The Value of Empathy in the Patient-Clinician Relationship Ceu · context of psychotherapy and about the role it plays in clinician-patient communication. ... cope with illness and

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THE VALUE OF EMPATHY IN THE

PATIENT-CLINICIAN RELATIONSHIP

Introduction

Empathy is considered fundamental to successful patient engagement and

healthcare outcomes. An empathic clinician can affect a patient’s levels of

anxiety and stress, patient satisfaction and adherence, and patient

enablement. Within a health team, empathic treatment enhances

information exchange between health team members, diagnosis and

treatment outcomes. Specifically, there is a significant correlation between

the empathic clinician and patient responsiveness to treatment.

The Role of Empathy

Empathy is a component of the clinical and therapeutic relationship and is

key to quality healthcare. Researchers have written about empathy in the

context of psychotherapy and about the role it plays in clinician-patient

communication. Empathy has a major impact on lowering anxiety and

distress in patients and results in better clinical outcomes.

Neuroscientific researchers have most recently studied the science of

empathy. It is a new field of research with clinical implications. They have

reported on a neurobiological basis for empathy following discovery of the

mirror neuron system (MNS) that affects an individual’s ability to be

empathetic. The mirror neuron system provides a neural mechanism

whereby individuals can understand the actions of others.74-76


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Recent studies using functional magnetic resonance imaging (fMRI)

experiments clinicians have looked at mirror neurons in the ventral premotor

cortex and parietal area of the brain. Neurons in the somatosensory areas

and in limbic and paralimbic structures are also seen. The insula, located

deep inside the lateral sulcus, within the cerebral cortex of the brain, plays a

role in connecting these regions. The fMRI experiments show that people

who score higher in a questionnaire measuring a tendency to relate to the

experiences of others activate the MNS region more strongly when listening

to other’s express their emotions.75 The neurobiological studies, however, do

not provide information about clinical outcomes.

Definition of Empathy in Healthcare

To assess the value of empathy in clinical practice, its definition must first be

understood. There is no standard definition of empathy but certain elements

can be identified. Empathy in healthcare is generally viewed as the

competence of a health clinician to understand the situation of a patient

including the patient’s perspective and feelings. It is also the ability to

communicate and to act on that understanding in a therapeutic way.1-5

Empathy can be defined as an attitude, competency, and behavior. Attitude

reflects in the respectfulness one shows toward another person. It also

reflects in the interest, impartial and receptive treatment one carries toward

others. Empathy is considered the basis of good clinician-patient

communication. It has an impact on patient satisfaction, adherence, anxiety

and stress, and on clinical diagnostics and outcomes.

Clinician competence can include empathic skill, communication skill, and

the skill to build a patient relationship based on mutual trust. Empathic skill

refers to how a health clinician can engage a patient by drawing close to


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their inner world. By recognizing a patient’s health needs, a clinician can

gain the patient’s trust and thereby obtain needed health information from

the patient. With effective communication skills, a clinician is able to check,

clarify, support, understand, reconstruct, and reflect on the perception of the

thoughts and feelings of a patient. When a clinician-patient relationship

based on mutual trust is developed this reflects the ability of a clinician to

emotionally resonate with a patient.1-5

A clinician’s behavior indicates how well the clinician recognizes a patient’s

feelings and identifies with him or her. Behavior includes verbal and

nonverbal skills whereby the clinician shows recognition of the emotional

state of a patient in their situation, such as a change of environment, or of

suffering from anger, grief, and disappointment. The empathic clinician

reflects on and communicates an understanding of the patient’s

circumstance to the patient. Empathy is considered by both patients and

clinicians as patient-centered and humane. A majority of patients would

recommend an emphatic clinician to someone else.77

Barriers to Empathy

Barriers to empathy have been identified as including an increase in

technology and emphasis on productivity in medical practice, which

influences aspects of patient care. A decrease in effective communication

and a low level of empathy in clinician-patient relationships has been

correlated to the rise of medical technology and productivity in everyday

practice.

Various authors have reported on a greater interest by clinicians in

technological and biomedical aspects of care. Some express concern that an

emphasis on technology means less interest in empathy. Recipients of


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healthcare may not feel clinicians are able to understand their situation and

then become dissatisfied with their care. The improvement of patient

satisfaction and adherence was addressed by Hojat, et al., who found a

correlation between patient satisfaction and perception of physician

empathic engagement.77,78 It was also found that the response of anxious

patients correlated with the response of their health clinician, and patients

tended to report lower levels of anxiety when under the care of an empathic

clinician.

Varied research studies confirmed data findings of patient satisfaction and

adherence. The data found links between health clinician empathy and

patient satisfaction in various clinical settings. Researchers reported that

empathy directly correlated with increased satisfaction, trust, and

adherence; and patients who were more satisfied with their care also

showed better adherence to treatment regimens. The same was found to be

true for Lelorain, et al.79 It was showed that a patient’s view of quality of

medical consultation related to health clinician competence and empathy.

Diagnosis and Clinical Outcomes

Better diagnostics and clinical outcomes were confirmed through the

research on empathy, indicating that communication between health

clinicians and patients is associated with underlying clinician attitudes.

Health clinicians with a positive attitude when addressing patient

psychosocial issues tended to show more concern and empathy. Improved

patient satisfaction and clinical outcomes correlated with patient appreciation

of empathy shown to them.3-5 An attitude of genuine empathy and concern

by the clinician, as well as an ongoing relationship with the clinician, was

highly valued by patients.


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Patients under the care of empathic health clinicians offered up more

personal information about social and psychological issues affecting their

health. Patients indicated how a clinician’s attitude hindered or helped them

when discussing their health problems. Patients also indicated how a

clinician helped them resolve or understand problems as well as supported

their efforts to change.

Hojat, et al., elaborated on a correlation with regard to health clinician

empathy and patients’ clinical outcomes. Patients with laboratory diabetes

testing who had been checked for their glycosylated hemoglobin (A1c) and

low density lipoprotein (LDL) were found to have better test results when

under the care of a clinician showing empathy. Empathy in the clinician-

patient relationship enhanced mutual understanding, trust and honesty

between both parties. It also provided good alignment of patient needs with

treatment plans, resulting in a more accurate diagnosis and improved

treatment adherence.77,78

Researchers have shown that when clinicians communicate with empathy

this can lead to better diagnostic and clinical outcomes. Patients talk more

about their symptoms and concerns, which enables clinicians to collect more

detailed personal health information, and to arrive at an accurate medical

and psychosocial evaluation, diagnosis, and treatment regimen. For a patient

group with higher health clinician empathy a duration of 5.89 days versus 7

days of hospital stay occurred.3-9

There have been reports that even the common cold may be less severe in

cases where empathy exists in the health clinician-patient relationship. More

evidence is needed about the effectiveness of empathy in the daily practice

of health clinicians.


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Patient Enablement

A higher level of patient enablement has been reported where health

clinician empathy exists. There is also a positive relationship between

enablement and changes in wellbeing and patient complaints. Patient

enablement may be measured through use of the Patient Enablement

Instrument (PEI). Questions in this test cover the ability of the patient to

cope with illness and life in general, as well as patient confidence about

health and the ability to remain independent.

Research studies have focused on the relationship between patient health

outcomes and clinician empathy. The use of empathy in communication was

raised as a soft element. Empirical evidence also exists relative to the

positive impact of clinician-patient interaction, including aspects of empathy

and patient satisfaction, adherence to treatment (during periods of patient

anxiety and distress), strengthening of patient enablement, and clinical

outcomes.77

Measuring Levels of Empathy

Researchers use various tests to measure levels of empathy, including those

outlined below.77-80

• Jefferson Scale of Patient Perceptions of Physician Empathy (JSPPPE):

a self-report measuring scale for cognitive and attitude factors.

• Consultation and Relational Empathy (CARE):

a patient rating system that measures clinician communication skills

and attitudes.

• Roter Interaction Analysis System (RIAS):

an observer-rating system that measures empathy skills.

• Tape Assisted Recall (TAR):


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measures the development of a long-working relationship.

A health clinician can be trained on ways to improve empathy and be tested

for empathy level and communication style. As mentioned earlier,

empathetic communication in the clinical encounter impacts the overall

satisfaction with healthcare service for a patient, adherence to regimens,

comprehension, and perception of a good relationship are related to the

interpersonal communication between a clinician and the patient. This is

particularly related to the clinician’s empathy. A warm communication style

can lead to a positive effect on patient anxiety and engagement.

The higher focus on research related to empathy in clinical practice has

emerged in the health literature. For example, in 2008 the World Health

Organization (WHO) raised the importance of primary healthcare in a report

Primary Health Care Now More Than Ever with the logo and key challenge to

clinicians to put people first, since good care is about people. Several

qualitative studies have shown that health clinicians link empathy to fidelity,

moral thinking, pro social behavior, good communication, patient and

professional satisfaction, good therapeutic relationships, fewer damage

claims, and good clinical outcomes.10 Ideally, the medical clinician can

communicate with patients, understand them, know the families, and regard

the patient as more than “a case.”

In a study on how primary care clinicians try to convey empathy to medical

students, basic principles of clinician empathy are raised. This includes moral

development in the clinician, a basic willingness to help, and a genuine

interest in the feelings of others. Limiting factors during clinical consultation

are time pressures, heavy workloads, a lack of skill, and a cynical view on

the effectiveness of empathy. Patients also tend to notice time pressures on


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a medical clinician as a barrier. While empathy is generally viewed as part of

good clinician-patient communication, barriers exist for implementing this in

general practice.80

Empathy in medical school has been specifically studied. Several reports

showed that empathy appeared to increase during the first year of medical

school, and it decreased after the third year. Empathy remained low in the

final year of medical school, as measured using the Jefferson Scale of

Physician Empathy – Student Version. Additional studies had suggested that

the degree of empathy shown by medical students declined over the course

of their training.81 Hojat, et al., had previously noted that there were no

gender differences in empathy levels for medical clinicians. Quince, et al.,

recognized that among male medical students their affective empathy

declined slightly but cognitive empathy did not change. For females,

affective and cognitive empathy did not change.82

According to Treadway and Chatterjee, when a medical student finally

begins clinical practice after medical school, the student may begin to lose

empathy. Possible explanations of the decline in empathy were identified as

a lack of good role models, changes in culture, and ethical views on health

and illness.83

The evidence of a positive impact between empathy and clinical outcomes

needs to be emphasized more among health clinicians, especially in light of

current education trends focused on technological changes and systems

approaches within healthcare. The heightened emphasis on technology could

influence the clinician-patient engagement in a negative way and to

potentially undermine clinician empathy. On the other hand, there are some


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who express the belief that clinician empathy will improve if it is stressed

more during education and training of all health clinicians.

Currently, a small empirically based examination explains the benefits of

empathy. There are some high-quality studies that show promising results

on evidence-based grounds but more research is needed. Neumann, et al.,

also highlighted the need for an examination of the cost-effectiveness of

empathy in light of the recent focus by policy makers and health insurers on

health systems and the efficiency of healthcare delivery. Raising awareness

on empathy in healthcare with policy makers to show it is an effective and

efficient way of managing patient outcomes has been pursued over the past

decade.84 Researchers have reported that empathy should improve the

clinician-patient relationship, and that more patients reported they want an

empathetic clinician.

A concern has existed that empirical studies on clinician empathy are

relatively scarce. However, the existing literature until now has clearly

revealed that empathy is an important factor in patient satisfaction and

adherence. It also helps decrease patient anxiety and distress and allows for

better diagnostic and clinical outcomes. Clinician empathy also strengthens

patient enablement and seems to improve physical and psychosocial health

outcomes. Importantly, empathy should result in satisfaction not just for the

patient but for the clinician because they will experience less compassion

fatigue or burnout. While more research is needed, clinicians need to learn

more about the practical use of empathy in healthcare settings, and focus

more on the effects of empathy in the clinician-patient relationship.

The above discussion highlights the measurement of empathy as an

important part of the current research and quality outcomes in healthcare


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delivery. It is often based on subjective self-reports. Other remote, objective

findings identifying concrete feelings, experiences, and interpretations in

clinical practice from the perspective of the clinician-patient encounter have

improved the evidence on the value of empathy in healthcare. Patient

perceived empathy is related to patient outcomes; a patient perceived

empathy scale to measure the empathy of a clinician has been implemented

in some healthcare settings to identify gaps in patient-centered care within

an organizational culture.85

Many patients look for empathy from their health clinicians. Outside of the

medical setting, empathy means a human understanding that involves

emotional resonance. Medical education has increasingly recognized this

need.

Detached Cognition In The Health Clinician

The concept of detached cognition relates to the way educators in the

medical field define empathy with a focus on emotional attunement and

understanding of a patient’s emotions. Educational curriculums in healthcare

are being evaluated more closely for how they are designed to teach

empathy to health clinicians. Medical clinicians have a challenging role in

that they try to be detached yet reliably care for all patients regardless of

their personal feelings.33-37

Medical educators as well as professional bodies overseeing licensing and

continuing education for health clinicians are increasingly recognizing the

importance of empathy. They define empathy in a unique way to be

consistent with the idea of detachment. As mentioned, outside of medicine,

the term empathy means a way of understanding and involves being moved

by the experiences of another person. The Society for General Internal


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Medicine defines empathy as the act of correctly acknowledging the

emotional state of another person without experiencing the state oneself. A

medical clinician cannot and should not experience the suffering of each

patient. The emphasis on clinician empathy is that it is intellectual and a way

of knowing how the other person may feel, but not emotional. The

assumption is that experiencing the emotion is not important for

understanding what the patient is feeling.3-5,33-37

The current medical literature defines health clinician empathy as cognitive

in contrast to sympathy. A clinician who is sympathetic could risk over

identifying with a patient.29 Emotional responses could be seen as a threat to

objectivity. In The New England Journal of Medicine and the Journal of the

American Medical Association during the 1950s and 1960s clinical empathy

was discussed as necessarily detached reasoning. This meant that the health

clinician would do what needed to be done for patient care without feeling

grief, regret, or other difficult emotions. The clinician was described as

having a primary role to observe the patient to predict a response to illness.

This concept of a detached clinician continues to persist throughout the

current literature. In a classic 1963 article, Training for Detached Concern,

Fox and Lief described how a medical student can dissect a cadaver without

disgust. This same detachment allows a clinician to listen empathically while

not becoming emotionally involved.

Meanings of Empathy and Detachment

Medical clinicians are trained to view the emotions of a patient objectively;

however, they should recognize that they cannot overcome all emotions. The

model of detached concern involves knowing that a person is in a certain

emotional state. The clinician does not just label the person’s emotion but

tries to recognize what it feels like to experience that emotional state.29-31


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Clinicians guided by empathy can know what emotional descriptor applies to

a patient. The following case examples illustrate the concepts of empathy

and detachment in clinical practice.

Example 1: Spinal Cord Injury Case

A 33-year old male patient has been paralyzed from the neck down following

a motor vehicle accident and becomes depressed and refuses treatment.

During a clinical encounter, the patient is immobile and struggles to whisper

through a tracheotomy tube to the clinician. The clinician responds to the

patient’s attempts to speak by speaking in a quiet and gentle way. Despite

the clinician’s gentle and non-threatening approach, the patient remains

withdrawn in his response to the clinician.

The clinician may feel shame and retreat, which is a reflection of what the

patient feels. Conversely, the clinician may recognize that continuing to

communicate to the patient in a quiet and gentle way might not be effective

because the patient is not engaging in treatment. The clinician may try

asking the patient what is bothering him in a more assertive manner, risking

an angry response from the patient to avoid sharing his true feelings. The

patient may even express feeling disrespected by such an approach to

engage. In such a scenario, the clinician and patient have engaged albeit

there may be emotional anger communication by the patient, and now the

clinician may begin an effective therapeutic approach.

Example 2: Pregnancy Case

A 20-year old pregnant patient meets with her obstetrician on what to

expect during her first labor and delivery. The young woman appears

anxious as the physician explains to her the options for pain relief. After he


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explained in detail about the patient’s options she still appeared anxious and

became more withdrawn. The obstetrician asked the patient what was

making her anxious, however she did not answer. When the patient did not

respond, the obstetrician continued to explain in more depth the options for

pain, and attempted to cheer and reassure the patient that all would be fine.

Shortly after that encounter, the patient moved her care to a new physician.

In this case, the patient’s unresolved anxiety included an element of panic

as the obstetrician tried to reassure her about pain relief. She may have

imagined being tied to an intravenous (IV) line as he explained the process

of IV analgesia during delivery. She may have feared being restrained and

losing control. In the patient’s medical history questionnaire, she had

reported a past experience of sexual abuse as a rape victim, which triggered

fear of being confined to an IV line. When the obstetrician explained options

to the patient, not taking into account her history of sexual abuse, she likely

felt that her fear was not being recognized. She may have felt that the

obstetrician appeared unconcerned about her past experience of trauma, as

he did not pause to listen or use nonverbal observation skills to cue the

patient that he was paying attention and understood her trauma was the

basis of her fears.

On Reflection: Case Summary

With each of the two above case examples, the medical clinicians are

genuinely concerned. They both asked the same questions related to what

was making the patient feel anxious. In the first case, emotional attunement

guided the timing and tone of the clinical encounter. In the second case, that

appeared to not occur where the obstetrician observed the fear however did

not pause when observing the patient become more frightened.


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Nonverbal Attunement

In clinician-patient interactions nonverbal attunement allows the clinician to

pause at moments of observing a patient’s heightened anxiety. With

nonverbal attunement, the patient is able to disclose information. When

clinicians do not pause to allow nonverbal attunement, patients do not share

vulnerable information even when the clinician asks an appropriate and

accurate question.

The key point to remember is that people rarely give a full and useful

response when asked a direct question. Clinicians need to rely on emotional

cues and shifts in the emotions of patients to understand the basis of their

anxiety, and to pause to allow the patient to reveal more information and for

engagement to occur.

The Empathic Clinician And Emotional Attunement

In this section, the concept of emotional attunement is discussed in more

detail as it relates to the empathic clinician. The prior section discussed

detached concern, which some may confuse as being the same as emotional

attunement, however they are not the same. Emotional attunement shapes

what a person imagines about the experience of another person.94

A health clinician may imagine and resonate with what a patient is feeling.

Resonance is part of ordinary communication; it can be subtle and involve a

nonverbal sense of what another person is feeling. It does not always

involve resonating with a strong feeling and verbalization. Empathy does not

require that a health clinician fully experience the emotions of a patient. The

focus should not be on the introspective response of the clinician but rather

on the patient.93,94


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In clinical practice, the challenge is to use skillful attunement in multiple,

rapid, and ordinary interactions. An example is if a patient reports stopping

prescribed medication and appears angry about the potential side effects.

The patient could also feel hopeless about having a certain diagnosis.

Addressing the patient appropriately depends on being attuned to the

emotions of the patient. In this case, the clinician’s best approach may be to

discover why the patient stopped taking medication, and to reflect on how to

respond empathically while deciding on other treatment options for the

patient.6,34-36

There are several ways a clinician can use their emotional response to

enhance patient care. First, they can use emotional attunement to

appreciate the meaning of the words of a patient. Second, their emotions

should focus and hold their attention on what is making a patient anxious.

Third, empathy can facilitate patient trust and disclosure. Empathy can

enhance a clinician’s individual practice and interactions with patients to be

more meaningful. In general, empathy is a way for the clinician to grasp the

emotional state of the patient.

Empathy in the clinical encounter involves perceptual activity however it also

operates alongside logical inquiry. If a clinician exercises the skill of logical,

objective reasoning as they reflect upon their empathic intuitions, this

enhances patient communication, and, as mentioned already, improves the

medical diagnosis and treatment options. A problem can arise if empathy is

viewed as dependent on emotional responses, which are outside of a

person’s immediate control.6,34-36

Listening to the Patient’s Story


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Health clinicians can reliably and reasonably empathize with a patient even

when experiencing a negative emotion. Emotional resonance can flow easily

at times however a busy and overworked clinician could find being

responsive to patients challenging or even impossible. One way to train

clinicians on empathic responses is to encourage them to keep a natural

curiosity about the lives of their patients. Encouraging clinicians to be

curious about patients involves training them on concepts of listening to the

patient’s story and then retelling the story as the patient shared their illness

and personal circumstance.

Training clinicians to write narrative histories helps them to more carefully

listen to the words of the patient.41 An example would be a patient who

became paralyzed and expressed that treatments were useless and a waste

of time. If a clinician focuses on the narrative, it can be useful to elicit

feedback from other health team members or peers on how to engage the

patient by repeating back the narrative during another clinical session when

the patient feels more prepared to explore treatment options. The goal of

repeating the patient’s story would be to help the patient consider and agree

to treatment options rather than continuing to feel as though life after a

traumatic injury or major illness was useless and a waste of time.

Barriers to Empathy

Barriers to empathy are important to understand, and at times multiple

barriers can exist. Barriers can be due to both the patient and clinician

responses. For example, patients could experience anxiety or other emotions

that interfere with empathic responses; or the clinician could be pressured

by the lack of time to listen. A significant barrier to empathy is when

clinicians do not see the emotional needs of the patient as an important part


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of care and illness. Research shows that clinicians communicate better if

they regularly include psychosocial dimensions of care in their practice.

An additional barrier to empathy concerns how negative emotions can arise

when tension exists between a clinician and patient.59,70,71 A clinician can feel

angry with a patient for not cooperating with treatment and this leads to

barriers to understand the perspective of the patient. Clinicians can be

educated to show tolerance and to be mindful of their own negative feelings,

such as when a psychiatry clinician learns to pay attention to

countertransference, which is redirection of the clinician’s feelings toward

the patient. Both empirical and theoretical work is needed to address these

barriers and to help provide steps for clinicians to include empathy into

everyday practice.

Clinician Education

Education curriculum has already been raised as a way to address barriers to

empathy in the clinician-patient relationship. Specifically, clinicians can be

trained to focus on the beginning of a patient interview, giving the patient

time to speak without interruption. This helps set the tone for patient

disclosure and trust to develop. Education can also focus on how the clinician

perceives the psychosocial needs of the patient as important and integral to

good diagnostic outcomes.

Clinicians also need to be educated to focus on their own self-care, and

potential anxiety as they often function within overworked and short-staffed

health teams. They need to be educated to acknowledge and seek

interventions for their own emotional needs.

Neural Basis Of Empathy


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Empathy is fundamental to the emotional and social lives of people and is

defined in general as the ability to share the feelings of others. As

mentioned, human imaging studies have been used to determine how

empathy consistently showed activation in regions of the brain that involve

experiencing pain. This suggests that empathy is based at least in part on

shared representations of firsthand and imagined experiences.86 These

emphatic responses are not static. They can be modulated by the

characteristics of a person such as the degree of alexithymia, which is the

subclinical inability to identify and describe emotions within oneself. This is a

marked dysfunction in emotional awareness, interpersonal relationships, and

social attachment.

Empathy-related insular and

cingulate activity (with the

cingulate cortex part of the brain

situated in the medial aspect of the

cerebral cortex) can reflect a

domain general computation,

representing and predicting feeling

states in oneself and others, and

believed to guide responses and

goal-directed behavior in dynamic

social contexts. Empathic neuronal

activation can also be modulated by

contextual appraisal that includes

perceived fairness or group

membership with others. Empathy


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can involve co-activation in further networks that are associated with social

cognition. This depends on the specific situation and the information

available in an environment.

Empathic Negotiation And Confrontation

Avoiding confrontations is often considered the best approach to handling a

difficult patient. However, a closer look at the topic of confrontation with

patients is needed to identify concepts and methods for coping strategies.

Kontos, Querques, and Freudenreich provided insights into the rationale and

responsibilities in patient confrontation. They identified that all clinicians can

find themselves challenged with patients who are behaviorally inflexible,

demanding, and temperamentally difficult.87

Being prepared through education on the empathic approach when dealing

with patients is the ideal in order to carry forward empathetic negotiation

and persuasion. There can be a natural reluctance to confront patients if

they are unresponsive to these approaches, and at times the confrontation

can be mishandled. Confrontation is defined as a clinical interaction that is

interpersonal, face-to-face, and has the potential for an emotional clash,

forcing a comparison of two points of view on medical care. Confrontation

can also be a communication tool for a clinician to use when attempting to

make decisions in a patient’s best interest. It can also be a patient-centered

approach and relies on shared responsibility.

Kontos, Querques, and Freudenreich made the case for effective use of

confrontation in patient care. Other interpersonal and social interventions

were raised. The goal was to discuss an approach that could improve

therapy, reduce clinician frustration, and minimize misallocation of


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resources. The authors noted that medical literature and training can neglect

guiding a clinician in managing poor patient behavior and attitudes.88

Confrontation with patients can seem inconsistent with medical best

practices. But there is an argument that confrontation and healing are not

mutually exclusive. Some have argued that clinician assertiveness has

therapeutic value with hesitant or oppositional patients. There needs to be a

balanced focus on patient care outcomes and clinician duty to confront a

situation. A poor confrontation with a patient can give a clinician a sense of

powerlessness with respect to the clinician’s concerns and judgment on safe

and appropriate patient care. Confrontation that is poorly executed can be

counter-therapeutic and sever the clinician-patient relationship.

The authors proposed three questions to help clinicians decide if

confrontation can be in the best interest of patients. The first question is:

Does my patient prioritize health? The second question is: Is Confrontation

of My Patient Ethically Permissible? The third question is: What If

Confronting My Patient Is Emotionally Gratifying? The authors recommended

that the clinician does not want to subdue the patient as an opponent.

Rather, the clinician wants to turn the patient into an ally to fight for their

own better health.

The most important question to ask in choosing if patient confrontation is an

option relates to whether the patient prioritizes health.89 The business of the

clinician includes patient attitudes and behaviors that negatively impact

clinical progress. If proper patient care cannot proceed, confrontation could

be justified. The proposal could be a negotiated change. If a patient does not

prioritize health, the clinician should explore and try to work with the

priorities of the patient. The clinician can try to influence the patient but


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cannot impose on the patient to minimize disease burden except in special

circumstances.

Problems can arise if a patient makes demands and does not highly prioritize

health. Take for example a 55-year-old patient with type 2 diabetes mellitus

and long standing poor glycemic control due to nonadherence who attends

appointments sporadically, refuses nutritional guidance, and has comorbid

heart disease. In this case, confrontation could be justified. In such a case,

the patient seeking care needs to improve cooperation with the diabetes

care being provided. Cooperation does not mean passivity. A responsible

patient should engage actively in their pursuit of health and in medical

decision-making. If there is clinical inefficacy due to a defect in the clinician-

patient relationship, this should be considered in the decision concerning

patient confrontation.

Ineffective clinical care can be due to an imbalance between the health

clinician’s and the patient’s responsibility. Confrontation could be justified to

bring these two components into a productive balance. For example, a

psychiatric illness could cause a failing clinician-patient relationship, such as

with a sociopathic patient who is angry and hateful. Challenging such a

patient, who may also have comorbid conditions related to the mental

illness, such as an addiction disorder, personality disorder, or other

psychopathology, is challenging however it is important for the clinician to

identify if a barrier to health is resolvable, and if the patient is invested in

his/her own health.

Avoiding conflict might not be the best option. Patients sincerely tending to

their health would likely inform the clinician of their needs and hope for a

remedy to their ailment. However, after identifying, adjusting to, and


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reducing barriers to care, if the patient is not invested in his/her own health

then confrontation could be an option to potentially correct the imbalance in

the clinician-patient relationship and ineffective clinical outcomes.

Confrontation and Ethics

Confrontation could be considered a violation of patient autonomy and

concerns medical ethics. Patient autonomy is a cornerstone of current

healthcare, but simply respecting a patient’s decision could be a dangerous

oversimplification. For example, consider the case of a 55-year old patient

with coronary artery disease who presents repeatedly to an emergency

department with worsening symptoms of shortness of breath and chest pain.

Each time the patient leaves the emergency department against medical

advice after receiving nitroglycerin and morphine. Confrontation by the

clinician might be the only way such a patient would stop with decisions that

are not helping his/her health.

In the clinician-patient relationship it is assumed that patients can do no

wrong. However, a clinician can use their expertise and authority to make

medical decisions and request patient accountability. In an ideal situation,

the clinician-patient relationship is between two autonomous parties with a

mutual goal, and where the clinician can have legitimate expectations of the

patient. The relationship should ideally include truthfulness, respect, and

adhering to a plan for care that is negotiated. In an honest relationship,

respectful confrontation can occur when one person bears a burden in a

failing direction. Because the clinician is considered a caring stakeholder in a

patient’s health, if the health of a patient is deteriorating due to patient

action or inaction and other avenues of intervention are exhausted, the

clinician should care (and be justified) to confront.


23

The main point in this section is that confrontation can become an option.

When the patient’s health is deteriorating, harm can occur through passivity

and a superficially inoffensive relationship between the clinician and patient.

Once the clinician has thought through in advance about whether a patient

has enough opportunity to control certain variables, the clinician should hold

the patient accountable.

Clinicians are also considered stewards of healthcare resources and if the

patient is unfairly and unjustifiably using finite resources, this should be

confronted as well. The issue of confronting a patient is a challenging issue

that some clinicians may prefer to avoid, but it is an increasing topic in the

health literature relative to clinician-patient engagement and a topic that

clinicians are recommended to focus on in terms of professional

development and competency.

Confrontation and Emotional Gratification

At times a clinician can feel frustration or anger with a patient and feel

compelled to step back. This frustration or anger can be due to

countertransference or simple human emotion. A good approach is not to

simply act on a positive or negative response, but to evaluate responses in

context of the clinician’s relationship with the patient.

A clinician must not simply indulge in self-gratification. On the other hand,

avoiding feelings and reactions could cut off a potentially helpful decision

about clinical action and result in harmful decisions. While a clinician can

love, hate, or fear a patient, he or she should acknowledge these feelings

and examine motives in clinical decision-making affecting patient health. An

example would be a 40-year old with systemic lupus erythematosus (SLE)

who is inconsistent with keeping medical appointments. Other complicating


24

factors could be that the patient is verbally abusive, refusing treatment and

yet accuses the clinician for not meeting health expectations. If the patient is

not cooperative, threatening and showing unacceptable behavior, avoiding

and/or disregarding the patient’s displeasure could pose risks for the

clinician in the end. If an unfavorable imbalance exists in the clinician-

patient relationship, it can lead to the clinician feeling constrained in terms

of communicating options to continue versus discontinuing the relationship

with the patient. In such cases, while the confrontation could be difficult it

may be needed and, in the end, helpful.

A patient can also have a powerful emotion and act in a way that renders a

clinician to act on them before the clinician realizes what is happening. This

is an unfortunate outcome, and is known as projective identification. If the

clinician disavows these feelings, a patient can sometimes escalate an

already irrational behavior.87-90 Although such circumstances can be

challenging, there is still an opportunity to turn the situation toward a more

therapeutic encounter. The clinician can choose to either tolerate the

unpleasant emotions or examine them from the patient’s perspective. The

patient may be helped to identify, understand, and manage their own state.

If a clinician responds in a way that is strategic and mature, this can be

useful and gratifying to all involved.

Judgment can be clouded by the need for self-gratification. Reactions to a

patient and projective identification can involve complex motives and

feelings. Clinicians should be aware of these possible outcomes in the patient

relationship when considering the need for confrontation. The ideal is that

the clinician is reflective and can self-assess their own feelings and

responses before, during, and after patient confrontation, and seeks periodic

consultation to make sure all factors are weighed responsibly.


25

In a clinician-patient relationship confrontation can be a legitimate option if

that relationship suffers from an imbalance related to a person’s privileges

and duties. Kontos, et al., focused more on principles and not on specific

techniques of confrontation.90 Some patients will be confronted and find

another health clinician to do what they want. More could be said in the

medical literature relative to patient confrontation, such as how to stay

consistent with the goals of patient-centered medicine though values of

honesty, social responsibility, and mutual accountability.87-90

Letting Go of Anger

Letting go of anger is a positive step for both a patient and health clinician.

If the clinician holds on to anger, he/she cannot effectively move forward

with a solution to problems. If a patient feels anger, they need to be guided

as well to let go of it.

Clinicians who feel anger, due to what a patient said or some other reason,

cannot effectively act as a health professional. If the clinician or patient are

not able to get rid of anger, the price could be high. Not letting go of anger

could cause individuals to suffer physically, emotionally, and spiritually; it

can lead to bitterness, lack of enjoyment of the present, depression, anxiety,

and a lack of connectedness with others. Letting go of anger is a conscious

decision, and it opens options for better feelings of understanding, empathy,

and compassion. When a person lets go of anger this leads to healthier

relationships, greater psychological wellbeing, less anxiety, less hostility,

less stress, lower blood pressure, fewer symptoms of depression, a stronger

immune system, improved heart health, and higher self-esteem.91-93

Techniques To Deal With A Difficult Patient


26

Insight on the art of handling difficult patients has been offered by

Chesanow who notes these patients can be the one many clinicians and staff

dread to see walk into a clinic or admitted to hospital. Difficult patients are

regarded as those who are angry, disrespectful, rude, demanding of certain

drugs or tests even when they are not needed, abusive, and even ask

clinicians to submit a fraudulent bill so that insurance will cover the cost of

treatment.94

One approach to dealing with the difficult patient is to draw boundaries.

Clarify what behavior is allowed and require them to act respectfully. A

patient may not be aware that they are being difficult and demanding. If

setting such boundaries does not work, the clinician could suggest to the

patient that he/she is not the best clinician for the patient. Alternatively,

another approach is to overcome the issues encountered with a difficult

patient. Trying to determine what the patient is unhappy about in the

clinician-patient relationship and being willing to apologize can help even if it

is not the fault of the clinician. For example, the patient may have had a

long waiting room stay or not happy with a specialist referral. The patient

could be forgiving with the clinician if they detect the clinician is genuinely

sorry for the patient’s unhappiness.

There is a reported 5 percent of patients that can cause 95 percent of the

problems in a clinician’s practice. It may not always be prudent to dismiss

the patient from the clinician’s practice; in that case, the clinician must deal

effectively with a rude and abusive patient. The clinician and the general

office staff need to be prepared to assist in the needs of a difficult patient.

The clinician should have staff prepared to deal with, for example, a patient

who gets impatient when an appointment wait is long.


27

In cases of unresolved conflict, the clinician may opt to write the patient a

letter or address the patient in the presence of an office manager. An

example would be when the clinician needs to calmly inform a patient that a

basic ingredient in the relationship needs to be addressed. If the patient’s

behavior appears to lack cooperation with the clinician and office staff, this

makes it impossible to engage with the patient to promote good health

outcomes. Options in such situations are to advise a patient to find another

medical clinician, provide a referral to them or ask for a referral from

another primary care physician. While the patient is seeking another medical

clinician, he/she can be advised that emergency care will be provided for one

month from the date of the termination of care letter. Any subsequent

behavioral issues should be documented.

Not all clinicians feel comfortable terminating a patient relationship. Some

have not been able to identify ever interacting with a difficult patient or

consider they have been effective with a difficult patient by listening to their

story without interruption. Much depends on the medical specialty and type

of clinical practice engaging with patients. A clinician can guide the

conversation if it becomes unproductive with unnecessary detail.

If a health clinician feels pressured for time, it may be hard to not show

impatience. This can inflame a situation. It is hard to feel compassion for

someone who is not cooperating. A clinician can also fear harming a patient

by missing a diagnosis or not recognizing a drug interaction, forgetting to

check a lab or missing a call back. A problem patient can cut into the time

needed for all of this. But a medical clinician can recognize that dealing with

a difficult patient is inevitable and requires clear boundaries to be

established for both patient and staff.


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Frequent Flyers

There are certain patients that arrive at the hospital emergency department

as if it was home. Such patients are often on a first name basis with the

staff. For example, they could have a history of substance use and addiction,

and staff tend to regard them as a regular visitor or frequent flyer.95

The medical frequent flyer generally refers to patients with a number of

health needs. Some are rebounding and challenged by alcohol and drug use

issues, and others need mental health care. Typically, frequent flyers use

the emergency department because they have no health insurance. They

usually have no primary care clinician. The frequent flyer may be driven by

anxiety and fear, chronic pain, yet feel reluctant to make an appointment to

see a primary care clinician.

Some health facilities are considering new ways of taking care of medical

frequent flyer patients, and to manage their needs in a more cost effective

way. Hospitals, healthcare systems, and academics have been prompted by

the urgent need to address the health of medical frequent flyers. The goal is

to curtail a problem some believe could become even worse without clear

planning and solutions to address it.19-26,95

Insurance companies are also working with hospitals to implement new

programs, for example for the frequent flyer with a mental illness or for

others with chronic conditions. The attempt is to divert these patients into

coordinated care plans that are hospital-sponsored. They also connect with

government and community-provided services. Often, case managers are

assigned to monitor these medical frequent flyers. The manager follows up

after an emergency department visit to prevent a recurring hospital stay.

Hospitals are now using electronic medical record programs to flag frequent


29

flyers for primary care clinicians and community organizations. Hospitals

may also assign social workers and nurses to look over records and identify

patients who come to the hospital often. They alert these patients that they

may need psychological or primary medical care rather than repeated

admissions to the emergency department.11-13,15-26

A medical frequent flyer may arrive at an emergency department as many

as five times per month. Patients who arrive at the emergency department

with such frequency may have drug or alcohol use disorders. Some are also

homeless. Often, frequent flyers in the emergency department have complex

and severe medical problems. Combined homelessness and addiction issues

can complicate the medical picture in the emergency department, for

example, the person may be intoxicated and having a myocardial

infarction.95 They may have fallen and hit their head and sustained a skull

fracture. Impaired patients cannot always explain how they are feeling.

Complexities are associated with frequent flyers and their use of emergency

departments. The use of an emergency department by a frequent flyer

involves a high health cost burden for a hospital. It is also a strain because

frequent flyers add to overcrowding in emergency departments, impacting

the patient waiting times and delaying emergency, life threatening

interventions for those in need. An urgent need exists for policy makers and

insurers of healthcare to address the growing needs of homeless and

uninsured individuals that become frequent flyers in hospital emergency

departments.11-13,15-17

Summary

There is no standard definition of empathy but certain elements can be

identified. Empathy in healthcare is generally viewed as the competence of a


30

clinician to understand the situation of a patient including their perspective

and feelings. It is also the ability to communicate and to act on that

understanding in a therapeutic way.

Empathy is considered the basis of good clinician-patient communication. It

has an impact on patient satisfaction, adherence, decrease of anxiety and

stress, better diagnostics and outcomes. Barriers to empathy exist and are

important to understand through clinical education and ongoing training.

Understanding patient anxiety or other emotions that could potentially

interfere with empathic responses is essential, and clinicians need to be

aware of their own detachment and emotional attunement to avoid patient

perceptions of a lack of time to listen and engage.

Clinicians can be trained on ways to improve empathy and their

communication style with patients. Empathetic communication in the clinical

encounter impacts the overall patient satisfaction with healthcare service,

and patient adherence to regimens, comprehension, and perceptions. A

warm communication style by clinicians can lead to a positive effect on

patients and lead to improved engagement and health outcomes.


31

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The Value of Empathy in the Patient-Clinician Relationship Ceu · context of psychotherapy and about the role it plays in clinician-patient communication. ... cope with illness and

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