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Understanding family practice residents’ conceptualization and experience of empathy Van Tongeren, Carlene 2006

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Understanding Family Practice Residents' Conceptualization and Experience of Empathy By Carlene Van Tongeren  Bachelor of Arts, Simon Fraser University, 2003 Liberal Arts Certificate, Simon Fraser University, 2003  A THESIS SUBMITTED IN PARTIAL F U L F I L L M E N T OF T H E REQUIREMENTS FOR T H E D E G R E E OF M A S T E R OF ARTS IN T H E F A C U L T Y OF G R A D U A T E STUDIES (Counselling Psychology)  T H E UNIVERSITY OF BRITISH C O L U M B I A  August, 2006  © Carlene Van Tongeren, 2006  11  Abstract A major problem in the medical profession is a lack of empathic communication skills in doctor-patient interactions. Studies have illustrated medical students' ability to learn effective communication skills, yet have found their empathy for patients to decline during the senior years of medical school and residency. Focus group interviews were conducted with Family Practice Residents from the University of British Columbia Medical School Program to investigate how they conceptualize and experience empathy in the medical context in order to better understand the processes involved in learning and understanding empathy as well as the barriers in transferring these skills to clinical practice. Themes were generated under five main categories including "The Characteristics of Empathy in the Medical Context"; "The Value of Empathy in the Medical Context"; "The Facilitating Factors in the Development of Empathy"; "The Hindering Factors in the Development of Empathy"; "The Challenging Factors in the Use of Empathy". Suggestions were developed regarding the implications of these findings for clinical training and practice as well as future research.  Ill  Table of Contents Abstract  ii  Table of Contents  .iii  List of Tables  v  List of Figures  vi  Acknowledgements Chapter I  Introduction  Background Rationale Purpose of Study Operational Definition of Empathy Assumptions and Limitations Chapter II  vii  Literature Review  Introduction Barriers in the Doctor-Patient Relationship Concept of Empathy. What Empathy is Not Operational Definition of Empathy Importance of Empathy Communication Skills and Patient Health Outcomes Empathy and Patient Outcomes Empathy and Patient Satisfaction and Compliance Empathy and Patient Health Outcomes Critique of Empathic Communication Research Impact of Communication Training Learning Empathy Critique of Learning Empathy Research Decline in Empathy Current Research  1  ,  1 3 5 5 6 8 8 8 11 12 13 14 17 18 19 21 27 29 31 34 34 39  iv  Chapter III  Method  .  42  Approach Focus Groups Participants Procedure Analysis of Data Validation Methods Confidentiality Chapter IV  42 42 44 44 46 47 48  Results  50  The Characteristics of Empathy in the Medical Context... The Value of Empathy in the Medical Context The Facilitating Factors in the Development of Empathy The Hindering Factors in the Development of Empathy The Challenging Factors in the Use of Empathy Validation Procedure Results Chapter V  Discussion  51 54 58 66 69 78 81  The Characteristics of Empathy in the Medical Context The Value of Empathy in the Medical Context The Facilitating Factors in the Development of Empathy The Hindering Factors in the Development of Empathy The Challenging Factors in the Use of Empathy Limitations Future Research Implications for Clinical Training and Practice Conclusions ;  81 83 84 87 89 91 94 96 100  References  102  Appendix A  119  Appendix B  120  Appendix C  122  Appendix D  ,  123  List of Tables Table 1  5  VI  List of Figures Figure 1  55  Vll  Acknowledgements  This thesis project has shed light on my humanness. I am truly thankful for God's generous gifts which He provides and H i s creativity that allows us to wonder about the intricate ' process of relationship and healing. I would like to express my appreciation to my thesis committee who each brought a different flavour of inspiration to this project. I am thankful for Dr. B i l l Borgen's wisdom and experience in qualitative research which shed light on the design and analysis of this study as well as his genuine and thoughtful feedback on my work. I am appreciative of Dr. Patricia Boston for generously sharing her experience of qualitative research in the medical field and encouraging my academic writing. I am grateful for Dr. David K u h l ' s inspiration and passionate heart for the role of empathy in the medical context. I am thankful for my supervisor Dr. Marv Westwood's willingness to provide consistent feedback and encouragement throughout this project. I would also like to thank Dr. E v a K n e l l for her spirit of enthusiasm and helpful assistance which greatly contributed to the development and'completion of this thesis. I would like to thank Dr. Ian Scott and Dr. Sharon Salloum who shared their wisdom of how empathy is taught in the medical curriculum and their observations of developing physicians in medical school. I am appreciative of my colleagues in the Masters of Counselling Program at U B C who journeyed through this thesis process alongside me. Particularly I am grateful for Masahiro's willingness to contribute his thoughts and ideas throughout many stages of this project. I would •  also like to thank Dal Sohal for her companionship in analyzing the data and developing themes for this research. I am grateful for the support and prayers of my dear friends and family who contributed strength and encouragement to begin this endeavor and maintain my sanity throughout the challenges. There are significant aspects of completing this thesis which I owe tribute to my father's 'constructive' feedback in the early years of my writing and to my mother's passionate support in helping me persevere with gusto! Lastly, I am indebted to my husband Chad. Witnessing his therapeutic gift with patients inspired me to believe in the healing role of empathy in medicine. His endless love and support has carried me through the most difficult moments and has made the peaks of accomplishment worth celebrating! His faith in me exceeds my understanding and that is a gift for which words cannot capture the depths of my gratefulness.  1  Chapter I Introduction Background Problems in the doctor-patient relationship have existed for many years and have been attributed primarily to poor physician communication skills (Korcsh, Gozzi, & Francis, 1968; Mitchell, Bradley, Anderson, Ffytche, & Bradley, 2002; Munn, 1990; Richards, 1990; SansonFisher & Maguire, 1980; Simpson et al., 1991). Tongue, Epps, and Forese (2005) reported that on average physicians interrupt their patients within twenty seconds of them describing their story and if physicians were to listen for two minutes, they would learn 80 percent of what they need to know to effectively diagnose their patients. Engel (1980) claimed that physicians using the traditional biomedical approach often do not gain a complete understanding of their patients' health issues due to a focus on strictly biological aspects in the patient interview. Furthermore, studies have also revealed that poor physician communication skills have contributed to malpractice suits among physicians (Beckman, Markakis, Suchman, & Frankel, 1994; Hickson et al., 1994; Levinson, Roter, Mullooly, Dull, & Frankel, 1997). Research on medical care provided by doctors and nurses has revealed that poor communication skills may contribute to patient suffering (Heyland et al., 2002; Kuhl, 1999; Teno, Clarridge, Casey, 2004). Some patients in Kuhl's (1999) study reported that the way in which their physicians informed them of their terminal illness diagnosis resulted in iatrogenic suffering. The experiences of these patients indicated that physician communication, particularly when conveying sensitive information, could cause harm to patients. Teno et al.'s (2004) study on end-of-life care found that patients reported dissatisfaction with physician communication as well as insufficient emotional support in the palliative care they received. Heaven and Maguire  2  (1996) examined nursing communication skills with patients and concluded that less than fifty percent of the nurses were able to identify their patient's biggest concern during treatment. Some authors have claimed that the greatest deficiency in physician-patient interviews is physicians' lack of empathic responses (Easter & Beach, 2004; Levinson et al., 1997). The literature has discussed how empathy fosters feelings of caring and compassionate actions towards one's patients, which contributes to the healing process (Davis, 2003; Gianakos, 1996; Larson & Yao, 2005). Moreover, empathy plays a role in facilitating a physician's understanding of the patient's illness and expectations (Bellet & Malloney, 1991; Tongue et al., 2005; Zinn, 1993) and improving the accuracy of a physician's diagnosis through eliciting more information from the patient (Bellet & Malloney; Colliver, Willis, Robbs, Cohen, & Schwartz, 1998; Fine & Therrien, 1977; Gianakos; Higgins, 1990; Levasseur & Vance, 1993). Furthermore, empathy allows physicians to gain insight into a patient's beliefs which in turn will assist them in making important decisions about treatment (Gianakos). Consequently, many physicians and researchers have argued that empathy is a crucial aspect to physician's effective communication skills in facilitating patient health outcomes (Aring, 1958; Book, 1991; Colliver et al.; Davis; Gianakos; Higgins; Hojat, Gonella, Nasca, Mangione, Vergare, & Magee, 2002; Jarski, Gjerde, Bratton, Brown, & Matthes, 1985; Lavasseur & Vance; Levinson, 1994; Shapiro, Morrison, & Broker, 2004; Tongue et al.). Empirical studies on physician empathy have found that empathy plays an important role in increasing patient satisfaction and compliance (Blanchard, Ruckdeschel, Fletcher, & Blanchard, 1986; Bertakis, Roter, & Putnam, 1991; Dimatteo, Hays, & Prince, 1986; Hall, Roter, & Rand, 1981; Ishikawa, Takayama, Yamazaki, Seki, & Katsumata, 2002; Kim, Kaplowitz, & Johnston, 2004; Mead, Bower, & Hann, 2002; Stewart, 1984; Stewart, McWhinney, & Buck,  3  1979; Sullivan, Stein, Savetsky, & Samet, 2000; Wasserman, Inui, Barriatua, Carter, & Lippincott, 1984; Winefield, Murell, Clifford, & Farmer, 1996; Zachariae, Pedersen, Jensen, Ehrnrooth, Rossen, & von der Maase, 2003), as well as physician satisfaction and psychological health (Ramirez & Graham, 1996; Suchman & Matthews, 1988). Research on empathy used by nurses and other health practitioners has shown the positive role of empathy in the facilitating patient enablement (MacPherson, Mercer, Scullion, & Thomas, 2003; Mercer, Reilly, Watt, 2002) and patient health outcomes (La Monica, Madea, & Oberst, 1987; Olson, 1995). Due to the plethora of research supporting the importance of physician communication skills, some medical school programs have developed specific training to increase empathy and other clinical competencies (Aspergen, 1999). Several studies have been conducted with medical students, residents, and practicing physicians which illustrated how communication skills can be improved through targeted training programs (Aspergen; Jenkins & Fallowfield, 2000; Fallowfield, Jenkins, Farewell, Saul, Duffy, & Eves, 2002; Markakis, Beckman, Suchman, & Frankel, 2000; Oh, Segal, Gordon, Boal, and Jotkowitz, 2001). More specifically, the literature has revealed that empathy is a skill that can be developed and improved through training, roletaking, observation, discussion, and experience in the medical field (Aring, 1958; Price & Archbold, 1997; Barone, Hutchings, Kimmel, Traub, Cooper, & Marshall, 2005; Elizur & Rosenheim, 1982; Fine & Therrien, 1977; Hatcher, 1994; Larson & Yao, 2005; Rogers, 1951; Shapiro et al., 2004; Stephan & Finlay; Wilkes, Milgrom, & Hoffman, 2002; Winefield & ChurHansen, 2000). Rationale Studies have found a detrimental decline of empathy during the senior years of medical school and residency programs (Bellini, Baime & Shea, 2005; Haidet et al., 2002; Hojat et al.,  2004; Newton et al., 2000). These research findings suggest the need for research to determine what is occurring during medical school training in the area of learning and understanding empathy. This is supported in the research as authors have recommended that future research studies investigate residents' mood changes and their impact on empathy development (Bellini et al., 2005), as well as the dynamics of medical education that affect "student attitudes toward patient-centred care" (Haidet et al., p.568). Bellet and Maloney (1991) stated that teaching residents and medical students empathy should be one of the highest priorities in medical education because "it is a cost-effective method to early diagnosis and proper treatment" (p. 1832). Correspondingly, Hojat, Gonella, Nasca, et al. (2002) emphasized the benefits that empathy has on patient care and stated that research on empathy "deserves attention because this essential humanistic aspect of medicine eludes the performance measures that are commonly used in medical education" (p. 1568). In order to teach empathy skills effectively to developing physicians, it is valuable for educators to gain insight into how they understand and experience empathy in the medical context. The importance of good empathic communication skills is of particular importance in family medicine as "they are primary health care providers in comparison to other more technologically-oriented specialties in which physicians are secondary health care providers" (Hojat, Fields, & Gonella, 2003, p.46; Stewart, 1984). Furthermore, family practice residents are in the unique position of just experiencing the period of time in which the decline of empathy was shown to occur and they are currently working with patients on a frequent basis. Consequently, this research will investigate family practice residents' conceptualization and experience of empathy in the medical context.  Purpose of the Study The purpose of this study is to present information on how family practice residents understand and learn empathy in the medical context. The aspiration was to provide insight for counsellors, physicians, medical students, and educators into how developing physicians conceptualize and experience empathy in the medical context. This research will contribute to counselling psychology by providing insight into how medical students' learn and observe counselling skills in health care. Furthermore, this study will provide information for the development and improvement of counselling skills training in medical school as educators and curriculum designers will gain a greater awareness of what affects the development of empathy during medical training. In order for educators to effectively teach empathy to developing physicians, it is vital for them to have an understanding of their perceptions of empathy within the context that this skill is being implemented. Another purpose of this research is to provide a voice for people in the medical profession to express their experiences of working with patients and their perceived role of empathy in the profession. Long-term benefits of this study may include a contribution to improvements in Health Care through bringing about awareness of the importance of empathy in the medical profession and the factors that influence its development among medical practitioners.  Operational Definition of Empathy In the literature there are numerous conceptualizations of empathy (Barrett-Lennard, 1981; Bohart, 1988; Carkhuff & Berenson, 1967; Davis, 2003; Dymond, 1949; Egan, 1998; Gagan, 1983; Gladstein, 1987; Hogan, 1969; Katz, 1963; Kohut, 1978; Larson & Yao, 2005; Rogers, 1951; Rogers, 1957; Rogers, 1975; Spiro, 1992; Squier, 1990; Stein, 1970; Stephan &  6 Finlay, 1999; Welch & Gonzalez, 1999; Zinn, 1993). Originating in the field of psychotherapy, Rogers (1951, 1957, 1975) made significant contributions to the development and recognition of the concept empathy. The operational definition used in this study is derived from empathy literature in psychology, counselling, and medicine (Barrett-Lennard; Hojat, Gonnella, Nasca, et al., 2002; Kim et al., 2004; Winefield & Chur-Hansen, 2000); and has been tailored to suit the specific culture of medicine, in which empathy has a less extensive role compared to psychology and counselling. Therefore, empathy will be defined in the context of medical practice as one's ability to comprehend a patient's emotions through his/her perspective and effectively communicate this understanding back to the patient. Assumptions and Limitations The research question was examined in the context of focus group discussions, with the assumption that the participants' contributions were representative of their personal perspectives. Regarding limitations, the participants in the study were volunteers, which may be a source of bias in the sample. Due to the time commitment of participating in the study, participants who were very motivated to express and discuss their views about empathy in medicine may have been more eager to volunteer. Another potential limitation is the social desirability bias or selfserving responses (Patton, 2002). This involves participants responding to the questions in a way that would reflect most favorably on themselves or appear most socially acceptable (Cozby, 2004). In this study, the participants may have desired to appear more devoted to valuing empathy in the medical context because of the group dynamic of the interview and the counselling psychology background of the interviewer. Furthermore, this research may have been limited by interviewer bias and interpretation bias as the researcher's own preconceptions and ideas are incorporated into the findings of this  7 study (Patton, 2002). However, the researcher approached the qualitative inquiry with authenticity and a stance of neutrality with a goal to understand the participants' perspectives without motivation to prove a specific theory (Patton, 2002). Additionally, there were several steps of validation that contributed to the credibility and trustworthiness of the research process and findings, which are describe in detail in the methodology section of the paper.  Chapter II Literature Review Introduction Researchers have been investigating the complex dynamics of the doctor-patient relationship for many years. The focus on physician empathy has become a more prominent focus in the literature as physicians and researchers have identified it as a key aspect of effective doctor-patient interactions. The discussion of barriers in the doctor-patient relationship illustrates the current issue of physician communication skills in the medical profession. The concept of empathy is outlined to provide a theoretical explanation of how empathy is effective in therapeutic relationships. The literature on empathic communication skills is explored to highlight the impact that effective communication skills, particularly the use of empathy, can have on patient outcomes. Furthermore, the research in learning empathy and communication skills training in the medical context is reviewed. The purpose of the current study is revisited to outline how the literature is connected to the proposed research question. Barriers in the Doctor-Patient Relationship As early as 1968, Korsch et al. found that some of the main barriers in the doctor-patient relationship were how doctors communicated with patients; including doctors' overlooking patient expectations and concerns, misinterpreting patient cues, and overusing medical jargon. The Toronto consensus statement reported that clinicians' communication issues are common and affect health outcomes for patients (Simpson et al., 1991). Additionally, researchers have found that problems in communication were the most common formal complaint of patients (Mitchell et al., 2002; Munn, 1990; Richards, 1990).  Tongue et al. (2005) reported that on average physicians interrupt their patients within twenty seconds of them describing their story and if physicians were to listen for two minutes, they would learn 80 percent of what they need to know to effectively diagnose their patients. Tongue et al. also discussed how orthopedic surgeons seldom use empathetic statements, which would facilitate their patients' support. Engel (1980) and Sanson-Fisher and Maguire (1980) claimed that physicians often do not gain a complete understanding of their patients' health issues due to a focus on strictly biological aspects in the patient interview. Gianakos (1996) explained that physicians will not have the complete answer to a medical problem unless they are able to understand the patient's beliefs and feelings associated with the problem and empathy is the tool which allows physicians to enter into the patient's viewpoints. Furthermore, physicians' poor communication skills have been significant contributors to patient dissatisfaction in malpractice claims of obstetricians in Florida (Hickson et al., 1994). More specifically, Hickson et al. discovered that the most reported patient complaints were associated with physicians' demonstrating poor listening skills and lack of concern for their patients, as well as withholding pertinent information from them. Beckman et al. (1994) also investigated the different types of communication problems found in malpractice cases. The four communication behaviours that were identified as the most problematic in over 70 percent of the malpractice dispositions were failing to understand patients' perspectives, deserting the patient, delivering the information poorly, and devaluing the patients' views (Beckman et al.). Similarly, Levinson et al. (1997) found that physicians without malpractice claims, in comparison to those with claims, were effective at expressing and recognizing emotional affect, clarifying patients' understanding, educating patients, and asking patients their opinions.  Research has also illustrated that residents have demonstrated inadequate communication with their patients, particularly in discussing the patients' perspective of their illnesses (Eggly, Afonso, Rojas, Baker, Cardozo, & Robertson, 1997). Milis et al. (2002) researched resident physicians' ratings of their communication skills and compared them with faculty observer ratings and patient ratings. They found a very low agreement between the ratings of patients and physicians, r = . 11, and noted that many residents over-estimated their ability and performance during the patient-interview. However, it should be noted that the study did not report the reliability of the measure used to assess the physicians' communication skills or the inter-rater reliabilities for the faculty raters and the standardized patients used in this study. Empathy has been argued to be a crucial aspect to physician's effective communication skills (Gianakos, 1996; Larson & Yao, 2005). As early as the 1950's, physicians have recognized and written about the importance of empathy in the doctor-patient relationship (Aring, 1958). Some authors have claimed that the greatest deficiency in physician-patient interviews is physicians' lack of empathic responses (Levinson et al., 1997). Easter and Beach (2004) found that physicians and residents missed 70 percent of the empathic opportunities during interview sessions. Furthermore, Suchman, Markakis, Beckman, and Frankel (1997) found that doctors working with patients in a primary care setting often ignored their patient's emotional expressions and focused on their physical symptoms. Mitchell et al.'s (2002) study on physicians treating patients with Macular Disease indicated that more physician empathy for the patients' experience of the illness was needed. Mitchell et al. claimed that an empathic approach with patients would assist patients in overcoming the shock of a Macular Disease diagnosis. Gianakos (1996) argued that without empathy, physicians were putting their patients at risk as they may make decisions that are not  11  congruent with the patient's values. Furthermore, failure for patients to be understood by health care professionals may be detrimental to their welfare (Williams, 1979) and may contribute to patient suffering (Cassel, 1982). Concept of Empathy The origin of the word empathy came from the German psychologist, Theordore Lipps, from the word Einfuhlung, which translated into "feeling into" (as cited in White, 1997). Carl Rogers was an early leader in researching the concept of empathy and believed that it was "an essential aspect of all interpersonal communication" (1951, p.348) and "one of the most potent forces of change" (1989, p.136). Rogers (1951) emphasized that empathy was beyond simply reflecting the client's feelings, but rather sensitively entering into the client's experience. He defined empathy in the context of the counselling relationship as the "means that the therapist senses accurately the feelings and personal meanings that the client is experiencing and communicates this acceptant understanding to the client" (Rogers, 1989, p. 136). In Rogers' early theory of psychotherapy, the aspects he emphasized were responding to clients' feelings, rather than the content of their expressions and accepting the expressed feelings (Zimring & Raskin, 1992). His later work focused more specifically on putting oneself in clients' situations and understanding their thoughts and feelings from their perspective (Rogers, 1975). Welch and Gonzalez (1999) stated that accurate empathy involves empathic observing, listening, and responding at both affective and cognitive levels, as well as acknowledgement from the client that she or he was understood. Empathic listening is described by these authors as being quiet within oneself in order to gain an understanding of the whole person, without one's judgement interfering.  12  Barrett-Lennard (1981) broadened Rogers's (1975) conceptualization of empathy by a thorough description of an empathic interaction as three main phases. Phase one is described as Person A experiencing an empathic resonation from listening to Person B's expression. Phase two involves Person A communicating one's understanding to Person B and phase three is Person B's awareness and acknowledgement of Person A's communication. Barrett-Lennard discussed how each phase is necessary in an empathic interaction as they each serve as preconditions for the subsequent phases creating the total process. What Empathy is Not Davis (2003) clarified how empathy differed from sympathy in that it is a more complex process of "crossing over into the lived experience of the other in a shared moment of meaning" (p.273). Landau (1993) emphasized the crucial aspect that distinguishes empathy from sympathy is vicariously experiencing the other's situation and identifying with their feelings and perspectives. Notably, Wispe (1986) clarified that sympathy, which involves sharing an emotion with another, may impair a doctor's ability to make sound medical decisions whereas empathy, which involves a shared understanding with the patient, could facilitate more constructive outcomes. In Nightingale, Yarnold, and Greenberg's (1991) study, they found that physicians who were prone to sympathetic responses to their patient's struggles, were more likely to order more laboratory tests, perform resuscitation for longer periods, and preferred intubation in comparison to physicians who selected empathic responses. Empathy has also been distinguished from identification, which "presupposes no separation between the subject and object" (Sharp, 2001, p.28). Notably, while empathy involves entering into one's feelings, it still involves an awareness of one's separation from the other and maintaining a sense of self (Aring, 1958; Bellet & Maloney, 1991). Furthermore, Batson, Fultz,  13  and Schoenrade (1987) clarified through a factor analysis that the concept of empathy is different from personal distress in that actions motivated by personal distress are centred on reducing one's own negative arousal whereas actions motivated by empathy are focused on reducing the other's suffering.  Operational Definition of Empathy There have been several conceptualizations of empathy discussed in the literature (Barrett-Lennard, 1981; Bohart, 1988; Carkhuff & Berenson, 1967; Davis, 2003; Dymond, 1949; Egan, 1998; Gagan, 1983; Gladstein, 1987; Hogan, 1969; Katz, 1963; Kohut, 1978; Larson & Yao, 2005; Rogers, 1951; Rogers, 1957; Rogers, 1975; Spiro, 1992; Squier, 1990; Stein, 1970; Stephan & Finlay, 1999; Welch & Gonzalez, 1999; Zinn, 1993). Kunyck and Olson (2001) reviewed five different conceptualizations of empathy from the nursing literature between the years 1992 and 2000. The five major conceptualizations of empathy were empathy as human trait, empathy as a professional state, empathy as a communication process, empathy and caring, and empathy as a special relationship. Squier (1990) proposed a dualistic model of empathy including both a cognitiveinformational component and an affective-motivational component which both address different needs of the patient. Hojat, Gonella, Nasca, et al. (2002) measured empathy among physicians and found three prominent factors emerged from their empathy scale. These included perspective taking, compassionate care, and standing in the patient's shoes, most importantly, perspective taking. The study revealed that the concept of empathy is multidimensional and there are significant differences in empathy scores among specialties. Some researchers have concluded that in order to proceed with understanding the impact of empathy, more conceptual work in clarifying and unifying the construct empathy is necessary  (Kunyck & Olson, 2001; Stephan & Finlay, 1999). For the purpose of this research study, a definition of empathy was chosen from various medical studies that combined some important aspects from the literature in psychotherapy. It is valuable to acknowledge that the role of empathy in the doctor-patient relationship is less extensive than the use of empathy in the counsellor-client relationship, so the definition was revised to suit the medical context. Therefore, empathy will be defined as one's ability to comprehend a patient's emotions through his/her perspective and effectively communicate this understanding back to the patient (BarrettLenard, 1981; Gagen, 1983; Hojat, Gonella, Nasca, et al., 2002; Kim et al., 2004; Winefield & Chur-Hansen, 2000). Importance of Empathy Rogers (1951) viewed empathy as the most important of the three crucial elements of his client-centered therapy as it facilitates the other aspects of therapy which lead to positive change. Empathy is viewed as a way of improving clinicians' effectiveness as it contributes to meaningful communication in that it enables one to understand what the other is expressing as well as the potential causes of these feelings (Truax & Carkhuff, 1967; Welch & Gonzalez, 1999). Welch (1998) claimed that "all psychotherapy begins in empathy. Any psychotherapy that does not have this origin is, at best, predictably unhelpful and, at worst, harmful" (p.6). The importance of empathy has expanded beyond psychotherapy into the health care field. Kunyck and Olson (2001) discussed how empathy is the foundation of understanding client needs as a nurse and is critical to the nursing profession (Kristjansdottir, 1992). Furthermore, Benner & Wrubel (1989) argued that empathy is the essence of effective nurse-client communication because unless nurses are able to understand patients' perspectives, then they  15  will not be able to assist them in coping with or increasing their awareness of the implications of their condition. Many researchers and physicians have passionately expressed how empathy is a fundamental aspect of being a true physician as it plays a critical role in establishing connectedness in a therapeutic relationship, which positively impacts patient health outcomes (Aring, 1958; Beck, Daughtridge, & Sloane, 2002; Book, 1991; Colliver et al., 1998; Davis, 2003; Gianakos, 1996; Higgins, 1990; Hojat, Gonella, Nasca, et al., 2002; Jarski, Gjerde, Bratton, Brown, & Matthes, 1985; Lavasseur & Vance, 1993; Levinson, 1994; Shapiro et al., 2004; Tongue et al., 2005). Additionally, the expression of empathy may decrease a patient's sense of shame about one's lifestyle choices and this would reduce the patient's suppression of important information due to fear of humiliation (Zinn, 1993). Empathy plays an important role in facilitating a physician's understanding of the patient's illness and expectations (Bellet & Malloney, 1991; Tongue et al.; Zinn) and improving the accuracy of a physician's diagnosis through eliciting more information from the patient (Bellet & Malloney; Colliver et al., Fine & Therrien, 1977; Gianakos; Higgins; Levasseur & Vance). Furthermore, empathy allows physicians to gain insight into a patient's beliefs which in turn will assist them in making important decisions about treatment (Gianakos, 1996). Naming the patient's emotion assists the patient in confronting its true meaning as well as motivating the patient to improve one's situation (Zinn, 1993). In turn, expressed empathy enables patients to release their emotions that are associated with their condition and feel more confident about . coping with their illness (Zinn; Squier, 1990). Empathy often fosters feelings of caring and compassionate actions towards one's patients, which contributes to the healing process (Davis,  16  2003; Gianakos, Larson & Yao, 2005). Wolf (1980) concluded that it is a physician's ethical responsibility to develop the ability to use empathy with patients. Colliver et al. (1998) proposed that empathy may be equal, if not, more valued by patients than their physician's competence as it is influential in the obtaining crucial information from patients and appropriately assessing the patient's problem. In turn, Colliver et al. argued that empathy could impact the physician's quality of care as well as the outcomes of the patient's health care. Their research evaluated whether medical students were viewed as empathic by standardized patients on a performance-based examination, and how empathy correlated with communications skills and clinical-competence measures. Their sample consisted of 1, 048 fourth year medical students from New York. Their empathy score was determined from a 26item interpersonal and communication-skills checklist, which was developed for the purpose of this research. The psychometric properties of the measure were not reported. Colliver et al.'s (1998) results indicated that 26 percent of the medical students were rated as empathic on all seven cases and 21 percent were rated as empathic on four or fewer cases. Empathy was most highly correlated to the communication skill of putting the patient at ease (r = 0.64) and reassuring the patient with appropriate touch (r = 0.46). Furthermore, students who were only considered empathic on less than half of the cases scored significantly lower on their history taking and physical examination performances. The authors concluded that these results support the claim that empathy is a facilitating factor of clinical competence, which greatly impacts patient health outcomes. However, there were several limitations to the study presented by Colliver et al. (1998). Firstly, the study did not clarify their working definition of empathy and they did not specify the criteria according to which the standardized patient was rating whether the medical student was  empathic or not. The clarification of the concept empathy and how they were utilizing this term is crucial in order to evaluate the results of their research on empathy. Communication Skills and Patient Health Outcomes There have been limited outcome studies in the medical context that have clearly demonstrated the direct impact that physician empathy has on patient health outcomes, possibly due to the conflicting conceptualizations of empathy (Hojat, Gonnella, Nasca, et al., 2002; Kristjansdottir, 1992) and the difficulty in isolating empathy as a specific component influencing patient health improvement. However, it has been recognized in the literature that empathy is the essential underlying quality of a humanistic doctor and is one of the most important skills of effective physician-patient communication (Bellet & Malloney, 1991; Colliver et al., 1998; Spiro, 1992; Winefield & Chur-Hansen, 2000). Spiro claimed that empathy should "frame the skills of all professionals who care for patients" (p.843). Therefore, studies on the effects of physician communication skills will be discussed under the assumption that empathy is one of the important aspects involved in effective physician-patient communication. Sanson-Fisher and Maguire (1980) summarized the research in physician-patient interactions and indicated the positive impact that effective communication skills can have on patient recall of information, patient compliance, patient satisfaction, and diagnosis of psychologically distressed patients. Stewart (1995) reviewed several studies regarding the impact that doctor-patient communication has on patient health outcomes and concluded that patients' emotional and physiological health can be significantly improved by physicians considering the patients' feelings, perspectives, and expectations during the doctor-patient interview. Greenfield, Kaplan, Ware, Yano and Frank (1988) implemented an intervention with 33 patients to assist them in participating more actively in their doctor-patient interview. In  18  comparison to the 26 patients in the control group, Greenfield et al. (1988) found that increasing patients' involvement and their sense of control in doctor-patient interactions was associated with significant decreases in blood-glucose levels of diabetic patients (t = 3.08, p < .001). Furthermore, patients' who were able to actively negotiate medical decisions with the physicians experienced a significant decrease in missed days from work in comparison to the control group (p < .001). The authors concluded that the patients' sense of control and involvement in the doctor-patient encounter may have motivated them to take a more active role in improving their health outcomes. Kaplan, Greenfield, and Jason (1989) discovered that physicians' communication, such as effective emotional expression and information-giving were significantly related to decreased levels of blood glucose and blood pressure of diabetic patients. Kaplan et al. (1989) investigated the impact of physician-patient communication on 252 patients with four different conditions including, ulcers, hypertension, diabetes, and breast cancer. An analysis of physician communication behaviours revealed that patient control and ability to express negative emotions during doctor-patient communication, as well as physician's expression of negative emotions and information giving was significantly related to a decreased blood pressure and cancer symptoms and decreased levels of blood glucose (p < .05). Empathy and Patient Outcomes Many studies in psychotherapy have shown that therapists who utilized accurate empathy facilitated greater client satisfaction and improvements in their psychological health (Gladstein, 1987; Quinn, as cited in Rogers, 1989; Rogers, 1959; Rogers, Genlin, Kiesler & Truax, 1967; Truax & Carkhuff, 1967). Additionally, several studies have illustrated the positive impact that physician empathy and effective communication skills has on patient satisfaction and compliance  19  (Blanchard et al., 1986; Bertakis et al., 1991; Dimatteo et al., 1986; Hall et al., 1981; Ishikawa et al., 2002; Kim et al., 2004; Mead et al., 2002; Stewart, 1984; Stewart et al., 1979; Sullivan et al., 2000; Wasserman et al., 1984; Winefield et al., 1996; Zachariae et al., 2003), as well as physician satisfaction and psychological health (Ramirez & Graham, 1996; Suchman & Matthews, 1988). Research has also investigated the impact that empathy in nurses and other health practitioners has in facilitating patient enablement (MacPherson et al., 2003; Mercer et al., 2002) and health (La Monica et a l , 1987; Olson, 1995). Empathy and Patient Satisfaction and Compliance Patient satisfaction and compliance are instrumental aspects of facilitating patient health as patients who trust their physicians' advice and adhere to their treatment suggestions will most likely experience improved health (Squier, 1990). Vermeire, Hearnshaw, Van Royen and Denekens (2001) reviewed several studies on patient compliance and concluded from their findings that adherence to treatment is the crucial link between process and outcome in health care. Furthermore, patient dissatisfaction could lead to lengthier recovery periods and decreased understanding of important medical information (Fallowfield, 1992). Wasserman et al. (1984) examined clinician-patient interactions of 40 mothers on the postpartum floor of a university hospital. The visits were videotaped through a one-way mirror and coded for physician use of empathy. The measure used to assess empathy was the Resource Exchange Analysis, which classified empathy as an "expression of intellectual appreciation of a parent's situation" (p. 1049). The coders were blind to the other aspects of the study for objectivity and agreement between them was .69, p < .001. The mothers filled out a selfadministered, 17-item questionnaire on their satisfaction with their clinician visit, which was created based on items from Ware and Snyder's questionnaire (as cited in Wasserman et al.). The  20  reliabilities and validity of the satisfaction measure were not provided. The results indicated that higher levels of physician-empathy was correlated with higher satisfaction and reduced concerns (P < .05). Sullivan et al. (2000) interviewed 146 patients with HIV over a six month period. The patients in Sullivan et al.'s study were primarily male (n= 109), diverse in ethnicity, and had a mean age of 37. Patients were interviewed during their initial visit to one of two urban health clinics in the Northeast of America and followed up six months later for a second interview. The patients who completed both interviews (72% of original sample) had a higher proportion of high school graduates but they were not significantly different on any other demographic statistic from those who only completed the baseline interview. The interviews consisted of structured questions with a 4-point Likert-type response scale, which provided global assessments of their satisfaction with primary care. The internal reliability of the measure was .83. Sullivan et al. found that patient satisfaction was significantly correlated with their primary care physician's empathy (p =.001). Kim et al. (2004) investigated the relationship of physician empathy and patient satisfaction and compliance. The participants were 550 patients from a university hospital in Korea. They measured patient satisfaction and compliance as well as perceived cognitive and affective empathy through a five-point Likert-type scale, which had modified items from several previously developed measures including, "Barrett-Lennard's (1981) Relationship Inventory for perceived-physician empathy, Comstock Hooper, Goodwin, & Goodwin's (1982) Satisfaction Questionnaire for patient satisfaction, DiMatteo et al.'s (1993) General Adherence Scale for patient compliance, Roter, Hall, and Katz's (1987) satisfaction questionnaire for Cognitive Information Exchange and Partnership, and Anderson and Derick's (1990) Trust in Physician  21  Scale for Perception of physician expertise and interpersonal trust" (Kim et al., p. 241). The internal reliabilities of the scales ranged from .68 to .87 and comparative fit analysis revealed that the structural model of the scale was a good fit (.93, p < .001). Results of their study indicated that affective empathy played the most important role in increasing satisfaction and compliance (p = .05). Kim et al. concluded that physicians' empathic communication skills could be one of the most influential aspects of increasing patient satisfaction and compliance. Zachariae et al. (2003) researched the impact of physician communication style with patient satisfaction, self-efficacy and emotional distress. The participants in this study included 500 oncology outpatients and 31 doctors from a University Hospital in Denmark. The patients filled out one questionnaire prior to their consultation which evaluated their distress level through a Brief Mood Scale (BMS) and the Cancer Behavior Inventory (CBI). After their consultation, they filled out the BMS, CBI, and the Physician-Patient Relationship Inventory (PPRI) to assess the physician's attentiveness and empathy. The internal reliabilities were reported for all the measures at over .82, indicating high internal consistencies. Zachariae et al. found that empathy was significantly correlated with greater patient satisfaction, improved selfefficacy, and reduced emotional distress (p < .01). In summary, these studies reflect how physicians' use of empathy when working with patients has a positive impact on patient satisfaction and compliance. Empathy and Patient Health Outcomes The role of empathy in the nursing profession has been researched for over thirty years (Kristjansdottir, 1992). Several authors argue that empathy is a critically valuable concept in nursing practice as it facilitates understanding of a patient's condition, increases patient selfdisclosure, and caring for the patient's needs (Forsyth, 1979; Kristjansdottir; La Monica et al.,  22  1987; Olson, 1995; Norman, 1996; Wheeler, 1995; Williams, 1979). Norman provided case examples of how empathy could play a crucial role in improving the care of patients with dementia and proposed that empathy training should be included in nurses' mental health education. La Monica et al.'s (1987) study investigated the impact that nurse-empathy training among nurses had on their patient's psychological health outcomes (anxiety, hostility, depression, and satisfaction). The literature review discussed the goals of the nursing profession as well as the facilitating role of empathy in effective helping relationships. The authors concluded that empathy is an important component in fulfilling the goals of the nursing profession. The study's focus was not on collecting data from one-to-one health care relationships but rather measuring the impact of nurse empathy training across a group of patients in acute-care facilities. The participants in this study were selected from four similar units (two medical and two surgical) in a major urban cancer centre. There were 109 registered nurses, primarily female (95.4%), between the ages of 20 and 39. The patient inclusion and exclusion criteria were clearly stated such that clients who were too ill to participate as well as those with private 24-hour nurses were not included in the final sample of 656 patients. The experimental condition and the control condition both had one medical and one surgical unit determined by hierarchical random assignment. Due to the temporary nature of the acute-care facilities, patients used to establish the baseline for Phase 1 of the study (n = 340) were different from those used in the post-treatment Phase 3 (n = 316). However, according to relevant demographic characteristics, chi-square tests indicated that participants across all groups were found to be similar, with the exception of a  23  minor age difference and the control patients requiring less care. Within Phase 2, the nurses were further randomly assigned to experimental or control conditions so that four groups of nurses composed the final sample. There were no significant differences in demographic variables found between the groups of nurses. The procedure of La Monica et al.'s (1987) research included three phases across twelve weeks. During Phase 1, baseline data was collected for four weeks on the patients' anxiety, depression, hostility, and satisfaction of nursing care. Phase 2 involved empathy training in the experimental group of nurses and physical assessment training in the control group. The nurse empathy training program was a 14-16 hour multi-method teaching approach designed and facilitated by La Monica. The techniques were based primarily on Carkhuff's work (as cited in La Monica et al.) and a few other empathy researchers. Phase 3 consisted of recollecting data from nurse-selected patients regarding their anxiety, depression, hostility, and satisfaction of nursing care. To increase objectivity, the data was collected by four nurses who were kept blind to the assigned conditions of the patients. There were three measures used in the study to assess patient mood, nurse-empathy, and patient satisfaction. The Multiple Affect Adjective Check List (MAACL) was used to assess states of anxiety, depression, and hostility. The self-report and client-rating versions of the Empathy Construct Rating Scale (ECRS) were administered to patients in phase 2 to evaluate the nurses' use of empathic communication. Both the M A A C L and ECRS measures were reported to have high validity and reliability, although the psychometric properties of the measures were not provided. The LaMonica/Oberst Patient Satisfaction Scale (LOPSS) was used to investigate patient satisfaction with nursing care and reported a high internal reliability of .92 on  24  hospitalized patients. Four sets of t-tests were performed to compare pretreatment and posttreatment means across the control and experimental groups and within the two sets of groups. La Monica et al.'s (1987) findings confirmed equivalence of patient samples in Phase 1 and Phase 3 through group comparisons using t-tests and one-way ANOVAs. Results from M A A C L and LOPSS showed significant decreases of anxiety and hostility in the experimental group from the initial baseline levels to the post treatment levels (p < .005). Furthermore, strong effect sizes were found for anxiety (-5.00) and hostility (-8.75), supporting the clinical importance of these findings. There were no significant differences found for depression and satisfaction of nursing care, although the effect sizes indicated a decrease in depression (-2.56) and an increase in satisfaction scores (1.20). There were no significant findings between the control and experimental groups on ECRS scores, suggesting that empathy training did not increase client- or nurse-rated empathy. The authors provided an explanation for the lack of increase in satisfaction scores among patients, implying that patient scores may have been more reflective of overall life satisfaction rather than the specific health care they were experiencing (La Monica et al., 1987). Furthermore, they suggested that the lack of significant differences found in empathy rating scores may have been due to clients' desire to maintain a positive view of their nurses and protect themselves from negative retaliation. However, the results from this study support the use of empathy in providing health care can have a positive impact on patient's psychological health outcomes. Olson (1995) researched the relationships between nurse-expressed empathy and patient distress and patient-perceived empathy. She hypothesized that there would be a negative relationship between nurse-expressed empathy and patient distress as well as a negative  25  correlation between patient-perceived empathy and patient distress. Furthermore, Olson postulated that there would be a positive relationship between nurse-expressed empathy and patient-perceived empathy. The participants consisted of 70 Registered Nurses (67 women and 3 men) and 70 patients (36 women and 34 men) from the hospital. The mean ages for the nurse participants and the patients involved in the study were 33 years and 59 years, respectively. The measure used in the study to assess nurse-expressed empathy was the Behavior Test of Interpersonal Skills (BTIS). The internal reliability was r = .80 between the empathy categories "Feelings" and "Content." Intrarater reliability was .93 and inter-rater reliability was .90. Content, construct, and criterion validity was discussed but only a low-to-moderate correlation was provided for construct validity (r = .32 - .51). Patient-perceived empathy was measured with the Barrett-Lennard Relationship Inventory (BLRI), which indicated moderate-tohigh levels of reliability (r = .64 - .92) in previous studies and cited validation of the measure from other research. Patient distress was assessed through the Profile of Mood States Inventory (POMS), which was reported to have high reliability and validity, although its psychometric properties were not specified. The data was collected through nurses completing the written portion of the BTIS in a private room and then being observed interacting with a patient by the researcher who evaluated nurse-expressed empathy. Subsequently the patient filled out the BLRI and the POMS in the context of the recent nurse interaction. The results supported the hypotheses that nurse-expressed empathy and patient-perceived empathy would be negatively correlated with patient distress at significant levels less than .001 (Olson, 1995). Two of the three BTIS components (the nurse's acknowledgement of the patient's statements and the nurses limited use of "don't feel" expressions) were moderately correlated with patient-perceived empathy (r = .47 and r = .37,  26  respectively). Overall, patients whose nurses were rated as highly empathic and had higher scores on nurse-expressed empathy indicated lower levels of distress (anger, depression, anxiety). Other health professions, such as acupuncture and homeopathy, consider empathy to be a critical component of treatment and have also investigated the impact of empathy on patient enablement and health outcomes (MacPherson et al., 2003; Mercer et al., 2002). MacPherson et al. evaluated 143 acupuncture patients' perceptions of their acupuncturist's empathy and statistically analyzed their responses in comparison to measures of enablement (PEI) and wellbeing (GHHOS). Enablement was defined as "the effect of the clinical encounter on a patient's ability to cope with and understand his or her illness" (Howie, Heaney, Maxwell, & Walker, as cited in MacPherson et al., p.870). Their results revealed that perceived empathy was significantly correlated with patient enablement (Spearman's p = .256, p = .006). Furthermore, enablement was significantly associated with improved self-reported health outcomes (Spearman's p = .524, p < .0001). The authors acknowledged that the retrospective use of the scales in the study may have influenced the results and argued that their findings may have been stronger with a greater sample size and more immediate post-consultation evaluation. Moreover, Mercer et al. (2002) investigated physician empathy and its association to enablement of 200 homeopathic patients. The measure used to assess enablement was the Patient Enablement Instrument (PEI) and to assess well-being, they used the Glasgow Homeopathic Hospital Outcome Scale (GHHOS). The analyses of variance indicated that patient enablement and well-being were significantly correlated to the patient's perception of their physician's empathy (Spearman's p = .37, p < .001). Furthermore, empathy accounted for 66% of the variation in patient enablement.  27  Critique of Empathic Communication Research Conversely, Kristjansdottir (1992) claimed that the "most serious problem in empathy research is the lack of established construct validity" (p. 135). Similarly, Gladstein (1987) highlighted the lack of conceptual clarity in empathy research as well as the inherent difficulties in isolating what specific aspects of empathy contribute to positive client outcomes. He also argued that empathy may be facilitative in therapeutic change but definitive evidence has not been provided to support the claim that empathy leads to helping behaviors. Furthermore, Mead and Bower (2002) reviewed the literature on patient health outcomes associated to patientcentered approaches and concluded that the results were ambiguous. They found a lack of conceptual clarity across articles on what was considered patient-centered communication behaviours and a tendency for low internal validity in the studies. However, Mead and Bower discussed how patient satisfaction and other "process-referent measures", rather than patient health outcomes, may be more sensitive indicators of the impact of interpersonal communication (P-52). It is evident that some of the empathy and patient outcome studies have limitations. The studies on physician empathy and its association to patient satisfaction and compliance could have been improved through increased sample sizes of greater diversity, greater control and monitoring of external factors, and more extensive and psychometrically sound measures (Kim et al., 2004; Sullivan et al., 2000; Zachariae et al., 2003). La Monica et al. (1987) acknowledged limitations in their study, such as the influence that nurses selecting the clients may have had on the results as well as the heterogeneity of the nurses across experimental groups. Moreover, a lack of significant differences found between the control and experimental groups indicates that a confounding variable may have influenced the data (La Monica et al.).  28  Olson's (1995) study would have been improved with more diverse participants and clearly stated psychometric properties of the measures, based on the current samples. The enablement and empathy studies would have been stronger if evidence of psychometric properties of the measure were provided (MacPherson et al., 2003; Mercer et al., 2002). Additionally the correlations could be larger in some of the studies to indicate a stronger relationship between empathy and patient outcomes (Kim et a l , 2004; La Monica et al., 1987; MacPherson et al.; Mercer et al.; Olson; Sullivan et al., 2000; Zachariae et al., 2003). Furthermore, some researchers have not found strong correlations between physicians' empathy and patient outcomes of satisfaction (Comstock et al., 1982). However, empathy is not clearly defined in Comstock et al.'s study and their findings may be related to lack of theoretical and conceptual clarity of empathy. Stiles (as cited in Winefield et al., 1996) argued that when measuring the impact of helping relationship skills, a lack of statistical correlation between two variables in process outcome research does not always indicate that the there is no clinical relevance to the relationship; but rather, the way it is being measured may not capture the influence of the skilled helping interaction. There is also a concern in the medical field that developing a close connection with their patients may inhibit physicians' professional judgement (Lavasseur & Vance, 1993) and could contribute to physician burnout (Suchman & Matthews, 1988). Huggard (2003) proposed that medical students and physicians did not need to disengage emotionally from their patients to prevent burnout but rather develop skills in self-awareness. These skills would enable them to gain insight into their own empathic responses to patients' stories and improve their well-being as physicians. Wolf (1980) proposed that empathy does not need to hinder a physician's  29  scientific approach, but when used effectively, it could add to one's interpretation of the patient's inner world. Some have argued that physicians do not have time for empathy because the way the system of health care delivery is structured puts a strong emphasis on physician efficiency (Book, 1991; Dickinson, Huels, & Murphy, 1983). However, Bellet and Maloney (1991) argued that over the long-term, empathy would save money and time as it facilitates a more trusting and understanding relationship between the physician and patient which leads to more accurate and efficient diagnoses as well as greater acceptance of the doctor's advice. Furthermore, Wasserman et al. (1984) found in their research that only a few statements of empathy during a patient visit yielded a strong positive impact on patient satisfaction. Additionally, Higgins (1990) found in her study with medical students that practitioners could use empathic communication within the short time frame of a doctor-patient interview. Thus a small investment of a physician's time using empathic communication could generate more positive patient well-being (Wasserman et al.) Impact of Communication Training The progression of research has revealed the importance of physician interpersonal skills, and consequently, courses on medical communication have been incorporated into medical school programs (Aspergen, 1999). Aspergen concluded from his review of the literature that communication skills can be learned by medical students and physicians to improve the doctorpatient relationship. However, if physicians did not practice these skills, they were found to be easily forgotten. Markakis et al. (2000) proposed a residency training program, which included a communication skills component that focused on survival, negotiation, and counselling skills.  30  They discussed how this training in interviewing communication skills would impact the residents towards more humanistic and professional attitudes and behaviours. Smith et al. (1995) evaluated a psychosocial training program for family practice and internal medicine residents. The 26 participants were randomly assigned to the control or experimental conditions. The experimental condition participated in a four week training program focused on interviewing, somatization, patient education, and self-awareness and the control condition took the course at a later date. The program outcomes were based on patient assessments of the residents. The results indicated that patients of the trained residents were more satisfied with their medical visits (P = .02) and had more confidence in their residents (P = .01) as compared to the untrained residents. Oh et al. (2001) researched the short-term and long-term effects of intensive training in patient-centered interviewing (PCI) on residents' retention and utilization of the skills acquired. The residents' interviewing skills were evaluated before, immediately after, and two years after the training in PCI using the Rhode Island Hospital Resident Interview Checklist developed by Novack, Dube, and Goldstein (1992). The results indicated that residents significantly improved in many areas of the physician-patient interview and these skills were maintained throughout the two years following the training. A limitation of Oh et al.'s (2001) research was the lack of a comparison group to evaluate whether the skill improvement was due to the training or other areas of change in the residency program. However, a control group was used in analyzing self-reported questionnaires which surveyed the residents' use of PCI skills. Notably, the significant difference found between residents who had attended PCI training compared to those who had not was their improved ability to use reflective statements to summarize the patients' emotions. Oh et al. discussed how  31  the significant difference in relationship skills found on the survey may indicate that this area is not emphasized enough during traditional medical school training in interviewing patients. Jenkins and Fallowfield (2002) researched the impact that communication skills training had on physicians' beliefs and attitudes towards patients. They found that physicians who attended a 3-day workshop on communication skills reported significantly more positive attitudes towards addressing psychosocial issues compared to those who did not attend the course. Their results showed that doctors who received instruction, assessment, and feedback on their communication displayed significantly more empathic responses, appropriate responding to patient cues, and psychosocial probing during patient interviews, compared to the control group. Cegala and Broz (2002) performed a meta-analysis of 26 studies on physician communication skills training. From their analysis, they concluded that there is very little consistency in what is considered to be a communication skill among the various studies and very limited details are provided regarding what specific skills were taught. Furthermore, they found a lack of congruency between what skills were taught and how they were evaluated. Cegala and Broz recommended that researchers provide a theoretical framework to support which communication skills should be taught in physician-training programs as well as congruent assessment methods to evaluate the effectiveness of interventions. Learning Empathy Rogers (1951) believed that empathy was a way of perceiving that could be developed through courses, "as some of our staff have demonstrated in teaching beginning graduate courses" (p.437). Empathy has been considered a communication process that could develop as one matures and becomes more self-aware (Price & Archbold, 1997; Elizur & Rosenheim, 1982), through role-taking and long-term observation of physician-patient interactions (Larson &  32  Yao, 2005), and by the depth of one's own emotional experiences (Aring, 1958). Similarly, Hatcher (1994) concluded from her research with high school and college students that empathy can be acquired and improved through training if individuals have an intellectual readiness, specifically the capacity for introspection and abstract thought. Stephan and Finlay (1999) discovered how empathy can be learned through specific training programs and can improve intergroup relations. Barone et al. (2005) evaluated changes in empathy of 54 first year graduate students in clinical psychology. The 23 participants in the experimental group were involved in an interviewing skills training with feedback on their empathic accuracy of video-taped client encounters during a 15 week course. The control group was 31 participants who participated in the interviewing skills course, but did not receive feedback on their empathic inferences. Two trained research assistants (who were 90% in scoring agreement) evaluated the graduate students' empathic accuracy and were blind to the participants' group assignment. Results from Barone et al.'s (2005) t-tests revealed that the experimental group improved significantly greater in empathic accuracy of inferring feelings (a = .05) compared to the control group. However, no significant differences were found between the groups with regard to inferring thoughts. The authors concluded that receiving feedback about one's empathic judgements is important to the advancement of empathic understanding of another's emotions. Fine and Therrien's (1977) research demonstrated that medical students who received empathy training significantly improved their empathic responses from 1.95 to 5.25 (p < 0.001) in comparison to students who did not participate in the course. The control group remained at empathic responses below 2 on the empathy scale. Correspondingly, Winefield and Chur-Hansen (2000) found significant improvements in first year medical students' knowledge of empathy  from participation in communication skills educational workshops. Furthermore, Elizur and Rosenheim (1982) found that medical students' who participated in a group experience of how to respond emotionally to patients developed significantly more empathy during their psychiatric clerkship in comparison to students who did not participate in the group instruction (p = .05). Wilkes et al. (2002) found that the perspectives of medical students towards patients could be influenced by an overnight hospitalization experience. They were quite surprised by the lack of warmth that the physicians exuded and found the lack of information about their condition that they were provided with during their stay very stressful. Many of the students concluded that compassionate attentiveness to patients' needs and frequent communication about their condition is very important to their well being (Wilkes et al.). Shapiro et al. (2004) performed a quantitative and qualitative study on the effect of studying humanities literature on medical students' empathy. The participants were 22 first year medical students from Southern California and they were randomly assigned to the intervention group of reading and small group discussions twice a month or a wait-list for delayed commencement of the intervention. Quantitative results from the Empathy Construct Rating Scale (ECRS) did not indicate significant improvements in empathy but the Balanced Emotional Empathy Scale (BEES) revealed that students improved significantly (P< 0.01) after receiving the humanities literature course. Furthermore, qualitative reports indicated that the students' understanding of patient perspectives "became more detailed and complex post-intervention" (p.79), although their definitions of empathy remained similar. Shapiro et al. (2004) concluded that the course in humanities literature had more influence on improving the emotional aspects of empathy (as measured by BEES) and on particular subgroups of medical students, including, females, Asian students, and those interested in  34  primary care specialties. Limitations of this study included a small sample size (N = 16) and failing to report the reliabilities and validities of the measures used in the study. Similarly, Spiro (1992) claimed that empathy could be fostered through discussions about patient stories and their reactions to their medical experiences. He argued that empathy should be taught throughout medical school and residency training, in particular during the final two years to strengthen humanistic attitudes towards patients. Critique of Learning Empathy Research However, some have argued that the development of empathy can be a challenge as worldviews, values, and culture may interfere with one's accurate understanding of another person (Welch & Gonzalez, 1999). Furthermore, a client may have difficulty finding the accurate words to describe one's personal experience (Welch & Gonzalez, 1999) and a clinician may have difficulty putting one's feelings of empathy into words (Egan, 1998). Additionally, Kupfer, Drew, Curtis, and Rubinstein (1978) found that certain personality styles were significantly related to empathy usage and thus the development and expression of empathy may be hindered by traits within an individual. Bandura (1977) argued that the acquisition of a skill does not necessarily lead to utilization of this skill as this depends on one's belief in the ability to perform well. Similarly, researchers have found that a major influence on medical students' capacity for empathy was their attitudes (Streit-Forest, 1982; Haidet et al., 2002). Decline in Empathic Communication Despite the advancement of research and training to prepare medical students to interact effectively with patients, studies have revealed a detrimental decline in empathic communication among senior medical students and residents (Bellini et al., 2005; Griffith & Wilson, 2001; Haidet et al., 2002; Hojat et al., 2004; Newton et al., 2000). Lu (1995) discussed how the  35  difficulties of learning compassion as a third year medical student were associated with the competitive culture of medicine which took precedence over caring for patients. Lu argued that in order for third year medical students to develop compassion for their patients, the importance of understanding patients' suffering needs to be encouraged and "cultivated as part of the curriculum" (p.457). Haidet et al. (2002) researched the attitudes of first, third and fourth year medical students towards the doctor-patient relationship through administering the Patient-Practitioner Orientation Scale (PPOS). The PPOS is comprised of caring and sharing dimensions in the context of the doctor-patient relationship and higher PPOS scores indicate more egalitarian and patient-centered attitudes. Their findings revealed that PPOS scores were inversely correlated with the number of years in medical school, suggesting that students in the last half of their third year and their fourth year are displaying less patient-centered attitudes. The purpose of Hojat et al.'s (2004) study was to investigate changes in empathy of students as they progressed through their third year of medical school. The authors discussed the influential role of empathy in establishing doctor-patient relationships and positive patient outcomes. This research offered valid support of their rationale of performing a study to measure changes in empathy among medical students with a psychometrically sound scale. They provided a comprehensible definition of empathy, "a cognitive attribute that involves an understanding of the inner experiences and perspectives of the patient as a separate individual, combined with a capability to communicate this understanding to the patient" (p.935). Hojat et al.'s (2004) hypothesis was clearly stated in the introduction, to assess whether in the absence of specific educational programs, one's orientation toward empathy declines during medical school. The participants in this study were 125 medical students in their third  36  year of an American undergraduate program, including 64 men and 61 women. The mean age and ethnic composition of the sample were not provided. The sample was only 56 percent of the total class (n = 223), yet the authors confirmed that the participants in the study did not differ significantly in gender and age from the rest of the class. Hojat et al. (2004) included a detailed description of the measure used in this study, Jefferson Scale of Physician Empathy (JSPE), including how it was developed and its psychometric properties. The convergent validity was supported through comparing JSPE scores with measures of compassion (r = 0.48 for medical students) and empathic concern (r =0 .40), and perspective taking (r =0 .29). The authors claimed that these correlations were high enough to show a relationship but did not suggest significant overlap between the measures. However, it may have strengthened the validity of the measure if its correlation to perspective taking was stronger, since this was an integral aspect in how they defined empathy. Discriminant validity was supported by a low correlation with an unrelated measure, self-protection (r = 0.11). The test-retest reliability was 0.65, and the internal consistency showed a high reliability of 0.89. Notably, the validities and reliabilities provided were based on medical student JSPE scores but were not based on the actual sample used in this study. The procedures of this pretest/post-test design included administering the JSPE at the beginning of third year during a course orientation session and re-administering it at the final examination. The specific timing of when the post-test was administered could have been improved, as final exam anxiety may have impacted the students' responses. The mean for the total empathy scores showed a significant decline of 2.5 points (P < .05). The specific items that showed the greatest declines were in the area of compassionate care.  37  Hojat et al. (2004) concluded that empathy is subject to change in a negative direction during medical school. They discussed their findings in comparison with several other studies that found similar and differing results in regards to changes in empathy among medical students. The authors highlighted the positive impact of empathic medical students and how their results illustrated the need for continual educational programs to prevent the decline of empathy in the medical profession. The authors clearly recognized the limitations of using participants from only one medical school and generalizing self-reported empathy to the actual practice of empathy in medicine. Overall, Hojat et al.'s research contributes to the evaluation of empathy among medical students and provides excellent directions for future research in this area, such as investigating the factors that facilitate this change in empathy. Griffith and Wilson (2001) assessed the changes in medical students before and after their 3 year medicine-surgery clerkships. Their findings indicated that the students' attitudes towards rd  elderly patients and patients with chronic pain become significantly less positive after their clerkship experience. The authors discussed how medical students have less idealistic thoughts of these two aforementioned patient groups and may develop stereotypes of these patients. A limitation of this research was that they did not report test-retest reliabilities or internal consistencies for the measure used with the sample in this study. This information is crucial for interpreting the value of their findings. Newton et al. (2000) compared medical students' empathy, based on Mehrabian's Balanced Emotional Empathy Scale (BEES), across all four years through to investigate whether there is a significant decline in empathy during their education. The sample consisted of 148 first year students, 130 second year students, 139 third year students, and 131 fourth year students from the University of Arkansas Medical School. There were no significant differences found  38 between groups on sex or specialty choice. The results of the BEES indicated a significant decrease in empathy among men from third year to fourth year of medical school. Marcus (1999) summarized the progression of empathy in medical students in four main stages, based on the analysis of resident and student dreams. During first year of medical school, students report an understanding of empathy that is actually identification. Rather than understanding what the patients feel, students feel that they are the patients. During second year, students move into empathic disidentity in which they want to be helpful but they feel inadequate to know what patients want. During third and fourth year, similar to findings described Haidet et al. (2002) and Hojat et al. (2004), students move into counter-identification and rigid emotional boundaries in order to protect themselves emotionally from the distressing encounters with patients. According to Marcus' stages, it is not until the later years of residency that developing physicians are able to adapt to the individual needs of their patients and understand how they are feeling. However, declines in empathy have also been found among residents in their internship programs (Bellini et al., 2005). Bellini et al. evaluated empathy and mood of 61 internal medicine residents four times during their internship year at the University of Pennsylvania Hospital. The population was 60% male and 40% female. They measured empathic concern, perspective taking, and personal distress through the use of three subscales of the Interpersonal Reactivity Index (IRI). Mood was assessed through the Profile of Mood States (POMS). Both measures were reported as reliable and valid with reference to previous studies with the measures. Baseline subscale scores for the IRI and POMS at Time 1 were compared to scores at Time 4 through paired t-test analyses. Results from the IRI indicated a significant decrease in residents' empathic concern (p = .005) and an increase in personal distress (p < .001). There was  39  no significant difference in means on the perspective taking subscale. The POMS scores indicated an increase in depression-dejection (P = .002), fatigue-inertia (P < .001); and angerhostility (P < .001). The authors concluded that the experience of internship is very strenuous and affects residents' personal well-being and their ability to be empathic. Current Research Several authors have speculated at the contributing factors to this current lack of empathy found in the medical profession today. Larson and Yao (2005) proposed that empathy is threatened by demanding work settings that do not place emphasis on empathy. Glick (1993) and Frymoyer and Frymoyer (2002) discussed the influence of technological advances on the decline of humanistic qualities in the medical profession and argued that the process of medical education emphasized cognitive skills rather than learning compassion for human life. Wilkes et al. (2002) discussed how the medical curriculum is too focused on teaching skills of protocol and knowledge of diseases at the expense of focusing on the patient as a person. Markakis et al. (2000) and Marcus (1999) claimed that the socialization of residents in training and the role modeling of their physician trainers are very important to their humanistic development. Glick argued that the professors, who are role models for developing physicians, may not be appropriate guides to teaching human relations. Some students and residents experience unnecessary disrespect during the development years of their medical training, which may affect their subsequent treatment of patients (Silver & Glicken, 1990). Dickinson et al. (1983) argued that the training in residency does not promote the use of empathy as it may be viewed as a distracter from objectivity or too time-consuming. Similarly, Marcus (1999) claimed that the enduring challenges through one's medical education may hinder the development of empathy in medical students and residents.  40  Several questions arise from the review of the literature which warrant future investigation. Hojat et al. (2004) supported further research in identifying the factors that influence the decrease in empathy among senior medical students. Additionally, researchers have recommended analyzing the dynamics of medical education that affect "student attitudes toward patient-centred care" (Haidet et al., 2002, p.568) as well as examine residents' mood changes and their impact on empathy development (Bellini et al., 2005). However, it appears that the primary question that needs to be addressed is how developing physicians conceptualize and experience empathy in the medical context. Further research of empathy in the medical profession is greatly supported by the literature. Bellet and Maloney (1991) stated that teaching residents and medical students empathy should be one of the highest priorities in medical education because "it is a costeffective method to early diagnosis and proper treatment" (p. 1832). Frymoyer and Frymoyer (2002) concurred with this statement in proposing that effective doctor-patient communication adds to the cost-effectiveness of patient care. Additionally, Hojat, Gonella, Nasca, et al. (2002) emphasized the benefits that empathy has on patient care and stated that research on empathy "deserves attention because this essential humanistic aspect of medicine eludes the performance measures that are commonly used in medical education" (p. 1568). The importance of good empathic communication skills is of particular concern in family medicine as "they are primary health care providers in comparison to other more technologically-oriented specialties in which physicians are secondary health care providers" (Hojat et al., 2003, p.46). This claim is supported by other authors and physicians who discussed the vital role of good communication skills in primary care disciplines (Beck et al., 2002;  Stewart, 1984). Therefore, this research investigated how family practice residents' conceptualize and experience empathy in the medical context.  42  Chapter III Method Approach Qualitative research methodology was selected for this study because its style of in-depth investigation is appropriate for obtaining an understanding of how family practice residents conceptualize empathy and what factors are involved in facilitating and hindering its development and utilization in the medical context. Qualitative research has been described as "multimethod in focus, involving an interpretive, naturalistic approach to its subject matter" and data collection is used to "describe routine and problematic moments and meaning in individuals' lives (Denzin & Lincoln, 1994, p.2). Merriam (2002) discussed four major characteristics of qualitative research which include, a focus on understanding the meaning participants have created about their experiences; the researcher is the major instrument of data collection and analysis; the process is inductive; and the purpose is to produce rich descriptions of experiences under study (Polkinghorne, 2002). Morgan (1998a) discussed how qualitative methods excel at providing an "understanding of why things are the way they are and how they got to be that way" (p. 12). A crucial aspect of this study is the unique perspectives of the participants as it is their experiences of learning, observing, and using empathy in the medical field that would contribute further understanding to the literature in this area. Therefore, qualitative methodology was the most suitable approach for exploring these research objectives. Focus Groups The method of qualitative research used to gather data in this study was through structured focus group interviews. A focus group has been defined as a "carefully planned series  43  of discussions designed to obtain perceptions on a defined area of interest in a permissive, nonthreatening environment" (Krueger & Casey, 2000, p.5). Kitzinger and Barbour (1999) described focus groups as "group discussions exploring a specific set of issues" (p.4). Kruger and Casey reported the evolution of focus groups, beginning in the 1940's when social scientists desired to use a nondirective technique to interview people in groups. In the 1950's, focus groups were used by market researchers who wanted to get people's opinions about products in an efficient and inexpensive fashion. Academic disciplines began to use focus group interviewing for research in the 1980's. Focus groups are a qualitative approach to collecting information that is both naturalistic and inductive (Krueger & Casey, 2000). They are useful in exploring participants' experiences, concerns and attitudes as well as understanding these perspectives in a social context (Kitzinger & Barbour, 1999; Kitzinger, 1995). Focus groups provide insight into a range of experiences and viewpoints and they use group interaction as a part of the research method (Kitzinger, 1995; Krueger & Casey, 2000; Morgan, 1998a). This method was particularly useful for this study as the interaction among participants generated more extensive descriptions of their opinions and experiences of empathy from their medical training. Furthermore, interviewing participants in focus groups offered insight into how participants arrived at their conclusions, and "highlighted (sub)cultural values" that exist in the group (Kitzinger, 1995, p.300). Specific to the goals of this research study, focus groups are facilitative of identifying potential problems in a learning environment as well as ways of improving educational programs (Krueger & Casey). Furthermore, the focus group format conveys the researcher's willingness to listen respectively and learn from the participants.  44  Participants The participants were eight first year family practice residents (five females and three males) from a medical training program in Western Canada. The participants were primarily Caucasian, but also included some ethnic diversity. The sample ranged from 24 to 37 years and had a mean age of 29.4 years. The inclusion criteria were: 1. voluntary participation 2. enrolled in first year of the Family Practice Residency program 3. able and willing to conduct interviews in English 4. able and willing to provide informed consent 5. able and willing to participate in audio taping of focus group interview The exclusion criteria excluded participants who did not meet the inclusion criteria listed above or who were not able to clearly describe their conceptualizations or experiences of empathy in the medical field. Procedure The research was conducted and analyzed by a graduate student in the U B C Counselling Psychology Master's program, under the supervision of Dr. Marvin Westwood. The researcher's academic background was in Psychology. The researcher presented her study to the residents during their Behavioural Medicine Program class and circulated a hand-out outlining the details of the study (See Appendix A). Participants enrolled in the study through contacting the researcher in person or by email. When the researcher was contacted, participants were informed about the commitment involved in participating in the study as well as further details describing the research objectives. The researcher also reviewed the consent form (See Appendix B) with participants at the initial  45  meeting. The researcher arranged a time and meeting place for the two focus groups to occur, which suited the schedules of the interested participants. Interviews with the family practice residents were conducted in private rooms at their program location in the Lower Mainland of British Columbia. The researcher conducted the first focus group interview for approximately seventy minutes with three participants from the same Family Practice Residency Program, as homogeneity is argued to be an important aspect of successful focus groups (Kitzinger, 1995; Morgan, 1998b; Morrison, 1998). The second focus group interview consisted of five participants from the same Family Practice Residency Program and involved approximately 90 minutes of discussion. The interviews began by establishing rapport with the participants and clarifying the residents' expectations, and concerns regarding the study. The researcher also reviewed the consent form and emphasized the participants' rights to withdraw from the study at any point throughout the research process. The researcher reviewed the steps that would be taken in order to maintain their confidentiality as well as the limits of confidentiality and answered any questions that the residents had. Following the introduction, the focus group consisted of ten main interview questions, which were designed to understand their conceptualization and experience of empathy in the medical context (See Appendix C). The initial questions inquired about the residents' conceptualization of empathy and consisted of: "What is your understanding of using empathy when working with patients? Describe to me what it would look like for a resident or physician to use empathy with a patient?" The subsequent questions elicited the residents' perspectives on the function of empathy in the medical context. These questions included: "What do you think the role of empathy is in the doctor-patient relationship? What do you see as the possible benefits  46  of learning/using empathy with your patients? What led you to value empathy?" The following questions investigated the residents' experiences and development of empathy, such as: "Have you ever experienced an empathic response toward something you said? What impact did it have on you? Have you ever spoken to someone when you "needed" an empathic response and didn't get it? What influenced your development of empathy? What has challenged your development of empathy during your medical education?" At the end of the interview, residents completed an optional anonymous demographic questionnaire which asked about their age, gender, first language, culture/ethnicity, religion, country of origin, previous education, and previous work experience in order to describe the characteristics of the participants in the study (see Appendix D). The focus group interviews were tape recorded and transcribed by the researcher in order to perform further in-depth analysis. Following the interviews, the researcher contacted the residents by email to verify the accuracy of their statements. They were also asked to assess whether the examples and theme categories accurately represented their contributions. Analysis of Data In order to ensure a rigorous analysis of the data, the researcher followed a systematic and sequential process of reviewing the transcripts (Krueger, 1998). Analysis of the data began during data collection as the researcher observed body language and tones of voice during the focus groups (Krueger). The interviews were transcribed and reviewed as a whole to gain a sense of the possible themes. The researcher recorded analytical insights throughout the transcription and analysis process (Patton, 2002). The researcher conducted content analysis to identify core meanings and categories observed in the data (Patton, 2002). This process initially involved open coding, a process of  47  inductive analysis, which Strauss (1987) outlines with four basic guidelines. These include: "ask the data a specific and consistent set of questions, analyze the data minutely, frequently interrupt the coding to write a theoretical note, and never assume the analytic relevance of any traditional variable such as age, sex, social class, and so forth until the data show it to be relevant" (p.30). Pearson (as cited in Berg, 1995) discussed the importance of keeping the initial aim of the research in mind while remaining open to new themes that may emerge from the data. Therefore, when a theme or idea was uncovered in the transcript, it was coded in the margin of the page with a label (Krueger, 1998). ,  Subsequently, the researcher performed axial coding in which intensive coding in one  category occurs (Strauss, 1987). The major theme categories were analyzed further to verify where sub-categories were necessary to accurately group the data together. Berg (1995) suggested that a minimum of three examples should be provided to support assertions made in the analysis. Once the major themes and sub-categories were established, examples that were deviant from the existing themes were carefully examined and considered (Patton, 2002). Validation Methods In order to ensure that the researcher was conducting the interviews in a rigorous manner, the method of conducting focus groups interviews was systematically reviewed with a focus group expert. The descriptive and interpretive validity of the examples supporting the categories and themes was assessed through cross-checking them with the participants in a follow-up email. The participants were asked if the content and categorization of their contributions accurately represented their thoughts and feelings (Krueger, 1998). Changes to the categories, the wording of the themes, and the creation of new themes took place throughout the analysis process.  48 The validity of the categories and themes was verified through two trained coders who independently categorized select portions of the data (approximately 25 percent of the examples). The coders did not have access to the raw data but were given examples from each theme on index cards and were asked to classify them into existing themes. Furthermore, tentative themes were presented to two experts associated with medicine to further validate the category selections. Their insights and contributions were taken into consideration in the categorization process. Finally, theoretical validity was evaluated through reviewing the relevant literature to assess its support of the categories and themes formed by the researcher. Confidentiality Carlene Van Tongeren, graduate student in the Counselling Psychology Masters program and her supervisor, Dr. Marvin Westwood, U B C Counselling Professor were the only people who had access to the raw data. No persons other than Mrs. Van Tongeren and Dr. Westwood had access to data that identifies the participants. Each participant's consent form was assigned a code number that was the only means of identification of the residents in this research study. These forms were kept in a locked filing cabinet to protect the confidentiality of the participants. During the analysis part of the study, the confidentiality of the participants was protected through providing anonymous examples from the transcript to coders and experts who assisted with this study. Further efforts to maintain confidentiality were made through omitting any identifying information about the residents or third parties involved in the examples provided. The wording of contributions was verified with participants to ensure that their anonymity was protected. Furthermore, the transcribed data, audiotapes, and computer disks will be stored in a locked filing cabinet for five years after publication. After five years has passed, the computer disks will  be erased, the audiotapes will be erased through demagnetization, and the transcripts will be shredded.  50 Chapter IV Results There were 14 themes identified from the focus group interviews, which are presented in Table 1 under the following main categories: "The Characteristics of Empathy in the Medical Context", "The Value of Empathy in the Medical Context", "The Facilitating Factors in the Development of Empathy", "The Hindering Factors in the Development of Empathy", and "The Challenging Factors in the Use of Empathy". The themes centred on how family practice residents understand and experience empathy in the medical context. The number of responses generated for each theme are presented in Table 1. Table 1: Themes and Number of Responses  The Characteristics of Empathy i n the Medical Context T h e m e 1:  Supportive/ Caring Language and Giving Time Responses: 17 T h e m e 2:  Understanding/ Perspective Taking Responses: 17  The Value of E m p a t h y i n the Medical Context  T h e m e 3:  Increased Patient Trust and Disclosure Responses: 9 T h e m e 4:  Increased Patient Compliance, Satisfaction and Healing Responses: 12  The Facilitating  The Hindering  Factors i n the  Factors i n the  Development of  Development of  Empathy  Empathy  T h e m e 5:  Didactic Medical Training and Positive Role Modeling Responses: 12  The Challenging Factors i n the U s e of E m p a t h y  T h e m e 9:  Theme 11:  Negative Role Models  Pressure of Time and Lack of Energy  Responses: 11  Responses: 15  T h e m e 6:  Exposure to Patients' Experiences and Recognizing the Privilege of the Medical Role  Theme 10:  Theme 12:  Criticism from Supervisors  Repetitive Exposure to Illness  Responses: 7  Responses: 7  Responses: 10 T h e m e 7:  Theme 13:  Personal Experience and Experiencing Empathy  Patient Characteristics and Expectations  Responses: 11  Responses: 13  Theme 8:  The Increased Appreciation for Empathy Responses: 8  T h e m e 14:  Uncertainty/ Hesitancy about the use of Empathy Responses: 7  51  /. The Characteristics of Empathy in the Medical Context The themes in this category, "Supportive/Caring Language and Giving Time" and "Understanding/Perspective Taking" emerged from the questions "describe to me what it would look like for a resident or physician to use empathy with a patient" and "from what you've learned, how would you define empathy in the medical context" as well as from further focus group discussions. There were 34 statements in total pertaining to this general heading. Theme 1. Supportive/Caring Language and Giving Time The participants identified empathy as doctors and residents communicating support and/or care to their patients. This involved verbal and nonverbal communication, including empathic phrases, facial expressions, and actions. They also regarded empathy as involving an aspect of residents and doctors giving time to their patients. It appeared that time was a valuable resource in the medical field and thus offering patients their time conveyed towards patients. There were 17 responses supporting this theme and selected examples are included below. Some of the participants described empathy as a general approach to a patient, that "it's more just, caring for a patient, giving them human respect", while others indicated specific aspects of empathy and claimed that "a huge component of it is listening and making the person feel like you care about their story and you want to hear what's going on for them." Additionally, the participants reported physical actions that conveyed empathy to patients, as illustrated in the example below: I've seen some palliative care docs and how they handle talking about family and how they get them in a secluded room and have the chairs facing each other to make sure they're comfortable, and they have tissues around and talk really softly and sometimes putting their hand on their hand or shoulder or something. I think they're very good at it.  Another prominent aspect of empathy that was referred to was residents or physicians offering their time to patients. One particular statement, which recounted a family practice doctor who was delivering bad news to a patient captured the importance of time in the expression of empathy. The participant expressed that "she was very empathetic, she gave him time...." Furthermore, other participants described situations in which they observed or experienced expressed empathy, which at its essence was the medical professional giving of one's time. Just watching the internist who you wouldn't expect to give that kind of time, because, I mean, time is money to them, but having his pager going off every two minutes, but just ignoring it and just sort of talking to the patient... Another participant recalled her experience with a preceptor who responded empathically to her situation, which involved offering his time to her. He was unbelievably perfect for me in that situation, he just sort of like, ushered me to the side and spent, I mean he has a very busy practice and he probably meant to come in and out and be like gone in 5 minutes because that's all he had time for, but he spent like, a full half hour, just sort of talking it out with me, sharing experiences that he had. Theme 2. Understanding/Perspective-Taking The participants discussed perspective-taking and efforts to understand patients as important qualities of empathy in the medical context. In the statements, it appeared that attempting to relate to and comprehend patients contributed to physicians and residents conveying respect for the humanity of their patients. There were 17 responses supporting this theme and selected examples are included below. Participants discussed how empathy involved trying to comprehend patients' experiences, such as:  53 .. .just showing them that you have a sense of what, not necessarily that you know exactly what they're going through, but that you understand what they're telling you and what it means to them. And, you know, you can imagine what it might be like for them. The participants reported the value in attempting to understand patients as one participant commented that "making that effort to understand where they're coming from... that goes a long way. And respect is huge too." The participants also discussed the aspect of empathy that involved perspective-taking. One participant described this process as "sometimes trying to step back and kind of see it, you know, from an outside perspective, and just watch the situation unfold before you" while others spoke about "putting yourself in their shoes, imagining what their life has been like and what's led them to be a drug addict.. .trying to understand that instead of just being angry with them for being a drug addict and causing their own illness." One participant commented that "the patient's perspective can be entirely different" and through the process of perspective-taking, "you gain more insight." Furthermore, one participant described the perspective-taking aspect of empathy in the medical setting as: .. .just remembering who we see on surgical rotations is like one little moment in time, it's just one moment of their life right? And they're a person with a history with, you know, lots of stories about who they are and we're just a seeing a little cross-section of that. And depending what you're doing, like if you're doing surgery or when you're focusing on one aspect of that person or their illness or whatever, part of using empathy is to remember that they're more than that.  54  II. The Value of Empathy in the Medical Context The themes in this category "Increased Patient Trust and Disclosure" and "Increased Patient Compliance, Satisfaction, and Healing" emerged from questions such as, "what do you think the role of empathy is in the doctor-patient relationship?" and "what do you see as the possible benefits of learning/using empathy with your patients?." There were 21 statements in total pertaining to this general heading. The examples in these themes illustrate the impact of empathy in the doctor-patient relationship and patient healing. Empathy contributes to increased patient trust, disclosure, and compliance which impact physicians' ability to accurately diagnose and treat patients effectively. These aspects of the doctor-patient relationship contribute both directly and indirectly to increased patient satisfaction and healing, which then reinforce the patient's trust. This pattern is illustrated in Figure 1.  55 Figure 1: The impact of empathy in the doctor-patient relationship.  V Increased Patient Trust  I  Increased Patient Disclosure of Information  Increased Patient Compliance  I  Increased Patient Satisfaction  I Increased Patient Healing  >>  Theme 3: Increased Patient Trust and Disclosure The participants discussed how empathy could be valuable in improving communication between doctors and patients. Specifically, the participants reported observing a connection between physician empathy and increased patient trust as well as an increase in patient disclosure of important information. Patient disclosure of information is relevant to the history-taking process that physicians conduct during their doctor-patient interviews, which provides the groundwork for making a medical diagnosis. There were nine statements supporting this theme, with selected examples included below. Participants reported that empathy "engenders trust" and that "if the patient feels empathy... they're more likely to share important information than if they don't. Patients will  56 shut down if they don't feel, like, the right feeling coming from their health care provider." One participant described the connection between patient trust and increased disclosure: If they feel like they can trust you and can confide in you, you're actually going to get the whole story. You're going to get the teenage girl who says "yeah, actually, I am having sex", sort of thing. Rather than, "I've got this abdominal pain and no, I'm not sexually active", when it could be a vital thing, right? If you've been a physician whose consistently proven yourself to be trustworthy and understanding, you know, not only are they going to reveal more information but if you say this is what I think needs to be done, they're way more willing to buy into that plan if... Furthermore, participants reported the facilitative aspect that empathy can have on one's medical practice because "it lets you get a better history, it lets you get the information and then it's actually the treatment too." Additionally, one participant commented that "it's always going to be beneficial, you're always going to get more information from the patient if they trust you more and make the right diagnosis." Theme 4: Increased Patient Compliance, Satisfaction, and Healing The participants discussed the role of empathy in improving patient compliance, satisfaction, and healing. Patient compliance included adhering to physician instructions related to their health care and actively participating in their treatment. The participants described examples of patients' opinions and feedback that they have witnessed which allude to the function of empathy in generating patient satisfaction in the medical system. The participants also discussed the aspects of medicine that they have experienced in which the use of empathic communication could have a positive impact on patient health. There were 12 statements supporting this theme, with selected examples included below.  57  Participants reported how empathy "has huge impact on whether your patient's going to follow your instructions. I mean, you can write them a prescription for that, you know, antidepressant, but if they think you're a jerk and that you don't know where they're coming from, then they're just going to toss the prescription and go, 'well, that wasn't helpful'." Furthermore, the participants alluded to the role of empathy in eliciting patients to take an active approach to their health care and emphasized the importance of this because "there's a lot of things that we can't treat unless a patient is engaged with that and is a willing participant in their care." Participants discussed the value of empathy in contributing to patient satisfaction and reported that: Definitely in family medicine, it's essential. Patients will leave if they don't feel like they have a good, you know, maybe not now because of the state because you can't leave to go anywhere else, because there's not enough family doctors. But I think in an ideal world, they would leave to go look for somewhere else. Furthermore, the participants reported how empathy may be at the core of the doctor-patient relationship and described how lack of empathy could result in patient dissatisfaction. They say lack of communication is kind of the number one thing, you know, but you could probably say the same thing for empathy right? It's lack of empathy towards patients that probably creates all that hostility towards you and the system and everything else right? Participants also discussed using empathy with patients as a preventative measure to patient satisfaction in the face of physician error or misjudgement.  58 They might not even think that you did the right thing or that you did a good job where someone else could not even do as good a job but show, you know, a little bit, show a little more feeling toward that person, and they'll say 'oh, I was in here and I had the most wonderful doctor, he fixed this and that'. The participants communicated how empathy played a role in patient healing and reported that "a lot of times, listening to them can cure their physical ailments. You know they say, 'oh, I feel better now', while I didn't do anything!" They also claimed that "even if you can't come up with a definitive answer of how to solve their problem, just talking to them gives them reassurance and that's often therapeutic enough." The impact of not using empathic communication with patients in the medical setting was captured by one participant's comment: Well, even just them talking about it, they could feel better as oppose to not acknowledging it, they go home, and they still have this pain and they go back to Emergency and it becomes a vicious cycle, costs the whole system then. ///. The Facilitating Factors in the Development of Empathy The themes in this category, "Didactic Medical Training and Positive Role Modeling", "Exposure to Patients' Experiences and Recognizing the Privilege of the Medical Role", "Personal Experience and Experiencing Empathy", and "The Increased Appreciation for Empathy" emerged from questions such as, "what influenced your development of empathy?", "has your understanding of empathy changed over time" and "if so, how has your understanding of empathy changed?." This general heading was the second largest category with 41 statements supporting these themes.  59 Theme 5: Didactic Medical Training and Positive Role Modeling The participants discussed their experiences associated with their didactic medical training that facilitated their development of empathy. This theme encompassed medical training experiences that were part of the academic curriculum of medical school, specifically teaching sessions. Additionally, the positive role modeling of empathy was another facilitative component in their development of empathy, which included a broad spectrum of people, such as, parents, physicians, residents, and colleagues. There were 12 statements supporting this theme, with selected examples included below. Participants reported that their didactic medical training provided them with opportunities to learn empathic communication skills. The participants stated that they "learn all the tools in med school on how to be empathetic, you know, all the catch phrases on how to be empathetic." Participants discussed the change in medical school training towards more patient-centred care and how this differs from their preceptors' experiences of medical school. I just think we're from a very different school of training than our preceptors are now. It's only in the last decade or maybe decade in a half that they've really done this whole, patient-centered sort of medicine. And so, I don't like, I don't want to say that I won't be that way, but I think it's just the way we've been taught through medical school and that whole school of thought. In this patient-centred approach to medicine, establishing rapport and communicating effectively with patients was emphasized throughout their medical training. We got a lot of communication skills, and yeah, clinical skills teaching. And a lot of that was appropriate draping patients, like give them time, never watch them change, and they  60 have very strict rules, well not rules, but guidelines and they even test you on them on OSCI exams. Participants reflected on the importance of empathic communication skills training and acknowledged its importance in medical school. I think it's good that it's emphasized in medical school. I haven't found that it's emphasized as much in residency but that it's emphasized in our training...sometimes it becomes routine for us and so by establishing those skills of empathy earlier on in our careers, hopefully, they're engrained in us now so that we don't get to the point where we're coming across to the patient that this is just routine to us, that, you know, although, again, like we might be focused on it, like I need to go and I need to express empathy but it's just part of how we practice medicine because we learned it so early in our training. Positive role modeling from a variety of sources was another influential aspect in the participants' development of empathy. One participant discussed the impact of his father's approach to medicine. Because my dad was a cardiologist in "blank" and same thing, I mean, having seen his patients walk up to him in the middle of the mall or something, just totally out of the blue, and just thank him for the way they were treated, regardless of what he actually did. You know, it was just him as a person that they were really warming up to and it's not necessarily the actual physical treatment. I mean it's pretty obvious that it was something in his personality, it had to be empathy or something along those lines to have really developed those relationships and I think that's what sort of struck a cord with me. Moreover, participants reported the positive role modeling from the physicians they observed during their medical training. For example, one participant stated, "I've seen doctors do it well  61  and I've seen doctors do it poorly and I try and emulate those who I think do it well. And when I see doctors doing it poorly, I really recognize it and try not to do that."  Theme 6: Exposure to Patients' Experiences and Recognizing the Privilege of the Medical Role The participants discussed the positive impact that being exposed to patients' experiences had on their development of empathy. The facilitative component that appeared throughout the participants' examples was the insight they gained into patients' lives beyond their physical illnesses. The participants also reported that being exposed to patients' experiences led to their realization of the privilege involved in their medical role. The aspects of the medical profession that were considered a privilege included, sharing in personal, valuable difficult and sensitive times of people's lives. This realization further influenced their development of empathy for patients. There were ten statements supporting this theme, with selected examples included below. Participants reflected upon their experiences with patients and concluded that: Just seeing patients...seeing how desperate people's lives actually are. I think in the hospital you see people at their lowest points and I think, yeah, just seeing that day after day, makes you go, wow, my life's good and it could be a lot worse. I think it just facilitates empathy... Participants also discussed how being exposed to patients' experiences contributed to a greater understanding of different people and leads to: ...personalizing experiences you haven't had before. Introducing you to people that are, people you definitely haven't been exposed to in your life before but actually being able to sit down and talk with them and relate to them on any level, maybe in the future will then make it easier for you to be empathic towards them. Another participant commented on her experience of getting to know patients at Chius:  62  Compared to the experiences you get with that particular population in the hospital or even when they are at a bonified medical visit for instance, you know where you have a bit of a timeline and you have to get something out of them. At least this way you get to talk and find out about what their life is like. You don't get that same kind of opportunity when you're in a medical, a real medical, or more medical experience. Furthermore, participants reported how recognizing the privilege of their medical role facilitated their development of empathy when working with patients. One participant reflected on his encounters with patients and expressed, "I still feel kind of privileged a lot of the time that I'm the person asking these questions or doing this thing, you know" and another participant concurred and said, "I think also being privileged enough to be involved in somebody at their lowest point in their life. And they're actually looking to you for help."  Theme 7: Personal Experience and Experiencing Empathy The participants described personal experience as another facilitative aspect of developing empathy. Personal experience included one's background, upbringing, previous employment, and life experiences. Some of the participants begged the question of whether empathy was something that could actually be learned as one's background and experience may have a more influential role in developing empathy. Furthermore, the participants discussed how their own personal experience of receiving empathy from a preceptor or supervisor played a facilitative role in their development of empathy. Although this theme shares similarities with the positive role modeling theme, it was distinguished for the purpose of highlighting the impact that personally experiencing empathy may have on the development of empathy in comparison to observing a patient or colleague receive an empathic response. There were 11 statements supporting this theme, with selected examples included below.  63  One participant asked, "doesn't empathy more come from, well not even necessarily something you're taught but something from your experiences?" and added that "having been through certain things in your life, you're more likely to have an appreciation for what that is when other people go through it, you know." The participants discussed further the influential role of personal experience in facilitating their development of empathy through reflecting upon personal growth they had experienced over the years. Your experiences can probably increase your empathy and I think that's true because when I think back to what I was like, you know, ten, fifteen years ago, having had fewer experiences in my life and, sort of, more on the whole good experiences in life, I don't think I was as empathic as I have maybe become, having had, you know, more exposure to a bit of hardship. You know, as easy as my life has actually been, but just having a little bit of, you know, seeing what it was like for myself to go through some tough days, or months, and just not being able to imagine if that had gone on for longer or if it were worse than it was. So, that is, you know, I always think of that every time I see somebody who's going through a really hard time, that empathy skills are really important. Participants included experiencing personally the medical system as a patient contributing to a greater understanding of what patients go through and could facilitate the development of empathy. I find it helps with empathy too when you actually use the system. Most people who are in medicine are pretty healthy and they don't have too many problems.. .but when you actually have to use the system and you experience the frustration and how impersonal it can be and how.. .then I think it really alters how you relate to those people...So you kind of feel, like when they're there, 'oh, there's so many sick people everywhere.' When you  64 think, 'what if I was lying in a stretcher in a hallway for three days without a room, you know, kind of being ignored, and saying, hey hey, hey, can you get me some water?' and everyone's walking past me, ignoring the fact that I'm calling, "can I get some help here? I need someone to take me to the bathroom." You know, we get use to that, and you think it would just be so horrendous and humiliating to be in that situation!...when you're on the other side of it, it's a totally different experience. Moreover, the participants discussed how personally experiencing an empathic response impacted their development of empathy during their medical school training. Participants described situations in which their preceptors expressed empathy to them during challenging situations with patients. I walked out of the room and I was really teary and my preceptor actually gave me a hug and the nurse was like, 'you know what, don't ever lose the fact that you care about your patients and that you're a human. It's good that you understand what they're going through'. And that was just really validating for me because at first I was like T shouldn't be.. .this is their sorrow, and I shouldn't be the one crying, I need to be strong for them, this is their sorrow, not mine'. And it was just really validating to be like, 'but you know what, you care and that's okay to care'. And so, in a way, like, maybe my tears were empathy for them, yet my colleagues, being the physician and the nurse, were empathic to me and just understanding that, yeah, 'this is the first time you've been through it and it is hard'. And then the next morning, my preceptor again was like, 'do you need to debrief, like how are you doing?' Another participant recalled her experience of empathy from a family physician:  65  The director of the ward, who happened to be coming in, happened to be this patient's family doctor as well, thank god, arrived. And he was unbelievably perfect for me in that situation, he just sort of like, ushered me to the side and spent.. .a full half hour, just sort of talking it out with me, sharing experiences that he had. But also, not downplaying it, but just sort of making me understand that this is going to happen all the time and he totally recognized that this person was obviously going to be really tough but to realize that this was part of what I was going to be experiencing lots of. And by, I don't know, he just, he didn't trivialize it, and I don't mean to use that word at all but he just sort of, put it in perspective a little bit. He was very helpful.  Theme 8: The Increased Appreciation for Empathy The participants' contributions illustrated that their intellectual understanding of the concept of empathy had not drastically changed throughout their medical education but rather the value they placed on the importance of empathy in the medical profession increased. They began to value the facilitative role of empathy in their medical profession. The increase in one's appreciation for empathy could also contribute to the development and use of empathy. There were eight statements supporting this theme, with selected examples included below. One participant claimed that his "definition of empathy hasn't changed, it's just how much I appreciated it more, like, how much more important it is in our profession, just yeah. The importance of it has changed, not the definition of it." Another participant commented that "I think that I've changed a little bit. Just in maybe in the respect that I've become more, a little bit more aware of, 'am I doing it the way I'd like to be doing it?'." Furthermore, the participants described the transition of their increased appreciation for empathy in the medical field. One participant recalled his reaction to teachings on empathy during the early years of his medical  66  school training, "this is so unimportant, why don't they teach us medicine? Like I can know how to be nice to people, like I'm nice to my friends and family already, right, like, that seems easy enough." Other participants concurred with each other in the frustration they initially experienced during empathy training in comparison to the appreciation they acquired for it in their later years of medical training. A: I felt like when I started medicine, I hated the whole, these lectures we had on empathy.. .1 thought it was so frustrating sitting here, you know, having a two hour lecture on this. So, yeah, because, you know, there was all this sort of, horrible, painfully long talks on... B: You just wanted to learn about the heart! A: But now I'm starting to realize that you do have to kind of, it is actually kind of a useful kind of skill, a useful tool, and it doesn't take that much effort. And you get way more information, and now I just think, 'that was awesome, cause I walked in there and the person wanted to complain about this and I really found out that that's not even the problem, it was this other thing', and you feel really good, you feel like you're really efficient with your time and you really found out what was going on with that person.. .because so many times, you can't really do anything very useful for most problems that come to you, so you kind of feel like, yeah, you know, actually, that person felt like I heard what they were saying, and kind of cared about their situation, and you think that's probably the most useful thing for them, right.  IV. The Hindering Factors in the Development of Empathy The themes in this category, "Negative role Models" and "Criticism from Supervisors" arose from the question, "what has challenged your development of empathy during your  67  medical education" as well as from further discussions in the focus group. The participants referred to experiences they had experienced or witnessed in the medical field that were hindering factors in the development of empathy. There were 18 statements in total supporting the themes in this category.  Theme 9: Negative Medical Role Models The participants described situations in their medical training in which medical role models did not treat their patients in an empathic manner and how this was a hindering factor in their development of empathy. Furthermore, the negative role modeling of their preceptors and medical educators conveyed a message that devalued the importance of empathy in the doctorpatient relationship. There were 11 statements supporting this theme, with selected examples included below. Participants recalled their reactions to witnessing physicians interact insensitively with patients, "we get a lot of these bedside teachings where it's not really, you're not dignifying the patient at all  " Another participant reported her experience of working with physicians on a  surgery ward, "it's like, you know, literally they walk in, 'are there bowl sounds? Is the drain draining? Can we pull this N G tube out? You need to change your diet, bye'." One participant's reaction to observing a physician who did not employ empathy caused him to question the value that he would need to place on it "because you look at these, you know, experienced docs, and they don't seem to waste a lot of time with that, so you thought, "oh, this is sweet, I won't have to really...". Additionally, a participant discussed his thoughts and feelings of discomfort while working closely with a physician on a medical procedure:  ~~  68  When you first start and you're a student and you're standing there with this experienced doctor and he's just like, 'okay, let's run an E C G now' and the person's lying there in pain and they may be crying or throwing up. And they're like 'okay, give me the differential' and you're kind of feeling like 'this is so awkward', you're standing here talking like, you feel like Spock right? You're having this intellectual conversation about physiology or what's going on for this person and for them, they're just throwing up.. .they probably want someone, you know to put a hand on their shoulder or something right?  Theme 10: Criticism from Supervisors The participants reported the negative impact that criticism from supervisors rather than empathic understanding had on their development of empathy. It appeared that some medical students were hardened by the criticism while others recognized its negativity and made attempts to act differently in the future to their medical subordinates. There were seven statements supporting this theme, with selected examples included below. One participant described some of the physicians that he had encountered in his medical training as "off-the-cuff, and very arrogant at times." He also described how constructive feedback for those physicians would take "more effort to approach it in a nice way, and approach criticism from a respectful manner, so that it doesn't get the learner all defensive." He reported that although he experienced this critical learning style at times, that when he has "interactions with medical students.. .I'm just like against trying to shame them in every sense of the word. I kind of vow not to do it."  69  Participants discussed the experiences they encountered during their medical school training in which they faced hurtful criticism from their medical training personnel when they were undergoing stressful situations. A: I think just as residents and, you kind of, at times, you can be subjected to a high level of criticism and critique and it's sort of, suppose to be helpful to you and educational and all those things. But you know, there's times when you want someone to acknowledge sort of, the situation you're in. Like you're so busy, you're so, you're trying hard already, and if you screw something up, or it's kind of cause, you know, it wasn't that you were trying to make a stupid decision right, it was that, just, you didn't know what to do or didn't have, you know, the experience to do it the right way. And it kind of, it makes a big difference if someone's like, 'okay, well I know that this is your situation, but, you know'...cause that's when it's hard, is when you haven't slept and you haven't you know, you're ignoring your family, and then you know, you haven't had any exercise for two weeks, you haven't had any fresh air, and then someone's like pointing out to you how stupid you are and you're kind of like 'ahhhh', you know? B: Well shame-based learning, that seems like shame-based learning. A: I guess you kind of have to adjust to it or thicken your skin to it or something right? B: I don't find it a good way to learn-1 get bitter. V. The Challenging Factors in the Use of Empathy The themes in this category, "Pressure of Time and Lack of Energy", "Repetitive Exposure to Illness", "Patient Characteristics and Expectations", and "Uncertainty/Hesitancy about the use of Empathy" arose from the question, "what has challenged your development of empathy during your medical education?" as well as from further discussions in the focus group  70 regarding the practice of medicine. These themes capture the difficulties that medical students and physicians encounter through their training and practice of medicine. There were 42 statements in total supporting the themes in this category, comprising the largest section of themes in this research study.  Theme 11: The Pressure of Time and Lack of Energy The participants reported experiencing and witnessing a difficulty in the use of empathy in the medical context due to the pressure of time. The participants also recounted situations in their medical experience in which their lack of energy challenged their ability to use empathy with patients in the way they aspired to. They also reported concerns about their capacity in the future to practice medicine in an empathic manner due to lack of energy. It appears that multiple demands on developing physicians and practicing doctors infringes on their capacity to use empathy in their interactions with patients. There were 15 statements supporting this theme, with selected examples included below. Participants discussed how their role as physicians results in "not always having the time to really fully understand people and sometimes feeling too rushed...It's certainly sometimes hard to always communicate with people or always relate to people in the way that I would like to, it's not always possible." Furthermore, the participants shared situations in which they have witnessed the impact that time pressure could have on physicians' ability to use empathy with patients. My preceptor had a teleconference for a provincial health committee at eleven o'clock and the last patient was like at five to eleven. And we open up the chart, like physical abuse, just left her husband, three boys at home, positive pregnancy test. And we were like, 'uhhh', and that's what he said, he said 'what bad timing'. Because meanwhile,  71  he's got to be on the phone, he's presenting over the phone to this provincial committee in five minutes and we now have to talk to her about, cause [sic] I mean, this relationship just broke up and she's probably eight weeks pregnant, and you have to walk through that and you know, you have five minutes. So, good thing I was there because, he went and did his meeting and I got to do the talking. One participant alluded to the difficulties of being a family physician in the health care system in Canada. She commented that "it is a challenge to providing [empathy] is the way family physicians are paid and the way that you get paid per patient you see, not how long you spend with the patient." She expanded upon this difficulty facing family doctors. On a society level that we don't have enough health, family physicians, so you have a huge line-up and there are people who are people waiting days to see you and you're trying to squish as many in as you can cause [sic], you know, there's such a high demand. She also discussed how family physicians "don't have the time in a 7 minute appointment" to provide empathy but she suggested that "it's the longevity of that doctor-patient relationship that I think really allows you to provide empathy." Another aspect of their profession as doctors that challenges their ability to use empathy with patients was lack of energy, particularly "at the end of a long shift." One participant commented that "there's been times where you're just like, 'man I'm so tired, I don't want to deal with this right now'." Another participant reported that "being exhausted for sure, like, takes away from your ability to do your best for everyone...." Another participant recounted her thoughts and feelings during these periods of fatigue: I am, you know, periodically exhausted, I become very disappointed in myself that I can't give, I just, there's no more energy to give. You know, it's taking me everything I have  72  just to get home and put food in my mouth. I kind of look, and I go, oh maybe I should go talk to, you know, Mrs. So and So on whatever ward and [heavy sigh], I just can't do it. I guess because it would take too much at that point and that's disappointing to me. Furthermore, the participants discussed how these experiences of exhaustion and fatigue have generated doubts in their minds about how they will be able to perform in the future as physicians. One participant explained: It makes me wonder how successful I'll be at it, when, you know, later on.. .1 wonder how on earth am I going to manage to keep this goal for myself of being the kind of doctor I want to be with the empathy and the energy for my patients and I'm not sure where it's going to come from. I guess you just do your best right?  Theme 12: Repetitive Exposure to Illness The participants described situations in the medical context in which repetitive exposure to illness challenged the medical practitioner's capacity to use empathy when interacting with patients. The participants reported how practicing physicians' expressed empathy may be negatively influenced by repetitive encounters with patients suffering from similar illnesses. There were seven examples supporting this theme, with selected statements included below. The participants discussed the impact that the repetitive exposure to illness has on their perception of patients and their ability to be empathic. For example, one participant shared his honest thoughts which occasionally occur while working with patients in hospital. I care about the fact that they're having trouble but at the same time, you know, there's a lot of sick people in the hospital and so you know, they're not the only person with cancer and you're busy and you're tired and you're, you know. So you kind of just want  73  to say the right thing and you know, get out of there right? And without trying to, drain yourself too much. Another participant commented that in her opinion, "the longer you're in medicine, the less you learn to be empathic. You don't even realize it." She described her experience of accompanying her sister to a visit to the doctor. My sister was sick with something that was really rare to her friends and her and, but I had seen a bunch of times. She went in and all the doctors were talking to her in these big words but I looked at her face watching these doctors explain to her what she had and they were talking in like, some foreign language to her. But I watched her face as they were talking and she was just like, about ready to faint. She was so stressed! And I had to go inside and translate everything for her. But really, I can picture myself having done the exact same thing that the doctor did, explain it the exact same way that they did. But to her, it was like, crisis mode, you know? But, this doctor had probably seen ten of those that morning. Furthermore, one participant commented that she was "amazed at how much empathy [the nurses in Emergency] actually do keep because they do see so much pain and so much misery that often people do bring upon themselves." She further explained that the nurses: .. .see it all the time, so it's so commonplace for them that it's hard, I think it would be very difficult for them to be empathic, because it's not extraordinary whereas for the person going in, their experience is extraordinary, that's why they're there. But it's so ordinary for the nurses, and for the staff, and you know, anybody who's spent much time in there, it's quite ordinary. So, it's not like you can build up this, you know, big  74 understanding look or anything because it's like, 'well okay, I saw a ton of those this morning'...  Theme 13: Patient Characteristics and Expectations The participants discussed the role of patient characteristics as a hindering factor in using empathy in the medical context. They reported circumstances in which they had observed or experienced personally the impact that patient characteristics had on their health care treatment. In particular, issues of prejudice and judgment of patients were discussed in relation to how empathically patients were treated in the medical setting. The participants also discussed the role of patient expectations in challenging their use of empathy in interactions with patients. The participants described their discomfort and difficulties in using empathy with patients in a variety of situations in which patients expressed expectations which hindered their capacity to engage in empathic encounters with patients. There were 13 statements that supported this theme, with selected examples included below. The participants discussed the way in which patient characteristics can play a challenging role in physicians using empathic communication with their patients and the impact that this has on patients. For example, one participant indicated that: Often, I mean, patients that I see at my family practice clinic, which is in the downtown eastside, they don't like the hospital at all because they feel that they're generally treated like, with a total lack of respect and not a lot of empathy. So they will get really sick, and they'll come to the clinic, and they'll refuse to go to the hospital. You know, we'll be trying to get them to go and they won't because they know from experience that they're treated badly. You know, they're treated badly because they're poor or because they're drug users or because they're First Nations or, you know whatever their thing is.  75  Additionally, participants discussed situations that they encountered when working in Emergency in which patient characteristics influenced the treatment they received in hospital. One participant commented that "when it comes to Emerg, a lot of us become sort of prejudice by every other person's experiences." The participants described this process in more detail: A: It's even harder when, you know, you're handed a chart and whatever, one of the Emerg docs sees it and recognizes the name or one of the nurses recognizes the name and they're like 'oh yeah, that person's here for another drug'. B: Yeah, like drug seeking, especially. A: And that gets into your head, and you're like, 'okay then I start to care less about this person' and just send them on their way...there's obviously no empathy there whatsoever. B: Yeah, there is a patient who comes into Emerg frequently and he drug seeks. But he comes in, T have chest pain, I have this kind of pain' and he comes in with complaints of pain, but it's drug seeking. So it's hard to say, T understand that you're in a lot of pain' when really what you want to say is 'no I'm not giving you anything'. Patient expectations can also play a role in challenging physicians to use empathy with patients. One participant recalled her struggle to relate empathically with patients: I think it's very hard to demonstrate empathy when they [referring to the patients] see you as this other thing on sort of a pedestal and it's different from them and they, they think you can't possibly, maybe relate or understand what they're going through. Furthermore, she elaborated upon this experience and reported that: They [referring to patients] make assumptions about me, and it's hard to be empathetic when people think it's kind of fake and that you're coming from this place of like,  76  slumrning with the low lives or whatever... sometimes, and I found this more since I've become a resident than when I was a medical student is I think that I have this feeling that people look at me and expect me to be this medical professional now, which I don't necessarily see myself as that and I have a hard time, like being called doctor for example.. ..I find myself wishing that patients that I'm interacting with and treating, or assessing, or whatever, kind of, what am I trying to say.. .understood me more as not being this medical professional that's, you know, sometimes that's what I am to them... Another participant reported how patients' expectations of the delivery of health care can also create difficulties in relating empathically to patients because: ...it's an expectation, it's considered a right. So sometimes, you get attitude back from patients and you're like, 'you have no idea that I've been up for thirty hours, I've delivered three babies overnight, I've worked in the clinic, I have been in Emerg since six o'clock... Furthermore, one participant recalled how some patients make assumptions that a physician's use of empathy implies a deficiency in one's medical skills. For example one patient responded to her personal recommendation of a physician's interpersonal skills as "well I don't want a great guy, I want a good surgeon." She interpreted this remark to imply that as a doctor "you couldn't be both." She went on to explain that "in some fields, people are under the impression that they'll trust you more, or at least this woman is an example of someone who would trust someone more, if they didn't get empathy, necessarily."  77  Theme 14: Uncertainty/Hesitancy about the use of Empathy This theme emerged from the focus group discussions in which participants alluded to an uncertainty or hesitancy about the use of empathy. Some participants seemed unclear of the proper parameters of using empathy with patients while others struggled with the emotional investment involved in empathizing with patients. Feelings of uncertainty or hesitancy about the use of empathy could present a challenging factor in utilizing empathy while working with patients. There are seven statements supporting this theme, with selected examples included below. The participants recounted some of their prior conversations that they had had about empathy and reported their queries of "How much is too far in empathizing with your patients? And where's the line between empathizing and sympathizing? And what are our professional boundaries? Which are difficult in family medicine when you've seen patients for years and years." The participants also discussed the ambiguity that they sometimes experienced regarding the use of empathy and the appropriate language in various circumstances. One participant commented that: Sometimes you sit there and say, am I really going to say this? Like, what is the exact right words? Do you say, you know, I understand where you're coming from, then I think that bothers people because then they say, 'oh, so when did you have cancer?' Yeah, okay, well, maybe I don't understand where you're coming from but, it looks like it's very difficult for you? Like I mean, you just don't know exactly what the phrase is!  78  Furthermore, the participants revealed a hesitancy towards using empathy with patients because "sometimes you do feel like, okay, well, do I really want to get involved in this whole emotional thing that's going on?"  Validation Procedure Results Participant Cross-Checking Descriptive and interpretive validity was determined through verifying the themes and examples with the participants through follow-up emails. The response rate of the participants was seventy-five percent. The respondents confirmed that the examples were accurate representations of their thoughts and feelings and that the themes effectively summarized the meaning of their contributions.  Inter-Rater Agreement The researcher educated two independent coders regarding the themes and subcategories chosen by the researcher. The researcher clarified the definitions of each category and clarified language that was specific to the medical context. Both independent coders were graduate students who were undergoing their own thesis projects and had prior knowledge of qualitative research. The trained coders independently categorized 36 examples of the data into the subcategories of each theme (approximately 25% of the data). Both of the coders sorted the examples into themes and achieved 88% agreement prior to discussion and negotiation. Discrepancies between the coders and the researcher were primarily due to the coders misunderstanding medical terminology or the need to refine the subcategory titles. After further clarification of the thematic categories and discussion between the researcher and coders, the agreement achieved was 100%.  Expert Agreement The tentative themes were presented to two experts in the field, both faculty members of the U B C School of Medicine. The first expert expressed agreement with the themes developed in this study. He indicated that the themes would have informative implications on the approaches used in medical education to teach empathy. Particularly, the themes under the category, "the value of empathy in the medical context", would be useful in illustrating the importance of empathy in the doctor-patient encounters. Furthermore, the examples contributed to this study provide insight for physicians, medical educators, and medical students regarding the relevant factors that influence both positively and negatively one's development and utilization of empathy. The second expert confirmed the accuracy and relevance of the themes in this research study. He reported the usefulness of the data in terms of illustrating the distinct difference between the empathy which is taught in medical school in comparison to the empathy developed in counselling psychologists. He observed in the participants' contributions that their conceptualization of empathy was primarily as a means to "fix" a patient rather than focusing on expressed empathy as a process of healing. Rather than using empathy as an approach to gain a greater understanding of the patient and his/her perspective on their health issue, he observed that many of the participants revealed an understanding of empathy which used themselves as reference points.  Theoretical Agreement Previous research and literature was found to support most aspects of the 14 themes in the research study. Specifically, theories of the empathic process (Barrett-Lennard, 1981; Rogers, 1971, 1957, 1989; Welch & Gonzalez, 1999), self-efficacy theory (Bandura, 1977), self-  80  determination theory (Markakis et al., 2000), and the stages of empathy development in medicine (Marcus, 1999) provided the basis for the theoretical agreement. Notably, the literature highlighted an aspect of the empathic process which was not addressed by the participants under the category of "The Characteristics of Empathy in the Medical Context" and there was a lack of research support for theme six's "Recognizing the Privilege of the Medical Role" as a facilitating factor in the development of empathy. Specific discussion of the research and theories which support the categories and themes of the study will be discussed in more detail in chapter five.  81  Chapter V  Discussion This chapter reviews the major findings in this study and compares them to the literature and previous research in the area. The five categories in this study that capture how family practice residents conceptualize and experience empathy in the medical context include: 1) The characteristics of empathy in the medical context; 2) The value of empathy in the medical context; 3) The facilitating factors in the development of empathy; 4) The hindering factors in the development of empathy; 5) The challenging factors in the use of empathy. These five main categories comprise the focus of the discussion, followed by the limitations of the study, implications of the findings for the medical and counselling professions and suggestions for future research.  /: The Characteristics of Empathy in the Medical Context The literature by Rogers (1989) and Welch and Gonzalez (1999) supports the characteristics of empathy, "Supportive/Caring Language and Giving Time" as well as "Understanding/Perspective Taking" that were discussed in this category. Rogers' definition of empathy which describes a therapist sensing a client's feelings and their meanings incorporates components of understanding and perspective taking. Additionally, Rogers described empathy as involving a therapist communicating this understanding to the client, which is similar to the Supportive/Caring Language aspect of Theme 1. Welch and Gonzalez described the process of empathy as involving empathic observing, listening, and responding at both affective and cognitive levels. Although there is some overlap that exists across the two themes in this category, it appears that the theme "Supportive/Caring Language and Giving Time" could involve more of the affective components of empathic observing, listening and responding,  82  whereas, the theme "Understanding/Perspective Taking" could involve the more cognitive aspects of empathic observing, listening, and responding. Furthermore, the themes in this category are supported by Kunyck and Olson's (2001) research on empathy in the medical context, which found "empathy and caring" and "empathy as a communication process" as two of the five different conceptualizations of empathy in the nursing literature. Lavasseur and Vance's (1993) discussion of empathy as a mode of caring and a process of understanding also shows agreement with the themes of this category. Hojat, Fields, and Gonnella (2003) described empathy in the medical context as involving a cognitive understanding of the patient's perspectives and experiences and conveying this understanding to the patient. This description of empathy supports aspects of both themes in this category, particularly the components of empathy that involve understanding and perspective taking. The contributions in these themes are discussed as aspects of empathy in the counselling and psychology literature although this literature describes a more complex and detailed description of the process of empathy (Barett-Lennard, 1981; Rogers, 1951, 1957, 1989; Welch & Gonzalez, 1999; Zimring & Raskin, 1992). In particular, the aspect of empathy that Welch and Gonzalez discussed that was not specifically reported by the participants in this study was the process of clarification that one's empathic statement resonated with the patient's own experience. This process of clarification is also described in phase three of Barrett-Lennard's (1981) conceptualization of empathy and he claimed that each phase was necessary for an empathic interaction to have an effective process. Therefore, there is strong support for the characteristics of empathy which were found in this study although there were some aspects of the empathic process which were not addressed by the participants. This gap between the participants' ideas and the counselling and psychology  83  literature may exist for several reasons. The focus group discussion may not have represented the depth of the participants' understanding of empathy and thus the discussion of the clarification process in an empathic encounter may have been neglected. On the other hand, the clarification aspect of the empathic process may not be taught or emphasized strongly in the medical context as an important part of empathic communication. Notably, the aspect of 'giving time' is not as salient in the psychology and counselling literature on empathy as it was in this research. This discrepancy could be due to the prominent time pressures which are involved in doctor-patient relationships in comparison to therapeutic relationships. Therefore, the gesture of a physician giving their patient time is regarded as an important quality of empathy because it demonstrates an element of care and compassion that could be considered unusual in the medical culture.  //: The Value of Empathy in the Medical Context The value of empathy in the medical context is supported by Rogers' (1951, 1957, 1989) research in client-centered therapy, which indicated that empathy was one of the most crucial aspects of therapy which contributes to positive change in clients. The pattern of overlapping influence in the doctor-patient relationship, that was outlined in Figure 1, including the themes, "Increased Patient Trust and Disclosure" and "Increased Patient Compliance, Satisfaction, and Healing" was also supported in the research. For example, research has indicated that empathy contributes to meaningful communication (Truax & Carkhuff, 1967; Welch & Gonzalez, 1999), which leads to increased understanding of patient issues (Benner & Wrubel, 1989; Kunyck & Olson; Kristjansdottir, 1992), which positively impacts the disclosure of patient information, which contributes to the improved accuracy of a physician's diagnosis (Bellet & Malloney, 1991;  84  Colliver et al., 1998; Fine & Therrien, 1977; Frymoyer & Frymoyer, 2002; Gianakos, 1996; Higgins, 1990; Levasseur & Vance, 1993). Physician empathy as contributing to increased patient compliance and satisfaction is clearly supported by research across several areas of medicine (Kim et al., 2004; Sullivan et al., 2000; Wasserman et al., 1984; Zachariae et al., 2003). Squier (1990) and Zinn (1993) discussed how expressed empathy permits patients to share their emotions and provides a sense of improved self-efficacy in managing their illness, which may also be linked to increased patient compliance and satisfaction. Furthermore, empathy contributing to the patient healing process is echoed in the research which discussed a connection between expressed empathy and the healing process in patients (Davis, 2003; Gianakos, 1996; Larson & Yao, 2005). It is difficult to isolate the specific aspect of the doctor patient relationship which is most significantly impacted by the physician's use of empathy as there are many overlapping processes involved in this encounter. Perhaps tied into the notion of trust in the doctor-patient encounter is the establishment of parameters for connection or relationship building. It is apparent that the use of empathy in doctor-patient interactions can create a positive impact on the doctor-patient relationship which contributes to patients' trust in their physician and overflows into areas that influence the patient's health, such as more accurate diagnoses and increased patient disclosure, compliance, satisfaction, and healing.  ///: The Facilitating Factors in the Development of Empathy The facilitating factors in the development of empathy are primarily supported in the literature. The theme "Didactic Medical Training and Positive Role Modeling" is supported by Rogers (1951) who claimed that courses in empathy involving role modeling have led to the development of empathy in graduate students. Several other studies support these findings that  85  course training and role modeling are effective ways of teaching empathy to students and professionals (Barone et al., 2005; Elizur & Rosenheim, 1982; Fine & Therrien, 1977; Larson & Yao, 2005). Furthermore, research in teaching patient centered interviewing and communication skills to medical students and physicians have found that role modeling and training have led to improved patient-interaction skills (Jenkins & Fallowfield, 2002; Markakis et al., 2000; Smith et al., 1995; Oh etal., 2001). Bandura (1977) outlined the importance of modeling by competent teachers and supervisor reinforcement in the development of one's self-efficacy in learning a skill. The opportunity for medical students to observe and practice empathy and receive feedback on their empathic communication skills will contribute to their self-awareness and confidence in developing empathy (Price & Archbold, 1997). Huggard (2003) suggested that physicians as medical educators can have a significant impact on developing physicians acquiring an empathic approach to medicine if they role model effective therapeutic relationships with their patients. Correspondingly, Larson and Yao (2005) emphasized that empathy is developed through longterm role modeling of other physicians interacting empathically with their patients. The themes of "Exposure to Patients' Experiences" and "Personal Experience and Experiencing Empathy" are supported by Wilkes et al.'s (2002) research in which overnight hospitalization experiences positively impacted medical students' perspectives of their interactions with patients. Furthermore, Price and Archibold (1997) and Elizur and Rosenheim (1982) have discussed the role of maturation and self-awareness as valuable qualities in the development of empathy, which support these subcategories as well. Particularly, Aring's (1958) claim that the depth of one's own emotional experiences contribute to one's development of  86  empathy relates to the theme of personal experience and experiencing empathy as facilitating factors in this process. However, "Recognizing the Privilege of the Medical Role" in the context of a facilitating factor in the development of empathy is not as prominent in the literature. It appears that past research has not investigated this aspect of medical students' perspectives and its impact on their interactions with patients. There is not disconfirming evidence to suggest that this theme is invalid but there is not research in the literature to support this finding. The final theme of the "Increased Appreciation for Empathy" as a facilitating factor in the development of empathy is supported by Marcus' (1999) research which suggested that developing physicians were able to understand their patients' feelings and adapt to their individual needs only in the later years of residency. Marcus' stages of empathy parallel this finding that the residents became more appreciative of the value of empathy in their profession as they entered into the later years of their medical training. Notably, there was one participant, a mature student, who reported that her appreciation for empathy had not changed throughout medical school. She reported that: I think that empathy is not something I think about trying to cultivate in myself or anything like that. I think it's just, for me, like I said earlier, it's just, you know, always trying to see people as people with stories, you know. I think that hasn't changed over the course of medicine, I think I've, and if it has it would only be in a negative way that comes from not always having the time to really fully understand people and sometimes feeling, too rushed and stuff like that. I mean, it hasn't changed the importance that I put on that or anything like that.  87  IV: The Hindering Factors in the Development of Empathy The theme of negative role models as a hindering factor in the development of empathy is well supported in the literature. Spiro (1992) summarized how a patient is often treated by teaching physicians "as only a model, a body to be treated, or a good 'teaching case' that illustrates a point (p.844)." Glick (1993) discussed how physicians may not be appropriate role models because many of these teachers have not received training in effective human interaction skills. He emphasized the importance of effective role models in medical education because "students often imitate their teachers" (p.89). Markakis et al. (2000) discussed the impact of the climate in which medical students are being trained, particularly the influence of attending physicians' behaviours. They reported how the physicians did not emphasize the importance of humanistic values and professionalism with patients. For example, physicians did not provide constructive feedback to residents who displayed inappropriate interpersonal skills with patients (Markakis et al.). Paice, Heard, and Moss (2002) reported how physicians who were teaching in Canadian medical schools often modeled insensitivity to the needs of patients and students. Students expressed dissatisfaction with their preceptors, particularly senior physicians, who did not engage in active discussion of different perspectives with students. Moreover, physicians indicated that their expectation of students' communication skills with patients were higher than what they demonstrated during their interactions with patients (Paice et al., 2002). Furthermore, Marcus (1999) discussed how medical students are strongly influenced by physician role models during their senior years of medical school and that they identify particularly with physicians who exhibit a lack of empathy towards patients as they are struggling to cope with their traumatic interactions with patients. He suggested that "how we teach is what we teach because  88  students identify with the attitudes implicit in our teaching methods and styles" (Marcus, 1999, p. 1214). Therefore, the way that physicians model interactions with patients and their medical students provides a template for the professional behaviour that developing doctors will employ. The theme of criticism from supervisors as a hindering factor in the development of empathy is also discussed in the literature. Silver and Glicken (1990) discussed how developing physicians are often treated with inconsideration and lack of empathy. Marcus (1999) reported the pattern for developing physicians to feel that their sense of self-esteem is continually being threatened. Ziegler, Strull, Larsen, Martin, and Coates (1985) described how myths such as physicians being all-knowing and uncertainty being an indicator of weakness have a negative impact on residents in training. This expectation of residents always knowing the correct diagnosis or response contributes to increased stress and burn-out of residents (Ziegler et al., 1985). Markakis et al.'s (2000) research on self-determination theory found that medical students who viewed their instructors to be more humanistic and supportive of their autonomy displayed greater patient-centred focus during medical interviews. Furthermore, medical students who had their psychological needs met during their training appeared to be more supportive of their patients' needs. This research supports the importance of supervising physicians providing an encouraging and supportive environment for medical students to learn and develop their clinical skills. The impact of criticism on medical students and residents' development of empathy is also supported by Bandura's (1977) theory of self-efficacy. Bandura discussed how cognitions, particularly the belief in one's capacity to effectively perform a skill, as well as one's level of anxiety impact one's utilization of a skill. Consequently, criticism from physician educators  89  could contribute to increased levels of anxiety in medical students and residents as well as decrease their confidence in practicing their empathic communication skills (Price & Archbold, 1997). Notably, participants also commented on how their encounters with negative role models and the ways in which they received criticism from supervisors advocated the students to behave differently during their encounters with future medical students. For example, one participant claimed that, "I have interactions with medical students now and I'm just like against trying to shame them in every sense of the word. I kind of vow not to do it." This indicates that although negative role models and criticism from supervisors may hinder some students' development of empathy, it may also inspire other students to improve their empathy skills such that they can act differently than the example they were exposed to.  V: The Challenging Factors in the Use of Empathy The theme of time pressure and lack of energy as a challenging factor in the use of empathy is supported in several aspects of the literature. Spiro (1992) discussed how medical students and residents are restricted by their demanding schedule, which allows them very little time and energy for focusing on interpersonal interactions with patients or contemplation of humanistic issues. Spiro suggested that the training which medical students and residents experience, which involves long hours, lack of sleep, and an emphasis on efficiency, does not provide space in their workload for utilizing empathy with patients. Griffith and Wilson's (2001) research indicated that the main frustration for medical students during their clerkship training was time conflicts. Similarly, Marcus (1999) described the challenges of residency involving lack of time to work effectively or process one's thoughts as well as a consistent sense of being overwhelmed.  90  Dickinson et al. (1983) support this study's finding that time pressure and lack of energy are perceived as challenging factors in the use of empathy, and they suggested that residency training may inhibit the use of empathy due to the time-consuming nature of one's workload. Additionally, Bellini et al.'s (2002) research found that fatigue and inertia reported by medical students significantly increased during their internship in internal medicine. Bellini et al. suggested that this increase in fatigue and decrease in vigor could contribute to a decrease in empathy among residents. Furthermore, the literature confirms the continued demands of practicing medicine beyond residency as there are multiple aspects which compete for a family physician's time and energy (Jaen, Stange, & Nutting, 1994; Larson & Yao, 2005). Finally, it may be that early career experiences for physicians in training are also anxious learning experiences, which contributes to the challenges of learning and using empathy. The themes of "Repetitive Exposure to Illness" as well as "Patient Characteristics and Expectations" as challenging factors in the use of empathy are supported by Griffith and Wilson's (2001) study on third year medical students. Their findings indicated that medical students' attitudes became less positive and stereotypes of patients developed after their clerkship experiences of multiple interactions with patients. Specifically, their attitudes towards the elderly patients and patients with chronic pain became less idealistic (Griffith & Wilson). Their findings suggest that repetitive exposure to illness and the attributes of patients can negatively impact developing physicians' utilization of empathy in the medical context. This is similar to the participants' discussions of how it was more challenging for them to be empathic towards patients who would repetitively visit the emergency ward seeking drugs. The theme of uncertainty/hesitancy about the use of empathy is supported by Marcus' (1999) research which described how medical students develop rigid emotional boundaries  91  during their third and fourth years of medicine in order to protect themselves emotionally. Huggard (2003) discussed how physicians may avoid emotional engagement with patients in order to protect themselves from fatigue or burnout as well as maintain more objectivity.  Limitations There are several limitations involved in this qualitative research. This study involved only a small number of participants, who were interested in participating in the research. Therefore, the ideas generated in this research are limited to participants who were interested in the topic of empathy in the medical context and who were currently enrolled in Year One of the University of British Columbia Family Practice Residency Program. Although this is not the focus of qualitative research, these results cannot be generalized to the general population of medical students and physicians (Patton, 2002). Furthermore, this study does not represent the ideas of family practice residents within the inclusion criteria who may not value this area of research as strongly. The researcher received some feedback from participants who were not interested in participating in the study, such as "empathy is just not my thing". It is evident that the views of these individuals may differ from those who participated in the study and their perspectives would be a valuable addition to understanding further this research topic. However, the focus of this qualitative study was to understand and communicate the experiences and conceptualizations of empathy through the perspectives of family practice residences within the ethical boundaries of voluntary participation and process consent (Hadjistavropoulos & Smythe, 2001). Another area of limitation is the interview methodology used by this study. The focus group interview format may have been limited by interviewer bias, which involves the interviewer inadvertently communicating their approval or disapproval of participants' responses  92  and subtly leading participants towards types of answers (Cozby, 2004). However, in order to minimize interviewer bias, the interviewer in this research project was trained in conducting focus groups by an expert and the process of the interviews was reviewed between focus groups by Dr. Marvin Westwood. Furthermore, the types of questions chosen for the interview were open-ended and the interviewer carefully reviewed with the expert the potential probing questions that may be asked to prevent leading questions or nonverbal responses that may bias the participants' discussion. Another drawback of the focus group approach is the social desirability bias or selfserving responses (Patton, 2002). This involves participants responding to the questions in a way that would reflect most favorably on themselves or appear most socially acceptable (Cozby, 2004). In this study, the participants may have desired to appear more devoted to valuing empathy in the medical context because of the group dynamic of the interview and the counselling psychology background of the interviewer. The participants were being interviewed with their peers and from the onset, the tone of the responses was positive towards the importance of empathy in medical interactions and this may have created a group norm that influenced what participants' reported. However, it was evident in the interviews that participants felt comfortable being open and honest in front of their colleagues and the interviewer as a wide range of experiences were disclosed, including situations in which the participants were not pleased with their perspectives or behaviours. Moreover, the questions were developed such that the participants could share specific examples of their experiences and perspectives without having to attach themselves to the situations. For example, one question asked "describe to me what it would look like for a resident or physician to use empathy in the medical context?". This question allowed participants  93  to reveal their understanding of empathy in the medical context without specifying whether this was their own personal use of empathy or a situation in which they witnessed a colleague or supervisor demonstrate empathy. This approach of questioning was used to decrease the pressure for participants to appear knowledgeable and proficient in the area of empathic communication while still eliciting with sufficient depth their understanding and experiences of empathy. Patton (2002) and Weiss (1994) discussed how qualitative interviews may be limited by participants' recall error or participants withholding negative information that could create conflict. The researcher attempted to reduce participants' withholding of information through ensuring confidentiality as well as emphasizing that the subjects reported in their discussions could remain anonymous as it was the conceptualizations and experiences of empathy that were pertinent to the study. Furthermore, the imperfect recall of information was minimized through providing the participants the opportunity to review their responses in writing and incorporate the necessary alterations or additions to their comments. Another limitation of this study was the potential for researcher bias in the interpretation of the data and formulation of themes. The researcher's own preconceptions and ideas are incorporated into the findings of this study and thus the aim of the researcher was a stance of neutrality towards the data (Patton, 2002). In order to provide support for the credibility of the results, there were several checking points. Firstly, the researcher approached the qualitative inquiry with authenticity and a stance of neutrality with a goal to understand the participants' perspectives without motivation to prove a specific theory (Patton, 2002). Secondly, the researcher invited participants to verify if their contributions were accurately captured by the themes generated. Thirdly, the researcher procedurally verified the themes with masters level students who were not related to the research. Moreover, the researcher worked closely with  94  faculty advisors to accurately present the focus group discussions in the themes and had experts in the medical field validate the themes.  Future Research There are several areas of future research which could expand upon the current study's findings. In regards to the characteristics of empathy, it would be valuable for future research to investigate what the core components of an empathic interaction are in the medical context. Specifically, it would be beneficial to understand if Welch and Gonzalez's (1999) cognitive and affective aspects are both necessary in an empathic encounter in medicine. Furthermore, it would be useful to examine if Barrett-Lennard's (1981) three phases of empathy, including the clarification process, are essential for a patient to experience an empathic response from their physician. The impact of residents and physicians recognizing the privilege of their medical role is another area of future research. In this study, participants indicated that recognizing the privilege of their role in patients' lives was a helpful perspective in facilitating their use of empathy. However, understanding further the perspectives of physicians and patients of the medical role of a family doctor may have further implications in the process of empathy in medicine. For example, physicians have the privilege to be in roles that ask respect and engender trust, which is important for empathy. It may be valuable to examine how the dynamics of the roles, such as the potential power differential between the doctor and patient, impact the empathic process in their encounters. Another area of future investigation could involve exploring in more detail the specific ways in which empathy impacts patient health. Although it appears to be difficult to isolate specifically how empathy improves patient health, a combination of quantitative and qualitative  95  research which examines this issue would greatly benefit the literature in this area. Research which could clearly outline the relationship, between empathy and patient healing would be valuable for medical educators to inform developing physicians of its role in the medical profession. Furthermore, this research could impact decisions involved in the medical curriculum as well as future decisions in the health care system. Further quantitative research could augment the current qualitative research on the facilitating and hindering factors in the development of empathy to identify on a broader sample of participants what the most influential factors are involved in acquiring empathic communication skills. Future research could investigate various methods of supporting the use of empathy in the medical context, such as focused discussion groups or preceptors reinforcing empathy skills. This information would be useful for both medical and counselling educators to improve their curriculum for teaching empathy to students. Additionally, further research could expand on the current research through investigating how physicians cope with the challenging factors in the use of empathy that were generated in this study. Medical and counselling educators as well as practitioners could benefit from greater insight into how professionals excel in empathic communication skills under the stressful conditions of their various work environments. Another area of research that could broaden the understanding of how family practice residents conceptualize and experience empathy would be to explore the perspectives of those who do not value empathy as strongly in their medical practice. Surveys conducted across residency programs may provide an anonymous and thus less threatening method for residents of varying viewpoints to share their ideas and experiences of empathy in the medical context. This  96  would be valuable in understanding whether there are factors contributing to a lack of importance placed on empathy.  Implications for Clinical Training and Practice The results of this research study may provide some valuable insight into the processes involved in acquiring empathy and employing empathic communications skills when working with patients. From the discussions of the characteristics of empathy in the medical context it was apparent that the participants identified many of the key components involved in empathic communication according to the counselling, psychology, and medical literature. However, the part of expressed empathy, which involves clarifying with patients that their understanding of the patients' perspective was accurate, was not clearly addressed by the participants. This process of clarifying with patients is valuable in improving the patients' ability to explain their experiences of the illnesses through listening to their physicians reflections and providing more specific and accurate details. This in turn is useful for physicians gaining a more comprehensive understanding of their patients' illness. Therefore, it may be valuable for practitioners who are developing and teaching empathy in the medical curriculum to emphasize thoroughly the complete process of an empathic encounter, particularly the clarification process. This study's findings regarding the value of empathy in the medical context provides important implications for medical educators and counsellors who are teaching empathy skills to students. It is evident in the current research and previous studies that empathy is a crucial component to effective doctor-patient interactions and patient healing (Aring, 1958; Book, 1991; Colliver et al., 1998; Davis, 2003; Gianakos, 1996; Higgins, 1990; Hojat, Gonella, Nasca, et al., 2002; Jarski et al., 1985; Lavasseur & Vance, 1993; Levinson, 1994; Shapiro et al., 2004; Tongue et al., 2005). However, the participants reported confusion about what empathy entailed  97  and disregard for its relevance in the earlier years of medical school, indicating the need for more in-depth explanation and emphasis of its role in the doctor-patient relationship. It would be valuable in educating physicians about patient healing to describe the theory behind developing empathic communication skills and its significant impact on patient healing. The empathic process, involving effective listening, understanding a patient's experience, as well as clarifying that their perspective is accurate, is crucial to physicians accessing essential information to make correct diagnoses and treatment plans for their patients. Furthermore, the process of empathic communication builds into the doctor-patient relationship, which influences patients' compliance and satisfaction with their health care. Correspondingly, Lavasseur and Vance (1993) described how empathy is a "fundamental requirement for the full development of practical clinical knowledge" as it provides an understanding of the patient's experience of the disease and thus further insight into the treatment needs of the patient (p.83). Therefore, the skill of empathy is foundational to the success of medicine and thus should be emphasized in medical training similarly to acquiring knowledge in human anatomy and physiology. If family doctors cannot access patients' experiences of their illnesses effectively, this greatly hinders their ability to use their medical knowledge to assist in patient health. The themes generated regarding the facilitating and hindering factors in the development of empathy indicate the importance of medical educators who are well trained and skilled in modeling as well as teaching empathic communications skills. Reuler and Nardone (1994) stated that role models are impactful in the transition of medical students to practicing physicians. A participant reported the significant impact that role modeling can have on the development of empathic communication skills. She reported that she would "try and do it the exact same way" and that she "would use that as a framework, because it was really helpful...."  98  Another critical aspect of teaching empathy effectively involves medical educators who can provide feedback in a constructive and not diminishing manner. A non-threatening learning environment with effective educators will enable developing physicians to gain a sense of competence in their empathic communication skills. One participant described the significant impact that criticism from her supervisor had on her. She stated that she "wanted to leave the ward for the rest of the day.. .it really derailed [her] confidence for a while." Additionally, the finding that there is an increased appreciation for empathy during the senior years of medical school and residency indicates other important implications for practice. Firstly, it may be more useful for medical educators to focus more specifically on the skill building aspect of empathy during these later years of medical school and residency because students will be more open and eager to learn empathic communication skills. During the earlier years of medical school, students are often overwhelmed by the amount of material and examinations in their curriculum and thus preoccupied with learning the medical anatomy and physiology. Moreover, the relevance of empathy is often unclear to medical students until they begin practicing medicine with patients. Therefore, when these students are exposed to lectures and clinical sessions on empathy, they may be less inclined to see its relevance to their profession and consequently less willing to learn and develop their empathic communication skills. Glick (1993) argued that there is a stronger emphasis on cognitive skills in medical schools rather than on developing human qualities, such as empathy. There are more drastic consequences for students if they do not excel in acquiring factual knowledge about human physiology or anatomy than if they reveal poor empathy skills (Glick). Similar to the literature in this area, the findings in this study beg the question of whether medical students receive the  99  implicit message that empathy is not highly valuable to their success in the medical profession. In order for medical students to develop empathy skills, it would be essential for programmers, educators, and preceptors to adjust the direct and indirect messages that are conveyed to students regarding the value of empathy in the medical field. Furthermore, the results of the challenging factors in the use of empathy also provide some important practical implications for teaching empathy. It appears that the most constraining factors that limit family practice residents' use of empathy with patients is the pressure of time and lack of energy. It seems as though developing physicians have the intentions to develop and apply empathic communication skills but the context of medical practice does not reinforce these competencies. Yet, given the importance of empathy skills in medicine, one may question whether physicians can afford not to take the time to use empathy with their patients. Consequently, it may be useful for medical educators to introduce these variables into the empathy training in order to improve the transferability of their skills to clinical practice. Educators could provide demonstrations and techniques that model empathic communication under conditions of limited time and energy as well as incorporate opportunities for students to practice and receive feedback under these conditions. Conversely, another valuable implication that can be derived from the theme of "Uncertainty/Hesitancy about the Use of Empathy" is importance of teaching specifically what empathy involves so that developing physicians feel a sense of competence in this area. Furthermore, developing medical students' awareness of their own boundaries and teaching coping mechanisms to effectively manage their emotional encounters with patients is also imperative. Physicians may refrain from using empathy with patients due to their fears of how patients may react and the potential negative impact on their own well being. It was evident in  100  this research that some participants were uncertain of the amount of emotional investment that is involved in an effective empathic encounter and thus discussions that would clarify boundaries and improve coping techniques would be valuable in preventing burnout among physicians.  Conclusions The aim of this research was to generate themes which captured how family practice residents conceptualize and experience empathy in the medical context. The five main categories and 14 themes under these headings fulfill the purpose of this study. Investigating how family practice residents understand empathy, their perspectives of its role in medicine, as well as the influencing factors in the development and use of empathy contributes to the improvement of medical training programs, the clinical practice of counselling and medicine, as well as the literature in this area. The results of this study indicate the significant value of empathy in medicine and the current challenges which family practice residents face in the development and use of empathy in their profession. Improving the health of patients is of primary importance in medicine and empathy is a crucial skill for physicians to facilitate patient trust, disclosure, compliance, satisfaction, and healing (Aring, 1958; Book, 1991; Colliver et al., 1998; Davis, 2003; Gianakos, 1996; Higgins, 1990; Hojat, Gonella, Nasca, et al., 2002; Jarski et a l , 1985; Lavasseur & Vance, 1993; Levinson, 1994; Shapiro et al., 2004; Tongue et al., 2005). Although, not specifically outlined in this study, it is apparent that there needs to be an emphasis placed on the connection ' aspect of the doctor-patient relationship. The importance of physician empathy is echoed in McWhinney's (1997) description of the fundamental principles of family medicine. He described that "to give primacy to the personhood of the patient requires that we attend very carefully to the meaning the illness has for him or her, not as an 'add-on' after clinical diagnosis but as a  101  central obligation." (p.90). The participants revealed a desire to be empathic, "I think if we just remember to treat a person and not a disease.. .we'll be fine at providing empathy", but it is evident that researchers, educators, and practitioners need to play a proactive role in fostering empathy in family physicians throughout their medical training and clinical practice.  102  References Aring, C D . (1958). Sympathy and empathy. 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British Journal of Cancer, 88, 658-65.  Ziegler, J.L., Strull, W . M . , Larsen, R.C., Martin, A.R., & Coates, T.J. (1985). Stress and medical training. Western Journal of Medicine, 142, 814-819. Zimring, F. M . & Raskin, N. J. (1992). Carl Rogers and client/person-centered therapy. In D. K. Freedheim (Ed.), History of psychotherapy: A century of change (pp. 629-656). Washington, DC: American Psychological Association. Zinn, W. (1993). The empathic physician. Archives of Internal Medicine, 153, 306-312.  119  Appendix A INFORMATION H A N D O U T FOR F A M I L Y PRACTICE RESIDENTS  Understanding Family Practice Residents' Conceptualization and Experience of Empathy Carlene Van Tongeren is seeking family practice residents as volunteers to participate in a University of British Columbia research study. To volunteer for the study you must be a family practice resident enrolled in your first year at U B C . This research is being conducted as one of the requirements for Carlene Van Tongeren to complete a Masters in Counselling Psychology at the University of British Columbia. Purpose: The purpose of this study is to investigate how family practice residents conceptualize and experience empathy in the medical context. This research project aims to contribute towards the development of medical curricula that fosters a greater understanding of empathy. Study Procedures: If you decide to participate in this study, you will be interviewed by Carlene Van Tongeren about your conceptualization and experiences of empathy. The interview will take place in focus groups of 3-5 Family practice residents. The interview will be audio taped and transcribed. You will be provided a copy of the transcript and invited to clarify the information you presented and provide further information if necessary. The information from the focus groups will be analyzed by the co-investigator for thematic patterns. You may be asked to provide feedback on the analysis during this process through a follow-up phone call. The total amount of time that will be necessary for you to participate in this study is approximately 1.5 hours. Confidentiality: Any information that you provide during the focus group interview will be kept confidential as all documents will be identified by a code number and kept in a locked filing cabinet. Participants will not be identified by name or initials in any reports of the completed study. During the transcription of the focus group interviews, data on the computer will be protected by a password. The researcher is external to the U B C Medical Program and is not in a position of evaluation. No one from the U B C Medical Program will have any access to the recorded or transcribed information you provide. Remuneration/Compensation: There will be food and refreshments provided during focus group interviews for your participation in this study. Contact: Your support and assistance in gathering information for this research would be greatly appreciated. If you are interested in participating in this study or desire further information with respect to this study, please contact Carlene Van Tongeren at: ctdaniel@interchange.ubc.ca.  120  Appendix B CONSENT F O R M  Understanding Family Practice Residents' Conceptualization and Experience of Empathy Principal Investigator & Faculty Advisor: Dr. Marvin Westwood, Department of Educational and Counselling Psychology University of British Columbia, Vancouver, B.C.  Co-Investigator: Dr. David Kuhl, Director, Centre for Practitioner Renewal, Providence Health Care  Graduate Student: Carlene Van Tongeren, Department of Educational and Counselling Psychology University of British Columbia, Vancouver, B.C.  Purpose: The purpose of this study is to investigate how family practice residents conceptualize and experience empathy in the medical context. This research project aims to contribute towards the development of medical curricula that fosters a greater understanding of empathy. This research is being conducted to complete a Masters in Counselling Psychology at the University of British Columbia. Study Procedures: If you decide to participate in this study, you will be interviewed by Carlene Van Tongeren about your conceptualization and experiences of empathy. The interview will take place in focus groups of 3-5 Family Practice Residents. The interview will be audio taped and transcribed. You will be provided a copy of the transcript and invited to clarify the information you presented and provide further information if necessary. The information from the focus groups will be analyzed by the co-investigator for thematic patterns. You may be asked to provide feedback on the analysis during this process through a follow-up phone call. The total amount of time that will be necessary for you to participate in this study is approximately 1.5 hours. Confidentiality: Any information that you provide during the focus group interview will be kept confidential as all documents will be identified by a code number and kept in a locked filing cabinet. Subjects will not be identified by name or initials in any reports of the completed study. During the transcription of the focus group interviews, data on the computer will be protected by a password. No one from the U B C Medical Program will have any access to the recorded or transcribed information you provide. Remuneration/Compensation: There will be food and refreshments provided during focus group interviews for your participation in this study.  121  Contact: If you have any questions or desire further information with respect to this study, you may contact Dr. Marvin Westwood at i or the graduate student involved, Carlene Van Tongeren at If you have any concerns about your treatment or your rights as a research subject, you may contact the Research Subject Information Line in the UBC Office of Research Services at or The Chair of the UBC/Providence Health Care Research Ethics Board at Consent: Your participation in this study is completely voluntary and you may refuse to withdraw from the study at any time without jeopardy to your medical education or future career. The researcher is external to the U B C Medical Program and is not in a position of evaluation. Your signature below indicates that you have received a copy of this consent form for your own records. I have read and understood the subject information and consent form. I have had sufficient time to consider the information provided and to ask for advice if necessary. I understand that I am not waiving any of my legal rights as a result of signing this consent form. I consent to participate in this study.  Subject Name (please print)  Subject Signature  Date  Witness Name  Signature of a Witness  Date  Co-Investigator Name (please print)  Co-Investigator Signature  Date  122  Appendix C R E S E A R C H INTERVIEW QUESTIONS 1. What is your understanding of using empathy when working with patients? 2. Describe to me what it would look like for a resident or physician to use empathy with a patient? 3. What do you think the role of empathy is in the doctor-patient relationship? 4. What do you see as the possible benefits of learning/using empathy with your patients? a. What led you to value empathy? 5. Have you ever experienced an empathic response toward something you said? a. How would you describe that response? b. What impact did it have on you? 6. Have you ever spoken to someone when you "needed" an empathic response and didn't get it? a. How would you describe that response? b. What impact did it have on you? 7. Has your understanding of empathy changed over time? a. If so, how? 8. What influenced your development of empathy? 9. What has challenged your development of empathy during your medical education? 10. From what you've learned, how would you define empathy in the medical context?  123  Appendix D OPTIONAL DEMOGRAPHIC QUESTIONS 1. Age: 2.  Gender:  3. First Language: 4.  Culture/Ethnicity:  5.  Religion:  6.  Country of Origin:  7.  Previous Post-Secondary Education:  8.  Previous Work Experience:  

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