US researchers studying doctors and surgeons treating lung cancer patients found they missed most opportunities to respond empathically in consultations where their patients expressed worries and concerns about symptoms, treatment options and death.
The study was the work of Dr Diane Morse, assistant professor of psychiatry and of medicine at the University of Rochester Medical Center, New York, and colleagues, and is published on 22 September in the Archives of Internal Medicine.
Empathy is where a person shows they identify with and understand what another person is going through. For example, “that must have been difficult”, in response to a terminally ill patient saying “I told my family about it yesterday”, is empathic. Studies have shown patients are more satisfied with their treatment and are more likely to follow their doctor’s advice when he or she is empathic.
Morse and colleagues analysed 20 recorded and transcribed consultations from a larger observational study of 137 patients.
The patients were consulting with thoracic surgeons and oncologists at a Veterans Affairs hospital in the southern United States for surgical diagnoses of lung cancer or a pulmonary mass.
As Morse explained:
“When patients are struggling and bring up important issues, doctors don’t have to take a lot of time to address them, but they do need to respond. Showing that they understand and giving their patients more of what they need is not that difficult.”
Morse said the study illustrates the kinds of opportunities that doctors and surgeons could learn to recognize. These are chances to express understanding and support, and the responses required to do that can be brief and do not make consultations last longer.
Morse and colleagues used a qualitative analysis method where several researchers analyse themes and subthemes across the conversations, then go back and code the transcripts by looking for agreed types of opportunities to intervene empathically. The results are then cross-checked among the analysers until they reach consensus. The particular qualitative analysis system they used is called “grounded theory”.
They found that the physicians routinely failed to give emotional support to their patients because they did not recognize many opportunities to respond and possibly ease the worries and concerns they expressed.
The results showed a number of subthemes, for example regarding patients’ statements about lung cancer there were concerns about morbidity or mortality, symptoms, relationship to smoking, treatment options, beliefs about and mistrust of medical care, treatment limitations, and confusion about status and treatment of the condition.
The researchers found 384 “empathic opportunities” where physicians could have or did respond, but they only did so in 10 per cent (39) of them.
Most of the time the physicians did not provide emotional support and shifted instead to “biomedical questions and statements”, said the researchers, who described these events as missed opportunities for “interval empathy”.
The analysis also revealed that 50 per cent of the empathic responses occurred in the last third stage of the encounter, whereas the rate of concerns expressed by the patients occurred evenly throughout.
One example of a missed opportunity to pick up on a patient’s worry about life expectancy was given in this extract of a consultation:
Patient: “I don’t know what the average person does in just two year, three years, a year?”
Physician: “I think that . . . you certainly could live two or three years. I think it would be very unlikely . . . But I would say that an average figure would be several months to a year to a little bit more.”
The physician appears to have missed the opportunity to say something like “This must be very difficult for you”.
Another transcript demonstrated a missed opportunity to acknowledge a patient’s regret about smoking, with the physician shifting abruptly to a “biomedical question”:
Patient: No, sir, I’ve never had a heart attack, Supposedly, I worked very hard when I was a young man, a young boy. I was doing a man’s labor and I was always told I had a good strong heart and lungs. But the lungs couldn’t withstand all that cigarettes . . .
Physician: Yeah.
Patient: Asbestos and pollution and second-hand smoke and all these other things, I guess.
Physician: Do you have glaucoma?
The researchers concluded that:
“Physicians rarely responded empathically to the concerns raised by patients with lung cancer, and empathic responses that did occur were more frequently in the last third of the encounter.”
“Our results may provide a typologic approach to help physicians recognize empathic opportunities and with further development may aid in improving physicians’ communication skills,” they added.
Morse and colleagues sugggested that physicians should be more empathic earlier in the relationship, especially with patients who have a life-threatening illness. Validating patient’s needs and concerns and finding ways to build understanding were important. It does not need a heavy touch, a light touch with a simple expression of “It sounds like you are very concerned about that” is often enough to start building understanding.
Morse said their findings were consistent with other studies that showed many doctors and surgeons in many types of settings rarely express empathy. Perhaps because they are so busy with different tasks and they avoid expressing empathy because it is not easy to respond to fears and concerns about mortality. There could be complex issues involved, not just to do with finding the time to gather one’s thoughts and pick an appropriate response, as the researchers explained:
“This difficulty may be related to limited cure potential that results in a sense of failure and/or identification with the patient that is difficult for the physician to acknowledge or express and may raise within the physician awareness of his or her own vulnerability to illness and mortality.”
A coach who trains service professionals in emotional intelligence skills, found that a difficulty that is often expressed, is they find hard to establish empathy while at the same time “delivering” their expertise. They are conscious of time pressure and the need to give the patient the best advice they can.
However, the success of “treatment” is also about the client or patient’s motivation, and this is affected by how they feel about their adviser or physician, for instance whether they can trust them. If you can make your client or patient feel understood, you are going a long way to establishing trust and building a productive collaborative relationship.
“Missed Opportunities for Interval Empathy in Lung Cancer Communication.”
Diane S. Morse; Elizabeth A. Edwardsen; Howard S. Gordon.
Arch Intern Med. 2008;168(17):1853-1858
Vol. 168 No. 17, September 22, 2008
Source: Journal Abstract, University of Rochester Medical Center.
Written by: Catharine Paddock, PhD