A Typology of Empathic Communication Strategies in Dental Visits

ABSTRACT

Introduction

Dentists' empathy for patients is associated with enhanced patient satisfaction and clinical outcomes, and with reduced patient anxiety and dentist burnout. Cognitive empathy has been distinguished from emotional empathy, but how these broad types are expressed within the dentist‐patient relationship has not been explored. The purpose of this study is to further differentiate types of empathy expressions in routine dental visits.

Materials and Methods

Third‐year students (n = 80) treated standardised patients (n = 11) portraying one of two patient profiles, each of which had multiple treatment needs in addition to a major systemic health problem: cancer or rheumatoid arthritis. After each visit, the patients completed assessment rubrics which included opportunities to comment on performance on four skillsets: visit initiation, patient interviewing, treatment planning and global communication. These comments were qualitatively content analysed. Comments (n = 301) were first deductively coded for valence (positive vs. negative evaluation) and empathy type (cognitive vs. emotional). Subsequently, comments were inductively coded for subtypes.

Results

Three subtypes of cognitive empathy were identified in patient comments: facilitating comprehension, resolving treatment barriers and relieving physical discomfort. Five types of emotional empathy were identified: comforting emotionally, validating, sympathising, encouraging and inspiring confidence. Unexpectedly, four subtypes emerged which could not definitively be classified as exclusively cognitive or emotional, so a hybrid type was identified for these subtypes: respecting, moderating, attending and destigmatizing.

Conclusion

Patients distinguish subtypes of cognitive and emotional empathy, but some hybrid expressions are powerful because they simultaneously convey both types of empathy.

1. Introduction

Empathy expressed by healthcare providers is widely acknowledged to enhance patient care. A growing body of research provides an evidence base for empathy's elevated status [1]. Dentist empathy is associated with a variety of positive patient responses, especially patient satisfaction [2]. Corah et al. surveyed 250 dental patients and concluded, ‘the dentist's empathy and communicativeness were among important correlates of patient satisfaction.’ [3] Hojat et al. reported a Pearson correlation of 0.93 between patient satisfaction and perceived physician empathy [4]. Empathic dentist behaviours also are associated with decreased patient anxiety, in both adult and paediatric dental patients [5, 6]. And Mercer et al. found a significant positive relationship between physician empathy and patient enablement in a practice serving economically disadvantaged patients [7].

Satisfaction, anxiety and enablement rely on self‐report measures, but empathy also is associated with more objective measures and clinical outcomes. Although research on associations between empathy and clinical outcomes in dentistry has not been published, physician empathy is associated with significantly better A1c and LDL‐C levels in patients with diabetes [8]. Similarly, physician empathy is associated with less severe and shorter colds, along with more significant changes in interleukin‐8 and neutrophil counts [9].

The benefits of empathy also accrue to healthcare providers. A 2017 systematic review found that healthcare provider empathy is a protective factor for professional burnout [10]. A 2019 study found dentists and dental students experience higher‐than‐normal rates of burnout, but that those with greater empathy reported less burnout [11]. Another 2019 study found dentists with higher empathy scores reported lower vicarious trauma—the impact on the dentist of a patient's anxiety and pain [12]. Dentists scoring higher on empathy report greater job satisfaction and less depression [13].

In sum, the research demonstrates that empathy is consistently associated with significantly elevated patient well‐being, dentist well‐being and clinical outcomes. Less consistent are conceptualizations of empathy, which hinders efforts to cultivate it in dentists. The English word empathy first appeared in a 1909 book by psychologist Edward Titchener, who thereafter was himself inconsistent in how he used the term [14, 15]. In the medical research literature, empathy is often not defined or is defined differently in different studies, complicating comparisons and efforts to develop training in empathy [5, 16].

Perhaps due to its similarity to sympathy, the lay understanding of empathy tends to focus on understanding the emotional state or responses of another. Some researchers of empathy's role in medical care reject emotional or affective empathy altogether, and emphasise that empathy is a cognitive attribute describing a person's ability to understand the patient's experiences and perspectives [17, 18]. Perhaps the most widely used measure of empathy in healthcare, the Jefferson Scale of Physician Empathy, elicits self‐reports of cognitive, but not emotional, empathy [19]. Researchers also disagree whether empathy requires communication [17, 18]. Is an internal empathic response sufficient, or must empathic thoughts or feelings be expressed to the patient to qualify as empathy?

The current study employs the definition put forward by Sherman and Cramer, who said empathy, ‘is the ability to understand a patient's experiences and feelings and the capability to communicate this understanding.’ [20] This definition incorporates cognitive empathy, emotional empathy and communication. Cognitive empathy is necessary because understanding patient decision‐making processes is central to developing treatment plans the patient is able and willing to implement. Emotional empathy is necessary because non‐rational influences like anxiety, fear, shame and joy feature prominently in patient decisions to seek care and to implement treatment recommendations. Finally, communication is necessary in order to distinguish empathy from critical thinking skills. Empathic understanding of the patient certainly enhances dentists' decision‐making, but many patient‐related correlates of empathy (e.g. patient satisfaction, reduced anxiety) depend on dentists communicating that empathic understanding, something that dental students, especially males, often struggle to do [21, 22]. Empirically researching empathy, moreover, depends on the ability to observe, document and replicate.

Much of the research to date relies on self‐reports of provider empathy. These do hold value, but also have shortcomings. First, they primarily measure provider understanding of their patients instead of their ability to communicate that understanding. Second, the reliance on self‐report is vulnerable to biases. Third, they do not offer explicit details on the way empathy is enacted with a patient in a dental chair. Replicating empathy based on self‐reported perceptions of one's own empathy (perceptual or communicative) is nearly impossible.

To summarise, existing research on healthcare provider empathy provides overwhelming evidence that it benefits both patients and providers, but also finds less agreement on what constitutes empathy or how empathy is communicated to patients. Rather than increasing empathy, time spent in dental school tends to reduce empathy, so modalities for cultivating empathy skills are much needed [20, 23]. A 2019 review attributed the decline in empathy among dental students to their exposure to patients—the defining feature of a dental career—and called for enhanced behavioural sciences training to prevent the decline in empathy and to maintain high levels across the career trajectory [24]. This study was designed to facilitate such training by clarifying the communication messages that can be classified as cognitive empathy and which ones can be classified as emotional empathy. The study seeks to answer the following research questions:

RQ1: How do clinicians express cognitive empathy to patients?

RQ2: How do clinicians express emotional empathy to patients?

2. Materials and Methods

The Human Subjects Office of the University of Iowa determined the research did not meet the regulatory definition of human subjects research and therefore was not subject to IRB review (IRB #202207181).

2.1. Participants

This research used written feedback from standardised patients (n = 11) who worked with third year (D3) dental students (n = 80) being assessed for competency in applying behavioural science principles during patient visits. Predoctoral students are enrolled in a four‐year program employing a clerkship model requiring them to begin seeing patients in the preventive dentistry clinic at the end of their first year. To demonstrate competence in communication skillsets, and to receive feedback on their abilities, students also conduct a visit with a standardised patient in each of their first 3 years. The standardised patients (SPs) in this D3 experience were recruited from the community, but most of them had previously worked in this capacity with dental students and all of them had experience working as a standardised patient in other contexts (e.g. the medical school).

Every SP underwent training which explained the purpose of the exercise and reviewed the socioeconomic and clinical history of the patient profiles assigned to the SPs. The instructor explained the assessment rubric's skillsets and evaluation criteria. Assessment was calibrated by watching videos of previous SP visits, assessing performance individually and discussing discrepant assessments to clarify the instructor's expectations for student performance. On five sequential Tuesday mornings between 27 September and 25 October 2022, D3 students conducted one‐hour visits with these standardised patients in clinic operatories. Upon completion of each visit, SPs debriefed the student by providing verbal feedback.

Empathy and compassion are consistent themes in the behavioural science curriculum at the College of Dentistry, and the D3 course in which the students were enrolled includes a dedicated instructional module on empathy and a poverty simulation to help student develop empathy for patients contending with financial barriers to care. Each SP was assigned to portray one of two patient profiles specifically developed to offer student clinicians opportunities to express empathy to patients. In keeping with the patient pool in the dental clinics, both profiles included financial challenges: no dental insurance and limited resources for out‐of‐pocket expenses. Both profiles also included systemic health problems. One profile included a diagnosis of rheumatoid arthritis which limited their ability to floss, to sit for long periods in the dental chair, and to turn to see the radiographs on the side monitor. The other profile included chronic hypertension and depression related being recently widowed and to a recurrence of breast cancer, for which the patient was receiving chemotherapy.

2.2. Measures

The rubric used to assess student performance in standardised patient visits consists of 19 criteria within four domains: visit initiation, patient interview, treatment planning and communication skills [25]. The first three domains assess specific actions students are expected to perform at prescribed points in the visit. For example: eliciting the chief concern/complaint in the visit initiation, documenting medicines in the patient interview, or describing the oral health conditions in treatment planning. The fourth domain, communication skills, comprised five global skills the students is expected to demonstrate throughout the visit. One of those skills was accommodation, described thus on the rubric: ‘Adapts to patient's characteristics and limitations (e.g. age, physical status, anxiety, health literacy, cultural norms, etc.) and responds sensitively to patient's reactions and questions.’ The survey requires SPs to assess the student on a four‐point scale for each of the 19 criteria. The SPs are encouraged, but not required, to type comments following each of the four domains.

2.3. Data Collection

Immediately after providing the post‐visit verbal debriefing, the SPs completed an online version of the assessment rubric using Qualtrics survey software. During training, the instructor advises the standardised patients during verbal debriefing to first elicit student perceptions, and afterward to use ‘When you ___I felt ___.’ statements which identify a clinician behaviour and clarify the patient's response to it. The response may be positive or negative, but it was emphasised that students benefit most from comments that balance criticism with praise. These comments delivered during the verbal debriefing are routinely repeated in the online assessment, which comprised the data analysed.

2.4. Data Analysis

Following completion of the SP exercises, the data and text were downloaded from Qualtrics into an Excel spreadsheet, where the data and text were deidentified and uploaded into QSR International's nVivo (Release 1.6.1) software. Using the Sherman and Cramer definition of empathy quoted above [20], each author read all the SP comments and identified every comment describing a student's ability to understand the SP's experiences and feelings and to communicate that understanding. During this unitizing process, the authors also deductively assigned categorical codes to comments to indicate valence and empathy type. Valence was positive when the SP approved of or praised a student's behaviour and negative when they offered criticism. Empathy type indicated whether the comment represented cognitive empathy (i.e. understanding patient experience and perspective) or emotional empathy (i.e. affective expression aligning with patient's feeling).

After this first individual and deductive coding, the authors met to address discrepancies and ambiguities. When it became clear that numerous comments could not be assigned unequivocally to the cognitive or emotional empathy type, a third type was created for hybrid or ambiguous comments. This process of discussing what the comments meant yielded a preliminary codebook describing within each type the subtype representing the function of the student communication behaviour commented on. The first author then refined this codebook during a second analysis of all comments using the constant comparative approach described by Corbin and Strauss [26]. The second author independently confirmed the validity of the analysis. Ultimately, in addition to being placed in one of three types and one of two valences, every comment was assigned to one and only one, subtype.

3. Results

The standardised patients entered text in 301 (94%) of the 320 comment sections. As there was no word limit imposed, each section could contain multiple comments. A total of 363 comments were identified as describing students' empathic communication, and 58% of these represented cognitive empathy (n = 212). Table 1 presents the three empathy subtypes within cognitive empathy. The most common subtype was facilitating comprehension, representing 64% of all cognitive empathy expressions and 37% of all expressions of empathy of any type. These comments were more often approving than critical and typically expressed appreciation for students' efforts to simplify or clarify clinical information which otherwise might have been confusing.

TABLE 1.

Cognitive empathy subtypes in standardised patient comments.

Subtype (n = 212)	Description	Examples
Facilitating Comprehension (135)	Student behaviour which enhances patient comprehension through explanation, or which enhances student clinician's comprehension of the patient's condition or circumstance through eliciting information.	Positive (86): [Student] wonderfully and clearly explained all necessary treatment and the options he suggested in such a way that I understood what was needed. Negative (49): There were many closed‐ended questions where you would give me a choice: for example, “Is it ‘this’ or ‘that’?” Sometimes I would say ‘Neither one of those.’ At times you would follow up and ask me to put it in my own words; at other times you didn't clarify what I meant.
Resolving Treatment Barriers (56)	Student behaviour which acknowledges a barrier to implementing a preventive treatment and offers a solution tailored to the patient's capabilities or resources.	Positive (44): You were mindful of my cancer condition and of my limited resources and made recommendations accordingly. I liked that you introduced silver diamine as an alternative to a filling as a cost saving measure. Negative (12): I needed to remind her that I am going to be without insurance, but then she came up with solutions around that problem.
Relieving Physical Discomfort (21)	Student behaviour which demonstrates an awareness of patient's physical discomfort or pain or an attempt to relieve it.	Positive (11): [Student] did a wonderful job noticing that I was uncomfortable and needed to move around and continued to do so throughout the interview. Negative (10): I was uncomfortable in the chair because of my arthritis but I hated to bring it up even though I was ‘fidgety’ while trying to get comfortable.

The second cognitive empathy subtype of resolving treatment barriers was also common, but appeared far less often than facilitating comprehension. This relative frequencies might reflect the fact that clinicians can facilitate comprehension throughout a visit, but presumably resolve treatment barriers only when treatment planning near the end of a visit. The third cognitive empathy subtype was relieving physical discomfort. While both profiles included systemic health problems, only the patient with arthritis (seen by half the students) needed accommodations to alleviate physical discomfort in the chair, which may account for the lower number of comments (n = 21) reflecting this theme.

The five emotional empathy subtypes are described in Table 2. Although there are more subtypes than in the other two types, they are mentioned less often in the comments than most of the other subtypes. The most common is comforting emotionally, which reflected efforts to alleviate patient anxiety and foster a relationship. A second subtype, validating, functioned to reassure patients they were valued and their concerns were not ignored or dismissed. Sympathising, the third subtype, generally reflected student behaviours that acknowledged the sadness of the patient with recurrent cancer and associated depression. Students are trained to offer positive comments and reinforcement of good oral health behaviours, and a few comments reflected the subtype of encouragement. Finally, four comments addressed the subtype of inspiring confidence, in which student behaviours inspired or undermined patient confidence in the clinician or the recommended treatment.

TABLE 2.

Emotional empathy subtypes in standardised patient comments.

Subtype (n = 66)	Description	Examples
Comforting Emotionally (23)	Student behaviour which alleviates dental anxiety or social anxiety, or which cultivates a comfortable relationship with the student clinician.	Positive (18): I felt ready to share my story b/c you created a comfortable environment. Negative (5): Your hand gestures were quite often in my ‘personal space’—so much so that toward the end of our discussion, I moved my body as far to the left as possible.
Validating (17)	Student behaviour which indicates listening or communicates that the student clinician is responding to the patient's individual circumstances and needs (vs. providing a generic response).	Positive (14): As a patient, I felt heard and listened to, as [student] made eye contact, nodded as I spoke. Negative (3): The main item I had a hard time with was eye contact and prolonged silences. When I responded to most of your questions, rather than listening and watching me, you looked down and immediately began writing. Sometimes you were looking down when you asked a question.
Sympathising (14)	Student behaviour which expresses sadness or sorrow related to the patient's bad news or health condition (e.g. a cancer diagnosis). The focus is life circumstances vs. affective state (as is the case for comforting emotionally).	Positive (12): I appreciated your acknowledgement that I'd been through a lot during the past 2 years. Negative (2): It would be good to acknowledge the heartbreak of having a recurrence of breast cancer. a few words of sympathy can go a long way in building rapport.
Encouraging (8)	Student behaviour which expresses praise or encouragement of patient behaviours or qualities (e.g. supporting self‐efficacy).	Positive (7): Appreciated that student offered praise at my brushing and mouth care. Negative (1): We spoke about that I had hoped for a bit of praise in my dental habits.
Inspiring Confidence (4)	Student behaviour which cultivates patient confidence in the treatment recommendation(s) or the student clinician.	Positive (2): When I said ‘are you sure you can be a dentist? You look 14!’ the student's response made me feel really confident in her skills. She acknowledged that she has a lot of confidence about her dentistry skills! Negative (2): At feedback time we talked about my pushing back and [student] said she wasn't sure how to respond to some of my comments, like, ‘You look 14, are you sure you can be a dentist?’

The third type, hybrid empathy, is described in Table 3. It was created by necessity when numerous comments (n = 58) would not fit unambiguously into either of the empathy types. Categorising them one way would ignore a valid interpretation of these comments as representing the other type. Ultimately, their ambiguity represented a strength because the student's behaviour could simultaneously represent both cognitive and emotional empathy. For example, the most common hybrid subtype, respecting, acknowledges an understanding of patients' decision‐making processes and their good feelings when their autonomy is acknowledged. Similarly, when moderating the amount or rapidity of information, the students were showing they understood patients were not cognitively processing as quickly as the student was talking, and also that patients were feeling overwhelmed. Another hybrid subtype, attending, simultaneously functioned to recognise patient needs (much like cognitive relieving physical discomfort) and also to proactively address them (much like emotional validating). Finally, destigmatizing recognised there are reasons for problematic patient behaviours or conditions and yet patients might be embarrassed to acknowledge them. Destigmatizing communication functioned to validate the reasons while minimising the attendant shame.

TABLE 3.

Hybrid empathy subtypes in standardised patient comments.

Subtype (n = 85)	Description	Examples
Respecting (27)	Student behaviour which acknowledges patient autonomy in participating in rapport or autonomy in electing treatment options, in a way that could signal cognitive or emotional empathy, or both simultaneously. Autonomy can be coded when a patient is persuaded to accept a recommendation as long as the patient feels their autonomy was respected during the process.	Positive (25): I told you that I do not want ‘any fillings of any kind because I heard they all cause mercury poisoning.’ You went on to give what I felt were very effective reasons that fillings are ‘safe’ today. You did this without any criticism of my opinion at all. […] You absolutely convinced me—as this patient—that fillings were safe. Negative (2): When you said you'd set up those three appointments for me, you neglected to involve me in the ‘preventive conversation and confirmation.’
Moderating (23)	Student behaviour which adapts to the patient's capacity for understanding information or interest in the information in a way that could signal cognitive or emotional empathy, or both simultaneously. Frequently relates to jargon or the use of ‘overwhelmed.’	Positive (9): Nice job realising that I was not ready to try to digest needing three fillings and just focusing on the one that is MOST necessary right now. Negative (14): As the patient, I felt overwhelmed b/c the student gave me quite a bit of information in the first 2 min of our encounter.
Attending (19)	Student behaviour which engages the patient verbally and/or nonverbally in a way that could signal cognitive or emotional empathy, or both simultaneously. Usually this relates to the student (not) sitting behind the patient.	Positive (6): However, when you turned to the computer images, I felt grateful when you noticed I couldn't turn my head to the right and back to see the screen. You lifted the chair arm so I could look directly at the screen. Negative (13): Since you always sat by my side, we were not able to have a more comfortable, face‐to‐face interaction. As a patient, I felt awkward.
Destigmatizing (16)	Student behaviour which strategically avoids embarrassing or shaming a patient in a way that could signal cognitive or emotional empathy, or both simultaneously.	Positive (12): You informed me how regularly drinking sweetened ice tea throughout day increases risk of cavities. However, you also shared that you loved ice tea and you did not make me feel guilty about this habit. Negative (4): We discussed at feedback that perhaps a sentence before eating disorder, mental health, smoke, alcohol and drug questions would make a patient feel more willing to share.

4. Discussion

In this study, we qualitatively analysed 363 standardised patient comments regarding the empathy of student clinicians during a simulated visit. The initial categorisation of comments as cognitive empathy or emotional empathy was complicated by a number of comments which could be interpreted as either cognitive or emotional empathy—or both. Thus, a hybrid type was assigned to these comments. Within the three types of empathy, 12 subtypes were identified, suggesting the communication of clinical empathy is a more nuanced and dynamic process than previously understood. These findings hold several implications for empathy research and clinical care.

First, standardised patients rarely use the word empathy, and yet they recognise it when they see it and they also note its omission when empathy would be expected or appreciated. The 301 comment boxes the SPs completed held 363 individual statements about students' empathy, an average of more than one assessment of empathy for each box. Of these, 90% (n = 327) were positive or approving comments and the remainder (n = 36) were negative or critical, typically noting missed opportunities or failure to recognise patient cues. Collectively, these observations emphasise the centrality of communication in empathy. These SPs did not comment on whether students understood patients or felt what patients were feeling. Instead, they commented on whether students communicated in a way that reassured the patients they understood. From a patient's perspective, therefore, empathy as a cognitive insight or emotional state is immaterial absent communication—a set of skills broadly comprising listening, observing, speaking and non‐verbal expression [25]. In clinical contexts, empathy should perhaps be taught as empathic communication.

Second, this study advanced understanding of cognitive and emotional empathy by identifying discrete subtypes within each. Cognitive empathy includes facilitating comprehension, resolving treatment barriers and relieving discomfort. As such, cognitive empathy is primarily concerned with problem‐solving. Critical thinking skills thus are a prerequisite for cognitive empathy, even though emotional co‐identification typically eclipses cognitive processing in definitions of empathy [27]. The number of cognitive empathy comments, however, were more than twice either emotional or hybrid empathy, indicating patients are highly sensitive to their dentist's ability to understand their motivations, their circumstances and their barriers to care—independent of their emotions about those elements or their dentist's capacity to feel those emotions. When we reduce empathy to sympathy or emotional resonance, we are missing a lot of the work dentists do to understand their patients and communicate that understanding as they are attempting to educate patients and plan treatment [28].

Third, emotional empathic communication remains important to patients and can be expressed in at least five ways. Significantly, the SPs noted empathy with both negative and positive emotions. Empathy is often construed as pity, sympathy or compassion—all of which assume negative patient emotions. Our SPs were certainly comforted when students expressed empathy for their sadness and anxiety. Yet, they also appreciated praise and encouragement, which tapped into positive emotions the patients felt, but may not have expressed. Raine and Chen developed an instrument that measures both negative and positive empathy, and more research is merited [29]. Our findings indicate that active listening is also a form of emotional empathy, in that it validates patients' feelings.

Fourth, the hybrid empathy subtypes were unexpected, but powerful, expressions of empathy. Respecting, moderating, attending and destigmatizing display high‐level skills requiring simultaneous patient observation and adaptation of clinician communication. Their impact is enhanced because they can be perceived by the patient as representing either cognitive or emotional understanding, or both. Further, these hybrid skills often entailed the students not communicating, which seems counterintuitive when student ‘performance’ is being assessed. Patients, however, approved or advocated restraint when students otherwise could have pressed a treatment option SPs were ambivalent about, could have offered more information than SPs wanted, or could have scolded SPs for behaviours both of them new were unhealthy. These hybrid skills thereby are manifestations of professional judgement as well as communication skill.

Although this study has the advantage of relying on standardised patient feedback rather than self‐report or third‐party observation to understand various manifestations of empathy, it does have some shortcomings. The patients were trained professionals and may have been more sensitive to specific behaviours than community patients would have been. And they portrayed only two profiles, which necessarily limits the range of conditions and behaviours the students could express empathy for. And definitions of empathy vary, so others may not endorse the Sherman and Cramer definition we employed [20].

The empathy types and subtypes we identified constitute a preliminary typology of empathy skills that can be taught and assessed in dental school. Future research should examine perceptions of community patients in dental clinics to determine if they identify similar subtypes of empathy, along with any other subtypes which we did not identify in our sample. Student insights would also be helpful to determine whether they are aware of the empathic messages they are sending patients and how that awareness affects their preparation and performance. Research suggests dentists' compassion does influence their treatment decisions [30]. Ultimately, future research should determine whether dentists' expressions of empathy is associated with patient outcomes.

5. Conclusion

In conclusion, this preliminary typology documented 12 subtypes of empathy as perceived by standardised patients. These patients did notice and comment on messages communicating cognitive understanding and emotional resonance, but they also included multiple hybrid empathy subtypes which communicated both simultaneously. Each of these subtypes is a skill which can enhance the oral health care provider's patient communication repertoire, patient relationships and perhaps patient health outcomes.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.