Gathering the Patient’s Story and Clinical Empathy

Gathering the Patient’s Story and Clinical Empathy

Jodi Halpern, MD, PhD

Winter 2012 - Volume 16 Number 1

http://dx.doi.org/10.7812/TPP/11-107

While nothing replaces meeting with a patient, reading another physician's description of interviewing a patient can provide insights into physician-patient interactions that we cannot get when we ourselves are involved. In my view, "A Case of Baffling Fatigue with a Spectral Twist" illustrates clinical empathy in action. Often confused with compassion, sympathy, and other benevolent emotions, clinical empathy involves emotional resonance, but is distinguished by curiosity. Whereas sympathy involves feeling as if one were "in the same boat" with another, empathy involves curiosity about another's distinct experience. Vividly and specifically imagining another's distinct world becomes possible with careful, attuned listening.

Until the past two decades, physicians (unlike other caregivers) have been skeptical about empathy, assuming that it would interfere with their clinical objectivity and effectiveness. This has shifted as research has shown that empathy plays a fundamental role in both diagnostic accuracy and treatment effectiveness. Repeated studies show that patients first give superficial clues about their histories until they sense empathy, and only then disclose anxiety-provoking information (as happened in the reported case).1 Such disclosure is crucial for making the correct diagnosis. Empathy is also important for establishing trust, and trust is a powerful determinant of adherence to treatment and thus effectiveness of care.2 Even when clinicians need to deliver bad news, their empathic engagement matters, empowering patients to take earlier steps in organizing treatment and self-care.3

Clinicians today want to provide empathic care, but are unsure of just what actions they are supposed to incorporate into their daily practice. Since we cannot just will ourselves to feel certain emotions, what needs to be taught are specific skills or approaches that engender empathy. One of the best studies thus far suggests that one way to "practice" empathy is to learn to help patients tell their stories, exactly as Kate Scannell, MD, does here.4 However, readers may wonder how Dr Scannell connects so well with this patient, enabling him to share his story. What specific skills or lessons can we glean from Dr Scannell's approach?

First, she is genuinely curious about the patient. This requires tolerating uncertainty, so that when the data points don't connect, Dr Scannell is intrigued rather than frustrated. Further, rather than defensively presuming that the patient is either "a poor historian" or worse, covering up or faking something, she assumes that "we physicians [are] inaccurately pinpointing the patient's story." So she meets the patient with empathic curiosity rather than suspicion.

Second, we might borrow her way of framing her interview with the patient. She asked him to tell her what had happened "from his beginning of the story, to his thoughts about its imagined end." Many of us occasionally ask the patient for his/her beginning, but we should do so more often. Not only does this provide information about symptoms that pre-exist medicalization, but the patient's subjective reconstruction of the past also helps us to understand what motivates him/her, which is crucial for building a therapeutic alliance.

Asking for the patient's imagined view of the end of the story is rarely done, and strikes me as a crucial innovation that we should all adopt. Dr Scannell describes beautifully how we can learn of the patient's "projections or fears—illness expressions that you can sometimes trace back to inchoate somatic murmurings in the present that translate into useful clues." This patient mentions his father, long dead.

What happens next is crucial. Dr Scannell does not challenge the patient on the facts, but rather invites him to tell her how his father looks in his imagined future. This is the gateway to his sharing his experience of ghosts, of needing the lights on and never sleeping. Insofar as empathic listening is an act of imagining, not an exercise in deductive reasoning, inconsistencies and irrationalities are crucial clues, rather than errors to be corrected.

Importantly, what invites this frightened patient to share this information is not just Dr Scannell's lack of suspicion and criticism. It is her positive presence. Her question about his father is followed by a long silence before the patient shares highly private thoughts. What is this silence like for the physician and for the patient?

Dr Scannell, like other very busy clinicians, finds it hard to wait and not interrupt. In reality, given the severe time constraints most physcians operate under, letting a patient talk without interruption might seem impossibly demanding. Despite some research studies showing that good communication can often be achieved in a time-efficient way,5 patients like Mr Gee clearly take more time to interview than current systems of care allow. Current systems are shortsighted to put clinicians under so much time pressure that listening to patients with complex histories becomes impossible. Careful listening not only directly improves patient satisfaction and effective care, it might actually save overall time by preventing conflicts and misunderstandings down the line.

Dr Scannell shows how patient listening contributes to history taking. She stays quiet to "cultivate a comfort zone for me and my patient … an opportunity for me to rest meditatively—if only for a minute—in my immediate experience of doctoring and relationship." Being calm and truly present with the patient is a powerful way to establish a therapeutic alliance. Taking a quiet moment is especially valuable for highly caring clinicians, who are more likely to become anxious when seeing patients whose treatment is not going well, which can interfere with empathy.6 Research shows that pausing and taking a breath decreases clinicians' anxiety and improves communication.7

How did the patient experience the silence? Research shows that patients judge the trustworthiness of the clinician on the basis of their nonverbal attunement or lack thereof. Being silently present with the patient as Dr Scannell describes is a good example of nonverbal attunement. Interrupting at such moments, in contrast, has repeatedly been shown to cut off patient disclosure. Assuming that Dr Scannell's facial and other gestures conveyed to the patient that she was present and not just spacing out, the patient is likely to have felt accompanied by her during the silence. Patients appreciate it when they feel a sense of "being with" their caregivers.

There are other specific lessons from Dr Scannell: ask the patient to restate medical terms in his or her own words, and ask them to describe medical procedures they do at home. In this case, for example, the patient tells her that he doesn't actually measure his blood pressure, so we realize that his description of blood pressure going up to "200 or more" is meant to describe the boiling up of intolerable feelings of guilt, fear, and anxiety.

In summary, empathic communication can be enhanced by specific practices, many of which are illustrated in this case report. When possible, invite the patient to tell you his or her own story, from its beginning to its imagined ending. Try to pause when the patient is obviously processing an emotional issue. Practice patience by becoming more aware of your own embodied reactions, and if you feel anxious, take breaths or otherwise relax yourself, to give the patient the message you are truly present and not in a rush. Your tone and gestures will convey your genuine emotional resonance, but be wary of making overreaching statements like: "I know how you feel." When a patient says something contradictory or seemingly irrational, avoid correcting him or her and ask instead, "Tell me what I'm missing?"

Beyond all these suggestions, cultivate an overarching attitude of engaged curiosity. This involves recognizing that patients bring in complex histories that we often misunderstand, and that we truly need to listen to their accounts to help us help them. Crucially, empathic curiosity is not the curiosity of a detective. Patients will not tell their stories if they feel barraged, or under an inquisition. Thus clinicians need to be mindful of their own emotional responses, and take quiet moments when necessary, so that they can be truly present and nonverbally attuned to their patients.

References
1.    Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA 1997 Feb 26;277(8):678-82.
2.    Roter DL, Hall JA, Merisca R, Nordstrom B, Cretin D, Svarstad B. Effectiveness of interventions to improve patient compliance: a meta-analysis. Med Care 1998 Aug;36(8):1131-61.
3.    Ptacek JT, Ptacek JJ. Patients' perceptions of receiving bad news about cancer. J Clin Oncol 2001 Nov 1;19(21):4160-4.
4.    Charon R, Wyer P; NEBM Working Group. Narrative evidence based medicine. Lancet 2008 Jan 26;371(9609):296-7.
5.    Langewitz W, Denz M, Keller A, Kiss A, Rüttimann S, Wössmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ 2002 Sep 28;325(7366):682-3.
6.    Halpern J. Empathy and patient-physician conflicts. J Gen Intern Med 2007 May;22(5):696-700.
7.    Halpern J. Empathy in clinical practice. In: Decety J, ed. Empathy: From bench to bedside (Social Neuroscience). Cambridge, MA:MIT Press; 2011. p 229-244.

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