Over the past several years while teaching communication skills, I have noticed that many clinicians respond to emotionally charged clinical conversations with biomedical, factual information or false reassurance rather than with empathy. The communication style displayed by the medical oncology fellow I observed on rounds at Baylor was hardly the exception. The literature confirms that clinicians, particularly physicians, miss many empathic opportunities, even though strong emotions permeate almost every conversation they have with patients. Clinicians understand on a conceptual level that empathy entails “standing in the other person’s shoes” or imagining what another person is thinking or feeling, yet they still find it difficult to occupy the emotional space with patients. There are several possible explanations for this apparent lack of empathy. One is that many clinicians have been taught to remain emotionally distant from patients to maintain composure and objectivity. I remember a small group session I facilitated in our “Difficult Conversations” series a few years ago that included an oncology fellow with an impressive research pedigree. He was a few years older than the other fellows, having earned a PhD and done a research postdoc before returning to clinical training. He seemed stoic and reserved during our large group sessions. However, when he assumed the role of physician caring for a young woman dying of breast cancer in our small group role play, he suddenly became overwhelmed with emotion and started crying. I learned from that experience that some clinicians who appear to be the most detached and scientific on the surface are actually the most sensitive and caring inside. I also learned to be empathic rather than judgmental toward colleagues who struggle to realistically discuss prognosis and goals of care with their patients. Discussing code status and transitioning to a purely palliative strategy is heart-wrenching work for anyone.
Clinicians may also miss many empathic opportunities because they lack a sufficient repertoire of empathic phrases with which to dive deeply into emotional conversations. If they say anything empathic, they often run out of steam after saying a few stock phrases, like “I cannot imagine how difficult this must for you” or any statement beginning with “I wish.” The NURSE acronym, a conceptual framework published by Pollak and colleagues in the Journal of Clinical Oncology in 2007, can be used as a teaching tool to address this challenge. The N in NURSE stands for naming the emotion, the U for understanding or validating the emotion, R for respect, S for support, and E for exploring emotions further to encourage more expression. The investigators characterized empathic responses in these categories as continuer statements that allow patients to continue expressing emotions and found that when oncologists respond with them, patients have less anxiety and depression and report greater satisfaction and adherence to therapy. I find that respectful empathic statements, symbolized by the R in NURSE, are particularly powerful for helping me connect with patients. Examples of such statements include “I respect your fighting spirit,” “I respect your strong religious faith,” and “I respect the love between you and your family.” This book contains many more such examples. These are healing words as long as they are heartfelt. The challenge for many clinicians is to incorporate these and many more empathic expressions into their practice to occupy the emotional space with the patient for as long as the patient will let them. Empathic expression should be more than just “one and done.”
I had an epiphany a couple of years ago that stimulated me to write this book. I was attending in the palliative care unit at MD Anderson, and as usual our team included two palliative medicine fellows and a medical oncology fellow who was completing his required palliative elective in our department, in addition to a pharmacist, counselor, chaplain, social worker, and nursing team. Alex Andreev, the medical oncology fellow, approached me one day after rounds and said, in essence, “I understand what empathy is, and I am impressed by how empathy helps you and others in your department connect with your patients, but I often cannot think of the right words to say when patients and families become emotional. Will you please give me a list of empathic phrases that I can memorize and use in my encounters?” When Dr. Andreev asked me for a list of phrases to memorize, I realized that such a list could be a precious resource for many clinicians, whose training involves memorizing huge quantities of factual information. Dr. Andreev is a physician-scientist who had the insight to know that clinicians can use their strong powers of memorization to strengthen their humanistic skills. He and I published a reflective essay in the Journal of Clinical Oncology “Art of Oncology” section in 2020 that describes our work together that month. The essay concludes as follows:
These observations, along with some profound patient encounters, led me to see that we have the potential to offer our patients a gift that is arguably as powerful and meaningful as targeted therapy or immunotherapy—the gift of humanity. If I can undergo this transformation, anyone can.
A short time later, Shine Chang PhD and Carrie Cameron PhD asked me to serve as an advisor for Laura Meyer, a college graduate who was accepted into their NCI-funded Cancer Prevention Research Training Program (CPRTP) Summer Internship. Laura has since completed her masters in social work and recently embarked on doctoral studies. Our goal for the summer was to develop a list of conversational challenges that often arise in the care of seriously ill patients and potential empathic responses to each challenge, as requested by Dr. Andreev a few months before. Laura and I first reviewed existing books and journal articles pertaining to empathy to determine that nothing like our proposed practical guide to empathic responding was already available. I then generated a list of scenarios and proposed empathic responses from my own practice as an oncologist and palliative doctor. We then built upon that foundation by anonymously surveying 44 palliative clinicians, including physician and non-physician providers at MD Anderson Cancer Center. We asked them to give examples of the conversations they find most challenging in their practice and then merged their responses with the original list as well as examples from the literature to create a more comprehensive list. We then assembled a focus group of five physicians, two advanced care providers, and one psychologist from the Department of Palliative Medicine at MD Anderson Cancer Center to get feedback about the format, themes, scenarios, and suggested empathic responses in the draft guide. Scenarios fell into several thematic categories, including denial, prognosis, existential concerns, difficult family dynamics, impact of illness on family, and nonmedical opiate use. We then formatted the list as a prototype for a clinician’s pocket guide and approached Karen Edmonson, who at the time was a content editor for McGraw Hill, to gauge interest in the project. Karen and her colleagues were enthusiastic, but they requested that we write a full book rather than just a pocket guide. Other editors at McGraw Hill subsequently worked with us on this project.
My next challenge was to decide how to convert a very practical list of empathic phrases for clinicians into a full manuscript. I knew I did not want this book to be another philosophical, theoretical, or technical look at clinical empathy, but rather an engaging, real-life resource for busy clinicians. I decided that the same narrative approach that I had used to write reflective pieces for the Journal of Clinical Oncology and other journals was best suited to the task. I also decided that I wanted this book to reflect the viewpoints of a culturally diverse group of clinicians from a variety of medical disciplines rather than just my viewpoints or the views of palliative clinicians. The authors include five medical oncologists, six palliative physicians, a surgical oncologist, a chaplain, a social worker, an infectious disease physician, a pediatrician, a clinical psychologist, and an ophthalmologist. Many of the first authors were born and raised in other countries, including Canada, Germany, Ghana, Guatemala, Nigeria, Pakistan, the Philippines, and Taiwan. The authors represent nearly an equal mix of men and women who are at various stages of career development. Each chapter is anchored by a true but anonymized story that describes a challenging clinical scenario from the first author’s clinical practice and relevant personal details about each author that helped shape their approach to empathic practice. This book ends with the concise pocket guide to empathic expression, the seed from which this book grew. I hope you will find this collection of real stories inspirational and enlightening.