Introduction

As we’ve discussed in past blogs, empathy is a central tenet for a patient-centered communication approach, such as motivational interviewing. A healthcare provider that can demonstrate understanding is more likely to have patients that feel less judged and more accepted. A patient that feels more supported and less defensive is more likely to be more open to treatment plan recommendations and lifestyle change. This process is correlated with both improved patient satisfaction and improved outcomes.^1-5 However, as simple as it sounds, “being more empathetic” is quite challenging to the average clinician. Training in how to listen empathically is normally not included in training (or perhaps just a bit) nor modeled for them during internships.^6-7 And, unfortunately, the literature informs us that people can’t accurately judge their own empathy; in fact, they tend to consistently over-estimate it.⁸

We’ve presented a case study below to illuminate the perspective of the patient, as well as the provider during a health coaching session to demonstrate how empathy and understanding can influence an intervention. By comparing a more traditional scenario with a more patient-centered one, we hope to model the answers to questions like:

• Can a provider provide adequate care if they lack context behind and understanding of patient behaviors or decisions?
• What encourages or discourages a patient from sharing the details of their circumstances?
• How might the agenda of the provider be perceived differently by the patient when empathy is present or absent?
• Does expressing empathy really make a difference in clinical outcomes?  

First, we’ll consider the worldview of the patient with a description of her health status, along with some of her beliefs and social situations that affect her self-care management. Next, we’ll give you a glimpse of the provider’s perspective to further understand what influences her decisions and procedures in her interactions with her patient. Lastly, we’ll present two hypothetical conversations; one in which the provider applies a paternalistic, directive, expert-driven approach and another in which a more collaborative, guiding and supportive approach is used. (Note: although the tone and dialogue for the encounters are drawn from years of experience listening to real clinician-patient encounters, this is a fictional scenario.)

Looking Through the Patient’s Lens

Marilyn Jones is a 66-year-old female who has been on dialysis for six months. She is finally getting used to the demanding schedule of spending most of three full days a week preparing for her treatments, traveling to and from the center, and discomfort of being on the machine for hours at a time. She doesn’t like that it takes her away from her grandkids and the comfort of her own home so regularly, but that is a sacrifice she is willing to make. 

Marilyn has struggled with her weight and her diabetes for a long time. She’s been trying to keep all these new rules and regulations with her diet straight, but it is complicated and her memory is not what it used to be. She gets mixed up when the dietitian overwhelms her with information on protein, phosphorus and potassium. Is she supposed to take her binders when she eats snacks that are high in potassium or phosphorus? (And, by the way, she is supposed to eat more protein and doesn’t cheese have protein, so it seems like it would okay for her. So confusing!) In addition, she hates the taste of her binders – they make her gag – so she has been avoiding them.

On top of her new treatment plan, she’s been having a tough time sticking to her food budget since she started depending on the monthly social security check last year after her husband died. With these new restrictions, it just seems that everything is more expensive. No more canned fruits and veggies, no more potatoes, no more rice pilaf – things that seemed cheap and easy but that she’s been told she can’t have anymore. The dietitian has zoned in lately about her consumption of mac and cheese. Apparently, it’s bad for her for all kinds of reasons, but this is her famous recipe that everyone asks for; it’s her go-to for church functions and birthday parties.

Sometimes, the dialysis staff treat her as if she doesn’t care about her health or treatment plan. She does care; she wants to watch her grandchildren grow up, she doesn’t want her health to keep spiraling down, and she’d like to get a kidney transplant eventually. She knows she needs to stay healthy to do all this and feels she has been trying her best to follow these complex dietary rules.

Looking Through the Provider’s Lens

Anita Miller has been a dietician for almost 20 years and, boy, has she seen it all! From patients that openly defy her by bringing in exactly what she tells them they can’t eat, to patients that have had heart attacks while on the machine, as well as some patients who follow her advice and live longer lives on dialysis. She gets along well with most of them though, although a few pretend that they are asleep when she walks up. They do like when she brings in dialysis-friendly treats for good lab results.

Anita was inspired to become a renal dietician because her own mother was on dialysis, never seemed to be able to follow her treatment plan well, and died too young. She wants to help others avoid this pitfall. She provides lots of good handouts, resources, and tips as she has a lot of years of experience. She used to believe that if a patient had all this information and advice that they would make informed decisions, but lately she’s been getting jaded and wondering what’s wrong with her patients’ motivation. Even when she shows them pictures of what happens to their skin when their phosphorus levels stay up, they don’t change their diet or take their binders regularly enough. Even when she tells them what they must do to get on the transplant list, many patients don’t change their behaviors.

Marilyn Jones seems like a nice woman, but doesn’t seem to pay attention to what she’s being told about the importance of sticking to a renal diet. Anita has told her about the dietary restrictions many times, but her phosphorous levels remain high. And several times, she has caught her with leftover macaroni and cheese, for goodness sakes! Anita is beginning to feel like a broken record and is frustrated that her patient is not making the changes she needs to make for her health. 

The Traditional Approach

Before checking in with Marilyn on Monday during her dialysis treatment, Anita pulls her labs. Although they’ve gone down a bit, phosphorus levels are still too high! She grabs her handouts on foods that are high in phosphorus and heads over.

RD:      “Hi Ms. Marilyn! How was your weekend?” [engaging]
PT:       “Oh hi Anita! It was great. Jackson had his 6^th birthday yesterday so I made his favorite mac n cheese – it was a real hit!"
RD:      “Yes, I see you brought some leftovers in. Do you remember what we talked about last week about the cheese?" [judging, scolding]
PT:       “Don’t you worry Anita, I cut back on my cheesy eggs this morning so it should even out. All in moderation, right?"
RD:      “Yes, well, I just pulled your labs and your phosphorus levels are still too high. Maybe we should review this phosphorous handout again Ms. Marilyn. You see here tht cheese is on the list of foods high in phosphorus and you seem to be eating way too much.” [Anita spends about 10 minutes going over the handout again.] [Giving info/advice without evoking or asking permission]
PT:      “I know, I know. But I am trying to cut back. Like I said, I cut back this morning. And I’m not even eating the tomatoes that come from our garden any more. Giving them all away! Honestly, I just miss the days before dialysis where I didn’t have to worry so much about every little thing I put in my mouth.”
RD:     “I understand it’s hard, but you know what happens when you don’t stay on your diet. You were just in the hospital with an infection a few months ago. And you want to get on that transplant list. Maybe you could put this handout on your fridge as a reminder like we talked about? Or if you want, I could talk to your daughter so she could help you remember?” [attempted empathy but not effective, ignores change talk, scare tactics, scolding, giving info/advice without evoking or asking permission]
PT:      “Yeah, I already put that one on my fridge last week. And I don’t want to worry Sarah with this stuff right now, her little one is sick right now and it’s me that needs to be helping her now.”
RD:     “Well what about a food log Ms. Marilyn? You could keep a food log and then we could go through it together to figure out where you are going wrong. Maybe if we can pinpoint it, then your labs will improve. You know your doctor would be happy if your labs were better!” [genuine intention to help by fixing, giving info/advice without evoking or asking permission]
PT:      “Sure, okay, we could try that… doesn’t hurt to try.”
RD:      “Okay, great, that’s your care plan this week – keeping your food log. Now, what about your binders, have you been taking them like you should?” [dictating the health goal   instead of evoking it from pt, closed question unlikely to elicit honest response]
PT:       “Yeah, uh-huh. I know I'm supposed to take them with meals and with snacks.”
RD:      “Good, good! I’ll check in with you next week to go over your food log.”

A Patient-Centered Approach

Here’s a repeat of the same scenario with the same amount of time, but with the assumption that Anita has been provided comprehensive MI training by her organization. The initial workshop was a true eye-opener! Afterwards, she practiced, attended all her skill-building sessions and has really seen a difference after using this new approach. She enjoys her job again and feels like she is making a difference in many of her patients’ lives.

RD:      “Hi Ms. Marilyn! How was your weekend?” [engaging]
PT:       “Oh hi Anita! It was great. Jackson had his 6^th birthday yesterday so I made his favorite mac n cheese – it was a real hit!"
RD:      “So you got in some good family time! That famous mac n cheese of yours is quite the temptation! I know you’ve been working hard on cutting back on cheese though for your phosphorous levels.” [complex reflection, engaging, affirmation]
PT:       “Oh yes, you know me and cheese! I did cut back on my cheesy eggs this morning though, so a little extra here and there shouldn’t hurt, right?”
RD:      “That’s wonderful you are making adjustments! You’re right that moderation is key and what you cut back is totally up to you.” [affirmation, support for patient’s autonomy]
PT:       “I guess I haven’t been cutting back enough though – I see you have my lab report there. I bet my phosphorus is still high."  
RD:      “Yes, it is, but everything else looks really good. And it has come down a bit. So what you are doing is making a difference.” [affirmation, addressing personal agency and self-efficacy]
PT:       “Well, like I said, I am trying to cut back on the cheese. And I’m not even eating the tomatoes that come from our garden any more. Giving them all away! Honestly, I just miss the days before dialysis where I didn’t have to worry so much about every little thing I put in my mouth.”
RD:     “Those are big steps to take! This is a really challenging diet for sure. And you have done a terrific job learning all of this – it does take time to figure it all out. I know you are trying hard and recognize how important it is to your health." [affirmation, validation with complex reflection, reflection about efforts to evoke change talk]
PT:       “Yes, I do know how important it is and I do try, although it gets confusing at times.”
RD:      “What keeps you motivated?” [evoking change talk]
PT:       “Those grandkids of mine. You know how much they mean to me. I just want to stay as healthy as I can so I keep helping my daughter out with those boys. And I would like to get on the transplant list if I could.”
RD:     “Staying healthy, getting on the transplant list, and those two little balls of energy are your best motivators. I wonder if it would be helpful to identify just one or two things that may help you this week stay on track?" [Complex reflection, asking permission, evoking solutions]
PT:       "With the phosphorus? [Anita nods.]  Well, those handouts are helpful but they just cover what’s bad. Do you have one that gives ideas about healthy foods I can pick up at the grocery store? Ones that aren’t expensive?"
RD:      "Absolutely! I have one on healthy foods and snacks and we can go through together and figure out which ones are less expensive. What else might help you?" [Evoking more solutions]
PT:       "I have to confess, I’m not taking my binders as much as I should. I just hate the taste- they make me gag sometimes."
RD:      "I’m so glad you mentioned that. That makes total sense that you wouldn’t want to take them. Did you know we have some different ones to try? Does that sound like something that would interest you?" [validation, providing possible solution but deferring to pt choice]  
PT:       "Oh! I didn’t know that. Yes, I would like to try a different one for sure."
RD:      "I’ll ask Judy to give you a few samples to take home and try. I know it’s getting time for you to get off the machine so we can wrap up if you don’t have any more questions. I’ll go grab that handout right now. What are your next steps?" [evoking next steps to strengthen commitment to plan]
PT:       "I’m going to get those samples from Judy before I leave today and I’ll try them out. I know that would help a lot if I took my binders more often. And I’m also going to work off the handout to pick foods that are better for me. I’m also going to try to cut back even more on my cheese – no more birthdays coming up for a while which should help!"
RD:      "That sounds like a wonderful plan. If you stay this committed, I know it’s going to make a big difference in your health. And it will get easier – I promise!" [affirmation and addressing personal agency and self-efficacy]

Conclusion

Without an empathic approach, we are unlikely to discover the patient’s perspective, insights, motivation, and barriers. It is only when we genuinely accept the patient’s readiness to change and embrace their worldview, that the patient will share with us openly and honestly so we can support them and influence their choices. Once we truly connect and collaborate with our patients, we can start to evoke the all-important change talk and be more successful with guiding our patients towards setting and reaching important health goals.  

In our next blog article, we will provide some concrete tips and suggested practice activities to improve your empathetic listening skills.

References

¹   Miller WR, Rollnick S. Motivational Interviewing: Helping People Change. Third Edition. New York: Guilford Publ.; 2013.
²  Butterworth S, Linden A, McClay W. Health coaching as an intervention in health management programs. Dis Manage Health Outcomes 2007;15(5):299-307.
³   Lake ET, Germack HD, Viscardi MK. Missed nursing care is linked to patient satisfaction: a cross-sectional study of US hospitals. BMJ Quality & Safety 2016;25(7):535-543.
⁴  Manary MP, Boulding W, Staelin R, Glickman SW. The Patient Experience and Health Outcomes. N Engl J Med 2013;368:201-203.
⁵ Tsai TC, Orav EJ, Jha AK. Patient Satisfaction and Quality of Surgical Care in US Hospitals. Ann Surg 2015;26(1):2-8.
⁶ Hojat M, Mangione S, Nasca TJ, et al. An empirical study of decline in empathy in medical schools. Med Educ 2004;38:934-941. 
⁷ Bellini LM, Shea JA. Mood change and empathy decline persist during three years of internal medicine training. Acad Med 2005;80:164-167.
⁸ Moyers TB, Miller WR. Is Low Therapist Empathy Toxic? Psych Addic Behav 2013;27(3):878-884.