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. Author manuscript; available in PMC: 2021 Dec 1.
Published in final edited form as: Patient Educ Couns. 2021 Apr 15;104(12):2944–2951. doi: 10.1016/j.pec.2021.04.002

Empathy and boundary turbulence in cancer communication

Susan H McDaniel a,*, Diane S Morse b, Elizabeth A Edwardsen c, Adam Taupin d, Mary Gale Gurnsey e, Jennifer J Griggs f, Cleveland G Shields g, Shmuel Reis h
PMCID: PMC8517043  NIHMSID: NIHMS1700156  PMID: 33947581

Abstract

Objectives:

To describe and deepen our understanding of patient-centeredness, empathy, and boundary management in challenging conversations. Previous studies show frequent physician self-disclosure, while empathy and boundary management are infrequent.

Methods:

Three standardized patients (SPs) portrayed cancer patients consulting a new community-based physician, resulting in 39 audio-recorded SP visits to 19 family physicians and 20 medical oncologists. Transcripts underwent qualitative iterative thematic analysis, informed by grounded theory, followed by directed content analysis. We further defined the identified communicative categories with descriptive and correlational calculations.

Results:

We identified patient-centered physician response categories—empathy, affirmation, and acknowledgement; and physician-centered categories—transparency, self-disclosure, and projection. Acknowledgement and affirmation responses were frequent and empathy rare. Physician transparency and self-disclosure were common. Useful and not useful self-disclosures were highly correlated; empathy, useful and not useful transparency, and projection were moderately correlated. Most physicians used self-disclosure but few of these were judged patient-centered.

Conclusions:

Physicians expressing empathy and patient-centered transparency were also more likely to use projection and physician-centered transparency, thus engaging in communication “boundary turbulence.” Patients may benefit from physicians’ improved use of empathy and boundary management.

Keywords: Communication, Empathy, Self-disclosure, Physicians, Family, Cancer, Patient centered

1. Introduction

Modern technology and regulatory structures create threats to the patient-physician relationship, while clinicians and researchers struggle to ensure more effective Patient-Physician Communication (PPC) [1,2]. Communication skills facilitate the development of the therapeutic alliance [1–3], with physician empathy as its cornerstone and a core medical education element [4–9]. Clinical empathy is a process whereby patients’ emotional cues are vicariously experienced and then conveyed back to the patient [4–9]. Empathy is associated with a host of improved outcomes, from higher patient satisfaction to better diabetes control [10–15]. Yet studies show that physician empathy is rare in medical encounters [7,16].

Prior research demonstrated that physicians interacting with patients with lung cancer responded empathically to only 1 in 10 patient cues [16]. Concerningly, while empathy was infrequent [16], physician self-disclosure (speaking about personal feelings or experiences to the patient) was frequent in medical encounters [17,18]. While 1 in 3 primary care visits included physician self-disclosure [17], only 15% of these self-disclosures were judged patient-centered or potentially helpful to the patient. [17] Physician self-disclosure has been associated with less patient satisfaction in primary care encounters [18].

Empathy can create vicarious suffering [4–6,9,19] for the clinician. As such, it involves a brief boundary crossing (“walking in the patient’s shoes”). Decety states that “empathy…covers a broad spectrum, including feeling concern for other people… experiencing emotions that match another individual’s emotions,…and blurring the line between self and other.” [4].

A boundary is a spatial metaphor from systems theory that demarcates the line where an individual ends and the other begins [20,21]. Health professionals who establish boundaries provide stability, structure, and emotional safety to patients during health crises [22,23]. Clinical ethics postulates strict adherence to professional boundaries in the patient-physician relationship (PPR) [24]. Thus, empathy, as well as self-disclosure [21], can constitute challenges to managing PPC boundaries.

Disclosure and boundaries are important in healthcare discourse across issues [24] including error disclosure [25], digital era professionalism,[26] and genetic risk [27]. When public health is at risk, such as with COVID-19, disclosure and confidentiality sometimes must be compromised [28,29]. Given our prior research on empathy [16] and self-disclosure [17] in challenging cancer interactions, we sought to describe and deepen our understanding of patient-centeredness, empathy, and boundary management in challenging conversations. The goal of the current study is to identify ways to improve the experiences of both patients and physicians through a better understanding of empathy and boundary management in PPC.

2. Methods

2.1. Study design

The study’s initial design and prior analyses have been previously described [16,17,30,31], and are summarized here.

Both primary care physicians and collaborating oncologists are important in the care of patients with cancer, hence we studied both. [32]. We reviewed dialogues of both groups seeing undetected standardized patients (SPs) with advanced cancer for an initial visit, and analyzed the recorded, transcribed dialogues qualitatively and, to a limited extent, quantitatively [33].

SPs are actors trained to accurately portray a patient role [34,35]. SPs conduct uniform encounters, avoiding confounding factors such as the Hawthorne effect, case-mix, mutual accommodation to each other’s communication styles, and self-selection of physicians by patients [36]. For this study, three male SPs were trained to portray an advanced lung cancer patient previously cared for by a physician in another state. Each carried hidden audio recorders. Medical oncology and communication experts developed the SP role to promote clinical realism and fidelity (script available upon request). The medical record made available to the physicians represented standard of care for advanced lung cancer [37].

Of 46 SP visits, 39 (19 family physicians and 20 medical oncologists) were successfully audio-recorded. Five physicians (13%) reported they suspected an SP during the visit and were excluded, leaving 34 recorded, undetected visits for this study [38].

2.2. Physician sample

The research team recruited 46 practicing physicians from communities across Indiana: 23 family physicians and 23 medical oncologists. Physicians were reimbursed $300. Physician’s age averaged 48.1 (SD = 9.2, range 31–72) years; 71% were male.

2.3. Analysis

We analyzed 34 transcribed visits using qualitative thematic analysis, informed by grounded theory, an inquiry into a social phenomenon with the goal of developing an explanatory theory [39]. We used an iterative process to generate themes, create a coding system, and then explored coded dialogue sequences in the context of the entire patient-physician exchange. All codes were entered into the qualitative data analysis program, Atlas ti, (version 5.7.1, 1993–2011, Gmbh, Berlin Program) to organize and manage the data.

Interdisciplinary research team members first read 10 transcripts, each reviewed by 2 team members to generate relevant categories or themes. This phase of immersion crystallization [40,41] involves a qualitative analysis framework with cycles of concentrated textual review of data, combined with reflection and intuitive insights, “until reportable interpretations” are reached [41]. This phase involved noting key words and phrases, and developing codes related to areas of interest in patient-physician communication. Coding development continued iteratively until saturation (when no additional codes were identified). With each revision, all previously coded interviews were re-coded by a minimum of 2 researchers. We resolved any coding differences by consensus [41].

The current paper presents the analyses focused on empathy and boundary elements. We used a stepped qualitative-quantitative approach [33]. Team members reviewed the coded documents and extracted dialogues involving empathy and boundary management. These included statements by the physician focusing on: patient experience—empathy, affirmation, and acknowledgement, and physician experience—self-disclosure, transparency, and projection. Empathy was coded when physician statements explicitly recognized a patient’s emotional experience [16], Affirmation when the physician validated or confirmed the patient’s experience [42], and Acknowledgement when the physician verbally recognized the existence or took notice of a statement, person, or event [43]. Self-disclosure was coded when the physician shared personal information with a patient [17], Transparency when the physician was openly sharing thoughts or feelings about the illness, treatment, or situation [44,45], and Projection when the physician made statements disconnected from those of the patient, seeming to represent the physician’s own suppressed issues, stress, or emotions distinct from those of the patient [46,47].

For those utterances focused on the physician’s experience, we judged each by whether they had a more patient-centered (useful) or physician-centered (not useful) [30] impact, by assessing them in the context of the patient’s statements prior and subsequent to the utterance [30]. If the patient indicated that they heard the statement, it related to the patient, or the patient responded affirmatively, the utterance was coded as patient-centered and “useful.” Conversely, if the comment did not relate to the patient, the patient changed the subject, or the patient continued their prior topic, the utterance was coded as physician-centered and “not useful.” (See Fig. 1.).

Fig. 1.

Fig. 1.

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Useful vs not useful physician utterance decision tree.

During our final data analysis, we used Communication Privacy Management (CPM) theory to describe, interpret, and expand our understanding of boundary management [22,23]. CPM is a rule-based system to examine the way people make decisions about balancing disclosure and privacy. Developed by the sociologist Petronio, one of its applications is in healthcare, in PPC with regard to privacy, confidentiality and boundaries. Among its useful features for the present discussion are confidentiality protection rules and the construct of boundary turbulence. Boundary turbulence refers to situations where boundaries are unclear, violated, or inconsistent, often in response to tense or anxiety-producing situations such as delivering bad news [22,23].

The team met several times to discuss the thematic and categorical structures as well as their interrelationships. Through this process, we reached consensus on a model of patient-physician communication and boundary management that emerged from the data and fits with CPM theory.

Finally, we determined potential associations by computing correlations between the number and nature of the codes and physician demographics, using SAS 9.4 (Cary NC) software. In particular, we examined whether patient or physician-centered statements differed by age, gender, or specialty of the physician, using t-tests to test for any difference.

3. Results

3.1. Patient experience

3.1.1. Empathy

In examining transcripts for empathy, we also recognized positive communications by the physicians that were supportive and relationship-building but had no affective component. We coded these categories as affirmation or acknowledgement.

Encounters contained a total of 456 statements by the patient indicating underlying emotion, which are cues for empathy by the physician. These cues occurred in all the encounters. Physicians responded empathically to 87 of the 456 patient prompts (19%). Twenty-four participant physicians (71%) provided at least one empathic response.

For example:

Dr. 39. And was anyone else with you at any point?

Pt. My wife, she died about five years ago of breast cancer.

Dr. 39. Oh I’m sorry.

Pt: No, I’m by myself pretty much, pretty self-sufficient.

Dr 39. So did she suffer a lot with her breast cancer?

Pt: Yes, yes she did.

For those cues that did not result in an empathic response (81%), the physician frequently followed the empathic cue by the patient with a biomedical statement or question.

Dr 28 …hold your breath. … Did you know … that you have a heart murmur?

Pt. Oh yes sir…. I was rejected from the military at age 18 because of that. They didn’t want the responsibility of taking me in…and then they’d have to take care of me the rest of my life.

Dr 28. Did you have rheumatic fever when you were a kid?

When delivering a terminal diagnosis, physicians used empathic communication 20% of the time.

Pt. I thought even though I was smoking, I cut way back… so I thought…the lung fixes itself after a while.

Dr. 30. Only to an extent. It doesn’t undo years of risk. The changes it can induce over time. So that’s tough news, isn’t it?

Here is an example of delivering bad news without empathy:

Dr 26. And what did [the doctors] tell you?

Pt. I don’t remember exactly what they said. “The chemotherapy won’t do you any good or there is no reason to do chemotherapy.” Something like that… And he said, “there is no use operating.”

Dr 26. … oncologists they will treat anything… you got a cancer, we got a poison for it. But, realistically, it might give you a little extra time, but it may shorten it too. That stuff kills good stuff as well as the bad stuff. …. I will just tell you that right up front. They might tell you that they are going to take this away from you, but they are lying.

3.1.2. Affirmation

In coding for empathy, we found that patients also provided cues for affirmation and acknowledgement. We coded a total of 451 such cues. Physicians responded to patient cues for affirmation (validation) or acknowledgement (simple recognition of the statement) 2 out of 3 times (66%). Of all participants, 30 of 34 physicians (88%) provided some acknowledgement or affirmation to their patients. Here is an example of affirmation of the patient by the physician:

Dr. 5. What do you do?

Pt. I was a …manager for a long time.

Dr. 5. You were a busy man.

Below is an example of an affirmation cue being ignored:

Pt. Now every so often I like to have a taste of cigarette, but just a taste. That’s all I want, maybe two.

Dr. 39. Any other surgeries?

3.1.3. Acknowledgement

Here is an example of acknowledgement by the physician:

Dr. 14. Do you have your family there?

Pt. I have a brother that lives down there, and a son.

Dr. 14. Brother and son.

This is an example of an acknowledgement cue from a patient that is ignored by the physician:

Pt. [My grandchildren will] come down and visit me. We’ll go to [the amusement park]. They’re getting to the age where it’s gonna mean something to them.

Dr 29. Getting around pretty well?

3.2. Physician Experience

3.2.1. Self-disclosure

Physician self-disclosure was coded when the physician shared personal information, experiences, or feelings [17]. Encounters contained 78 physician self-disclosures in 22 of 34 (65%) office visits. Nineteen physician (24%) self-disclosures were coded as patient-centered or useful, i.e. comments that provided education or support. Not useful self-disclosures were coded when the comments were physician-centered and without clear benefit to the patient.

Here is an example of a useful physician self-disclosure that is supportive to the patient:

Pt. I live in an apartment.

Dr. 12. How’s that going for ya?

Pt. It’s all right. I’m not looking for anything special.

Dr. 12. You’re just looking for a place to keep the rain off your head, right?

Pt. Yeah.

Dr 12. Like me, you know, all I need is a place to keep rain off.

Pt. Right, right, right.

Here is an example of a not useful physician self-disclosure:

Dr. 8 No difficulty swallowing your food? It’s going down ok through that passageway? Because that can also get dry in there after radiation. I was looking at your ring over there, is that….

Pt. Yeah…

Dr. 8 For some reason I had a chunk of lapis and I am going to show you. It’s about this big, I sometimes carry it in my pocket. For some reason, that color makes me feel better and I put this on a couple weeks ago when my sister passed away at age 53 and it hangs down right here at my heart. Every once and a while I just touch it and go, yeah, it makes me feel better. I just love the color of that stone.

3.2.2. Transparency

Other exchanges related to boundary management emerged during the analyses, expanding the spectrum of physician self-disclosure to include transparency and projection. We defined transparency as thinking aloud with the patient about the illness, treatment, or clinical situation [44,45]. Patient-centered exchanges (e.g., useful transparency statements) provided information or support to the patient. However, in a number of exchanges that we deemed physician-centered and not useful, the physician’s thinking aloud conveyed information that may have been scary or offensive to the patient (e.g., detailed biomedical information, medical jargon, unfiltered prognostic information, or negative reactions to prior treatment). Encounters contained 270 physician transparency statements in 31 of 34 encounters (92%); 151 (56%) transparencies were coded useful. Below is an example of useful transparency:

Dr. 18. Stage 4 lung cancer means that it has gone beyond the lungs to somewhere else such as the bones. That’s definitely a treatable cancer.

Pt. I see.

Dr. 18. The radiation may help, and it may help for a long period of time…

Here is an example of not useful transparency, in which the physician thinks out loud, catastrophizes, and expresses her own fears and concerns without seeming to help the patient cope emotionally with such an eventuality:

Dr. 39. So it didn’t get bigger? Because tumors you expect to double in size very quickly.

Pt. Hmmm

Dr. 39. It’s something that you notice may happen very quickly. Something you may have to go to the emergency room for cause that could be deadly really quickly, if it happens.

3.2.3. Projection

Thematic analysis also revealed a category relevant to boundaries labeled projection, or the attribution of the physician of his own suppressed ideas, feelings or attitudes to the patient [46,47]. We found 67 projections in 16 of 36 encounters (44%). Here is an example:

Pt. I don’t know anybody.

Dr 14. You don’t know anybody here at all? Okay…it is important. Attaching to support and everything. Because if you are going to undergo further treatment for the cancer, you don’t want to be alone. So, maybe you should look for a girlfriend.

Pt. Well I…. My daughter, she really takes charge.

To summarize the qualitative analysis, physician transparency and self-disclosure were common in these encounters. Close to half of transparency statements were not useful. Twice as many physician self-disclosures were not useful as useful. As with the physician’s projection in the example above, no disclosures about the physician’s family were useful.

In the quantitative analyses, we found no significant differences between the frequency of empathy, affirmation, acknowledgement, self-disclosure, transparency, or projection between family physicians and oncologists, and no difference between disciplines in whether these elements were viewed as helpful or not helpful to the patients. (See Table 1) Family physicians and oncologists handled these aspects of delivering bad news similarly.

Table 1.

Means for empathy, transparency, self-disclosure, and projection.

Variable Family Physician
 Oncologist
 T score
Mean SD Mean SD
Empathic Response 2.61 3.29 2.50 2.03 0.12
Acknowledge Response 11.10 10.53 8.68 7.91 0.73
Affirm Response 8.88 7.60 6.40 6.40 1.04
Useful Transparency 3.44 3.29 4.63 2.99 −1.09
Not useful Transparency 3.89 3.29 2.50 2.90 1.30
Helpful Self Disclosure 1.39 1.50 1.00 1.67 0.71
Not Helpful Self Disclosure 1.89 2.35 3.06 4.25 −1.01
Projection 2.33 4.80 1.56 1.82 0.60
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These boundary-related elements, useful and not useful, co-occur. (See Table 2). Useful and not useful self-disclosure were highly correlated with each other. Of the three physician demographic variables, only physician gender (i.e. male) was associated with fewer helpful self-disclosures (r = − 0.38, p < .05). Empathy, useful and not useful transparency, and projection were moderately correlated with each other. Empathic physicians were also more likely to have porous boundaries in terms of transparency, and projections that were not useful or patient-centered.

Table 2.

Relationships among demographic variables, empathy, acknowledgement, affirmation, transparency, self-disclosure, and projection.

Variable MALE 2 3 4 5 6 7 8 9 10
2. Age 0.11
3. Oncologist 0.04 −0.19
4. Empathic Response −0.11 −0.13 0.03
5. Acknowledge Cue 0.01 0.04 −0.14 0.40 *
6. Affirm Cue −0.07 0.04 −0.19 0.64 ** 0.56 **
7. Useful Transparency −0.07 −0.23 0.21 0.47 * 0.20 0.44 *
8. Not Useful Transparency 0.00 −0.05 −0.22 0.39 * −0.05 0.39 * 0.33*
9. Useful Self Disclosure −0.36 * −0.19 −0.13 −0.06 0.31~ 0.43 * −0.11 −0.13
10. Not Useful Self Disclosure 0.14 0.14 0.15 −0.11 0.28 0.47 * −0.14 −0.15 0.97 **
11. Projection 0.21 −0.06 −0.12 0.39 * 0.24 0.52 * 0.35 * 0.48 * 0.00 −0.05
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Key:

*

p < .05,

**

p < .005.

We developed two figures to describe the model based on our results. Fig. 2 displays the categories we identified as they relate to patient-centered care, with empathy, affirmation, and acknowledgment at the patient-centered end, and transparency, self-disclosure, and projection at the physician-centered end. The middle category, transparency, can be useful if it extends to patient-centered affirmation and empathy, and not useful if it extends to physician-centered self-disclosure and projection.

Fig. 2.

Fig. 2.

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A Continuum of physician responses & patient-centered care.

Fig. 3 displays the categories as they relate to boundary management. Empathy, affirmation, and acknowledgment are located at the respectful end of the continuum, with self-disclosure and transparency in the middle, as sometimes respectful and sometimes intrusive, and projection located at the intrusive end of the continuum.

Fig. 3.

Fig. 3.

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Physician communication categories and boundary qualities in challenging patient interactions.

4. Discussion and conclusion

4.1. Discussion

Because of its validity, we believe the use of unannounced patient visits is a valuable, though underutilized, area of physician-patient communication observation and assessment. Our study found physicians infrequently made empathic comments in their discussions of the patients’ late-stage, cancer- related care [16]. Instead, our findings suggest that more often physicians use “empathy-light” statements, such as affirmation and acknowledgement, which lack an affective component and do not require the more sophisticated use of boundary crossing and returning to oneself that is needed when making empathic statements.

In addition, our study found most physicians engaged in self-disclosure but, as in previous studies, few self-disclosures were classified as useful to the patient.[17] Some of the self-disclosures involved comments about prior physicians, most of them negative, in spite of the record revealing standard of care [38]. In half the encounters, physicians used projection, imposing their own emotions or experience on the patients rather than eliciting the patient’s perspective, hence a form of self-disclosure.

Of note, patient-centered physicians who used empathic statements and useful transparency were also more likely to use projection and not-useful transparency. It seemed that physicians who sensed and understood patients’ feelings may be more likely to express their own thoughts or feelings as they arise, without considering what is helpful to the patient. Alternatively, physicians that were heavily defended and perhaps not understanding their own feelings may have overly rigid boundaries, unlikely either to empathize or to commit these boundary violations that require emotional communication.

In summary, we found that physician acknowledgement and affirmation statements (“empathy-light”) were common and empathy was rare. Physicians who used these patient-centered communication skills frequently also used physician-centered transparency, self-disclosure, and projection judged as not useful to the patient. Thus, physicians who provide empathy and useful transparency may be at risk for boundary turbulence, which is defined as a failure of boundary management in response to tense or anxiety-producing situations, such as delivering bad news. Boundary turbulence is created when emotion is high, boundaries can be challenged, and can become unclear or violated [22].

The challenge for physicians is to communicate medical knowledge in the context of individual patients’ experiences [48], and convey supportive acknowledgement, affirmation, helpful transparency, and empathy without potentially distracting or intrusive physician transparency, self-disclosure, or projection. This insight, emergent from our data, is the basis of the model of boundary management illustrated in Figs. 1 & 2 and expands former models of empathy, self-disclosure, and their inter-relationship.

Our findings support that in “…numerous observational studies, physicians and other clinicians routinely speak to patients and families,… miss cues that patients are experiencing emotions,… and subtly block patient questions and concerns” [48]. Recent literature on empathy explores the complex nature of the construct [49–51].

Research on empathy, and communication with cancer patients, documents deficiencies in clinicians’ skills [52]. The Verona group that created the elaborate VR-CoDES system for coding sequences of communication, has described clinicians’ responses to patient cues and concerns as either providing or reducing space for further patient disclosure cues, concerns, and emotions [53,54]. They list acknowledgement and exploration as intermediate space-providing responses, as well as implicit empathy and empathy when “the provider… shares the patient’s emotion.” Our findings display a good fit with these current reports regarding empathy [5,6,8,48–54].

Literature on PPC discusses the concept of boundaries, mostly in ethics and psychotherapy education [55,56]. These writings mostly address severe boundary violations, often necessitating punitive responses, such as breaches of confidentiality and sexual relations with patients [24,57]. Our findings expand this discourse to subtler communication elements.

According to Petronio’s work on Communication Privacy Management (CPM) theory, boundary management is a process by which people make decisions balancing disclosure and privacy, resulting in a privacy boundary that they co-create with their clinician [22,23]. People manage their privacy by their own rule-based system, balancing what they keep private and what they disclose [22,23]. Patient-physician communication as part of the patient- physician relationship is a specific application of CPM. Patients often disclose private information to their physicians, as well as stigmatizing secrets [22]. They do so because they trust that their physicians are bound by professional confidentiality, as well as an evolving therapeutic relationship [58].

Petronio uses the terms “fuzzy boundaries” and “boundary turbulence” to describe a failure of boundary management. Unclear boundaries result when communication is characterized by elements such as not helpful self-disclosure, transparency, and projection. The communication of traumatic events, such as the disclosure of a terminal diagnosis, is an anxiety-producing situation, at risk for unclear boundaries and boundary turbulence [22,59]. Boundary turbulence is created when emotion or tension is high, and when boundaries can be challenged and become unclear or violated. An example is the dialogue above of unhelpful physician self-disclosure when the physician spontaneously describes her lapis stone and its meaning in the middle of the encounter. Here, boundaries are crossed, and no discussion follows of the violation, its utility, or how the patient sees it. The result is fuzzy boundaries [22].

Since empathy involves “putting yourself in another’s shoes,” it can constitute a temporary boundary violation. The seasoned clinical “empathizer” reconstitutes the boundary, cognizant of the empathic understanding gained, in order to effectively and humanely communicate with and care for the patient. Boundary turbulence occurs when this reconstitution does not happen, fully or partially, as reflected in our data. Physician-centered communications such as projection, not useful self-disclosure, and not useful transparency, tend to be expressions of boundary violation or turbulence without reconstitution. Petronio asserts that turbulent tensions play an important part in high stress situations such as contraception, miscarriage, bereavement, and grief [22,23]. Petronio’s use of the boundary metaphor, and constructs such as boundary turbulence, enable an expanded and fine-grained discourse of boundaries beyond a purely ethical one. CPM describes complex behaviors and provides a framework for clinicians to understand communication and emotions—their own and their patients [22,23].

Several interventions have been shown to improve communication skills among primary care physicians and oncologists [47,48,59–64]. Communication training has been a central feature of primary care education, focusing, for example, on active listening, better response to cues, concerns, emotion expression, and empathy [52,60]. Our study shows a need to highlight boundary management as part of such training for sophisticated empathic communication skills, including attention to the sequence and shades of empathy, as well as the risk for not useful self-disclosure, transparency, and projection. Discussing the need for communication training for oncologists, Back et al. said, “We already knew how to be nice. What we didn’t know was how to integrate an enormous amount of biomedical expertise with the lived experiences of individual patients” [48].

4.2. Strengths and limitations

This study presents data on actual practicing physicians and controls for patient variability. We also acknowledge study limitations. Our results may not generalize to other medical conditions or other clinicians or physician specialties. The actors may not present the same stimulus to physicians that real patients do. The portrayed cases represent a first visit so may not generalize to communication in an ongoing relationship. With audiotapes and transcripts, we were not able to code for non-verbal communication.

Future research could study these aspects of boundary management and empathy with the addition of other kinds of clinicians and physician specialties, with real patients, and in ongoing relationships, including physician evaluations and patient self-reports of the encounters.

4.3. Conclusions

These findings yield an expanded view of the interplay of empathy (and its constituents), self-disclosure, transparency, and projection. Applying CPM to these findings provided a framework of boundary management and the ubiquity of boundary turbulence in difficult communications, which expands our understanding of these communication behaviors. The challenge for physicians is to communicate their medical knowledge in the context of individual patients’ experience’ and to convey acknowledgement, affirmation, and empathy without potentially distracting or intrusive physician transparency, self-disclosure, or projection. This approach minimizes boundary turbulence and supports positive physician boundary management. These findings, which are surprising and relatively counter-intuitive, call for further training in responding empathi- cally to patients and addressing boundary management issues.

4.4. Practice implications

  1. Well-intended physicians who provide empathy and transparency may be at risk for boundary turbulence.

  2. Training that encourages empathic responses (including “empathy-light”) and useful transparency and discourages physician-centered elements that fuel boundary turbulence, needs to be emphasized in patient-physician communication instruction.

Acknowledgements

The authors thank Mechelle Sanders Ph.D. for her input on Figure 1, and the members of Dr McDaniel’s Family Medicine Professional Writing Seminar for their review of the manuscript.

Funding

This project was supported by NCI grant R21CA124913 and NCI grant R01CA155376 for Dr. Shields, and NIMH T32 MH18911 PI Eric Caine for Dr. Morse.

Footnotes

Ethics

The present analysis was exempted by the University of Rochester Research Subjects Review Board as part of a larger study approved by Purdue University and Indiana University research subjects review boards.

Competing interests

None reported.

Declarations of interest

None.

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