Empathy in the Emergency Department

Author: Drew A. Long, BS (@drewlong2232, Vanderbilt University School of Medicine) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

You are nearing the end of your shift, when you see the results of an MRI you ordered for one of your patients near the beginning of the shift.  Mr. Smith, a 65-year-old gentleman with CAD and hypertension, presented with back pain that has been worsening over the past several weeks, associated with left foot drop and paresthesias in the right foot.  While several components of the history were concerning, he was able to ambulate, though L5 on the left was weak and sensory in the right foot and ankle was decreased.  An MRI is obtained, notable for multiple spinal bony metastases of unknown origin.  How do you communicate this result to Mr. Smith and his family?

What is Empathy? 

In the Emergency Department (ED), a physician’s attention is pulled many ways by a continually shifting barrage of tasks that demand our attention.  At the center of this chaotic environment is the patient.  This patient is most likely stressed to be in the ED, frustrated by time spent waiting to be seen, and worried about their medical condition.  As previously stated about a patient entering the ED “every patient suffers some sense of alienation:  catapulted into an unfamiliar world, depersonalized by an unmarked uniform, transformed into an object of scientific and social scrutiny.”¹ In the busyness of the ED, how can an Emergency Physician (EP) successfully build trust and communicate meaningfully to a frightened patient?  Empathy plays a large role in navigating barriers to patient communication and establishing “emergency rapport.”¹

Empathy has been defined many ways.  In a systematic review of empathy in medical literature, Derksen et al. in 2013 defined empathy as “the competence of a physician to understand the patient’s situation, perspective, and feelings; to communicate that understanding and check its accuracy; and to act on that understanding in a helpful therapeutic way.”² This definition employs several concepts including understanding the patient, communicating with the patient, and acting on behalf of the patient.  As opposed to sympathy, empathy employs “compassionate detachment,”^3,4 which maintains objectivity in medical management and has been thought of as a complementary state of separateness and sharing.  Along with this notion, the Society of General Internal Medicine defined clinical empathy as “the act of correctly acknowledging the emotional state of another without experiencing the state oneself.”⁵ As opposed to sympathy, which can potentially impede a physician’s impartiality and judgment, there is no negative effect from too much empathy on the part of the physician.⁶

How does empathy impact patient care? 

Empathy is the cornerstone of the patient-physician relationship and has been shown to have multiple effects.  Jani et al. constructed a model outlining the potential beneficial effects of a physician applying empathic communication, depicted in Figure 1.

Figure 1.  Model for empathic communication⁷

Studies have shown that effects of empathic communication include improvement in patient satisfaction and adherence to the treatment plan; decreased anxiety and patient distress; better diagnostic and clinical outcomes; and increased patient enablement.^8-14  Thompson et al. examined various factors in patient satisfaction during his/her visit to the ED.  They found that patients’ perceptions regarding waiting time, information delivery, and expressive quality were predictive of overall patient satisfaction with their ED visit.¹⁵ Regarding expressive quality, Rosenzweig coined the term “emergency rapport” to describe the working alliance created between the Emergency Physician and the patient.¹ Physicians with high expressive quality are able to quickly develop “emergency rapport” with their patients.  In this study, patients described these physicians as “courteous,” “understanding,” “concerned,” “kind,” and “conscientious.”¹⁵

Emergency Medicine has been associated with a higher risk of litigation than other specialties.¹⁶ Empathy has been linked to a reduction in malpractice litigation.  A recent randomized controlled trial in 2016 by Smith et al. analyzed the role of EP empathy in reducing litigation.¹⁷ They found that the addition of brief empathic statements in an ED discharge scenario decreased thoughts of litigation.

Most professionals in medicine would agree that empathy contributes to overall better patient care.  One reason is that many patients feel more comfortable divulging information to physicians they see as empathic.  This is especially important in Emergency Medicine, where patients withholding information they are ashamed or embarrassed about (such as illicit drug use or risky sexual behaviors) can adversely impact their medical care and complicate their medical course.^18-20

What are strategies in the ED for conveying empathy? 

There are many methods that can be helpful in conveying empathy and establishing “emergency rapport” with patients in the ED.  Whatever a physician’s style in interacting with patients, the importance of listening and genuinely caring about a patient cannot be overvalued!  The patient and family will notice sincere care and consideration on the part of the EP.  The ED is a hectic environment and physicians are often rushing room to room to lay eyes on patients.  It is important for a physician to quiet his/her mind before each patient encounter, to ensure that during each patient encounter they are in the moment, and not thinking about the disposition of the lower GI bleed in the previous room.

There are both nonverbal and verbal strategies effective in promoting empathy in patient interactions.  Various studies have depicted the importance of nonverbal communication.  Nonverbal skills such as body posture and eye contact can improve empathy perceived by patients.^21,22 As may be encountered in the ED, lack of time is a proposed barrier to empathic interaction.⁷ It is vital to not act rushed when interacting with patients (such as glancing at the clock on the wall or your watch, interrupting the patient, etc.).

An aspect of nonverbal communication that has been studied is physician standing versus sitting at the bedside.  Swayden et al. concluded in a randomized-controlled trial that sitting instead of standing increased the patient’s perception of time spent by the physician at the bedside.²³ In this study, patients thought the physician spent an adequate amount of time with them and addressed their questions when he sat, versus seeming hurried and abrupt when he stood in the room.  They concluded, “the patients felt the physician was not rushed when he sat, and that his being physically closer and perhaps making better eye contact increased the empathy he expressed both verbally and nonverbally.”²³

What a physician says to a patient and how he/she says it also is a major determining factor in building emergency rapport.  As everyone was instructed early in medical school, it is helpful to introduce yourself to everyone in the room and identify their relationship to the patient.  In the ED, it shows respect to the patient to thank them for their patience in waiting to be seen and receive medical care.  As Rosenzweig astutely described, “the long wait is difficult, anxiety provoking, demeaning, and reminiscent of sitting outside the principal’s office in the third grade.”¹

It is important to begin each encounter empathically and to set expectations.  For instance, before even beginning to dive into the chief complaint, an empathic word can start to lay the foundation for emergency rapport.  Saying “You look so uncomfortable, what can I do to help?” shows a genuine interest in the patient’s well-being before even beginning to gather the history.  Setting expectations can also be helpful during the initial patient encounter.  In setting expectations, honesty is vital.  Statements such as “We may not be able to get the final answer during this visit” or “we will treat your pain as best we can but we are unlikely to get it to a zero” can prevent the patient from false expectations and subsequently being disappointed or frustrated with the result of his/her visit.^1,24

Several phrases can help convey empathy and caring during the patient encounter.  A group of statements used to show empathy are the NURSE statements, displayed in Figure 2.²⁴ The NURSE statements are geared towards acknowledging and responding to emotions from the patient and family, and can be invaluable in building a therapeutic alliance with the patient.

Figure 2.  NURSE statements.  Data from Rodriguez V.  Communication:  the most valuable palliative care tool.  Available at:  https://www.wuantiamd.com/player/yemuezwgd?cid=1818.  Accessed November 5, 2015; and Back AL.  Approaching difficult communication tasks in oncology.  CA Cancer J Clin 2005;55(3):164-77.  Originally appeared in McEwan A, Silverberg JZ.  Palliative Care in the Emergency Department.  Emerg Med Clin N Am 34 (2016):667-85.

Other empathic statements include “tell me more about…” and “I wish” statements.  Utilizing “I wish” statements conveys that you are on the patient’s side but recognizing the reality of the patient’s current situation.  Another technique that can be useful is the ask-tell-ask technique.  This technique assesses the patient’s understanding of their medical situation, which allows the physician to appropriately communicate necessary information.  The physician can then inquire “what do you think or feel about what I said?”  or “what other concerns or questions do you have?”  This technique can be particularly useful when breaking bad news.

Breaking Bad News

Breaking bad news has traditionally been difficult for both physicians and patients, as physicians are often nervous or afraid to tell the patient bad news.^25,26 However, patients want the truth, even if it is not favorable.  How bad news is communicated can impact the patient’s comprehension of the information,²⁷ satisfaction with medical care,^28,29 hopefulness moving forward,³⁰ and psychological adjustment.^31-33  A technique designed for breaking bad news is the SPIKES protocol,³⁴ which is depicted in Figure 3.

Figure 3.  SPIKES Protocol for Breaking Bad News.  Data from Rodriguez V.  Communication:  the most valuable palliative care tool.  Available at:  https://www.wuantiamd.com/player/yemuezwgd?cid=1818.  Accessed November 5, 2015; and Back AL.  Approaching difficult communication tasks in oncology.  CA Cancer J Clin 2005;55(3):164-77.  Originally appeared in McEwan A, Silverberg JZ.  Palliative Care in the Emergency Department.  Emerg Med Clin N Am 34 (2016):667-85.

In the SPIKES protocol, perception is similar to the “Ask-tell-ask” strategy, in which the physician asks the patient his/her understanding of the medical situation.  Additionally, the EP should ask a patient how much of the information he/she wants disclosed, as a patient may not want to know and may just want his/her family to hear the information, or vice versa.  Simply saying, “I have some information to tell you.  Do you want to hear it, or want everyone in the room to hear?” can ensure the patient’s wishes are fulfilled about how much information he/she knows and who hears the information.

When giving the bad news, it is important to start with a warning shot, to assure you do not drop a bad news bomb on an unsuspecting patient.  For instance, “We were worried about X, which is why we ordered this imaging test.”  When breaking the bad news, start softly:  “I’m sorry to tell you that…” Avoid medical jargon, use terms the patient can understand.  For instance, as opposed to “metastasis,” use “spread.”  It is also helpful to give the information in small chunks and to be as concise as possible to present the information in a manner that is easy to understand.

After delivering the information, it is imperative to be quiet and give the patient a moment to process the information.  The patient will not hear anything else after you break the bad news.  During this pause, it is often appropriate to address the patient’s emotions.  While this is often a difficult time for the patient and potentially uncomfortable for the physician, keep in mind that just being there with them is helpful.  The physician’s presence is often supporting and reassuring.  If appropriate, a hand on the knee or arm can provide additional comfort.  Empathic statements, such as “I can’t imagine how this feels” may be beneficial.

Lastly, it is often beneficial to offer aid and support to the patient’s family.  Caring for sick or dying family members can be exhausting, both physically and emotionally.  It is imperative to check on the family members, especially the primary caregiver.  It shows concern to ask the family member “what can we do for you?” or “how can we help you?”  One of the main tasks of a physician is to provide healing for the patient and their family, and it is important to keep the well being of the family in mind so they can adequately care both for themselves and their loved one.

The Death of Empathy? 

Unfortunately, multiple studies have found that empathy declines significantly during the latter stages of medical school and the beginning of residency.³⁵ Other studies have shown that empathy decreases with fatigue, chronic sleep deprivation, high levels of anxiety, depression, and burnout.^36-38 This is especially concerning in Emergency Medicine, where the burn out rate is particularly high.  Interestingly, high levels of empathy may be protective against burnout. Recognizing and dealing with burnout is of the utmost importance, both for the physician and the patients he/she sees everyday.  For more on burnout and management strategies, go to http://www.rcemfoamed.co.uk/portfolio/the-rules-of-the-house-of-god/

Pearls and Pitfalls

• Burnout is an ever-increasing problem in Emergency Physicians and can adversely impact patient care. Know your limits and know when to seek help.
• While medical knowledge and competence are important, empathy is vital in building emergency rapport with the patient, successfully communicating information, and making the patient feel comfortable telling his/her story.
• The ED is a hectic environment. Be in the moment!  If necessary, quiet yourself before going into the room so you are able to give the patient and their family your full attention.
• Nonverbal communication including good eye contact, nodding, not acting rushed, and sitting down conveys concern for the patient.
• Sitting increases the patient’s perception of time spent by the physician at the bedside, which in turn plays a role in patient satisfaction with his/her visit.
• NURSE statements in addition to “I wish” statements and the ask-tell-ask technique are effective in articulating empathy.
• The SPIKES protocol is a useful guideline for delivering bad news and preparing the patient for the next step of his/her medical journey.

Case Resolution

You return to the room of the 65 y/o gentleman with the MRI showing vertebral metastases.  You quietly close the door behind you, reintroduce yourself to this patient and his family, and pull up a stool next to his bed and take a seat.  You ask about his understanding of his medical condition and why you ordered the imaging of his spine.  After listening, you say, “I have some information regarding your imaging results, would you like to hear it and everyone in the room to hear it?”  He nods yes and his family agrees.  You continue, speaking slowly and clearly “We ordered the MRI of your spine because we were worried about your back pain, and concerned that you might have spread of a cancer, an infection, or pinching of part of your spine.”  You pause for a moment and tell the patient, “I’m sorry to say that your MRI showed concerning signs of a cancer that has spread to your back.”  The patient and his family are visually upset, and you give them time to react to this information.  You spend the next several minutes explaining what this means, the next steps for him, answering questions, and providing reassurance to him and his family. After finishing your shift, you reflect on this encounter.  You know that while this patient is going through a difficult time, you played an important part in discovering the cause of his back pain, disclosing this news to him, and maintaining reassurance and hope for this patient and his family in the next stage of his medical journey.

References/Further Reading

1. Rosenzweig S. Emergency Rapport.  J Emerg Med 1993 Nov-Dec;11(6):775-8.
2. Derksen F, Bensing J, Lagro-Janssen A. Effectiveness of empathy in general practice:  a systematic review.  Br J Gen Pract 2013 Jan;63(606):376-84.
3. Nightingale SD, Yarnold PR, Greenberg MS. Sympathy, empathy, and physician resource utilization. J Gen Intern Med 1991; 6:420–423
4. Blumgart HL. Caring for the patient. N Engl J Med 1964; 270: 449–456
5. Markakis K, Frankel R, Beckman H, Suchman A. Teaching empathy:  it can be done.  Working paper presented at the Annual Meeting of the Society of General Internal Medicine.  San Francisco, CA, 1999.
6. Hojat M, Gonnella JS, Nasca TJ, Mangione S, Verare M, Magee M. Physician empathy:  definition, components, measurement, and relationship to gender and specialty.  Am J Psychiatry 2002 Sep;159(9):1563-9.
7. Jani BD, Blaine DN, Mercer SW. The role of empathy in therapy and the physician-patient relationship.  Forsch Komplementmed 2012;19(5):252-7.
8. Hojat M, Louis DZ, Maxwell K, et al. A brief instrument to measure patients’ overall satisfaction with primary care physicians. Fam Med 2011; 43(6): 412–417
9. van Dulmen S, van den Brink-Muinen A. Patients’ preferences and experiences in handling emotions: a study on communication sequences in primary care medical visits. Patient Educ Couns 2004; 55(1): 149–152
10. Levinson W, Roter D. Physicians’ psychosocial beliefs correlate with their patient communication skills. J Gen Intern Med 1995; 10(7): 375–379.
11. Buszewicz M, Pistrang N, Barker C, et al. Patients’ experiences of GP consultations for psychological problems: a qualitative study. Br J Gen Pract 2006; 56(528): 496–503.
12. Hojat M, Louis DZ, Markham FW, et al. Physicians’ empathy and clinical outcomes for diabetic patients. Acad Med 2011; 86(3): 359–364.
13. Rakel D, Barrett B, Zhang Z, et al. Perception of empathy in the therapeutic encounter: Effects on the common cold. Patient Educ Couns 2011; 85(3): 390–397.
14. Mercer SW, Neumann M, Wirtz M, et al. General practitioner empathy, patient enablement, and patient-reported outcomes in primary care in an area of high socio-economic deprivation in Scotland — a pilot prospective study using structural equation modeling. Patient Educ Couns 2008; 73(2): 240–245.
15. Thompson DA, Yarnold PR, Williams DR, Adams SL. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department.  Ann Emerg Med 1996 Dec;28(6):657-65.
16. Jena AB, Seabury S, Lakdawalla D, et al. Malpractice risk according to physician specialty.  N Eng J Med 2011;365:629-36.
17. Smith DD, Kellar J, Walters EL, et al. Does emergency physician empathy reduce thoughts of litigation?  A randomised trial.  Emerg Med J 2016 Aug;33(8):548-52.
18. Coulehan JL, Platt FW, Egener B, Frankel R, Lin CT, Lown B, Salazar WH: ‘Let me see if I have this right…’: words that help build empathy. Ann Intern Med 2001;135:221–227.
19. Maguire P, Faulkner A, Booth K, Elliott C, Hillier V: Helping cancer patients disclose their concerns. Eur J Cancer 1996;32A:78–81.
20. Graugaard PK, Holgersen K, Finset A: Communicating with alexithymic and non-alexithymic patients: an experimental study of the effect of psychosocial communication and empathy on patient satisfaction. Psychother Psychosom 2004;73:92–100.
21. Myers S: Empathic listening: reports on the experience of being heard. J Hum Psychol 2000;40:148– 173.
22. Watson JC: Re-visioning empathy; in Cain DJ, Seeman J (eds): Humanistic Psychotherapies: Handbook of Research and Practice. Washington, DC, American Psychological Association, 2001, pp 445–471.
23. Swayden KJ, Anderson KK, Connelly LM, et al. Effect of sitting vs. standing on perception of provider time at bedside:  a pilot study.  Patient Educ Couns 2012 Feb;86(2):166-71.
24. McEwan A, Silverberg JZ. Palliative Care in the Emergency Department.  Emerg Med Clin N Am 34 (2016):667-85.
25. Oken D. What to tell cancer patients:  a study of medical attitudes.  JAMA 1961;175:1120-1128.
26. Friedman HS. Physician management of dying patients:  an exploration.  Psychiatry Med 1970;1:295-305.
27. Maynard DW. On “realization” in everyday life: the forecasting of bad news as a social relation. Am Sociol Rev 1996;61:109-131.
28. Ford S, Fallowfield L, Lewis S. Doctor-patient interactions in oncology. Soc Sci Med 1996;42:1511-1519.
29. Butow PN, Dunn SM, Tattersall MH. Communication with cancer patients: does it matter? J Palliat Care 1995;11:34-38.
30. Sardell AN, Trierweiler SJ. Disclosing the cancer diagnosis. Procedures that influence patient hopefulness. Cancer 1993;72:3355-3365.
31. Roberts CS, Cox CE, Reintgen DS et al. Influence of physician communication on newly diagnosed breast cancer patients’ psychologic adjustment and decision-making. Cancer 1994;74:336-341.
32. Slavin LA, O’Malley JE, Koocher GP et al. Communication of the cancer diagnosis to pediatric patients: impact on long-term adjustment. Am J Psychiatry 1982;139:179-183.
33. Last BF, van Veldhuizen AM. Information about diagnosis and prognosis related to anxiety and depression in children with cancer aged 8-16 years. Eur J Cancer 1996;32:290-294.
34. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, and Kudelka AP. SPIKES—A Six-Step Protocol for Delivering Bad News:  Application to the Patient with Cancer.  Oncologist 2000;5(4):302-11.
35. Neumann M, Edelhauser F, Tauschel D et al. Empathy decline and its reasons:  a systematic review of studies with medical students and residents.  Acad Med  2011 Aug;86(8):996-1009.
36. Thomas et al. How do distress and well-being relate to medical student empathy?  A multicenter study.  J Gen Intern Med.  2007 Feb;22(2):177-83.
37. Brazeau et al. Relationships between medical student burnout, empathy, and professionalism climate.  Acad Med.  2010 Oct;85(10 Suppl):S33-36.
38. Rosen et al. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy and burnout among interns.  Acad Med.  2006;81:82-85.