- Email: [email protected]
Showing you care: An empathetic approach to doctor–patient communication
Showing you care: An empathetic approach to doctor–patient communication Mitchell J. Lipp, Christopher Riolo, Michael Riolo, Jonathan Farkas, Tongxin Liu, and George J. Cisneros Our College recently convened a series of retreats bringing together faculty, administrators and employees to identify common concerns. Stakeholders working independently in small groups separately and collectively agreed that our major organizational concern was communication. This theme played out in various ways. From not knowing what was going on beyond an individual’s immediate work area to broader interpersonal challenges. Some felt a lack of caring or appreciation. Often the word, “respect,” was used. Perceived deficiencies extended to students, faculty, administrators, staff, and most troubling, to patients. Communication skills are recognized as essential to professional competence by the Commission on Dental Accreditation, the American Dental Education Association, and the Interprofessional Educational Collaborative. It is a theme that crosses disciplines and is foundational to patient-centered care. As scientifically driven evidencebased healthcare and technologies progress, the emotional, psychological, social and cultural needs of patients may be neglected. Communication skills centered on empathy and showing you care, yield benefits to both the doctor and patient in terms of satisfaction, compliance, and treatment outcomes. (Semin Orthod 2016; ]:]]]–]]].) & 2016 Elsevier Inc. All rights reserved.
Introduction mpathy is part of being human. Through empathy we connect to others and share in their felt experiences. Science is responsible for a remarkable transformation in health care. Yet there is increasing recognition that filtering a human being through tests and images and making objective evidence-based decisions is somehow incomplete. The emotional “truths” that propel people through life have been largely excluded from the process. Health professional groups, including The Commission on Dental Accreditation and the American Dental Education Association, include standards that
E
Department of Orthodontics, NYU College of Dentistry, New York, NY; Department of Orthodontics, University of Washington School of Dentistry, Seattle, WA; Department of Orthodontics, University of Detroit Mercy School of Dentistry, Detroit, MI. Address correspondence to Mitchell J. Lipp, BA, DDS, Department of Orthodontics, NYU College of Dentistry, Room 683 W Dental Center, 421 First Ave., New York, NY. E-mail: [email protected] & 2016 Elsevier Inc. All rights reserved. 1073-8746/12/1801-$30.00/0 http://dx.doi.org/10.1053/j.sodo.2016.04.002
emphasize “patient centered care” in a “humanistic environment.” This article will focus on the role of empathy in the doctor–patient relationship. It is without question that communication skills are necessary to succeed in orthodontic practice. Many studies in health care suggest that communication between the doctor and the patient positively impacts on satisfaction, decreased malpractice claims, and improved health outcomes.1–4 One article in the orthodontic literature reported a dramatic decrease in treatment time when greater attention was paid to communication.5 While dental and medical education programs regard communication as a core competency, it appears infrequently (or is under reported) in the orthodontic literature. The consequences of miscommunication can be dire, like the 71 million dollar malpractice settlement when emergency health care workers mistranslated the word “intoxicado” to mean intoxicated instead of the intended meaning of “feeling sick to the stomach” that caused a delay in making the correct diagnosis resulting in a potentially preventable quadriplegia.6
Seminars in Orthodontics, Vol ], No ] (), 2016: pp ]]]–]]]
1
2
Lipp et al
The doctor–patient relationship is deeper than a transactional relationship. Communication in this area goes beyond the exchange of information. Orthodontists need to understand the complete set of wants and needs of the patient; often going beyond objective findings in order to consider psycho-social dimensions that affect care. Empathy is a discrete and complex phenomenon that has subtle and foundational influences in the doctor–patient relationship. Because empathy affects the information that the patient discloses, this fact alone may significantly affect diagnosis, treatment planning, practice management, and other related skills and behaviors that lead to a more trusting relationship between the doctor and patient.
Empathy Empathy is the experience of understanding another person’s condition from their perspective by placing yourself in another’s shoes and feeling what they are feeling. Empathy is known to increase prosocial (helping) behaviors. Researchers have differentiated between the two types of empathy. “Affective empathy” refers to sensations and feelings—an emotional response. This may include mirroring what a person is feeling, or anticipating what they may feel. For example, a guttural shriek when witnessing a person falling and possibly getting hurt. “Cognitive empathy,” sometimes called “perspective taking,” is the mental act of projecting oneself into another person’s perspective, and through this process being able to identify and understand another person’s emotions. In the example of seeing someone fall, this would equate to appreciating the embarrassment and frustration that person may feel. There is some disagreement concerning the value of affective empathy in training health professionals. Some feel that by becoming too emotionally invested in a patients’ personal perspective, objective based health advice may be compromised.7 Others stress that the key component of empathy is the emotional connection with the patient, and without this affective bond, behavioral attempts at empathy, that is, “acting” as if you are really concerned, would not be as productive.8 Dr. Rita Charon has advocated the use of narratives, literature, shared stories as methods to reveal the felt emotional
experience of the patient, hence deepening the empathetic relationship.9 Empathy is rooted in our biology, in our brains and in our bodies. It has been observed in various species including rats.8 In the last decade, more attention has been focused on the role that mirror neurons play in empathy.10 Mirror neurons are cells in the brain that fire when we observe someone performing an action in the same way that they would fire if we performed that action. The primacy of mirror neurons in empathy has more recently been brought into question. However, their contribution to a neuronal understanding of empathy remains under investigation. Empathy is also modified by external factors such as social–cultural considerations and socioeconomic status.11
A patient-centered environment Doctor–patient relationships are affected by the various aspects of the health care process and environment. These physical and social components inherent in this environment begin as early as the first phone greeting or online contact. Once inside the physical office, the environment includes structural elements like location, décor, furnishings, equipment, cleanliness, order, and soundscape. This environment is further supported in part by the entire orthodontic health care delivery team in that (1) each patient should feel as if they are the center of the universe with their wants and needs as the primary focus; (2) the environment promotes the feeling of safety and confidentiality; and (3) the staff exhibit caring and positive attitudes. Implicit in this team centered office environment is a congenial supportive team that emulates empathetic communication practices. Effective and empathetic communication is not only useful in patient management but also in managing team member relationships. If the orthodontist intends to lead the team, each communicative interaction should be designed to increase awareness of the empathetic role each team member should display. All of the staff involved, whether engaged in support services or involved with direct patient care should be employing a “Show You Care” communication style thus reinforcing that the primary concern is the patient’s welfare.
Doctor–patient communication
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Table. A Framework for Showing You Care
Attitudes
Interpersonal Skills
Building Rapport Patience Respect Being fully present Connecting on a human level Nonjudgmental
Verbal Avoid interrupting Avoid too quick of an interpretation Partnership statements Appropriate language
Taking patient seriously Cultural competence Recognition of differences like ethnicity or gender, Cognition Humor Tactfulness Enthusiasm Relating
Normalizing: recognizing emotional reactions that anyone would have Giving feedback Eliciting patient concerns Language terminology relating to the patient's illness, clearly describing one's condition, the treatment plan proposed and associated risks and benefits Articulation Vocal placement (timbre, tone, color, etc.), volume, and size Pace of speaking Varying one's delivery approach (pitch, pace, rate, and emphasis)
Behaviors Giving a direct phone line Making follow-up calls Escorting patients Coordinating referrals Position self in relation to patient (proximity, level, bearing, etc.) Introduces names and positions of all health care team members present Establishes an environment of safety and confidentiality Asking permission before touching or intruding on one's privacy or personal space
Reflective listening Provides appropriate wait time after asking questions. Responding to questions. Clarifying Paraphrasing Acknowledging Nonverbal Eye contact Tone of voice Body posture Facial expression Appropriate touch Allowing crying Mirroring patient's body language. Checking for nonverbal signs (understanding) Integrations Integrating verbal with other communication modes (visual, aural, kinesthetic, etc.) Note the overlapping boundaries and integration of empathetic skills with other communication skills. In our framework, we proceed from a theatrical or actor's perspective. Mastering the role begins with understanding the attitudes and attributes of an empathetic doctor. After understanding the role, we proceed to awareness of the skills required to effectively communicate and experience/express empathy. Finally these skills need to be integrated and regularly applied in daily living.
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Despite all good intentions we live in an imperfect world, largely because we are imperfect. Things do go wrong and when they do, it is essential to acknowledge the fact and move ahead. Do not hesitate to say, “I’m very sorry this has happened. We will continue to do everything we can to resolve (the issues under discussion) as well as any others that may occur as we proceed with your care.” The practitioner needs to keep staff included, supported, and supportive. A team that shares ownership for the patient’s welfare is the ultimate goal. Opportunities for training (and re-training) in communication skills, with role-playing and scenarios may be helpful. Much like exhibiting empathy towards one’s patients, the orthodontist should express the “Show You Care” communication styles to all team members.
Empathy in clinical practice Generally, empathy has been studied using surveys or rating forms in which patients or observers rate the practitioner relative to response options. Most scales focus on ultimate outcomes and not isolated skills or behaviors. One study took a novel approach by having medical educators work with professional theater educators that adapted actor-training tools incorporated in the health care setting12. This tool, unlike other empathy scales, offered insight into the observable methods a doctor may use to improve communication and convey empathy. From this tool and other sources, we have attempted to isolate skills and behaviors that are associated with demonstrating empathy (Table). If the perspective toward building empathetic skills stems from the realm of theater, perhaps the clinical orthodontist should begin by understanding the role-internalizing core values like altruism and beneficence; as well as attributes such as, approachability, nonjudgmental attitude, and expressing an active interest in the patient. After understanding the role of the empathetic doctor, one should then focus on skills that effectively lead to establishing and encouraging an empathetic relationship.
Key themes Educating and communicating A significant fear for any patient is fear of the unknown.13 This can be mitigated by calmly
explaining things while minimizing technical jargon, and quickly defining any word which may cause confusion. Visual aids can be helpful to demonstrate procedures and appliances and overcome language barriers. Techniques such as, tell, show, and do can be very useful for younger patients. However, overcompensating or overusing any approach or aid in this area can become problematic as sometimes the patient (or parent) can perceive oversimplified explanations as a form of condescension. Care must be taken to gauge the mental capacity of the patient (or parent) possibly using education level as a guide. Adjusting to match cognitive and/or language levels of your audience (patient and parents) is another part of the challenge in communication. Orthodontic treatment of younger children occasionally requires effective communication not only with the patient but also with the parents as well. A guiding principle in building empathetic relationships is to strive to understand the unique needs of each individual and modulate communication skills and behaviors accordingly.
Active listening Engage the communication process by first, asking open-ended questions; and second, by keeping the number of your interruptions to the minimum. Allow patients to do most of the talking. Whenever possible, only interject at appropriate points, using open-ended questions, to elicit additional information allowing you to “funnel down” into more focused questions. Patients need to feel heard. Ask prompting questions like “Is there anything else?” or “Tell me more about that” and then pause to listen to the response. Phrases such as “I can imagine how that made you feel,” or even remaining silent can be effective as long as the patient feels encouraged and is assured that she is being heard. If appropriate, take notes while the patient is speaking. This conveys the aura of active listening and supports the patient’s perception of being heard. Once again, be careful about overdoing it. Losing focus by taking too many notes can be distracting and thwart the impression of actively listening to the patient. Framing statements convey the intention of obtaining an accurate understanding.14 Phrases like “Let me see if I understood everything correctly…”
Doctor–patient communication
demonstrate actively trying to understand the patient’s situation. Giving back to the patient what you think they have stated not only makes the patient feel understood but also provides opportunities for clarification. Listening to and repeating or rephrasing the patient’s words can help orthodontists recognize the patient’s feelings from their perspective.15 It allows the doctor and the patient to bridge perspectives moving toward empathy. Patients that feel understood tend to reciprocate by trusting their health care provider. The benefits of empathy are tangible and measurable resulting in improved treatment adherence, quality of care, decreased health care costs, and decreased psychological distress.16
Body language The nonverbal communication an orthodontist conveys is a crucial element in patient understanding and satisfaction.17 In one study, physicians were asked to disclose medical errors to patients, by contrasting error disclosure with or without nonverbal involvement such as, appropriate touch, personal space proxemics, forward leaning, body orientation, prolonged gaze, vocal animation, attentiveness and interest, affirmative head nods, an numerous other nonverbal communicative techniques. When nonverbal communication was absent, physician’s apologies were interpreted as being less sincere and remorseful.18 The study demonstrated how nonverbal involvement facilitated more accurate patient understanding and assessment of the medical error as well as its consequences on the patient’s health and their quality of life. Body language needs to be open, not constrained, and includes such acts as pausing, nodding, all while maintaining eye contact.14 Starting with body positioning and hand gestures, creating a welcoming safe environment for the patient in order to share information and be made to feel at ease is important. For example, maintaining focus and proximity to the patient while leaning forward to hear the patient’s narratives conveys interest and helps the practitioner better understand the patient’s wants, needs, and expectations regarding treatment. As noted previously this impression starts the minute the patient enters the office. Thus the proverbial “you never get a second chance to make a good first impression,” starts with how the
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front desk staff treats the new patient. Maintaining eye contact, within a comfortable proximity to the patient, inclined forward to hear what they have to say conveys interest and not only helps the listener to really hear the patient but provides the patient with the feeling that they are truly being heard. Asking the patient if they have any special requests or needs is another mechanism that can be used to enhance their experience. Whenever the doctor is with the patient, the patient needs to receive the practitioner’s full attention regardless of other people being in or near the treatment area. This concept also includes the idea that whenever possible, the doctor should not be interrupted by members of the staff to attend to other needs within the office until the patient encounter is completed. Active listening continues by sustaining an open body position—never appear to be closed off by folding your arms across your chest. Respond nonverbally by nodding your head while remaining engaged in the conversation. Smiling is a very powerful type of body language. Interestingly, but not surprisingly, a randomized controlled trial demonstrated a significant negative effect on perceptions of empathy when doctors wore facemasks while interviewing patients.19 The orthodontist should also be aware that some patients may be anxious just being in a clinical setting, the so-called “white-coat syndrome,” which has been found to elevate the patient’s blood pressure (a key measurement of anxiety). Establishing an empathetic doctor–patient relationship can modulate this anxiety.
Match patient’s nonverbal style Language matters but the manner in which we say things has been shown to be powerful, sometimes more powerful than what we actually say. For instance, one’s tone of voice, volume, and pacing of speech, all play a role.13 This paralanguage skill is most effective when used to mirror the patient’s own tone. In fact, it has been shown that when practitioners attune to patients nonverbally, patients feel more comfortable and give fuller histories.15 Tone should never be uncaring, apathetic, express frustration, or stress. Modulating your tone of voice can markedly modify the patient’s behavior and reduce agitation; a key factor in managing the child
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patient. Used pointedly, tone can help the doctor take charge of a situation, but it must be used in moderation.
Expressing empathy Perhaps the clearest way to demonstrate empathy is to validate the patient’s emotional target. The two steps in accomplishing this process are first, finding the target; and second, empathizing with the patient. An ideal target is one that is close to the other person’s emotional epicenter. It could be mirroring back the other person’s rationale of how they are seeing things and why they feel the way the way they do. It could be picking up on secondary elements that they are experiencing which are true, and offering confirmation of that fact. There is little empathy in saying “I’m sorry thumb sucking makes you feel bad.” It’s more empathetic to say “After hearing that your friends are making fun of you, I understand how embarrassing thumb sucking is.”
Conclusion Clinicians should be prepared and ready to recognize and react appropriately to the emotional needs of their patients by showing genuine sensitivity and compassion. Empathy must flow naturally from the professional and his/her staff to the patient in order to “Show You Care” and acknowledge that you have a stake in their wellbeing. Unlike other areas in dentistry and medicine, orthodontics is less frequently an urgent care service. Patients seek care largely for an esthetic or quality of life benefit. Being transparent and bringing financial discussions to the forefront of the process, engenders trust, pushes aside any underlying stress, and allows the patient to be focused during the interview. Generally, there is a developmental progression in learning or acquiring new skills and behaviors. Prior to learning the student or neophyte practitioner is in a state of, “unconscious incompetence”: ignorance, not knowing or even being aware of what is not known. As learning begins the novice becomes aware of their incompetence (conscious incompetence). Generally, the purpose of dental or orthodontic training programs is to give the predoctoral or post-doctoral candidate sufficient experience to become fully aware and competent (conscious competence). This process continues
during the early phases of one’s professional career and with continually gained experience, by virtue of practice and repetition, the maturing practitioner approaches the final phase,” unconscious competence.” This final phase, somewhat synonymous with expertise, reflects the seamless and facile integration of knowledge and complex cognitive and procedural skills without much conscious effort. Like driving a car—at first it requires concentration and effort, after enough practice; it becomes an almost automatic response. Communication skills, both verbal and nonverbal, that lead to empathetic doctor–patient relationships follow a similar pathway. This essay was intended to bring this subject of empathetic communication and its associated skills and behaviors into the practitioner’s consciousness. By developing an understanding of this subject the doctor can begin to apply these concepts and techniques into clinical practice. Some of us may recall a time, prior to today’s data driven era when, “chairside manner” counted. Considering that empathetic behavior results in higher patient satisfaction, better patient perceived outcomes, a lesser tendency for the initiation of malpractice claims, happier offices, and less doctor burnout this subject should be given greater attention in both the educational and clinical orthodontic environments.
References 1. Clever SL, Jin L, Levinson W, Meltzer DO. Does doctor– patient communication affect patient satisfaction with hospital care? Results of an analysis with a novel instrumental variable. Health Serv Res. 2008;43(5): 1505–1519. 2. Stewart MA. Effective physician–patient communication and health outcomes: a review. Can Med Assoc J. 1995;152(9): 1423–1433. 3. Korsch BM, Gozzi EK, Francis V. Gaps in doctor–patient communication. Pediatrics. 1968;42:855–871. 4. Wanzer MB, Booth-Butterfield M, Gruber K. Perceptions of health care providers’ communication: a relationship between patient-centered communication and satisfaction. Health Commun. 2004;16(3):363–384. 5. Shelton CE, Cisneros GJ, Nelson SE, et al. Decreased treatment time due to changes in technique and practice philosophy. Am J Orthod Dentofac Orthop. 1994;106:654–657 [How do write the name if he’s a “junior”?]. 6. Palmer, C. HHS offers cultural diversity guide—miscommunication prompts government to enhance national standards. ADA News May 20, 2013. 7. Newton BW. Walking a fine line: is it possible to remain empathic physician and have a hardened heart? Front Hum Neurosci. 2013;7:1–12.
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8. Bartal IB, Decety J, Mason P. Empathy and pro-social behavior in rats. Science. 2011;334:1427–1430. 9. Arntfield SL, Slesar K, Dickson J, et al. Narrative medicine as a means of training medical students toward residency competencies. Patient Educ Couns. 2013;91(3):280–286. 10. Lamm C, Majdandzic J. The role of shared neural activations, mirror neurons, and morality in empathy— a critical comment. Neurosci Res. 2015;90:15–24. 11. Piff PK, Stancato DM, Côté S, et al. Higher social class predicts increased unethical behavior. Proc Natl Acad Sci U S A. 2012;109(11):4086–4091. 12. Dow AW, Leong D, Anderson A, et al. Using theater to teach clinical empathy: a pilot study. J Gen Intern Med. 2007;22(8):1114–1118. 13. Frenkel M, Cohen L. Effective communication about the use of complimentary and integrative medicine in cancer care. J Altern Complement Med. 2014;20(1):12–18.
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14. Coulehan JL, Platt FW, Egener B, et al. Let me see if I have this right…: words that build empathy. Ann Intern Med. 2001;135(3):221–227. 15. Halpern J. What is clinical empathy? J Gen Intern Med. 2003;18:670–674. 16. Shay LA, Dumenci L, Siminoff LA, et al. Factors associated with patient reports of positive physician relational communication. Patient Educ Couns. 2012;89:96–101. 17. Larsen KM, Smith CK. Assessment of nonverbal communication in the patient-physician interview. J Fam Pract. 1981;12(3):481–488[Abstract]. 18. Hannawa AF. Disclosing medical errors to patients: effects of nonverbal involvement. Patient Educ Couns. 2014;94:310–313. 19. Wong CKM, Yip BHK, Stewart M, et al. Effect of facemasks on empathy and relational continuity: a randomized controlled trial in primary care. BMC Fam Pract. 2013; 14:200.
Introduction mpathy is part of being human. Through empathy we connect to others and share in their felt experiences. Science is responsible for a remarkable transformation in health care. Yet there is increasing recognition that filtering a human being through tests and images and making objective evidence-based decisions is somehow incomplete. The emotional “truths” that propel people through life have been largely excluded from the process. Health professional groups, including The Commission on Dental Accreditation and the American Dental Education Association, include standards that
E
Department of Orthodontics, NYU College of Dentistry, New York, NY; Department of Orthodontics, University of Washington School of Dentistry, Seattle, WA; Department of Orthodontics, University of Detroit Mercy School of Dentistry, Detroit, MI. Address correspondence to Mitchell J. Lipp, BA, DDS, Department of Orthodontics, NYU College of Dentistry, Room 683 W Dental Center, 421 First Ave., New York, NY. E-mail: [email protected] & 2016 Elsevier Inc. All rights reserved. 1073-8746/12/1801-$30.00/0 http://dx.doi.org/10.1053/j.sodo.2016.04.002
emphasize “patient centered care” in a “humanistic environment.” This article will focus on the role of empathy in the doctor–patient relationship. It is without question that communication skills are necessary to succeed in orthodontic practice. Many studies in health care suggest that communication between the doctor and the patient positively impacts on satisfaction, decreased malpractice claims, and improved health outcomes.1–4 One article in the orthodontic literature reported a dramatic decrease in treatment time when greater attention was paid to communication.5 While dental and medical education programs regard communication as a core competency, it appears infrequently (or is under reported) in the orthodontic literature. The consequences of miscommunication can be dire, like the 71 million dollar malpractice settlement when emergency health care workers mistranslated the word “intoxicado” to mean intoxicated instead of the intended meaning of “feeling sick to the stomach” that caused a delay in making the correct diagnosis resulting in a potentially preventable quadriplegia.6
Seminars in Orthodontics, Vol ], No ] (), 2016: pp ]]]–]]]
1
2
Lipp et al
The doctor–patient relationship is deeper than a transactional relationship. Communication in this area goes beyond the exchange of information. Orthodontists need to understand the complete set of wants and needs of the patient; often going beyond objective findings in order to consider psycho-social dimensions that affect care. Empathy is a discrete and complex phenomenon that has subtle and foundational influences in the doctor–patient relationship. Because empathy affects the information that the patient discloses, this fact alone may significantly affect diagnosis, treatment planning, practice management, and other related skills and behaviors that lead to a more trusting relationship between the doctor and patient.
Empathy Empathy is the experience of understanding another person’s condition from their perspective by placing yourself in another’s shoes and feeling what they are feeling. Empathy is known to increase prosocial (helping) behaviors. Researchers have differentiated between the two types of empathy. “Affective empathy” refers to sensations and feelings—an emotional response. This may include mirroring what a person is feeling, or anticipating what they may feel. For example, a guttural shriek when witnessing a person falling and possibly getting hurt. “Cognitive empathy,” sometimes called “perspective taking,” is the mental act of projecting oneself into another person’s perspective, and through this process being able to identify and understand another person’s emotions. In the example of seeing someone fall, this would equate to appreciating the embarrassment and frustration that person may feel. There is some disagreement concerning the value of affective empathy in training health professionals. Some feel that by becoming too emotionally invested in a patients’ personal perspective, objective based health advice may be compromised.7 Others stress that the key component of empathy is the emotional connection with the patient, and without this affective bond, behavioral attempts at empathy, that is, “acting” as if you are really concerned, would not be as productive.8 Dr. Rita Charon has advocated the use of narratives, literature, shared stories as methods to reveal the felt emotional
experience of the patient, hence deepening the empathetic relationship.9 Empathy is rooted in our biology, in our brains and in our bodies. It has been observed in various species including rats.8 In the last decade, more attention has been focused on the role that mirror neurons play in empathy.10 Mirror neurons are cells in the brain that fire when we observe someone performing an action in the same way that they would fire if we performed that action. The primacy of mirror neurons in empathy has more recently been brought into question. However, their contribution to a neuronal understanding of empathy remains under investigation. Empathy is also modified by external factors such as social–cultural considerations and socioeconomic status.11
A patient-centered environment Doctor–patient relationships are affected by the various aspects of the health care process and environment. These physical and social components inherent in this environment begin as early as the first phone greeting or online contact. Once inside the physical office, the environment includes structural elements like location, décor, furnishings, equipment, cleanliness, order, and soundscape. This environment is further supported in part by the entire orthodontic health care delivery team in that (1) each patient should feel as if they are the center of the universe with their wants and needs as the primary focus; (2) the environment promotes the feeling of safety and confidentiality; and (3) the staff exhibit caring and positive attitudes. Implicit in this team centered office environment is a congenial supportive team that emulates empathetic communication practices. Effective and empathetic communication is not only useful in patient management but also in managing team member relationships. If the orthodontist intends to lead the team, each communicative interaction should be designed to increase awareness of the empathetic role each team member should display. All of the staff involved, whether engaged in support services or involved with direct patient care should be employing a “Show You Care” communication style thus reinforcing that the primary concern is the patient’s welfare.
Doctor–patient communication
3
Table. A Framework for Showing You Care
Attitudes
Interpersonal Skills
Building Rapport Patience Respect Being fully present Connecting on a human level Nonjudgmental
Verbal Avoid interrupting Avoid too quick of an interpretation Partnership statements Appropriate language
Taking patient seriously Cultural competence Recognition of differences like ethnicity or gender, Cognition Humor Tactfulness Enthusiasm Relating
Normalizing: recognizing emotional reactions that anyone would have Giving feedback Eliciting patient concerns Language terminology relating to the patient's illness, clearly describing one's condition, the treatment plan proposed and associated risks and benefits Articulation Vocal placement (timbre, tone, color, etc.), volume, and size Pace of speaking Varying one's delivery approach (pitch, pace, rate, and emphasis)
Behaviors Giving a direct phone line Making follow-up calls Escorting patients Coordinating referrals Position self in relation to patient (proximity, level, bearing, etc.) Introduces names and positions of all health care team members present Establishes an environment of safety and confidentiality Asking permission before touching or intruding on one's privacy or personal space
Reflective listening Provides appropriate wait time after asking questions. Responding to questions. Clarifying Paraphrasing Acknowledging Nonverbal Eye contact Tone of voice Body posture Facial expression Appropriate touch Allowing crying Mirroring patient's body language. Checking for nonverbal signs (understanding) Integrations Integrating verbal with other communication modes (visual, aural, kinesthetic, etc.) Note the overlapping boundaries and integration of empathetic skills with other communication skills. In our framework, we proceed from a theatrical or actor's perspective. Mastering the role begins with understanding the attitudes and attributes of an empathetic doctor. After understanding the role, we proceed to awareness of the skills required to effectively communicate and experience/express empathy. Finally these skills need to be integrated and regularly applied in daily living.
4
Lipp et al
Despite all good intentions we live in an imperfect world, largely because we are imperfect. Things do go wrong and when they do, it is essential to acknowledge the fact and move ahead. Do not hesitate to say, “I’m very sorry this has happened. We will continue to do everything we can to resolve (the issues under discussion) as well as any others that may occur as we proceed with your care.” The practitioner needs to keep staff included, supported, and supportive. A team that shares ownership for the patient’s welfare is the ultimate goal. Opportunities for training (and re-training) in communication skills, with role-playing and scenarios may be helpful. Much like exhibiting empathy towards one’s patients, the orthodontist should express the “Show You Care” communication styles to all team members.
Empathy in clinical practice Generally, empathy has been studied using surveys or rating forms in which patients or observers rate the practitioner relative to response options. Most scales focus on ultimate outcomes and not isolated skills or behaviors. One study took a novel approach by having medical educators work with professional theater educators that adapted actor-training tools incorporated in the health care setting12. This tool, unlike other empathy scales, offered insight into the observable methods a doctor may use to improve communication and convey empathy. From this tool and other sources, we have attempted to isolate skills and behaviors that are associated with demonstrating empathy (Table). If the perspective toward building empathetic skills stems from the realm of theater, perhaps the clinical orthodontist should begin by understanding the role-internalizing core values like altruism and beneficence; as well as attributes such as, approachability, nonjudgmental attitude, and expressing an active interest in the patient. After understanding the role of the empathetic doctor, one should then focus on skills that effectively lead to establishing and encouraging an empathetic relationship.
Key themes Educating and communicating A significant fear for any patient is fear of the unknown.13 This can be mitigated by calmly
explaining things while minimizing technical jargon, and quickly defining any word which may cause confusion. Visual aids can be helpful to demonstrate procedures and appliances and overcome language barriers. Techniques such as, tell, show, and do can be very useful for younger patients. However, overcompensating or overusing any approach or aid in this area can become problematic as sometimes the patient (or parent) can perceive oversimplified explanations as a form of condescension. Care must be taken to gauge the mental capacity of the patient (or parent) possibly using education level as a guide. Adjusting to match cognitive and/or language levels of your audience (patient and parents) is another part of the challenge in communication. Orthodontic treatment of younger children occasionally requires effective communication not only with the patient but also with the parents as well. A guiding principle in building empathetic relationships is to strive to understand the unique needs of each individual and modulate communication skills and behaviors accordingly.
Active listening Engage the communication process by first, asking open-ended questions; and second, by keeping the number of your interruptions to the minimum. Allow patients to do most of the talking. Whenever possible, only interject at appropriate points, using open-ended questions, to elicit additional information allowing you to “funnel down” into more focused questions. Patients need to feel heard. Ask prompting questions like “Is there anything else?” or “Tell me more about that” and then pause to listen to the response. Phrases such as “I can imagine how that made you feel,” or even remaining silent can be effective as long as the patient feels encouraged and is assured that she is being heard. If appropriate, take notes while the patient is speaking. This conveys the aura of active listening and supports the patient’s perception of being heard. Once again, be careful about overdoing it. Losing focus by taking too many notes can be distracting and thwart the impression of actively listening to the patient. Framing statements convey the intention of obtaining an accurate understanding.14 Phrases like “Let me see if I understood everything correctly…”
Doctor–patient communication
demonstrate actively trying to understand the patient’s situation. Giving back to the patient what you think they have stated not only makes the patient feel understood but also provides opportunities for clarification. Listening to and repeating or rephrasing the patient’s words can help orthodontists recognize the patient’s feelings from their perspective.15 It allows the doctor and the patient to bridge perspectives moving toward empathy. Patients that feel understood tend to reciprocate by trusting their health care provider. The benefits of empathy are tangible and measurable resulting in improved treatment adherence, quality of care, decreased health care costs, and decreased psychological distress.16
Body language The nonverbal communication an orthodontist conveys is a crucial element in patient understanding and satisfaction.17 In one study, physicians were asked to disclose medical errors to patients, by contrasting error disclosure with or without nonverbal involvement such as, appropriate touch, personal space proxemics, forward leaning, body orientation, prolonged gaze, vocal animation, attentiveness and interest, affirmative head nods, an numerous other nonverbal communicative techniques. When nonverbal communication was absent, physician’s apologies were interpreted as being less sincere and remorseful.18 The study demonstrated how nonverbal involvement facilitated more accurate patient understanding and assessment of the medical error as well as its consequences on the patient’s health and their quality of life. Body language needs to be open, not constrained, and includes such acts as pausing, nodding, all while maintaining eye contact.14 Starting with body positioning and hand gestures, creating a welcoming safe environment for the patient in order to share information and be made to feel at ease is important. For example, maintaining focus and proximity to the patient while leaning forward to hear the patient’s narratives conveys interest and helps the practitioner better understand the patient’s wants, needs, and expectations regarding treatment. As noted previously this impression starts the minute the patient enters the office. Thus the proverbial “you never get a second chance to make a good first impression,” starts with how the
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front desk staff treats the new patient. Maintaining eye contact, within a comfortable proximity to the patient, inclined forward to hear what they have to say conveys interest and not only helps the listener to really hear the patient but provides the patient with the feeling that they are truly being heard. Asking the patient if they have any special requests or needs is another mechanism that can be used to enhance their experience. Whenever the doctor is with the patient, the patient needs to receive the practitioner’s full attention regardless of other people being in or near the treatment area. This concept also includes the idea that whenever possible, the doctor should not be interrupted by members of the staff to attend to other needs within the office until the patient encounter is completed. Active listening continues by sustaining an open body position—never appear to be closed off by folding your arms across your chest. Respond nonverbally by nodding your head while remaining engaged in the conversation. Smiling is a very powerful type of body language. Interestingly, but not surprisingly, a randomized controlled trial demonstrated a significant negative effect on perceptions of empathy when doctors wore facemasks while interviewing patients.19 The orthodontist should also be aware that some patients may be anxious just being in a clinical setting, the so-called “white-coat syndrome,” which has been found to elevate the patient’s blood pressure (a key measurement of anxiety). Establishing an empathetic doctor–patient relationship can modulate this anxiety.
Match patient’s nonverbal style Language matters but the manner in which we say things has been shown to be powerful, sometimes more powerful than what we actually say. For instance, one’s tone of voice, volume, and pacing of speech, all play a role.13 This paralanguage skill is most effective when used to mirror the patient’s own tone. In fact, it has been shown that when practitioners attune to patients nonverbally, patients feel more comfortable and give fuller histories.15 Tone should never be uncaring, apathetic, express frustration, or stress. Modulating your tone of voice can markedly modify the patient’s behavior and reduce agitation; a key factor in managing the child
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Lipp et al
patient. Used pointedly, tone can help the doctor take charge of a situation, but it must be used in moderation.
Expressing empathy Perhaps the clearest way to demonstrate empathy is to validate the patient’s emotional target. The two steps in accomplishing this process are first, finding the target; and second, empathizing with the patient. An ideal target is one that is close to the other person’s emotional epicenter. It could be mirroring back the other person’s rationale of how they are seeing things and why they feel the way the way they do. It could be picking up on secondary elements that they are experiencing which are true, and offering confirmation of that fact. There is little empathy in saying “I’m sorry thumb sucking makes you feel bad.” It’s more empathetic to say “After hearing that your friends are making fun of you, I understand how embarrassing thumb sucking is.”
Conclusion Clinicians should be prepared and ready to recognize and react appropriately to the emotional needs of their patients by showing genuine sensitivity and compassion. Empathy must flow naturally from the professional and his/her staff to the patient in order to “Show You Care” and acknowledge that you have a stake in their wellbeing. Unlike other areas in dentistry and medicine, orthodontics is less frequently an urgent care service. Patients seek care largely for an esthetic or quality of life benefit. Being transparent and bringing financial discussions to the forefront of the process, engenders trust, pushes aside any underlying stress, and allows the patient to be focused during the interview. Generally, there is a developmental progression in learning or acquiring new skills and behaviors. Prior to learning the student or neophyte practitioner is in a state of, “unconscious incompetence”: ignorance, not knowing or even being aware of what is not known. As learning begins the novice becomes aware of their incompetence (conscious incompetence). Generally, the purpose of dental or orthodontic training programs is to give the predoctoral or post-doctoral candidate sufficient experience to become fully aware and competent (conscious competence). This process continues
during the early phases of one’s professional career and with continually gained experience, by virtue of practice and repetition, the maturing practitioner approaches the final phase,” unconscious competence.” This final phase, somewhat synonymous with expertise, reflects the seamless and facile integration of knowledge and complex cognitive and procedural skills without much conscious effort. Like driving a car—at first it requires concentration and effort, after enough practice; it becomes an almost automatic response. Communication skills, both verbal and nonverbal, that lead to empathetic doctor–patient relationships follow a similar pathway. This essay was intended to bring this subject of empathetic communication and its associated skills and behaviors into the practitioner’s consciousness. By developing an understanding of this subject the doctor can begin to apply these concepts and techniques into clinical practice. Some of us may recall a time, prior to today’s data driven era when, “chairside manner” counted. Considering that empathetic behavior results in higher patient satisfaction, better patient perceived outcomes, a lesser tendency for the initiation of malpractice claims, happier offices, and less doctor burnout this subject should be given greater attention in both the educational and clinical orthodontic environments.
References 1. Clever SL, Jin L, Levinson W, Meltzer DO. Does doctor– patient communication affect patient satisfaction with hospital care? Results of an analysis with a novel instrumental variable. Health Serv Res. 2008;43(5): 1505–1519. 2. Stewart MA. Effective physician–patient communication and health outcomes: a review. Can Med Assoc J. 1995;152(9): 1423–1433. 3. Korsch BM, Gozzi EK, Francis V. Gaps in doctor–patient communication. Pediatrics. 1968;42:855–871. 4. Wanzer MB, Booth-Butterfield M, Gruber K. Perceptions of health care providers’ communication: a relationship between patient-centered communication and satisfaction. Health Commun. 2004;16(3):363–384. 5. Shelton CE, Cisneros GJ, Nelson SE, et al. Decreased treatment time due to changes in technique and practice philosophy. Am J Orthod Dentofac Orthop. 1994;106:654–657 [How do write the name if he’s a “junior”?]. 6. Palmer, C. HHS offers cultural diversity guide—miscommunication prompts government to enhance national standards. ADA News May 20, 2013. 7. Newton BW. Walking a fine line: is it possible to remain empathic physician and have a hardened heart? Front Hum Neurosci. 2013;7:1–12.
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8. Bartal IB, Decety J, Mason P. Empathy and pro-social behavior in rats. Science. 2011;334:1427–1430. 9. Arntfield SL, Slesar K, Dickson J, et al. Narrative medicine as a means of training medical students toward residency competencies. Patient Educ Couns. 2013;91(3):280–286. 10. Lamm C, Majdandzic J. The role of shared neural activations, mirror neurons, and morality in empathy— a critical comment. Neurosci Res. 2015;90:15–24. 11. Piff PK, Stancato DM, Côté S, et al. Higher social class predicts increased unethical behavior. Proc Natl Acad Sci U S A. 2012;109(11):4086–4091. 12. Dow AW, Leong D, Anderson A, et al. Using theater to teach clinical empathy: a pilot study. J Gen Intern Med. 2007;22(8):1114–1118. 13. Frenkel M, Cohen L. Effective communication about the use of complimentary and integrative medicine in cancer care. J Altern Complement Med. 2014;20(1):12–18.
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14. Coulehan JL, Platt FW, Egener B, et al. Let me see if I have this right…: words that build empathy. Ann Intern Med. 2001;135(3):221–227. 15. Halpern J. What is clinical empathy? J Gen Intern Med. 2003;18:670–674. 16. Shay LA, Dumenci L, Siminoff LA, et al. Factors associated with patient reports of positive physician relational communication. Patient Educ Couns. 2012;89:96–101. 17. Larsen KM, Smith CK. Assessment of nonverbal communication in the patient-physician interview. J Fam Pract. 1981;12(3):481–488[Abstract]. 18. Hannawa AF. Disclosing medical errors to patients: effects of nonverbal involvement. Patient Educ Couns. 2014;94:310–313. 19. Wong CKM, Yip BHK, Stewart M, et al. Effect of facemasks on empathy and relational continuity: a randomized controlled trial in primary care. BMC Fam Pract. 2013; 14:200.