E.M.P.A.T.H.Y.: a tool to enhance nonverbal communication between clinicians and their patients

The importance of contextual aspects in the care for patients with functional somatic symptoms

Functional somatic symptoms refer to physical symptoms that cannot be (bio) medically explained. The pattern or clustering of such symptoms may lead to functional syndromes like chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, among many others. Since the underlying pathophysiology remains unknown, several explanatory models have been proposed, nearly all including social and psychological parameters. These models have stimulated effectiveness studies of several psychological and psychopharmacological therapies. While the evidence for their effectiveness is steadily growing, effect-sizes are at most moderate and many patients do not benefit. We hypothesize that the context in which interventions for functional somatic symptoms are delivered substantially influences their effectiveness. Although this hypothesis is in line with explanatory models of functional somatic symptoms, to our knowledge, studies primarily focusing on the influence of contextual aspects on treatment outcome are scarce. Contextual research in the field of somatic symptoms has (irrespective whether these symptoms can be medically explained or not), however, just begun and already yielded some valuable results. These findings can be organized according to Duranti's and Goodwin's theoretical approach to context in order to substantiate our hypothesis. Based on this approach, we categorized empirical findings in three contextual aspects, i.e. 1) the setting, 2) the behavioural environment, and 3) the language environment. Collectively, some support is found for the fact that early identification of patients with functional somatic symptoms, starting treatment as soon as possible, having a neat appearance and an organized office interior, a warm and friendly nonverbal approach and a language use without defensiveness are contextual parameters which enhance the assessment by the patient of the physician's competence to help. Nonetheless, in vivo studies addressing the most aspects, i.e. nonverbal behaviour and language, are needed for better understanding of these contextual aspect. Moreover, future research should address to what extent optimizing contextual aspects improve care for functional somatic symptoms.

Improving Patient Experience by Teaching Empathic Touch and Eye Gaze: A Randomized Controlled Trial of Medical Students

Background

Empathy is critical for optimal patient experience with health-care providers. Verbal empathy is routinely taught to medical students, but nonverbal empathy, including touch, less so. Our objective was to determine whether instruction encouraging empathic touch and eye gaze at exit can impact behaviors and change patient-perceived empathy.

Materials

A randomized, controlled, double-blinded trial of 34 first-year medical students was conducted during standardized patient (SP) interviews. A video either encouraging empathic touch and eye gaze at exit or demonstrating proper hand hygiene (control) was shown. Encounter videos were analyzed for touch and eye gaze at exit. The Jefferson Scale of Patient Perceptions of Physician Empathy was used to measure correlations. Intervention students were surveyed regarding patient touch.

Results

Of this, 23.5% of intervention students touched the SP versus zero controls; 88.2% of intervention students demonstrated eye gaze at exit. Eye gaze at exit positively impacted patient-perceived empathy (correlation = 0.48, P > .001). Survey responses revealed specific barriers to touch.

Conclusion

Medical students may increase perceived empathy using eye gaze at exit. Instruction on empathic touch and sustained eye gaze at exit at the medical school level may be useful in promoting empathic nonverbal communication. Medical educators should consider providing specific instructions on how to appropriately touch patients during history-taking. This is one of the few studies to explore touch with patients and the first ever to report the positive correlation of a health provider's sustained eye gaze at exit with the patient's perceived empathy. Further studies are needed to explore barriers to empathic touch.

Assistive Robots for the Social Management of Health: A Framework for Robot Design and Human-Robot Interaction Research

There is a close connection between health and the quality of one's social life. Strong social bonds are essential for health and wellbeing, but often health conditions can detrimentally affect a person's ability to interact with others. This can become a vicious cycle resulting in further decline in health. For this reason, the social management of health is an important aspect of healthcare. We propose that socially assistive robots (SARs) could help people with health conditions maintain positive social lives by supporting them in social interactions. This paper makes three contributions, as detailed below. We develop a framework of social mediation functions that robots could perform, motivated by the special social needs that people with health conditions have. In this framework we identify five types of functions that SARs could perform: (a) changing how the person is perceived, (b) enhancing the social behavior of the person, (c) modifying the social behavior of others, (d) providing structure for interactions, and (e) changing how the person feels. We thematically organize and review the existing literature on robots supporting human-human interactions, in both clinical and non-clinical settings, and explain how the findings and design ideas from these studies can be applied to the functions identified in the framework. Finally, we point out and discuss challenges in designing SARs for supporting social interactions, and highlight opportunities for future robot design and HRI research on the mediator role of robots.

Clinical empathy as emotional labor in medical work

The ongoing social transformation of the American healthcare system brings both structural and interpersonal changes to the delivery of healthcare. Some of these changes have been motivated by patients, who increasingly desire emotionally warm interactions with physicians. This is a departure from the detached concern that characterized physician-patient interactions in the mid-twentieth century. Concurrently, medical training continually adapts to trends in medical practice so that future physicians are prepared to enter practice. In this paper, we examine the rise of clinical skills training courses and assessments in medical school, highlighting the changing role of emotion in training about communication in the doctor - patient relationship. Drawing on an interpretive analysis of interviews with and ethnographic observations of medical students and residents from two United States medical schools, we elaborate the concept of clinical empathy to describe the character of emotional engagement in the contemporary clinical encounter. In the analysis we show how standards of emotional conduct are taught in medical school, how clinical empathy is operationalized in the patient encounter, and how clinical empathy may be used instrumentally to smooth the physician's work. Finally, we position the consistent performance of clinical empathy as a form of emotional labor, expanding the reach of studies of emotional labor in professions.

Effects on Medical Students of Longitudinal Small-Group Learning about Breaking Bad News

INTRODUCTION

Delivering bad news is a difficult task for physicians, and medical schools do not always prepare future physicians for this inevitable task.

OBJECTIVE

To examine training in breaking bad news, to improve medical students' competence and confidence in dealing with this important aspect of clinical practice.

METHODS

An exploratory study using a qualitative approach was done at a Brazilian public university's medical school, which receives 30 medical students per semester. Two focus groups were conducted in 2018, with 15 students per group, before and after the training. The intervention consisted of a 6-month (4 h/wk) course about breaking bad news offered to 30 third-year medical students. The communication course included the perspectives of health care professionals, patients, and their families; the SPIKES protocol and the "ABCDE" mnemonic for delivering bad news; general guidelines; and role-playing/simulation strategies to improve students' skills and reduce their personal limitations.

RESULTS

Results of the preintervention focus group demonstrated that only 30% of the students were aware of the importance of breaking bad news and of the existence of specific protocols to guide physicians in these situations. Findings from the postintervention focus group indicated that 90% of students understood the importance and began to apply protocols in their practice.

DISCUSSION

Breaking bad news is a challenge for undergraduate medical students. The results of our qualitative study showed that students' perceptions about their capability in delivering bad news increased significantly after regular and focused training. The knowledge, skills, and attitudes acquired strengthened the students' self-reported ability to deal with situations requiring breaking bad news.

CONCLUSION

The activities offered helped students develop communication skills. They made connections between their formal training (communication and cognitive skills) and actual clinical practice in a community-based rotation. The knowledge and skills acquired gave them tools needed to deliver bad news in their future clinical practice.

Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter

IMPORTANCE

Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.

OBJECTIVE

To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.

EVIDENCE REVIEW

Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their "top 5" practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.

FINDINGS

The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient's story (consider life circumstances that influence the patient's health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient's emotions).

CONCLUSIONS AND RELEVANCE

This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

EMPATHY IN NURSING STUDENTS FROM THE METROPOLITANA UNIVERSITY OF BARRANQUILLA (COLOMBIA)

ABSTRACT Objective: to evaluate the Empathic Orientation in Nursing students of the Universidad Metropolitana of Barranquilla (Colombia). Method: a descriptive, exploratory and transversal study in which the Jefferson Medical Empathy Scale in an anonymous and confidential manner was applied to 489 students from the first to fourth undergraduate year of the Nursing Program of the Universidad Metropolitana (Barranquilla, Colombia); the corresponding ethical and methodological rigor was kept. Results: the ANOVA results were not significant in the Academic Year factor and in the interaction (p=0.261), but significant by Gender. It was observed that behavior was different in both genders. The masculine gender tends to descend between the first and third undergraduate year and female gender also descends between first and second undergraduate year to later reach the average levels of empathy of the male gender. Conclusion: the results obtained show that the means of the variable studied do not show a great difference between the different undergraduate courses, nevertheless, a slight increase in the fourth undergraduate year is observed. There were significant differences between genders, the scores observed in men students were higher than those obtained from women students.

A taxonomy to assess the interaction between nurses and children: Development and reliability

AIMS AND OBJECTIVES

The aim of this study was to develop a valid and reliable instrument to assess the nurse-child interaction during medical or nursing interventions.

BACKGROUND

Communication is an important competency for the professional practice of nurses and physicians. The nurse-patient relationship is fundamental for high-quality care. It has been suggested that if nurses have more skills to interact with children, care will be less distressing and less painful for the children.

DESIGN

A qualitative observational psychometric study; the GRRAS checklist was used.

METHODS

In-depth video-analyses, taxonomy development (19 videos) and testing it is psychometric properties (10 videos). Three observers micro-analysed video recordings of experienced nurses changing children's wound dressing in a specialised Burn Centre.

RESULTS

The nurse-child interaction taxonomy (NCIT) was developed to observe and score the interactional behaviour between nurse and child. The taxonomy has three main patterns: being considerate, attuning oneself, and procedural interventions, subdivided in eight dimensions. These dimensions contain 16 elements that can be observed and scored on a 7-point scale. Intra-rater, inter-rater reliability and agreement were good.

CONCLUSIONS

This study shows that interaction between nurses and children can be assessed reliably with the NCIT by an experienced observer or alternatively, scoring by two observers is recommended.

RELEVANCE TO CLINICAL PRACTICE

The development of the taxonomy is an important step to find evidence for the best way for nurses to interact with children during nursing interventions or medical events and as such, ultimately, contributes to providing the best care possible.

"I had the feeling that I was trapped": a bedside qualitative study of cognitive and affective attitudes toward noninvasive ventilation in patients with acute respiratory failure

Background

Noninvasive ventilation (NIV) is the application of mechanical ventilation through a mask. It is used to treat certain forms of acute respiratory failure in intensive care units (ICU). NIV has clinical benefits but can be anxiogenic for the patients. This study aimed at describing cognitive and affective attitudes toward NIV among patients experiencing NIV for the first time in the context of an ICU stay.

Methods

Semi-structured interviews were conducted in 10 patients during their ICU stay and soon after their first NIV experience. None of the patients had ever received NIV previously. Evaluative assertion analysis and thematic analysis were used to investigate cognitive and affective attitudes toward NIV before, during, and after the first NIV experience, as well as patient attitudes toward caregivers and relatives.

Results

Before their first NIV session, the cognitive attitudes of the patients were generally positive. They became less so and more ambiguous during and after NIV, as the patients discovered the actual barriers associated with NIV. Affective attitudes during NIV were more negative than affective attitudes before and after NIV, with reports of dyspnea, anxiety, fear, claustrophobic feelings, and reactivation of past traumatic experiences. The patients had more positive attitudes toward the presence of a caregiver during NIV, compared to the presence of a family member.

Conclusion

This study corroborates the possibly negative—or even traumatic—nature of the NIV experience, with emphasis on the role of affective attitudes. This is a rationale for evaluating the impact of NIV-targeted psychological interventions in ICU patients with acute respiratory failure.

A Young Man with Trisomy 21 and Sudden Behavioral Changes

Grant is a 13-year-old boy with trisomy 21 who presents with his mother for concerns regarding the emergence of several new disruptive behaviors. While he is verbal, he also communicates through an augmentative communication device. He currently attends a residential school. Over the past 2 months, he has begun spitting at the staff, engaging in self-injurious behaviors, placing his hands in his pants, and frequently talking about "pee and poop." Notably, Grant has undergone several changes to his educational placement and medical health over the past several months. He recently transferred to his current residential school from another placement to be closer to his family, although this has meant that Grant was unable to work with his long-time aide. Additionally, most of the students at Grant's current school are significantly lower functioning than him, such that Grant is one of the few verbal children.Approximately 3 months ago, Grant underwent significant dental work under anesthesia. Grant had previously taken an alpha-agonist for behavioral management, although he was weaned off this 4 months ago because of increasing somnolence increasing somnolence. Grant's recent behavioral challenges make performing community and home activities more challenging.Grant's behavioral history is notable for a previous episode of behavioral and emotional challenges 18 months ago. This occurred in the setting of transitioning to a new classroom with higher academic and behavioral expectations and decreased time spent with his family. These behaviors had consisted of self-injurious behaviors and tantrums consisting of crying and social withdrawal. This was managed by increased behavioral and academic supports via trained teachers and aides, medication management, and optimizing his augmentative communication. After these interventions, Grant's behavioral and emotional functioning improved and remained stable until this current episode.Grant's mother is concerned about what may be causing these emerging behaviors and wondering if any of the recent educational and medical stressors could be contributing. What do you do next?

The Tinnitus Retraining Therapy Trial's Standard of Care Control Condition: Rationale and Description of a Patient-Centered Protocol

Purpose The selection and design of control conditions are critical factors in minimizing the influence of unwanted variables in randomized controlled trials (RCTs). This article describes the rationale, design, and content of a standard of care control condition in a Phase III RCT of tinnitus retraining therapy. Method Existing tinnitus practices at military hospitals were identified and aligned with the American Speech-Language-Hearing Association's (2006) preferred practice patterns for tinnitus management and counseling and embedded in a patient-centered protocol to ensure uniformity and treatment fidelity. Results For those involved in the design of behavioral RCTs, the article identifies options and methods to consider in the selection and design of control conditions. Conclusion For those who provide tinnitus services, the standard of care protocol developed for the tinnitus retraining therapy trial constitutes a patient-centered approach to intervention that can be implemented clinically. Supplemental Material https://doi.org/10.23641/asha.9342503.

"It is through body language and looks, but it is also a feeling" - a qualitative study on medical interns' experience of empathy

BACKGROUND

Empathy has long been recognized as a fundamental part of the professionalism of doctors and is considered to be both necessary and beneficial to doctor-patient relationships, although empathy is notoriously difficult to define and measure. Previous research on empathy has mostly consisted of quantitative studies measuring and evaluating empathy levels in students or medical residents. The aim of our qualitative study was to explore the lived experience of empathy among medical interns in Sweden.

METHOD

We interviewed 16 medical interns, using semi-structured interviews. Content analysis was used to analyse the interviews.

RESULTS

The analysis led to the emergence of a main theme of empathy as being multifaceted and conflictual, consisting of descriptions (subthemes) of "being" and "doing"; of being uncontrollable and contextual; biased and situated and essential and conflictual. Since the components of empathy were also found to be interwoven, to provide a more holistic presentation of the results, we applied a socio-ecological model to the results inspired by Bronfenbrenner.

CONCLUSIONS

We concluded that empathy is situated and contextual. By using the socioecological model empathy can be described as a systemic interaction between doctor and patient. Based on this we propose a more holistic approach to empathy in medical education to better prepare students for clinical practice.

Functional Somatic Symptoms

BACKGROUND

Approximately 10% of the general population and around one third of adult patients in clinical populations suffer from functional somatic symptoms. These take many forms, are often chronic, impair everyday functioning as well as quality of life, and are cost intensive.

METHODS

The guideline group (32 medical and psychological professional societies, two patients' associations) carried out a systematic survey of the literature and ana- lyzed 3795 original articles and 3345 reviews. The aim was to formulate empirically based recommendations that were practical and user friendly.

RESULTS

Because of the variation in course and symptom severity, three stages of treatment are distinguished. In early contacts, the focus is on basic investigations, reassurance, and advice. For persistent burdensome symptoms, an extended, simultaneous and equitable diagnostic work-up of physical and psychosocial factors is recommended, together with a focus on information and self-help. In the pres- ence of severe and disabling symptoms, multimodal treatment includes further elements such as (body) psychotherapeutic and social medicine measures. Whatever the medical specialty, level of care, or clinical picture, an empathetic professional attitude, reflective communication, information, a cautious, restrained approach to diagnosis, good interdisciplinary cooperation, and above all active interventions for self-efficacy are usually more effective than passive, organ- focused treatments.

CONCLUSION

The cornerstones of diagnosis and treatment are biopsychosocial ex- planatory models, communication, self-efficacy, and interdisciplinary mangagement. This enables safe and efficient patient care from the initial presentation onwards, even in cases where the symptoms cannot yet be traced back to specific causes.

Navigating Tensions of Efficiency and Caring in Clerkship: A Qualitative Study

Phenomenon: Clerkship is a challenging transition during which medical students must learn to navigate the responsibilities of medical school and clinical medicine. We explored how clerks understand their roles as both medical learners and developing professionals and some of the tensionss that arise therein. Understanding how the clinical learning environment shapes the clerkship role can help educators foster compassionate care. Approach: We conducted 5 focus groups and 1 interview with 3rd-year medical students (n = 14) at University of Toronto between January and June 2016 regarding the perceived role of the clerk, compassionate care, assessment and feedback. Data were analyzed thematically. Findings: In addition to transitioning to a new learning environment, clerkship students assume different roles in response to complex and often competing expectations from preceptors. We identified three main themes: learning to impress preceptors with varying expectations, providing compassionate care-sometimes supported by preceptors, other times being secondary to efficiency-and passing assessments that required a different skill set than simply being a "good clerk." Insights: Clerks perceive their role as providing compassionate care to patients and balance this with fulfilling the (sometimes) competing roles of being a student and developing medical professional. In a system where efficiency is often prioritized, medical students are afforded an opportunity to help satisfy the demand for greater compassion in patient-centered care.

Telepsychiatry: A New Treatment Venue for Pediatric Depression

The benefits and acceptability of using telepsychiatry to provide psychiatric treatment to youth in their homes, schools, primary care provider offices, juvenile correction centers, and residential facilities are well established. Telepsychiatry removes geographic barriers between patients and providers and improves the access to and ease of receiving quality care. Effective telepsychiatrists use strategic room staging, enhanced nonverbal communication, and technical experience to ensure sessions provide an authentic treatment experience and strong provider-patient alliances are forged. When the telepsychiatry venue is used properly, sessions feel authentic and pediatric treatment outcomes meet and sometimes exceed those of sessions conducted in traditional venues.

Coming in Warm: Qualitative Study and Concept Map to Cultivate Patient-centered Empathy in Emergency Care

BACKGROUND

Increased empathy may improve patient perceptions and outcomes. No training tool has been derived to teach empathy to emergency care providers. Accordingly, we engaged patients to assist in creating a concept map to teach empathy to emergency care providers.

METHODS

We recruited patients, patient caretakers and patient advocates with emergency department experience to participate in three separate focus groups (n = 18 participants). Facilitators guided discussion about behaviors that physicians should demonstrate to rapidly create trust; enhance patient perception that the physician understood the patient's point of view, needs, concerns, and fears; and optimize patient/caregiver understanding of their experience. Verbatim transcripts from the three focus groups were read by the authors, and by consensus, five major themes with 10 minor themes were identified. After creating a codebook with thematic definitions, one author reviewed all transcripts to a library of verbatim excerpts coded by theme. To test for inter-rater reliability, two other authors similarly coded a random sample of 40% of the transcripts. Authors independently chose excerpts that represented consensus and strong emotional responses from participants.

RESULTS

Approximately 90% of opinions and preferences fell within 15 themes, with five central themes: provider transparency, acknowledgment of patient's emotions, provider disposition, trust in physician, and listening. Participants also highlighted the need for authenticity, context, and individuality to enhance empathic communication. For empathy map content, patients offered example behaviors that promote perceptions of physician warmth, respect, physical touch, knowledge of medical history, explanation of tests, transparency, and treating patients as partners. The resulting concept map was named the "Empathy Circle."

CONCLUSIONS

Focus group participants emphasized themes and tangible behaviors to improve empathy in emergency care. These were incorporated into the Empathy Circle, a novel concept map that can serve as the framework to teach empathy to emergency care providers.

Perceptions of health professionals about the quality of communication and deliberation with the patient and its impact on the health decision making process

The information process is considered a core element in decision- making and an obligatory matter of concern for the health professional. Rather than information per se, we should perhaps mention the need for communication between the health professional and the patient, which should be appropriate to each specific case and situation. Interaction and communication during the relationship generates a degree of trust that contributes to improving care quality and health-related results. The aim of this study is to know the perception of professionals on the quality of communication and its impact on the decision-making process of the patient and the degree of involvement of health professionals in the process of communication with the patient. A sample of 2186 health professionals (1578 nurses, 586 physicians, and 22 pharmacists) was studied. A questionnaire composed of 20 items dealing with the process of communication with the patient and obtaining informed consent was administered. Our study revealed the high consideration that professionals hold of their communication skills with patients since almost 80% of those surveyed, think they are sufficiently skilled in this area. Professionals refers that nurses are most skilled at communicating with patients. Communication in the clinical relationship must not only serve as a way for the professional to obtain information from the patient on their pathology, but also as a means to inform patients so that they understand their illness. Patients also like to feel that they are being listened to and are co-participants in the care process. Communication should be a continuous object of study for all health professionals, both in primary and specialised attention.

Compassionate Care in Behavior Analytic Treatment: Can Outcomes be Enhanced by Attending to Relationships with Caregivers?

The practice of behavior analysis has become a booming industry with growth to over 30,000 Board Certified Behavior Analysts (BCBAs) who primarily work with children with autism and their families. Most of these BCBAs are relatively novice and have likely been trained in graduate programs that focus primarily on conceptual and technical skills. Successfully working with families of children with autism, however, requires critical interpersonal skills, as well as technical skills. As practitioners strive to respond efficiently and compassionately to distressed families of children with autism, technical skills must be balanced with fluency in relationship-building skills that strengthen the commitment to treatment. The current article provides an outline of important therapeutic relationship skills that should inform the repertoire of any practicing behavior analyst, strategies to cultivate and enhance those skills, and discussion of the potential effects of relationship variables on treatment outcomes.

Patient-Centered Bedside Rounds and the Clinical Examination

Bedside hospital rounds promote patient-centered care in teaching and nonteaching settings. Patients and families prefer bedside rounds and provider acceptance is increasing. Efficient bedside rounds with an interprofessional team or with learners requires preparation of the patient and the rounding team. Bedside "choreography" provides structure and sets expectations for time spent in the room. By using relationship-centered communication, rounds can be both patient proximate and patient centered. The clinical examination can be integrated into the flow of the presentation and case discussion. Patient and provider experience can be enhanced through investing time at the bedside.

Empathy in Internal Medicine Residents at Community-based Hospitals: A Cross-sectional Study

INTRODUCTION

Many research reports revealed declining empathy in medical schools that continues in postgraduate years of training.

OBJECTIVE

The aim of this study is to examine the self-reported empathy levels of internal medicine (IM) residents in 3 community-based teaching hospitals.

METHODS

The Jefferson Scale of Physician Empathy, Health Professionals version, is an online, self-administered, questionnaire that was offered to 129 current and incoming residents at 1 osteopathic and 2 allopathic, IM training programs in Flint, Michigan.

RESULTS

Forty-five residents responded (35% response rate). Our residents' cumulative mean empathy score was 112.5 with a SD of 12.72, which is comparable with the cumulative empathy scores for IM residents at university hospitals. There was an increase in empathy score from the beginning level of training, postgraduate year 0 (PGY0), to the PGY1 level, and a noticeable, although statistically non-significant, decrease in empathy score for both PGY2 and PGY3 residents. The graduating residents' scores were higher compared with incoming residents.

CONCLUSIONS

The cumulative mean empathy score in community-based IM residents showed an increase in the beginning of residents' training and decrease in empathy score by the end of training. There were significant differences in empathy scores by level of training at individual hospitals. This might be related to different targeted curricula.

Mental well-being of patients from ethnic minority groups during critical care: a qualitative ethnographic study

OBJECTIVES

To investigate the state of the mental well-being of patients from ethnic minority groups and possible related risk factors for the development of mental health problems among these patients during critical medical situations in hospital.

DESIGN

Qualitative ethnographic design.

SETTING

Oneintensive care unit (ICU) of a multiethnic urban hospital in Belgium.

PARTICIPANTS

84 ICU staff members, 10 patients from ethnic-minority groups and their visiting family members.

RESULTS

Patients had several human basic needs for which they could not sufficiently turn to anybody, neither to their healthcare professionals, nor to their relatives nor to other patients. These needs included the need for social contact, the need to increase comfort and alleviate pain, the need to express desperation and participate in end-of-life decision making. Three interrelated risk factors for the development of mental health problems among the patients included were identified: First, healthcare professionals' mainly biomedical care approach (eg, focus on curing the patient, limited psychosocial support), second, the ICU context (eg, time pressure, uncertainty, regulatory frameworks) and third, patients' different ethnocultural background (eg, religious and phenotypical differences).

CONCLUSIONS

The mental state of patients from ethnic minority groups during critical care is characterised by extreme emotional loneliness. It is important that staff should identify and meet patients' unique basic needs in good time with regard to their mental well-being, taking into account important threats related to their own mainly biomedical approach to care, the ICU's structural context as well as the patients' different ethnocultural background.

Ethical Implications of the Electronic Health Record: In the Service of the Patient

Electronic health records (EHRs) provide benefits for patients, physicians, and clinical teams, but also raise ethical questions. Navigating how to provide care in the digital age requires an assessment of the impact of the EHR on patient care and the patient-physician relationship. EHRs should facilitate patient care and, as an essential component of that care, support the patient-physician relationship. Billing, regulatory, research, documentation, and administrative functions determined by the operational requirements of health care systems, payers, and others have resulted in EHRs that are better able to satisfy such external functions than to ensure that patient care needs are met. The profession has a responsibility to identify and address this mismatch. This position paper by the American College of Physicians (ACP) Ethics, Professionalism and Human Rights Committee does not address EHR design, user variability, meaningful use, or coding requirements and other government and payer mandates per se; these issues are discussed in detail in ACP's Clinical Documentation policy. This paper focuses on EHRs and the patient-physician relationship and patient care; patient autonomy, privacy and confidentiality; and professionalism, clinical reasoning and training. It explores emerging ethical challenges and concerns for and raised by physicians across the professional lifespan, whose ongoing input is crucial to the development and use of information technology that truly serves patients.

Empathic nonverbal behavior increases ratings of both warmth and competence in a medical context

In medicine, it is critical that clinicians demonstrate both empathy (perceived as warmth) and competence. Perceptions of these qualities are often intuitive and are based on nonverbal behavior. Emphasizing both warmth and competence may prove problematic, however, because there is evidence that they are inversely related in other settings. We hypothesize that perceptions of physician competence will instead be positively correlated with perceptions of physician warmth and empathy, potentially due to changing conceptions of the physician’s role. We test this hypothesis in an analog medical context using a large online sample, manipulating physician nonverbal behaviors suggested to communicate empathy (e.g. eye contact) and competence (the physician’s white coat). Participants rated physicians displaying empathic nonverbal behavior as more empathic, warm, and more competent than physicians displaying unempathic nonverbal behavior, adjusting for mood. We found no warmth/competence tradeoff and, additionally, no significant effects of the white coat. Further, compared with male participants, female participants perceived physicians displaying unempathic nonverbal behavior as less empathic. Given the significant consequences of clinician empathy, it is important for clinicians to learn how nonverbal behavior contributes to perceptions of warmth, and use it as another tool to improve their patients’ emotional and physical health.

Culture and nonverbal expressions of empathy in clinical settings: A systematic review

OBJECTIVE

To conduct a systematic review of studies examining how culture mediates nonverbal expressions of empathy with the aim to improve clinician cross-cultural competency.

METHODS

We searched three databases for studies of nonverbal expressions of empathy and communication in cross-cultural clinical settings, yielding 16,143 articles. We examined peer-reviewed, experimental or observational articles. Sixteen studies met inclusion criteria.

RESULTS

Nonverbal expressions of empathy varied across cultural groups and impacted the quality of communication and care. Some nonverbal behaviors appeared universally desired and others, culturally specific. Findings revealed the impact of nonverbal communication on patient satisfaction, affective tone, information exchange, visit length, and expression decoding during cross-cultural clinical encounters. Racial discordance, patients' perception of physician racism, and physician implicit bias are among factors that appear to influence information exchange in clinical encounters.

CONCLUSION

Culture-based norms impact expectations for specific nonverbal expressions within patient-clinician dyads. Nonverbal communication plays a significant role in fostering trusting provider-patient relationships, and is critical to high quality care.

PRACTICE IMPLICATIONS

Medical education should include training in interpretation of nonverbal behavior to optimize empathic cross-cultural communication and training efforts should accommodate norms of local patient populations. These efforts should reduce implicit biases in providers and perceived prejudice in patients.

Effectiveness of the addition of therapeutic alliance with minimal intervention in the treatment of patients with chronic, nonspecific low back pain and low risk of involvement of psychosocial factors: a study protocol for a randomized controlled trial (TalkBack trial)

Background

The stratified model of care has been an effective approach for the treatment of low back pain. However, the treatment of patients with low risk of psychosocial-factor involvement is unclear. The addition of the therapeutic alliance to a minimal intervention may be an option for the treatment of low back pain. This paper reports on the rationale, design and protocol for a randomized controlled trial with blind assessor to assess the effectiveness of the addition of therapeutic alliance with minimal intervention on pain and disability in patients with chronic, nonspecific low back pain.

Methods

Two hundred and twenty-two patients with chronic, nonspecific low back pain and low risk of involvement of psychosocial factors will be assessed and randomly allocated into three groups (n = 74 patients per group). The Positive Therapeutic Alliance group will receive counseling and guidance with an emphasis on therapeutic alliance and empathy. The Usual Treatment group will receive the same information and counseling with limited interaction with the therapist. The Control group will not receive any intervention. The treatment will be composed by two intervention sessions with a 1-week interval. A blinded assessor will collect the following outcomes at baseline, 1 month, 6 months and 12 months after randomization: pain intensity (Pain Numerical Rating Scale), specific disability (Patient-specific Functional Scale), general disability (Oswestry Disability Index), global perceived effect (Global Perceived Effect Scale), empathy (Consultation and Relational Empathy Measure), credibility and expectations related to treatment. The analysis will be performed using linear mixed models.

Discussion

This will be the first study to understand the effect of combining enhanced therapeutic alliance to a treatment based on counseling, information and advice (minimal intervention). The addition of the therapeutic alliance to minimal intervention may improve the treatment of chronic, nonspecific low back pain.

Trial registration

ClinicalTrials.gov, NCT 02497625. Registered on 10 July 2015.

Electronic supplementary material

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Facial emotion recognition in psychiatrists and influences of their therapeutic identification on that ability

OBJECTIVES

Although emotional cues like facial emotion expressions seem to be important in social interaction, there is no specific training about emotional cues for psychiatrists. Here, we aimed to investigate psychiatrists' ability of facial emotion recognition and relation with their clinical identification as psychotherapy-psychopharmacology oriented or being adult and childhood-adolescent psychiatrist.

METHODS

Facial Emotion Recognition Test was performed to 130 psychiatrists that were constructed by a set of photographs (happy, sad, fearful, angry, surprised, disgusted and neutral faces) from Ekman and Friesen's.

RESULTS

Psychotherapy oriented adult psychiatrists were significantly better in recognizing sad facial emotion (p=.003) than psychopharmacologists while no significant differences were detected according to therapeutic orientation among child-adolescent psychiatrists (for each, p>.05). Adult psychiatrists were significantly better in recognizing fearful (p=.012) and disgusted (p=.003) facial emotions than child-adolescent psychiatrists while the latter were better in recognizing angry facial emotion (p=.008).

CONCLUSION

For the first time, we have shown some differences on psychiatrists' facial emotion recognition ability according to therapeutic identification and being adult or child-adolescent psychiatrist. It would be valuable to investigate how these differences or training the ability of facial emotion recognition would affect the quality of patient-clinician interaction and treatment related outcomes.

Dissociating emotional and cognitive empathy in pre-clinical and clinical Huntington's disease

Huntington's disease (HD) is centrally characterized by motor, neurocognitive and psychiatric symptoms, but impaired emotional decoding abilities have also been reported. However, more complex affective abilities are still to be explored, and particularly empathy, which is essential for social relations and is impaired in various psychiatric conditions. This study evaluates empathic abilities and social skills in pre-clinical and clinical HD, and explores the distinction between two empathy sub-components (emotional-cognitive). Thirty-six HD patients (17 pre-clinical) and 36 matched controls filled in the Empathy Quotient Scale, while controlling for psychopathological comorbidities. At the clinical stage of HD, no global empathy impairment was observed but rather a specific deficit for the cognitive sub-component, while emotional empathy was preserved. A deficit was also observed for social skills. Pre-clinical HD was not associated with any empathy deficit. Emotional deficits in clinical HD are thus not limited to basic emotion decoding but extend towards complex interpersonal abilities. The dissociation between impaired cognitive and preserved emotional empathy in clinical HD reinforces the proposal that empathy subtypes are sustained by distinct processes. Finally, these results underline the extent of distinct affective and social impairments in HD and the need to grasp them in clinical contexts.

Integrating Compassionate, Collaborative Care (the "Triple C") Into Health Professional Education to Advance the Triple Aim of Health Care

Empathy and compassion provide an important foundation for effective collaboration in health care. Compassion (the recognition of and response to the distress and suffering of others) should be consistently offered by health care professionals to patients, families, staff, and one another. However, compassion without collaboration may result in uncoordinated care, while collaboration without compassion may result in technically correct but depersonalized care that fails to meet the unique emotional and psychosocial needs of all involved. Providing compassionate, collaborative care (CCC) is critical to achieving the "triple aim" of improving patients' health and experiences of care while reducing costs. Yet, values and skills related to CCC (or the "Triple C") are not routinely taught, modeled, and assessed across the continuum of learning and practice. To change this paradigm, an interprofessional group of experts recently recommended approaches and a framework for integrating CCC into health professional education and postgraduate training as well as clinical care. In this Perspective, the authors describe how the Triple C framework can be integrated and enhance existing competency standards to advance CCC across the learning and practice continuum. They also discuss strategies for partnering with patients and families to improve health professional education and health care design and delivery through quality improvement projects. They emphasize that compassion and collaboration are important sources of professional, patient, and family satisfaction as well as critical aspects of professionalism and person-centered, relationship-based high-quality care.

Improving Self-Management Skills Through Patient-Centered Communication

PURPOSE

We tested relationships between patient-centered communication (PCC), relatedness to health care providers, and autonomy around health care management among youth with and without mobility limitations (MLs) and examined whether the relationship between PCC and autonomy was mediated by how connected youth feel to their health care providers.

METHODS

Stratified multiple regression models were used to examine predicted associations for youth with and without MLs.

RESULTS

PCC was significantly associated with relatedness to health care providers and autonomy for managing health care among youth with and without MLs. After controlling for covariates, evidence of mediation was observed among youth without MLs but not for youth with MLs.

CONCLUSIONS

For youth without MLs, mediation suggests that youth's connection to their health care provider contributes to higher levels of health-related autonomy. For youth with MLs, independent of feeling connected to health care providers, more frequent PCC resulted in higher levels of health-related autonomy.

Fellow use of medical jargon correlates inversely with patient and observer perceptions of professionalism: results of a rheumatology OSCE (ROSCE) using challenging patient scenarios

The NYC Rheumatology Objective Structured Clinical Examination (NYC-ROSCE) is held annually to assess fellow competencies. We recently redesigned our OSCE to better assess subspecialty trainee communication skills and professionalism by developing scenarios in which the patients encountered were psychosocially or medically complex. The objective of this study is to identify which types of verbal and non-verbal skills are most important in the perception of professionalism in the patient-physician interaction. The 2012-2013 NYC-ROSCEs included a total of 53 fellows: 55 MD evaluators from 7 NYC rheumatology training programs (Hospital for Special Surgery-Weill Cornell (HSS), SUNY/Downstate, NYU, Einstein, Columbia, Mount Sinai, and North Shore/Long Island Jewish (NSLIJ)), and 55 professional actors/standardized patients participated in 5 stations. Quantitative fellow performance assessments were made on the following: maintaining composure; partnering with the patient; honesty; professionalism; empathy; and accountability. Free-text comments were solicited regarding specific strengths and weaknesses. A total of 53/53 eligible (100 %) fellows were evaluated. MD evaluators rated fellows lower for professionalism than did the standardized patients (6.8 ± 0.6 vs. 7.4 ± 0.8, p = 0.05), suggesting that physicians and patients view professionalism somewhat differently. Fellow self-evaluations for professionalism (6.6 ± 1.2) were concordant with those of the MD evaluators. Ratings of empathy by fellows themselves (6.6 ± 1.0), MD evaluators (6.6 ± 0.7), and standardized patients (6.6 ± 1.1) agreed closely. Jargon use, frequently cited by evaluators, showed a moderate association with lower professionalism ratings by both MD evaluators and patients. Psychosocially challenging patient encounters in the NYC-ROSCE permitted critical assessment of the patient-centered traits contributing to impressions of professionalism and indicate that limiting medical jargon is an important component of the competency of professionalism.

The link between perception of clinical empathy and nonverbal behavior: The effect of a doctor's gaze and body orientation

OBJECTIVES

Clinical empathy is considered to be one of the most important skills for medical professionals. It is primarily conveyed by nonverbal behavior; however, little is known about the importance of different types of cues and their relation to engagement and sincerity as possible correlates of perceived clinical empathy (PCE). In this study, we explored the effect of doctor's gaze and body orientation on PCE with the help of 32 video vignettes.

METHODS

Actors impersonating medical interns displayed different combinations of gaze and body orientation while uttering an empathetic verbal statement. The video vignettes were evaluated in terms of the perceived clinical and general empathy, engagement and sincerity.

RESULTS

A principal component analysis revealed a possible single-factor solution for the scales measuring the two types of empathy, engagement and sincerity; therefore, they were subsumed under general perceived empathy (GPE). An analysis of variance showed a main effect of gaze and body orientation, with a stronger effect of gaze, on GPE. We subsequently performed a linear random effects analysis, which indicated possible gender-related differences in the perception of gaze.

CONCLUSIONS

The outcomes of our experiment confirm that both gaze and body orientation have an influence on the GPE. The effect of gaze, however, appears to be gender-dependent: in the experiment, males were perceived as slightly more empathetic with patient-centered gaze, while for females averted gaze resulted in higher GPE scores.

PRACTICE IMPLICATIONS

The findings are directly relevant in the context of medical communication training. Perception of clinical empathy supports medical information transfer, diagnosis quality and other patient outcomes.

Exploring residents' communication learning process in the workplace: a five-phase model

Context

Competency-based education is a resurgent paradigm in professional medical education. However, more specific knowledge is needed about the learning process of such competencies, since they consist of complex skills. We chose to focus on the competency of skilled communication and want to further explore its learning process, since it is regarded as a main competency in medical education.

Objective

This study aims to explore in more detail the learning process that residents in general practice go through during workplace-based learning in order to become skilled communicators.

Methods

A qualitative study was conducted in which twelve GP residents were observed during their regular consultations, and were interviewed in-depth afterwards.

Results

Analysis of the data resulted in the construction of five phases and two overall conditions to describe the development towards becoming a skilled communicator: Confrontation with (un)desired behaviour or clinical outcomes was the first phase. Becoming conscious of one’s own behaviour and changing the underlying frame of reference formed the second phase. The third phase consisted of the search for alternative behaviour. In the fourth phase, personalization of the alternative behaviour had to occur, this was perceived as difficult and required much time. Finally, the fifth phase concerned full internalization of the new behaviour, which by then had become an integrated part of the residents’ clinical repertoire. Safety and cognitive & emotional space were labelled as overall conditions influencing this learning process.

Conclusions

Knowledge and awareness of these five phases can be used to adjust medical working and learning environments in such a way that development of skilled medical communication can come to full fruition and its benefits are more fully reaped.