Empathy: what does it mean for GPs? A qualitative study

Background.

Research has highlighted empathy as an important and effective factor in patient–physician communication. GPs have extensive practical experience with empathy. However, little is known about the personal views of GPs regarding the meaning and application of empathy in daily practice.

Objectives.

To explore GP’s experiences and the application of empathy in daily practice and to investigate the practical use of empathy. Facts such as preconditions, barriers and facilitating possibilities are described.

Methods.

Qualitative interview study; 30 in-depth interviews were performed between June 2012 and January 2013 with a heterogeneous sample of Dutch GPs. Interviews were recorded and transcribed verbatim; content analysis was performed with the help of ATLAS-ti.

Results.

Empathy was seen as an important quality-increasing element during the patient–GP consultation. The application of non-verbal and verbal techniques was described. Attention to cues and references to previous consults were reported separately. Required preconditions were: being physically and mentally fit, feeling no time pressure and having an efficient practice organization. Not feeling connected to the patient and strict medical guidelines and protocols were identified as obstacles. A key consideration was the positive contribution of empathy to job satisfaction.

Conclusions.

The opinions of GPs in this research can be considered as supplementing and strengthening the findings of previous researches. The GPs in this study discussed, in particular, ideas important to the facilitation of empathy. These included: longer consultations, smaller practices, efficient telephonic triage by practice assistants, using intervision to help reflect on their work and drawing financiers’ attention to the effectiveness of empathy.

Introduction

Empathy is considered an important requirement in patient–physician consultation (1,2). In health care, empathy is usually considered to be the competence of a physician to understand the patient’s situation, perspective and feelings; to communicate that understanding and check its accuracy and to act on that understanding in a helpful therapeutic way; there are cognitive, emotional and behavioural aspects (1). Its effectiveness has been empirically proven to contribute to: an increase in patient satisfaction, detailed knowledge of patients’ symptoms and psychosocial concerns and considerably more commitment to the proposed therapy on the part of the patient (1–7).

Recent research on patient experiences shows that empathic statements obtained the highest quality rating from all participants, irrespective of their background characteristic and nationality (8). From the perspective of a patient, an important part of the quality of care is an empathic doctor, who is willing to take the time to listen (9).

In recent literature, some authors have reported that there has been a rise, during the last decade, of the technological and biomedical aspects of care and of more emphasis on effectiveness and productivity in family care (10,11). These developments can create barriers to empathic relationships (11). Other researchers call for more attention to be paid to the role of bureaucratization and consumerism (12). Changes in the consulting room, like the greater use of computers, also affect the communication (13). There seems to be a danger that empathy, despite its proven effectiveness (6) and the above-mentioned importance in the patient–GP consultation, is seen increasingly as a ‘soft’ aspect in general practice communication (10).

In applying empathy in general practice, GPs are faced with a complex situation. They have to combine evidence-based medical knowledge and protocols with their own emotions, moral standards and intuitions and those of their patients. There is little research available that explores the personal thoughts and opinions of GPs on the practical use of empathy in daily practice. The objective of our study therefore is to explore how GPs experience and apply empathy in daily practice and to investigate the problems they come across when using empathy.

Methods

Study design

The GPs were interviewed from June 2012 to January 2013. In-depth interviews were employed because, as a method for data collection in qualitative health research, these explore experiences in daily practice and the significance GPs attribute to them; they also give an insight into the priorities of participants (14). In this article, we applied the consolidated criteria for reporting qualitative research (COREQ) (15).

Preparation and participants

Thirty-one interviews were undertaken. Prior to the interviews, four test interviews were audio-taped and discussed with a research assistant. Participants were recruited from the NIVEL (Netherlands Institute for Health services research) GP registrar. With help of a statistical employee, a systematic random sampling was applied. In order to produce a heterogeneous sample and to achieve, as much as possible, a normal representation of Dutch GPs, characteristics such as: age (<45, 45–55, >55), gender, practice type (solo, duo or group) and degree of urbanization were used in the selection process. A total number of 147 GPs were selected and approached with a personal letter, explaining the subject of the research. Also the interviewer, as a retired GP, was introduced (see Supplementary Data). The GPs were telephoned some weeks after receipt of the invitation. After 100 telephone calls, 31 GPs consented to participate. They also consented to the data being used for this research. The rest, 47 GPs of the totally selected, were placed on a reserve list. An appointment was made with the 31 GPs, and anonymity and confidentiality were ensured.

Data collection and analyses

The interviews were held face to face at the participating GPs own practice and lasted for between 45 and 70 minutes. All fieldwork was conducted by a single researcher (FD).

The interviews were based on an interview guide that in turn was based on literature and expert opinions (see Supplementary Data). No repeat interviews were carried out. All interviews were recorded with audio equipment (one recording failed) and transcribed verbatim by the interviewer. After eight interviews (which were part of the succeeded 30 research interviews), style and content were analyzed by two supervisors (ALJ and JB); this resulted in a more profound interviewing style and achieved more detailed information. Creswell’s (14) guidelines state that 20–30 participants are sufficient for assuming saturation and a variety of perspectives. In our study, we found that saturation occurred at approximately interview 20, no new topics were then introduced. Hereafter, the next interviews were used to explore special aspects such as: GPs ideas regarding facilitation. To analyze the data, content analysis was employed (16–18).The systematic examination of transcripts involved three members of the research team: the interviewer and two doctoral medical students (FD, SK and MvM). This team of three researchers was formed in order to minimize the influence of personal characteristics on the analysis of data. ATLAS-ti (software package) was used to assist with registering, searching and coding the data. The researchers read and re-read the transcripts independently but met regularly to discuss the subjects and interpretations. In addition after 3, 12 and 30 interviews, the coding process was discussed with a supervisor (ALJ). By using axial and selective coding, codes and super codes were attributed to text segments. Codes referring to the same phenomenon were grouped in categories and significant themes and key concepts were made explicit and arranged. These themes formed the structure of the final result.

Results

Thirty GPs participated. The demographics of the participants show variability concerning gender, age, degree of urbanization and practice type and are representative of the total GP population as shown in Table 1. Non-participation was checked: no time to participate in research (n = 19), no affinity with the subject (n = 2), poor health (n = 2), wrong address or telephone number/unknown person (n = 33) or no promised re-call after the first contact by telephone (n = 14).

Defining and valuating empathy

At first, to develop a clear interpretation of the findings of this research, it was considered useful to gain some insight into the interviewees own views on empathy. They were asked to give their own definition. The description of their answers can be found in Table 2. The answers were coded and categorized with help of empathy levels (attitude, competency and behaviour) as has been discussed in earlier research (6). Some views were common to many interviews. Openness to the patient was regarded as an important element and seen as a ‘communication skill’ and an ‘attitude’, in other words, the personal capacity to have respect for the patient’s thoughts and feelings.

As a ‘competency’, recognizing patients as equal human beings was highly emphasized and a ‘behaviour’ expressing empathy was highlighted (see Table 2).

Participants were also asked to value the importance of empathy in daily practice, using a score of 1–10. The resulting scores showed that it was regarded to be an important part of the consultation; the average score appeared: 8.12 (see Table 2).

The generated themes

The analysis of the interviews generated four themes, which will be described below. The themes are: the realization of empathic behaviour, preconditions and barriers, views on the facilitation of empathy and the positive effects of empathy.

The applied quotations were in Dutch; they are translated with help of a native speaker.

The realization of empathic behaviour

Many GPs described that empathy was shown through non-verbal and verbal skills.

Non-verbal skill

Most of the GPs regard non-verbal communication as a vital empathic skill. They mentioned: an interested facial expression, keeping eye contact and leaning backward or forward to emphasize listening. Some recognized the importance of physical contact like a hand on the shoulder or an embrace or offering a handkerchief when the patient is crying:

“Often when I go and fetch a patient from the waiting-room I’ll say ‘Come on in” (making welcoming gestures with her arms), and make them feel welcome.” (23, female, 55 years)

“Part of it is obviously putting it into words, like “how awful” or “that must be very upsetting for you”, but also, I’m not chained to my chair, I’m dynamic, sometimes I walk over to the patient and put my arm around them…yes, it can be quite physical too.” (28, female, 61 years)

Verbal skill

Different kinds of verbal skills were mentioned such as: a relaxed tone of voice, pauses, interested listening, clarifying the question, summarizing and reflecting on the patients’ thoughts and feelings. Specially mentioned were attention to ‘cues’ and reference to previous consults or events in the life of the patient:

“..... I listen very attentively to people and the cues are extremely important.” (11, male, 42 years)

“Well, when a patient comes for a new consultation I ask them how things turned out after their previous visit.” (9, female, 44 years)

Preconditions and barriers

Preconditions

Most of the GPs deemed their own physical fitness and being free of private worries important preconditions to being empathic. GPs considered being genuine and respectful, reaching equality and a good atmosphere as essential. Furthermore, the following aspects were mentioned: the absence of time pressure, an efficient practice organization and not being disturbed by practice assistants or telephone calls. Some of them indicated that it was important not to have negative feelings based on issues from the past:

“That time I was definitely less empathic, because I was so tired, and I was hasty and short-tempered. I was simply exhausted, and that definitely affected my work. I’m certain that patients would have noticed; so these factors definitely play a part: how you feel, did you sleep well, are you hung-over, that kind of thing.” (11, male, 42 years)

When it is influenced by something, now or from the past, coming from yourself or from the person opposite to you, the signals which are transmitted can cause obstacles in the story.” (10, female, 59 years)

Barriers

A great number of interviewees described the necessity of feeling connected to the patient as an essential part of being able to work empathically. Reasons for the absence of a connection can be caused by aggression coming from a patient or a GP’s own feeling of aversion, for instance in the case of a perpetrator of child abuse. Personal and organizational barriers were mentioned as well:

Personal barriers

“ You see, empathy comes more easily when there is a click with someone, and if there is some barrier, whether through signals from yourself or from the person sitting opposite you, the whole thing gets a lot harder.” (10, female, 59 years)

Organizational barriers

Strict medical guidelines and standardized treatments, so-called managed care, were assessed as important obstacles to being empathic. They were considered a restriction, not allowing time and space for other important patient problems. Some GPs were worried about the emphasis on measuring the quality of care by the figures of a protocol what does not include the importance of empathy as a quality indicator.

“..too much registration of less important things, while you should spend time on the real problems of that patient. Too much paperwork, looking at your screen and not at the patient.”(2, male, 39 years)

“The fact is, delivering certain lab-figures to insurance companies is obligatory, good or bad quality of care isn’t measurable by figures.”(14, male, 50 years)

Views on the facilitation of empathy

Personal, practice-organizational and health-organizational views on the facilitation of empathy were mentioned as well.

Personal views

Several interviewees stressed the importance of a more continuous support of professionalism through following specific refresher courses for consultation skills and through participation in intervision. Thus, enabling self reflection, talking about doubts and emotions and working on self-awareness:

“Intervision has taught me a lot about myself. Observing myself I was quite struck by how, even though I thought I could hide my feelings from the patient, I obviously can’t: a lot can be deducted from my facial expression, or from the way I fiddle with something or suddenly look away when I lose interest. You can learn so much from it.” (3, male, 52 years)

Practice-organizational views

Many GPs emphasized the need to be able to spend more time with their patients as an important precondition and facilitation as well; consequently, longer consultation time. However, some of the interviewed GPs identified that initially it takes time to build an empathic relationship but that this approach becomes cost- and time-effective in the long run. A longer consultation time requires efficient telephonic triage by practice assistants and a more flexible system of appointments. A reduction of practice size was also seen as a possibility but should not, in their opinion, lead to a lower income.

“I would certainly prefer to have fewer patients; I think I could then do this part of my work.” (3, male, 52 years)

‘There is a case to be made for smaller practices and standard consults of 15 minutes per patient, but that shouldn’t result in a lower income.” (11, male, 42 years)

Health-organizational views

Various interviewees drew attention to the discrepancy between the importance they attach to empathy in daily practice and the attitude of health financiers. Even though, GPs were convinced that using empathy can help in cutting back costs, they noticed that financiers show a reluctance to give any attention to this. This lack of attention is probably caused by the difficulty of measuring the effects of empathy during a consultation.

Nevertheless, according to the GPs, possibilities exist for facilitating the role of the financiers. They mentioned items such as: changing the payment methods, financial support in practice size reduction and financial compensation after following empathic skill-related trainings.

“They (the financiers) should reward it, and not finish us with the mean HbA1c score of our diabetic patients.” (28, female, 61 years)

“When the Government appreciates our work; empathy is something we employ, and when you consider the commitment to our patients, that’s a big part of the quality of our work. That quality, should be rewarded through facilitating and financing. “ (2, male, 39 years)

“I think it would be very good to compare similar practices and look at the differences that come up, like less referrals.” (9, female, 44 years)

“…it would be like: we’ll give you a bonus per patient when you can show that you’ve done something, for instance when you’ve followed a relevant course; you’ve got a kind of added value, a kind of GP-plus.” (15, male, 55 years)

The positive effects of empathy

The positive effects of empathy for both GP and patient were also mentioned. Most GPs were convinced that the use of empathy makes a positive contribution to therapy adherence, receiving useful and detailed information, a better interpretation of complaints and improved diagnostics. This enabled GPs to deal better with the patient’s problems and to achieve successful treatment.

“I think that when people feel you listen to them, they in turn listen to you, resulting in improved compliance and adherence and more tendency to listen to what you have to say.” (2, male, 39 years)

A number of the participants conclude that applying empathy resulted in a greater job satisfaction.

“Well, being empathic is being sincere, and when I can stay close to myself and at the same time get close to a patient, it gives me a lot of satisfaction and feeling of calm.” (20, female, 34 years)

“It makes you feel very good…; it’s a valuable thing, it also gives you a whole lot of positive energy.” (30, female, 57 years).

Discussion

To summarize, GPs in this research regarded empathy as an important element during consultation. It helps to recognize patients as equal human beings. Imagining the thoughts and feelings of patients and receptivity were mentioned. ‘Showing’ feelings of sympathy was also considered important. And, in addition, empathy was seen as a positive factor that contributed to job satisfaction.

The prerequisites necessary to apply empathy were considered to be: being genuine and respectful and cultivating a good atmosphere and feelings of equality. Participants considered non-verbal aspects of empathic communication as very important, but verbal aspects such as: being alert to cues and referring to previous consults or life events were also regarded to be essential.

The interviewed GPs perceived: good physical fitness, being free of private worries, the absence of time pressure, an efficient practice organization and not being disturbed by practice assistants or telephone calls as important preconditions for being empathic.

Not feeling connected to the patient and the existence of many medical guidelines and protocols were considered to be obstacles to empathy in daily practice.

To facilitate the preconditions and to address the obstacles interviewees offered different solutions or compromises. For example, in order to have the opportunity to reflect on their work, organized intervision or Balint groups were regarded as essential. Furthermore, longer consultation time, efficient telephonic triage by practice assistants and smaller practices were suggested.

Drawing the attention of the financiers to the effectiveness of empathy was regarded as an opportunity. This, firstly because of the efficient and detailed exchange of information during consultations and secondly because of the time-cost effectiveness.

Following some of the present research findings will be discussed in more detail in relation to previous research. To begin with participants in this study seemed to be aware of most of the elements found in literature defining empathy (6) (see Table 2).

Secondly, the positive thoughts in this research about the effectiveness of empathy seem to be connected to job satisfaction. The exposure of this relationship is important and surprising; it is to a certain extent related to the results of earlier research. To illustrate, it was found that positive moments in GPs’ relationships with patients are experienced as gratifying elements, which enrich professional life and give pleasure (19). Furthermore, feelings of fulfilment, job satisfaction, achievement and pride have been found as positive side-effects of being empathic—in that way, a defence against depression, compassion fatigue and burn-out (12,20,21). Other research has found that GPs with high levels of burn-out showed less patient-centred communication (22). Although some literature puts forward the assumption that a high level of empathy causes an emotional burden, possibly creating ‘compassion fatigue’ (23), even though specifically queried, none of the interviewees considered this as a negative side effect of being empathic. In literature, attention has already been paid to non-verbal and verbal ways of empathic communication (3,5,24–28). Interviewees in this study highlighted the importance of reacting to ‘cues’ as essential in verbal empathic communication. This observation can be seen as quite remarkable, as generally speaking physicians tend to miss most patients’ ‘cues’ and even adopt behaviours that discourages disclosure. However, communication training improves the detection of ‘cues’ (29). Broadly speaking, ‘cues’ ought to be seen as subtle signals that relay the patient’s emotional concerns. Recognizing and responding to these signals enhances gathering information and benefits the relationship (30,31).

Finally, the concern raised by the respondents about the role of medical protocols and paperwork/computer requirements as ‘straitjackets’, by which attention to more important complaints, usually not-fitting these protocols is decreased, can be regarded as quite a new and important result which echoes the theoretically based assumptions of other studies (32). Also the practical barriers of time pressure, practice organization, physical fitness and the more emotionally oriented problems of personal worries, and negative past feelings, partly mentioned elsewhere (33), were well recognized in this study. Additionally, to these aspects, interviewees in this study particularly discussed supplementary ideas on how to improve and facilitate the use of empathy. Although there is insufficient evidence and divided support for the hypothesis that the completion of special communication courses and Balint training has any tangible effect, participants felt it would be beneficial (34–36). The opportunity to reflect on work and experiences with other professionals would give support and insight into their own roles, skills and emotional balances. It would also help provide insight into the effect of an empathic approach to patient–doctor relationships. It was deemed essential that this kind of intervision should have recognized certification. Longer consulting time and smaller practices were also highlighted as possibilities for facilitating empathy. In the long run, the cost- and time-effectiveness of empathy is seen by the GPs as a positive facilitating element and a solid discussion point to promote the interest of financiers. This firmly supports the ideas of Neumann et al. who already highlighted the need for investigating this element (7,37).

Implications and recommendations

Empathy is a two-way process, so essential attention should be given to the patients viewpoints about empathy during consultation. Furthermore, if the conclusions of this research can be generalized, further detailed research should be done into the views of GPs on the facilitation of empathy in daily practice and on their thoughts about the borders between intimacy and professional autonomy. Research into the existence of awareness in general practice about a connection between empathy and aspects such as a patient-oriented approach and relationship-centred care could also be proposed. Considering the results of this research, a possible next step would be a study of the obstructing effects of protocol-based care. It would be interesting and inspiring to study the views of financiers on the role of empathy in GP’s daily practice. Throughout the training of GPs programs should be continued to provide students with empathic tools; attention should be given to the development of competencies like alertness to ‘cues’ and referring to previous consults or life events. Training programs should also be aware of the personal development of students.

Strengths and limitations

To the best of our knowledge, the focus on GP’s personal experiences and subjective interpretations of empathy is a significant and hitherto under-researched aspect of the GP’s daily practice.

Being interviewed by a colleague, as an active participant, may affect the data collection (38). Despite this, considered as mutual confidants, interviewees may have given more detailed information. Some respondents experienced the opportunity to talk reflectively about their views as fascinating and clarifying, underlined the importance of this research and were curious about the results. The negative aspects of such a ‘shared’ relationship could be too little objectivity on the interviewer’s part and giving socially desirable answers on the participants’ part. A weakness in this research could be that the GPs who consented to participate are likely to have a positive interest in the issue of empathy. This may influence their answers and could affect the interpretation of the findings. Underexposure of negative ideas about empathy is a possibility. So we are cautious about transferring findings directly to daily practice or in generalizing the ideas.

Conclusion

Although the interviewed GPs in this study volunteered to discuss empathy and showed for the most part positive ideas about the position of empathy in daily practice, the findings also offer additional information about some aspects of empathy in patient–GP consultation. Previously unexplored in GP research are the attention to ‘cues’ during the consult and the reference to previous consults or life events as specific empathic skills.

GPs described feeling connected as a basic need in empathic behaviour; this connection needs preconditions and meets obstacles. In this research, GPs specifically discussed ways of overcoming these barriers. They were positive about facilitating possibilities as: organizing intervision, more time for the patient, efficient practice organization and using the empirically proven effective benefits of empathy in discussions with financiers.

Supplementary material

Supplementary material is available at Family Practice online.

Declaration

Funding: none.

Ethical approval: according to Dutch legislation, interviewing health care professionals with respect to professional beliefs does not require the approval of an ethics committee.

Conflict of interest: none.

Acknowledgements

The authors would like to thank interviewees who took part in this research for their time and valuable input.

References