Impact of communication training on physician expression of empathy in patient encounters

Abstract

Objective

To examine whether an educational intervention that focused on physician communication training influenced physician empathic expression during patient interactions.

Methods

This study used a quantitative research method to investigate the influence of communication training on physician-expressed empathy using two measures (global and hierarchical) of physician empathic behavior.

Results

The differences in global empathy scores in the physician training group from baseline to follow-up improved by 37%, and hierarchical scores of physician empathic expression improved by up to 51% from baseline scores for the same group.

Conclusions

The results strongly supported the hypotheses that training made a significant difference in physician empathic expression during patient interactions demonstrated by both outside observer measures of global ratings and hierarchical ratings of physician empathic behavior.

Practice implications

These findings have significant implications for program design and development in medical education and professional training with the potential to improve patient outcomes.

Introduction

Health outcomes are associated with the human connectedness between patients and their physicians [1], [2], [3]. Although measuring the degree of connectedness that patients feel with their physicians presents a methodological challenge for researchers, physician empathy has been identified as one of the most essential relational elements valued by patients [1], [4]. Caring, as demonstrated by physician-expressed empathy, is considered a core and teachable communication skill. Despite the evidence demonstrating the high value placed on physician empathy by patients, studies document that this element is often lacking in medical encounters [5], [6].

A 2001 consensus statement produced by experts and authorities in medical education delineated a coherent set of essential elements based upon the premise that “a strong, therapeutic relationship is the sine qua non of physician–patient communication” p. 391 [7]. These essential elements, an integration of fundamental aspects of communication models [8], [9], provided a coherent framework for training and assessment and listed rapport-building and trust as primary skills [10]. Yet research studies have indicated that physicians acknowledge a gap in communication skills training particularly in managing emotional and behavioral reactions of patients [11], [12].

The impetus for this study was the dearth of evidence of how an educational intervention for physicians enhances the likelihood that they will respond effectively to empathic opportunities in their patient interactions. There are limited research studies of physician behavior using multiple measurements with an intervention such as communication training to evaluate the specific question of whether empathy can be taught [12], [13], [14], [15], [16], [17], [18]. Using observational data collected from a randomized controlled trial of a physician communication training intervention, this research investigated whether the intervention improved physician empathic expression.

To address this question, we utilized observational measures of expressed empathy that included assessment of the frequency and nature of physician empathic responses to empathic opportunities presented by patients. The investigators hypothesized that the training intervention would significantly increase physician expression of empathy when compared to the control condition.

The Institute of Medicine Report on Health Professions and Training [19] called upon educators and licensing organizations to strengthen physician and health professional training requirements in the delivery of patient-centered care. The patient-centered care model [20] underscores the essential features of the physician–patient relationship. This model of care relies heavily on core communication skills, such as open-ended inquiry, reflective listening and empathy, as a way to respond to the unique needs, values and preference of individual patients [21].

Empathy is considered essential to quality medical care [22]. A 2002 meta-analysis of medical interactions in primary care found that physician empathic appreciation of the patient's situation was linked with increased patient satisfaction, adherence, patient comprehension, and patient perception of a good interpersonal relationship [23]. Other research has supported the contention that physician-expressed empathy enhances the quality and quantity of clinical data [24], promotes patient satisfaction [25], reduces malpractice risk [26], and leads to improved patient health status [2], [27], [28].

Despite significant evidence suggesting that empathy is a core skill for physicians and that its expression is most valued by patients [1], [7], [29], [30], [31], most doctors fail to effectively exhibit empathy toward their patients. Levinson et al. [6] found that physicians responded to patients’ emotional clues in only 21% of primary care and 38% of surgical cases; they also frequently missed opportunities to acknowledge the patient's actual feelings. The literature suggests there are specific physician behaviors, both verbal and nonverbal, that increase the probability that a patient will perceive the physician as caring [23].

Recent research has begun to examine the extent to which patients present opportunities to physicians to communicate empathically [6], [32], [33], [34], [35] and how physicians respond to those opportunities. Several studies have investigated the outcomes of missed patient emotional cues during the medical encounter [12], [36]. For instance, Easter and Beach [37] found that 70% of physician opportunities to address patients’ emotional cues were missed among residents in first-visit oncology interviews. Bylund and Makoul [34] reported that the majority of patient consultations include one or more empathic opportunities as previously reported in the literature [6], [32], [35]. Levinson et al. [6] identified patient clues as direct and indirect comments where the patients communicated personal aspects of their lives and emotions and reported that physicians frequently missed opportunities to adequately acknowledge and address those clues. Medical consultations with adverse outcomes are frequently characterized by unvoiced patient concerns and agenda items [5]. Further, when physicians frequently interrupt, it often results in patients’ failure to disclose important problems and concerns [24], [38].

Previous evaluation studies of the impact of communication training on physician empathy have not provided sufficient methodology to adequately study how empathic communication occurs between physician and patient. Many studies of physician communication behaviors, including those that investigated physician empathy, used single evaluation measures such as physician self-report, a method found to be often inaccurate in assessment of physician communication behaviors [13], [14], [15]. Further, the literature lacked an adequate intervention study of physician empathy using large datasets, multiple measurements, and actual medical encounters that have taken place over time before and after a medical education intervention.