Compassionate Communications in Medicine
Information on communication skills and compassion in medicine
I. Cultivating Compassion and Empathy
Compassion and empathy are very similar concepts and the terms are sometimes used interchangeably in medicine. Both involve being deeply engaged with the other person and present as you listen to their stories about their suffering and needs. Both involve being a very attentive witness to the other’s suffering. The word empathy is used different ways but often includes the elements of 1) feeling what another person is feeling and 2) conveying your understanding to the person in a caring manner. Feeling just enough of another person’s pain or upset to understand it and then emphasizing the understanding and caring part of empathy can help clinicians avoid feeling overwhelmed by the suffering they witness. Compassion overlaps with empathy and includes the desire to help meet their needs:
What Is Compassion?
A description of compassion by healthcare providers
A study of healthcare providers’ understanding of compassion produced the following descriptions: (Sinclair et al., 2018):
Compassion Definition: “An intentional response to know a person, to discern their needs, and ameliorate their suffering through relational understanding and action.”
Compassion’s Impact on Healthcare Providers: Deep satisfaction of coming to know another person deeply. Being able to use valued virtues to alleviate the suffering of another and strengthen the therapeutic relationship.
The Components of Compassion:
The following aspects of compassion in clinical practice were summarised from descriptions by healthcare professionals and are similar to the way patients describe compassion. (Sinclair et al., 2018)
- Virtuous Intent:
- Purposeful expression of virtues, such as love, acceptance, honesty, kindness, genuineness, care, and peace
- Expressed through one’s character and embodied presence
- Self-effacing and curious attitude towards the patient
- Orientation to the patient’s perspective
- Relational Space:
- The caregiver engages the suffering of the other person with virtuous intent (See #1)
- Coming to Know the Person:
- Engaging patients sensitively, attuning to their presence and interpersonal cues
- Seeing the patient as a person, extending one’s vision beyond their illness
- Understand patient circumstances and accept them unconditionally
- Forging an In-Depth Healing Alliance, which is:
- Being present in demeanor using verbal and non-verbal communication
- In-depth understanding of the patient, becoming engrossed in their story. Using active listening to understand their needs
- Relational, reciprocal communication, may include mutual story-telling
- Therapeutic relationship with expressions of caring and your desire to promote health
- Ameliorating Suffering:
- Discerning, anticipating, and prioritizing patient needs
- Proactively addressing needs, providing an attuned response to suffering
- Providing emotional and existential support for fears, distress, and uncertainty by “eliciting meaningful memories, affirming strengths, and providing supportive touch and words of affirmation”
Sinclair S, Hack TF, Raffin-Bouchal S, et al. What Are Healthcare Providers’ Understandings and Experiences of Compassion? The Healthcare Compassion Model: A Grounded Theory Study of Healthcare Providers in Canada. BMJ Open. 14 2018;8(3):e019701. doi:10.1136/bmjopen-2017-019701. PMCID: PMC5857658. PMID: 29540416.
What is Empathy?
Empathy has been defined in medical literature as “the ability to sense, feel, and understand another’s emotions.” (Patel, 2018)
Finding the Words to Express Empathy
Words of empathy can validate the other person’s experience and show caring and concern. For some people, verbalizing empathy is a challenge, even when it is felt. They may find it hard to find the right words to say when a peer or patient is feeling pain or is sad. So, it can help to be prepared with a few commonly used responses. The following statements express empathy and might be appropriate, depending upon the situation: The following 28 empathetic statements are possible ways of expressing empathy in different situations that may help inspire you to find the words to say.
|Are you okay?||I can appreciate how difficult it was for you.|
|Things like this are never easy.||That’s awful! I don’t know what to say.|
|That sounds frightening.||I am sad to hear what happened.|
|That sounds so challenging!||I could see it wasn’t easy talking about it.|
|I’m glad you told me.||What a shift you had!|
|Sounds like a really tough thing to go through.||What a disappointment!|
|That must have really hurt!||I can see how deeply it affected you.|
|That would upset me, too.||I’m sorry you are going through this.|
|It sounds discouraging.||I could tell it mattered to you a lot.|
|It looks like you have strong feelings about it.||I hear you.|
|That sounds exhausting!||I would be mad, too, if I was in your shoes.|
|It sounds like a major conflict. How difficult!||You just went through a lot.|
|Whew!||You did the best you could.|
|I can see how much you care.||You have a right to feel this way.|
- Don’t rush the conversation after you express empathy. Give the other person time to process their feelings.
- Keep in mind that non-verbal expressions of understanding and caring are a part of conveying empathy. Sometimes, just making eye contact and nodding can convey empathy. If it is appropriate in the relationship, a hand on the shoulder or taking the other’s hand are other ways to convey empathy and compassion.
Skills and Techniques to Cultivate Compassion for Self and Others
1. Contemplating Loving-Kindness
The steps for contemplating loving-kindness (each around 30 seconds) are:
- Start seated in a relaxed, meditative posture in a quiet place: Bring to mind two people who love you standing on either side of you and imagine them sending you their love with an attitude of kindness.
- Now think about sending that love and kindness back to them.
- Next, imagine sending that loving-kindness feeling toward an acquaintance.
- Finally, imagine sending that feeling toward the whole world.
- You can repeat these steps with wishes for happiness, well-being, and health.
In a study of 134 college students, a 10-minute session of contemplating loving-kindness improved wellbeing and feelings of connection more than inducing a positive mood not related to compassion or a neutral visualization (Seppala et al., 2014).
Source: Patel, S., Pelletier-Bui, A., Smith, S., Roberts, M. B., Kilgannon, H., Trzeciak, S., & Roberts, B. W. (2019). Curricula for empathy and compassion training in medical education: A systematic review. PLoS ONE, 14(8). https://doi.org/10.1371/journal.pone.0221412
Seppala EM, Hutcherson CA, Nguyen DT, Doty JR, Gross JJ. Loving-Kindness Meditation: A Tool to Improve Healthcare Provider Compassion, Resilience, and Patient Care. Journal of Compassionate Health Care. December 19, 2014;1(1):5. doi:10.1186/s40639-014-0005-9.
Loving-Kindness Meditation (Audio) by Greater Good In Action, Science-based Practices for a Meaningful Life, Berkely University of California.
2. Wishing wellbeing for someone’s suffering (Tonglen)
This exercise is adapted from a meditative technique for cultivating compassion (Tonglen). It helps you become more aware of the suffering of other people and to wish them well.
It may be easiest to learn this skill while thinking of someone you love first and then to use it with others. Seated in a relaxed, meditative posture:
- As you breathe in, bring to mind someone you love who is suffering. If it feels sad, heavy, or another unpleasant feeling, open your chest and breathe freely and with ease so that the feeling does not get stuck.
- As you breathe out, imagine you are breathing out a sense of relief, freshness, and lightness as if you are sharing that with your loved one. Breathe freely and openly, as you wish this feeling for them.
- Repeat these two steps for several minutes. Breathe in a relaxed, deep, very open, non-stuck way.
- Switch the focus of your thought from just your loved one to a particular person or all people suffering in the same way, breathing in their suffering and breathing out relief, directed towards them.
3. Focus on your breathing to support the release of your stuck feelings
You can use a similar breathing technique to the one described above, but focused on yourself, to process unpleasant or difficult feelings you may have that feel stuck, such as feelings of self-criticism, being unfairly judged, or resaentment over an overwhelming work-load.
- As you breathe in, think about your difficult feeling and breathe deeply into where it feels stuck in your body.
- As you breathe out, think about that stuck feeling relaxing, the difficulty dissolving, or that burden being lifted and carried away. Try a second breath as if drawing the breath to that part of the body, and imagine it cleaning up and clearing out any remaining tension from that area of your body as you breath out. You may still want to take some action to correct the situation if possible, but you will carry less of the pain and tension of it around with you all the time.
Reference for meditation #3:
Chodron P. Guided Tonglen practice. [Video]. YouTube. July 16, 2016. (running time: 11 minutes)
II. Compassion in Medical Practice
A compassionate approach in medicine has a positive impact on patients and healthcare providers. Compassion helps buffer the impact of stress on the well-being of providers, improves patient outcomes (Seppala et al., 2014), and improves your ability to support your peers. Expressing empathy is part of communicating compassion.
Compassion Fatigue vs. Compassion Satisfaction and Resilience
What is Compassion Fatigue?
Compassion fatigue (CF) is the symptom that comes from being exposed, usually multiple times, to traumatized, suffering individuals beyond one’s ability to cope (Cocker & Joss, 2016). Healthcare providers are susceptible, especially in a long-term crisis. Health effects of CF can include posttraumatic stress disorder (PTSD), anxiety, or depression. CF often manifests as exhaustion, anger, irritability, less enjoyment or satisfaction with work, increased absenteeism, and may result in harmful coping behaviors such as alcohol and drug abuse or overeating. Programs to combat CF that help develop self-efficacy and resilience have shown some effectiveness.
Professional Quality of Life Scale – Self Assessment: Measures Compassion Satisfaction vs Compassion Fatigue (Burnout or Secondary Traumatic Stress – from exposure to traumatic events). PROQUOL Version 5, 2009
Video: Compassion Resilience and Setting Boundaries for Healthcare Workers by Sara Reed. 2020. Mental Health America. This hour-long video is rich with insights on setting boundaries to improve compassion resilience.
Cocker, F., & Joss, N. (2016). Compassion Fatigue among Healthcare, Emergency and Community Service Workers: A Systematic Review. International Journal of Environmental Research and Public Health, 13(6). https://doi.org/10.3390/ijerph13060618
III. Compassionate Communication Skills
Communication skills will help you help a patient or peer who may be experiencing a challenge, stress, painful emotion, or conflict.
Compassionate listening involves listening deeply to someone with the purpose of helping the person unload their suffering or empty their heart (Bird et al., 2020). It involves paying full attention to the other person while listening. Just the act of listening often relieves the storyteller of their suffering.
The following steps have been identified for compassionate listening (Bird et al., 2020). They can be used by physicians to help relieve the suffering of patients and by medical students to help relieve the suffering of patients and peers.
Steps for Compassionate Listening:
- Take a deep breath and remind yourself that this is an opportunity to be completely present with the person before you.
- As you listen, your mind may wander to what you want say to soothe them or solve their problem. If this happens, gently bring your attention back to the person’s voice, facial expression, or how they are sitting .
- Try to look into the person’s eyes as they are speaking and acknowledge you are hearing their story by nodding, leaning in, and using appropriate facial expressions, eg., smile when they are saying something meant to be funny.
- Repeat parts of their story to yourself to fully appreciate the details of the story.
- Once the person ends their story, thank them for sharing. Let them know you are sorry they are dealing with something so challenging.
- Let them know you are here for them if they need someone to listen.
Tips for Compassionate Listening (AMA, 2016):
- Listen for underlying feelings, needs, or values. Give the patient ample time to express themselves.
- Set aside distractions such as patient charts, computers, phones, and alarms, and give the patient your full attention. The first few minutes are important for connecting with the patient, so be fully present from the outset.
- Watch for cues that the patient is talking about something they value, such as talking faster, changing their facial expression, or using more gestures.
- To avoid interrupting the patient, watch for cues that the patient has finished speaking about a topic, such as decreased emotional intensity, a sigh, or leaning back.
From (with minor changes):
Bird Amber, Tomescu Oana, Oyola Sonia, Houpy Jennifer, Anderson Irsk, Pincavage Amber. A Curriculum to Teach Resilience Skills to Medical Students During Clinical Training. MedEdPORTAL. 2020;16:10975. doi:10.15766/mep_2374-8265.10975. PMID: 33015355 PMCID: PMC7526502.
AMA. Empathetic Listening. AMA STEPSforward, AMA Ed Hub. August 31, 2016.
Active listening is similar to compassionate listening but more focused on the mechanics of how to listen well.
- Give your peer your full attention.
- Use body language that shows you are actively listening (Patel, 2019):
- Face the other person directly at the same eye level or sit beside them if they seem overwhelmed.
- Use non-verbal communication of caring, including eye contact.
- Maintain an open posture with your arms and legs uncrossed and avoid leaning backward.
- Maintain an appropriate distance, sitting at the same level without a desk between you.
- Use short verbal and non-verbal responses to show you are listening and responding: Nod your head or use responsive facial expressions or sounds.
- Example: Softly blow out some air when the other person says something very emotional.
- Listen for the meaning and emotions behind the other person’s words. Look for non-verbal cues of distress or changes in the tone, pitch, and pacing of their speech. Check with the other person for the accuracy of any conclusions you draw, however.
- Provide verbal statements of acknowledgment (“That does sound challenging!”), validation (“I think anyone would feel that way”), and support (“That’s what I’m here for. Go right ahead.”)
Patel, S., Pelletier-Bui, A., Smith, S., Roberts, M. B., Kilgannon, H., Trzeciak, S., & Roberts, B. W. (2019). Curricula for empathy and compassion training in medical education: A systematic review. PLoS ONE, 14(8). https://doi.org/10.1371/journal.pone.0221412
Reflective listening is a specific way of responding to what the other person says that helps them feel heard. It, too, is a skill that will support compassionate listening.
- Reflective listening is when you convey your understanding of what the other person said by briefly paraphrasing it in your own words. It is important to:
- Emphasize their thoughts and feelings.
- Focus on what seems most important to them.
- Check with the other person for the accuracy of your understanding.
- The following opening words might help you get started. Be careful not to use them too often in the same way, or you’ll trigger a feeling of being in therapy, rather than of support:
Sounds to me like…
So, in other words…
What you’re saying is…
Use Open-Ended Questions to Elicit Information
When trying to draw out a patient or peer who has a concern, using open-ended questions can be more effective at getting them to open-up about what is bothering them.
Try your skill at recognizing open vs. closed questions among the following (15 questions):
Conveying Difficult Information
An article (Murphy, 2019) in the AMA’s news for medical students recommends the following steps:
- Understand the gravity of the news
- Prepare the patient for what you are about to say
- Have a plan
- Be honest
A list of skills needed to deliver bad news has been used successfully to train medical students (Vermylen et al., 2019). These include:
- Create initial rapport.
- Assess the patient’s (and family’s) perception and understanding of their medical situation.
- Ask permission to give the news, give the news in the first few minutes of the conversation.
- Give a clear and concise warning.
- Use the word “cancer” or other serious diagnosis rather than euphemisms.
- Wait some time after delivering bad news to let them process it, but not too long, judging as best you can by their reaction. Around 3 seconds is often a good pause.
- Express empathy as your next statement and as your response to their reaction, rather than hurrying to provide reassurance.
- Discuss the plan, but only after the patient asks or gives permission and not while they are feeling very emotional
Use general, good patient-centered communication skills, including use of summary statements, avoiding jargon, chunking information.
Resources on Delivering Bad News:
4 things medical students should know about delivering bad news – by Brendan Murphy, Patient Support and Advocacy, January 7, 2019, AMA
Read about a medical student’s practice session in breaking bad news to a standardized patient at the University of Michigan.
Vermylen JH, Wood GJ, Cohen ER, Barsuk JH, McGaghie WC, Wayne DB. Development of a Simulation-Based Mastery Learning Curriculum for Breaking Bad News. J Pain Symptom Manage. March 2019;57(3):682-687. doi:10.1016/j.jpainsymman.2018.11.012. PMID: 30472316.
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