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UC Berkeley Press Release

Researcher offers steps to help doctors move past anger with patients

– Doctors are human, and are thus susceptible to the same feelings of anger and frustration that plague all of us from time to time. But what happens when those emotions are directed at patients under their care?

Dr. Jodi Halpern, a bioethicist at the University of California, Berkeley, addresses this dilemma in an article, "Empathy and Patient-Physician Conflicts," appearing in the May issue of the Journal of General Internal Medicine.

She noted that doctors may experience a range of negative emotions when confronted with patients who, for instance, refuse necessary treatment or are angry. Physicians also frequently feel overworked, said Halpern, and they may blame a patient for contributing to their workload.

Halpern's examination of empathizing in the face of conflict is especially relevant now, she said, because physicians are increasingly frustrated and dissatisfied with their profession.

"Although more conflicts and adversarial interactions with patients are being described in the clinical literature, what is missing is a thorough analysis of the impact of this on perhaps the core aspect of the art of medicine: physician empathy," said Halpern.

The problem, said Halpern, is that doctors are still being trained to be detached and emotionally distant during conflicts in the belief that it is necessary to remain objective, a reaction that can actually work against improving a patient's outcome. Particularly when they are frustrated, doctors turn off all of their feelings, and distance themselves from their patients, said Halpern.

"Yet, a growing body of research is finding that doctors who show genuine empathy, who are emotionally attuned to their patients, can actually increase the effectiveness of treatment," said Halpern, an associate professor at UC Berkeley's School of Public Health who specializes in bioethics. "The key is you can't fake it. Patients are very good at reading body language, and if they don't think their doctor is genuinely receptive to their needs, they are less likely to disclose information that could be important for an accurate diagnosis. Doctors who are perceived as emotionally detached also are less likely to engender adherence to treatment."

Halpern pointed out that a good bedside manner can alleviate the common problem of patients taking their medications incorrectly, or not at all. "Patients trust doctors who are emotionally engaged, and that increases the level of adherence to treatment," she said.

Emotional detachment can also have a particularly negative impact on patients when their doctors give them bad news, Halpern added.

Research has shown that a cancer patient's perception of whether or not the physician was genuinely empathic while giving them the diagnosis was directly related to how effective patients were in seeking subsequent care and in making treatment decisions. Based on this and many other studies, Halpern has argued that the traditional stance of professional detachment is, in fact, harmful to patients.

Halpern, who has a background in psychiatry and philosophy, presented in her paper real-life examples of the positive therapeutic impact of empathizing with patients during conflicts. In one case, an 18-year-old athlete turned down life-saving surgery for his bowel disease because he could no longer be "active" in sports. Most of his doctors "became frustrated or furious and withdrew emotionally" when with the patient, wrote Halpern.

It wasn't until the young man spoke with an older female nurse who had had colon surgery that he opened up to his fears that the surgery would prevent him from having an active sex life, something he found exceedingly difficult to discuss with the young, male doctors he saw as virile and unable to empathize with his viewpoint. The patient agreed to the surgery after the nurse reassured him.

"Caregivers who can learn to sustain their genuine curiosity about and receptivity to patients' perspectives, even in the midst of emotionally charged interactions, not only reduce levels of anger and frustration for both parties, they can significantly improve decision-making on both ends and increase the effectiveness of treatment," said Halpern.

Halpern advanced the concept of clinical empathy in 2001 in her seminal book, "From Detached Concern to Empathy: Humanizing Medical Practice." She is careful to distinguish clinical empathy from sympathy. The former not only involves being emotionally attuned to a patient's needs, but also becoming consciously curious about a patient's distinct perspective.

In particular, Halpern shows that for clinicians, it is crucial that they respond to what is important from the patient's perspective rather than projecting their own views, as happens too often. That is why she urges avoidance of phrases like "put yourself in the patient's shoes." Rather, she says the distinction is understanding how the patient feels in his or her own shoes.

In contrast, sympathy is much less precise, involving sharing a feeling with and supporting the patient, but not learning an individual's particular concern.

While there is growing recognition of the importance of empathy, little information exists about how any human being, including a doctor, can empathize with another person when he or she is angry with that person or just generally frustrated. Research shows that people not only find it difficult to feel for another individual during conflicts, but to even cognitively see things from the other person's perspective. Addressing this gap, Halpern offered these guidelines for doctors:

  1. Recognize one's own emotions and feelings during the actual clinical encounter. Evidence suggests that taking even a few moments for self-awareness can reduce errors, improve decision-making and resolve conflict.
  2. Reflect on negative emotions after the encounter. Physicians are socialized to immediately suppress their negative feelings, yet people are hard-wired to become reflective when feeling badly, and engaging in such reflection even briefly is calming and actually increases insight into other people's feelings.
  3. Attune to emotional messages in a patient's story. Physicians may miss opportunities for empathy when they restrict their attention to the clinical facts rather than to the emotional meanings of patients' words. When something appears emotional to the patient, simply repeating the patient's exact words and truly wanting to know more will inspire patients to talk about important needs they otherwise wouldn't discuss.
  4. Attend to non-verbal communication. Patients first give non-verbal hints that they have something important to say. If physicians respond at these critical moments, patients then open up more fully.
  5. Accept negative feedback. This runs counter to many ingrained qualities of medical culture, but it is essential to accept negative feedback without becoming defensive or controlling. Accepting criticism without becoming defensive provides a gateway to empathy, enabling patients to share more difficult feelings lying underneath their anger.

In this era of managed care, one may wonder whether doctors have the time or energy to become emotionally engaged with their patients. But Halpern argues that empathy actually saves time by improving communication between doctors and patients, and by preventing an incorrect diagnosis.

"Most people have the human capacity for empathic curiosity, for genuine interest in and emotional responsiveness to another person's perspective, but they can turn it on and off," said Halpern. "Doctors actually learn to turn it off at work, and that's a big mistake."