In this set of encounters, physicians rarely responded empathically to statements of patients with lung cancer regarding morbidity or mortality, symptoms, or treatment limitations. We found numerous missed opportunities to recognize and possibly to ameliorate patients’ concerns.1–4
When physicians offered empathic responses, half occurred in the latter third of these encounters, notwithstanding the presence of opportunities throughout the encounters. Physicians seemed more likely to offer an empathic response when the patient was lamenting a difficulty with the health system or a difficulty making decisions about treatment. In addition, we found that physicians’ empathic responses occurred in similar proportions with both black and white patients, but that oncologists were more likely than surgeons to give an empathic response to an empathic opportunity. Nonetheless, our data add to a growing literature that physicians’ use of empathy in medical encounters is limited. Furthermore, our data suggest that empathic responses can be brief and may not notably lengthen encounters, and if empathic opportunities are not addressed, physicians will get another chance and sometimes several more chances to respond empathically. We suggest that particularly when communicating with patients who have a life-threatening illness, physicians consider providing empathy earlier and at intervals throughout the encounter (interval empathy) to explore and validate patients’ needs and concerns and build understanding to allow progressive establishment of rapport and trust. Effective handling of empathic opportunities can include phrases such as: “I can imagine how difficult that is,” “Sounds like what you’re telling me is …,” or “It sounds like you were really frightened when you got that news about the cancer.”24
Our findings are consistent with results of other studies1–4,10,18,25
that have reported that primary care physicians, oncologists, and surgeons infrequently use empathic responses. Nevertheless, it is surprising that our data had a lower frequency of empathic responses (10%) to clues from patients with a life-threatening cancer compared with those of prior studies of empathy provided by primary care physicians (21%), oncologists (22%), and surgeons (38%).2,10,18
In particular, our data had a lower frequency of empathic responses from surgeons than these other studies reported. Our data also indicated that empathic clues during the beginning and middle of the encounter were less likely to be addressed. It is possible that a low frequency of empathic responses early in the encounter, perhaps when they are most valuable and when relationship-building is thought to occur, is associated with patient production of empathic clues later in the encounter as patients continue to seek validation and support.26
Overall, physicians’ low rate of response to empathic opportunities by patients in this study seems to represent a pattern in which physicians provide too little empathy, too late in the encounter.
Physicians may not respond empathically to the empathic opportunities presented by their patients for a number of reasons. First, in a busy clinic, physicians may believe that there is no time for empathic responses. Our data and those from other studies suggest that patients did not respond excessively when empathy was provided and suggest that visits with missed opportunities may be longer than visits with an empathic response.2,4,5
Second, physicians may not recognize empathic opportunities, perhaps because they are busy attending to other tasks (eg, diagnosis). Alternatively, physicians may consciously avoid responding empathically to some patient concerns. For example, patients’ morbidity and mortality concerns can be particularly difficult for physicians to address. 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.27–29
Clinicians may manage this sense of failure by blaming patients’ behavior or seeing it as “just” for those who have cancer and other conditions or situations.15,27–33
Conversely, physicians may falsely assume that a long biomedical response is reassuring. Instead, focusing on the patient,34
allowing spiritual and mortality concerns to be voiced (perhaps particularly important for black patients),35
and responding empathically may facilitate patients’ ability to listen to brief biomedical explanations.36
Third, physician burnout and distress has also been associated with decreased provision of empathy; yet, paradoxically, studies37–39
suggest that providing empathy is one way to prevent burnout, reduce physician stress, and make medical practice more rewarding. Finally, physicians may believe that some patients (eg, VA hospital patients, in our study) are stoic and would not welcome empathic responses, hence causing a lower empathic response rate in our study. However, our data suggest that these patients present empathic opportunities at rates similar to those from other studies and responded positively when empathy was provided.
The current study adds to the literature evaluating empathy in physician-patient communication and is one of the first, to our knowledge, to focus on the types of empathy patients produced. Our focus on patients with lung cancer provided a rich sample from which to code patients’ empathic opportunities. In addition, our focus on classifying the empathic opportunities raised by patients differs from many studies and provides a starting typologic approach that, with further development, may assist physicians in identifying patients’ empathic opportunities.
Our results should be interpreted in the context of several limitations. First, because we used transcripts of medical encounters, we were not able to account for nonverbal behaviors (eg, voice tone and body language) that may have communicated empathy. Second, we do not know whether empathic responses are best provided in response to patients’ clues or in response to other opportunities that we did not evaluate (eg, situational opportunities without a patient clue such as cancer, untreatable cancer, or uncertainty). Third, the study was conducted in a selected set of encounters between patients with lung cancer and their physicians at 1 hospital, and the communication behaviors may not generalize to other patients, other physicians at the clinics studied, or to other clinics. Although we believe that empathic responses should respond to patients’ emotional needs, it is possible that patients who have more difficulty expressing emotional responses to taxing diseases such as cancer should receive encouragement to do so from their physician; hence, the need for empathy may be even higher than reflected by the number of empathic opportunities identified in our study.18
Finally, our list of themes and subthemes may not represent fully and may differ in frequency from those of patients with other conditions or in other health care settings.
Our data document limited physician response to empathic opportunities raised by patients, and we define a typologic approach of empathic opportunities that might be an aid to physicians in formulating responses. We suggest the use of interval empathy to respond to empathic opportunities offered by patients periodically throughout the encounter, particularly in encounters with patients with life-threatening conditions who may be most likely to raise multiple empathic opportunities. Use of this communication skill may allow increased understanding and progressive rapport and trust with patients. Fortunately, studies2,4,10,24
indicate that expressing empathy can be taught and that these statements can be brief and powerful, not prolonging the encounter or necessarily changing a physician’s style. Future studies are needed to evaluate from the patients’ perspective which physician behaviors and statements communicate empathy and how these are efficiently applied to build relationships and improve encounters.