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ORIGINAL RESEARCH PAPER
Year : 2008  |  Volume : 21  |  Issue : 2  |  Page : 144

Differences between Emergency Patients and Their Doctors in the Perception of Physician Empathy: Implications for Medical Education


1 School of Medicine, Fu-Jen Catholic University, Hsinchuang, Taipei, Taiwan
2 Department of Emergency Medicine, Catholic Mercy Hospital, Taiwan
3 Graduate Institute of Health Allied Education, National Taipei College of Nursing, Taipei, Taiwan

Date of Submission29-Nov-2007
Date of Acceptance03-Jul-2008
Date of Web Publication23-Aug-2008

Correspondence Address:
C-S Lin
No. 365, Min Te Road, 11257 Taipei
Taiwan
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Source of Support: None, Conflict of Interest: None


PMID: 19039746

  Abstract 

Context and Objectives: Conveying empathy is a multi-phase process involving an inner resonation phase, communication phase, and reception phase. Previous investigations on physician empathy have focused on a physician's inner resonation phase or communication phase and not on the patient's reception phase. The purpose of this study was to investigate the differences in the perception of physicians' empathy between emergency physicians (EPs) and their patients. The answer to this question will allow us to more fully understand all phases of empathy and will help guide the teaching of how to effectively communicate empathy in the clinical setting.
Methods: From 2004 to 2005, we conducted in-depth, semi-structured interviews with 7 each of EPs, patients, patients' family members and nurses. A phenomenological approach was used to analyze the data.
Results: Four themes emerged from the analysis: (1) When patients expressed their feelings, EPs usually did not resonate with their concerns; (2) Patients needed EPs to provide psychological comfort, but EPs focused only on patients' physical discomfort; (3) Patients needed appropriate feedback from EPs, but EPs did not reflect on whether their patients had received empathy from them; (4) EPs' ability to empathize was affected by environmental factors, which EPs found difficult to overcome.
Conclusion: EPs and their patients perceive the physicians' empathy differently. These findings provide insights into patients' perceptions of their physicians' empathic expressions and provide a framework for teaching physicians how to convey empathy in the emergency department setting.

Keywords: Empathy, physician-patient relations, medical education


How to cite this article:
Lin CS, Hsu MYF, Chong CF. Differences between Emergency Patients and Their Doctors in the Perception of Physician Empathy: Implications for Medical Education. Educ Health 2008;21:144

How to cite this URL:
Lin CS, Hsu MYF, Chong CF. Differences between Emergency Patients and Their Doctors in the Perception of Physician Empathy: Implications for Medical Education. Educ Health [serial online] 2008 [cited 2020 Aug 8];21:144. Available from: http://www.educationforhealth.net/text.asp?2008/21/2/144/101572

Introduction



One of the main objectives of medical education is the cultivation of altruistic behavior in physicians (Medical School Objectives Writing Group, 1999), and empathy is considered to be a precursor of altruistic behavior (Halpern, 2001). Development of empathy is a multi-phase process rather than a single event (Benbassat & Baumal, 2004). During a clinical encounter a physician can develop a good rapport with the patient and understand the patient’s concern, and then effectively convey this understanding to the patient so that the patient is aware of and receptive to the physician’s empathy. In other words, empathy involves an inner resonation phase within the physician, a communication phase wherein the physician conveys their empathic feelings to the patient, and a reception phase in which the patient recognizes the physician’s expression of empathy (Barrett-Lennard, 1981). When assessing a physician’s ability to empathize, each of these phases should be measured.



Previous research on physicians’ empathy has focused on the physician’s inner resonation and communication phases and has not addressed the patient’s reception phase (Shapiro, 2002; Hojat et al., 2005). When clinical teachers look to the findings of these studies to guide how they teach empathy as part of the medical curriculum, there is no information available to indicate how physicians can best express empathy to meet the needs of patients and their family members. Furthermore, available studies have been conducted in classroom settings and outpatient clinics (Mangione et al., 2002; Deloney & Graham, 2003), whereas other clinical settings can affect how physicians are able to express their empathy (Bennett, 1995). Studies have shown that when empathy is expressed by physicians in the emergency department (ED) setting and patients’ needs are heeded, patients, in turn, express higher satisfaction with care and voice fewer complaints (Taylor et al., 2002; Sinclair et al., 2006). To date, there is no consensus on how to teach empathy in the ED setting. From 2004-2005, we carried out a study to address the following question: Do EPs and their patients differ in how they perceive the physicians’ empathy? Answering this question will allow us to more fully understand all phases of empathy and should help guide the teaching of empathy within the emergency setting.



Methods



Design



A qualitative study approach was used with in-depth semi-structured interviews conducted with EPs, patients, patients’ family members and nurses, to investigate differences between EPs and their patients in the perception of the EPs’ empathy. A phenomenological approach was used because it is useful for understanding human experience and is particularly useful in assessing phenomena such as values, beliefs, and emotions (Wimpenny & Gass, 2000).



Settings



The study took place in the EDs of three hospitals in Taiwan. One hospital is a medical center affiliated with the Taipei Medical School with 600 beds, approximate 55,000 ED visits per year and ten EPs. The two others are district general teaching hospitals, with 250 and 300 beds, approximate 25,000 and 35,000 ED visits per year and four and six EPs respectively.



Sample



Eligible patients were those who were deemed clinically stable by EPs, were able to articulate clearly and could therefore relay their experiences, and agreed to an audio taped-interview. Patients were selected only after physicians had examined them and just prior to being either discharged or transferred to medical wards. EPs were not aware before the clinical encounters who would be interviewed for this study. The interview sequence was the patient, the patient’s family member, the EP, and then the nurse. These four members constituted an interview group. Each member of the group was interviewed individually by one of the investigators (Lin CS), who is an emergency physician with 15 years of clinical experience. The interview content was kept confidential from other group members. We included family members and nurses because they are integral to the interactions between patients and physicians and their observations can provide an independent perspective. Three groups were interviewed at the medical center, and two groups were interviewed in each of the two district general hospitals, for a total of seven groups. The seven EPs were males aged from 35 to 45 years (M = 40, SD = 4), clinical experience of between 9 and 17 years (M = 10, SD = 3) and all are attending physicians. The only communication skills training these EPs received was from their medical school and residency years: no further training in this area was provided in relation to this study. The seven nurses were females aged from 25 to 42 years (M = 29, SD = 6), and clinical experience of between 2 and 21 years (M = 7, SD = 2). The patients consisted of 4 females and 3 males with ages ranging from 38 to 75 years (M = 63, SD = 15): one received care in emergent triage, and two each in semi-urgent, urgent and non-urgent care settings. The seven family members were females aged from 28 to 50 years (M = 38, SD = 9).



Data Collection



This study received approval from the institutional review boards of the three hospitals to conduct a study involving human subjects. The purpose and the procedure were explained to the interviewees, and the interview was conducted only after they had provided written consent. Participants were asked to describe how the EP expressed empathy during the clinical encounter and their opinion of the manner of expression by EPs. Questions included: (1) How did the EP feel after he listened to the patient’s concerns? (2) How did the EP express his understanding of the patient’s concerns? (3) How did the patient feel about the EP’s empathy? (4) How did the patient give feedback to the EP? (5) If this encounter were to start all over again, how should the EP improve the communication? Appropriate changes were made in the phrasing of the questions to reflect the role differences of the interviewees. Question 1 was directed only to physicians and question 3 was directed to patients, while all interviewees were asked the remainder of the questions. The duration of the interviews ranged from 40 to 60 minutes. After the interview, the results were provided back to the participants in summary fashion for confirmation and any additions and clarifications.



Data analysis



All audiotapes were transcribed verbatim. Each transcript was compared with the audiotape and corrected when necessary and returned to all members of each interview group to check for accuracy. Three physicians returned the transcripts with minor corrections; others made no alterations.



The transcripts were analyzed by one of the investigators (Lin CS) using Giorgi’s four-step analysis method, selected for its congruence with Husserl’s approach to phenomenology (Husserl, 1965; Giorgi, 1989). Details of Giorgi’s method, as used, are outlined below. First, the investigator endeavored to bracket his own knowledge of empathy to maintain a neutral attitude, and then read all the transcripts to gain a global feeling and understanding of the content. Second, after obtaining a sense of the whole, the investigator reread the transcripts comparing responses to the same question posed to EPs, patients, families, and nurses within each group, then underlining meaningful sentences and inscribing the interpretation of the interviewees’ statements on both sides of the margins. Thirdly, the investigator extrapolated common meanings and identified initial themes, to ensure that the essence of the interviewees’ experiences was captured within the themes. Finally, the meanings and themes were transformed into a structural description of the interviewees’ experiences.



Results



Using the above framework, four themes emerged from the analysis of the interview transcripts: (1) When patients expressed their feelings, EPs usually did not resonate with their concerns; (2) Patients needed EPs to provide psychological comfort, but EPs focused only on patients’ physical discomfort; (3) Patients needed appropriate feedback from EPs, but EPs did not reflect on whether their patients had received empathy from them; (4) EPs’ ability to empathize was affected by environmental factors, which EPs found difficult to overcome (Table 1).



Table 1:  Themes and Interview Data







When patients expressed their feelings, EPs usually did not resonate with their concerns



Regarding patients’ expression of their feelings, 6 out of 7 EPs indicated that they did not have any emotional reactions to patients’ situations. One EP said that: “I could feel a patient’s worries but emotionally was not affected by this.” The attitude of EPs towards empathy was “to take a neutral stand to understand the patient but remain detached from their worries.” In addition, because “the chief complaints of patients are generally similar,” EPs felt that they already knew “what they [patients] want,” therefore EPs did not resonate with each individual patient.



Patients needed EPs to provide psychological comfort, but EPs focused only on patients’ physical discomfort



All the physicians interviewed indicated they often express empathy which focuses on the patient’s illness and not on their psychological needs. For example, one physician said, when he was asked how he expressed his understanding of the patient’s concern, “I will first ask about his medical condition, his current condition, where he is not feeling well, and whether this has happened before.” One nurse noted that physicians “usually do a good job at assessing illness, but very few assess psychological needs of the patients.”



However, with a physician-centered communication method, patients usually expressed their physical discomforts such as “difficulty in breathing,” “pain,” or “cough,” with little or no expression of their psychological issues. One patient described the situation as “I just answered what he asked. I had no opportunity to say anything about special feelings.” Another patient said if a physician only expressed his concern about the patient’s illness, the patient would feel that the physician only understood “70-80%” of the patient.



Patients needed appropriate feedback from EPs, but EPs did not reflect on whether their patients had received empathy from them



After a physician had expressed his understanding of the patient’s concerns, a patient would sometimes give feedback to the physician. EPs usually responded to patients’ feedback with a “smile”, or “thanking the patient.” They seldom used reflective thinking to evaluate the feedback from the patient to assess if they had satisfied the patient’s needs.



When a patient felt that the physician did not understand his/her feelings, he/she would respond negatively, for instance by complaining directly to the physician. Some patients indicated that they might not complain for fear of offending the physician. They would “repeatedly ask similar questions”, indicating to the physician that he/she still did not understand the patient, therefore requiring further attention from the physician. One patient wished “the doctor had asked me more questions about whether I had other areas of discomfort or difficulties”. One family member said that: “Chinese are usually quite reserved and afraid to ask questions. When the doctor or nurse sees that the patient still has other worries or questions, they should actively inquire whether there are other areas they can assist the patient with”.



EPs’ ability to empathize was affected by environmental factors, which EPs found difficult to overcome



There are many aspects of the ED setting that can affect EPs’ abilities to empathize. Delays in the workflow, such as in the assignment of the patient to a treatment area, ordering of tests and transfer to the ward, can affect the evaluation of a physician’s empathy by the patient. One patient stated her experience that “ED situation is different. There is always the wait. You wait for the tests. You wait for the transfer to the ward.” “I hope EPs can pay more attention to expressing empathy to patients under such situations.” One physician admitted reluctantly that “we cannot compare Taiwan’s health care system with those abroad. Each of us has to take care of too many patients, making it impossible to have detailed conversation with the patients. In other countries, you may have a longer chat with patients, but we cannot do this here.”



In spite of these hindrances, a physician can still seek the assistance of health care team members or family members to compensate for the shortage of time. One nurse believed that “nurses also need to have empathy because ED work is team work. This is different from hospital wards where there is a clear delineation of responsibilities between nurses and doctors.” One physician recounted how he comforted a patient through a family member as follows: “After learning the necessary information about the patient from a family member, I asked the person to convey to the patient that I was doing something to help him, that I hope he will cooperate with us so that he can feel better soon”



Discussion



The ability of medical students to empathize often declines as they progress through the medical school curriculum from preclinical training through clinical clerkships (Hojat et al., 2004). This decline is a source of concern for medical educators because humanistic attitudes are important components of patient care. Some studies have found that role modeling is principally used to teach empathy to physicians (Shapiro, 2002), but a recent review found that students sometimes choose the wrong role models (Benbassat & Baumal, 2004).



We studied how EPs expressed empathy utilizing the perspectives of the patients, family members, and nurses. The findings provide insights regarding the feelings of patients and suggest a framework for teaching empathy to EPs. To meet the expectations of patients, teaching empathy in ED settings can be approached at the environmental and individual physician levels (Table 2). Methods to overcome environmental barriers include involving the health care team and improving ED efficiency. Individual physician training should include instruction to understand physician attitudes, and in reflective thinking. These aspects are discussed in more details below in relation to clinical teaching.



Table 2:  Teaching of Empathy in Emergency Department Settings







Most EPs in this study took a neutral stance towards the feelings of their patients. They did not resonate with patients’ feelings when faced with commonly seen medical conditions. A physician’s expression of empathy, theoretically, is influenced by two factors (Davis, 1994). The first factor is the physician’s empathic resonation, which helps create an emotional link between the physician and patient that leads to the development of empathy and its expression (Halpern, 2001). Unfortunately, traditional medical training only requires physicians to be able to carry out their clinical duties without expecting them to share the feelings of their patients (Blumgart, 1964; Branch, 2001). Some physicians believe that without empathic resonation, they can concentrate their treatment efforts on clinical tasks and avoid distraction and clinical errors. There is no evidence to support the belief that avoiding empathy lessens errors (Halpern, 2001). The second factor is the magnitude of the patient’s situation and how this affects the physician. The more tragic the patient’s situation, the stronger the empathy elicited in the physician. From a clinical teaching viewpoint, situational factors come from the patient’s narrative and are not under the physician’s control, therefore it cannot be changed through physician education. On the other hand, a physician’s empathic resonation can be changed through multiple educational strategies. These include establishing a climate of humanism and teaching by the use of seminal events and role modeling, actively engaging learners, and using situations and approaches that are practical and relevant (Branch, 2001).



Patients expect physicians to possess the appropriate communication skills to express their empathy and satisfy both their physical and psychological needs (Shapiro, 2002). Most EPs in this study, however, focused their expression of empathy mainly on the patients’ physical illness and suffering, which is not the only thing patients need. In fact, the provision of emotional support is one of the main reasons patients seek help in the ED, an aspect generally ignored by the health care staff (Barsky, 1981). Based on our findings, the training of physicians in communication skills should include instruction in the cognitive ability to identify patients’ psychological concerns, in addition to looking after their physical suffering (Taylor et al., 2002).



A patient may provide positive or negative feedback to a physician’s expression of empathy, and the physician should use reflective thinking to understand this feedback. Our data show that physicians used nodding or verbal thanking to respond to patients but did not reflect on whether their patients had understood their empathy. In order to help patients best, physicians should use self-reflection to assess their way of expressing empathy and to gain a better and deeper understanding of their patients (Egan, 2006). Educators should strengthen the training of EPs so that they learn how to assess their own expressions of empathy and make any necessary changes.



Environmental factors within the ED setting can also affect EPs’ abilities to empathize. These factors include long waiting room time and long lengths of stay within the ED. Previous research on empathy has generally been in the psychotherapy field and has ignored these extrinsic environmental factors (Baillie, 1996). If a physician wishes to express empathy effectively, these challenging environmental interferences must be managed. This study suggests that involving other health care team members, such as nurses, can be helpful because these others can obtain information on how patients are feeling when the physician is too pressed for time to do so (Sinclair et al, 2006). Textbooks on medical communication skills typically emphasize only the physicians’ individual skills and attitudes while ignoring the potential contribution of care teams (Nestel & Tierney, 2007). In teaching clinical empathy, the curriculum should not overlook the principles of the team approach to care as a means to overcoming the competing demands on EPs’ time.



There are two principal limitations to our study. First, there are potential biases introduced by the gender composition of our study sample. All the physicians interviewed were male and all family members were female. We do not know, therefore, the views on physician empathy held by female physicians and male family members. The EP specialty was established in Taiwan in 1997. By 2008, there were 1080 registered EPs, of which only 49 (4.5%) were female (Taiwan Society of Emergency Medicine, 2008). In addition, in oriental culture females tend to family affairs, including health care issues, whereas men typically look after affairs outside the family. Consequently, it is difficult to gather information from family members of both genders. Secondly, even though we have provided a framework for teaching empathy to EPs based on our data, it remains to be tested whether employing this will improve relationships between EPs and patients. Furthermore, more studies are needed to understand if patients have different needs for empathy from physicians of other specialties. These are areas for future studies.



Acknowledgement



We thank Robert M.K.W. Lee, Ph.D., McMaster University, Canada, for assistance with manuscript development and English revision; Cheng-Yao Liu, MD, Department of Emergency Medicine, Taipei Medical University Taipei Municipal Wan Fang Hospital; and Yu-Chun Yang, MD, Department of Emergency Medicine, Cathay General Hospital, Hsinchu, for assistance with data collection. This study was supported by the School of Medicine, Fu-Jen Catholic University.



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