefulness of this simple measure of empathy and illustrate the need for feedback to address any problems.
This chapter provides an overview and integration of what we know about human emotion and features of effective comforting messages in order to suggest how the two are linked. The first section of the chapter summarizes the results of several streams of research examining the features of more and less effective comforting messages. Next, we provide an extended discussion of appraisal theories of emotion, focusing particularly on how affective distress is conceptualized by appraisal theories. We then present a reformulation of the comforting process from the perspective of appraisal theory, specifying how supportive conversations can assist distressed persons in coping with their emotions. Finally, we describe how a variety of conversational behaviors and message strategies can help accomplish critical functions in constituting and conducting effective supportive interactions, detailing some of the mechanisms through which these behaviors and strategies may work. We conclude the chapter by elaborating some implications of our analysis for future empirical work examining the comforting process. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This . . . volume focuses on interdisciplinary approaches to understanding the process, structure, and function of communication in support and helping relationships. Researchers present diverse perspectives showing how support is co-constructed between providers and recipients. Unique in its approach, chapters examine functional and dysfunctional patterns involved in the communication of support, and offer both scholarly and applied audiences an understanding of social support as a communication process grounded in ongoing relationships.
"Communication of Social Support" is [intended] for anyone studying or working in social support environments and a valuable text for courses in social psychology, social interaction, personal relationships, interpersonal communication, communication theory, and related areas. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The E4 model for physician-patient communication is presented with specific techniques for implementing the model. Derived from an extensive review of the literature on physician-patient communication, the model has proved to be a useful tool in workshops for and coaching of physicians regardless of specialty, experience or practice setting. Information on how to obtain descriptive materials about the workshop and an annotated bibliography is included.
To determine the effectiveness of teaching interpersonal skills in a general internal medicine residency, a program was developed utilizing videotape feedback of house-staff/patient interactions, a modification of Interpersonal Process Recall (IPR). Fifty-one randomly selected house officers at different levels of training were included in a controlled, pretest-posttest study design. The major pre-post measures were three independent ratings of videotapes of actual first-visit interviews between resident and patient. House officers in the experimental group significantly increased the proportion of each interview devoted to psychosocial issues compared with controls, although the interviews remained predominantly medical; increased the use of effective responses; and improved their level of empathy with patients. Personality and attitude measures were found not to correlate with observed interpersonal skills on pretest or posttest videotapes. House officers rated the training program as being interesting, valuable, relevant, and nonthreatening. The data suggest that interpersonal skills can be effectively taught to internal medicine residents utilizing a videotape feedback training program.
Research has indicated that patients are greatly concerned about the poor quality of doctors' interpersonal communication skills, but such training is infrequently incorporated into medical education. An experimental study, which used a commercially available training programme, is described. Undergraduate medical students were the subjects of the study, and their ability to empathize was assessed in the actual interview. Results indicated that training was effective in increasing the students' levels of empathy.
This empirical study was designed to test the effects of a systematically designed training program intended to help medical students develop empathic responses to patients and to attend not only to disease symptoms but also to the patient as a unique individual with a disease symptom. This training was meant not to enable the student to conduct a complete medical interview but to facilitate initial rapport between the student and his patient. The subjects in this study were 43 medical student volunteers, 20 of whom received the training while 23 served as a control group. The experimental group, following training, was found to function at a significantly higher empathy level than the control group. The participants also were significantly more able to attend to the patient with a medical problem, while the control group response remained predominantly an impersonal discussion of the medical problem only.
Recent advances in educational theory and methodology have made it possible to teach medical interviewing with as much rigor as other clinical skills. We describe a firstsemester, first-year medical student course that effectively teaches basic interviewing skills. This course provides faculty development, small group learning, detailed faculty and student coursebooks, and an interview checklist that delineates specific interviewing skills and content areas, serving as a template for teaching, practice, and feedback. Students have many opportunities for practice in role play and with patients, followed by feedback by self, peers, and faculty. Use of audiotape and videotape reviews enhances the learning experience. This article describes our course, suggests educational principles and standards for the teaching of medical interviewing, and presents educational research demonstrating significant gains in students' skills associated with improvement in standardized patient satisfaction.
(Arch Intern Med. 1992;152:1814-1820)
To study the differences between cognitive and noncognitive skills of men and those of women entering internal medicine.
Comparison of program directors' ratings of overall clinical competence and its specific components and pass rates for men and women taking the Certifying Examinations in Internal Medicine in 1984-1987.
14,340 U.S. and Canadian graduates taking the Certifying Examinations of the American Board of Internal Medicine for the first time in 1984-1987.
Average program directors' ratings of overall competence were 6.70-6.78 for men and 6.60-6.71 for women. The greatest differences in ratings of specific components of competence were in the areas of medical knowledge and procedural skills, where men were rated higher than women, and humanistic qualities, where women were rated higher than men. Pass rates were stable over the four years of the study, and ranged from 85 to 86% for men and from 79 to 81% for women. Men consistently performed slightly better than women regardless of the type of residency or quality of medical school attended.
Small but consistent differences were found in the performances of men and those of women completing training in Internal Medicine as measured by program directors' ratings and ABIM Certifying Examination performances.
A new instrument to elicit patients' appraisals of physician performance has been developed from a previously-derived taxonomy of desired physician attitudes and behavior. The instrument allows patients to give ratings for their physicians' discrete, observable items of behavior, and also for complex, multidimensional attributes. When the instrument was administered to 131 randomly chosen medical inpatients, the results showed that technical competence and interpersonal (or humanistic) qualities were equally valued, and that physicians received high ratings for most features of performance. Except for less satisfaction in younger patients, clinical and demographic characteristics had little impact on the ratings. The performance characteristics of the instrument appear satisfactory, and its potential applications and proposals for further research are discussed.
Despite criticisms of the quality of health care for women and considerable research on sex differences in illness behavior and utilization of health services, little research has addressed the potential impact of physician gender on the physician-patient relationship and its outcomes. With the entry of more women into the medical profession, opportunities to investigate effects of physician gender will increase. A theoretical rationale for expecting physician gender to affect the key dimensions of the interactive physician-patient relationship (communication of information, affective tone, negotiative quality) and its outcomes (satisfaction, compliance, health status) is presented. Physician gender might impact on the relationship through three mechanisms: sex differences among physicians, particularly with respect to sex-role attitudes; patients' different expectations of male and female physicians; or increased status congruence between physician and patient in same-sex, as compared to opposite-sex, physician-patient dyads. Recent research related to these topics is discussed and found to support the plausibility of these mechanisms of potential gender effects. Some methodological suggestions for future research are presented, including the suggestion that future research identify specific conditions under which physician gender effects might be more salient.
Empathy is an important skill for the medical practitioner or medical students to develop when interviewing patients. It helps the interviewer establish effective communication, which is important for accurate diagnosis and patient management. Two facets of medical education limit students' development of accurate empathy: the traditional format of interviewing training and the social ethos of medical training and medical practice, which stress clinical detachment. A number of researchers and educators have developed consulting skills training programmes, designed to enhance students' empathic skills and ability. One difficulty for researchers has been the conceptual complexity of the term ‘empathy’ and greater difficulty in measuring the dimension.
This paper reviews the range of approaches to the measurement of empathy and reports on a research study designed to evaluate a two-stage measurement technique, involving a pencil-and-paper test of empathy and independent observer ratings of medical students' actual interview behaviours. Results lead to the conclusion that pencil-and-paper tests of empathy cannot incorporate the range of complex cognitive, emotional and behavioural components of the empathy construct. On the other hand, trained observers have been able to use items on a specially developed History-taking Rating Scale to discriminate between the empathic behaviours of a group of students trained in consulting skills with those of a group of control students who each carried out videotaped history-taking interviews with hospitalized patients.
Empathy is a process for understanding an individual's subjective experiences by vicariously sharing that experience while maintaining an observant stance. It is a useful tool in the medical encounter as it provides the physician with a fuller, more personalized view of the patient, and it provides the patient with a sense of connectedness to the physician that may allow him/her to more freely express his/her emotional distress. The roots of empathy are explained as a process that evolves from a developmental substrate with the addition of relevant experience, memory, and fantasy. While understanding the patient alone is a worthwhile goal, the physician's empathic insight can have therapeutic impact by its reflection back on the patient, through the use of language, to express support or sympathy, to justify behavior, or to foster deeper emotional expression.
(Arch Intern Med. 1993;153:306-312)
While the literature shows the clinical value for medical practitioners of skill in communicating with patients in an empathetic manner, objective evaluations of methods to teach empathy are few.
This paper describes a method of teaching entry-level medical students the elements of effective communication with patients, in preparation for their first practical exercises. The paper focuses on how the outcomes of the teaching were evaluated with special attention to empathy.
Student evaluative ratings were collected after training, and students also completed a pencil-and-paper test of empathy, both before and after the training. While all data were anonymous, student pre- and post-training empathy scores could be compared to assess individual changes in knowledge of empathy after training.
Most students (81%) felt better prepared to interview after the training. The pencil-and-paper measure of empathy has good reliability, both internal (alpha 0.83 and 0.91) and inter-rater (kappa 0.96). Overall, students made significant gains in their ability to make empathetic responses, although some (30%) showed no gains.
Further research is required to identify students who fail to acquire skill in expressing empathy after undergoing training, and to validate the pencil-and- paper measure of empathy against real-life performance.
This study introduces, profiles, and tests the explanatory value of reliance, a construct that emerged from, and is expected to illuminate, consideration of perceived control in medical encounters. The investigation also links communication science with the truly interactive perspective of reciprocal determinism, highlighting the impact of personal relations and the significance of perceived control. Data from 271 encounters between general practitioners and patients in Oxford (England) were collected by means of videotapes, patient questionnaires, medical record reviews, and physician questionnaires. The analysis indicates that physician-reliant patients (i.e., those who rely on physicians to make decisions for them) tend to be older and from a more working-class background than were self-reliant patients (i.e., those more interested in participating in choices about their health care). The physician-reliant patients also had more externally oriented outcome expectations and tended to see physicians more often than did their self-reliant counterparts. In addition to defining reliance at the conceptual and operational levels, this study provides preliminary evidence that reciprocal determinism is operating in medical encounters: Despite their preference for patients who feel in control of their health, physicians tended to adapt to patients' reliance orientation, sharing decisions with self-reliant patients and making decisions for physician-reliant patients. Accommodating the passive orientation of physician-reliant patients is likely to diminish patients' chances for maintaining control in the medical encounter, which has implications for health outcomes, cost, and compliance.
This article examines uses and characteristics of the SEGUE Framework, a research-based checklist of medical communication tasks. A recent survey of US and Canadian medical schools indicates that the SEGUE Framework is the most widely used structure for communication skills teaching and assessment in North America. Student and faculty response to the SEGUE Framework as a teaching tool has been positive. Data drawn from clinical skills assessments with standardized patients provide evidence of concurrent and construct validity. Analysis of visits between general internists and their patients reinforces validity of the SEGUE Framework in an actual practice setting. Interrater reliability is high when standardized patients are recording student performance immediately after a live encounter, and when coders are evaluating videotaped or audiotaped encounters; intrarater reliability is strong as well. The SEGUE Framework has a high degree of acceptability, can be used reliably, has evidence of validity, and is applicable to a variety of contexts. Studies of predictive validity are needed.
Physician gender has been viewed as a possible source of variation in the interpersonal aspects of medical practice, with speculation that female physicians facilitate more open and equal exchange and a different therapeutic milieu from that of male physicians. However, studies in this area are generally based on small samples, with conflicting results.
To systematically review and quantify the effect of physician gender on communication during medical visits.
Online database searches of English-language abstracts for the years 1967 to 2001 (MEDLINE, AIDSLINE, PsycINFO, and Bioethics); a hand search was conducted of reprint files and the reference sections of review articles and other publications.
Studies using a communication data source, such as audiotape, videotape, or direct observation, and large national or regional studies in which physician report was used to establish length of visit, were identified through bibliographic and computerized searches. Twenty-three observational studies and 3 large physician-report studies reported in 29 publications met inclusion criteria and were rated.
The Cohen d was computed based on 2 reviewers' (J.A.H. and Y.A.) independent extraction of quantitative information from the publications. Study heterogeneity was tested using Q statistics and pooled effect sizes were computed using the appropriate effects model. The characteristics of the study populations were also extracted.
Female physicians engage in significantly more active partnership behaviors, positive talk, psychosocial counseling, psychosocial question asking, and emotionally focused talk. There were no gender differences evident in the amount, quality, or manner of biomedical information giving or social conversation. Medical visits with female physicians are, on average, 2 minutes (10%) longer than those with male physicians. Obstetrics and gynecology may present a different pattern than that of primary care, with male physicians demonstrating higher levels of emotionally focused talk than their female colleagues.
Female primary care physicians engage in more communication that can be considered patient centered and have longer visits than their male colleagues. Limited studies exist outside of primary care, and gender-related practice patterns in some subspecialties may differ from those evident in primary care.
A meta-analytic review was undertaken of seven observational studies which investigated the relation between physician gender and patient communication in medical visits. In five of the studies the physicians were in general practice, internal medicine, or family practice and were seeing general medical patients, and in two of the studies the physicians were in obstetrics-gynecology and were seeing women for obstetrical or gynecological care. Significant findings revealed that, overall, patients spoke more to female physicians than to male physicians, disclosed more biomedical and psychosocial information, and made more positive statements to female physicians. Patients also were rated as more assertive toward female physicians and tended to interrupt them more. Several results were weaker, or even reversed, in the two obstetrics-gynecology studies. Partnership statements were made significantly more often to female than male physicians in general medical visits but not in obstetrical-gynecological visits.
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Comforting as social support: relational consequences of supportive behaviors
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