CORR Insights®: There is Little or No Association Between Independently Assessed Communication Strategies and Patient Ratings of Clinician Empathy

Where Are We Now?

Trust in clinicians, organizations, and systems is essential to the practice of orthopaedic surgery. Strong relationships between patient and provider have been associated with greater patient satisfaction, beneficial health behaviors, fewer symptoms, and better quality of life [1]. Musculoskeletal specialists may therefore use communication and relationship-building strategies to achieve these aims, and independent observations and measurement of effective strategies would be helpful in order to learn and improve most effectively and efficiently.

The study by Brown et al. [2] in this month’s Clinical Orthopaedics and Related Research® is important because it challenges assumptions about the correlation between communication effectiveness and perceived empathy. Clinic visits between musculoskeletal providers and patients were video-recorded, patients completed post-visit questionnaires, and trained communication scholars observed the videos. The authors found little or no association of observed communication behaviors with patient-rated empathy of the clinician and concluded that either effective communication alone is insufficient for high levels of empathy or that existing measures of effective communication or empathy are inadequate or inappropriate [2]. Based on this evidence, clinicians, organizations, and systems should not spend a lot of time or money on “perfecting” communication strategies for all clinicians using our existing measures. Resources would be better directed to underperformers and trainees, or to research to better understand other factors that influence the experience of empathy.

Where Do We Need To Go?

This study demonstrates gaps in our understanding of communication skills in practice. Although communication skills training may help trainees avoid poor communication behaviors, this study [2] suggests that even superlative communication skills may not be enough to influence a patient’s perception of clinician empathy during the typical clinic visit. I wonder whether the impact of excellent communication might be easier to measure, though, in “atypical” visits—such as those involving difficult physician–patient conversations, discussions about death or high-risk interventions, conversations in which a medical error is disclosed, or visits involving greater levels of stress such as those that might arise when a patient’s expectations have gone unmet.

Regardless, we need to delineate and measure the other benefits of improved communication strategies, because conversations in the office are not used purely to convey empathy. Effective communication strategies provide greater clarity for the patient and greater confidence in the care provided and improve the efficiency of the visit. Empathy may be too narrow a measure of the visit experience. What are the other benefits of clear communication?

Our approaches to measuring communication skills may also need improvement. When trained observers review a clinical interaction, there may be intonation, body language, or other factors that are not immediately visible but substantially influence a patient’s perception of the visit. There might also be cultural cues that are visible to some people but not others. Investigation into such subtle cues may better illuminate how better communication improves interactions.

The authors in this study in CORR® [2] also noted that patients who are married or live with a partner feel more empathy owing to good communication strategies. Why is this group more influenced by these strategies than single patients? Does the experience of living with someone give greater appreciation for communication skills in others?

How Do We Get There?

To better study this problem, we first need to identify patients with the greatest need for empathy. Studies of depression, catastrophizing, and post-traumatic stress symptoms have shown that clinicians often underrecognize the emotional needs of their patients through routine care [3, 4, 6, 7], so this will likely be achieved with the development of screening questionnaires. This may require screening of the clinician and provider, because the greatest need for empathy may occur when expectations are furthest apart in the therapeutic relationship. In joint arthroplasty clinics, for example, patients with the greatest disability before undergoing surgery often have the greatest expectations about their postoperative functional outcomes [5].

Observational studies that assess text comments before and after clinic visits (for example, regarding expectations and satisfaction) could identify patients who are most in need of empathy or increased skill in communication and assess factors predictive of increased communication needs in the clinic. Brown et al. [2] noted the ceiling effects of existing measures of perceived empathy, and they noted that natural language processing of verbatim text comments from patients about their care experience may result in a more normal distribution of patient experience scores and no ceiling effect.

We also need to explore advanced measures for measuring communication skills. As suggested in the study in this month’s CORR [2], computer-rated measurements of emotional content of clinicians’ facial expressions [8] may be worth exploring. Machine learning may help better understand subtle intonation, body language, facial expressions, or other cues that are imperceptible to a human observer. Through use of computer algorithms and the analysis of large numbers of observations they would facilitate, we may be able to discover complex patterns and make predictions without human observation.

To answer why adults who are married or living with a partner perceive greater empathy owing to communication strategies, we may need to assess whether such adults are more observant or appreciative of efforts in this regard. Surveys could be done to determine whether a history of long-term relationships helps adults recognize communication skills in others. A further study could determine whether such recognition is associated with greater patient perception of clinician empathy. If so, it may be okay for patients to be aware of our sometimes mechanical efforts to communicate better, and simply appreciate that we care enough to try.