Showing papers by "Richard M. Frankel published in 2001"

“Let Me See If I Have This Right …”: Words That Help Build Empathy

Abstract: In clinical medicine, empathy is the ability to understand the patient's situation, perspective, and feelings and to communicate that understanding to the patient. Certain well-timed words and sent...

Let me see if I have this right...

Abstract: Consider these two physicianpatient dialogues: 1. Patient: You know, when you discover a lump in your breast, you kind of feelwell, kind of(her speech tapers off; she looks down; tears form in her eyes). Dr. A: When did you actually discover the lump? Patient: (absently) I don't know. It's been a while. 2. Patient: (same as above) Dr. B: That sounds frightening. Patient: Well, yeah, sort of. Dr. B: Sort of frightening? Patient: Yeah and I guess I'm feeling like my life is over. Dr. B: I see. Worried and sad too. Patient: That's it, Doctor. Dr. A's patient may well go home feeling unheard and misunderstood. Dr. B's patient, while equally distressed about the possibility of having breast cancer, may leave the office believing that her doctor understands her. One of the most widespread and persistent complaints of patients today is that their physicians don't listen. For their part, physicians complain that they no longer have sufficient time to spend with patients, and they often blame economic pressures imposed by managed care (1, 2). Nonetheless, they acknowledge that personal encounters with patients constitute the most satisfying aspect of their professional lives. They recognize that empathy, the ability to connect with patientsin a deep sense, to listen, to pay attentionlies at the heart of medical practice (1, 3, 4). In clinical medicine, empathy is the ability to understand the patient's situation, perspective, and feelings and to communicate that understanding to the patient. The effective use of empathy promotes diagnostic accuracy, therapeutic adherence, and patient satisfaction, while remaining time-efficient (5-11). Empathy also enhances physician satisfaction (12). As with any other tool, clinical empathy requires systematic practice to achieve mastery (13, 14). Certain well-timed words and sentences facilitate empathy during the clinical encounter. These words that work are the subject of this paper. Empathy in Theory Tichener coined the term empathy in 1909 from two Greek roots, em and pathos (feeling into) (15). For some 50 years thereafter, empathy was discussed in the psychological and psychoanalytic literature as a type of vicarious emotional response (16-23). For example, Katz (24) wrote when we experience empathy, [it is] as if we were experiencing someone else's feelings as our own. We see, we feel, we respond, and we understand as if we were, in fact, the other person. Lief and Fox (25) diluted this strong sense of identification when they used the word to designate the vector for detached concern. They wrote that empathy involves an emotional understanding of the patient, while maintaining sufficient separation so that expert medical skills can be rationally applied to the patient's problem (25). In practice, emotional understanding has to be tested by checking back with the patient, and its accuracy is enhanced through iteration. The concept of empathy has three important implications. First, empathy has a cognitive focus. The clinician enters into the perspective and experience of the other person by using verbal and nonverbal cues, but she neither loses her own perspective nor collapses clinical distance. Second, empathy also has an affective or emotional focus. The clinician's ability to put herself in the patient's placeor walk a mile in his moccasinsrequires the experience of surrogate or resonant feelings (26). Finally, the definition requires that clinical empathy have an action component. One cannot know without feedback. The practitioner communicates understanding by checking back with the patient, using, for example, statements such as Let me see if I have this right or I want to be sure I understand what you mean. This gives the patient opportunities to correct or modulate the physician's formulation. At the same time it expresses the physician's desire to listen deeply, thereby reinforcing a bond or connection between clinician and patient. Empathy is sometimes confused with sympathy, or emotional identification with the patient's plight. Sympathetic responses include a physician's feeling sad and becoming teary eyed when his patient starts crying, or a physician's experiencing righteous anger when her patient recounts an injustice. Sympathy also applies to feelings of loss that people experience in response to another's loss. When present, sympathy often contributes to the physicianpatient relationship, yet physicians may not always exhibit sympathy because some patients are disagreeable, culpable, or unlikable. Empathy, by contrast, does not depend on having congruent feelings and thus may be more versatile. A physician can be empathic even when he or she cannot be sympathetic (27, 28). Numerous investigators have demonstrated the importance of empathy in the medical encounter. Empathy allows the patient to feel understood, respected, and validated. This promotes patient satisfaction, enhances the quantity and quality of clinical data, improves adherence, and generates a more therapeutic physicianpatient relationship (5-11, 29-31). To achieve these goals, medical educators conceptualized empathy as a set of teachable and learnable skills and developed a new focus on communication skills in the medical curriculum (13, 14, 32-36). More recently, some educators have explored the roles of narrative and literature in teaching clinical empathy (37-39), and others have emphasized the importance of reflection and self-awareness in maintaining one's empathic skills (40-44). Empathy in Practice Clinical empathy can be visualized as a positive feedback loop, or a neurologic track with afferent and efferent components (45, 46). The afferent arm includes verbal and nonverbal cues that lead to the practitioner's initial appraisal or understanding of the patient's message. The efferent arm includes the practitioner's responsesqueries such as Tell me more or statements such as I can imagine how difficult it is. Such responses elicit additional information. While it is impossible for the clinician to understand exactly how the patient feels, in clinical empathy successive cycles may lead to a clearer, more accurate fix on the patient's perspective and feelings. Thus, empathic communication includes the following components. Active Listening This requires nonverbal and paralanguage skills, such as appropriate position and posture; good eye contact; mirroring of facial expression; and facilitative responses, such as nodding and minimal expressions (for example, Hmmm and Uh-huh). It also demands that the physician remain silent and focus her attention on the patient's story (47, 48). Framing or Sign Posting Clinicians often initiate an empathic response when they pick up a suggestion or indication that the patient is experiencing concern, conflict, or emotion. Because accurate understanding is not commonly attempted in ordinary conversation, patients may be unaccustomed to empathic responses. Clinicians may need to disclose their intent, providing a frame or signpost for the patient (35). Lengthy warning may be inefficient and exhausting, so we usually abbreviate it in these ways: Let's see if I have this right. Sounds like what you're telling me is Or simply Sounds like Reflecting the Content An empathic response accurately identifies the factual content of the patient's statement, as well as the nature and intensity of the patient's feelings, concerns, or quandaries. A reflection of content (symptoms or ideas) might sound like the following: So you were fine until this morning when you woke up with pain in your belly, and it's been growing more severe ever since. Sounds like you think that you have appendicitis and that you might need to go into the hospital. The physician may also mirror the patient's interests and values: So, if I'm hearing you right, what you really enjoy is going out at night with your friends and having a few drinks. Identifying and Calibrating the Emotion Clinical empathy often entails responding to the patients' expressed (or suggested) feelings. This means identifying the emotion and calibrating its intensity. Sometimes emotional content is evident, but the nature of the emotion is unclear. In such cases the patient will often reveal the feeling, if given an opportunity. Tell me how you're feeling about this. I have the sense that you feel strongly, but I'm not sure I understand exactly what the feeling is. Can you tell me? The following are examples of empathic responses to patient statements that express sadness, fear, anger, distrust, and ambivalence. Sadness: That must have been a pretty painful experience for you, you sound like it was very sad. Fear: Sounds like you were really frightened when you discovered that lump. Anger: That situation really got to you, didn't it? I can imagine how angry I'd feel if that happened to me. Distrust: It seems you're not sure whether you should trust me further after I didn't get that test result back to you last week. Ambivalence: It seems to me that you're caught in a bind about whether to stop smoking or not. Feelings vary markedly in intensity; often, clinicians tend to sanitize or dilute them. Consider this example: Patient: Most days the pain is so terrible that I just want to stay in bed. I just stare at the ceiling what's the point of it all? Doctor: So you're frustrated about the pain? In this case, the physician identified an emotion (frustration) but failed to capture the patient's profound sense of helplessness. Weak affective words such as bother, annoy, upset, uneasy, and apprehensive are sometimes appropriate. At other times, red-blooded adjectives such as infuriated, enraged, tormented, overwhelmed, and terrified are more in order. This patient feels so depressed and helpless that he asks, What's the point of it all? By hearing only annoyance or frustration in the statement, the physician missed a diagnostic cue and perhaps a useful path of inquiry and has distanced herself from the patient. An alternative an

Getting the most out of the clinical encounter: the four habits model.

Abstract: Medical interviewing is the foundation of medical care and is the clinician's most important activity. A growing body of evidence suggests that clinicians use distinctive, describable behaviors to conduct medical interviews. This article describes four patterns of behavior that we term Habits and reviews the research evidence that links each Habit with both biomedical and functional outcomes of care. The Four Habits are: Invest in the Beginning, Elicit the Patient's Perspective, Demonstrate Empathy, and Invest in the End. Each Habit refers to a family of skills. In addition, the Habits bear a sequential relationship to one another and are thus interdependent. The Four Habits approach offers an efficient and practical framework for organizing the flow of medical visits. It is unique because it concentrates on families of interviewing skills and on their inter-relationships.

Earnouts: The Effects of Adverse Selection and Agency Costs on Acquisition Techniques

Abstract: structure of the consideration offered in an acquisition. Specifically we investigate factors affecting the benefits arising from use of earnouts. We find that when targets have greater private information, consideration is more likely to be based on the future performance of the target. We also find an earnout is more likely to be used in an acquisition if the target is a smaller, private company in a different industry than the acquirer. In addition, earnouts are more likely to be used when fewer acquisitions take place within an industry and when targets are service companies or companies with more unrecorded assets. Finally, we compare the use of earnouts with the use of stock and find that financing considerations are a more important factor in the use of stock.

Reflections on integrating theories of adult education into a medical school faculty development course.

Abstract: The purpose of this study was to test a three-day course model for medical school faculty designed to promote self-directed learning, teaching skills, personal awareness and interdisciplinary collegiality. The training program described was conducted three times in our medical school. Fifty-eight faculty from 11 clinical departments have participated in this intensive experience of learning how to teach, based on principles of learner-centered learning and adult education theory. Participants defined their own learning objectives and worked collaboratively in facilitated small groups to develop teaching skills. Reflection groups engaged in discussion on critical incidents of experience as teachers and learners, and promoted awareness regarding personal approaches to teaching. Qualitative and quantitative data showed that the course was effective in: (1) providing an academically and emotionally safe environment for learning; (2) enabling participants to recognize and value learner-centered learning; (3) i...

Personal growth in medical faculty: a qualitative study

Abstract: A physician's therapeutic effectiveness requires good communication and technical and cognitive skills used with personal maturity, wisdom, compassion, and integrity. The development of the last 4 qualities requires understanding oneself and one's relations to others.1 Physicians' conscious and unconscious attitudes, beliefs, previous life experiences, emotions, and psychological and cultural background influence their care of patients,1,2,3,4,5,6,7,8,9,10,11,12 sometimes detrimentally.1,3,5,6,8,11,12 By being aware of and managing these factors, physicians can better serve the needs of patients1,5,8,12 and of themselves.13,14 Although methods to promote the growth of personal awareness in physicians have been described,1,8,15 we know of no empiric studies that examine the process and outcomes of such personal growth. In this study, we qualitatively analyze stories of personal growth to uncover the process and outcomes of personal growth in a selected group of medical faculty, and to develop an explanatory framework that might be useful to learners, educators, and researchers. Summary points Lack of physicians' personal awareness can adversely affect patient care In this study, the processes involved in growth in personal awareness were powerful experiences, helping relationships, and reflection or introspection Outcomes of personal growth include changes in values and goals; improved behaviors and relationship; and increased energy, productivity, and creativity Awareness of these processes of personal growth, if confirmed in other studies, could lead to improvements in medical education and practice

One year's experience with a program to facilitate personal and professional development in medical students using reflection groups.

Abstract: Purpose (1) to integrate sociobehavioral science concepts into the early curriculum through a continuity ambulatory clinical experience in primary care, and (2) to expose students to a learning environment in which self-awareness and emotional development are nurtured in the context of dealing with the stresses of an early clinical experience. Methods Second-year students spent half a day twice monthly in a primary care community practice, kept a journal of their experiences, and attended biweekly 60-minute Reflection Groups designed to foster personal awareness and empathic witnessing. Analysis of journal entries and Reflection Group field notes identified stressors occurring during the students' clinical encounters. Results Three sources of stress are illustrated: the role and responsibility of the physician, death and dying, and racial issues. Reflection Groups provided students with opportunities to identify and describe stressors, to feel less isolated, to begin the process of self-awareness development, and to integrate behavioral and social science concepts into clinical practice. Our program incorporates students' early clinical experience with facilitated opportunities to reflect on the emotional challenges of becoming a physician.

Clinical care and conversational contingencies: The role of patients' self-diagnosis in medical encounters

Abstract: Patients' understanding of the origins and consequences of their medical problems (self-diagnosis) has historically been viewed by social scientists as either an asymmetry in role relations (physicians are high status and have access to technical understanding; patients are of variable status and do not really understand what is wrong with them), or as an effect of cognition (health beliefs) on health care processes and outcomes. Recent efforts to understand the medical encounter as a speech event have yielded important insights about how physicians and patients communicate with one another. The role of patient self-diagnosis in the encounter remains under-researched, however. Using a case example, in which an unstated difference in perspectives between a patient and provider regarding her diagnosis was followed by the patient's suicide, three social psychological theories of physician-patient communication are reviewed to see how they deepen understanding of the case. Based on interactional evidence from the third approach, micro-interactional analysis, two key observations are offered. The first comes from evidence based on the initial data gathering segment of the encounter. Here, in an experimental manipulation involving standardized patients being interviewed by second-year medical students, it is shown that eliciting patients' self-diagnosis (attribution) systematically leads to more complete and accurate diagnoses. The second observation is that physicians' delivery of diagnostic information' at the conclusion of the visit is contingent upon the patient's initial statement of concerns, including attribution whether stated or unstated, and the range of questions and topics pursued by the clinician between the statement of the problem and the delivery of diagnosis. A lack of agreement or alignment between the problem statement and the proposed solution can result in outright or unstated rejection of the diagnostic news, as detailed analysis of two cases reveal

Getting qualitative research published.

Abstract: Translating research findings in health education into a publishable manuscript is challenging regardless of whether qualitative or quantitative methods are used. In this paper, we offer practical advice about how to successfully prepare and guide manuscripts based on qualitative research methods, in particular through the peerreviewed journal publication process. Researchers trying to publish qualitative findings may face some unique challenges, given the field's current knowledge of qualitative methods, evaluation criteria, and conventional manuscript styles and length.

Cracking the code: theory and method in clinical communication analysis.

Abstract: (2001). Cracking the Code: Theory and Method in Clinical Communication Analysis. Health Communication: Vol. 13, No. 1, pp. 101-110.

Small-group Teaching Emphasizing Reflection Can Positively Influence Medical Students' Values

Abstract: Coulehan and Williams 1 have provided a thoughtful framework to explain the widely noted phenomenon whereby medical students lose their idealism as they are socialized into being physicians. Although I don’t believe theirs is the whole story, detachment, entitlement, and non-reflective professionalism certainly characterize parts of the professional persona that doctors adopt during clinical training. Young physicians in training also are inculcated with a strong sense of responsibility to provide excellent clinical care to their patients, no matter the long hours and emotionally straining work. One question is whether these two sets of values are tradeoffs. Must the young physician become detached and non-reflective in order to develop his or her sense of responsibility and ability to care for patients? I do not believe there is necessarily a tradeoff, nor do I think that the solutions suggested by Coulehan and Williams fully take into account the experience and evidence to date regarding solving this problem. They dismiss medical ethics and humanities teaching ‘‘in the majority of medical schools’’ as having generally limited impact. I believe the limited impact results from a lecture-style format, and from timing the courses in the first two years of medical school, not from an inherent impotency of medical education to create a reflective practitioner. Coulehan and Williams embrace the family medicine, primary care, and generalist movements as potentially valuable in maintaining students’ commitment to moral and professional values. Here, I agree and would argue that these movements accomplish much chiefly because they often do offer educational interventions aimed at teaching human values during the clinical years. Coulehan and Williams also discuss managed care and the possibility of more socially relevant clinical experiences as additional antidotes against loss of idealism. Without a long discussion, I would note that managed care is losing some of its impetus at present, and that if its chief impact on physicians is to undermine their professional commitment to taking responsibility for the care of individual patients, then it will be destructive mostly of professionalism in medicine. Socially relevant clinical experiences should be tried, but there are few examples that I know that have been well organized and integrated into the clinical curriculum. Rather, these rotations carry the danger of being ‘‘show and tell’’ experiments at various community facilities. What I want to get to is the documented impact of educational interventions that occur during the clinical years and are designed to counterbalance the non-reflective aspects of clinical training. Such interventions have been under way for more than ten years. I believe the common feature of effective intervention in the clinical years is small-group teaching facilitated by highly respected faculty role models that allows students to reflect on their values, beliefs, and experiences in a safe and intimate setting on a regular basis. Most successful programs have combined the opportunities for reflection with learning patient–doctor communication skills. Extensions of these programs beyond medical school into residency training also seem to me to be necessary to achieve their full impact. This educational approach counterbalances non-reflectiveness with reflectiveness. To do so requires the safe, smallgroup environment so that students or residents can freely express their feelings and concerns regarding patient care in a mutually supportive atmosphere. It is also necessary to reinforce the impact of small-group discussions with highly effective bedside teaching of humanism. Evidence suggests that intensive educational interventions such as these improve physicians’ abilities to convey fundamental values of the medical profession, such as compassion and respect, to their patients. My concern is that despite the proven impact of such programs, they continue to be given lip service by the leaders of medical education in most medical schools, who have yet to commit the resources to mount and evaluate large-scale interventions despite clear evidence that there is a problem needing to be addressed and a means available to address it. Furthermore, I fear that emphasis on too many options and alternatives to address the problem of non-reflectiveness and loss of values and idealism will disperse efforts in a non-focused way, leading to the prolongation of impotence in this component of medical education. Thus, I suggest that medical schools commit the needed resources to counteract what Coulehan and Williams so aptly term ‘‘vanquishing virtue.’’ A final word on the resources needed. There are enough clinical faculty at most medical schools to provide smallgroup facilitators for medical students and housestaff. The chief lack is the will to implement such programs, and the understanding that untrained faculty require a well-designed faculty development program if they are to be useful guides, role models, facilitators, and mentors for their students and residents.

Earnouts: The Effects of Adverse Selection and Agency Costs on Acquisition Techniques

Abstract: We examine the effects of adverse selection and agency costs on the structure of the consideration offered in an acquisition. Specifically, we investigate factors affecting the benefits arising from use of earnouts. We find that when targets have greater private information, consideration is more likely to be used in an acquisition if the target is a smaller, private company in a different industry than the acquirer. In addition, earnouts are more likely to be used when fewer acquisitions take place within an industry and when targets are service companies or companies with more unrecorded assets. Finally, we compare the use of earnouts with the use of stock and find that financing considerations are a more important factor in the use of stock.