Empathic Failures from the Patient Perspective: Validation in the Acute Setting

One widely accepted definition of empathy involves both an understanding of patients' experiences, concerns and perspectives as well as an ability to communicate this understanding to patients.⁵ This implies that in order for a patient to experience the benefits of being cared for by an empathic physician, the physician must also be an effective communicator who successfully conveys understanding and validation. But communication breakdown is rampant in medicine; a recent study comparing a self-rated measure of empathy in medical students with a patient-rated empathy tool demonstrated consistently higher self-rating when compared with scores given by patients,¹ indicating a gap between physician intention and patient perception.

Most studies of empathic communication in the patient-physician relationship focus on the primary care setting. While the same trends might be applicable to the inpatient setting, there are additional challenges inherent to effectively communicating empathy in the faster-paced, episodic environment of inpatient care. This becomes difficult in situations where physician-patient interaction is brief, patients are seriously ill, and the venue is disorienting and unfamiliar. These challenges become particularly apparent in consultation psychiatry, where effective communication and validation of patient experiences is crucial to building a therapeutic alliance and achieving successful treatment outcomes. Needless to say, the chaotic context is ripe for empathic failures. The introduction of a new consultation team to a hospitalized patient already overwhelmed by people, tests and procedures can pose an additional burden.

The following case illustrates such a breakdown in empathy, as well as its rapid recovery through bedside validation techniques.

Case Vignette

Mr. L is a 70-year-old male with a medical history of chronic pancreatitis, hypertension, diabetes, hyperlipidemia and peripheral artery disease who was admitted for abdominal pain. Although in the past his recurrent bouts of pancreatitis responded well to bowel rest and pain control, on this occasion, he developed a gram negative bacteremia three days after admission, resulting in septic shock and acute respiratory distress syndrome (ARDS). Mr. L was intubated and treated in the intensive care unit (ICU); after several days he was transferred to a regular nursing floor, though quickly returned to the ICU after becoming hypotensive and required aggressive fluid resuscitation. The consultation psychiatry team was asked to evaluate Mr. L for confusion in the earlier portion of his admission; toward the end of this care, he struggled with lingering sleep-wake reversal while in the ICU. The following is the final consultation psychiatry visit during which a new staff attending physician evaluated Mr. L for the first and only time. Mr. L's delirium and agitation by now had been replaced by irritability and anxiety as observed by the primary medical team and nursing staff.

• Dr. (accompanied by two medical students):

• My name is Dr. ____.

• It's nice meeting you – I'm from the psychiatry team.

• Mr. L (appearing impatient, sitting in ICU bed with monitors beeping): Hi Doc.

• Dr.: We were just swinging by to see how you were, especially to see how your sleep is.

• Mr. L (looking down): It is what it is … not good.

• Dr.: I think a lot of it has to do with being here in the ICU.

• Mr. L: I'm sure it is.

• Dr.: What is the medical update? What is next for you?

• Mr. L (annoyed): I don't know, it's always something. (Shaking head slightly).

• Dr.: I think we first started seeing you for confusion – but you seem pretty sharp right now.

• Mr. L (still annoyed, shaking head again): I'm fine. (At this point answered a few orientation questions accurately).

• Dr.: How long have you been here now?

• Mr. L: Too long. (Raising voice)

• Dr.: And there's still no clear information on what's next. That must be frustrating. (Pause.) I bet the not knowing is difficult.

• Mr. L (quickly, making direct eye contact and engaged): Of course it is. I've been here for two months or whatever – can't do anything, just keep staring at this same little space and the same people. (Pointing at the narrow space between the curtains on either side of him.)

• Dr.: And everyone just does the same thing over and over.

• Mr. L: Yep … (Pause.)

• Dr. (hoping to assess neurological functioning): Well, I wonder if it would be OK with you if this medical student here examined your arms.

• Mr. L (irritable, brisk): Actually, it's not OK!

• Dr. (reacting to what just occurred): You're absolutely right. It's not OK. (Pause.) I just realized we are doing what we just were saying was a big problem here … the repetitive tests.

• Mr. L (hesitant): Yes … we can't do that all the time.

• Dr.: Whether it's the nurses or the doctors, they keep doing the same thing. Checking you here, examining you there …

• Mr. L (interrupting): And pulling the sheets, the gowns, grabbing my arm for the … the …

• Dr. (assisting): the blood pressure and –

• Mr. L: right, all of that. … Enough is enough. (Pause.)

• Dr.: We did the same thing you've been sick and tired of. That has to be extremely upsetting that it keeps happening. (Pause.) We don't need to do that exam, and maybe simply talking like we were is best.

• Mr. L: That would be best.

• Mr. L's condition, long hospitalization and uncertain future were further validated, to which he responded well. He thanked the team for seeing him, something he hadn't done with many clinical groups. The consultation psychiatry team discussed his diagnosis and predicament using the concept of demoralization, as well as the role of validating and empathic statements.

• Mr. L was shortly thereafter discharged to a skilled nursing facility.

Discussion

In the case above, the physician fell into a similar pattern of rote data collection (neurological assessment) exactly when the patient benefited from something altogether different. Luckily, the physician was able to quickly recognize this empathic failure and even discuss it openly with the patient. Repeated validation of the patient's situation allowed for improved rapport, and recommendations to continue this approach were passed on to the primary team and nursing staff.

Empathic validation is a well-recognized psychotherapeutic intervention⁴ that is easily adaptable to acute settings. It is especially powerful in cases of demoralization, in which patients experience changes in mood, thinking, or behavior when the patient feels overwhelmed by protracted medical illness and lack of progression.⁹ Differing from clinical depression, demoralization responds best to bedside interventions aimed at increasing agency, understanding, and purpose.³ Furthermore, validating communication should focus on the use of acknowledging statements such as, “This must be very difficult for you, Mr. L,” instead of unintentionally invalidating questions (via seeming naivety) such as, “What is wrong, Mr. L?”

Beyond personal validation, empathic stances offer a variety of health benefits. Patients who rated their physicians more highly on the Consultation and Relational Empathy (CARE) Questionnaire experienced decreased severity and reduced duration of common cold symptoms, as well as a greater increase in IL-8 levels, demonstrating increased immune system activation.⁸ Those whose physicians score higher on the Jefferson Scale of Professional Empathy (JSPE) have been shown to achieve superior HbA1C and LDL control compared with patients of lower-scoring physicians.⁶ Patients of more empathic physicians also report lower levels of anxiety¹⁰ and greater levels of empowerment and enablement in achieving their health goals.^7,2

In conclusion, it is important that clinicians remind themselves that the practice of empathic care is a mindful one warranting constant vigilance to prevent communication breakdowns. It can be communicated with simple but important validating messages. Perhaps most important, empathic care may result in actual health benefits, enhancing medical outcomes.