Bringing Back Bedside Manner: Empathic Communication in Telemedicine

It is a general concern among medical professionals that the healthcare system is suffering from a deficiency of empathy and compassion for patients.  Physicians across the country are leaving their small individual practices and going to work for large healthcare systems where much of the time previously spent face-to-face with patients is replaced by time spent in front of the computer screen, reviewing and collecting documentation in cumbersome electronic health record systems.  Today medical assistants record most of the patient’s medical history, and physicians sit distractedly in rooms, buried behind electronic health records and paperwork.  The result of this is that patients are feeling more and more disconnected from their physicians and taking less interest in partnering in their own medical care.  Physicians are overscheduled, overbooked, and overworked and general etiquette is deteriorating.  Bedside manner is getting lost in the drive to see more patients and complete more paperwork.

One main concern is that telemedicine will further strain the physician-patient relationship by creating physical and psychological distance between the patient and the physician.  The assumption of many people is, if you are not able use tactile adjuncts to communicate, then what remains of empathy and compassion in the current medical interaction will eventually disappear completely.  I believe this is missing the key point.  In many cases physicians in training are taught to refrain from using physical touch to create a sense of intimacy with patients.  Training teaches us that empathy and compassion are not only imparted in physical touch, but also, and with even greater impact, in the verbal and non-verbal components of empathic communication. The key is the correct and consistent use of empathic communication, and this form of communication can exist between to people regardless of the setting.  In fact, for a physician who uses Televideo as a tool to improve access to healthcare services there is increased face-to-face time with a patient and a necessary emphasis on accurate and compassionate history taking as an adjunct to the physical exam. Technology now becomes a facilitator of empathic communication rather than an impediment.  Physician-patient partnerships are created and strengthened through this adherence to positive and affirming communication, direct questions, genuine care and concern in providing patient answers, identifying patient emotional responses, recognizing patient needs and values, and providing patients with increased education and autonomy to act as partners in their own healthcare.

Empathic communication relies on four basic principles that can be applied to patients in a telemedicine encounter, in the same way as a traditional medical setting:  emotive and moral capacity to attend to the emotional experience of others, ability to maintain openness to and awareness of a patient’s emotional clues, accurately understanding the patient’s feelings, and being able to effectively communicate that understanding back to the patient.  The AMA has produced a teaching module entitled “STEPSforward Listening with Empathy” that outlines the following eight steps in empathic communication:

1. Decide before the interaction to connect with empathy: emotionally charged situations are the best time to employ empathic listening, but all patient interactions should start with openness to listen to and connect with a patient’s emotional perspective.  We must take great care to treat each patient as an individual and focus our attention directly on them when they are present for the encounter.
2. Reduce external distractions so that you can focus exclusively on the patient. This can also mean reducing your own internal distractions. Our mental presence is vital to this type of communication. Honor the first moments of conversation.  Do not interrupt and set aside anything that would be a distraction to give your full attention to the patient.  This will save time later because you will be more likely to understand the patient’s concerns.  Stay attentive throughout the interaction, not only to verbal but also non-verbal cues of the patient’s emotional state.
3. Assess the patient’s underlying feelings. Reflect on what you are also feeling which may give you a clue to the patient’s emotional state.  Pause, change your tone, and invite the patient to share more about what they are feeling during the interaction.
4. Listen to the patient’s emphasis on underlying needs and values. These can include subsistence, safety, work, honesty, autonomy, challenge, transcendence, rest, empathy and community.  It is important to identify which needs/values are being effected by the patient’s current condition to create meaningful goals for recovery.
5. Remain present with the patient. Adopt an open stance.  Do not cross your arms.  Make eye contact.  Lean in.  Match the speaker’s emotionally intensity with your own intonation.   Include simple responses and nod your head at appropriate intervals to convey interest.
6. Consider appropriate times to respond verbally. Timing is important, as verbal responses too early in the patient’s narrative may be deemed as an interruption.  First acknowledge what the patient has said by naming the emotion, reflecting understanding, respecting or acknowledging the patient’s perspective or supporting.   Next respond with compassion using reflective statements, offering support, validating the patient’s perspective, and/or making a partnership statement.  Summarize what the patient has said and the key points of their problem as you understand it.  A summary shows the patient that you were listening, and gives them a chance to modify any information or correct any misconceptions or misrepresentations.
7. Look for cues that the patient has finished expressing him/herself. Do not interrupt.  We often wish to move the conversation along so that we can move on to the next patient or problem on our agenda.   Interruptions take away from really hearing what the other person is saying, and in doing so you may miss an integral piece of information necessary to determining an individualized treatment plan.
8. Following the interaction reflect on your experience and rejuvenate yourself for the next interaction.

Empathic communication skills can be easily taught to physicians and physicians in training.   Training in empathic verbal and non-verbal communication skills has been shown to improve all aspects of the patient-physician interaction by facilitating effective transmission of information, improving the effectiveness of questioning, improving patient perceptions of the interaction, and encouraging partnerships and participatory decision-making.   There has also been shown be greater adherence by patients to prescribed treatment plans, and more open discussion of risks, benefits, alternatives, and expectations of treatment.

Conversely, when physicians failed to recognize expressions of affect by patients and provide immediate empathy and concern, patients expressions of emotion were often escalated to the point of the physician labeling the patient and/or interaction as “difficult.”  Patients rarely offered direct communication of emotion during the interview, and it was necessary for the physician to utilize empathic listening skills to avoid missing opportunities to connect with and encourage patients.   A lack of acknowledgment of patient emotional needs and responses is a threat to the patient-physician relationship and has been shown to be a predisposing factor in many lawsuits.

Empathic listening and communication builds trust between two people, reduces tension, encourages honesty, and creates an environment that fosters problem solving and mutually beneficial solutions.  This trust will not only foster a full disclosure and more complete history of illness or injury, it will also facilitate the performance of all necessary parts of the telemedicine physical exam with less tension and reticence on the part of the patient. When empathic communication is used consistently patients are more satisfied with the care they receive, more adherent to treatment plans, and less likely to pursue legal action against their treating physician.

Bibliography

• AMA. (n.d.). STEPSforward: Listening with Empathy. Retrieved from American Medical Association: https://www.stepsforward.org/modules/empathetic-listening
• DiMatteo, K. B. (2009, August). Physician communication and patient adherence to treatment: A meta-analysis. Medical Care, 47(8), 826-834.
• Z Di Bassi, E. H. (2001, March). Influence of context effects on health outcomes: a systematic review . Lancet, 357(9258), 757-762.