Patients Wonder: 'Could This Be Something Serious?' Doctors Who Express Empathy Get Highest Patient Ratings

The study, led by Ronald Epstein, M.D., professor of Family Medicine at the University of Rochester Medical Center, is published in the December Journal of General Internal Medicine. 

Epstein and colleagues observed how doctors responded when patients asked loaded questions indicating worry about symptoms involving chest pain. The study builds on previous work by Epstein's group, in which they have described how good communication between doctors and patients, and a willingness to explore concerns, results in improved health care and lower costs.

An analysis of the doctor-patient interactions showed that doctors voiced empathy in only 15 percent of the office visits, even after repeated prompting by the patients.

"I think this study supports the notion that 'mindfulness' is an essential clinical skill," said Epstein, who also directs Rochester's Center to Improve Communications in Health Care. "Mindfulness helps the doctor understand the patient's world to a sufficient degree, so that no matter what the doctor's personal style is, he or she can express empathy."

The research began with 100 consenting doctors (47 family physicians and 53 general internists) in the greater Rochester area in 2001-2002. The doctors agreed to receive two unannounced visits over a one-year period by actors trained to portray patients in a realistic and uniform way. The actors would record the visits without the doctors' knowledge. Meanwhile, the research team also collected 10-minute surveys from real adult patients in a variety of doctors' waiting rooms. About 96 percent of the all patients approached agreed to take the survey, yielding 4,746 completed questionnaires.

The actors portrayed two roles. They all claimed to be new patients, 48 years old, with chest pain. Some described their pain as characteristic of gastroesophageal reflux disease (GERD), while others presented more ambiguous chest pain, poorly characterized. They all took part in standard, 15-to-20-minute acute visits.

Researchers trained the actors to deliver prompts that might elicit empathy, such as "Do you think this could be something serious?" Or to say something like, "You hear a lot about cancer and heart disease, and I was worried about that."

They used the patient surveys from the waiting rooms and transcripts of the audio-recorded exams to evaluate the doctors' responses. Researchers characterized the responses by type, frequency, pattern, and communication style, and correlated them with patient satisfaction ratings. They also looked for signs that doctors doled out empty reassurances, were dismissive, or made statements that served as conversation-stoppers.

The most common physician response was a simple acknowledgement of the symptoms, followed by biomedical questions or medical explanations. Later, some physicians reassured the patients and suggested diagnostic tests, medications, or other treatments. Surprisingly, reassurance from the doctor sometimes increased patient anxiety, the study said.

Patients reported the most satisfaction when doctors empathized with them in challenging situations, such as when the medical answer was not clear-cut, the study said.

Few studies have noted that empathy makes a difference in health care, Epstein said. The research also spotlighted nuances about communication and behavior, such as whether the timing of empathetic statements is important, and how long it takes to voice empathy in the context of a typical office visit.

The Agency for Healthcare Research and Quality funded the study. Co-authors from the University of Rochester Medical Center are: Taj Hadee, M.D., M.P.H., department fellow, Family Medicine; Jennifer Carroll, M.D., M.P.H., research assistant professor, Family Medicine; Sean C. Meldrum, M.S., statistician and associate, Family Medicine; Judi Larder, B.S., research assistant, Family Medicine; and Cleveland Shields, Ph.D., of the Purdue University Relationships in Healthcare Research Program.