New Practitioners Forum
New Practitioners Forum Empathy and the new practitioner
W
ith advances in pharmacy practice and specialty training, clinical pharmacists in inpatient settings are finding themselves on the frontline of patient care but may lack formal instruction in empathetic communication. While pharmacy practice and specialty residencies adequately prepare clinical pharmacistsin-training for the scientific aspects of healthcare, these programs may fall short in preparing the resident to care for the whole patient. As a consequence, clinical pharmacists may be less equipped to deal with the emotional aspects of patient care and thus risk being perceived as the more detached member of the healthcare team.1 Fortunately for the new pharmacy practitioner, clinicians well versed in end-of-life conversations have developed an effective model for empathetic communication that can be borrowed and implemented by pharmacists in any setting. Thus, the intent of this article is to provide a framework for recognizing emotions and articulating empathetic statements that the new practitioner can use and share with learners to change the culture of pharmacist detachment. The importance of empathy. Empathy can be defined as “a process for understanding an individual’s subjective experience by vicariously sharing that experience while maintaining an observant’s stance.”2 In order to begin a dis-
cussion of empathetic communication, the term empathy must be differentiated from the term sympathy, which denotes
sharing the feelings of a person in such a way that one suffers in response to that person’s suffering.3 Simply put, sympathy places the focus on oneself, while empathy maintains the focus on the patient.4 Sympathy sounds like this: “I know how you feel; I am so sorry for your loss.” While the second statement can be appropriate, the first may cause the patient to retort “No, you don’t!” Therefore, empathetic statements such as “It sounds like you are sad” and “I cannot imagine what it is like to . . .” may be more helpful in developing rapport.5 At its core, the empathy-building process involves finding a “certain resonance with the emotional state” of a person and displaying “verbally and
The New Practitioners Forum column features articles that address the special professional needs of pharmacists early in their careers as they transition from students to practitioners. Authors include new practitioners or others with expertise in a topic of interest to new practitioners. AJHP readers are invited to submit topics or articles for this column to the New Practitioners Forum, c/o Jill Haug, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8821 or [email protected]).
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non-verbally this resonance.”6 A shared experience is not necessary to “resonate” with a patient, but empathy requires that the clinician reflect back to the patient an understanding and appreciation of the emotions and concerns divulged.5 For the new practitioner just beginning to develop professional and life experiences, this is good news; empathy (or at least aspects of it) can be developed through practice. While becoming empathetic will certainly rely on the emotional and moral capacities of the pharmacist, the cognitive and behavioral aspects of empathy can be learned.7,8 In fact, interventions designed to increase empathy among pharmacy students, such as patient simulations, workshops on aging, and courses on death and dying, have been published with favorable results, which supports this idea of acquired empathy.1,9,10 Recent academic standards from the Accreditation Council for Pharmacy Education and the Center for Advancement of Pharmacy Education have emphasized the importance of empathy in patient care—and with good reason.11,12 Literature has shown that quality communication incorporating empathetic dialogue results in greater patient satisfaction, comprehension, and adherence in some cases, even improved clinical outcomes.13-16 Specifically in end-of-life care, empathy is also useful for initiating and guiding goals-of-care conversations and as a means of eliciting information about pain and other physical or psychological symptoms such as depression, anxiety, and fear.17,18 Research, however, has suggested that oncologists and other physicians too often focus on the medical aspects of disease and treatContinued on page 2046
New Practitioners Forum Continued from page 2042
ment during patient encounters at the cost of not recognizing and addressing patient concerns.6,18 As a result, several programs have been developed to assist medical fellows in enhancing their communication skills and comfort level with difficult communication tasks (e.g., breaking bad news, discussing palliative or hospice care, conducting family conferences).5,18 Such tasks are key objectives of OncoTalk, a program designed to improve oncology fellows’ communication with patients.18,19 VitalTalk was later developed to reach a broader oncologist audience, and resources from both programs are available online.19,20 These programs and others like them—GeriTalk for geriatrics fellows and IntensiveTalk for critical care fellows—utilize evidence-based educational techniques and structured skills practice to improve physician communication with patients facing lifelimiting illnesses.21 Although a similar program for pharmacists has yet to be developed, focusing on the first communication task in the first OncoTalk training module—“responding to emotional concerns and affect”5—could prove to be very useful to pharmacists wishing to enhance their patient interactions. Responding to emotion and articulating empathy. In end-of-life care, strategies for handling emotion and displaying empathy revolve around three major concepts: (1) identifying the emotion or mood for oneself, (2) naming the emotion for the patient, and (3) exploring this emotion further.5,6 Identi-
fying the emotion or mood involves the cognitive skill of recognizing the mood in the patient’s room or the emotion the patient is exhibiting. This is the first step in preparing for an empathetic exchange: pinpointing what is happening. It is usually a task accomplished through silent contemplation, but it can at times be helpful to express statements such as “How sad” and “How awful.” These statements are, in themselves, empathetic expressions and may serve to draw attention to an emotional subtext that can be explored.6 After identifying the mood in the room, one simple way to acknowledge the patient’s emotion is by naming it aloud using an empathetic phrase such as “You seem concerned.” While naming an emotion is the most commonly used empathetic statement, the palliative care literature suggests that in order to truly resonate with a patient’s emotional suffering, other verbal or even nonverbal expressions may be needed.6 Recognizing this, the OncoTalk and VitalTalk programs both utilize the mnemonic NURSE to provide clinicians with other ways of addressing and responding empathetically to patients’ emotions and concerns.5,22 The NURSE approach entails • Naming the patient’s emotion, • Understanding the patient’s situation or feelings, • Respecting the patient’s emotions and conveying that such emotions are not only permissible but valuable, • Supporting the patient by expressing concern, committing to help, and ver-
Dialogue Scenario 1 Pharmacist: Before you were admitted, how many times per day were you taking the hydromorphone? Patient: I take it just as prescribed—every six hours—but it just does not last long enough. I take a dose right before bed, and I awaken four hours later in pain. I think this means my cancer is worsening. I used to be able to sleep through the night. [empathetic opportunity] Pharmacist: It sounds like you are frustrated and worried about your pain control. [naming] I can tell that you have been trying to follow your doctor’s instructions. [respecting] No need to worry anymore; the team and I will work on making sure your pain is well controlled and your sleep improves. [supporting] Is there anything else that worries you? [exploring] [empathetic responses]
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bally recognizing the patient’s coping efforts, and • Exploring the emotion further.5
Eliciting further exploration of emotions is an important step, as it may reveal helpful subjective data, enhance understanding of the patient’s experience or interpretation of his or her illness, and provide additional support to the patient. Beyond naming and exploring patients’ emotions, clinicians may even consider sharing their own emotions with patients and families in certain situations, according to James Hallenback, a palliative care physician and author of Palliative Care Perspectives.6 In that book he argued that clinicians, after all, are human and that their sharing of human emotions could be therapeutic to the patient or family. For instance, while sharing in grief or sadness may be difficult—and perhaps even perceived as improper—Hallenback asked clinicians to look at this issue in a different way: “Consider how you might feel if a physician shed a few tears when pronouncing [dead] a loved one of yours. Would you consider it unprofessional or a tribute?” In addition to verbal expression of empathy, the value of nonverbal demonstration of empathy cannot be ignored. Physical actions such as a gentle touch, holding a patient’s hand, or pulling a chair up to the bedside to sit closer to the patient can provide a tacit compassionate connection. When the patient expresses sorrow, pain, or another difficult emotion, a change in the clinician’s position or posture—even a facial expression such as furrowing the brows—can demonstrate empathy.5,6 Moreover, listening to patients without interruption except for brief remarks such as “I see” and “Yes, go on” can be very effective in developing rapport.23 Such active listening can be practiced by pausing for a few moments when the urge to speak arises.24 Given the importance of unspoken empathy, it would benefit the new pharmacist to look to his or her nursing colleagues for a model of nonverbal communication. In the nursing literature, such wordless expressions of empathy are considered the crux of the nurse–patient Continued on page 2052
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relationship and are communicated by modest head nodding, eye contact, and minimizing activity or movement.23 In the same vein, it is also important to pay attention to the emotions patients express through nonverbal cues; for instance, wrinkling the forehead or wringing the hands may be suggestive of anxiety, and noticing those cues could provide an opportunity to further explore this emotion.23 Recognizing empathetic opportunities. The cognitive component of empathy refers to the clinician’s ability to detect and understand the emotions relayed by the patient. Cognitively, the pharmacist engaged in a patient interaction can also learn to identify “empathetic opportunities,” which simply means situations in which the patient has expressed an emotion and, thus, the opportunity for an empathetic response is created.25 Conversely, a “missed empathetic opportunity” is a situation in which a clinician fails to insert an empathetic response when the opportunity arises.25 To illustrate these two concepts, three fictitious pharmacist–patient communication scenarios are presented in this article. These dialogues were adapted from examples of physician–patient interactions compiled during a qualitative study of verbal exchanges published by Suchman and colleagues.25 The examples have been modified for increased relevance to patient–pharmacist interactions in an inpatient setting; however, the concepts conveyed are applicable in any patient care setting. In scenario 1, the patient does not verbalize an emotion directly but rather offers a statement of concern that might be linked with an emotion. Often when such indirect statements are given, the patient’s nonverbal cues may bring the perceived emotion into greater focus. Emotion can also sometimes be identified in a patient’s voice: He or she may get choked up when speaking, the voice may quiver, and, of course, the tone of the voice can be indicative of a particular emotion. In the aforementioned study by Suchman et al.,25 a frequent observation was that patients rarely verbalize their emotions directly. The researchers proposed that this can be remedied by the interviewer if he or she invites the patient to explore the emotion further by using a “potential empathetic opportunity continuer,” as illustrated in scenario 2. Continuers might include a gently interjected “uh-huh” or an encouraging statement (e.g., “I see, go on.”)—or even a question (e.g., “How do you feel about that?”). After studying 21 physicians’ verbal exchanges with patients, Suchman and colleagues25 found that, in most cases, instead of using continuers (as illustrated in scenario 2) physicians tended to redirect the conversation by stating a new question or making an unrelated comment. In their study report, Suchman et al. referred to these phrases as “potential empathetic opportunity terminators.” They speculated that physicians’ overuse of such terminators most likely stemmed from a preoccupation with obtaining objective data.25 In that respect pharmacists may not be too different from physicians; whether due to a lack of time or a lack of communications Continued on page 2054
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training, pharmacists may also find themselves prioritizing objective data over subjective information. Yet, it is the subjective information that may help foster more authentic patient relationships and facilitate a deeper understanding of the patient’s illness.6 Hypothetical scenario 3 illustrates a missed empathetic opportunity—a missed chance to fully understand and support the patient. By sticking to the agenda of obtaining a medication history, the pharmacist would likely fail to obtain valuable subjective information. If the pharmacist had recognized and chosen to pursue the empathetic opportunity, he or she could have said something like “I cannot imagine what that must feel like.” Such a statement is in line with the NURSE approach (i.e., by acknowledging the emotion without suggesting that it is completely understood, the patient is invited to explore the emo-
Dialogue Scenario 2 Pharmacist: Do you drink alcohol? Patient: No. Pharmacist: Do you smoke? Patient: Yes. I have tried to quit. [potential empathetic opportunity] Pharmacist: Oh. How did that go? [potential empathetic opportunity continuer] Patient: I tried everything—the gum, the patches— but nothing seemed to work. I just can’t seem to kick this habit. Pharmacist: Uh-huh. I see. [potential empathetic opportunity continuer] Patient: I have two daughters, you know. I need to be around for them. My brother died of lung cancer last year. [empathetic opportunity] Pharmacist: How awful. You seem very concerned for your own health. [empathetic responses: identifying the mood and naming] Patient: I really am. Pharmacist: You may be a candidate for other tobacco cessation methods. I will speak to your physician about other alternatives to help you quit smoking. [empathetic response: supporting]
Dialogue Scenario 3 Patient: I have been so nauseated. I can’t keep any food down. It’s awful. [empathetic opportunity] Pharmacist: Are you still able to keep your medications down? How many doses would you say you miss on an average day? [missed empathetic opportunity] Continued on page 2056
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tion further).5,22 Another possibility is that the pharmacist in scenario 3 noticed the “emotional cue” but chose to ignore it due to a singular focus on completing the medication history. According to a recent article by VitalTalk faculty members Anthony Back and Robert Arnold,26 in such situations the pharmacist should not try to “dissipate” the patient’s emotion or “wait for it to pass” but should instead “connect” and “engage with the patient’s emotional mind.” Learning from palliative care providers. Beyond being empathetic, many palliative care providers possess “core attitudes” that aid in the development of successful patient relationships. In a small study of 10 palliative care professionals, investigators Simon and colleagues27 deduced several core qualities of clinicians who care for patients with life-limiting illnesses: authenticity, personal presence, honesty, and mindfulness. While many of these core attitudes can fully mature only through personal and professional experiences, new practitioners’ awareness of these values and how they affect patient interactions can help foster an appropriate bedside manner. The palliative care professionals interviewed by Simon et al.27 identified authenticity as a fundamental core attitude in building rapport with patients. To project authenticity during an encounter with a new patient, the study’s participants advised, clinicians should focus on simply “being a person” instead of “behaving only in a specific role” (e.g., physician, pharmacist). Other key components of authenticity include modesty and displaying an “honest interest” in the patient. Personal presence, described as “completely being in the here and now,” was also found to be an essential characteristic of palliative care professionals in the study of Simon et al.27 While similar to authenticity, personal presence involves focusing on the patient, whereas being authentic requires an inwardly focused effort to shed professional barriers. Creating a personal presence ultimately reassures the patient that he or she is the “focus of the current moment and all other things are secondary.”27 Establishing that 2056
presence requires a conscious effort on the part of the clinician, as visiting patients while distracted could thwart the rapport-building process. In a recent qualitative study, patients and their families also identified presence—both physical and emotional—as one of the most important behaviors of palliative care professionals.14 In the minds of the professionals studied by Simon et al.,27 honesty is more than a core competency in palliative care; it is a prerequisite for a good patient– clinician relationship. Honesty requires communicating accurate information to patients at all stages of care—from a discussion of expected outcomes of drug therapy to delivery of a prognosis. Using language such as “I wish . . .” statements may help the new practitioner respond to questions honestly when the answer cannot truly be known.22 Such statements include “It would be wonderful to know for certain how much time you have left” and “I wish it were possible to know if the tumor will respond this time.”2,22 If the health professional conveys empathy with the patient’s desire for “greater certainty,” the patient–clinician relationship may be strengthened.28 Mindfulness denotes being open to the patient’s concerns, feelings, and needs without casting judgment or even acting to evaluate them. It suggests being attentive to the current moment and to the patient in that moment. Simon et al.27 suggested that patients who are ill or dying may be in “special need of mindfulness.” The new pharmacy practitioner, however, may find it particularly beneficial to adopt the practice of nonjudgmental appreciation to improve interactions in other phases of patient care. By keeping these four core attitudes in mind when entering a patient’s room, the new practitioner may begin to create a space for the patient to feel safe and communicate honestly without fear of reprehension. In an interview with Simon and colleagues,27 one palliative care expert stated that this space is “created through the way of contact or the atmosphere in the room” and that it is the clinician’s “role to create the space” for the patient. This idea of “creating space” is echoed in an article by Back and Arnold,17 in which a skilled clinician is depicted cre-
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ating an “environment” or a “reflective space” for his patients by offering “verbal empathy.” Closing notes. Looking to our colleagues in end-of-life care, we find a wellestablished model for empathetic expression and a foundation for creating a safe, comfortable space for this communication. By practicing the cognitive and behavioral strategies for acknowledging and responding to patient emotions, new pharmacy practitioners can begin to develop their own empathetic process. This process can then be shared and modeled for students, residents, and even veteran pharmacists to enhance their bedside conversations with patients. 1. Manolaski ML, Olin JL, Thornton PL et al. A module on death and dying to develop empathy in student pharmacists. Am J Pharm Educ. 2010; 75:article 71. 2. Zinn W. The empathic physician. Arch Intern Med. 1993; 153:306-12. 3. Khanuja S, Dongalikar V, Arora R, Gupta A. Empathy and sympathy in the medical profession: should we stop the desertion? Pravara Med Rev. 2011; 3:37-9. 4. Isle of Wight NHS Trust. End of life care: understanding and using empathy. www. iow.nhs.uk/Working-With-Us/learningzone/training-tracker_2.htm (accessed 2014 Dec 30). 5. OncoTalk. Module 1: fundamental communication skills. www.oncotalk.info (accessed 2014 Dec 30). 6. Hallenback JL. Palliative care perspectives. New York: Oxford Univ. Press; 2003:159-90. 7. Morse JM, Anderson G, Bottorff JL et al. Exploring empathy: a conceptual fit for nursing practices? Image J Nurs Sch. 1999; 24:273-80. 8. Nyatanga B. Empathy in palliative care: is it possible to understand another person? Int J Palliat Nurs. 2013; 19:471. 9. Lor KB, Truong JT, Ip EJ, Barnett MJ. A randomized prospective study on outcomes of an empathy intervention among second-year student pharmacists. Am J Pharm Educ. 2015; 79:article 18. 10. Van Winkle LJ, Fjortoft N, Hojat M. Impact of a workshop about aging on the empathy scores of pharmacy and medical students. Am J Pharm Educ. 2012; 76: article 9. 11. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree (February 17, 2006). www.acpe-accredit.org/pdf/ FinalS2007Guidelines2.0.pdf (accessed 2015 Apr 13).
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12. American Association of Colleges of Pharmacy. Educational outcomes 2013. www.aacp.org/resources/education/cape/ (accessed 2015 Apr 13). 13. Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient satisfaction and compliance. Eval Health Prof. 2004; 27:237-51. 14. Ciemins EL, Brant J, Kersten D et al. A qualitative analysis of patient and family perspectives of palliative care. J Palliat Med. 2015; 18:282-5. 15. Bonvicini KA, Perlin MJ, Bylund CL et al. Impact of communication training on physician expression of empathy in patient encounters. Patient Educ Couns. 2009; 75:3-10. 16. Hojat M, Louis DZ, Markham FW et al. Physician empathy and clinical outcomes for diabetic patients. Acad Med. 2011; 86:359-64. 17. Back AL, Arnold RM. Isn’t there anything more you can do? When empathic statements work, and when they don’t. J Palliat Med. 2013; 16:1429-32.
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18. Back AL, Arnold RM, Tulsky JA et al. Teaching communication skills to medical oncology fellows. J Clin Oncol. 2003; 21:2433-6. 19. OncoTalk. Improving oncologist’s communication skills. www.oncotalk.info (accessed 2015 Apr 13). 20. VitalTalk. Home page. www.vitaltalk.org (accessed 2015 Apr 13). 21. GeriPal. OncoTalk legacy: IntensiveTalk and GeriTalk (August 8, 2012). www. geripal.org/2012/08/oncotalk-legacyintensivetalk-and.html (accessed 2014 Dec 30). 22. VitalTalk. NURSE: one page guide. www. vitaltalk.org/clinicians/track-respondemotion (accessed 2014 Dec 30). 23. Kacperek L. Non-verbal communication: the importance of listening. Br J Nurs. 1997; 6:275-9. 24. Stanford Faculty Development Center. End-of-life care module 3: communicating with patients and families. www. growthhouse.org/stanford (accessed 2015 Jan 3). 25. Suchman AL, Markakis K, Beckman HB, Frankel R. A model for empathic com-
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munication in the medical interview. JAMA. 1997; 277:678-82. 26. Back AL, Arnold RM. “Yes it’s sad, but what should I do?”: moving from empathy to action in discussing goals of care. J Palliat Med. 2014; 17:141-4. 27. Simon ST, Ramsenthaler C, Bausewein C et al. Core attitudes of professionals in palliative care: a qualitative study. Int J Palliat Nurs. 2009; 15:405-11. 28. Hallenback JL. op cit. :15.
Laura Meyer-Junco, Pharm.D., BCPS, CPE, Clinical Assistant Professor University of Illinois at Chicago College of Pharmacy, Rockford Campus Rockford, IL [email protected]
The author has declared no potential conflicts of interest. DOI 10.2146/ajhp150020
New Practitioners Forum Empathy and the new practitioner
W
ith advances in pharmacy practice and specialty training, clinical pharmacists in inpatient settings are finding themselves on the frontline of patient care but may lack formal instruction in empathetic communication. While pharmacy practice and specialty residencies adequately prepare clinical pharmacistsin-training for the scientific aspects of healthcare, these programs may fall short in preparing the resident to care for the whole patient. As a consequence, clinical pharmacists may be less equipped to deal with the emotional aspects of patient care and thus risk being perceived as the more detached member of the healthcare team.1 Fortunately for the new pharmacy practitioner, clinicians well versed in end-of-life conversations have developed an effective model for empathetic communication that can be borrowed and implemented by pharmacists in any setting. Thus, the intent of this article is to provide a framework for recognizing emotions and articulating empathetic statements that the new practitioner can use and share with learners to change the culture of pharmacist detachment. The importance of empathy. Empathy can be defined as “a process for understanding an individual’s subjective experience by vicariously sharing that experience while maintaining an observant’s stance.”2 In order to begin a dis-
cussion of empathetic communication, the term empathy must be differentiated from the term sympathy, which denotes
sharing the feelings of a person in such a way that one suffers in response to that person’s suffering.3 Simply put, sympathy places the focus on oneself, while empathy maintains the focus on the patient.4 Sympathy sounds like this: “I know how you feel; I am so sorry for your loss.” While the second statement can be appropriate, the first may cause the patient to retort “No, you don’t!” Therefore, empathetic statements such as “It sounds like you are sad” and “I cannot imagine what it is like to . . .” may be more helpful in developing rapport.5 At its core, the empathy-building process involves finding a “certain resonance with the emotional state” of a person and displaying “verbally and
The New Practitioners Forum column features articles that address the special professional needs of pharmacists early in their careers as they transition from students to practitioners. Authors include new practitioners or others with expertise in a topic of interest to new practitioners. AJHP readers are invited to submit topics or articles for this column to the New Practitioners Forum, c/o Jill Haug, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8821 or [email protected]).
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non-verbally this resonance.”6 A shared experience is not necessary to “resonate” with a patient, but empathy requires that the clinician reflect back to the patient an understanding and appreciation of the emotions and concerns divulged.5 For the new practitioner just beginning to develop professional and life experiences, this is good news; empathy (or at least aspects of it) can be developed through practice. While becoming empathetic will certainly rely on the emotional and moral capacities of the pharmacist, the cognitive and behavioral aspects of empathy can be learned.7,8 In fact, interventions designed to increase empathy among pharmacy students, such as patient simulations, workshops on aging, and courses on death and dying, have been published with favorable results, which supports this idea of acquired empathy.1,9,10 Recent academic standards from the Accreditation Council for Pharmacy Education and the Center for Advancement of Pharmacy Education have emphasized the importance of empathy in patient care—and with good reason.11,12 Literature has shown that quality communication incorporating empathetic dialogue results in greater patient satisfaction, comprehension, and adherence in some cases, even improved clinical outcomes.13-16 Specifically in end-of-life care, empathy is also useful for initiating and guiding goals-of-care conversations and as a means of eliciting information about pain and other physical or psychological symptoms such as depression, anxiety, and fear.17,18 Research, however, has suggested that oncologists and other physicians too often focus on the medical aspects of disease and treatContinued on page 2046
New Practitioners Forum Continued from page 2042
ment during patient encounters at the cost of not recognizing and addressing patient concerns.6,18 As a result, several programs have been developed to assist medical fellows in enhancing their communication skills and comfort level with difficult communication tasks (e.g., breaking bad news, discussing palliative or hospice care, conducting family conferences).5,18 Such tasks are key objectives of OncoTalk, a program designed to improve oncology fellows’ communication with patients.18,19 VitalTalk was later developed to reach a broader oncologist audience, and resources from both programs are available online.19,20 These programs and others like them—GeriTalk for geriatrics fellows and IntensiveTalk for critical care fellows—utilize evidence-based educational techniques and structured skills practice to improve physician communication with patients facing lifelimiting illnesses.21 Although a similar program for pharmacists has yet to be developed, focusing on the first communication task in the first OncoTalk training module—“responding to emotional concerns and affect”5—could prove to be very useful to pharmacists wishing to enhance their patient interactions. Responding to emotion and articulating empathy. In end-of-life care, strategies for handling emotion and displaying empathy revolve around three major concepts: (1) identifying the emotion or mood for oneself, (2) naming the emotion for the patient, and (3) exploring this emotion further.5,6 Identi-
fying the emotion or mood involves the cognitive skill of recognizing the mood in the patient’s room or the emotion the patient is exhibiting. This is the first step in preparing for an empathetic exchange: pinpointing what is happening. It is usually a task accomplished through silent contemplation, but it can at times be helpful to express statements such as “How sad” and “How awful.” These statements are, in themselves, empathetic expressions and may serve to draw attention to an emotional subtext that can be explored.6 After identifying the mood in the room, one simple way to acknowledge the patient’s emotion is by naming it aloud using an empathetic phrase such as “You seem concerned.” While naming an emotion is the most commonly used empathetic statement, the palliative care literature suggests that in order to truly resonate with a patient’s emotional suffering, other verbal or even nonverbal expressions may be needed.6 Recognizing this, the OncoTalk and VitalTalk programs both utilize the mnemonic NURSE to provide clinicians with other ways of addressing and responding empathetically to patients’ emotions and concerns.5,22 The NURSE approach entails • Naming the patient’s emotion, • Understanding the patient’s situation or feelings, • Respecting the patient’s emotions and conveying that such emotions are not only permissible but valuable, • Supporting the patient by expressing concern, committing to help, and ver-
Dialogue Scenario 1 Pharmacist: Before you were admitted, how many times per day were you taking the hydromorphone? Patient: I take it just as prescribed—every six hours—but it just does not last long enough. I take a dose right before bed, and I awaken four hours later in pain. I think this means my cancer is worsening. I used to be able to sleep through the night. [empathetic opportunity] Pharmacist: It sounds like you are frustrated and worried about your pain control. [naming] I can tell that you have been trying to follow your doctor’s instructions. [respecting] No need to worry anymore; the team and I will work on making sure your pain is well controlled and your sleep improves. [supporting] Is there anything else that worries you? [exploring] [empathetic responses]
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bally recognizing the patient’s coping efforts, and • Exploring the emotion further.5
Eliciting further exploration of emotions is an important step, as it may reveal helpful subjective data, enhance understanding of the patient’s experience or interpretation of his or her illness, and provide additional support to the patient. Beyond naming and exploring patients’ emotions, clinicians may even consider sharing their own emotions with patients and families in certain situations, according to James Hallenback, a palliative care physician and author of Palliative Care Perspectives.6 In that book he argued that clinicians, after all, are human and that their sharing of human emotions could be therapeutic to the patient or family. For instance, while sharing in grief or sadness may be difficult—and perhaps even perceived as improper—Hallenback asked clinicians to look at this issue in a different way: “Consider how you might feel if a physician shed a few tears when pronouncing [dead] a loved one of yours. Would you consider it unprofessional or a tribute?” In addition to verbal expression of empathy, the value of nonverbal demonstration of empathy cannot be ignored. Physical actions such as a gentle touch, holding a patient’s hand, or pulling a chair up to the bedside to sit closer to the patient can provide a tacit compassionate connection. When the patient expresses sorrow, pain, or another difficult emotion, a change in the clinician’s position or posture—even a facial expression such as furrowing the brows—can demonstrate empathy.5,6 Moreover, listening to patients without interruption except for brief remarks such as “I see” and “Yes, go on” can be very effective in developing rapport.23 Such active listening can be practiced by pausing for a few moments when the urge to speak arises.24 Given the importance of unspoken empathy, it would benefit the new pharmacist to look to his or her nursing colleagues for a model of nonverbal communication. In the nursing literature, such wordless expressions of empathy are considered the crux of the nurse–patient Continued on page 2052
New Practitioners Forum Continued from page 2046
relationship and are communicated by modest head nodding, eye contact, and minimizing activity or movement.23 In the same vein, it is also important to pay attention to the emotions patients express through nonverbal cues; for instance, wrinkling the forehead or wringing the hands may be suggestive of anxiety, and noticing those cues could provide an opportunity to further explore this emotion.23 Recognizing empathetic opportunities. The cognitive component of empathy refers to the clinician’s ability to detect and understand the emotions relayed by the patient. Cognitively, the pharmacist engaged in a patient interaction can also learn to identify “empathetic opportunities,” which simply means situations in which the patient has expressed an emotion and, thus, the opportunity for an empathetic response is created.25 Conversely, a “missed empathetic opportunity” is a situation in which a clinician fails to insert an empathetic response when the opportunity arises.25 To illustrate these two concepts, three fictitious pharmacist–patient communication scenarios are presented in this article. These dialogues were adapted from examples of physician–patient interactions compiled during a qualitative study of verbal exchanges published by Suchman and colleagues.25 The examples have been modified for increased relevance to patient–pharmacist interactions in an inpatient setting; however, the concepts conveyed are applicable in any patient care setting. In scenario 1, the patient does not verbalize an emotion directly but rather offers a statement of concern that might be linked with an emotion. Often when such indirect statements are given, the patient’s nonverbal cues may bring the perceived emotion into greater focus. Emotion can also sometimes be identified in a patient’s voice: He or she may get choked up when speaking, the voice may quiver, and, of course, the tone of the voice can be indicative of a particular emotion. In the aforementioned study by Suchman et al.,25 a frequent observation was that patients rarely verbalize their emotions directly. The researchers proposed that this can be remedied by the interviewer if he or she invites the patient to explore the emotion further by using a “potential empathetic opportunity continuer,” as illustrated in scenario 2. Continuers might include a gently interjected “uh-huh” or an encouraging statement (e.g., “I see, go on.”)—or even a question (e.g., “How do you feel about that?”). After studying 21 physicians’ verbal exchanges with patients, Suchman and colleagues25 found that, in most cases, instead of using continuers (as illustrated in scenario 2) physicians tended to redirect the conversation by stating a new question or making an unrelated comment. In their study report, Suchman et al. referred to these phrases as “potential empathetic opportunity terminators.” They speculated that physicians’ overuse of such terminators most likely stemmed from a preoccupation with obtaining objective data.25 In that respect pharmacists may not be too different from physicians; whether due to a lack of time or a lack of communications Continued on page 2054
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training, pharmacists may also find themselves prioritizing objective data over subjective information. Yet, it is the subjective information that may help foster more authentic patient relationships and facilitate a deeper understanding of the patient’s illness.6 Hypothetical scenario 3 illustrates a missed empathetic opportunity—a missed chance to fully understand and support the patient. By sticking to the agenda of obtaining a medication history, the pharmacist would likely fail to obtain valuable subjective information. If the pharmacist had recognized and chosen to pursue the empathetic opportunity, he or she could have said something like “I cannot imagine what that must feel like.” Such a statement is in line with the NURSE approach (i.e., by acknowledging the emotion without suggesting that it is completely understood, the patient is invited to explore the emo-
Dialogue Scenario 2 Pharmacist: Do you drink alcohol? Patient: No. Pharmacist: Do you smoke? Patient: Yes. I have tried to quit. [potential empathetic opportunity] Pharmacist: Oh. How did that go? [potential empathetic opportunity continuer] Patient: I tried everything—the gum, the patches— but nothing seemed to work. I just can’t seem to kick this habit. Pharmacist: Uh-huh. I see. [potential empathetic opportunity continuer] Patient: I have two daughters, you know. I need to be around for them. My brother died of lung cancer last year. [empathetic opportunity] Pharmacist: How awful. You seem very concerned for your own health. [empathetic responses: identifying the mood and naming] Patient: I really am. Pharmacist: You may be a candidate for other tobacco cessation methods. I will speak to your physician about other alternatives to help you quit smoking. [empathetic response: supporting]
Dialogue Scenario 3 Patient: I have been so nauseated. I can’t keep any food down. It’s awful. [empathetic opportunity] Pharmacist: Are you still able to keep your medications down? How many doses would you say you miss on an average day? [missed empathetic opportunity] Continued on page 2056
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tion further).5,22 Another possibility is that the pharmacist in scenario 3 noticed the “emotional cue” but chose to ignore it due to a singular focus on completing the medication history. According to a recent article by VitalTalk faculty members Anthony Back and Robert Arnold,26 in such situations the pharmacist should not try to “dissipate” the patient’s emotion or “wait for it to pass” but should instead “connect” and “engage with the patient’s emotional mind.” Learning from palliative care providers. Beyond being empathetic, many palliative care providers possess “core attitudes” that aid in the development of successful patient relationships. In a small study of 10 palliative care professionals, investigators Simon and colleagues27 deduced several core qualities of clinicians who care for patients with life-limiting illnesses: authenticity, personal presence, honesty, and mindfulness. While many of these core attitudes can fully mature only through personal and professional experiences, new practitioners’ awareness of these values and how they affect patient interactions can help foster an appropriate bedside manner. The palliative care professionals interviewed by Simon et al.27 identified authenticity as a fundamental core attitude in building rapport with patients. To project authenticity during an encounter with a new patient, the study’s participants advised, clinicians should focus on simply “being a person” instead of “behaving only in a specific role” (e.g., physician, pharmacist). Other key components of authenticity include modesty and displaying an “honest interest” in the patient. Personal presence, described as “completely being in the here and now,” was also found to be an essential characteristic of palliative care professionals in the study of Simon et al.27 While similar to authenticity, personal presence involves focusing on the patient, whereas being authentic requires an inwardly focused effort to shed professional barriers. Creating a personal presence ultimately reassures the patient that he or she is the “focus of the current moment and all other things are secondary.”27 Establishing that 2056
presence requires a conscious effort on the part of the clinician, as visiting patients while distracted could thwart the rapport-building process. In a recent qualitative study, patients and their families also identified presence—both physical and emotional—as one of the most important behaviors of palliative care professionals.14 In the minds of the professionals studied by Simon et al.,27 honesty is more than a core competency in palliative care; it is a prerequisite for a good patient– clinician relationship. Honesty requires communicating accurate information to patients at all stages of care—from a discussion of expected outcomes of drug therapy to delivery of a prognosis. Using language such as “I wish . . .” statements may help the new practitioner respond to questions honestly when the answer cannot truly be known.22 Such statements include “It would be wonderful to know for certain how much time you have left” and “I wish it were possible to know if the tumor will respond this time.”2,22 If the health professional conveys empathy with the patient’s desire for “greater certainty,” the patient–clinician relationship may be strengthened.28 Mindfulness denotes being open to the patient’s concerns, feelings, and needs without casting judgment or even acting to evaluate them. It suggests being attentive to the current moment and to the patient in that moment. Simon et al.27 suggested that patients who are ill or dying may be in “special need of mindfulness.” The new pharmacy practitioner, however, may find it particularly beneficial to adopt the practice of nonjudgmental appreciation to improve interactions in other phases of patient care. By keeping these four core attitudes in mind when entering a patient’s room, the new practitioner may begin to create a space for the patient to feel safe and communicate honestly without fear of reprehension. In an interview with Simon and colleagues,27 one palliative care expert stated that this space is “created through the way of contact or the atmosphere in the room” and that it is the clinician’s “role to create the space” for the patient. This idea of “creating space” is echoed in an article by Back and Arnold,17 in which a skilled clinician is depicted cre-
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ating an “environment” or a “reflective space” for his patients by offering “verbal empathy.” Closing notes. Looking to our colleagues in end-of-life care, we find a wellestablished model for empathetic expression and a foundation for creating a safe, comfortable space for this communication. By practicing the cognitive and behavioral strategies for acknowledging and responding to patient emotions, new pharmacy practitioners can begin to develop their own empathetic process. This process can then be shared and modeled for students, residents, and even veteran pharmacists to enhance their bedside conversations with patients. 1. Manolaski ML, Olin JL, Thornton PL et al. A module on death and dying to develop empathy in student pharmacists. Am J Pharm Educ. 2010; 75:article 71. 2. Zinn W. The empathic physician. Arch Intern Med. 1993; 153:306-12. 3. Khanuja S, Dongalikar V, Arora R, Gupta A. Empathy and sympathy in the medical profession: should we stop the desertion? Pravara Med Rev. 2011; 3:37-9. 4. Isle of Wight NHS Trust. End of life care: understanding and using empathy. www. iow.nhs.uk/Working-With-Us/learningzone/training-tracker_2.htm (accessed 2014 Dec 30). 5. OncoTalk. Module 1: fundamental communication skills. www.oncotalk.info (accessed 2014 Dec 30). 6. Hallenback JL. Palliative care perspectives. New York: Oxford Univ. Press; 2003:159-90. 7. Morse JM, Anderson G, Bottorff JL et al. Exploring empathy: a conceptual fit for nursing practices? Image J Nurs Sch. 1999; 24:273-80. 8. Nyatanga B. Empathy in palliative care: is it possible to understand another person? Int J Palliat Nurs. 2013; 19:471. 9. Lor KB, Truong JT, Ip EJ, Barnett MJ. A randomized prospective study on outcomes of an empathy intervention among second-year student pharmacists. Am J Pharm Educ. 2015; 79:article 18. 10. Van Winkle LJ, Fjortoft N, Hojat M. Impact of a workshop about aging on the empathy scores of pharmacy and medical students. Am J Pharm Educ. 2012; 76: article 9. 11. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree (February 17, 2006). www.acpe-accredit.org/pdf/ FinalS2007Guidelines2.0.pdf (accessed 2015 Apr 13).
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12. American Association of Colleges of Pharmacy. Educational outcomes 2013. www.aacp.org/resources/education/cape/ (accessed 2015 Apr 13). 13. Kim SS, Kaplowitz S, Johnston MV. The effects of physician empathy on patient satisfaction and compliance. Eval Health Prof. 2004; 27:237-51. 14. Ciemins EL, Brant J, Kersten D et al. A qualitative analysis of patient and family perspectives of palliative care. J Palliat Med. 2015; 18:282-5. 15. Bonvicini KA, Perlin MJ, Bylund CL et al. Impact of communication training on physician expression of empathy in patient encounters. Patient Educ Couns. 2009; 75:3-10. 16. Hojat M, Louis DZ, Markham FW et al. Physician empathy and clinical outcomes for diabetic patients. Acad Med. 2011; 86:359-64. 17. Back AL, Arnold RM. Isn’t there anything more you can do? When empathic statements work, and when they don’t. J Palliat Med. 2013; 16:1429-32.
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18. Back AL, Arnold RM, Tulsky JA et al. Teaching communication skills to medical oncology fellows. J Clin Oncol. 2003; 21:2433-6. 19. OncoTalk. Improving oncologist’s communication skills. www.oncotalk.info (accessed 2015 Apr 13). 20. VitalTalk. Home page. www.vitaltalk.org (accessed 2015 Apr 13). 21. GeriPal. OncoTalk legacy: IntensiveTalk and GeriTalk (August 8, 2012). www. geripal.org/2012/08/oncotalk-legacyintensivetalk-and.html (accessed 2014 Dec 30). 22. VitalTalk. NURSE: one page guide. www. vitaltalk.org/clinicians/track-respondemotion (accessed 2014 Dec 30). 23. Kacperek L. Non-verbal communication: the importance of listening. Br J Nurs. 1997; 6:275-9. 24. Stanford Faculty Development Center. End-of-life care module 3: communicating with patients and families. www. growthhouse.org/stanford (accessed 2015 Jan 3). 25. Suchman AL, Markakis K, Beckman HB, Frankel R. A model for empathic com-
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munication in the medical interview. JAMA. 1997; 277:678-82. 26. Back AL, Arnold RM. “Yes it’s sad, but what should I do?”: moving from empathy to action in discussing goals of care. J Palliat Med. 2014; 17:141-4. 27. Simon ST, Ramsenthaler C, Bausewein C et al. Core attitudes of professionals in palliative care: a qualitative study. Int J Palliat Nurs. 2009; 15:405-11. 28. Hallenback JL. op cit. :15.
Laura Meyer-Junco, Pharm.D., BCPS, CPE, Clinical Assistant Professor University of Illinois at Chicago College of Pharmacy, Rockford Campus Rockford, IL [email protected]
The author has declared no potential conflicts of interest. DOI 10.2146/ajhp150020
