Article Review: 'Missed Empathic Opportunities in Cancer Communication'

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Based on an Article Review By Daniel Epner, M.D., associate professor in the Department of General Oncology Read the Full Article Review

Empathy is important in patient/physician communication and is associated with improved patient satisfaction and adherence to physicians' recommendations.

Morse analyzed 20 audio-recorded, transcribed consultations between patients with lung cancer and their thoracic surgeons or oncologists to evaluate how often physicians responded appropriately to patient emotions, a situation which the authors call "empathic opportunities."

Examples of empathic responses to patient emotion include: "This must be very difficult for you" or "I wish I had better news for you" after delivery of bad news. They detected 384 empathic opportunities during the 20 encounters. The authors grouped these opportunities into seven categories, including:

  • Morbidity or mortality concerns
  • Cancer-related symptoms
  • Relationship to smoking
  • Decisions about treatment
  • Beliefs about or mistrust of medical care
  • Factors limiting ability to treat cancer
  • Confusion regarding cancer status and treatment

Remarkably, doctors offered empathic responses only 10% of the time, which compares poorly with previous studies in the literature showing doctors acknowledged 25% to 30% of such opportunities. For instance, in one scenario cited in the paper, the patient described his situation as "very, very scary," yet the doctor responded with purely technical information about treatment options rather than an empathic response. The authors conclude that their results may help physicians recognize empathic opportunities and thereby become more empathic.

The poor results of the study may be due to the fact that the authors set a very low threshold for "empathic opportunities."

 For instance, in one scenario, the patient said:

"It's on the bottom of my lung ... It's about as big as a golf ball ... they want to see if they can get another doctor to see if they can cut it out or ..."

The doctor replied:

"When you breathe, you barely get a quart ... The amount of disease you have is normally treated with surgery, but we cannot operate on you because you will not have enough lungs to live with."

In this interchange, it can be argued that the patient may not have been expressing an emotion (which would call for an empathic response), but may have been relaying information from another doctor or a consultation. In this case the patient may have actually expected technical feedback rather than empathy. Although one might argue that the physician could have explored for emotion in the patient, it seems that the doctor's response was not particularly insensitive, which is what the authors suggest. This points out a methodological issue in these kinds of studies, which speaks to the difficulty in identifying exactly what is an emotion and when it calls for an empathic response.

Nonetheless, even if the authors had only selected truly obvious empathic opportunities -- such as when patients cried or mentioned fear -- the results undoubtedly would have shown many missed opportunities.

BOTTOM LINE: Empathic acknowledgment of patient emotions and concerns may have a number of beneficial outcomes, such as strengthening the relationship with the patient and identifying important patient concerns. Contrary to popular thinking, responding emphatically doesn't necessarily prolong patient visits.

We need to be better at recognizing empathic opportunities and responding to them appropriately. Our empathic responses should occur earlier and at intervals throughout encounters to explore and validate patients' needs and concerns and build understanding to allow progressive establishment of rapport and trust.

Daniel Epner, M.D., associate professor in M. D. Anderson's Department of General Oncology, reviews an article on physician/patient communication. "Missed Opportunities for Interval Empathy in Lung Cancer Communication" appears in Archives of Internal Medicine. Authors Diane S. Morse, M.D.; Elizabeth A. Edwardsen, M.D.; Howard S. Gordon, M.D. Arch Intern Med. 2008;168(17):1853-1858.

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