Physicians must tap into patients’ emotions

Empathy should become routine

When Kathryn Markakis, MD, and her colleagues at Highland Hospital in Rochester, NY, decided to find out how physician empathy influenced patient outcomes in 1996, they were startled to find that their original premise was wrong. "What we thought should be happening and was happening between some doctors and their patients actually occurred rarely. We set out to measure better outcomes and instead found an appalling paucity of empathy," explains Markakis, assistant professor of medicine at the University of Rochester.

If doctors are to embark on advance care planning and values assessment with patients, they first must learn to listen and not focus exclusively on diagnosis and treatment, she says. "What doctors need to offer is themselves."

To determine patterns of communication that lead to a standard practice of empathic communication, her colleagues used audio- and videotaped conversations between physicians and patients during primary office visits. Results of the study were published in the Journal of the American Medical Association.1

Don’t change the subject

Physicians must learn to identify empathic opportunities that patients initiate, respond in a way that encourages the dialogue, and stop themselves from changing the subject and terminating these opportunities, the study concluded.

Many patients want to express their emotional needs to their doctors, but they look for permission before speaking up. Too often, Markakis says, their doctors fail to encourage them. "Doctors somehow don’t feel comfortable exploring these feelings with the patient. It’s not that the doctor is uncaring."

In their study of the interactions, the researchers found that a physician typically redirected ["probably unconsciously"] any patient discussion that presented an empathic opportunity or the possibility of one.

Here is an example of one such missed opportunity, drawn from the transcript of a physician/patient visit and reported in JAMA:

Physician: "Does anybody in your family have breast cancer?"

Patient: "No . . . . Now I just started [unintelligible] after I had my hysterectomy. I was taking estrogen, right?"

Physician: "Yeah?"

Patient: "You know how your breasts get real hard and everything? You know how you get sorta scared?"

Physician: "How long were you on estrogen? . . . When did you have the hysterectomy?"

Videotaping has become an essential tool in resident education at the University of Rochester and has led to better empathic communication as Markakis and her colleagues continue to evaluate these interactions.

"The main focus is to do the videotaping and education in a way that is nonjudgmental," she says. "Show physicians how they can grow in their practice, not how badly they are doing."

Patients rarely verbalize their emotions directly or spontaneously, she says. They offer clues, statements or concerns that might be associated with their feelings about an illness or disease. Physicians should look for signs of emotion in patients’ physical expressions, posture, and tone of voice.

Many patients seek praise from their doctors for "good behavior." Yet doctors often fail to acknowledge this emotion as well. Physicians can become better at recognizing when patients express their emotions and at responding in a way that encourages patients to continue this type of communication, says Markakis. "I feel much better myself knowing that I am more aware of the patient’s needs, and I listen to what I am saying in response."

If you are uneasy listening to your patients’ feelings at first, Markakis recommends using words such as "OK, yes" to invite them to continue. "If you use a continuer word to allow the full story to emerge, you will be in a better position to offer an appropriate and effective empathic response," she says.


1. Suchman AL, Markakis K, Beckman HB, et al. Model of empathic communication: The medical interview. JAMA 1997; 277:678-682.