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Empathy training and stress : their role in medical students' responses to emotional patients 1990

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EMPATHY TRAINING AND STRESS: THEIR ROLE IN MEDICAL STUDENTS' RESPONSES TO EMOTIONAL PATIENTS by HEATHER MARIE HIGGINS B.Sc. Mount A l l i s o n University, 1974 ,A. The University of B r i t i s h Columbia, 1979 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (In t e r d i s c i p l i n a r y Studies) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1990 ®Heather Marie Higgins, 1990 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada DE-6 (2/88) Abstract This study investigated the e f f e c t s of empathy t r a i n i n g on medical students' responses to emotionally intense s i t u a t i o n s . It also explored the i n t e r a c t i o n between empathy and stress. Thirteen volunteers from a second-year medical class completed the study which u t i l i z e d a two-factor crossover design. In the f i r s t of three t e s t i n g situations, each subject p a r t i c i p a t e d i n a 15-minute videotaped interview with an actor who portrayed an angry, f e a r f u l , or grieving patient. Each medical student then completed measures of empathic understanding and perceived stress regarding the encounter, as well as scales of coping and hardiness. Each simulated patient rated the medical student 1s l e v e l of empathic understanding. Two raters, b l i n d to the experimental design, analyzed the tapes and rated the medical students 1 degree of communicated empathy. Subjects were then randomly assigned to one of two groups: t r a i n i n g with follow-up, or control with delayed t r a i n i n g . The f i r s t group received four 3-hour weekly sessions i n empathy t r a i n i n g while the second group served as a w a i t - l i s t control. A l l subjects then p a r t i c i p a t e d i n a second taped interview and completed a l l measures again. The subjects i n group two received the t r a i n i n g while the f i r s t group received no further treatment. A l l subjects were tested a t h i r d time which concluded the experimental procedure. i i i The p r i n c i p a l s t a t i s t i c a l analyses comprised a series of 2 x 2 ANOVAS tested at the .05 l e v e l of s i g n i f i c a n c e . Results revealed that, following the t r a i n i n g , subjects learned to int e r a c t i n a more empathic manner; e f f e c t sizes ranged from 1.08 to 18.32. Also, subjects* stress l e v e l s regarding the emotionally intense encounters were reduced; the e f f e c t s i z e was -1.95. As hypothesized, these changes i n empathy and stress were not observed for the w a i t - l i s t control group, while t r a i n i n g e f f e c t s were maintained for subjects i n the follow-up group. Changes i n hardiness and coping were not s t a t i s t i c a l l y s i g n i f i c a n t . An outline i s presented which i l l u s t r a t e s the mediating function of empathic responding i n s t r e s s f u l interactions. Also addressed are implications for empathy t r a i n i n g i n medical education and for communication i n the physician-patient r e l a t i o n s h i p . i v Table of Contents Page Abstract i i Table of Contents i v L i s t of Tables v i i i L i s t of Figures x Acknowledgements x i Dedication x i i CHAPTER I: Introduction Background 1 Objectives of the Study 4 Operational De f i n i t i o n s 7 Empathy 7 Stress 8 Coping 8 Assumptions and Limitations 9 Overview of the Document 11 CHAPTER II: Literature Review Introduction 12 Value of E f f e c t i v e Communication i n the Medical Interview 13 E f f e c t s of Miscommunication i n the Medical Interview 14 The Emergence of Communication S k i l l s Training i n Medical Education 15 Increasing Humanism i n Medical Students 19 The Concept of Empathy 21 Empathy i n the Physician-Patient Relationship 2 6 Intense Emotions as Sources of Stress for Medical P r a c t i t i o n e r s 29 Need for Empathy Training 32 V Page Effectiveness of Empathy i n Emotionally-Intense Situations 34 Previous Research Examining Empathy and Stress 37 Hypotheses Related to Empathy and Stress 41 Previous Research Related to Exploratory Analyses ... 42 Hardiness 42 Ways of Coping 45 Methodological Issues I d e n t i f i e d i n Relevant Previous Research 47 CHAPTER I I I : Method Introduction 54 Experimental Design 54 Subjects 60 Populations and Samples . . .-. 60 Recruitment and Selection 60 Selection of the Trainer, Raters, and Simulated Patients 61 Selection of the Trainer 61 Selection of the Raters 62 Selection of the Simulated Patients 62 Supervision of the Trainer and Raters 62 Research Measures 63 Carkhuff Empathy Rating Scale 63 Barrett-Lennard Relationship Inventories 65 Perceived Stress Questionnaire 66 Hardiness Scale 66 Ways of Coping Scale 67 Session and Overall Training Evaluation 69 Experimental Procedure 69 The Experimental Treatment - Empathy Training . . 69 Equipment and F a c i l i t i e s 70 Scenarios for Testing Situations 70 Training of the Simulated Patients 72 Emotion and Gender Combinations during Testing Occasions 73 Pre-Testing of Subjects ' 74 Assignment to Group 75 Administration of Training and Post-Testing .... 76 v i Page S t a t i s t i c a l Considerations 77 Designs Used to Test the Hypotheses 84 Additional Exploratory Questions 90 Data Analysis Procedures 90 CHAPTER IV: Results Introduction 91 Subject C h a r a c t e r i s t i c s 91 Implementation Check of Simulated Patients 91 Inter-rater R e l i a b i l i t y 92 Analyses of Training E f f e c t s 92 Hypothesis 1A and IB 95 Hypothesis 2Ai through 2 B i i i 103 Hypothesis 3A and 3B 108 Summary I l l Results of Exploratory Analyses 112 Hardiness Scale 112 Behavioural Coping Measures 115 E f f e c t Sizes 121 Session and Training Evaluation 123 Summary of Findings 130 CHAPTER V: Discussion Introduction 132 Summary 132 Discussion of Results of Dependent Measures 13 3 Percentage of Level 3 Responses 133 BLRI (Patient Ratings of Empathy Scale) 134 BLRI (Medical Student Ratings of Empathy Scale) 135 Perceived Stress Questionnaire 13 6 Hardiness 138 Behavioural Coping Strategies 139 E f f e c t Sizes 140 v i i Page Implications for Empathy S k i l l Training i n Medical Education 14 0 Implications for Communication i n the Physician-Patient Relationship 149 Suggestions for Further Research 157 References 160 Appendix A 178 Appendix B . . 180 Appendix C 183 v i i i L ist of Tables Table Page 1. Gender of Medical Student and Simulated Patient by Emotion of Scenario 73 2. Means and Standard Deviations for Dependent Measures (N = 13) 93 3. Summary of Analyses of Variance for Dependent Measures (Hypotheses (1A & IB: Comparison of Cells 1 & 2 with 4 & 5, N = 13) 96 4. Summary of Analyses of Variance for Dependent Measures (Hypotheses 2 Ai & 2 Bi: Comparisons of Cells 2 & 3 with 4 & 5, N = 13) 104 5. Results of the T-Tests for Carry-Over and Wait-List Effects 107 6. Summary of Analyses of Variance for Dependent Measures (Hypotheses 3A & 3B: Comparison of Cells 1 & 2 with 5 & 6, N = 13) 109 7. Summary of Analyses of Variance for Hardiness Scale (N = 13) 113 8. Summary of Analyses of Variance for Emotion-Focused Coping Scale (Number of Strategies Used) N = 13 116 9. Summary of Analyses of Variance for Problem-Focused Coping Scale (Number of Strategies Used) N = 13 117 10. Behavioural Coping Strategies Used by a l l Subjects Pre- and Post-Training (N = 13). ... 12 0 11. Effect Sizes for Measures (N = 13, 2 Groups Pooled) 121 12. Fequency of Responses from Session Feedback 124 i x Table Page 13. Number of Responses to Evaluation for A l l Sessions 127 14. Suggestions for Improvements to the Course. . 128 15. Summary of S i g n i f i c a n t Results from Analyses of Variance for the Main Hypotheses 130 X L i s t of Figures Figure Page 1. A transactional model i l l u s t r a t i n g some possible factors involved i n the process of poor physician-patient communication 4 2. Testing room arrangement 71 3. Training room arrangement VI 4. Experimental design 79 5. C e l l s used i n ANOVAS to te s t hypotheses 1A and IB 86 6. C e l l s used i n ANOVAS to te s t hypotheses 2Ai through 2 B i i i 87 7. C e l l s used i n ANOVAS to te s t hypotheses 3A and 3B 89 8. Means for percentage of l e v e l 3 responses rated on the Carkhuff Empathy Scale 98 9. Means for simulated patient ratings on the Empathy Scale of the BLRI 99 10. Means for medical student ratings on the Empathy Scale of the BLRI 100 11. Means for medical student ratings on the Perceived Stress Scale 101 12. Means for Hardiness Scale 114 13. Means for Emotion-Focused Coping Scale 118 14. Means for Problem-Focused Coping Scale 119 15. Outline of differences i n medical students emotions and coping behaviours before and af t e r empathy t r a i n i n g 138 x i Acknowledgements I wish to express my h e a r t f e l t gratitude to the members of my d i s s e r t a t i o n committee, Dr. Don Dutton, Dr. Carol Herbert, and Dr. Doug Willms for t h e i r time, patience, and suggestions throughout the preparation of t h i s research project. My deep appreciation goes to my chairman, Dr. B i l l Borgen, for h i s constant support, encouragement, and assistance. Dr. Keith Dobson and Dr. Peter Grantham offered valuable ideas during the design stage of t h i s study. I am g r a t e f u l to the 13 graduate students i n counselling psychology who served as simulated patients, t r a i n e r , and raters. My thanks go also to the medical students who devoted t h e i r time for t h i s study. In loving memory of my Mother, Mary Kathleen "In the earliest days and weeks of l i f e , the mother . . . initiates an empathic relationship. . . whereby the child can, in turn, be empathic with others. — G l a d s t e i n , 1987: 122 1 CHAPTER I I n t r o d u c t i o n Background The i n t e r a c t i o n between physicians and t h e i r patients has been said to be the keystone of medicine (Engel, 1973). An in t e g r a l aspect of t h i s interpersonal encounter i s communication. I t i s through communication with patients that physicians are able to e l i c i t and convey information which may have an impact upon the e f f e c t i v e delivery of health care (White, 1988). Indeed, Cassell (1985) suggested that e f f e c t i v e communication represents the central s k i l l on which a l l other a b i l i t i e s i n the practice of medicine depend. Even though e f f e c t i v e communication i s v i t a l i n medicine, only recently has much emphasis has been placed on communication s k i l l s (Badenoch, 1986; Waitzkin, 1984). Most medical schools, u n t i l the l a s t decade, d i d not o f f e r interpersonal communication s k i l l s t r a i n i n g (Kahn, Cohen, & Jason, 1979). The assumptions appeared to be that ei t h e r a person had the i n s t i n c t s to be a good communicator or not, and that these s k i l l s would be developed with experience through i n t u i t i o n or.imitation (Riccardi & Kurtz, 1983). Recent research, however, indicates that more attention needs to be given to the development of communication s k i l l s i n medical students and physicians (Bernstein & Bernstein, 1985; Cassell, 1985; White, 1988). 2 One aspect of communication s k i l l s t r a i n i n g which has been i d e n t i f i e d as lacking i n medical schools i s the teaching of empathy s k i l l s (Sanson-Fisher & Maguire, 1980). The main purpose of t h i s study was to examine the effectiveness of empathy s k i l l s t r a i n i n g for medical students, p a r t i c u l a r l y when they are challenged by emotionally intense encounters with simulated patients. Empathy, which i s a core ingredient of the helping process i n counselling and psychotherapy (e.g., Rogers, 1957; Egan, 1986), may help physicians i n t h e i r c l i n i c a l interviews to understand patients' emotional needs which often accompany i l l n e s s . Dealing with such emotional needs often involves working with intense a f f e c t related to su f f e r i n g , fear and death (McCue, 1982). Also, patients often expect counselling and help from t h e i r physicians i n dealing with t h e i r psychosocial issues (Baker & Cassata, 1978; Good, Good, & Cleary, 1987; Hansen, Bobula, Meyer, Kushner, & Pridham, 1987; Herbert, Cooke, Gutman & Schechter, 1986). Working with such intensely emotional aspects of patient care has been i d e n t i f i e d as a source of stress f o r p r a c t i s i n g physicians (Herbert & Grams, 1986; May & Revicki, 1985; McCranie, Hornsby, & Calvert, 1982). Medical students also reported that coping with intense emotions i n t h e i r interactions with patients contributes to t h e i r high stress l e v e l s ( F i r t h , 1986; Knight, 1983). F i r t h (1986) concluded that there i s a need to i d e n t i f y means which can help 3 a l l e v i a t e medical students' d i s t r e s s when dealing with s t r e s s f u l aspects of patient care such as su f f e r i n g . Branch (1987) suggested that the reason physicians experience discomfort i n dealing with the emotional needs of patients i s that they lack t r a i n i n g i n t h i s area. Heavy (1988) pointed out that physicians, f e e l i n g a sense of f a i l u r e i n the curing r o l e , may avoid dealing with patients' issues and so may appear aloof or i n s e n s i t i v e . She concluded that i t i s necessary for medical p r a c t i t i o n e r s to receive empathy t r a i n i n g for the sake of both themselves and t h e i r patients. Physicians themselves have indicated a need for t r a i n i n g i n dealing with psychosocial needs of patients. In a survey of 151 physicians from a va r i e t y of s p e c i a l t i e s , Lewis, Wells, and Ware (1986) found that 85 percent of them agreed that counselling patients was important; however, only 12 percent said they were e f f e c t i v e i n counselling. Medical students also have indicated a need for t r a i n i n g i n dealing with emotional issues. Batenburg and Gerritsma (1983) found that medical students indicated a need for further experience i n coping with patients' emotions even though they had a basic interviewing s k i l l s course. I t i s important, then, for medical students to receive empathy communication s k i l l s t r a i n i n g because they spend considerable time, both as students and as p r a c t i s i n g physicians, i n emotionally intense involvement with patients which can be a s i g n i f i c a n t source of stress. 4 Figure 1 i l l u s t r a t e s some of the consequences of lack of t r a i n i n g and ensuing stress experienced by medical students and physicians when they are presented with emotionally intense interactions. Presentation of Expectations Lack of training. Strong emotional Stress for both intense emotional by patient of in communication discomfort by physician physician and patient issue by patient ^ ^ physician to deal ̂  ^ skills by physician ̂  ^ and possible 4 ^ ensues, which may result with intense to respond avoidance of emotional issue effectively to patient's emotional intense emotional issue issue in an unsatisfactory physician-patient relationship Figure 1. A transactional model i l l u s t r a t i n g some possible factors involved i n the process of poor physician- patient communication. Objectives of the Study The recognition of the importance of good physician- patient communication highlights the need for research to determine the effectiveness of interpersonal communication s k i l l s t r a i n i n g i n t h i s s e t t i n g (Betchart, Anderson, Thompson, & Mumford, 1984). Poole and Sanson-Fisher (1979) recommended that t r a i n i n g i n empathic s k i l l s be provided, but only with continual evaluation of i t s effectiveness. However, a number of methodological issues have been i d e n t i f i e d which must be considered when determining the effectiveness of a communication s k i l l s t r a i n i n g course. C a r r o l l and Munroe (1980) and Sanson-Fisher, Fairbairn, and Maquire (1981), i n t h e i r two reviews of the methodologies 5 of studies used to evaluate the ef f e c t s of communication s k i l l s t r a i n i n g , suggested that the great majority of studies have employed weak research designs (e.g., no control group), and so the v a l i d i t y of the findings must be questioned. They suggested r e p l i c a t i n g studies with more control over p o t e n t i a l l y confounding factors. Kahn et a l . (1979) i n another review of studies reported that while 95 percent of interviewing courses had an evaluation component, 87 percent of these used i n d i r e c t methods such as class attendance or student knowledge. Few used d i r e c t observation of s k i l l s or criterion-referenced instruments. Wolraich, Albanese, and Stone (198 6) pointed out that one of the ba r r i e r s to evaluating physician-patient interactions i s the dearth of r e l i a b l e and v a l i d instruments to assess communication s k i l l s . Gask, Goldberg, Lessar, and M i l l a r (1988) suggested that few communication t r a i n i n g courses evaluated the changes i n s k i l l s by assessing videotaped interviews pre- and post-training. The purpose of the present study was to examine the effectiveness of empathy communication s k i l l s t r a i n i n g for medical students e s p e c i a l l y when they are challenged by emotionally intense c l i n i c a l s i t u a t i o n s . To avoid some of the shortcomings of previous research i n the area, t h i s study employed a "true" experimental design (Cook & Campbell, 1979), d i r e c t observation of s k i l l s from videotaped interviews, and r e l i a b l e and v a l i d research instruments designed to measure aspects that the intervention was meant to a f f e c t . 6 Many studies have attempted to evaluate the effectiveness of physicians' communication s k i l l s i n terms of patient s a t i s f a c t i o n . However, one of the common reasons why communication s k i l l s t r a i n i n g i s not offered i n medical schools as suggested by Wakeford (1983) i s "You haven't proved that i t w i l l help the medical students" (p. 245). This study investigated whether empathy s k i l l s t r a i n i n g would help medical students by decreasing t h e i r stress l e v e l s i n emotionally intense s i t u a t i o n s . The main research question of t h i s study was: What i s the impact of empathy t r a i n i n g for medical students, both i n terms of increasing t h e i r l e v e l s of empathy as well as decreasing t h e i r l e v e l s of perceived stress i n emotionally intense c l i n i c a l interactions? Exploratory questions which, were addressed also i n t h i s study included: (1) Do ce r t a i n personality c h a r a c t e r i s t i c s and behavioural coping strategies change as a r e s u l t of empathy training? (2) What kinds of coping strategies are most commonly used by medical students to cope with the stress of medical training? (3) What processes of the t r a i n i n g do the trainees l i k e the best, the least, and learn by the most? 7 O p e r a t i o n a l D e f i n i t i o n s Empathy Barrett-Lennard (1981) suggested that the process of empathy involves three d i s t i n c t phases. Phase one ref e r s to the inner process of empathic l i s t e n i n g and understanding by the c l i n i c i a n . Phase two refers to the communicated or expressed empathic understanding by the c l i n i c i a n . The t h i r d phase of the empathy cycle i s received empathy by the c l i e n t . Barrett-Lennard d i f f e r e d from Truax and Carkhuff with regard to the operational d e f i n i t i o n of empathy. Truax and Carkhuff (19 67) held the view that empathy may be defined i n terms of the therapist's behavior alone. Barrett-Lennard maintained that the c l i n i c i a n ' s and c l i e n t ' s subjective experience p a r t l y defines the empathic process, and he included the c l i n i c i a n ' s and c l i e n t ' s inner processing i n his operational d e f i n i t i o n (Barrett-Lennard, 1962, 1981). In t h i s study, medical student experienced empathy, or empathic understanding, i s operationally defined as a score on the c l i n i c i a n form (MO) of the Empathy scale of the Barrett- Lennard Relationship Inventory (Barrett-Lennard, 1962). Communicated empathy i s defined as the degree to which medical students 1 statements expressed empathic understanding as measured by Carkhuff's (1969) 5-point scale. Received empathy, or how empathic the simulated patient perceived the medical student to be, i s operationally defined as the score on the c l i e n t form (OS) of the Empathy scale of the Barrett- Lennard Relationship Inventory (Barrett-Lennard, 1962). 8 S t r e s s Researchers who study stress have been unable to reach general agreement regarding a d e f i n i t i o n of stress. Monat and Lazarus (1985) suggested that stress i s a general l a b e l for a complex and i n t e r d i s c i p l i n a r y area of study. Stress generally refe r s to "any event i n which environmental demands, in t e r n a l demands, or both tax or exceed the adaptive resources of an i n d i v i d u a l " (Monat & Lazarus, 1985, p. 3). Folkman and Lazarus (1980) defined two important processes involved when a person i s affected by a s t r e s s f u l occurrence i n the environment. One i s appraisal and the other i s coping. Appraisal refers to the cognitive processes used to evaluate the s t r e s s f u l s i t u a t i o n and the options available to deal with i t . In t h i s study, appraisal by the subjects of the emotionally intense interactions with the simulated patient i s operationally defined as scores on the Perceived Stress Scale which I developed for the purposes of t h i s research. Coping Coping ref e r s to an i n d i v i d u a l 1 s response to stress or one's e f f o r t s to adapt i n situations which one appraises as being harmful, threatening, or challenging (Lazarus & Folkman, 1984). There appears to be two d i f f e r e n t approaches to the study of coping. Some investigators have emphasized coping t r a i t s or personality dispositions (Goldstein, 1973), while 9 other researchers have studied active, ongoing coping strategies used i n p a r t i c u l a r s t r e s s f u l s i t u a t i o n s (Folkman & Lazarus, 1980). Monat and Lazarus (1985) suggested that the study of coping, which i s t i e d to the study of stress, should focus on measuring both coping processes and personality d i s p o s i t i o n s . In the present study, coping with stress with respect to personality d i s p o s i t i o n was operationally defined by scores on Kobasa's (1979) personality-based Hardiness measure comprised of commitment, control and challenge. Stress with respect to coping behaviours used to cope with the stress of medical t r a i n i n g was operationally defined as the number and types of coping strategies used (problem focused and emotion focused) as indicated on the Ways of Coping Scale (Donnelly, 1979). Assumptions and Limitations The context for examining the research question was an i n t e r a c t i o n between a medical student and a simulated patient. One assumption of t h i s study was that the analog would be s u f f i c i e n t l y s i m i l a r to a session of an actual medical interview to enable the r e s u l t s to be generalized to such a session and that simulated patients could be regarded as s i m i l a r to patients i n general, who are functioning normally and who are free of gross psychopathology. Researchers have found that the use of simulated patients has been e f f e c t i v e i n assessing medical students' 10 communication s k i l l s (e.g., Sanson-Fisher & Poole, 1980; Hannay, 198 0). One of the advantages of using simulated patients i n the study of physician-patient interactions i s that i t i s possible to have more control over maintaining s i m i l a r i n t e n s i t y l e v e l s and nature of emotions presented. Further, simulated patients were found to be so authentic that medical students and physicians could not d i s t i n g u i s h them from r e a l patients (Norman, Tugwell, & Feightner, 1982; O'Hagan, 1986; Sanson-Fisher & Poole, 1980). Also Zimbardo (1977) found, i n h i s mock prison research, that the guards and• prisoner subjects developed attitudes which were quite indistinguishable from r e a l guards and prisoners. Thus the assumption that r e s u l t s can be generalized to r e a l patient- physician interactions has some empirical support. The experiencing of intense emotions was assumed to be a universal human experience which i s consistent across persons from a l l cultures (Buck, 1984). A further assumption was that only those professionals who have professional t r a i n i n g and experience i n interpersonal s k i l l s are able to assess empathy accurately (Carkhuff & Burstein, 1970). Regarding l i m i t a t i o n s , the subjects were a l l volunteers which may have been a source of bias i n the sample. P a r t i c i p a t i o n i n the study was time-consuming, so that those subjects who were most motivated to learn empathy communication s k i l l s may have volunteered. 11 This study was conducted with subjects from a second year medical c l a s s . S t r i c t l y speaking, r e s u l t s may be generalized to those medical students i n t h i s class year. However, i t possesses implications for physician-patient interactions i n general. I assume that empathy i s a core f a c i l i t a t i v e condition i n any helping rel a t i o n s h i p and that high l e v e l s of helper empathy may help to increase helpee s e l f awareness and release the poten t i a l for the helpee to make constructive changes with regard to the problem presented. Overview o f t h e Document Chapter two contains a review of the relevant l i t e r a t u r e and a rat i o n a l e for the research problem. Chapter three provides d e t a i l s about the research design and experimental procedures. Results of the s t a t i s t i c a l treatment of the data are presented i n chapter four. Chapter f i v e includes a discussion of the re s u l t s and suggestions for further research. 12 CHAPTER II Literature Review Introduction The pu r p o s e s o f t h e f i r s t p a r t o f t h i s l i t e r a t u r e r e v i e w a r e t o p r o v i d e a r a t i o n a l e f o r t h e s t u d y and t o c l e a r l y d e f i n e t h e r e s e a r c h problem. The c h a p t e r opens w i t h a d i s c u s s i o n o f t h e v a l u e o f e f f e c t i v e communication and s k i l l t r a i n i n g f o r m e d i c a l p r a c t i t i o n e r s . The t r e n d t oward a d o p t i n g a b i o p s y c h o s o c i a l model o f m e d i c i n e and t r a i n i n g p h y s i c i a n s t o be more humane i s examined. A d i s c u s s i o n o f t h e c o n c e p t o f empathy i s f o l l o w e d by an e x p l o r a t i o n o f t h e i m p o r t a n c e o f empathy i n t h e p h y s i c i a n - p a t i e n t r e l a t i o n s h i p , e s p e c i a l l y i n e m o t i o n a l l y l a d e n e n c o u n t e r s w h i c h can be a s o u r c e o f s t r e s s f o r m e d i c a l p r a c t i t i o n e r s . P r e v i o u s r e s e a r c h l i n k i n g t h e t o p i c s o f empathy and s t r e s s a r e examined. St a t e m e n t s o f t h e hyp o t h e s e s a d d r e s s e d i n t h i s i n v e s t i g a t i o n a r e i n c l u d e d . L i t e r a t u r e r e l e v a n t t o t h e e x p l o r a t o r y q u e s t i o n s i s a l s o r e v i e w e d . The second p a r t o f t h i s c h a p t e r c o n t a i n s a r e v i e w o f some o f t h e e m p i r i c a l s t u d i e s r e l e v a n t t o t h e r e s e a r c h problem and a d i s c u s s i o n o f i s s u e s i n v o l v e d i n empathy t r a i n i n g f o r p r a c t i c i n g p h y s i c i a n s and m e d i c a l s t u d e n t s . 13 V a l u e o f E f f e c t i v e Communication i n t h e M e d i c a l I n t e r v i e w E f f e c t i v e communication between physicians and t h e i r patients i s an important component of medical care. Patients value and appreciate good communication with t h e i r physicians. Matthews, Sledge, and Lieberman (1987) found through an evaluation of 27 interns by 212 inpatients that the patients valued interpersonal s k i l l s and c l i n i c a l s k i l l s equally. B u l l e r and B u l l e r (1987) also found that patients' evaluations of medical care and patients' evaluations of t h e i r physicians' communication competence were strongly associated. P o s i t i v e communication influences not only patients' subjective evaluations, but biochemical processes as well. Kaplan, Greenfield, and Ware (1989) found that patients' health outcomes whether measured p h y s i o l o g i c a l l y , behaviourally, or subjectively were a l l related to aspects of the interactions between physicians and t h e i r patients. Indeed scholars have concluded that the process of healing i s p a r t i a l l y interpersonal, and i s greatly influenced by physician-patient communication (Cousins, 1982). According to Friedman and DiMatteo (1979), to ignore t h i s fact i s a s c i e n t i f i c error. Physicians also recognize that e f f e c t i v e communication with patients i s important. For instance, i n a survey of 387 general p r a c t i t i o n e r s concerning t h e i r r o l e i n the health care system, 92.9% of the respondents indicated t h e i r strong support of the view that communication i s important (Cockburn, 14 K i l l e r , Campbell, & Sanson-Fisher, 1987). The advantages of e f f e c t i v e communication are not li m i t e d to s p e c i a l t i e s such as family pra c t i c e . In surgery, for instance, e f f e c t i v e communication reduces post-operative complications and analgesic requirements (Richards & McDonald, 1985). E f f e c t s of Miscommunication i n the Medical Interview Poor communication i n the physician-patient r e l a t i o n s h i p can lead to negative consequences. For instance, miscommunication i n the medical interview can lead to poor rapport, patient noncompliance and d i s s a t i s f a c t i o n , errors i n diagnosis and "doctor-shopping" (DiMatteo, Prince, & Hays, 1986; Harrigan & Rosenthal, 1986; J a r s k i , Gjerde, Bratton, Brown, & Matthes, 1985; Lavin, 1983; Ley, 1982; Riccardi & Kurtz, 1983). Patients complain more about poor communication with t h e i r physicians than about any thing else (Murtagh & E l l i o t t , 1987). In fact, poor communication between patients and t h e i r physicians has been c i t e d as the most common cause of malpractice l i t i g a t i o n (Garr & Marsh, 1986; Numann, 1988). Because of the public d i s s a t i s f a c t i o n with the qual i t y of the physician-patient relationship, one remedy may be to give more attention to the development of communication s k i l l s i n medical students and physicians (Bernstein & Bernstein, 1985; Cas s e l l , 1985). C a r r o l l and Monroe (1979) reviewed 73 studies on medical interviewing and concluded that ". . .. the importance of medical interviewing s k i l l s i s demonstrated by recent research i d e n t i f y i n g interpersonal communication as a 15 major cause o f v a r i a n c e i n p a t i e n t s a t i s f a c t i o n , p a t i e n t c o m p l i a n c e , and t h e i n c i d e n c e o f m a l p r a c t i c e l i t i g a t i o n " (p. 498) . The Emergence o f Communication S k i l l s T r a i n i n g i n M e d i c a l E d u c a t i o n I n s p i t e o f t h e f a c t t h a t communication between p h y s i c i a n s and p a t i e n t s has been acknowledged as b e i n g i m p o r t a n t , i t has o n l y been i n r e c e n t y e a r s t h a t any emphasis has been p l a c e d on t e a c h i n g o r r e s e a r c h i n g t h e e f f e c t i v e n e s s o f communication s k i l l s t r a i n i n g . A number o f r e a s o n s can be i d e n t i f i e d why m e d i c a l s c h o o l s have n o t f o c u s e d a t t e n t i o n on t e a c h i n g communication s k i l l s u n t i l r e c e n t l y . F i r s t o f a l l , t h e r e seemed t o be t h e a s s u m p t i o n t h a t t h e a b i l i t y t o communicate e f f e c t i v e l y was i n n a t e and t h a t t h e s e s k i l l s would be d e v e l o p e d t h r o u g h i n t u i t i o n o r i m i t a t i o n ( R i c c a r d i & K u r t z , 1983). However, a r e c e n t s t u d y by Kramer, Ber, and Moore (1989) r e v e a l e d t h a t i n o r d e r f o r s t u d e n t s t o l e a r n communication s k i l l s , t h e y had t o p a r t i c i p a t e i n t r a i n i n g ; b e i n g t a u g h t r e g u l a r c l a s s e s by i n s t r u c t o r s who r e c e i v e d t h e t r a i n i n g and who a c t e d as r o l e models was n o t e f f e c t i v e i n i m p r o v i n g m e d i c a l s t u d e n t s ' s k i l l s . A n o t h e r r e a s o n t h a t communication s k i l l s were n o t o f f e r e d i s t h a t t h e b i o m e d i c a l model w h i c h has been t h e dominant c l i n i c a l method i n m e d i c i n e f o r o v e r 100 y e a r s f o c u s e s p r i m a r i l y on t h e p h y s i c a l a s p e c t s o f i l l n e s s . I t i s p u r e l y 16 objective and does not focus on such subjective processes as interpersonal relationships and feelings (McWhinney, 198 6). T r a d i t i o n a l medical t r a i n i n g has concentrated on teaching technical and s c i e n t i f i c material, taking a more mechanistic approach (Cockburn et a l . , 1987; Numann, 1988; Putnam, S t i l e s , Jacob, & James et a l . , 1988). Further, there have been many advances i n technology and medical knowledge (Schwartz & Wiggins, 1985). Consequently, the t r a d i t i o n a l biomedical method, which was based on the notion of Cartesian dualism, resulted i n the s p l i t i n focus between the psyche and soma (Carek, 1987). Unfortunately, what seems to have occurred i s a p o l a r i t y between the science and the a r t of medicine, between "compassion and competence," between caring and curing, between technology and human factors (Cousins, 1988). As a r e s u l t of t h i s mind-body s p l i t the physician-patient r e l a t i o n s h i p has suffered. Physicians themselves are recognizing the consequences of the imbalance i n focus between technological advances and emotional aspects of curing. As stated by G o r l i n and Zucker (1983) i n a s p e c i a l a r t i c l e i n the New England Journal of Medicine: Something has gone wrong i n the practice of medicine, and we a l l know i t . I t i s i r o n i c that i n t h i s era, dominated by technical prowess and rapid biomedical advances, patient and physician each f e e l s increasingly rejected by the other. Clearly, one root of the problem l i e s i n the patient-doctor r e l a t i o n s h i p , (p. 1059) Lipkin (1987) further elaborates on the breakdown i n physician-patient relationships: 1 7 Patients have been alienated by the growing schism between the human and the medical. The prestige of the physician has appeared to dwindle: increasingly, people f e e l that t h e i r doctors do not or cannot l i s t e n . . . The s k i l l s of interviewing and physical examination that once linked the doctor and the patient have rusted. There has been a breakdown i n communication here. (p. 363) There appears to be an e f f o r t towards finding a balance between natural science and humanism. Recent attempts to conjoin natural sciences and humanism have been c a l l e d the "doctor's dilemma" (Moulyn 1988, p.149) and the "challenge for the 1980's and beyond" (Arnold, Povar, & Howell, 1987, p.3). Questions ensuing from t h i s challenge include: "How i s humanism to be incorporated with the t r a d i t i o n a l biomedical model?" and "How can humanism be taught?" There have been some attempts to introduce a l t e r n a t i v e s to the t r a d i t i o n a l biomedical model i n order to increase physicians* s e n s i t i v i t i e s to patients' emotional concerns. For instance, B a l i n t i n the l a t e 1950's introduced h i s notion of patient-centred medicine as opposed to disease-centred medicine, and he began to o f f e r groups for general p r a c t i t i o n e r s i n order to focus on physicians' feelings about interactions with patients (Balint, 1957). Later, i n 1977, Engel introduced an a l t e r n a t i v e model to the t r a d i t i o n a l one, which he termed the biopsychosocial model. He proposed that psychological and s o c i a l aspects of a person be considered i n medical interactions because the current biomedical model was inadequate i n t h i s regard. More recently, Levenstein, McCracken, McWhinney, Stewart, and Brown 18 (1986) introduced the patient-centred c l i n i c a l method fo r family medicine. In t h i s model in c l u s i o n i s made of not only doctors' agendas, as i s the case i n disease-centred medicine, but of patients' agendas as well. These scholars encouraged physicians to make e f f o r t s to understand p a t i e n t s 1 experiences of t h e i r i l l n e s s e s . With the emergence of new trends i n medicine, and value being placed on p o s i t i v e physician-patient communication, medical educators are now placing focus on acquiring e f f e c t i v e communication s k i l l s (Bernstein & Bernstein, 1986; C a s s e l l , 1985). As Reiser pointed out i n C a s s e l l (1985): I t i s c r u c i a l for modern medicine to e s t a b l i s h a balance between understanding general b i o l o g i c processes that make us i l l and understanding the i l l n e s s as experienced and produced by the patient. To learn of the l a t t e r , the verbal and nonverbal elements of human communication i n medical care must be understood and mastered, (p., x) A conclusion r e s u l t i n g from a conference i n which 40 physicians and other scholars met to discuss the biopsychosocial model of health and disease was that " a c q u i s i t i o n of interviewing and communications s k i l l s i s not only a desirable means, but probably the only means, for both appreciating and applying a more i n c l u s i v e model of health and disease" (White, 1988, p. 37). A recommendation made at t h i s conference was that further research using sound empirical methods i s needed to support the adoption of the more in c l u s i v e medical model. To date, much of the evidence has 19 been anecdotal and descr i p t i v e . In p a r t i c u l a r , more research i s needed which demonstrates the effectiveness of communication s k i l l s t r a i n i n g (White, 1988). One of the goals of the present study i s to provide such research. Increasing Humanism i n Medical Students In order to improve the q u a l i t y of the physician-patient r e l a t i o n s h i p so that good communication can occur, attempts are being made by medical educators to enhance humanistic q u a l i t i e s such as compassion and caring i n medical students (Henderson, 1981; Robinson & B i l l i n g s , 1985). In 1980, the American Board of Internal Medicine Committee on the D e f i n i t i o n of C l i n i c a l Competence i d e n t i f i e d s i x basic elements of c l i n i c a l competence, two of which were humanistic q u a l i t i e s and communication s k i l l s (Blurton, & Mazzaferri, 1985). The Committee, concluded i n 1983 that medical t r a i n i n g programs had a major r e s p o n s i b i l i t y to stress human q u a l i t i e s , e s p e c i a l l y i n t e g r i t y , respect, and compassion i n the physician-patient r e l a t i o n s h i p (Benson et a l . , 1983). The Board now requires that a l l residents be assessed for t h e i r humanistic q u a l i t i e s and behavior i n order for them to be c e r t i f i e d (Krevans, 1983). Also, i n 1987, the medical ethics subcommittee of the American Board of Ped i a t r i c s published a paper i n d i c a t i n g that interpersonal s k i l l s was one of the subject areas i n which t h e i r candidates would be examined for c e r t i f i c a t i o n . Included was the requirement that physicians should have some knowledge of and s k i l l s i n counselling 20 techniques to enhance p o s i t i v e communication with patients and t h e i r families (Daeschner, 1987). Harvard University has begun a new Pathway Program with the goals of creating more humane and caring physicians so that relationships with patients can be improved (Stark, 1986). Herbert (1986) stated that "the approach at U.B.C. Medical School c i r c a 1986 i s to emphasize the biopsychosocial model of disease and i l l n e s s as the context for a l l teaching and treatment" (p. 537). I t was recommended by a U.B.C. Faculty of Medicine Subcommittee that behavioral science as i t applies to medicine, including the s k i l l area of the doctor- patient r e l a t i o n s h i p , be integrated into a l l medical d i s c i p l i n e s (Herbert, 1986). In h i s President's address to the American Medical Association i n June, 1989, Nelson urged that research be done to investigate ways to increase such values as humanism and altruism i n medicine and also to develop ways to measure humanism i n attempts to meet the challenge of reducing the imbalance between the a r t and science of medicine. Nelson (1989) suggested, "The a b i l i t y to provide the s c i e n t i f i c miracles of the future w i l l depend on our understanding and application of the art of medicine" (p. 1230). While there appears to be widespread agreement that attempts must be made to create more humane physicians, scholars i n the area have recognized that there i s a lack of agreement as to the d e f i n i t i o n of humanism. Arnold et a l . (1987) suggested that a humane physician possesses not only 21 technical competence, but also humanistic attitudes, behavior and knowledge of humanistic concepts. Linn, DiMatteo, Cope, and Robbins, (1987) suggested that humanism be measured i n terms of attitudes, values and behaviors. In order to investigate the way i n which "humanism" was defined and measured, Linn et a l . (1987) conducted both a l i t e r a t u r e review and a survey of researchers and c l i n i c i a n s who were interested i n the area of patient-physician r e l a t i o n s h i p s . They found that there were 132 d i f f e r e n t d e f i n i t i o n s of "humanism"; however, the most frequently mentioned q u a l i t y of a humanistic physician was empathy. S i m i l a r l y , Kramer,Ber, and Moore (1987) defined "dehumanization" i n part as the reduction of empathic behaviors. Empathy, then, may be considered to be one key dimension of "humanism". Also research has shown a l i n k exists between empathy and altruism (Batson, Fu l t z , & Schoenrade, 1987). One way to increase humanism and altruism therefore may be to o f f e r empathy communication s k i l l s t r a i n i n g . Before a discussion of issues involved i n empathy t r a i n i n g however, the top i c of defining the concept of empathy w i l l be addressed. The Concept o f Empathy The word "empathy" was translated i n the early 1900s by E.B. Tirchener from the German word "Einfuhlung" which means "f e e l i n g together with" (Goldstein & Michaels, 1985). The early Greek word "empatheia" means a strong f e e l i n g of connection with another person, with a q u a l i t y of s u f f e r i n g . 22 Empathy i n the general sense may re f e r to the process of understanding others (Allport, 1963) or to a "connectional q u a l i t y " which has to do with the meaning of being human (Barrett-Lennard, 1981). For example, one person may imagine another who has suffered a tragedy as f e e l i n g sad, because she herse l f has f e l t sad, although the circumstances for the two indi v i d u a l s which give r i s e to the f e e l i n g may be very d i f f e r e n t . This f e l t sense of "putting oneself i n another's shoes and understanding how the other i s thinking and f e e l i n g " can occur without two people necessarily i n t e r a c t i n g . Observational empathy ( i . e . , being emotionally moved while observing others and not necessarily i n t e r a c t i n g with them), i s a common everyday experience, and "may make the difference between a world of profound a l i e n a t i o n or danger for humankind, and a progression toward the common experience of humanity as f a m i l i a r " (Barrett-Lennard, 1981, p. 98). Indeed, some people hold the view that empathy can help to resolve tensions not only between indi v i d u a l s , but among nations and t e r r o r i s t groups as well (Gladstein, 1987). In the early 1950s, Carl Rogers presented the f i r s t therapeutic application of the word "empathy" at the time when he led the humanistic movement i n psychology. The term became well known a f t e r Rogers introduced empathic understanding as one core a t t i t u d i n a l condition of his client-centered ( l a t e r known as person-centered) psychotherapy. His d e f i n i t i o n of empathy was "to perceive the in t e r n a l frame of reference of another with accuracy, and with the emotional components and 23 meanings which pertain thereto, as i f one were the other person, but without ever l o s i n g the 'as i f condition" (1959, p. 210). According to Rogers, empathy i s not only a basic element of e f f e c t i v e interpersonal relationships, but also one of the three e s s e n t i a l c h a r a c t e r i s t i c s of a successful therapeutic relationship, along with helper genuineness and unconditional p o s i t i v e regard. Although Rogers suggested that the three are e s s e n t i a l , he was of the opinion that empathy was of prime importance. From Roger's perspective, empathy i s v i t a l for any therapeutic i n t e r a c t i o n . I f a helper i s empathic, that i s , acknowledges the helpee's inner world of feelings and meanings, and communicates t h i s understanding, then the helpee f e e l s accepted and safe enough to continue s e l f - e x p l o r a t i o n , thus allowing p o s i t i v e change to occur. Rogers believed that when the helpee experiences t h i s caring ". . . the growthful p o t e n t i a l of any i n d i v i d u a l w i l l tend to be released . . . " (Meador & Rogers, 1982, p.131). Research has revealed that e f f e c t i v e therapists, regardless of t h e i r t h e o r e t i c a l orie n t a t i o n or t r a i n i n g , convey empathic understanding to t h e i r c l i e n t s (Baruth & Huber, 1985). Empathy, then, i s a c r u c i a l element which has application i n interpersonal helping re l a t i o n s h i p s where the healthy psychological growth of i n d i v i d u a l s i s a goal. E l l i o t t (1982) observed that "empathy i s probably the most widely c i t e d and studied process variable i n counselling and psychotherapy l i t e r a t u r e " (p. 379) . However, as a number 24 of scholars have noted, the concept of empathy i s both complex and elusive (e.g., Batson et a l . , 1987; Gladstein, 1987; Goldstein, & Michaels, 1985). Batson et a l . (1987) have said "Psychologists are noted for using terms loosely, but i n our use of empathy we have outdone ourselves," (p. 19). Hackney (1978) pointed out that by 1968, i n the counselling psychology l i t e r a t u r e alone, there were 21 d e f i n i t i o n s of empathy. While Rogers' d e f i n i t i o n focused more on the empathic state or condition of a helper, Truax and Carkhuff (1967) included emphasis on the communication of empathic understanding, that i s , behavioral and verbal expressions by the helper, i n t h e i r d e f i n i t i o n of empathy. Thus there was a s h i f t of emphasis from in t e r n a l state to external s k i l l , from q u a l i t a t i v e condition to quantifiable s k i l l (Hackney, 1978). As the d e f i n i t i o n s of empathy since the introduction of the therapeutic meaning of the term by Rogers evolved and moved away from a q u a l i t a t i v e attitude toward a quantifiable process, t r a i n i n g procedures changed i n t h i s d i r e c t i o n also. Empathy t r a i n i n g models began to focus less on helper attitudes and more on behavioural helping s k i l l s (Kurtz & Marshall, 1982). Although the core conditions of Rogers' theory have been emphasized as key elements i n widely practised helping models such as those of Carkhuff (1969), Gazda, Walters, and Childers (1975) and Egan (1986), the emphasis of these t r a i n i n g models appears to be on developing helper communication s k i l l s . 25 Barrett-Lennard (1981) suggested that, i n order to f u l l y understand the concept of empathy, i t must be viewed as a process, not only as verbal communication by the c l i n i c i a n . The process of empathy involves three d i s t i n c t phases. Phase one ref e r s to the inner process of empathic l i s t e n i n g and understanding by the c l i n i c i a n . Phase two ref e r s to the communicated or expressed empathic understanding by the c l i n i c i a n . The t h i r d phase of the empathy cycle i s received empathy by the c l i e n t . This empathy cycle takes into account both a f f e c t and cognition as well as the experience of both c l i e n t and c l i n i c i a n . Several instruments have been developed designed to measure the various aspects of empathy. Barrett-Lennard developed the Empathic Understanding Scales which are part of the Relationship Inventory that measures the f i r s t and t h i r d phase of empathy cycles. These subjective scales are completed by both the helper (phase one) and helpee (phase three). Truax and Carkhuff (1967) hold the view that empathy may be defined i n terms of the helper's behaviour alone, and they developed a 5-point rating scale which measures phase two of the empathy cycle. The r a t i n g scales developed by Barrett-Lennard and Truax and Carkhuff are the two most common instruments used to measure empathy. Together they are e f f e c t i v e i n measuring the effectiveness of an empathy t r a i n i n g model because they measure a l l components of the empathy cycle. L i t t l e research however, has been done to t e s t the v a l i d i t y of the empathy 26 cycle, and the e f f e c t s of empathy t r a i n i n g for medical students on the three phases has not been examined. In fact, Gladstein (1987) i s of the opinion that well-founded empirical evidence i n the area of empathy i s lacking. Empathy i n t h e P h y s i c i a n - P a t i e n t R e l a t i o n s h i p One of the goals of both the biopsychosocial model and the patient-centred c l i n i c a l method i n family practice appears to be for physicians to achieve an understanding of patients' experiences of t h e i r i l l n e s s e s (Levenstein et a l . , 1986; Weston, Brown, & Stewart, 1989) and to gain some insight into patients' " l i f e w o r l d s " (White, 1988). Understanding patients from t h e i r point of view gives information to physicians about the factors involved i n i l l n e s s . Levenstein et a l . (1986) have pointed out that the idea of a patient-centred approach i s s i m i l a r to Rogers' person-centred approach i n counselling. One of the goals of both i s to understand patients from t h e i r point of view. One of the most important ways to accomplish t h i s goal would appear to be to develop a strong sense of empathy for patients because, according to Rogers, empathy i s the a b i l i t y to understand the " i n t e r n a l frame of reference of another" and communicate t h i s understanding i n terms of feelings and meanings. Carkhuff (1969) wrote of the general importance of empathy i n the helping process: 27 Empathy i s the key ingredient of helping. I t s e x p l i c i t communication, p a r t i c u l a r l y during early phases of helping i s c r i t i c a l . Without an empathic understanding of the helpee's world and h i s d i f f i c u l t i e s as he sees them there i s no basis for helping, (p. 173) The a b i l i t y . o f physicians to project empathic understanding may be p a r t i c u l a r l y important f o r a number of reasons. F i r s t of a l l , patients are now taking more r e s p o n s i b i l i t y for t h e i r health and they have ideas and are making more decisions about what kind of medical treatment they want (Tuckett et a l . , 1986). Patients want t h e i r physicians to show caring, support, and concern towards them (Ben-Sira, 1980; Campion, 1987, Korsch & Negrete, 1972; Wolinsky & Steiber, 1982). A study of 800 interactions between physicians and mothers who brought t h e i r children to a p e d i a t r i c c l i n i c showed that the main reasons for mothers' d i s s a t i s f a c t i o n were physicians' lack of warmth and f a i l u r e to show in t e r e s t i n the mothers' concerns (Korsch & Negrete, 1972). Empathy i s a way of demonstrating i n t e r e s t and support towards patients. A second reason physicians need empathy s k i l l s i s that many patients expect help from physicians i n managing t h e i r psychosocial concerns. Studies have shown that patients want to be asked about (Yaffe & Stewart, 1986) and provided help with t h e i r psychosocial problems by t h e i r family physicians. Indeed a high percentage of patient v i s i t s i n primary care settings have a psychosocial component (Baker & Cassata, 1978; Good et a l . , 1987; Hansen et a l . , 1987; Herbert et a l . , 1986). 28 Psychosocial problems may be the primary or secondary complaint (Frowick, Schank, Doherty, & Powell, 1986 ). Bernstein and Bernstein (1985) wrote: "As Rakel (1977) points out, primary care physicians need to be prepared to deal with emotional problems since patients tend to cast them i n the counsellor r o l e , prepared or not" (p. 137). I t has been documented that physicians need t r a i n i n g i n counselling s k i l l s (Hansen et a l . , 1987; J a f f e , Radius, & G a l l , 1988). A group of participants at the 1979 National Conference of Family Practice Residents ranked counselling s k i l l s as the area from behavioral sciences which was most relevant to family medicine (Shienvold, Asken, & Cincotta, 1979) . Agras (1982) suggested that physicians must be able to i d e n t i f y those situations i n which patients need counselling. Physicians have i d e n t i f i e d that they do not have the s k i l l s to counsel patients, but they have acknowledged they need them. For instance, i n a survey conducted on 151 physicians, which included 45 general and family physicians, 44 i n t e r n i s t s , 49 surgeons, and 11 obstetrician-gynecologists, 85 percent agreed that counselling i s important and 87 percent agreed that physicians have an ob l i g a t i o n to counsel. However, only 21 percent agreed that physicians knew how to counsel and only 12 percent agreed that they themselves were e f f e c t i v e i n counselling (Lewis et a l . , 1986). Empathy, which i s a core s k i l l i n most counselling models, can be useful to physicians i n situations requiring counselling. 29 A t h i r d reason that i t i s important for physicians to convey empathic understanding to patients i s that many c l i n i c a l encounters are a f f e c t i v e l y laden such as i n the care of terminally i l l people and i n communicating with grieving families (Cassidy, 1986; Fletcher & Sarin, 1988; F u l l e r & Geis, 1985; T o l l e , Bascom, Hickam, & Benson, 1986). E f f e c t i v e communication i s also important when in t e r a c t i n g with angry patients. For example, i n a survey of physicians concerning the r i s k and incidents of abuse by aggressive patients, the respondents indicated that good interpersonal s k i l l s were the most important factors i n l i m i t i n g aggressive incidents (D'Urso & Hobbs, 1989). Empathy has been s p e c i f i c a l l y suggested as a valuable communication s k i l l physicians can use when in t e r a c t i n g with terminally i l l cancer patients (Kinzel, 1988), depressed patients (Peteet, 1979), and angry patients (Lane, 1986). I n t e n s e Emotions as Sources o f S t r e s s f o r M e d i c a l P r a c t i t i o n e r s Working with highly emotional aspects of patient care such as g r i e f , anger, fear, and death i s a source of stress for physicians (Herbert St Grams, 1986; McCranie et a l . , 1982; McCue, 1982). Intense emotions have been found to be s t r e s s f u l for medical students as well. For instance, F i r t h (1986), i n a study of fourth year medical students, found that two of the four categories most commonly reported as s t r e s s f u l 30 were t a l k i n g to ps y c h i a t r i c patients, and dealing with death and s u f f e r i n g . The stress caused as a r e s u l t of working with highly emotional aspects of patient care can evoke intense emotions for physicians and medical students. Powers (1985) suggested that problem patients can evoke negative feelings such as f r u s t r a t i o n and apathy on the part of physicians. Medical students have d i f f i c u l t y addressing emotional issues with patients as well as coping with t h e i r own emotions during such interactions (Batenburg & Gerritsma, 1983). Knight (1983) found that medical students experienced feelings of inse c u r i t y , anxiety, h o s t i l i t y , and destructive argumentativeness, as well as a sense of g u i l t and helplessness when confronted with seriously i l l or dying patients. I f physicians and medical students have not learned to deal with emotionally intense encounters, they may also f e e l embarrassed and i l l at ease (Slevin, 1987). Buckman (1984), i n h i s discussion of physicians' feelings of inadequacy when dealing with patients' emotional reactions to medical treatment stated: Not knowing how to deal with the consequences of what we do breaks one of the most important rules of accepted medical behaviour. I t makes us inadequate i n our own eyes and those of others. There i s also the embarrassment. . . . (p. 1598) Other reactions that physicians might have when presented with highly emotional and s t r e s s f u l aspects of patient care include 31 denying t h e i r pain (Buckman, 1984; Slevin, 1987), appearing aloof or i n s e n s i t i v e , avoiding the obviously p a i n f u l issues, or being inappropriately o p t i m i s t i c (Heavey, 1988). They may in t e r a c t with patients or family members i n a very harsh manner or be overly hasty i n emotional si t u a t i o n s because of t h e i r discomfort (Fletcher & Sarin, 1988). A further reason which contributes to emotionally intense encounters being s t r e s s f u l for physicians i s that they may not have had any t r a i n i n g to cope with t h e i r own reactions. By being trained i n the t r a d i t i o n a l medical model they may have been taught to not show emotion. Thus, they may be overwhelmed by t h e i r own feelings such as g u i l t , shame or a sense of f a i l u r e i f they are not able to o f f e r a cure for a s i t u a t i o n (Heavey, 1988). Cassidy (1986) pointed out that part of the d i s t r e s s caused by dealing with intense emotions associated with terminal i l l n e s s (e.g. fear, g r i e f , anger) i s due to the fact that caregivers are reminded of t h e i r own mortality. Such stress may lead to emotional impairment of medical students. For instance, Smith, Denny, and Witzke (1986) reported that, over a 5 year period, 55.5% of i n t e r n a l medicine t r a i n i n g programs granted leaves of absence to medical residents due mainly to depression. Girard et a l . (1986) also found that depression and fatigue increased while s a t i s f a c t i o n with the decision to become a physician decreased during education. F i r t h (1986) concluded that "stress among 32 medical students should be acknowledged and attempts made to a l l e v i a t e i t " (p. 1177). Need f o r Empathy T r a i n i n g ; There i s a need to t r a i n medical p r a c t i t i o n e r s i n communication s k i l l s to use when in t e r a c t i n g with patients i n emotionally intense situations (Herbert & Grams, 1986). Branch (1983) suggested that the reason physicians f e e l so uncomfortable i n emotionally intense si t u a t i o n s i s that they have not received enough t r a i n i n g to deal with such encounters. Medical students should also receive systematic t r a i n i n g i n how to deal s p e c i f i c a l l y with emotionally laden encounters (Hornblow, Kidson, & Ironside, 1988; Sanson-Fisher and Maguire, 1980) and i n counselling s k i l l s (Lewis & Freeman, 1987). Poole & Sanson-Fisher (1979) suggested that empathy i s not being acquired by medical students or residents and they concluded that the s k i l l of empathic communication does not necessarily develop with experience. In fact Engler, Saltzman, Walker, and Wolf (1981) found that as medical students advanced through t r a i n i n g , t h e i r medical-technical s k i l l increased, but the a b i l i t y to r e l a t e well to patients interpersonally decreased i f students were not involved i n appropriate communication t r a i n i n g . Medical students who have taken a basic interviewing s k i l l s course have indicated they would l i k e further t r a i n i n g to acquire s k i l l s to use when dealing with patients' emotions (Batenburg & Gerritsma, 1983). As was discussed e a r l i e r , 33 coping with emotionally intense encounters has been shown to be a source of stress for medical students ( F i r t h , 1986). And Burnett and Thompson (1987) suggested that the problems which medical students experience when t a l k i n g to patients i n t h e i r early c l i n i c a l years w i l l not be resolved i f the issues are not dealt with then. Even though there seems to be agreement i n the l i t e r a t u r e that e f f e c t i v e physician-patient communication i s c r u c i a l , and empathy i s a desirable c h a r a c t e r i s t i c of physicians, and one which can be developed, Wakeford (1983) pointed out that introducing courses on communication s k i l l s into undergraduate medical education i n the United Kingdom i s often not supported. A common reason for t h i s , he suggested, i s that there i s l i t t l e proof that teaching such s k i l l s w i l l help the medical students (p. 245). There have been a r t i c l e s which suggested how patients benefit from e f f e c t i v e physician- patient communication, and how i t can lead to increased s a t i s f a c t i o n or compliance. There i s l i t t l e evidence, however, which suggests that teaching communication s k i l l s benefits medical students d i r e c t l y . One of the aims of t h i s study, i n addition to measuring the development of medical students' empathic responses, was to examine whether t h e i r stress l e v e l s i n emotionally intense encounters would decrease, as a r e s u l t of empathy s k i l l s t r a i n i n g . 3 4 Effectiveness of Empathy i n Emotionally-Intense Situations Empathic responding may be a p a r t i c u l a r l y useful and relevant intervention for medical p r a c t i t i o n e r s to use i n emotionally laden encounters. By using the s k i l l s of empathic communication, medical students and physicians may f e e l confident knowing that, i n situations where no concrete medical treatment can solve a patient's problem, they have useful s k i l l s which can help patients. As one subject i n t h i s study wrote "The thrust of medicine i s to do something." In a study by Putnam et a l . (1988) i n which interviewing techniques were taught to medical residents, the residents reported f e e l i n g worried that patients would bring up emotional issues with which they could not deal. However, these researchers found that the underlying reason for the residents* anxiety was that the residents were concerned that they could not "do something", to solve patients' psychosocial concerns. Even though empathic responding may not seem as concrete as a biochemical event or a medical procedure, which may be used to heal a physical wound, i t may be therapeutic when patient's have an "emotional wound" (CP. Herbert, personal communication, 1989). In emotionally intense s i t u a t i o n s when the patient knows that the physician cannot solve h i s or her problems, the patient may be appreciative of the opportunity to express feelings and receive some empathic understanding (Lidz, 1976). Rogers believed that empathy conveyed through a therapeutic r e l a t i o n s h i p was curative and that " i t i s the 35 experience of f e e l i n g understood i t s e l f that e f f e c t s growthful change" (Meador & Rogers, 1979, p. 152). In addition to bel i e v i n g that they are doing something h e l p f u l for t h e i r patients, medical p r a c t i t i o n e r s may also f i n d they can remain more objective i n emotionally intense encounters. One stressor for physicians appears to be attempting to prevent themselves from becoming too deeply emotionally involved with t h e i r patients (Korsch and Negrete, 1972). The practice of empathic responding means "putting yourself i n the other person's shoes" while never l o s i n g your own perspective. Empathy i s not sympathy which i s f e e l i n g sorry f o r the other person, nor i s i t i d e n t i f i c a t i o n which i s f e e l i n g the same as the other person. Rather, empathy i s a f e e l i n g with another person, which means having a continuous awareness your own experience (Muldary, 1983). Rogers 1 spoke about experiencing another person's feelings as i f they were your own, but never l o s i n g the "as i f " aspect. Thus, the s k i l l of empathic responding may enable physicians and medical students to acknowledge patients' d i f f i c u l t and intense emotions while keeping t h e i r own perspective, which may help decrease t h e i r stress l e v e l s . During the past decade, much has been written about patients' reactions concerning a f f e c t i v e aspects,of interactions with t h e i r physicians. However, r e l a t i v e l y l i t t l e emphasis seems to have been placed on emotional reactions of physicians i n such emotionally-laden encounters (Buckman, 1984). Physicians themselves are suggesting that, 36 i t may be h e l p f u l for physicians to become aware of t h e i r own feelings i n c l i n i c a l encounters (Longhurst, 1988; Zinn, 1988) and t h i s may be another way to increase humanism. As was stated by G o r l i n and Zucker (1983) "awareness of one's own feelings and the a b i l i t y to cope with them constructively i s an e s s e n t i a l aspect of humanistic medical teaching" (p. 1061). Indeed Longhurst (1988) suggested that self-awareness i s "the neglected i n s i g h t " (p. 121), and he suggested that s e l f awareness builds compassion which i s so h e l p f u l i n the physician-patient r e l a t i o n s h i p . One advantage of empathy t r a i n i n g may be that through role-playing and other exercises, trainees learn to become aware of emotions, both t h e i r own and patients'. By attending to patients' feelings through both r o l e reversal and empathic responses, trainees attend to a f f e c t i n addition to medical aspects of the interviews. Through awareness of t h e i r own feelings, physicians' a b i l i t i e s to learn empathic responding may be enhanced. Also i t might help to a l l e v i a t e the stress of emotionally intense situations for physicians to acknowledge t h e i r own feelings rather than to t r y to deny or suppress them. By being aware of t h e i r own feelings, physicians may be i n a p o s i t i o n to better cope with patients' emotional reactions. Also Smith (1986) suggested that, i n addition to teaching cognitive aspects of improving the physician-patient relationship, there i s a need to develop teaching methods i n order to help medical students become aware of and manage t h e i r emotional responses to patients. However, as Mengel and Mauksch (1989) pointed out, i t remains to be empirically demonstrated that s e l f - e v a l u a t i o n by the physicians of t h e i r own feelings would be related to improvements i n t h e i r relationships with patients. Previous Research Examining Empathy and Stress While a number of studies were found i n the l i t e r a t u r e on the subjects of either empathy or stress, few attempted to l i n k the two topics. Also, no intervention studies were noted which examined how the two constructs may be causally connected. Letourneau (1981) compared the l e v e l s of stress of mothers who were p h y s i c a l l y abusive with t h e i r children with mothers who were i d e n t i f i e d as not abusive. Levels of stress were measured by the Schedule Of Recent L i f e Experiences devised by Holmes and Rahe (1969). Two indices were used to measure empathy i n the subjects, the Hogan Empathy Test (Hogan, 1969) and a questionnaire devised by Mehrabian and Epstein (1972). Letourneau predicted that mothers who experienced high empathy and low stress would be much less abusive than mothers who experienced low empathy and high stress. T-tests revealed that the more abusive mothers scored s i g n i f i c a n t l y lower on measures of empathy. However, the abusive mothers did not score s i g n i f i c a n t l y higher on measures of stress. Further, Letourneau found that empathy was negatively correlated with aggression, a finding which 3 8 supported her theory that empathy serves as a mediator for the stress - abuse re l a t i o n s h i p . Letourneau also compared the categories of high empathy and high stress to low empathy and low stress to assess whether empathy or stress was the more important predictor of abuse. Following the categorization of subjects around the grand mean, Fisher's exact t e s t was used to examine the conditions under which abuse was more l i k e l y to occur and to examine the in t e r a c t i o n between empathy and stress. Letourneau found that the percentage of abusive mothers i n the category of low empathy and low stress was much higher that these mothers i n the category of high empathy and high stress. Further, for mothers who scored low i n empathy, the percentages of abusive mothers i n the categories of high and low stress were not s i g n i f i c a n t l y d i f f e r e n t . The degree to which mothers were empathic as opposed to how much stress they experienced seemed to be the more c r i t i c a l factor i n pred i c t i n g abusive behaviour. Letourneau concluded that "the fact that many mothers apparently function adequately i n the presence of high stress, or inadequately even when experiencing low l e v e l s of stress, suggests that empathy and stress somehow int e r a c t and that empathy serves a mediating function" (p. 387). In Letourneau's study, however, only the s t r e s s f u l l i f e events indicated by the subjects were measured. Coping di s p o s i t i o n s or strategies were not investigated as suggested by Monat and Lazarus (1985). Nor was a behaviourally-based 3 9 measure o f empathy used; Hogan 1s empathy s c a l e i s a s e l f - a s s e s s e d t r a i t s c a l e . J a r s k i e t a l . (1985), i n a comparison o f f o u r empathy i n s t r u m e n t s i n s i m u l a t e d p a t i e n t - m e d i c a l s t u d e n t i n t e r a c t i o n s , found t h a t empathy w h i c h was a s s e s s e d on t h e Hogan's S c a l e d i d not c o r r e l a t e s i g n i f i c a n t l y w i t h any o f t h e b e h a v i o r - b a s e d measures. The p r e s e n t s t u d y used empathy measures w h i c h a r e recommended i n t h e l i t e r a t u r e t o examine p h y s i c i a n - p a t i e n t i n t e r a c t i o n s i n an a t t e m p t t o g a i n a b e t t e r u n d e r s t a n d i n g o f t h e r e l a t i o n s h i p between empathy and s t r e s s . B a t s o n e t a l . (1987) s u g g e s t e d t h a t empathy and d i s t r e s s ( i . e . , t h e emotion e x p e r i e n c e d as a r e s u l t o f s t r e s s ) a r e q u a l i t a t i v e l y v e r y d i f f e r e n t emotions. When a p e r s o n p e r c e i v e s a n o t h e r who i s s u f f e r i n g , he/she can have one o f two r e a c t i o n s . One r e s p o n s e can i n v o l v e f e e l i n g s o f p e r s o n a l d i s t r e s s ( e . g . , u p s e t , w o r r i e d ) and t h e o t h e r r e s p o n s e can i n v o l v e f e e l i n g s o f empathy (e . g . , compassion, t e n d e r n e s s ) . D i s t r e s s may be v i e w e d as e v o k i n g an e g o i s t i c m o t i v a t i o n t o h e l p a n o t h e r i n need. That i s , t h e d e s i r e d consequence i s t o reduce one's own a v e r s i v e r e s p o n s e . Empathy, however, may evoke an a l t r u i s t i c m o t i v a t i o n t o h e l p a n o t h e r . That i s , t h e u l t i m a t e g o a l i s t o h e l p t h e o t h e r p e r s o n i n need; t o reduce one's own d i s t r e s s i s n o t t h e p r i m a r y m o t i v a t i o n . Empathy may be v i e w e d as more o t h e r - f o c u s e d , w h i l e d i s t r e s s may be viewed as more s e l f - f o c u s e d . T h i s t w o - p a r t model i s s i m i l a r t o t h e v i e w h e l d by McDougall (1908). A more r e c e n t v i e w p r e s e n t e d by H u l l (1943) was t h a t empathy and d i s t r e s s a r e s i m i l a r i n t h a t t h e u l t i m a t e g o a l o f b o t h emotions i s t o reduce one's own 4 0 l e v e l of arousal whether or not t h i s process involves helping another person i n need. Batson et a l . (1987, 1988) provided empirical evidence i n support of the view that empathy and d i s t r e s s are q u a l i t a t i v e l y d i f f e r e n t emotions and that experiencing empathy toward a person i s associated with the ultimate goal of helping that person. They suggested that further research i s needed to support the view that d i s t r e s s leads to e g o i s t i c and empathy leads to a l t r u i s t i c motivation to help. L i t t l e i s known about the function of empathy i n the int e r a c t i o n of empathy and stress as suggested by Letourneau (1981). Folkman and Lazarus (1988) suggested that coping a f f e c t s emotion possibly by acting as a mediator. T r a d i t i o n a l l y , theory and research focused on how emotion a f f e c t s coping, but l i t t l e attention has been given to studying whether the reverse i s true. Folkman and Lazarus suggested that coping a f f e c t s emotion i n a b i - d i r e c t i o n a l manner, that i s , each a f f e c t s the other. F i r s t a s i t u a t i o n i s appraised as s t r e s s f u l . This generates emotion which i n turn influences coping processes which a l t e r s the person- environment re l a t i o n s h i p . This reappraised person-environment re l a t i o n s h i p r e s u l t s i n a change i n emotion. Empathic responding may be evaluated by medical students as an e f f e c t i v e means of coping which, i n turn, decreases the stressfulness of the encounter. Thus empathic responding may be viewed as a mediator to reduce the stress of emotionally intense c l i n i c a l encounters. More research however, i s needed 41 to c l a r i f y the nature of the buffering aspects of empathy i n s t r e s s f u l s i t u a t i o n s . Hypotheses R e l a t e d t o Empathy and S t r e s s The following hypotheses were tested i n the present study. Hypothesis 1A: Subjects who receive empathy s k i l l t r a i n i n g w i l l demonstrate s i g n i f i c a n t l y higher scores on measures of empathy than w i l l subjects who are i n a w a i t - l i s t (delayed-treatment) control group. Hypothesis IB: Subjects who receive empathy s k i l l t r a i n i n g w i l l demonstrate s i g n i f i c a n t l y lower scores on a measure of perceived stress than w i l l subjects who are i n a w a i t - l i s t (delayed-treatment) control group. Hypothesis 2 A i : Subjects who are i n the post-training follow-up group w i l l demonstrate s i g n i f i c a n t l y higher scores on measures of empathy than w i l l subjects i n the w a i t - l i s t control group. Hypothesis 2 A i i : Subjects who are i n the post-training group w i l l maintain scores on measures of empathy during the follow-up time period. Hypothesis 2 A i i i : Subjects who are i n the w a i t - l i s t (delayed-treatment) control group w i l l not increase i n scores on measures of empathy during the w a i t - l i s t control time period. Hypothesis 2 B i : Subjects who are i n the post-training follow-up group w i l l demonstrate s i g n i f i c a n t l y lower scores on 42 a measure of perceived stress than w i l l subjects i n the wait- l i s t control group. Hypothesis 2 B i i : Subjects who are i n the post-training group w i l l maintain scores on a measure of perceived stress during the follow-up time period. Hypothesis 2 B i i i : Subjects who are i n the w a i t - l i s t (delayed-treatment) control group w i l l not decrease i n scores on a measure of perceived stress during the w a i t - l i s t control time period. Hypothesis 3A; Subjects who receive empathy s k i l l s t r a i n i n g at d i f f e r e n t points i n time w i l l increase i n scores on measures of empathy. Hypothesis 3B: Subjects who receive empathy s k i l l s t r a i n i n g at d i f f e r e n t points i n time w i l l decrease i n scores of a measure of perceived stress. Previous Research Related to Exploratory Analyses Hardiness Antonovsky (1979) suggested that research i n stress and i l l n e s s has begun to s h i f t toward the study of resistance resources which help a person cope with s t r e s s f u l events. Folkman and Lazarus (1980), defined two important processes involved when a person i s affected by a s t r e s s f u l occurrence i n the environment. One i s appraisal which refe r s to the cognitive processes used to evaluate the s t r e s s f u l s i t u a t i o n and the options available to deal with i t . Appraisal or 43 evaluation of the s t r e s s f u l s i t u a t i o n has been discussed i n terms of the Perceived Stress Questionnaire. The second process involves the coping approach to the appraisals of stress. The coping responses may r e f e r to actual processes used, such as problem-focused or emotion- focused e f f o r t s (Folkman, Lazarus, Gruen, & DeLongis, 1986), or they can r e f e r to antecedents of coping such as personality c h a r a c t e r i s t i c s or t r a i t s such as hardiness (Kobasa, 1979). May and Revicki (1985) have i l l u s t r a t e d a stress and coping model for primary care physicians i n which two of the four moderators of stress mentioned, which may determine successful or unsuccessful coping, were coping s k i l l s and personality s t y l e . May and Revicki (1985) s p e c i f i c a l l y stated that hardiness i s one example of a personality s t y l e which may be a c r i t i c a l moderating factor i n coping with the stress of medical p r a c t i c e . Fain and Schreier (1989) recommended that the personality variable of hardiness should be considered i n the s e l e c t i o n of medical personnel for disa s t e r or emergency si t u a t i o n s . Hardiness was conceptualized by Kobasa (1979) as having three components; commitment, control and challenge. Commitment refers to being a c t i v e l y involved i n one's growth and being i n touch with one's own feelings and values as opposed to being alienated from one's s e l f . Control refers to having a b e l i e f that one i s able to influence one's environment rather than being t o t a l l y influenced by others. 44 Challenge ref e r s to viewing l i f e as having opportunities for change and growth rather than threats to security. Kobasa's (1982) research suggested that the personality c h a r a c t e r i s t i c of psychological hardiness functions as a resistance resource i n buffering the e f f e c t s of s t r e s s f u l events. Kobasa, Maddi, and Kahn (1982) viewed t h i s concept from an e x i s t e n t i a l perspective. Hardiness was considered to be a moderator of stress because s t r e s s f u l events would not be appraised to be uncontrollable or meaningless. Just as empathic s k i l l can be learned, Kobasa (1982) suggested that the personality c h a r a c t e r i s t i c of hardiness or "stress resistance" could be developed. She recommended that research be conducted to gain an understanding of how hardiness develops, and indicated that there i s a need to devise interventions to develop t h i s t r a i t . Although studies- have examined whether health professionals who have high l e v e l s of hardiness allowed them to better cope with work stress (e.g. Maloney & Bartz, 1983), no studies were found which examined whether an intervention (designed to reduce the stress of medical situations) was associated with a change i n hardiness or "stress-resistance." One of the goals of t h i s study was to investigate whether hardiness would develop i n medical students who received empathy s k i l l s t r a i n i n g . 45 Ways o f Co p i n g I n o r d e r t o i n v e s t i g a t e t h e t y p e o f r e s p o n s e s used by i n t e r n s t o cope w i t h t h e s t r e s s o f i n t e r n s h i p , D o n n e l l y (1979) d e v i s e d a Ways o f Coping S c a l e based on t h e c o p i n g s t r a t e g i e s w h i c h were r e p o r t e d by t h e i n t e r n s . The s t r a t e g i e s f e l l i n t o t h e two c a t e g o r i e s o f (a) n o n - p a l l i a t i v e o r p r o b l e m - f o c u s e d c o p i n g ( p r o b l e m - s o l v i n g a c t i o n s t o t r y t o a l l e v i a t e t h e s t r e s s o r a l t e r t h e environment) and (b) p a l l i a t i v e o r emo t i o n - f o c u s e d c o p i n g ( a c t i o n s t o t r y t o a l l e v i a t e t h e e m o t i o n a l d i s t r e s s caused by t h e s i t u a t i o n ) . D o n n e l l y found t h a t t h e i n t e r n s who had h i g h e r ego development used s t r a t e g i e s from b o t h c a t e g o r i e s i n c o p i n g w i t h t h e s t r e s s o f i n t e r n s h i p . S u b j e c t s who had l o w e r ego development used m a i n l y non- p a l l i a t i v e (problem-focused) c o p i n g s t r a t e g i e s . F u r t h e r , t h e i n t e r n s who had a c o m b i n a t i o n o f h i g h ego development and used b o t h p r o b l e m - f o c u s e d and e m o t i o n - f o c u s e d c o p i n g s t r a t e g i e s r e c e i v e d t h e h i g h e s t c l i n i c a l performance r a t i n g s by a group o f u n i v e r s i t y f a c u l t y and house m e d i c a l o f f i c e r s . The s u b j e c t s w i t h low ego development who used m a i n l y p r o b l e m - f o c u s e d c o p i n g were more co n c e r n e d w i t h t r y i n g t o a l t e r t h e environment t o cope w i t h s t r e s s because, p e r h a p s , t h e y v i e w e d s t r e s s as b e i n g caused more by e x t e r n a l e v e n t s . The s u b j e c t s w i t h h i g h ego development who used b o t h t y p e s o f c o p i n g s t r a t e g i e s , on t h e o t h e r hand, t r i e d t o a l t e r t h e m s e l v e s as w e l l as t h e environment. The i n t e r n s i n t h e h i g h performance group were f l e x i b l e i n t h e i r use o f c o p i n g s t r a t e g i e s and had a w i d e r range o f r e s p o n s e s t o s t r e s s . 46 Donnelly suggested that medical education should make attempts to t r y to design ways to reduce the stress of medical education and to increase coping a b i l i t i e s of students. She recommended that further research examine coping s t y l e s of students and the contribution of coping strategies to the stages of medical education, because coping strategies used during medical t r a i n i n g may predict a future a b i l i t y to deal with stress i n medical practice. No further studies were found which used Donnelly's Ways of Coping Scale. However, the problem of stress among medical students i s the subject of recent research. For instance, Spiegel, Smolen, and Hopfensperger (1986) who examined medical student stress and how i t related to c l i n i c a l performance found an inverse r e l a t i o n s h i p between medical students' ratings of interpersonal c o n f l i c t s and measures of t h e i r academic performance. They suggested that, i n order to understand t h i s r e l a t i o n s h i p further, research i s needed on how coping resources, among other factors, contribute to students' performance i n medical school. V i t a l i a n o , Masuro, M i t c h e l l , and Russo (1989) pointed out that while many studies have examined the reactions of medical students to s t r e s s f u l s i t u a t i o n s , (e.g., suicide, drug abuse), few have examined in d i v i d u a l v u l n e r a b i l i t i e s and int e r n a l resources of medical students which influence how they cope with the stress of medical t r a i n i n g . These scholars recommended that interventions should be designed to a s s i s t medical students cope with stress. One of the purposes of t h i s present study 4 7 was to investigate whether the number of coping strategies changed for medical students who received the intervention of empathy s k i l l s t r a i n i n g . M e t h o d o l o g i c a l I s s u e s I d e n t i f i e d i n R e l e v a n t P r e v i o u s R e s e a r c h In 1980, C a r r o l l and Munroe published a review of the empirical research on i n s t r u c t i o n a l programs for teaching c l i n i c a l interviewing. They reported that the great majority of these studies had employed weak research designs. Therefore, the v a l i d i t y of reported findings must be questioned. Many of the studies were One Group Pretest- Posttest Designs, that i s , pre-experimental designs, and thus were susceptible to many confounding factors. Studies often used nonequivalent control groups, that i s , the assignment of students to the experimental condition was by means of i n t a c t groups rather than by random assignment. Only f i v e out of twenty-seven studies which compared interpersonal s k i l l s t r a i n i n g with no interpersonal s k i l l s t r a i n i n g incorporated true experimental designs. In these studies, p a r t i c i p a n t s were randomly assigned to groups, and were tested before and a f t e r i n s t r u c t i o n . C a r r o l l and Monroe suggested that there i s a need to r e p l i c a t e studies and control for pot e n t i a l confounding factors such as history, practice, maturation and i n t e r a c t i o n e f f e c t s . Sanson-Fisher et a l . (1981) also published a review of the methodology of studies designed to teach communication 4 8 s k i l l s s p e c i f i c a l l y to medical students. They conducted a survey of experienced researchers i n order to determine what constituted adequate methodology for such studies. Among the c r i t e r i a indicated for adeguate studies of the teaching of communication s k i l l s were: a) random a l l o c a t i o n or matched control group, b) assessments of medical students' a b i l i t i e s using d i r e c t methods (e.g., interviews and r e l i a b l e t e s t shown to measure s k i l l ) versus i n d i r e c t measures such as p e n c i l and paper te s t s , or comments, and c) estimates of r e l i a b i l i t y of ratings. To examine how adequately studies were designed to teach communication s k i l l s to medical students using the c r i t e r i a l i s t e d above, Sanson-Fisher et a l . reviewed 4 6 studies. They found that 28 (61 percent) of the studies were des c r i p t i v e , containing no experimental evidence that the teaching methods improved communication s k i l l s . Of the 18 studies which were determined to be experimental, few met the c r i t e r i a . For instance, out of the 18 experimental studies, only h a l f used a control group, and only 39 percent used random a l l o c a t i o n or a matched control group. Only 11 percent presented and described a s t a t i s t i c a l index of r e l i a b i l i t y . Sanson-Fisher et a l . concluded that "those who advocate new approaches must demonstrate that they are e f f e c t i v e and superior to e x i s t i n g methods. They can only do t h i s i f they adopt an adeguate methodology" (p.37). DiMatteo (1979) echoed the suggestions of Sanson-Fisher et a l . (1981), as he also reported that many studies lacked sound evaluation techniques due to such factors 49 as inadequate experimental designs and lack of control groups. He suggested that future research must be designed to provide physicians with e f f e c t i v e methods of developing interpersonal aspects of patient care such as empathy. DiMatteo (1989) suggested that medical educators w i l l probably consider the recommendations of s o c i a l s c i e n t i s t s concerning such things as communication s k i l l s only i f the information i s grounded upon "methodologically sound research findings" (p. 29). Recommendations have been made by other researchers about considerations when designing research to evaluate the effectiveness of communication s k i l l s t r a i n i n g for medical students and physicians. For instance, there i s a need to investigate the ef f e c t s of t r a i n i n g on ratings of both the trainees and the simulated patients ( C a r r o l l & Munroe, 1980). Such evaluation outcome measures should be d i r e c t l y relevant to patient variables such as s a t i s f a c t i o n ( C a r r o l l & Munroe, 1980, DiMatteo, 1979). A suggestion made by other investigators included the objective evaluation of s k i l l s of trainees (Betchart et a l . , 1984). Kahn et a l . (1979) i n t h e i r review of interviewing s k i l l courses found that 87 percent used i n d i r e c t methods such as student s a t i s f a c t i o n , while only a few used criterion-referenced instruments or d i r e c t observation of s k i l l s . Gask et a l . (1988) suggested that few studies evaluated change i n interviewing by the rat i n g of s k i l l s using videotaped sessions with r e a l or simulated patients. J a r s k i et a l . (1985) suggested that studies designed to examine changes i n empathy should have objective 50 measures by external raters which can be compared with the perceptions of patients because p a t i e n t s 1 ratings are c l o s e l y related to therapeutic outcomes. Another recommendation made by Shore and Franks (1986) was that while most instruments examine patients' s a t i s f a c t i o n regarding encounters with physicians, the examination and study of physician s a t i s f a c t i o n has been neglected. Physician s a t i s f a c t i o n with c l i n i c a l encounters would be an important outcome measure since i t would provide a more complete analysis of physician-patient interactions. Such a measure would lend empirical support i n response to Wakeford's suggestion that the reason communication s k i l l s courses are not taught more frequently i s that there i s no evidence which shows how programs help medical students. I reviewed the l i t e r a t u r e to examine i f studies employed methodology which included the c r i t e r i a discussed above. While several of these studies examined l e v e l s of empathy i n medical students and physicians and correlated them with other measures through a one-time t e s t i n g occasion (e.g., Dornbush et a l . 1984; Evans, Kiellerup, Stanley, Burrows, & Sweet, 1987; Hornblow, Kidson, & Jones, 1977; Linn et a l . 1987), few intervention studies designed to increase empathy l e v e l s using pre- and post-measures were noted. Some studies (e.g., Dickinson, Huels, & Murphy, 1983; Wolf, Woolliscroft, Calhoun, & Boxer, 1987) reported the ef f e c t s of a general communication s k i l l s t r a i n i n g courses on measures of empathy. For instance Wolf et a l . , 1987, i n a 51 study of communication s k i l l s t r a i n i n g for f i r s t year medical students, included i n t h e i r course strategies f o r responding empathically. They found that average scores on an understanding scale which measured preferences for written empathic responses of patients emotional needs increased s i g n i f i c a n t l y a f t e r t r a i n i n g . However, d i r e c t observation of s k i l l s was not examined. Dickinson et a l . (1983) examined empathy of p e d i a t r i c house o f f i c e r s as rated by observers on the C l i n i c a l Assessment Scale for Pe d i a t r i c Interviewing before and a f t e r an interviewing course. They found that empathy scores did not increase. Weihs and Chapados (1986) conducted a study of the e f f e c t s of an interviewing s k i l l s course, based on Carkhuff's model, on verbal responses by f i r s t year medical students. The study involved a treatment group (n = 16) and a control group (n = 16). Scores based on Carkhuff*s 5-point model were s i g n i f i c a n t l y higher a f t e r t r a i n i n g for the treatment group as compared with the control group. These r e s u l t s are s i m i l a r to the ones presented by Poole and Sanson-Fisher (1979) who demonstrated a s i g n i f i c a n t increase i n empathy by objective raters based on Truax and Carkhuff's 9-point scale a f t e r an empathy t r a i n i n g program for p r e c l i n i c a l medical students as compared with a control group. Kramer et a l . (1989) used an observational schedule developed by Alroy, Ber, and Kramer (1984) to observe verbal and non-verbal supporting behaviours of which empathic responses were a part. F i f t h year I s r a e l i medical students 52 were observed before and a f t e r a course i n empathy t r a i n i n g and r e s u l t s showed that there was a s i g n i f i c a n t and l a s t i n g increase over time i n the number of supporting behaviours and a s i g n i f i c a n t decrease i n number of r e j e c t i n g behaviours. The reverse was true for the control group. E l i z u r and Rosenheim (1982) conducted a study also of I s r a e l i medical students to determine whether a p s y c h i a t r i c clerkship combined with group experience, compared to a clerkship with no group experience had any impact on l e v e l s of empathy. These researchers used Mehrabian's Emotional Empathic Tendency Scale (Mehrabian & Epstein, 1972) as a written s e l f - r a t e d empathy scale as well as ratings by peers using a sociometric technique. They found that the students who p a r t i c i p a t e d i n a group experience had s i g n i f i c a n t l y higher scores on the Empathic Tendency Scale than those who had the clerkship alone. Further, a f t e r the clerkship, there was a s i g n i f i c a n t c o r r e l a t i o n between self-reported and other- reported empathy for the students with group experience. The authors concluded that the group experience contributed to increased s e n s i t i v i t y and a deepening of empathy. None of the four studies mentioned above nor any other study was found which evaluated the e f f e c t s of an empathy t r a i n i n g program using students' self-assessment of s k i l l s i n comparison to the assessments of simulated patients. This i s important because patients' responses may be linked to outcome and therefore have important implications for the understanding of physician-patient re l a t i o n s h i p s . 53 J a r s k i et a l . (1985) presented an argument that "studies should be devised where the r e s u l t s of empathy ratings by external observers can be compared with the perceptions of patients and objective therapeutic outcomes" (p. 550). Based on h i s findings, he recommended the Barrett-Lennard Relationship Inventory for use i n medicine. He also suggested that objective ratings of empathy, such as C a r k h u f f s , 1969 r a t i n g scale, be completed by professionals trained i n scoring them. In s p i t e of J a r s k i et a l . ' s suggestions, and the fact that the Barrett-Lennard and Carkhuff's Scales are the most extensively used subjective and objective measures of empathy (Barrett-Lennard 1981), no study was found where they were a l l used as outcome measures to determine the effectiveness of empathy t r a i n i n g programs for medical students or physicians. In view of the above discussion and based on recommendations of previous researchers, t h i s study was designed to incorporate recommended methodological features including using a control group, d i r e c t assessments of communication s k i l l s with criterion-referenced instruments, students' assessments of t h e i r own communication s k i l l s using r e l i a b l e instruments which could be compared to assessments by simulated patients, and students' responses to the interview as measures of the impact of empathy t r a i n i n g . 54 CHAPTER III Method Introduction This chapter opens with the rationale and d e t a i l s of the experimental design chosen to t e s t the hypotheses i n t h i s study. Information about people who p a r t i c i p a t e d i n the study i s followed by a description of measures and other materials required for the execution of the research. Details concerning the experimental procedures are included and a des c r i p t i o n of data analyses close the chapter. Experimental Design The design employed i n t h i s study was a crossover control design for two equivalent groups. In Campbell and Stanley's (1963) terminology the design i s i l l u s t r a t e d as: R X 0 2 °3 R 0 4 0 5 X 0 6 where R indicates random assignment of subjects, X indicates t r a i n i n g , and 0 represents t e s t i n g using the research measures. In t h i s design a l l subjects are measured on the dependent variables and randomly assigned to one of two groups. The f i r s t group receives the treatment (experimental group), while the second group serves as a w a i t - l i s t control. Measures are then c o l l e c t e d for a l l subjects, halfway through the study. The treatment crossover then takes place and 55 subjects i n group two receive treatment. The f i r s t group receives no further intervention and so serves as a control or follow-up group. Measures are co l l e c t e d a t h i r d time, completing the procedure. The crossover design allows for an examination of the ef f e c t s of treatment compared with a no-treatment condition for a l l subjects. (Epstein & Tripodi, 1977). Campbell and Stanley (1963) place such a design under the heading of "counterbalanced" design. This type of design i s referred to also as.a "change-over design" ( G i l l , 1978; Neter & Wasserman, 1974) a "cross-over design" (Cochran & Cox, 1957, Neter & Wasserman, 1974), and a time-lagged crossover or crossover comparative experimental design (Epstein & Tr i p o d i , 1977). The crossover control design has several advantages. F i r s t , i t i s a "true" experimental design because subjects are randomly assigned to treatments. Random assignment helps a researcher make causal inferences because i t i s the best way to ensure that the groups are genuinely comparable. In other words, i t can be assumed that the features of subjects i n one group w i l l be counterbalanced by comparable, but not i d e n t i c a l , features of subjects i n the other group (Cook & Campbell, 1979). Also because one of the "treatments" used i n t h i s crossover design i s a no-treatment control, and because subjects are randomly assigned to the two groups, threats to int e r n a l v a l i d i t y ( i . e . , factors i d e n t i f i e d by Campbell and Stanley, 1963) are controlled (Epstein & Tr i p o d i , 1977; Cates, 1985). For instance, the e f f e c t s of contemporary h i s t o r y and 56 maturation processes are limited and the effects of testing are reduced by assessing the control group. Cook and Campbell (1979) identify four threats to internal vali d i t y that randomization does not rule out. These threats w i l l now be identified and suggestions given as to why they are probably not valid threats to this study. (1) Imitation of Treatment - While i t i s true that there was no certain method to prevent the possibility of subjects who were involved in the second training period from learning about the details of the empathy training, the subjects who received the training f i r s t were asked not to reveal the nature of the training to the people in the delayed training group. Imitation of treatment i s more li k e l y to be a threat i f two different types of training were to be used in the study. (2) Compensatory equalization - There was no need for compensation since every subject received the treatment; thus no inequality resulted from random assignment. (3) Compensatory Rivalry - A l l subjects received the same training. Each subject was tested individually in a one- to-one therapeutic interaction. Further, the type of emotion presented at each testing occasion was counterbalanced so that each subject had experience with each type of emotion. It would seem unlikely, then, especially since subjects were asked not to discuss details about the training to subjects in the wait-list group, that subjects would want to prove that their training group 1s performance was superior over the other. I believe that because the one-to-one encounters of the t e s t i n g occasions were somewhat s t r e s s f u l , that subjects did the best they could given t h e i r t r a i n i n g . There were, i n fact, no verbal expressions of such r i v a l r y by the control subjects during the t e s t i n g occasions. (4) Demoralization i n Groups - This may happen i f subjects i n a group learn that they w i l l receive a l e s s desirable treatment and thus they become r e s e n t f u l . Certainly i n d i v i d u a l subjects want to receive the more desirable treatment or else they may f e e l deprived when compared to the other group. However, i n t h i s study subjects knew they would a l l receive the same t r a i n i n g . In summary, Cook and Campbell (1979) stated that these four threats r e s u l t from the "focused i n e q u i t i e s that i n e v i t a b l y accompany experimentation because some people receive one treatment and others receive d i f f e r e n t treatments or no treatment at a l l " (pp 56-57). In other words there i s a v i o l a t i o n of what i s f a i r and j u s t . One of the advantages of t h i s crossover design, and something that a l l subjects were t o l d during the pretest interview, was that they were to receive equivalent treatment. That i s , a l l subjects p a r t i c i p a t e d i n the same empathy t r a i n i n g and three t e s t i n g occasions. Cook and Campbell (1979) suggested that threats to i n t e r n a l v a l i d i t y are caused by a t y p i c a l behaviour of subjects i n a no-treatment control group or groups that receive less desirable treatments. They suggested the best way to ensure 58 t h a t t h e s e t h r e a t s do not o p e r a t e i n an e x p e r i m e n t i s t o have d i r e c t measures f o r a l l groups o f t h e p r o c e s s t h a t t h e t r e a t m e n t was t o e f f e c t i n o r d e r t o make a v a l i d c a u s a l c o n n e c t i o n . Such measures were t a k e n i n t h i s s t u d y , as i n d i c a t e d by t h e s e v e r a l dependent measures o f empathy and d i s t r e s s w h i c h t h e empathy t r a i n i n g was meant t o i n f l u e n c e . A l s o t h e b e h a v i o u r o f t h e n o - t r e a t m e n t c o n t r o l group was examined t o c o n t r o l f o r i m i t a t i o n o f t r e a t m e n t . F u r t h e r m o r e , s t a t i s t i c a l p r o c e d u r e s examined t h e p r e s e n c e o f a group main e f f e c t t o a s s e s s whether t h e r e was compensatory r i v a l r y between groups. Thus, a f u r t h e r advantage o f t h e c r o s s o v e r c o n t r o l d e s i g n i s t h a t t o some e x t e n t i t c o n t r o l s f o r t h e s e f o u r t h r e a t s t o i n t e r n a l v a l i d i t y t h a t r a n d o m i z a t i o n does n o t r u l e out- A second advantage, as Cook and Campbell (1979) p o i n t e d o u t , i s t h a t d e s i g n s i n w h i c h an e f f e c t can be demonstrated w i t h two samples a t d i f f e r e n t moments i n t i m e have t h e p o t e n t i a l f o r e x t e n d i n g c o n s t r u c t and e x t e r n a l v a l i d i t y . The b u i l t - i n r e p l i c a t i o n o f t h e e x p e r i m e n t i n t h e second group o f t h e c r o s s o y e r d e s i g n makes i t p o s s i b l e t o i n f e r t h a t f i n d i n g s from t h e e x p e r i m e n t can be g e n e r a l i z e d t o o t h e r s i m i l a r s u b j e c t p o p u l a t i o n s . A f u r t h e r advantage o f t h e b u i l t - i n r e p l i c a t i o n i n t h i s d e s i g n i s t h a t , f o r s t u d i e s w h i c h have a s m a l l sample s i z e , t h e problem o f low power i s p a r t i a l l y overcome. P r o v i d i n g t h e t r e a t m e n t a t d i f f e r e n t t i m e s f o r t h e two s i m i l a r samples drawn from t h e same p o p u l a t i o n c o n f i r m s t h e f i n d i n g s ( C a t e s , 1985). 59 A t h i r d advantage of t h i s design i s that a l l subjects receive the intervention. The denial of an intervention to subjects, e s p e c i a l l y i n f i e l d studies, may be e t h i c a l l y and pro f e s s i o n a l l y unacceptable (Epstein & Trip o d i , 1977). For instance, i n t h i s study, there may have been some emotional discomfort on the part of the medical students when they took the pretests because of the i n t e n s i t y of the emotions and subject matter. Therefore I thought that i t would be unfai r to have subjects complete t e s t i n g only and not receive the t r a i n i n g . In summary, Epstein and Tripodi (1977) stated that "the unique advantage of t h i s (crossover control) design i s that i t provides the s c i e n t i f i c r i g o r of a control group experiment without requiring any service denial to any agency c l i e n t s " (p. 165). As a number of scholars have indicated (e.g., Armitage & H i l l s , 1982; M i l l a r , 1983), the crossover design has further advantages including economy of subjects and increased power. Because each subject provides more than one observation, fewer subjects are required for a within-subjects design than for a between-groups design. And not only does the crossover design i n the present study have the advantage of having a control group, each subject also acts as h i s or her own contro l . Therefore, the source of error due to differences between subjects i s removed as comparisons are made within subjects. H i l l s and Armitage (1979) stated, "A comparison of treatments on the same subject i s expected to be more precise than a 60 c o m p a r i s o n between s u b j e c t s and t h e r e f o r e t o r e q u i r e fewer s u b j e c t s f o r t h e same p r e c i s i o n " (p. 7 ) . A l i t e r a t u r e r e v i e w r e v e a l e d t h a t few s t u d i e s e v a l u a t i n g t h e e f f e c t s o f t r a i n i n g u t i l i z e d t h e c r o s s o v e r d e s i g n . Repeated measures d e s i g n s a r e . t h e most commonly used d e s i g n s when t h e e f f e c t s o f l e a r n i n g o r t r a n s f e r o f t r a i n i n g i s o f i n t e r e s t . A l t h o u g h r e p e a t e d measures d e s i g n s a r e common i n l e a r n i n g s t u d i e s , c r o s s o v e r d e s i g n s may be u n d e r - u t i l i z e d i n r e s e a r c h e v a l u a t i n g t h e e f f e c t s o f t r a i n i n g . G i v e n t h e advantages d i s c u s s e d above, t h i s d e s i g n s h o u l d perhaps be employed more o f t e n . Subjects Populations and Samples The t a r g e t p o p u l a t i o n i n t h i s s t u d y was m e d i c a l s t u d e n t s . The a c c e s s i b l e p o p u l a t i o n c o n s i s t e d o f second y e a r m e d i c a l s t u d e n t s a t U.B.C. The a c t u a l sample c o n s i s t e d o f v o l u n t e e r s from t h e second y e a r m e d i c a l c l a s s . Recruitment and Selection F o l l o w i n g p e r m i s s i o n b e i n g g r a n t e d by t h e U.B.C. M e d i c a l F a c u l t y , t h e B e h a v i o r a l S c i e n c e s S c r e e n i n g Committee, and Re s e a r c h S e r v i c e s , s t u d e n t s were r e c r u i t e d from t h e second y e a r m e d i c a l c l a s s . A p r e s e n t a t i o n was made t o t h e e n t i r e c l a s s i n v i t i n g t h e s t u d e n t s t o t a k e p a r t i n a s t u d y , t h e purpose o f w h i c h was t o examine t h e v a r i o u s ways i n w h i c h m e d i c a l s t u d e n t s respond t o e m o t i o n a l l y i n t e n s e p h y s i c i a n - 61 patient interactions. They were t o l d they would have an opportunity to receive t r a i n i n g i n communication s k i l l s which would p o t e n t i a l l y enhance t h e i r a b i l i t y to communicate with patients who were f e a r f u l , angry or grieving. Forty-one indivi d u a l s indicated i n t e r e s t i n the study. However, because the follow-up component of another study on communication s k i l l s t r a i n i n g was being conducted concurrently, I was required to eliminate 17 subjects who were p a r t i c i p a t i n g i n the previous study. Of 24 volunteers who were avail a b l e for the present study, 18 were s t i l l interested i n p a r t i c i p a t i n g when the t r a i n i n g began. During the t r a i n i n g 5 students f e l t i t necessary to withdraw c i t i n g demands of medical t r a i n i n g (e.g., exams) as the reasons. A t - t e s t revealed that scores on the blocking variable for those subjects who withdrew did not d i f f e r from the pre-test scores for the 13 subjects who completed the study (p = .76). The 13 subjects who remained i n the study completed a l l three t e s t i n g occasions. Selection of the Trainer, Raters, and Simulated Patients Selection of the Trainer A male who was a recent graduate of the U.B.C. master's program i n Counselling Psychology was the empathy s k i l l s t r a i n e r . He had received at least 100 hours of intensive t r a i n i n g i n empathic responding, and he had had experience teaching empathic communication s k i l l s to groups. The same t r a i n e r was employed for a l l t r a i n i n g sessions so that t r a i n e r 62 would not be an experimental variable which could confound the re s u l t s . Selection of The Raters One male doctoral student and one female master's student i n Counselling Psychology were the raters of empathic responding as measured by the Carkhuff scale. Both had received at l e a s t 100 hours of t r a i n i n g i n empathic responding and were experienced i n rating t r a n s c r i p t s using the Carkhuff method. The raters were b l i n d as to which group the subjects were i n and b l i n d to the nature of the experimental design. Selection of the Simulated Patients Individuals who were enrolled i n the doctoral and master's programs i n the Counselling Psychology Department at U.B.C. were the actors i n the simulated physician-patient t e s t s i t u a t i o n s . From the doctoral program there were four males and three females and from the master's program there were three females and one male. Some of the same actors were used across groups at each t e s t i n g time, although the actors sometimes d i f f e r e d at each t e s t i n g occasion. Supervision of the Trainer and Raters I observed a l l t r a i n i n g sessions and met with the t r a i n e r before and a f t e r a l l sessions to discuss the t r a i n i n g process. I also met with the raters separately and reviewed the Carkhuff scale with them before the rat i n g procedure began. 63 Both raters rated a l l utterances i n the study. An utterance was defined as a medical student response of at l e a s t one sentence separated by two simulated patient phrases or sentences. The raters worked independently of one another and rated the tapes at d i f f e r e n t points i n time. Research Measures Carkhuff Empathy Rating Scale Communicated empathy was measured by Carkhuff's (1969) Empathic Understanding i n Interpersonal Process 5-point Scale. A l e v e l 1 response refers to one i n which a helper obviously does not show any s e n s i t i v i t y to another's expressed feelings or experience. I t detracts from the expressions of the helpee. Level 2 ref e r s to a response which indicates that the helper shows some acknowledgement of the helpee's obvious feelings and/or experiences, but does so i n a way which d i s t o r t s the true meaning of what the helpee i s expressing. A l e v e l 2 response subtracts from what the helpee i s attempting to communicate. Level 3 refers to a helper's response which i s interchangeable with that of the helpee i n that i t accurately expresses e s s e n t i a l l y the same f e e l i n g and content. Responses at l e v e l 3 are considered to be minimally f a c i l i t a t i v e empathic responses. A l e v e l 4 response adds to the expressions of the helpee i n that i t acknowledges deeper feelings of which the helpee may have been unaware. Level 5 refe r s to a highly additive helper response which leads to a 64 helpee experiencing his/her deepest feelings which had been previously unexplored (Carkhuff, 1969). Level 3 responses are considered to be primary empathic statements and l e v e l s 4 and 5 responses are considered to be advanced empathic statements. The aim of the empathy t r a i n i n g i n the present study was to teach the medical students to respond to patients using primary accurate empathic responses ( i . e . , l e v e l 3). Responses at l e v e l s 4 or 5 would be more appropriately covered i n counsellor t r a i n i n g because deep exploration of c l i e n t s ' thoughts and feelings i s part of a more extensive counselling process. The percentage of the responses which were at l e v e l 3 or higher was used i n the analyses. The Carkhuff Scale i s the most commonly used objective scale to independently judge actual counselling sessions (Gladstein, 1987) and i s the best available measure of expressed empathy. Carkhuff and Burstein (1970) reported r e l i a b i l i t i e s of .90 and .88 respectively on i n t r a and i n t e r c o r r e l a t i o n s among raters. There does not seem to be agreement on at what point i n an interview ratings should be taken, and many studies randomly chose segments to be rated. However, i n t h i s study a l l utterances were rated by both raters. In t h e i r review of the construct v a l i d i t y of Carkhuff's measure, Feldstein and Gladstein (1980) suggested that because t h i s scale ignores nonverbal communication and a f f e c t i v e experience of the counsellor, i t should not be used alone i n 65 research. Therefore, other measures of empathy were included i n t h i s study. Barrett-Lennard Relationship Inventories (BLRI) Medical students 1 empathic understanding or experienced empathy and simulated patients' received empathy or empathy based on the experience of simulated patients were measured using the two Empathic Understanding subscales of the Barrett- Lennard Relationship Inventories, forms MO and OS respectively (Barrett-Lennard, 1962). Each item of the scales has a 6-point scale anchored with -3 = "no I strongly f e e l that i t i s not true" to +3 = "yes I strongly f e e l that i t i s true." Each scale has eight negative items and eight p o s i t i v e items. To score the inventory, the p o s i t i v e and negative items are summed separately to form sub-totals; the negative sum score i s m u l t i p l i e d by -1 and the two sub-totals are then added to obtain the t o t a l score. Possible scores ranged from -48 to +48. J a r s k i et a l . (1985) suggested that t h i s scale i s the best measure of empathy for use i n medical research for a number of reasons, including the fact that the scale has known and acceptable v a l i d i t y and r e l i a b i l i t y , face v a l i d i t y , and relevant items. Barrett-Lennard (1962) reported that the s p l i t - h a l f r e l i a b i l i t y of these two forms ranged from .75 to .94, and a t e s t - r e t e s t c o r r e l a t i o n over a two to s i x week period was .92. The Barrett-Lennard Relationship Inventories have been validated with a va r i e t y of populations and have 66 been used i n over 100 studies, including at le a s t two with medical personnel (Jarski et a l . , 1985). Perceived Stress Questionnaire I devised a scale consisting of four questions and scored i t using a 7-point L i k e r t scale (see Appendix A). This scale gave an in d i c a t i o n of the stressfulness of the in t e r a c t i o n with the simulated patient as experienced by the subjects. To compute the perceived stress score, the f i r s t two items were p o s i t i v e l y scored and the l a s t two items ( i . e . , questions 4 and 5) were reversed scored. The items were summed for the t o t a l perceived stress score and the maximum possible score was 28. Internal consistencies as measured by Gronbach's alpha for the 4-item scale were .69 (scores for pre-trained S's, n = 19), .68 (scores for post-trained S's, n = 20), .84 (combined, N = 39). A f i f t h question concerning the subject's perception of the l e v e l of emotional d i s t r e s s of the simulated patient was included i n the middle of the questionnaire. This was a measure to ensure that there was no s i g n i f i c a n t difference i n the amount of d i s t r e s s portrayed by the simulated patients over the d i f f e r e n t t e s t i n g periods. Hardiness Scale The construct of psychological hardiness was measured using the scales employed by Kobasa et a l . (1982). This instrument i s a composite questionnaire made up of items from six instruments, a l l of which were chosen for t h e i r 67 t h e o r e t i c a l relevance and empirical r e l i a b i l i t y . The hardiness measure was scored using the 4-point scale labeled 0, 1, 2,3 for the items i n the f i r s t four scales, as suggested by S.C. Kobasa and S.R. Maddi (personal communication, November 1, 1982). The majority of items are negatively keyed. The binary scored items from the Rotter External Locus of Control Scale (1966), were scored as 0 = .5 and 1 = 2.5. The maximum possible score was 102.5. Kobasa and Maddi (1982) reported that estimates of int e r n a l consistency for the hardiness measure have been i n the . SO's and t e s t - r e t e s t r e l i a b i l i t y over a five-year period was .61. The shortened, refined form of the hardiness scale, which was used i n t h i s study, showed i n t e r n a l consistency ( c o e f f i c i e n t alpha of .86), and correlated .89 with the longer composite. Kobasa and Maddi reported that t h i s refined composite duplicates a l l the major findings reported with the longer one. The hardiness questionnaire measures a degree of control (internal rather than external), commitment (to s e l f rather than a l i e n a t i o n from s e l f ) , and challenge (vigorousness rather than vegetativeness). Ways of Coping Scale D i f f e r e n t i a l coping strategies were examined using the items from the Ways of Coping Checklist (Donnelly 1979), 1 which was based on a taxonomy developed by Lazarus (1966). The •'•The Ways of Coping items were used by permission of J.C. Donnelly. 6 8 items l i s t e d were strategies reported by interns as the ones most useful i n coping with s t r e s s f u l s i t u a t i o n s associated with t h e i r medical t r a i n i n g . This scale was chosen over Lazarus' (1966) measure because i t appeared to be more relevant and have more face v a l i d i t y for a medical student population. The 74 items on the scale are c l a s s i f i e d into two categories: problem-focused and emotion-focused. The 34 problem focused or non-palliative items include such coping strategies as: "I l e f t the h o s p i t a l " and "I looked i t up". The 40 emotion-focused or p a l l i a t i v e items include such coping measures as "I believed i n myself" and "I paid attention to my f e e l i n g s " . These items were l i s t e d i n random order to avoid a set response to either category. Instead of using a binary scoring system ( i . e . , "used", "not used"), I chose to use a 4-point scale anchored with 0 = "not used" to 3 = "used a great deal", i n order to determine the extent to which the coping strategies were used. This 4-point scoring procedure was used by Folkman et a l . (1986). Although Donnelly (1979) did not compute r e l i a b i l i t y or v a l i d i t y data on the scale, the i n t e r n a l consistencies were computed for the sample used i n t h i s study and were high (Pal, N = 39, a = .89; Nonpal, N = 39, a = .87). 69 Session and Overall Training Evaluation At the end of each i n d i v i d u a l t r a i n i n g session, the subjects were asked to complete the following sentences: What I learned today was . . . What I l i k e d most about today was ... . What I l i k e d l e a s t was . . . I thought i t was important to have immediate feedback on the t r a i n i n g and to i d e n t i f y those elements which should be incorporated into future t r a i n i n g s . A f t e r the course was completed, students were asked also about any general feedback and suggestions f o r improvement to the t r a i n i n g . Because one of the aims of t h i s research i s to i d e n t i f y how empathy t r a i n i n g helps medical students, I thought t h i s information would be relevant and useful. Experimental Procedure The Experimental Treatment - Empathy Training Subjects received four weekly three-hour long t r a i n i n g sessions i n empathic communication s k i l l s . Twelve hours of empathic s k i l l s t r a i n i n g was chosen because t h i s has been the length of other communication s k i l l s t r a i n i n g programs for health providers (Cline & Garrard, 1973; F r i e d r i c h , L i v e l y , Schacht, 1985; Poole & Sanson-Fisher, 1979). A v a r i e t y of approaches were used - lectures, modelling, films and videotaping, selected readings, r o l e playing s i t u a t i o n s , group exercises, feedback, and discussion. The standard steps i n a s k i l l s t r a i n i n g program as outlined by Egan (1986) were used 70 i n c l u d i n g development o f c o g n i t i v e and b e h a v i o r a l c l a r i t y o f empathic communication, p r a c t i c e o f s k i l l s , e v a l u a t i o n and feedback, and r e f l e c t i o n on t h e t r a i n i n g p r o c e s s . An o u t l i n e o f t h e t r a i n i n g program w h i c h I d e v e l o p e d can be found i n Appendix B. Equipment and F a c i l i t i e s The U.B.C. Department o f F a m i l y P r a c t i c e p r o v i d e d t h e l a r g e t r a i n i n g room as w e l l as t h e t e s t i n g room, b o t h o f which had v i e w i n g rooms complete w i t h one way m i r r o r s so t h a t I c o u l d m o n i t o r a l l s e s s i o n s . The room where t h e m e d i c a l s t u d e n t - s i m u l a t e d p a t i e n t i n t e r a c t i o n t o o k p l a c e was a r e g u l a r / m e d i c a l e x a m i n a t i o n room complete w i t h such i t e m s as a s i n k and an e x a m i n a t i o n t a b l e w h i c h i n c r e a s e d t h e m e d i c a l atmosphere and r e a l i s m o f t h e e n c o u n t e r . These rooms were a l s o e q u i p p e d w i t h t h e a u d i o v i s u a l equipment ( i . e . , v i d e o cameras and p l a y b a c k u n i t s ) n e c e s s a r y t o conduct t h i s s t u d y . F l o o r p l a n s o f t h e t e s t i n g and t r a i n i n g rooms can be seen i n F i g u r e s 2 and 3. Scenarios f o r Testing Situations The t h r e e t e s t s i t u a t i o n s i n c l u d e d p r e s e n t a t i o n s by t h e a c t o r s o f anger, f e a r , and g r i e f (see Appendix C ) . They were a d a p t a t i o n s o f s c e n a r i o s by Cooke and H e r b e r t (1986). R i c c a r d i and K u r t z (1983) mentioned emotions such as g r i e f , anger, and d e p r e s s i o n as ones f o r w h i c h p a t i e n t s r e q u i r e s u p p o r t i v e c o u n s e l l i n g . The d i f f e r e n t t e s t s i t u a t i o n s were Table w i t h c a s s e t t e r e c o r d e r and microphone- Si m u l a t p a t i e n t I — ^ M e d i c a l L _ r student Camera on w a l l E l e c t r i c a l c ord between rooms connect i n g v i d e o equipment one-way m i r r o r Viewing and au d i o - v i s u a l c o n t r o l room f o r r e s e a r c h e r - Video r e c o r d e r and p l a y b a c k u n i t S -Table w i t h t i m e r Figure 2. Testing room arrangement. M e d i c a l students • • • • • • Table w i t h l i t e r a t u r e and refreshments ' F l i p c h a r t | — T r a i n e r | j g — V i d e o T y tn Video p l a y b a c k equipment One-way m i r r o r Researcher V i e w i n g room Figure 3. Training room arrangement. 72 counterbalanced to eliminate possible confounding of order with treatment e f f e c t s . Each subject interacted with three simulated patients, one at each t e s t i n g occasion, each of whom presented a d i f f e r e n t emotion. Every medical student interacted with actors of both sexes and at each t e s t i n g time each one interacted with a d i f f e r e n t actor. There was one exception to t h i s (One subject saw the same actor twice due to a l a s t minute cancell a t i o n of another actor); however, neither the medical student nor the simulated patient made any acknowledgement of t h i s . T r a i n i n g of t h e Simulated P a t i e n t s The actors were asked to read the scenario describing the emotion and the type of patient they were to portray. They then f a m i l i a r i z e d themselves with the t r i g g e r sentences and were asked to use as many of them as they could remember. The simulated patients then engaged i n a short r o l e play with me i n order to ensure that they could demonstrate the appropriate emotion through t h e i r verbal and non-verbal responses. This also served as a warm-up for the actors. They were asked not to s p e c i f i c a l l y state t h e i r emotion at the beginning of the interview but rather to use the t r i g g e r sentences and non-verbal behaviours to display t h e i r emotion. Actors were t o l d that i f the medical students acknowledged the emotion, they were to de-escalate the i n t e n s i t y of the emotion while at the same time continue to explore the nature of the problem. In other words, the actors were to continue to give 73 the medical students subject matter to which they could respond, but i n a less intense way. Actors were also instructed not to ask any medical questions which may have been beyond the knowledge of second year medical students. Emotion and Gender Combinations during Testing Occasions Table 1 outlines the gender of both the medical student and the simulated patient who interacted i n each of the t e s t i n g occasions as well as the type of emotion which was presented. Table 1, Group 1 Gender of Medical Student and Simulated Patient by Emotion of Scenario Gender of Testing Occasion Medical Student I II III Subject 1 M F _ Grief M - Fear F - Anger Subj ect 2 F M - Grief F - Anger F - Fear Subj ect 3 M M - Anger F - Grief M - Fear Subject 4 M M - Anger M - Fear F - Grief Subj ect 5 F M - Fear M - Anger F - Grief Subj ect 6 F F - Fear F - Grief M - Anger Subj ect 7 F F — Grief F - Anger M - Fear Group 2 Gender of Testing Occasion Medical Student I II III Subject 1 F M Anger F - Fear M - Grief Subject 2 F F - Fear M - Grief M - Anger Subj ect 3 M F - Fear F - Anger M - Grief Subj ect 4 M F - Anger F - Fear M - Grief Subj ect 5 F M - Grief F - Anger F - Fear Subj ect 6 M M - Grief F - Anger F - Fear 74 I n summary, t h e n , t h e number o f t i m e s each emotion was p r e s e n t e d i n t h e t e s t i n g s i t u a t i o n s b e f o r e and a f t e r s u b j e c t s r e c e i v e d t h e t r a i n i n g a r e as f o l l o w s : F e a r : 6 p r e , 7 p o s t ; Anger: 7 p r e , 6 p o s t ; and G r i e f : 6 p r e , and 7 p o s t . Thus, t h e d e s i g n was f u l l y c o u n t e r b a l a n c e d f o r t h e 3 e m o t i o n a l c o n d i t i o n s on p r e and p o s t t r a i n i n g f o r each group. P r e - T e s t i n q o f S u b j e c t s I t e l e p h o n e d a l l s u b j e c t s t o a r r a n g e a s u i t a b l e t i m e f o r t h e p r e - t e s t . I a l s o b r i e f l y e x p l a i n e d t o each s u b j e c t i n what a c t i v i t i e s t h e y c o u l d e x p e c t t o be i n v o l v e d d u r i n g t h e t e s t s i t u a t i o n . The t y p i c a l t e s t i n g o c c a s i o n i n v o l v e d one m e d i c a l s t u d e n t a r r i v i n g a t t h e F a m i l y P r a c t i c e U n i t and m e e t i n g w i t h me where I e x p l a i n e d f u r t h e r t h a t t h e f i r s t p a r t o f t h e t e s t i n g i n v o l v e d i n t e r a c t i n g w i t h a s i m u l a t e d p a t i e n t . The m e d i c a l s t u d e n t s were not t o l d o f t h e e m o t i o n a l c o n d i t i o n , b u t t h e y were g i v e n a s h e e t w i t h g e n e r a l d e t a i l s about t h e p a t i e n t ' s c o n c e r n (Appendix C ) . S u b j e c t s were t o l d t h a t t h e y had 15 m i n u t e s t o e x p l o r e t h e n a t u r e o f t h e p a t i e n t ' s problem, r e c o g n i z i n g t h e l i m i t a t i o n s o f t h e i r t r a i n i n g t o d a t e . A f t e r f a m i l i a r i z i n g t h e m s e l v e s w i t h t h e s i t u a t i o n , t h e m e d i c a l s t u d e n t e n t e r e d t h e t e s t i n g room t o i n t e r a c t w i t h t h e s i m u l a t e d p a t i e n t who was s i t t i n g i n t h e t e s t i n g room. The i n t e r v i e w was v i d e o t a p e d and o b s e r v e d by m y s e l f from t h e a d j a c e n t room. A f t e r 12 m i n u t e s , I ta p p e d on t h e g l a s s o f t h e one-way m i r r o r t o i n d i c a t e t h a t t h e r e were up t o 3 m i n u t e s l e f t t o complete t h e i n t e r v i e w . 75 After the interview, the medical student returned to the o r i g i n a l examination room where he/she met with me. The subject was asked "What was that experience l i k e for you?", i n order that they might have an opportunity to express any immediate feel i n g s . No debriefing about the nature of the experimental hypotheses was given. The subject was then asked to complete the Perceived Stress Questionnaire, The BLRI, the Hardiness Questionnaire and the Ways of Coping Scale. I then went to the t e s t i n g room and requested that the simulated patient complete the c l i e n t form of the BLRI. When the subject completed a l l forms, I t o l d him/her that further contact would be made about when he/she could begin the t r a i n i n g . Assignment t o Group To ensure that assumptions of group equivalence had been met and to ensure that s i g n i f i c a n t i n i t i a l differences would not confound the r e s u l t s , groups were equated before random assignment to groups. In other words, with such a small number of subjects, i t was important that not a l l subjects who rated highly on the empathy pre-tests be i n one group. The blocking procedure used was the one f o r equivalent groups recommended by Cook and Campbell (1979). Individuals were ranked according to pre-test scores on the c l i e n t form of the BLRI, counterbalanced for gender, and then randomly assigned to a group. Because Mendez, Shymansky, and Wolraich (1986) found that female physicians demonstrated more frequent 76 r e f l e c t i o n of feelings than male physicians, and Carney and Mi t c h e l l (1986) found that patients tended to rate female medical students higher than male medical students on a measure of communication s k i l l s , I wanted a balance of males and females i n each group. I wanted to ensure also that not a l l the subjects who were rated as highly empathic were i n one group. Blocking i s a procedure which i s encouraged by researchers. For instance, Huck, Cormier, and Bounds (1974) suggested that randomization and matching can be combined and that "the combination of f i r s t matching and then random assignment w i l l perhaps y i e l d greater design p r e c i s i o n than would randomization alone" (p. 244). I t i s p a r t i c u l a r l y wise to block when using a crossover design as Poloniecki, Hews, and Barker (1982) noted i n t h e i r review of crossover studies, "Matching of patients between the two groups makes good s c i e n t i f i c sense. This can be done on such variables as age, sex and scores on subjective t e s t s " (p. 71). This procedure i s followed because i t i s desirable to conclude that s i g n i f i c a n t experimental e f f e c t s are due to the experimental intervention rather than due to intersubject v a r i a b i l i t y . Administration of Training and Post-Testing The sessions proceeded according to the outline of t r a i n i n g (see Appendix B). During each session there was a short break i n which subjects enjoyed refreshments and s o c i a l i z e d among themselves. I observed a l l t r a i n i n g sessions 7 7 to ensure that the t r a i n i n g procedure was standardized. The subjects i n the f i r s t t r a i n i n g period were asked not to reveal d e t a i l s about the nature of the empathy t r a i n i n g (e.g., empathy formula) to subjects who were i n the delayed-training group. Following the f i r s t t r a i n i n g , a l l subjects were tested using a l l measures once again. Then the second group of subjects ( i . e . , w a i t - l i s t control group) received the empathy t r a i n i n g . Following the second t r a i n i n g period, measures were taken once again on a l l subjects. In t o t a l then, each of the 13 subjects was d i r e c t l y involved i n the study for approximately 15 hours ( i . e . , 3 one-hour t e s t i n g occasions plus 12 hours of t r a i n i n g ) . I did not act as a t r a i n e r , a rater, or a simulated patient for any t e s t i n g or t r a i n i n g sessions. However, I did observe a l l t r a i n i n g sessions and co-ordinated and administered a l l t e s t i n g sessions which were conducted with only one subject and one simulated patient at a time. S t a t i s t i c a l C o n s i d e r a t i o n s Crossover designs were f i r s t used i n a g r i c u l t u r a l experiments i n the 1940's (Fellingham, Bryce, & Carter, 1981) because large experimental animals were expensive and fewer animals were required for a study. Since then, crossover designs have been extremely popular i n c l i n i c a l pharmacological research. In fact, McNair reported that 68% of studies t e s t i n g anti-anxiety drugs used the crossover 78 design (cited i n Brown, 1980). The crossover design has been used also i n c l i n i c a l psychological research (Chassan, 1979; Kazdin, 1980) to compare two or more d i f f e r e n t therapies. Armitage and H i l l s (1982) noted that the crossover design i s a simple and a t t r a c t i v e design which i s used extensively, e s p e c i a l l y i n drug studies. In discussing the p r i n c i p a l s t a t i s t i c a l aspects of the crossover design they stated, "One might have thought that i t s s t a t i s t i c a l properties were f a m i l i a r and well-documented. However, i t i s d i f f i c u l t to f i n d adeguate discussions of the design i n textbooks, and many of i t s properties are widely misunderstood" (p. 119). Because the crossover design i s not presented s p e c i f i c a l l y i n standard texts such as Winer (1971) and Kirk (1968), a thorough investi g a t i o n was done to determine the l o g i c a l type of s t a t i s t i c a l analyses which would answer the questions of i n t e r e s t i n t h i s study. The crossover design uses a Latin-square arrangement ( i . e . , an x by x arrangement i n which x appears only once i n each row and column) to counterbalance the subjects. In t h i s study, the simplest form, the 2 x 2 Latin square, was used to produce the 2 possible arrangements i n the treatment sequence that i s , A B and B A, where A = treatment and B = absence of treatment. Neter and Wasserman (1974) pointed out that the crossover design has aspects of both a completely randomized block design (subjects are blocks) and a Latin square arrangement. A crossover design uses three c l a s s i f i c a t i o n s : groups, t e s t i n g occasions, and treatments. Each treatment 79 occurs only once i n each column and only once i n each row (Campbell & Stanley 1963). Figure 4 i l l u s t r a t e s the mixed two-factor crossover control experimental f a c t o r i a l design chosen for t h i s study. Bold double l i n e s indicate the point at which empathy t r a i n i n g was introduced. Factor A (order of training) i s a between- groups, fixed factor. Factor B (testing occasion) i s a within-groups, fixed, repeated-measures factor. Subjects, a random factor, are nested within groups. Training i s f u l l y crossed with groups. Factor A Factor B - Testing Occasion Order of Intervention I II III Level A^ (Training-Control) 1 2 3 Level A 5 (Control-Training) 4 5 6 Figure 4. Experimental design. An i n i t i a l glance at Figure 4 reveals a 2 x 3 mixed model, and an analysis for a standard s p l i t - p l o t design (e.g., Kirk, 1968) was i n i t i a l l y considered. However, even though the crossover and the s p l i t - p l o t are both repeated measures designs, G i l l (1978) pointed out a major difference. In the s p l i t - p l o t design, a d i f f e r e n t treatment i s applied to each 80 group of subjects and what i s of i n t e r e s t are trends over time. In the crossover design, however, two or more treatments are applied to a l l groups of subjects, and time of treatment i s confounded with groups. What i s of i n t e r e s t are comparisons of the e f f e c t s of each of these treatments at various times. Also, because the groups are equivalent and receive i d e n t i c a l treatments, although not necessarily at the same point i n time, i t may be of i n t e r e s t to collapse some groups to examine e f f e c t s ; whereas, i n the s p l i t - p l o t design i t i s not. For instance, i n drug studies, treatment e f f e c t s of each of 2 drugs i s examined by looking at differences i n scores pre-post drug A, and pre-post drug B, regardless of the time i t was administered. In most crossover drug study designs, a carry-over e f f e c t of one drug into the next time period i s undesirable; and often a "washout" period i s included to ensure that the f i r s t treatment does not contaminate the second. However, i n t h i s study, a carry-over e f f e c t i s desirable. Because i t was hoped that there would be a reactive treatment i n the f i r s t group, i t was not expected that the follow-up group would y i e l d l e v e l of scores s i m i l a r to the w a i t - l i s t control group. In other words, although scores for the two groups immediately pre- and post-treatment could be collapsed, optimal r e s u l t s would include s t a b i l i t y of scores for the w a i t - l i s t and follow-up groups although they would be at a d i f f e r e n t l e v e l . Therefore a standard ANOVA for a two-period crossover design which collapses r e s u l t s over the two treatments, has order of 81 treatment and subjects as factors, and has no int e r a c t i o n , was inappropriate for t h i s study. A s i m i l a r design i s used i n time ser i e s studies i n which a treatment i s delayed for one group of subjects but not another. I t i s known as the staggered baseline or time-lagged control design f i r s t suggested by Gottman, McFall, and Barnett (1969). However, the analyses for a time-lagged multiple time series was c l e a r l y inappropriate for t h i s study. The design used i n t h i s study had a time lag, but not enough points for time ser i e s analyses. Another s i m i l a r design, known as a two-period crossover design with repeated measures within a period, was suggested by Ott (1988). He described t h i s design as an "extension" to repeated measures designs i n which the concepts of repeated measures and crossover designs are combined. However, Ott made no suggestion for analysis of variance for t h i s design. Collapsing the two sets of pre-tests for group two and the two sets of post-tests for group one ( i . e . , c e l l s 2 with 3 and 4 with 5 i n Figure 4) and computing a 2 x 2 between - within ANOVA was considered. However an analysis of t h i s sort would not allow the investigation of w a i t - l i s t and follow-up e f f e c t s . From the above discussion i t i s evident that the choice of analysis was not clear. A standard 2 x 3 analysis of variance with post hoc comparisons would have been inappropriate because trends over time for blocks of subjects receiving d i f f e r e n t treatments were not of in t e r e s t . Also 82 there would be a problem with in t e r p r e t a t i o n of the main and time e f f e c t s as well as the i n t e r a c t i o n because of the confounding by the treatment crossover ( i . e . , the treatment point f o r each group was not the same time). Of i n t e r e s t i n t h i s study were comparisons of how the two groups changed as a r e s u l t of the t r a i n i n g which was introduced at d i f f e r e n t times. Therefore, I decided that the best way to give c l e a r answers to the questions of i n t e r e s t i n t h i s study would be to compute a series of 2 x 2 repeated measures analyses of variance with one between-subjects factor ( i . e . , Group) and one within-subjects factor ( i . e . , Testing Occasion). Neither the type of analyses nor any references to any empirical studies which u t i l i z e d the two-period time-lagged crossover control design for two groups were suggested by Epstein and Tripodi (1977). They did, however, suggest the contrasts of i n t e r e s t for t h i s design which include: 1. Before and a f t e r comparisons within and between the two groups following the f i r s t intervention. In other words, the t y p i c a l comparisons used to determine treatment effectiveness i n any c l a s s i c a l experiment which includes a control group. 2. Comparisons to determine whether the treatment e f f e c t s i n group one were maintained over time, that i s , whether there were carry-over e f f e c t s . 3. Analyses to determine whether the experiment had been re p l i c a t e d with the second group and whether the treatment had been equally e f f e c t i v e for both groups. 83 A s e r i e s of 2 x 2 ANOVAS and t- t e s t s proved e f f e c t i v e i n e x p l i c i t l y examining these comparisons and shedding l i g h t on questions of in t e r e s t i n t h i s study. The .05 l e v e l of sig n i f i c a n c e was u t i l i z e d to tes t the F-ratios for the primary contrasts. The use of MANOVA to simultaneously t e s t a l l the variables was considered over a series of ANOVAS. One advantage of using a multivariate analysis over a series of ANOVAS i s that too many univariate tests can lead to an increase i n a Type I error rate. However, even though MANOVA would have been preferable, the use of a multivariate analysis was ruled out for two reasons. When using MANOVA, i t i s important to have a greater number of subjects per c e l l than the number of dependent variables (Schutz & Gessaroli, 1987; Tabachnick & F i d e l l , 1983). Because of the small number of subjects i n the present study, the power of the MANOVA would be lowered because of reduced degrees of freedom for error (Tabachnick & F i d e l l , 1985). Also, i f a l l the variables were to be tested i n a single analysis, small differences on the exploratory variables might obscure a r e a l difference on some of the other variables for which there was strong rationale (e.g., measures of empathy). Since MANOVA detects mainly error for the set of variables, there would be a r i s k that i t would show no r e l i a b l e o v e r a l l difference (Stevens, 1986). 84 Schutz and Gessaroli (1987) pointed out that employing a MANOVA with small numbers may lack power to detect even large e f f e c t s i z e s . These and other scholars (e.g., Tabachnick & F i d e l l , 1983) suggested that the ANOVA method may be more powerful than MANOVA for analyzing repeated measures designs with small numbers. In addition to the ANOVAS and t - t e s t s , e f f e c t sizes were calculated. E f f e c t sizes (Cohen, 1988) are measures expressed i n standard deviation units which y i e l d an in d i c a t i o n of the magnitude of treatment gains. Kazis, Anderson, and Meenan (1989) suggested that e f f e c t sizes can serve as benchmarks for int e r p r e t i n g change, not only i n the behavioural sciences, but in medicine as well, where they appear to be under-utilized. E f f e c t sizes for t h i s study were calculated using the methods discussed by Cohen (1988), Glass and Hopkins (1984) and Kazis et a l . (1989). The s p e c i f i c c a l c u l a t i o n involved taking the difference i n the means immediately before and af t e r t r a i n i n g and di v i d i n g i t by the pooled pre-treatment standard deviation. Designs Used to Test the Hypotheses In t h i s section, each substantive hypothesis i s stated f i r s t followed by an indi c a t i o n of the c e l l s used i n the analyses to te s t each hypothesis. I have also given a name to each design. As well, the s t a t i s t i c a l hypotheses, and 2While the substantive hypotheses are stated d i r e c t i o n a l l y , the s t a t i s t i c a l hypotheses are stated i n the n u l l form, and 2-tai l e d t e s t s were used i n a l l s t a t i s t i c a l analyses. 85 contrasts of primary inter e s t to t e s t the hypotheses, are emphasized. Hypothesis 1A: Subjects who receive empathy s k i l l t r a i n i n g w i l l demonstrate s i g n i f i c a n t l y higher scores on measures of empathy than w i l l subjects who are i n a w a i t - l i s t (delayed-treatment) control group. Hypothesis IB: Subjects who receive empathy s k i l l t r a i n i n g w i l l demonstrate s i g n i f i c a n t l y lower scores on a measure of perceived stress than w i l l subjects who are i n a w a i t - l i s t (delayed treatment) control group. The design used to t e s t hypotheses 1A and IB i s a c l a s s i c pre-post treatment design with a control group (Campbell & Stanley, 1963). The purpose of t h i s analysis i s to determine whether there i s a treatment e f f e c t and whether t h i s e f f e c t i s greater for the treatment group than for the control group which has had t e s t i n g only. C e l l s used i n ANOVAS to t e s t hypotheses 1A and IB are indicated with a slash i n Figure 5 . The s t a t i s t i c a l hypothesis expressed i n n u l l form i s as follows: H o : (^2 " ~ ^ 5 ~ ^4) = ° - The contrast of primary in t e r e s t to t e s t t h i s hypothesis was the Group-by-Time in t e r a c t i o n term. That i s , i f the t r a i n i n g were to be s u f f i c i e n t l y potent, an i n t e r a c t i o n would r e s u l t . 86 Time I II III Group 1 Group 2 Figure 5. C e l l s used i n ANOVAS to t e s t hypotheses 1A and IB. Hypothesis 2Ai: Subjects who are i n the post t r a i n i n g follow-up group w i l l demonstrate s i g n i f i c a n t l y higher scores on measures of empathy than w i l l subjects i n the w a i t - l i s t control group. Hypothesis 2Bi; Subjects who are i n the post t r a i n i n g follow-up group w i l l demonstrate s i g n i f i c a n t l y lower scores on a measure of perceived stress than w i l l subjects i n the wait- l i s t control group. The c e l l s used i n the analyses to t e s t the second t e s t of hypotheses are indicated with a slash i n Figure 6. Using the terminology of Cook and Campbell (1979), i t could be named a removed-treatment, no-treatment comparison with measures on two occasions. The purpose of t h i s analysis was to determine whether the e f f e c t s of the intervention were maintained for the treated group a f t e r the t r a i n i n g was terminated and whether or not t h i s e f f e c t of t r a i n i n g was greater for the post-treatment group than for the control group which had 8 7 t e s t i n g only. The s t a t i s t i c a l hypothesis expressed i n n u l l form i s as follows: /i3 + /i2 M 5 + / i 4 H 0 : H-2-*> " (-^T- 4) = 0 The main contrast of int e r e s t to t e s t hypothesis 2Ai and 3Bi was i n the group main e f f e c t . The second set of ANOVAS compared two post-training scores for group one with two pre- t r a i n i n g scores for group two. That i s , desirable r e s u l t s included a strong main e f f e c t due to the potency of the intervention. Time I I I I I I Group 1 Group 2 Figure 6. C e l l s used i n ANOVAS to te s t hypotheses 2Ai through 2 B i i i . Hypothesis 2 A i i : Subjects who are i n the post-training group w i l l maintain scores on measures of empathy during the follow-up time period. 1 / 2 / 3 / 5 6 88 H y p o t h e s i s 2 B i i : S u b j e c t s who a r e i n t h e p o s t - t r a i n i n g group w i l l m a i n t a i n s c o r e s on a measure o f p e r c e i v e d s t r e s s d u r i n g t h e f o l l o w - u p t i m e p e r i o d . The h y p o t h e s i s t o t e s t h y p o t h e s i s 2 A i i and 2 B i i e x p r e s s e d i n n u l l form i s Ho: M3 - ^2 = 0 H y p o t h e s i s 2 A i i i : S u b j e c t s who a r e i n t h e w a i t - l i s t ( d e l a y e d t r e a t m e n t ) c o n t r o l group w i l l n o t i n c r e a s e i n s c o r e s on measures o f empathy d u r i n g t h e w a i t - l i s t c o n t r o l t i m e p e r i o d . H y p o t h e s i s 2 B i i i : S u b j e c t s who a r e i n t h e w a i t - l i s t ( d e l a y e d t r e a t m e n t ) c o n t r o l group w i l l n o t d e c r e a s e i n s c o r e s on a measure o f p e r c e i v e d s t r e s s d u r i n g t h e w a i t - l i s t c o n t r o l t i m e p e r i o d . The h y p o t h e s i s t o t e s t h y p o t h e s i s 2 A i i i and 2 B i i i e x p r e s s e d i n n u l l form i s H Q: M 5 - A*4 = 0 P a i r e d group t - t e s t s were computed t o d e t e r m i n e t h e s e p a r a t e e f f e c t s o f t i m e , t h a t i s whether t h e r e were c a r r y - o v e r o r r e t e n t i o n e f f e c t s f o r group one and whether t h e r e was any d i f f e r e n c e between t h e p r e - t e s t and p o s t - t e s t f o r t h e w a i t - l i s t c o n t r o l group. 89 H y p o t h e s i s 3A: S u b j e c t s who r e c e i v e empathy s k i l l s t r a i n i n g a t d i f f e r e n t p o i n t s i n t i m e w i l l i n c r e a s e i n s c o r e s on measures o f empathy. H y p o t h e s i s 3B: S u b j e c t s who r e c e i v e empathy s k i l l s t r a i n i n g a t d i f f e r e n t p o i n t s i n t i m e w i l l d e c r e a s e i n s c o r e s o f a measure i n p e r c e i v e d s t r e s s . C e l l s used i n a n a l y s e s t o t e s t h y p o t h e s e s 3A and 3B a r e i n d i c a t e d w i t h a s l a s h i n F i g u r e 7. I t i s an e x t e n s i o n o f t h e c l a s s i c one-group p r e - p o s t d e s i g n (Campbell & S t a n l e y , 1963). t h a t i s , one-group p r e - p o s t d e s i g n w i t h r e p l i c a t i o n . The p u r pose o f t h i s d e s i g n i s t o d e t e r m i n e whether t r a i n i n g has an e f f e c t , and whether o r n o t t h i s e f f e c t i s s i m i l a r f o r b o t h g r o u p s . The s t a t i s t i c a l h y p o t h e s i s e x p r e s s e d i n n u l l form i s as f o l l o w s : Time I I I I I I Group 1 Group 2 F i g u r e 7. C e l l s used i n ANOVAS t o t e s t h y p o t h e s e s 3A and 3B. 90 The contrast of primary in t e r e s t to t e s t t h i s hypothesis was in the time main e f f e c t . I f the groups were genuinely equivalent, and the treatment s u f f i c i e n t l y potent, there should have been a d e f i n i t e time e f f e c t . A d d i t i o n a l E x p l o r a t o r y Q u e s t i o n s A seri e s of 2 x 2 ANOVAS s i m i l a r to those used to t e s t the hypotheses were used also to explore the questions of whether hardiness and number of problem-focused and emotion- focused coping strategies changed as a r e s u l t of empathy t r a i n i n g . An examination of frequency counts i d e n t i f i e d the ways of coping most commonly used by t h i s sample of second year medical students. Data A n a l y s e s P r o c e d u r e s The analyses of variance were computed using the BMDP 4V computer package. BMDP i s the program recommended by many researchers (e.g., Schutz & Gessaroli, 1987; Hertzog & Rovine, 1985) to analyze repeated measures data, due to i t s v e r s a t i l i t y . Another major reason that t h i s program was chosen to analyze the data for t h i s study was that i t does not require an equal number of subjects per group. I t uses the unweighted means solution to adjust for unequal sample size s . The SPSS program was used to compute r e l i a b i l i t i e s (Cronbach's alpha, Pearson product-moment correlations) and t- t e s t s . The Tell-A-Graf Graphics Program was used to generate the graphs. 91 CHAPTER IV R e s u l t s I n t r o d u c t i o n This chapter presents the re s u l t s of the study with emphasis on the s t a t i s t i c a l treatment of the data. I t opens with a description of the sample and a report on the research procedures. The re s u l t s of the analyses to t e s t the hypotheses are then presented, followed by re s u l t s of analyses for some additi o n a l exploratory questions. The chapter concludes with a summary of r e s u l t s . S u b j e c t C h a r a c t e r i s t i c s Of the 13 volunteer subjects who completed the study, 6 were male and 7 were female. The f i r s t group consisted of 4 women and 3 men, and the second group consisted of 3 women and 3 men. The subjects ranged i n age from 24 to 28 years with an average age of 2 5.5 years. Group one had an average age of 25.7 years; group two had an average age of 25.3 years. A l l subjects had an academic background i n the sciences except for one person who had an education degree. I m p l e m e n t a t i o n Check o f t h e S i m u l a t e d P a t i e n t s The tapes of the interviews were checked by myself and by one of the raters to ensure that at lea s t 3 of the 4 t r i g g e r sentences were used by a l l the actors. Although the verbal messages seemed to be very s i m i l a r across a l l actors, the ways i n 9 2 which the emotions were presented varied. For instance, g r i e f statements were accompanied by tears for some actors and by low mood and lethargy by others. Although the actors d i f f e r e d to some extent i n t h e i r presentations of the emotion, both raters and I agreed that the in t e n s i t y of the emotion displayed by the simulated patients was s u f f i c i e n t l y high for a l l actors. In addition, a t - t e s t revealed no s i g n i f i c a n t difference before and a f t e r t r a i n i n g i n the degree of emotional d i s t r e s s displayed by the simulated patients as perceived by the subjects based on scores on the t h i r d question of the Perceived Stress Questionnaire (Mean before t r a i n i n g = 5.47; Mean a f t e r t r a i n i n g = 5.53; t = -0.19, p = .85). I n t e r - r a t e r R e l i a b i l i t y In the study, there were 1160 medical student utterances a l l of which were rated by both raters. The average percentage of responses which were at l e v e l 3 or above for the two raters were used i n the data analyses. The i n t e r - r a t e r r e l i a b i l i t y was calculated using a Pearson product - moment c o r r e l a t i o n . Agreement between the raters' scores for a l l utterances was r = .88 (p < .001). A n a l y s e s o f T r a i n i n g E f f e c t s In t h i s section, the means and standard deviations for a l l measures over a l l times are presented f i r s t (Table 2). Results of t e s t s of the hypotheses are then described. The section Table 2. Means and Standard Deviations f o r Dependent Measures (N=13) Carkhuff Empathy Rating Scale (Percentage of Level 3 Responses) Time 1 Time 2 Time 3 Group 1 M SD 3 .20 2.76 40.56 17.55 49.29 19.81 Group 2 M SD 5.77 2.61 3.01 1.96 55.86 17 .33 BLRI (Simulated Patient Rating of Empathy Scale) Time 1 Time 2 Time 3 Group 1 M SD 1.43 24.38 23.14 15. 09 29.86 10.42 Group 2 M SD 0.33 21.71 2.33 13.29 23 . 83 13 . 64 BLRI (Medical Student Rating of Empathy Scale) Time 1 Time 2 Time 3 Group 1 M SD 14.57 8.20 25.57 7.64 24.43 8.38 Group 2 M SD 8.67 7.58 8.67 7.53 17.17 8.98 Perceived Stress Scale Time 1 Time 2 Time 3 Group 1 M SD 17.71 3.35 10.29 1.80 11.86 2.67 Group 2 M SD 18.67 3.72 18.33 2.50 14.33 3.45 Table 2 (cont'd) Hardiness Scale Time 1 Time 2 Time 3 Group 1 M 75.29 76.21 75.36 SD 10.86 10.14 12.82 Group 2 M 66.58 64.58 66.58 SD 14.09 12.04 13.37 Emotion-Focused Scale (Number of Strategies Used) Time 1 Time 2 Time 3 Group 1 M 25. 00 27.14 26.14 SD 3.37 5.61 4.88 Group 2 M 27.67 26.33 28 . 50 SD 6.77 6.89 8.41 Problem-Focused Coping Scale (Number of Strategies Used) Time 1 Time 2 Time 3 Group 1 M 22.86 25.29 26.57 SD 3.85 4.15 4.10 Group 2 M 24.00 26. 67 27.00 SD 5.44 5.35 6.07 95 concludes with the r e s u l t s of analyses of the exploratory questions. Hypotheses 1A and IB Hypothesis 1A: Subjects who receive empathy s k i l l t r a i n i n g w i l l demonstrate s i g n i f i c a n t l y higher scores on measures of empathy than w i l l subjects who are i n a w a i t - l i s t (delayed- treatment) control group. Hypothesis IB: Subjects who receive empathy s k i l l t r a i n i n g w i l l demonstrate s i g n i f i c a n t l y lower scores on a measure of perceived stress than w i l l subjects who are i n a w a i t - l i s t (delayed-treatment) control group. Carkhuff Empathy Rating Scale (Percentage of Level 3 Responses) The re s u l t s of the 2 x 2 analysis of variance for the percentage of l e v e l 3 responses for each t e s t i n g occasion are shown i n Table 3(a). The comparison of primary i n t e r e s t , the group-by-time in t e r a c t i o n i s s t a t i s t i c a l l y s i g n i f i c a n t (p < .05). That i s , the treated group increased i t s scores s i g n i f i c a n t l y more that the w a i t - l i s t group. An examination of the means i n Table 2 reveals that a f t e r t r a i n i n g the score on the post-test for group 1 i s much higher than any of the remaining means for t h i s comparison. In addition, as may be seen i n the graph of means for t h i s measure (Figure 8), when t e s t i n g occasions 1 and 2 are compared, the 3 means for c e l l 1, 4 and 5 c l u s t e r whereas the mean for c e l l 2 i s much more elevated. That i s to say, the percentage of responses at l e v e l 3 was much higher following the empathy t r a i n i n g than i n 9 6 Table 3. Summary of Analyses of Variance for Dependent Measures (Hypotheses 1A & IB: Comparison of C e l l s 1 & 2 with 4 & 5, N=13) 3(a) Percentage of Level 3 Responses Source of Variance SS df MS F p Between Groups: Group (G) 1976.48 1 1976.48 19.08 .001 Error: between groups 1139.25 11 103.57 Within Groups: Time (T) 1933.13 1 1933.13. 26.32 .000 GXT 2601.01 1 2601.01 35.42 .000 Error: within group 807.85 11 73.44 3(b) BLRI Empathy Scale (Simulated Patient Rating) Source of Variance SS df MS F p Between Groups: Group (G) 775.09 1 775.09 3.07 .108 Error: between groups 2779.52 11 252.68 Within Groups: Time (T) 908.44 1 908.44 1.65 .225 GXT 627.82 1 627.82 1.14 .308 Error: within group 6041.71 11 549.25 9 7 Table 3 cont'd 3(c) BLRI Empathy Scale (Medical Student Rating) Source of Variance SS df MS Between Groups: Group (G) Error: between groups 840.00 942.10 1 11 840.44 85.65 9.81 .010 Within Groups: Time (T) GXT Error: within group 195.46 195.46 382.00 1 1 11 195.46 195.46 34.72 5.63 5.63 .037 .037 3(d) Perceived Stress Scale Source of Variance SS df MS Between Groups: ' Group (G) Error: between groups 130.85 82.00 1 11 130.85 7.45 17.55 .002 Within Groups: Time (T) GXT Error: within group 97.32 81.32 105.52 1 1 11 97.32 81.32 9.59 10.15 8.48 .009 .014 98 60 - i 50- 40 30 £ 2 0 10 Legend O Group One A Group Two 0 Testing Occasion Figure 8. Means for percentage of l e v e l 3 responses rated on the Carkhuff Empathy Scale. 99 Testing Occasion Figure 9. Means for simulated patient ratings on the Empathy Scale of the BLRI. 100 26 n 1 1 1 1 2 . 3 Testing Occasion Figure 10. Means for medical student ratings on the Empathy Scale of the BLRI. r o i 1 9 - | 1 1 1 1 2 . 3 Testing Occasion Figure 1 1 . Means for medical student ratings on the Perceived Stress Scale. 102 the w a i t - l i s t control condition. Since a l e v e l of at l e a s t 3 on the Carkhuff Scale i s interpreted as an interchangeable response of f e e l i n g and content of the simulated patient's response by the medical student, the t r a i n i n g , i t appears, enabled the subjects to i n t e r a c t i n a more empathic fashion. BLRI Empathy Scale (Simulated Patient Ratincr) - The summary ANOVA table for the f i r s t set of comparisons for the simulated patient ratings for the Empathy Scale of the BLRI may be found i n Table 3(b). The e f f e c t s of treatment were i n the hypothesized d i r e c t i o n ; however, the group x time in t e r a c t i o n was not s t a t i s t i c a l l y s i g n i f i c a n t . This may have been due to the wide range i n i n d i v i d u a l scores by the actors as well as the small numbers of subjects r e s u l t i n g i n a r e l a t i v e l y large standard error. BLRI Empathy Scale (Medical Student Rating) - Table 3(c) contains the analysis of variance table for the subject rated scores for the Empathy Scale of the BLRI for the f i r s t analysis. The contrast of primary inte r e s t , the i n t e r a c t i o n between group and time achieved the p r o b a b i l i t y value of less than .05. I t can be seen i n Table 2 and Figure 10 that the post-test score for group 1 i s higher than the pre-training scores for groups 1 and 2. That i s , a f t e r p a r t i c i p a t i n g i n the t r a i n i n g the medical students perceived themselves as being more empathic. Perceived Stress Scale - Table 3(d) presents the ANOVA table for the Perceived Stress Scale. The group x time i n t e r a c t i o n was s t a t i s t i c a l l y s i g n i f i c a n t at p < .05. The mean score for group 1 (Table 2) was lower than for either the pre-training score or for 103 both mean scores for group 2. The graph for the perceived stress measure (Figure 11) i l l u s t r a t e s the fact that the perceived stress scores f o r group 1 were reduced a f t e r t r a i n i n g , while the scores for group 2 did not increase or decrease over time. Thus empathy t r a i n i n g i s associated with a s i g n i f i c a n t decrease i n perceived stress. Hypotheses 2 A i through 2 B i i i Hypothesis 2Ai: Subjects who are i n the post-training follow-up group w i l l demonstrate s i g n i f i c a n t l y higher scores on measures of empathy than w i l l subjects i n the w a i t - l i s t control group. Hypothesis 2Bi: Subjects who are i n the post-training follow-up group w i l l demonstrate s i g n i f i c a n t l y lower scores on a measure of perceived stress than w i l l subjects i n the w a i t - l i s t control group. The r e s u l t s of the 2 x 2 ANOVAS for a l l four dependent measures to t e s t the second hypotheses may be found i n Tables 4a to 4d. A l l four dependent measures resulted i n a s t a t i s t i c a l l y s i g n i f i c a n t group main e f f e c t (p < .05), which gives an ind i c a t i o n of the potency of the intervention. The increased l e v e l s of empathy and decreased l e v e l s of perceived stress which resulted from the t r a i n i n g were maintained for subjects during the follow-up time period and were s i g n i f i c a n t l y d i f f e r e n t from the scores on these measures than those of subjects i n the wait- l i s t control condition. 104 Table 4 . Summary of Analyses of Variance for Dependent Measures (Hypotheses 2Ai & 2Bi: comparisons of c e l l s 2 & 3 with 4 & 5, N=13) 4(a) Percentage of Level 3 Responses Source of Variance SS df MS Between Groups: Group (G) Error: between groups 10614.7 2586.31 1 11 10614.7 235.12 45.15 .000 Within Groups: Time (T) GXT Error: within group 57.31 213.25 1670.80 1 1 11 57.31 213.25 151.89 .38 1.40 .552 .261 4(b) BLRI Empathy Scale (Simulated Patient Rating) Source of Variance SS df MS F p Between Groups: Group (G) 4092.49 1 4092.49 17.01 .001 Error: between groups 2646.67 11 240.61 Within Groups: Time (T) 122.67 1 122.67 .41 .533 GXT 35.90 1 35.90 .12 .734 Error: within group 3257.71 11 296.16 105 Table 4 cont'd 4(c) BLRI Empathy Scale (Medical Student Rating) Source of Variance SS df MS F p Between Groups: Group (G) 1723.79 1 1723.79 87.89 .000 Error: between groups 916.67 11 83.33 Within Groups: Time (T) 2.11 1 2.11 .05 .820 GXT 2.11 1 2.11 .05 .820 Error: within group 425.43 11 38.68 4(d) Perceived Stress Scale Source of Variance SS Between Groups: Group (G) Error: between groups 356.57 70.43 Within Groups: Time (T) GXT Error: within group 2.48 5.86 92.52 df MS 1 11 356.57 6.40 55.69 .000 1 1 11 2.47 5.86 8.41 .29 .70 .598 .422 106 An examination of Table 2 reveals that there was very l i t t l e change i n the means for the pre-and post-scores during the no intervention period. This e f f e c t can also be found i n the graphs for the empathy and perceived stress measures (Figures 8-11) when t e s t i n g occasions 2 and 3 for group one are compared with t e s t i n g occasions 1 and 2 for group two. Hypothesis 2 A i i : Subjects who are i n the post-training group w i l l maintain scores on measures of empathy during the follow-up time period. Hypothesis 2 A i i i : Subjects who are i n the w a i t - l i s t (delayed-treatment) control group w i l l not increase i n scores on measures of empathy during the w a i t - l i s t control time period. Hypothesis 2 B i i : Subjects who are i n the post-training group w i l l maintain scores on a measure of perceived stress during the follow-up time period. Hypothesis 2 B i i i : Subjects who are i n the w a i t - l i s t (delayed-treatment) control group w i l l not decrease i n scores on a measure of perceived stress during the w a i t - l i s t control time period. Hypotheses 2 A i i , 2 A i i i , 2 B i i , and 2 B i i i were tested using paired (dependent) group t - t e s t s with a relaxed alpha of .25 i n order to be c e r t a i n that there was no change ( i . e . , increase i n empathy and decrease i n perceived stress) i n scores i n the absence of any treatment. The t- t e s t s used to t e s t hypotheses 2 A i i and 2 B i i serve also as comparisons of simple main e f f e c t s ( i . e . , simple e f f e c t s tests comparing l e v e l s of one factor at a p a r t i c u l a r l e v e l of the second factor) when a s i g n i f i c a n t 107 i n t e r a c t i o n i s o f i n t e r e s t f o r hy p o t h e s e s 1A and IB. The r e s u l t s found i n T a b l e 5, showed t h a t none o f t h e p a i r s o f means was s i g n i f i c a n t l y d i f f e r e n t w i t h t h e e x c e p t i o n o f one ( C a r k h u f f p e r c e n t a g e l e v e l 3 r e s p o n s e s , p = .11 f o r h y p o t h e s e s 2 A i i i ) . I n f a c t , however, t h e mean s c o r e s f o r t h i s measure a c t u a l l y d e c r e a s e d a c r o s s t i m e f o r t h e w a i t - l i s t c o n t r o l group i n t h e absence o f t r e a t m e n t (M, p r e = 5.77, M, p o s t = 3.01). Thus, t h e w a i t i n g p e r i o d d i d n o t r e s u l t i n an i n c r e a s e i n p e r c e n t a g e o f l e v e l 3 r e s p o n s e s . Only one out o f t h e e i g h t t - t e s t s a p p r o x i m a t e d s i g n i f i c a n c e a t a = .25, and i t was i n t h e o p p o s i t e d i r e c t i o n . Table 5. Results of the T-Tests f o r Carry-over and Wait-List E f f e c t s Measure C a r k h u f f BLRI BLRI P e r c e i v e d % L e v e l 3 S-P Rat e d M-S R a t e d S t r e s s C a r r y o v e r e f f e c t s (n = 7) ( i . e . , c o m p a r i s o n s o f c e l l 2 v s c e l l 3 i n group 1, F i g u r e 4) Mean C e l l 2 40.56 23.14 25.57 10.29 Mean C e l l 3 49.29 29.86 24.43 11.86 t -0.99 -1.15 .58 -1.14 p .36 .29 .58 .30 Wait l i s t c o n t r o l (n = 6 ) ( i . e . , c o mparisons o f c e l l 4 v s c e l l 5 i n group 2, F i g u r e 4) Mean C e l l 4 5.77 .33 8.67 18.67 Mean C e l l 5 3.01 2.33 8.67 18.33 t 1.92 ^0.15 .0 .18 p .11 .88 1.0 .87 108 T h e r e f o r e t h e r e s u l t s i n d i c a t e t h a t empathy measures d i d n ot i n c r e a s e s i g n i f i c a n t l y d u r i n g t h e w a i t i n g p e r i o d f o r t h e d e l a y e d - t r a i n i n g group, w h i l e t h e e f f e c t s o f empathy t r a i n i n g were m a i n t a i n e d f o r t h e p o s t - t r e a t m e n t f o l l o w - u p group. S i m i l a r l y , p e r c e i v e d s t r e s s d i d n o t d e c r e a s e i n t h e p o s t - t e s t o f t h e d e l a y e d - t r a i n i n g group, and c a r r y - o v e r e f f e c t s o f p e r c e i v e d s t r e s s f o r t h e empathy t r a i n e d groups were m a i n t a i n e d . Hypotheses 3A and 3B H y p o t h e s i s 3A; S u b j e c t s who r e c e i v e empathy s k i l l s t r a i n i n g a t d i f f e r e n t p o i n t s i n t i m e w i l l i n c r e a s e i n s c o r e s on measures o f empathy. H y p o t h e s i s 3B: S u b j e c t s who r e c e i v e empathy s k i l l s t r a i n i n g a t d i f f e r e n t p o i n t s i n t i m e w i l l d e c r e a s e i n s c o r e s o f a measure i n p e r c e i v e d s t r e s s . The r e s u l t s o f t h e 2 x 2 ANOVAS f o r a l l f o u r dependent measures t o t e s t t h e t h i r d h y p otheses may be found i n T a b l e s 6a t o 6d. The c o n t r a s t o f p r i m a r y i n t e r e s t , t h e t i m e main e f f e c t , a c h i e v e d t h e p r o b a b i l i t y v a l u e o f l e s s t h a n .05 f o r a l l measures. O v e r a l l t h e p o s t - s c o r e s were d i f f e r e n t from t h e p r e s c o r e s i n t h e d i r e c t i o n p r e d i c t e d by t h e s u b s t a n t i v e h y p o t h e s e s . An e x a m i n a t i o n o f t h e means i n T a b l e 2 and t h e ANOVA r e s u l t s shown i n T a b l e 6 a-d r e v e a l t h a t , a f t e r t r a i n i n g t h e s c o r e s f o r t h e t h r e e empathy measures f o r b o t h groups were s i g n i f i c a n t l y h i g h e r t h a n t h e p r e - t r a i n i n g means. As F i g u r e s 8-10 show, when t e s t i n g o c c a s i o n s 1 and 2 f o r group one and t e s t i n g o c c a s i o n s 2 Table 6. Summary of Analyses of Variance for Dependent Measures (Hypotheses 3A & 3B: Comparison of C e l l s 1 & 2 with 5 & 6, N=13) 6(a) Percentage of Level 3 Responses Source of Variance SS df MS F p Between Groups: Group (G) 368.61 1 368.61 2.24 .163 Error: between groups 1809.48 11 164.50 Within Groups: Time (T) 13146.2 1 13146.2 90.10 .000 GXT 387.68 1 387.68 2.66 .131 Error: within group 1604.93 11 145.90 6(b) BLRI Empathy Scale (Simulated Patient Rating) Source of Variance SS df MS F p Between Groups: Group (G) 4.11 1 4.11 .02 .900 Error: between groups 2735.27 11 248.66 Within Groups: Time (T) 3016.69 1 3016.69 7.58 .019 GXT .75 1 .74 0.00 .989 Error: within group 4375.46 11 397.77 Table 6 cont'd 6(c) BLRI Empathy Scale (Medical Student Rating) Source of Variance SS Between Groups: Group (G) 330.77 Error: between groups 872.85 Within Groups: Time (T) 614.25 GXT 10.10 Error: within group 566.75 df MS F p 1 330.77 4.17 .066 11 79.35 1 614.25 11.92 .005 1 10.10 .20 .667 11 51.52 6(d) Perceived Stress Scale Source of Variance SS Between Groups: Group (G) Error: between groups 35.18 53.67 Within Groups: Time (T) GXT Error: within group 210.99 18.99 123.86 df MS 1 11 35.18 4.88 7.21 .021 1 1 11 210.99 18.99 11.26 18.74 1.69 .001 .221 I l l and 3 for group two are compared, the post-training means are s i g n i f i c a n t l y higher than the pre-training means r e s u l t i n g i n p a r a l l e l l i n e s (therefore no i n t e r a c t i o n ) . That i s , scores for both subjective and objective measures of empathy were s i g n i f i c a n t l y higher following the empathy t r a i n i n g for both groups. Following t r a i n i n g , the means for the perceived stress measure f o r both groups were lower than the pre-treatment means (Table 2). As Figure 11 shows, when t e s t i n g occasion 1 and 2 for group one and t e s t i n g occasions 2 and 3 for group two are compared, the post-training means are lower than the pre-training means, thus p a r a l l e l l i n e s r e s u l t . Scores on the perceived stress measure were s i g n i f i c a n t l y lower for subjects following the empathy t r a i n i n g . Summary From the r e s u l t s presented above, i t i s c l e a r that i n general the data confirmed the hypotheses. The treatment was s u f f i c i e n t l y potent to enable the differences to be s t a t i s t i c a l l y s i g n i f i c a n t . The one e f f e c t which was non-significant was probably due to a combination of a small c e l l number and a large standard deviation. Thus, these r e s u l t s support the main hypothesis that empathic communication s k i l l s t r a i n i n g increases l e v e l s of empathy and decreases perceived stress of second year medical students. 112 R e s u l t s o f E x p l o r a t o r y A n a l y s e s H a r d i n e s s S c a l e The r e s u l t s of the set of 2 x 2 ANOVA's f o r the Hardiness Scale can be found i n Table 7 and displayed graphically i n Figure 12. There was no s i g n i f i c a n t difference on any of the comparisons of primary i n t e r e s t . The series of ANOVAS were also computed for each of the hardiness subscales of commitment, control and challenge. Again the re s u l t s were i n s i g n i f i c a n t f or a l l contrasts. A l i t e r a t u r e review revealed only one study which reported scores for the various subscales for the short form of the hardiness measure (Hull, VanTreuren & V i r n e l l i , 1987). In order to compare r e s u l t s , I contacted Hull to v e r i f y h i s scoring procedure, and then the hardiness measure for the present sample was rescored using h i s method. I t i s of in t e r e s t to note that the scores for the medical students i n the present study were not s i g n i f i c a n t l y d i f f e r e n t from the scores of a group reported by Hull et a l . (1987) of 447 psychology undergraduates. The re s u l t s were as follows: Commitment resulted i n a mean of 16.15 and standard deviation of 3.45 i n Hull's sample, and with a mean of 16.82 and standard deviation of 4.71 i n the current study. Control resulted i n a mean of 34.67 and standard deviation of 8.58 i n Hull's sample, and with a mean of 32.40 and standard deviation of 10.65 i n the present study. Challenge resulted i n a mean of 20.54 and standard deviation of 3.12 i n Hull's sample, while i n t h i s study there was a mean of 21.36 and a standard deviation of 2.71. 113 Table 7. Summary of Analyses of Variance for Hardiness Scale (N=13) (a) Comparison of C e l l s 1 & 2 with 4 & 5 Source of Variance SS df MS F Between Groups: Group (G) 667.82 1 667.82 2.51 .1414 Error: between groups 2927.17 11 266.11 Within Groups: Time (T) 1.85 1 1.85 .17 .6838 GXT 13.85 1 13.85 1.31 .2772 Error: within group 116.61 11 10.60 (b) Comparison of C e l l s 2 & 3 with 4 & 5 Source of Variance SS df MS Between Groups: Group (G) 672.57 1 672.57 2.33 .555 Error: between groups 3180.27 11 289.12 Within Groups: Time (T) 13.19 1 13.19 1.02 .335 GXT 2.11 1 2.11 .16 .694 Error: within group 142.43 11 12.95 (c) Comparison of C e l l s 1 & 2 with 5 & 6 Source of Variance SS df MS Between Groups: Group (G) 667.87 1 667.87 2.57 .138 Error: between groups 2863.17 11 260.29 Within Groups: Time (T) 13.85 1 13.85 1.89 .197 GXT 1.85 1 1.85 .25 .625 Error: within group 80.61 11 7.33 114 115 Thus the sample of medical students who p a r t i c i p a t e d i n t h i s study scored neither higher nor lower i n hardiness than did a large sample of students enrolled at an American academic i n s t i t u t i o n . B e h a v i o u r a l C o p i n g Measures As can be seen i n Table 2, the mean number of both emotion- focused and problem-focused strategies used by the subjects to cope with the stresses of medical t r a i n i n g increased a f t e r the empathy t r a i n i n g . The r e s u l t s of the sets of 2 x 2 ANOVAS for number for both emotion-focused and problem-focused coping strategies can be found i n Tables 8 and 9. There was no s i g n i f i c a n t difference for any of the comparisons of primary i n t e r e s t . The same series of 2x2 ANOVAS was computed on the degree to which the coping strategies were used ( i . e . , computed on the 0-3). Again the r e s u l t s were non-significant for contrasts of primary i n t e r e s t (see Figures 13 and 14). Frequency counts were computed to i d e n t i f y the coping strategies which were used by a l l the subjects pre- and post- t r a i n i n g (Table 10). T-tests were computed for subjects immediately pre-and post-training to determine i f there was any difference i n the r a t i o of the number of emotion-focused compared with the number of problem-focused coping strategies. Before t r a i n i n g t h i s difference was non-significant (p = .33). However, a f t e r the empathy t r a i n i n g , the number of emotion-focused coping strategies compared with the number of problem-focused coping strategies used approached s i g n i f i c a n c e (p = .053). 1 1 6 Table 8. Summary of Analyses of Variance for Emotion-Focused Coping Scale (Number of Strategies Used) N=13 (a) Comparison of C e l l s 1 & 2 with 4 & 5 Source of Variance SS df MS Between Groups: Group (G) Error: between groups 5.57 647.43 1 11 5.57 58.86 .09 .764 Within Groups: Time (T) GXT Error: within group 1.06 19.52 76.10 1 1 11 1.06 19.52 6.92 .15 2.82 .703 .121 (b) Comparison of C e l l s 2 & 3 with 4 & 5 Source of Variance SS df MS Between Groups: Group (G) Error: between groups .82 785.71 1 11 .82 71.43 .01 .916 Within Groups: Time (T) GXT Error: within group 8.80 .18 12.67 1 1 11 8.80 .18 1.15 7.64 .16 .018 .700 (c) Comparison of C e l l s 1 & 2 with 5 & 6 Source of Variance SS df MS Between Groups: Group (G) Error: between groups 11.69 757.85 1 11 11.69 68.90 .17 .688 Within Groups: Time (T) GXT Error: within group 30.00 .92 89.85 1 1 11 30.00 .92 8.17 3.67 0.00 .08 .99 117 Table 9. Summary of Analyses of Variance for Problem-Focused Coping Scale (Number of Strategies Used) N=13 (a) Comparison of C e l l s 1 & 2 with 4 & 5 Source of Variance SS df MS F i Between Groups: Group (G) 10.29 1 10.29 .28 .605 Error: between groups 400.10 11 36.37 Within Groups: Time (T) 41.94 1 41.94 5.52 .039 GXT .92 1 .92 .01 .915 Error: within group 83.52 11 7.59 (b) Comparison of C e l l s 2 & 3 with 4 & 5 Source of Variance SS df MS F p Between Groups: Group (G) 2.29 1 2.29 .05 .830 Error: between groups 525.10 11 47.74 Within Groups: Time (T) 25.23 1 25.23 14.32 .003 GXT 3.08 1 3.08 1.75 .213 Error: within group 19.38 11 1.76 (c) Comparison of C e l l s 1 & 2 with 5 & 6 Source of Variance SS df MS Between Groups: Group (G) 49.29 1 49.29 1.28 .283 Error: between groups 425.10 11 38.65 Within Groups: Time (T) 12.32 1 12.32 1.43 .256 GXT 7.09 1 7.09 .83 .383 Error: within group . 94.52 11 8.59 Ld 25 Legend O Group One A Group Two Testing Occasion Figure 13. Means for Emotion-Focused Coping Scale. 27 26 H CD i _ O o CO CO 25- c *o_ o O x> CD CO CU  24 ± o LZ 1 1 E CD _Q O Q_ 23- C c o CD 2 22 21 0 ^ ' Legend O Group One A Group Two Testing Occasion F i g u r e 14. Means f o r Problem-Focused Coping S c a l e , 120 Table 10. Behavioural Coping Strategies Used by a l l Subjects Pre- and Post-training (N=13) Pre-Training Coping Strategies Emotion-Focused: 7* I believed i n myself. 60 I had learned to accept c e r t a i n things. 68 I talked with others. Problem-Focused: 4 I l o g i c a l l y thought things out. 19 I did what I needed to do. 39 I hung i n there and kept plugging away. 46 I did the best I could. 55 I was organized and e f f i c i e n t . 57 I assumed a professional role/acted l i k e an adult. 69 I responded to p o s i t i v e feedback. Post-Training Coping Strategies Emotion-Focused: 7 I believed i n myself. 9 I used/kept my sense of humor. 62 What I could not do then, I did l a t e r . 68 I talked with others. 74 I enjoyed i t and wanted to be there. Problem-Focused: 2 I stepped back and t r i e d to evaluate how I was doing. 4 I hung i n there and kept plugging away. 12 I ordered things by p r i o r i t y . 27 I had set my own expectations. 29 I accommodated/made compromises. 40 I t r i e d to understand what people were saying. 44 I had established cl e a r p r i o r i t i e s . 46 I did the best I could. 55 I was organized and e f f i c i e n t . 57 I assumed a professional role/acted l i k e an adult. *Item number 121 E f f e c t Sizes The table of effect sizes for measures in this study can be found in Table 11. The magnitude of the effect sizes for the three empathy measures and the perceived stress measure was very large. For instance on the empathy measures, subjects gained an average of 18.32 standard units on the Carkhuff Scale, 1.25 standard units on the BLRI (M-S Rating), 1.08 on the BLRI (S-P Rating), while perceived stress was lowered by 1.95 standard units as indicated by the negative effect size. Table 11. E f f e c t Sizes for Measures (N = 13, 2 Groups Pooled) Unweighted Unweighted Pooled Standard E f f e c t Measure Mean (Pre) Mean (Post) Deviation (Pre) Size Carkhuff Empathy 3.11 47.62 2.43 18.32 Scale (percentage of responses > l e v e l 3) BLRI (medical 11.85 21.69 7.90 1.25 student ratings) BLRI (simulated 1.85 23.46 20.11 1.08 patient ratings) Perceived Stress 18.00 12.16 2.99 -1.95 Scale Hardiness Scale 70.35 71.77 11.41 .13 Emotion-Focused 25.61 27.77 5.27 .41 Coping Scale (number of ways) Problem-Focused 24.62 26.08 4.59 .32 Coping Scale (number of ways) 122 The pre-training standard deviation for the Carkhuff Scale was very small due to a small variance and f l o o r e f f e c t s . The t r a i n i n g had the e f f e c t of r a i s i n g and spreading out the scores, as there was a large range of scores on post-testing. The e f f e c t s i z e was calculated using the pre-training standard deviation based on the recommendation of Glass and Hopkins (1984) that when "the treatment can a f f e c t the heterogeneity as well as the mean of the treatment group, s c o n ^ . r o ^ should be used i n the denominator" (p. 236). Hence, the r e s u l t i n g e f f e c t s i z e was very large. However, i f the pooled post-training standard deviation were to be used i n the c a l c u l a t i o n , the e f f e c t s i z e of t h i s measure would be much smaller than 18.32. I t i s of i n t e r e s t to note that using the post-training standard deviation would r e s u l t also i n a larger e f f e c t s i z e for BLRI simulated patient ratin g . The standard deviations of the other measures, however, were much less v a r i a b l e pre- and post-training (see Table 2) and so the e f f e c t sizes would be approximately the same. These e f f e c t sizes v e r i f y the r e s u l t s of the hypotheses that empathy t r a i n i n g leads to an increase of scores on measures of empathy and a decrease of scores on a measure of perceived stress. Even though t h i s study had a small number of subjects, the high power due to the repeated measures design means that there was a high p r o b a b i l i t y that i t would lead to the r e j e c t i o n of the f a l s e n u l l hypotheses i f the intervention were to be s u f f i c i e n t l y potent. Large e f f e c t sizes mean that the intervention was e f f e c t i v e because e f f e c t sizes are the degree to 123 w h i c h t h e r e s u l t i n g change i n s c o r e s e x i s t due t o t h e t r e a t m e n t and n o t t o chance (Cohen, 1988). E f f e c t s i z e s f o r t h e measures o f t h e e x p l o r a t o r y a n a l y s e s ( h a r d i n e s s , and number o f c o p i n g s t r a t e g i e s ) were much s m a l l e r t h a n f o r t h e measures o f t h e main h y p o t h e s e s . T h i s may be due, i n p a r t , t o l a c k o f power, w i t h a s m a l l number, t o d e t e c t changes i n t h e s e p a r t i c u l a r measures. Session and Training Evaluation Comments by t h e s u b j e c t s on t h e i n d i v i d u a l t r a i n i n g s e s s i o n s were p l a c e d i n t o c a t e g o r i e s based on t h e s t a n d a r d s t e p s i n a s k i l l s - t r a i n i n g program i d e n t i f i e d by Egan (1986). They i n c l u d e c o g n i t i v e c l a r i t y , b e h a v i o u r a l c l a r i t y , p r a c t i c e , e v a l u a t i o n , and r e f l e c t i o n . A l l segments o f t h e w r i t t e n f eedback c o u l d be e a s i l y c a t e g o r i z e d i n t o t h e s e m u t u a l l y e x c l u s i v e g r o u p i n g s ( T a b l e s 12 & 13) . F o r t y - n i n e p e r c e n t o f t h e answers c o n c e r n i n g what t h e s u b j e c t s l e a r n e d p e r t a i n e d t o c o g n i t i v e c l a r i t y ( e . g . , i m p o r t a n c e o f empathy). The a s p e c t o f t h e c o u r s e w h i c h t h e s u b j e c t s e n j o y e d t h e most was p r a c t i s i n g (both p a t i e n t and p h y s i c i a n r o l e s ) as was i n d i c a t e d by 49 p e r c e n t o f t h e r e s p o n s e s . The a s p e c t s o f t h e c o u r s e w h i c h t h e c l i e n t s l i k e d t h e l e a s t were i n d i c a t e d as r e f l e c t i o n , e.g., " I was t i r e d and had d i f f i c u l t y c o n c e n t r a t i n g " (30% o f r e s p o n s e s ) and " N o t h i n g I d i d n ' t l i k e " (26% o f r e s p o n s e s ) . S u g g e s t i o n s f o r improvement o f t h e c o u r s e a r e p r e s e n t e d i n T a b l e 14. J u s t as p r a c t i c e o f s k i l l s was t h e a s p e c t o f t h e c o u r s e w h i c h t h e s u b j e c t s appeared t o l i k e t h e most, more T a b l e 12. F r e q u e n c y o f Responses from (A) WHAT I LEARNED TODAY WAS . . . Theme No. of Session 1 Responses Cognitive Clarity 15 Practice 9 Reflection on Training 4 Session 2 Cognitive Clarity 6 Practice 4 Behavioural Clarity 2 Evaluation 1 Session 3 Behavioural Clarity 7 Cognitive Clarity 4 Reflection 3 Practice 1 Evaluation 1 Session 4 Cognitive Clarity 11 Behavioural Clarity 5 Evaluation 1 124 s i on Feedback Examples Purpose and rationale of the course e.g. , importance of paraphrasing Active listening To trust my intuition on how I perceive another is feeling Empathy formula How to "concentrate" on reflecting Integrating the specific skil ls with my style Became more aware of non verbal cues from videotaping How anger can be handled using empathy Nature of the emotion of anger Awareness of self, i .e . , my empathizing with anger involves avoidance Practice of skil ls I need to build my vocabulary of phrases to use for the empathic responses Grief is a complex emotion Mechanics of empathic responding From feedback - insight into personal attributes and idiosyncrasies 125 Table 12 Continued (B) WHAT I LIKED MOST ABOUT TODAY WAS Theme Session 1 Practice Behavioral Clarity Reflection on Training Cognitive Clarity Session 2 Evaluation Practi ce Refl ection Cognitive Clarity Session 3 Practice Evaluation Cognitive Clarity Behavioral Clarity Session 4 Practice Evaluation Behavioral Clarity Cognitive Clarity No. of Responses 12 5 3 1 5 4 3 1 Examples Small group practice of skil ls Model 1ing Being challenged and having informal structure Simple principles taught Usefulness of videotaped feedback Role playing Feeling that I've accomplished something Usefulness of empathic formula Role playing (including role of patient being played by instructor) Videotaping and following discussions Awareness that you can apply empathy to various emotions SIMED tape on anger Chance of doing 2 interviews Feedback from videotaping Having leader role-play Critical thinking can be suspended in interview to benefit both the patient and doctor 126 Table 12 Continued (C) WHAT I LIKED LEAST ABOUT TODAY WAS . . . Theme No. of Session 1 Responses Reflection 6 Cognitive Clarity 4 Practice 4 Nothing I didn't like 4 Session 2 Reflection 4 Evaluation 4 Nothing I didn't 1 ike 2 Session 3 Nothing I didn't like 6 Practice 5 Reflection 1 Session 4 Nothing I didn't 1 ike 5 Reflection 4 Evaluation 3 Cognitive Clarity 2 Examples Goal-oriented attitude in myself and others; The feeling that being empathic doesn't achieve anything concrete Listening to difference between empathy and sympathy Having to "act" doesn't come easy to me My own hesitancy in giving feedback Being on videotape with myself as the patient Acting the emotion Feeling not in control during my interview I was tired and had difficulty concentrating Role playing - I can't "act"! Wanted more discussion on grieving and how a grieving patient may present 127 T a b l e 13. Number o f Responses t o E v a l u a t i o n s f o r a l l S e s s i o n s "What I learned ..." Cognitive c l a r i t y 15 Practice 9 Reflection 4 Behavioural c l a r i t y - Evaluation "What I l i k e d most" Cognitive c l a r i t y 1 Behavioural c l a r i t y 5 Practice 12 Reflection 3 Evaluation 0 Session 3 4 2 1 1 3 7 1 11 5 1 36 14 7 14 3 74 1 0 4 3 5 1 1 6 0 4 1 1 9 0 7 4 7 31 6 16 64 "What I l i k e d l e a s t " Cognitive c l a r i t y 4 Behavioural c l a r i t y 0 Practice 4 Reflection 6 Evaluation 0 Nothing 4 0 0 0 4 4 2 0 0 5 1 0 6 2 0 0 4 3 5 6 0 9 15 7 17 54 128 practice was also the most frequently mentioned suggestion for improvement. T a b l e 14. S u g g e s t i o n s f o r Improvements t o t h e Course Suggestion No. of Times Mentioned 1. More time for ro l e playing i n front of the video camera ( i . e . , more practice) and less time watching. 5 2. More integration with the medical interview 2 3. Have people other than classmates ( i d e a l l y r e a l patients) do the ro l e playing to help i n terms of realism. 2 4. Fix feedback noise on video machine. 2 5. Suggest to students that they implement t h e i r s k i l l s with patients once a week and r e l a t e i t back to the group. 1 6. Have more discussion on how to recognize p a r t i c u l a r emotions i n a patient. 1 7. Have group s i t i n a c i r c l e . 1 8. Start course e a r l i e r i n the year. 1 9. Shorten the sessions to 2 hours and have them more frequently. 1 The o v e r a l l comments from a l l the subjects were very favourable. Subjects expressed appreciation for the course and the o v e r a l l feedback was predominantly enthusiastic. Excerpts from the general set of comments from three subjects w i l l now be presented. 129 " I t h i n k t h e c o u r s e was g r e a t ! I'm s u r e i t w i l l be v e r y u s e f u l and h e l p f u l i n p r a c t i c e . W atching t h e v i d e o t a p e s o f t h e T.V. c o u r s e , as w e l l as e x p e r i e n c e i n my own l i f e , r e a l l y b r o u g h t t o my a t t e n t i o n how i m p o r t a n t empathic t r a i n i n g i s . The s k i l l s a r e h e l p f u l t o t h e p a t i e n t and t o t h e d o c t o r as w e l l . I'm amazed i n t e r v i e w i n g s k i l l s (and empathic t r a i n i n g ) a r e n ' t t a u g h t t o a l l h e a l t h c a r e s t u d e n t s i n 1 s t y e a r . The s k i l l s a r e r e l a t i v e l y easy t o l e a r n and make a w o r l d o f d i f f e r e n c e i n h e l p i n g t h e p a t i e n t work t h r o u g h t h e i r p r o b lem and i n h e l p i n g t h e d o c t o r t o u n d e r s t a n d t h e p a t i e n t b u t remain o b j e c t i v e and c a p a b l e o f s e e i n g t h e n e x t p a t i e n t " . "The c o u r s e i s e x t r e m e l y u s e f u l , a l r e a d y , i n " r a i s i n g t h e c o n s c i o u s n e s s " o r awareness t o t h e p a t i e n t ' s f e e l i n g s and agenda ( i n t h e 2nd y e a r m e d i c a l s t u d e n t ) . There a r e a l m o s t a h a n d f u l o f o c c a s i o n s i n t h e l a s t 6 weeks on t h e wards where I n o t i c e d t h a t t h e p a t i e n t ' s c o n c e r n s were n o t a d d r e s s e d and were c a u s i n g him/her d y s t r e s s ( s i c ) . A good e x p e r i e n c e . I e n j o y e d m y s e l f and l e a r n e d a good d e a l a t t h e same t i m e . " " I f e l t t h i s t r a i n i n g was e x c e l l e n t and t h a t I have r e a l l y b e n e f i t e d from i t . I f e e l l i k e I c o u l d go i n t o a l m o s t any s i t u a t i o n and come o u t o f i t h e l p i n g t h e p a t i e n t f e e l b e t t e r . I t h i n k t h i s t r a i n i n g ( o r a m o d i f i c a t i o n o f i t ) would be v e r y w o r t h w h i l e f o r 130 anybody i n the f i e l d of medicine, and would help both the physician and patient". Summary of Findings A summary of the findings from the tests of the main hypotheses can be found i n Table 15. Table 15. Summary of S i g n i f i c a n t Results from Analyses of Variance for the Main Hypotheses Carkhuff BLRI BLRI Perceived % Level 3 Sim.-Pt. Med. Stud. Stress Hypothesis 1A & IB (Treatment vs Control) .00* ns .04 .01 Group x Time Interaction Hypotheses 2Ai & 2Bi (Follow-Up vs Control) .00 .00 .00 .00 Group Main E f f e c t Hypotheses 3A & 3B (Pre- vs Post-Treatment).00 .02 .01 .00 Time Main E f f e c t *p values In addition, t - t e s t s revealed that the empathy scores did not increase and the perceived stress scores did not decrease for the subjects i n the delayed treatment control group. Results of t- t e s t s also showed that empathy and perceived stress scores were maintained a f t e r a follow-up time period. A n a l y s e s o f v a r i a n c e r e v e a l e d t h a t t h e s c o r e s on h a r d i n e s s , and number o f e m o t i o n - f o c u s e d and p r o b l e m - f o c u s e d c o p i n g s t r a t e g i e s d i d n o t change s i g n i f i c a n t l y o v e r any t i m e p e r i o d . E f f e c t s i z e s as a r e s u l t o f t r e a t m e n t were l a r g e f o r a l l dependent measures used t o t e s t t h e main h y p o t h e s e s . 1 3 2 CHAPTER V Discussion Introduction This chapter opens with a summary of r e s u l t s followed by discussion of the findings for each of the measures. Implications for empathy s k i l l t r a i n i n g i n medical schools and for physician-patient communication are suggested. Recommendations for further research close the chapter. Summary The r e s u l t s from t h i s study showed that second year medical students learned to interact with emotionally intense simulated patients i n a more empathic manner as a r e s u l t of a short t r a i n i n g course i n empathic communication. Also, a f t e r the treatment, t h e i r perceived stress concerning these emotionally intense encounters was reduced. These r e s u l t s were not demonstrated with a control group of students who had been enrolled i n regular medical classes. A f t e r p a r t i c i p a t i n g i n the empathy t r a i n i n g however, the students i n the (delayed- treatment) control group also demonstrated a s i g n i f i c a n t increase i n empathy scores and a s i g n i f i c a n t decrease i n perceived stress. Results from a short follow-up for subjects who received the i n i t i a l t r a i n i n g showed that these e f f e c t s were maintained. 133 D i s c u s s i o n o f R e s u l t s o f Dependent Measures P e r c e n t a g e o f L e v e l 3 Responses No other study was found which used percentage of t o t a l responses considered to be minimally f a c i l i t a t i v e as an outcome measure. For instance, i n the Poole and Sanson-Fisher (1979) study, three, 2-minute randomly selected segments for each subject were rated. The o v e r a l l l e v e l was the mean of the three separate ratings. A further difference i n the two studies was that subjects i n the present study were unaware that t h e i r responses were going to be rated using the Carkhuff scale. In contrast, subjects i n the Poole and Sanson-Fisher (1979) study were t o l d s p e c i f i c a l l y to empathize as best as they could with the patients and that t h e i r responses would be rated using the Accurate Empathy Scale. Further, to motivate the subjects, the Poole and Sanson-Fisher subjects were t o l d i f they achieved a rating.at a ce r t a i n l e v e l , then they would be exempt from taking an additional communication course. During the t r a i n i n g sessions of the present study, i n answer to the question, "How long do we continue to give empathic responses?" medical students were t o l d to use t h e i r judgement to determine when the emotional i n t e n s i t y of the interview had de-escalated to a point where they could go on to more medical aspects of interviewing. Subjects were not t o l d to give as many empathic responses during the t e s t i n g occasions as they could; they were instructed on the written information sheet to "explore the nature of the problem" (See Appendix C). The average mean of the percentage of l e v e l 3 134 responses for the three post-training c e l l s was 49%. On average, then, approximately h a l f of the interviews were spent i n i n t e r a c t i n g i n an empathic manner with the simulated patients. This would not, however, necessarily r e f l e c t a goal f o r r e a l interviews i n which physicians must follow a medical agenda as well. Further research such as i n t e r a c t i o n a l analysis i s needed to explore, for example, possible markers which indicate at what points medical students could move on to more medical aspects of the interview. BLRI (Patient Ratings of Empathy Scale) The r e s u l t s for t h i s measure showed that when the two groups* scores were collapsed and compared immediately pre- and post-training, the subjects were rated by the simulated patients as being s i g n i f i c a n t l y more empathic. Even though the means were much higher f o r subjects i n the f i r s t t r a i n i n g group compared to those i n the control group for the patient rated empathy subscale, the wide range i n d i s t r i b u t i o n of scores led to a non-significant difference. The large standard deviation indicates that there were varied and unique interactions. As Schweitzer has said "medicine i s . . . the a r t of l e t t i n g our own i n d i v i d u a l i t y i n t e r a c t with the i n d i v i d u a l i t y of the patient" (cited i n Siegel, 1986, p. 33). Also, as I have mentioned i n chapter 3 when discussing i n t e r n a l threats to v a l i d i t y , I think the medical students performed as best as they could i n a l l t e s t i n g occasions. Most people w i l l respond to a physician who i s 135 t r y i n g hard to communicate with them (Fletcher & Sarin, 1988). The simulated patients may have given high ratings to the subjects whom they perceived to be making great attempts to understand them through for example non verbal means. As one simulated patient wrote on the BLRI a f t e r i n t e r a c t i n g with a pre-trained subject: "[name of subject] has the understanding (I f e l t he was s e n s i t i v e ) , but not the words. He wants to understand, but f e e l s awkward, I think, without the words." Perhaps some of the simulated patients, gave ratings to the subjects p a r t l y based on a "nice guy" quality, or rated subjects on t h e i r inner s e n s i t i v i t y . Indeed Barrett-Lennard (1981) noted that empathic understanding i s not a concept i n the awareness of a person answering the BLRI since i t does not require them to rate the subject's l e v e l of empathy d i r e c t l y . The instrument i s an in d i c a t i o n of " r e l a t i o n a l response, which are then put together and interpreted as providing an index of empathic understanding" (Barrett-Lennard, 1981, p. 95). BLRI (Medical Student Rating of Empathy Scale) One of the purposes of t h i s study was to show how empathy s k i l l t r a i n i n g would help medical students. One of the ways i t may have helped i s that a f t e r t r a i n i n g the medical students perceived themselves to be more empathic than before they received the t r a i n i n g . This means, according to some questions on t h i s scale, that the medical students saw themselves as more understanding toward the patients and better able to appreciate patients' experiences without 136 l e t t i n g t h e i r own f e e l i n g s i n t e r f e r e . They were a b l e t o re s p o n d c o n c r e t e l y t o t h e f e e l i n g s and meanings a s s o c i a t e d w i t h p a t i e n t s ' e x p e r i e n c e s , and p o s s i b l y found empathy t o be a h e l p f u l and c r e d i b l e t a s k as i m p o r t a n t t o p a t i e n t s as a m e d i c a l a c t i v i t y g i v e n t h a t p a t i e n t s were e x p e r i e n c i n g c o n s i d e r a b l e e m o t i o n a l d i s t r e s s . The l a s t t h r e e s e c t i o n s p r o v i d e d a d i s c u s s i o n o f t h e phases i n v o l v e d i n t h e c y c l e o f empathic i n t e r a c t i o n . The complete p r o c e s s was examined t o a v o i d m e a s u r i n g v e r b a l empathy o r a f f e c t i v e s e n s i t i v i t y o n l y . T h i s i s i m p o r t a n t because a p e r s o n c o u l d communicate v e r b a l empathy y e t l a c k s e n s i t i v i t y , o r c o n v e r s e l y , a p e r s o n c o u l d have i n t e r n a l empathic s e n s i t i v i t i e s b u t l a c k t h e a b i l i t y t o v e r b a l i z e a f f e c t i v e awareness (Hackney, 1978). A l l t h r e e s t a g e s o f t h e c y c l e o f empathic communication were measured i n an a t t e m p t t o g a i n a g r e a t e r u n d e r s t a n d i n g o f changes as a r e s u l t o f empathy s k i l l s t r a i n i n g . P e r c e i v e d S t r e s s Q u e s t i o n n a i r e A f t e r t h e empathy t r a i n i n g , s u b j e c t s i n g e n e r a l v iewed i n t e r a c t i o n s w i t h s i m u l a t e d p a t i e n t s as b e i n g l e s s s t r e s s f u l and l e s s demanding t h a n b e f o r e t h e t r a i n i n g . They a l s o f e l t more c o n f i d e n t i n t h e i r r e s p o n s e s and more h e l p f u l t o s i m u l a t e d p a t i e n t s a f t e r t h e c o u r s e . Thus, by a t t e n d i n g t o t h e s i m u l a t e d p a t i e n t s * i n t e n s e emotions and by h a v i n g t h e s k i l l s t o respond i n a way t h a t t h e y v i e w e d as h e l p f u l , and by v i e w i n g t h e m s e l v e s as empathic, t h e m e d i c a l s t u d e n t s ' s t r e s s 137 l e v e l s were apparently decreased. In other words, by having concrete s k i l l s , they were able to cope with the s t r e s s f u l s i t u a t i o n more appropriately, and thus appraised the s i t u a t i o n as being l e s s s t r e s s f u l . Batson et a l . (1987) presented a two-part model suggesting that d i s t r e s s leads to motivation to reduce one's own l e v e l of arousal while empathy leads to motivation to reduce the other's need. This suggests that the two are mutually exclusive, that i s , an "either-or" s i t u a t i o n . Results from t h i s study may suggest that a f t e r empathy t r a i n i n g empathic responding also resulted i n subjects' own d i s t r e s s being reduced. Folkman and Lazarus (1988) suggested that coping a f f e c t s emotion possibly by acting as a mediator. Afte r t r a i n i n g , subjects may have f e l t more confident with t h e i r a b i l i t i e s to deal with the emotionally intense situations due to having some useful coping s k i l l s . Thus, t h e i r stress l e v e l s would be decreased. Empathic responding may be viewed as a form of emotion-focused coping, that i s , an action to t r y to a l l e v i a t e the emotional d i s t r e s s of the s i t u a t i o n . A f t e r t r a i n i n g the medical students' focus may have been more on the simulated patients' feelings and experiences instead of on t h e i r own sense of helplessness and f r u s t r a t i o n as i n pre-training. The subjects f e l t confident that they could manage because they had some appropriate s k i l l s . The a c t i v i t y of empathic responding, then, may have a mediating function which when used reduced the stressfulness of the emotionally intense 1 3 8 encounter. Medical students may have f e l t e f f e c t i v e because they were doing something which was hel p f u l to the patient. A model i l l u s t r a t i n g the difference between empathy and di s t r e s s , and suggesting how empathic responding acts as a mediator of emotion i s presented i n Figure 15. Distress (Pre-Training) Presentation of Awareness by intense emotional medical student issue by patient £ ^ of patient's ^ 1) intense emotion, A* and of emotional reaction in self. Desire to "do something." Distress experienced by medical ^— student e.g., frustration Ineffective coping (i.e., Uncertainty as to how best ^ - to deal with the situation) Increase in stress level of -^medical student Empathy (Post-Training) Presentation of intense emotional issue by patient ^~ Awareness by medical student -^of patient's ^ intense emotion, and of emotional reaction in self. Desire to "do something." Empathy experienced by medical ^ student e.g., confidence in ability to respond to patient's feelings. Effective coping (i.e., Empathic responding which £ - also helped the patient) Decrease in stress level of medical student Figure 15. Outline of differences i n medical students' emotions and coping behaviours before and a f t e r empathy t r a i n i n g . Hardiness There was no change i n the hardiness scores as a re s u l t of the treatment. Hardiness may be considered to be a stable t r a i t measure which may not be amenable to change over a short period of time. I t appears that subjects i n t h i s study were a 139 f a i r l y homogeneous group with respect to hardiness. The fact that t h e i r scores were no d i f f e r e n t than a group of 447 psychology undergraduates (Hull et a l . , 1987) may lend support to the conclusion that persons need not be superior with respect to "stress-resistance" i n order to learn empathic responding and be able to cope e f f e c t i v e l y with emotionally- intense s i t u a t i o n s . B e h a v i o u r a l C o p i n g S t r a t e g i e s Overall, the number of coping strategies used to cope with the stress of medical t r a i n i n g did not increase as a r e s u l t of the empathy t r a i n i n g . However, two trends are worth noting. F i r s t , a f t e r the empathy t r a i n i n g , the number of emotion-focused coping strategies compared with the number of problem-focused coping strategies approached s i g n i f i c a n c e (p=.053). Perhaps the empathy t r a i n i n g , i n which subjects acknowledged other's emotions, encouraged them also to attend to t h e i r own emotions and seek actions or thoughts to r e l i e v e the emotional impact of stress. Further research i s needed to investigate whether empathy t r a i n i n g has an impact on the number of coping strategies used to deal with the stress of medical t r a i n i n g . Second, a f t e r the empathy t r a i n i n g , the number of emotion-focused coping strategies used by subjects i n both groups compared with the number used before t r a i n i n g approached si g n i f i c a n c e at (p=.08). Empathic responding may be viewed as a form of emotion-focused coping ( i . e . , action to 140 reduce t h e e m o t i o n a l impact o f s t r e s s ) , and so t h e number o f o t h e r e m o t i o n - f o c u s e d ways o f c o p i n g may have i n c r e a s e d a l s o . F u r t h e r r e s e a r c h i s needed t o i n v e s t i g a t e whether empathy t r a i n i n g r e s u l t s i n a s i g n i f i c a n t i n c r e a s e i n t h e number o f e m o t i o n - f o c u s e d s t r a t e g i e s used t o cope w i t h t h e s t r e s s o f m e d i c a l t r a i n i n g . Ways o f c o p i n g may be h a b i t s , l e a r n e d o v e r a l o n g p e r i o d o f t i m e , and so may be r e s i s t a n t t o change as a r e s u l t o f a s h o r t term i n t e r v e n t i o n . E f f e c t Sizes One might e x p e c t b i g g e r e f f e c t s i z e s f o r t h e empathy and p e r c e i v e d s t r e s s measures because t h e y may be more d i r e c t l y r e l a t e d t o and i n f l u e n c e d by t h e t r a i n i n g . As was d i s c u s s e d , h a r d i n e s s may be a more s t a b l e p e r s o n a l i t y t r a i t and ways o f c o p i n g may be l o n g term h a b i t s ; b o t h may n o t be e a s i l y i n f l u e n c e d by such a s h o r t term i n t e r v e n t i o n . Implications for Empathy S k i l l Training i n Medical Education One o f t h e i m p l i c a t i o n s o f t h e r e s u l t s o f t h i s s t u d y i s t h a t m e d i c a l s t u d e n t s can l e a r n t o respond t o s i m u l a t e d p a t i e n t s i n a more empathic manner a f t e r p a r t i c i p a t i n g i n an empathy s k i l l s t r a i n i n g c o u r s e . A l t h o u g h s t u d i e s have been co n d u c t e d w h i c h e v a l u a t e d t h e e f f e c t s o f a g e n e r a l . i n t e r v i e w i n g s k i l l s c o u r s e f o r second y e a r m e d i c a l s t u d e n t s ( e . g . , Monahan, G r o v e r , Kavey, Greenwald, J a c o b s e n , & Weinberger, 1988), no s t u d y was found i n w h i c h empathy 141 t r a i n i n g s p e c i f i c a l l y was offered to second year students. I t may be important for medical students to receive empathy t r a i n i n g i n addition to a basic interviewing s k i l l s course. They have indicated a need to acquire s p e c i f i c s k i l l s to use when dealing with patients' emotions (Batenburg & Gerritsma, 1983). Intense emotions can be very challenging and require spe c i a l s k i l l s . One subject, a f t e r a post-training interview i n response to the question "What made t h i s s i t u a t i o n demanding for you?": wrote " I t i s more d i f f i c u l t (demanding) to help a patient deal with an intense emotion than to take a medical hi s t o r y " . This echoes the often quoted words of Kafka (1971). "To write prescriptions i s easy, but to come to an understanding with people i s hard" (p. 223). The second year of medical t r a i n i n g may be an appropriate time to introduce a short course i n empathy s k i l l s t r a i n i n g into the medical school curriculum. Medical students could then begin early i n t h e i r t r a i n i n g , when they f i r s t begin to see patients, to i d e n t i f y situations i n which empathic responding may be appropriate. For instance, during t h i s t r a i n i n g , one subject said she noticed that when one hospital patient's emotional issue was not acknowledged by her physician, the patient kept bringing up the issue. By acquiring empathy s k i l l s early i n t h e i r t r a i n i n g , medical students could practice and gain more experience i n managing emotionally intense encounters. When students begin to interview patients, they may have anxieties about t h e i r communication s k i l l s , t h e i r medical knowledge, and t h e i r role 142 as physicians. In situations i n which there are no easy medical solutions or when patients somatize d i s t r e s s , medical students may f i n d empathic responding to be useful as a method of dealing with patients' emotional issues. During the t r a i n i n g one subject reported an experience i n which she found empathic responding to be e f f e c t i v e . She was t a l k i n g to some members of a family who expressed a l o t of t h e i r f r u s t r a t i o n s associated with placing an aging parent into a nursing home. While she recognized that there was nothing medical which could be done, she reported that by l i s t e n i n g and empathizing and allowing the people to express t h e i r feelings, she f e l t she was able to do something which was h e l p f u l to the family members at the time. As a r e s u l t of empathy t r a i n i n g , the high stress l e v e l s associated with emotionally intense interactions may be reduced because medical students have e f f e c t i v e coping s k i l l s . Students need more than to mean well; they want to do something. Before the t r a i n i n g , the subjects appeared eager to help the simulated patients; however many f e l t distressed i n not knowing the best way to proceed. Although empathic responding may not seem as concrete as a medical procedure, through r o l e playing students r e a l i z e that i t i s an additional s k i l l which i s therapeutic for patients. Researchers have concluded that while patients do not expect physicians to solve a l l of t h e i r problems, they do expect t h e i r doctors to l i s t e n to them (Putnam et a l . , 1988). Eisenberg (1988) also noted: 143 Doctors are trained to 'do something'. They believe that patients expect a consultation to have a tangible outcome: a p i l l or a shot. I t requires the disruption of overlearned habits to change from doing to l i s t e n i n g (and to come to recognize that l i s t e n i n g i s an important way of doing). I t demands a s h i f t i n paradigms from disease to i l l n e s s i n order to change from prescribing to attending to meanings and to helping patients to examine options, (p. 208) Through practice and reinforcement i n a course early i n medical t r a i n i n g , students can incorporate empathic responding into t h e i r natural communication s t y l e . However, i t i s necessary also to review empathy s k i l l s i n subsequent years, given Engler et a l . ' s (1981) r e s u l t s that while medical and technical s k i l l increases with medical t r a i n i n g , the a b i l i t y to communicate well with patients i s not maintained i f the students do not receive appropriate s k i l l t r a i n i n g . Wolraich et a l . (1981) also found that while f i r s t year medical students did inquire about patients' psychosocial concerns, senior students neglected to gather psychosocial data while being e f f i c i e n t i n hi s t o r y taking around physical concerns. Having more medical knowledge appeared to i n t e r f e r e with communication i n the physician-patient r e l a t i o n s h i p . Putnam et a l . (1988) reported a study i n which medical residents f e l t inadequate as counsellors, but, because they wanted to "do something", they searched even harder for b i o l o g i c a l causes for patients* psychosocial problems, even though they knew t h i s was quite f u t i l e . Thus empathy s k i l l s should be continually reinforced with t r a i n i n g so they are not forgotten with medical and technical knowledge. In addition, i n order 144 to reinforce students' learning i t would be most he l p f u l to have instructors and peers use empathy s k i l l s . As a r e s u l t of empathy t r a i n i n g , medical students have an opportunity to b u i l d t h e i r confidence about managing emotionally intense situations, so that when they i n t e r a c t with " r e a l " patients, i t i s not a completely foreign experience for them. A number of subjects remarked, a f t e r demanding interviews with simulated patients, that they were ce r t a i n they would encounter s i m i l a r emotionally intense sit u a t i o n s i n t h e i r practice. Logan (1987) suggested that communication s k i l l s w i l l remain relevant throughout students' medical careers, while medical knowledge may not. And Numann (1988) concluded that i f medical students do not receive courses during t h e i r medical t r a i n i n g , then there i s no assurance that students w i l l be able to communicate e f f e c t i v e l y with patients. Another advantage of introducing empathy s k i l l s early i n medical t r a i n i n g i s that students who are admitted into medicine may be low i n empathic tendency, and may require more s k i l l t r a i n i n g to enhance t h i s desirable q u a l i t y . Diseker and Michielutte (1981) measured empathy i n a class of medical students i n 1979 using Hogan's empathy scale, and they found that the scores were unrelated either to academic performance or to performance on Parts I or II of the exams of the National Board of Medical Examiners. Empathy scores also correlated negatively with Medical College Admission Test Scores, and these authors concluded that " i t i s possible that 145 the medical student s e l e c t i o n process i s biased i n favor of nonempathic students" (p. 1009). Other measures have been used to assess empathic q u a l i t i e s of applicants to medical schools. For instance, scholars at Michigan State University, a f t e r finding no e x i s t i n g empathy t e s t nor interviews to be s a t i s f a c t o r y , devised a new measure to assess a v a r i e t y of s k i l l s related to empathy. This t e s t , which takes one hour to complete, consists of three written subtests and two v i s u a l subtests (Krupka, Epstein, Molidor, King, Parsons & Son, 1977 c i t e d i n Rezler & Flaherty, 1985). Entry scores on the Empathy S k i l l s Rating Scale were related to faculty ratings of empathy but were unrelated to scores on tests measuring knowledge (Rezler & Flaherty, 1985). DiMatteo et a l . (1986) pointed out that two routes ex i s t to increase humanism i n medical p r a c t i t i o n e r s : s e l e c t i o n and t r a i n i n g . However, these scholars concluded that to date no acceptable measures of interpersonal s k i l l s are available to screen applicants for medical school or residency programs. Training, they suggested may be a much better approach to enhance the l e v e l of humanism i n medical p r a c t i t i o n e r s . One of the reasons that the t r a i n i n g given i n the current study increased l e v e l s of empathy may have been due to the ex p e r i e n t i a l nature of the exercises. Role-playing allowed the subjects the opportunity to imagine and i d e n t i f y patients' f e e l i n g s . They were also encouraged to be aware of what they 146 themselves were experiencing. I f medical students receive empathy t r a i n i n g , they may not avoid or deny intense emotions eithe r i n themselves or t h e i r patients. Through debriefing t h e i r p r a c t i s e exercises, students have an opportunity to express and discuss t h e i r feelings, e s p e c i a l l y t h e i r fears, about i n t e r a c t i n g with emotional patients. By being aware of t h e i r own emotions, students may have more energy f o r t h e i r work given that less energy i s required to keep t h e i r own emotions dampened down. Awareness of t h e i r own emotions i s necessary also for empathic responding to patients. As was stated by Craig (1987), "Our capacity to empathize and share others' experience of d i s t r e s s . . . provides a basis for caring for others i n physical d i s t r e s s (p. 311). And E l i z u r and Rosenheim (1982) noted that an understanding of one's own emotions allows one to i d e n t i f y other's fee l i n g s . Rogers stressed the importance of maintaining the "as i f " stance i n order to remain objective, because empathy i s f e e l i n g with others and not f e e l i n g as do others. Yet the c l i n i c i a n must remain i n touch with his or her own feelings as a foundation on which to r e l a t e emotionally to a patient (Meador & Rogers, 1981). During the empathic process Rogers believed that: The therapist . . . t r i e s to immerse himself i n the f e e l i n g world of h i s c l i e n t and to experience that world within himself. His understanding comes out of h i s own inner experiencing of h i s c l i e n t s ' feelings, using h i s own inner processes of awareness for a referent. He a c t i v e l y experiences not only hi s c l i e n t ' s feelings, but also h i s own inner responses to those feelings. (p. 132) 147 A further advantage of being self-aware, i s that medical students may not project t h e i r own emotions onto t h e i r patients. This i s important i n l i g h t of the r e s u l t s reported by Hornblow et a l . (1988) which showed that fourth year medical students who were themselves more anxious or depressed consistently overrated anxiety and depression i n patients. Hornblow et a l . concluded: These data suggest a need i n medical education for systematic teaching of empathic s k i l l s and f o r recognition of pot e n t i a l bias i n c l i n i c a l d e c i s i o n - making a r i s i n g from the c l i n i c i a n ' s own emotional state, (p. 16) In the present study, a f t e r the t r a i n i n g , subjects reported experiencing much less d i s t r e s s when they engaged i n emotionally intense sit u a t i o n s . Empathy t r a i n i n g may p o t e n t i a l l y help to combat depression, fatigue, and d i s s a t i s f a c t i o n which scholars (e.g. Girard et a l . , 1986; Smith et a l . , 1986) have found increases during medical education. In addition, medical students may have more energy to cope with other patients and may not carry t h e i r own d i s t r e s s and f r u s t r a t i o n s into t h e i r next medical encounter. Ultimately empathy t r a i n i n g may be a factor i n helping to decrease s t r e s s - r e l a t e d conditions such as negative attitudes towards patients, emotional burnout, and substance abuse. Further studies are needed to investigate whether r e s u l t s from the present study generalize to students i n other medical class years as well as to p r a c t i c i s i n g physicians and actual 148 patients. Also, a long term follow up may prove e f f e c t i v e i n determining the l a s t i n g benefits of empathy t r a i n i n g . Recently, scholars have suggested that the high l e v e l s of stress experienced by medical students may lead to the development of negative coping patterns and may i n t e r f e r e with the natural development of humanistic and interpersonal s k i l l s which, i n turn, adversely a f f e c t s the physician-patient r e l a t i o n s h i p (Matthews, Classen, Willms, & Cotton, 1989; McCue, 1982). I t i s my hope that the advantages of empathy t r a i n i n g may f u l f i l l , i n part, a need expressed by a Harvard medical student when discussing h i s t r a i n i n g : There i s no time to express our feelings of sadness for the patient, to a r t i c u l a t e our fear that he or she or our r e l a t i v e s or ourselves w i l l die, to discuss the impact of our decision to enter a profession where suffering i s a constant companion. Instead, we flounder, s t r i v i n g to ask i n s i g h t f u l questions both to impress our instru c t o r s and to combat our sense of sadness and inadequacy. We are taught from the beginning not to express our emotions, as i f they might i n some way i n t e r f e r e with our a b i l i t y to be competent doctors . . . I often question . . . whether I w i l l be able to keep up with recent advances, . . . or to understand and empathize with my patients. . . . My medical t r a i n i n g , by ignoring these questions, i s not making me more confident about these issues, rather i t i s teaching me not to consider them, denying me the chance to recognize my fears. ( H i l f i k e r , 1985, p. 205) / 149 Implications for Communication i n the Physician-Patient Relationship The purpose o f t h i s s e c t i o n i s t o p r e s e n t c l i n i c a l i m p l i c a t i o n s and t o s u g g e s t how t h e r e s u l t s o f t h e p r e s e n t s t u d y s u p p o r t t h e a d o p t i o n o f t h e more i n c l u s i v e b i o p s y c h o s o c i a l model o f m e d i c a l i n t e r v i e w i n g . A d i s c u s s i o n o f how empathy may h e l p a c h i e v e two p u r p o s e s o f t h e m e d i c a l i n t e r v i e w i s p r e s e n t e d . The f i r s t o f t h e s e g o a l s as o u t l i n e d by E n g l e r e t a l . (1981) i s t o g a t h e r i n f o r m a t i o n c o n c e r n i n g t h e n a t u r e o f p a t i e n t s ' , i l l n e s s e s i n o r d e r t o i d e n t i f y c o r r e c t d i a g n o s e s and t r e a t m e n t p l a n s . A second g o a l o f t h e m e d i c a l i n t e r v i e w i s t o e s t a b l i s h i n t e r p e r s o n a l r e l a t i o n s h i p s between p h y s i c i a n s and p a t i e n t s so t h a t e f f e c t i v e communication can o c c u r . A c e n t r a l theme o f t h e b i o p s y c h o s o c i a l model o f m e d i c i n e i s t h a t p h y s i c i a n s must g a t h e r i n f o r m a t i o n c o n c e r n i n g t h e i r p a t i e n t s ' " l i f e w o r l d s . " These f a c t o r s w i l l h e l p p h y s i c i a n s u n d e r s t a n d t h e cause o f t h e i l l n e s s e s and p a t i e n t s ' s u b j e c t i v e e x p e r i e n c e s o f them. Such i n f o r m a t i o n w i l l e n a b l e p h y s i c i a n s t o make more a c c u r a t e d i a g n o s e s and e f f e c t i v e t r e a t m e n t p l a n s . Empathy c o u l d be a v a l u a b l e s k i l l t o use i n u n d e r s t a n d i n g p a t i e n t s ' p e r s p e c t i v e s because, by d e f i n i t i o n , i t i s t h e a b i l i t y t o u n d e r s t a n d o t h e r p e r s o n s ' f e e l i n g s and meanings o f t h e i r e x p e r i e n c e s . E n g e l (1988), t h e p h y s i c i a n who f i r s t d e s c r i b e d t h e b i o p s y c h o s o c i a l model, s u g g e s t e d t h a t i n o r d e r f o r p h y s i c i a n s t o be t r u l y s c i e n t i f i c , t h e y must t a k e i n t o a c c o u n t p a t i e n t s ' 150 "inner experiences" (p. 121), because such information allows physicians to gather complete and accurate data. He supported the use of empathy i n t h i s process as indicated i n h i s writing: The physician has no alte r n a t i v e but to behave i n a humane and empathic manner, that i s , to understand and be understanding, i f the patient i s to be enabled to report c l e a r l y and f u l l y . Only then can the physician proceed s c i e n t i f i c a l l y ; to be humane and empathic i s not merely a p r e s c r i p t i o n f o r compassion . . . i t i s a requirement for s c i e n t i f i c work i n the c l i n i c a l realm. (p. 122) Physicians must have s k i l l s to e l i c i t relevant information from patients - which may be a challenging task due to the complexity of human beings. As Stephens (1988) pointed out, patients present themselves i n "exasperating wholeness." In situations i n which a problem i s highly a f f e c t i v e l y charged or has psychosocial roots, patients may be emotional and may not be aware of what information i s relevant or what i s i r r e l e v a n t . I t i s thus imperative that physicians have s k i l l s to i d e n t i f y and attend to relevant information (Schwartz & Wiggins, 1988). Empathy can be e f f e c t i v e i n e l i c i t i n g information regarding patients' emotional concerns. I f patients f e e l understood by physicians who demonstrate empathic understanding, they may continue to volunteer useful information - information which can c l a r i f y the source and cause of factors related to i l l n e s s . In addition, physicians, by being less stressed, may also be less defensive when dealing with patients' emotions such as anger. Research 151 c o n d u c t e d by Gibb (1961) r e v e a l e d t h a t d e c r e a s e d d e f e n s i v e n e s s l e a d s t o more e f f i c i e n t communication. By b e i n g l e s s d e f e n s i v e , m e d i c a l p r a c t i t i o n e r s may be a b l e t o b e t t e r p r o c e s s t h e i n f o r m a t i o n t h e y g a t h e r from p a t i e n t s . The communication o f empathy may be p a r t i c u l a r l y h e l p f u l f o r p h y s i c i a n s t o use when t h e f e e l i n g s t a t e i s t h e p r i m a r y p r o b lem o r , i n t h e term o f E i s e n b e r g (1988) , when p a t i e n t s " s o m a t i z e d i s t r e s s " (p. 205). I f p h y s i c i a n s acknowledge emotions d i r e c t l y , p a t i e n t s t h e n have an o p p o r t u n i t y t o e x p r e s s t h e i r emotions and, t h r o u g h t h i s v e n t i l a t i o n , t h e e m o t i o n a l i n t e n s i t y may be d i f f u s e d . P h y s i c i a n s may t h e n be a b l e t o a s s e s s what p a r t emotions have i n t h e p r e s e n t i n g p r oblems. The d i a g n o s i s may be "no f o r m a l d i s e a s e p r e s e n t " ; t h a t i s , t h e f e e l i n g s t a t e may be t h e problem. P h y s i c i a n s may be a b l e t o b e t t e r r e c o g n i z e , f o r example, t h a t a p a t i e n t who has s u f f e r e d a r e c e n t l o s s and i s c r y i n g , may be e x p e r i e n c i n g i n t e n s e sadness and not n e c e s s a r i l y c l i n i c a l d e p r e s s i o n and may n o t r e q u i r e m e d i c a t i o n . The t r e a t m e n t p l a n may i n c l u d e a n o t h e r v i s i t w i t h t h e p h y s i c i a n o r an a p p r o p r i a t e r e f e r r a l . I n some c i r c u m s t a n c e s t h e e m o t i o n a l r e l e a s e a f f o r d e d by empathic communication may i n i t s e l f be s u f f i c i e n t t r e a t m e n t f o r t h e p a t i e n t (C.P. H e r b e r t , p e r s o n a l communication, 1989). Empathy may be a v a l u a b l e s k i l l f o r p h y s i c i a n s t o use i n o t h e r s i t u a t i o n s i n wh i c h a h i g h l y c h a r g e d e m o t i o n a l component o r p s y c h o s o c i a l f a c t o r accompanies a p h y s i c a l c o m p l a i n t . As was d i s c u s s e d i n t h e l i t e r a t u r e r e v i e w , p s y c h o s o c i a l f a c t o r s 152 a r e a p a r t o f p a t i e n t s 1 c o n c e r n s i n a m a j o r i t y o f v i s i t s w i t h t h e p r i m a r y c a r e p h y s i c i a n . I f t h e emotion i s n o t acknowledged, t h e p a t i e n t may be so p r e o c c u p i e d w i t h i t t h a t t h e p h y s i c i a n cannot o b t a i n f u r t h e r i n f o r m a t i o n r e g a r d i n g t h e p h y s i c a l c o m p l a i n t and t h i s may r e s u l t i n t h e i n a b i l i t y o f t h e p a t i e n t t o f o c u s on m e d i c a l a d v i c e o f f e r e d and r e s u l t a l s o i n b o t h p e r s o n s becoming h i g h l y s t r e s s e d ( K o r s c h & N e g r e t e , 1972). I f , however, t h e p h y s i c i a n acknowledges t h e emotion, t h e i n t e n s i t y o f t h e a f f e c t may be r e d u c e d so t h a t f u r t h e r d a t a c o l l e c t i o n r e g a r d i n g t h e p h y s i c a l c o m p l a i n t may be an e a s i e r t a s k ( E n g l e r e t a l . , 1981). Empathy i s , p e r h a p s , a means t o acknowledge, e x p l o r e , and d e a l w i t h t h e e m o t i o n a l component o f p a t i e n t s ' c o m p l a i n t s . F u r t h e r s t u d i e s a r e needed t o examine t h e u s e f u l n e s s o f empathy i n a c t u a l m e d i c a l i n t e r v i e w s . I n t h e t e r m i n o l o g y o f t h e p a t i e n t - c e n t r e d model ( L e v e n s t e i n e t a l . , 1986), by a c k n o w l e d g i n g emotions d i r e c t l y and t h e r e b y c o n s i d e r i n g p a t i e n t s ' agendas, p h y s i c i a n s may f i n d t h a t i t f a c i l i t a t e s a t t e n d i n g t o t h e i r own agendas w h i c h i n c l u d e s g a t h e r i n g i n f o r m a t i o n , making a c c u r a t e d i a g n o s e s , and g i v i n g u s e f u l m e d i c a l a d v i c e . By e x p l o r i n g p a t i e n t s ' l i f e w o r l d s ' i n a d d i t i o n t o a t t e n d i n g t o t h e b i o m e d i c a l a s p e c t s o f t h e c o m p l a i n t , p h y s i c i a n s make p o s s i b l e an i n t e g r a t i o n o f b o t h agendas. Empathy i s an e f f e c t i v e s k i l l f o r b o t h p h y s i c i a n s and c o u n s e l l o r s even though t h e p r o c e s s and aims o f t h e two t y p e s o f h e l p i n g p r o f e s s i o n a l s may be d i f f e r e n t . The f o c u s o f t h e 153 medical interview i s on diagnosis and treatment i n the context of generally b r i e f and infrequent contact, whereas, the focus of counselling interviews i s on promoting desired changes i n in d i v i d u a l s which occur as a r e s u l t of a series of longer v i s i t s . However, both d i s c i p l i n e s require s k i l l s to e s t a b l i s h rapport and therapeutic relationships with c l i e n t s , and both require s k i l l s to successfully i d e n t i f y and explore the nature of complaints. Empathy i s a common s k i l l which can a s s i s t both types of professionals i n the helping process. A popular b e l i e f i s that demonstrating empathy takes too much time - time which busy physicians do not have (Dickinson et a l . , 1983). However, as the r e s u l t s from t h i s study show, i t i s possible both for medical p r a c t i t i o n e r s to explore simulated patients' feelings and to respond empathically, and for simulated patients to f e e l understood, i n the time frame of the short o f f i c e interview. From physicians' points of view, empathic responding and attending to patients' cues may a s s i s t them i n gaining an accurate understanding of patients' experience of t h e i r i l l n e s s - an understanding which may ultimately save time and health costs. As a r e s u l t of early recognition of a a psychosocial factor, a more accurate diagnosis may be revealed avoiding the need for repeated v i s i t s , c o s t l y and perhaps r i s k y diagnostic t e s t s and procedures, and use of unnecessary drugs and r e f e r r a l s (Branch, 1987; Eisenberg, 1988; C.P. Herbert, personal communication, 1989). Empirical evidence i s needed to examine 154 whether i n f o r m a t i o n g a i n e d from a c t u a l p a t i e n t s as a r e s u l t o f empathic r e s p o n d i n g l e a d s t o a more a c c u r a t e d i a g n o s i s . Empathy may h e l p t o a c h i e v e a second g o a l o f t h e m e d i c a l i n t e r v i e w w h i c h i s t o e s t a b l i s h a t r u s t i n g i n t e r p e r s o n a l r e l a t i o n s h i p so t h a t good communication can o c c u r . I m p r o v i n g empathy s k i l l s o f m e d i c a l p r a c t i t i o n e r s may improve t h e i r r e l a t i o n s h i p s w i t h p a t i e n t s , p a r t i c u l a r l y i n e m o t i o n a l l y i n t e n s e i n t e r a c t i o n s . P a t i e n t s , by h a v i n g t h e i r emotions acknowledged and l e g i t i m i z e d , m ight f i n d t h a t t h e i r p o t e n t i a l t o manage t h e i r own i s s u e s i s r e l e a s e d . I m p r o v i n g r e l a t i o n s h i p s w i t h p a t i e n t s i s i m p o r t a n t because, as s t a t e d i n e a r l i e r c h a p t e r s , miscommunication can be a major f a c t o r i n p a t i e n t d i s s a t i s f a c t i o n , n on-compliance, poor h e a l i n g , poor r a p p o r t , m a l p r a c t i c e l i t i g a t i o n , e r r o r s i n d i a g n o s i s , and can r e s u l t a l s o i n a s t r e s s f u l r e l a t i o n s h i p f o r b o t h p h y s i c i a n and p a t i e n t . P r o v i d i n g i n t e r v i e w i n g and communication s k i l l s c o u r s e s t o p h y s i c i a n s was i d e n t i f i e d as a means t o a m e l i o r a t e t h e s e problems as n o t e d by White (1988): Of a l l t h e e f f o r t s t h e m e d i c a l e s t a b l i s h m e n t might make, t h i s one i s t h e most l i k e l y t o reduce m a l p r a c t i c e l i t i g a t i o n , improve p a t i e n t c o m p l i a n c e , save money and enhance t h e m e d i c a l p r o f e s s i o n ' s p u b l i c image. (p. 71) A s p e c t s o f t h e i n t e r a c t i o n between p h y s i c i a n s and p a t i e n t s have been shown t o be i m p o r t a n t f a c t o r s i n v o l v e d i n p a t i e n t s a t i s f a c t i o n and c o m p l i a n c e ( B e n - S i r a , 1980; D i M a t t e o , T a r a n t a , Friedman, & P r i n c e , 1980; K o r s h & N e g r e t e , 1972). P h y s i c i a n s ' b e h a v i o r w h i c h was more p a t i e n t - c e n t e r e d has been 155 associated with better outcome. The Headache Study Group (1986) found that patients who perceived that t h e i r physicians engaged i n a thorough discussion about t h e i r headaches during an i n i t i a l interview reported better recovery from headaches one year l a t e r . Stewart (1984) found that patients who expressed t h e i r feelings (e.g., tensions) as a r e s u l t of physicians' f a c i l i t a t i n g behaviours tended to be more s a t i s f i e d and reported greater compliance. A f t e r reviewing relevant outcome research Stewart, Brown, and Weston (1989) concluded, "that important patient outcomes are improved by communication between doctors and patients that i s characterized by f u l l expression of the patients' problems, leading to a mutual understanding" (p. 160). E f f e c t i v e relationships between physicians and t h e i r patients i s not a new area of attention or i n v e s t i g a t i o n . B a l i n t (1957) maintained that a t r u s t i n g r e l a t i o n s h i p between a physician and patient can be healing i n i t s e l f . Patients have always appreciated physicians who were se n s i t i v e to t h e i r emotional needs (DiMatteo, et a l . , 1986). In fact, one of the v i r t u e s of the general p r a c t i t i o n e r before the r i s e i n therapeutic advances i n medical technology was h i s caring interpersonal manner. For instance, I often heard my grandmother praise the doctor who, i n r u r a l Nova Scotia at her farmhouse, delivered her 10 babies. When I asked my 91 year old grandmother what was so special about him, she r e p l i e d , "Oh, he was j u s t an ordinary man, and he j u s t knew how you were s u f f e r i n g . " Her reply to my inquiry about the medical 156 equipment he c a r r i e d was, "Not much - too l s for d e l i v e r i n g babies, that's about a l l " and she r e i t e r a t e d that "he j u s t knew how you were s u f f e r i n g . " I was impressed that i t was not that t h i s doctor took away patients' s u f f e r i n g , but that he understood and acknowledged i t which made him so s p e c i a l . This physician's interpersonal caring manner was fondly remembered - even a f t e r he had been dead for over 25 years. R e a l i s t i c a l l y , however, the old general p r a c t i t i o n e r i s not a r o l e model for physicians today (Eisenberg, 1988). Society i s much more transient now, and the family physician i s not as l i k e l y to know the family network. Also, there i s much more pressure on physicians to be aware of the many advances i n medicine. Whereas the general p r a c t i t i o n e r of yesteryear had an abundance of caring and compassion, and few e f f e c t i v e medical treatments to o f f e r , physicians today have technological advantages and many impressive treatment options. These technological developments can make medical treatment seem very impersonal, and can r e s u l t i n patients' pain and s u f f e r i n g (Cassel, 1982; Maquire, 1981). Therefore, patients may depend even more on t h e i r physicians for human caring and compassion (Messenger, 1989). I t i s important therefore to sustain a balance between natural science and humanism. McWhinney (1988) stated: Paradoxically, i t i s the successes of medical technology that have exposed so v i v i d l y the l i m i t a t i o n s of the t r a d i t i o n a l method. Concentration on the technical aspects of care has diverted us from the patient's inner world, an aspect of i l l n e s s the method does not routinely force on our attention. The complexities and 157 discomforts of modern therapeutics have made i t even more important for us to understand the patient's experience. (p. 221) Research from t h i s present study supports the recent l i t e r a t u r e which indicates that empathy i s an important communication s k i l l for medical p r a c t i t i o n e r s . In addition to stress reduction, empathy may also provide a balance between o v e r i d e n t i f i c a t i o n and dehumanization i n regard to physicians' responses to patients. Carek (1987) suggested that empathy can bridge the gap between psyche and soma, between the mind- body dualism. In 1927 Peabody concluded that "the secret of the care of the patient i s i n caring for the patient" (p. 882). Buchsbaum (1986) stated that "empathy conveys caring, the sine qua non of the doctor-patient r e l a t i o n s h i p " (p. 425). I f empathic communication i s , as suggested by Carkhuff (1969) "the key ingredient of helping," then i t i s important that a l l medical p r a c t i t i o n e r s possess such an a b i l i t y . S u g g e s t i o n s f o r F u r t h e r R e s e a r c h Suggestions for further research include: (a) Medical student-simulated patient encounters could be analyzed using i n t e r a c t i o n a l analysis such as Bales Interaction Process Analysis (1951) or Kagan's (1975) Interpersonal Process Recall technique i n order to begin to generate a functional model of how empathic responding may be incorporated with the more medical aspects of 158 interviewing. The model could have separate sections for the d i f f e r e n t emotions of fear, anger, and g r i e f . Also, the tapes from t h i s study could be analyzed using the c r i t e r i a i d e n t i f i e d by the Patient-Centred C l i n i c a l Method (Stewart, Brown, Levenstein, McCracken, & McWhinney, 1986) . (b) This study could be r e p l i c a t e d using p r a c t i s i n g physicians as well as students i n other medical class years to see i f the r e s u l t s would be r e p l i c a t e d . (c) Subjects could be followed-up to see i f the r e s u l t s are maintained over a long time period. (d) I t would be of i n t e r e s t to r e p l i c a t e t h i s study using outcome measures from actual patients; however, control concerning the i n t e n s i t y and nature of the emotions presented would not be possible. An advantage of studying actual patients i s that i t would be possible to examine whether an association e x i s t s between empathy measures and patients' health outcome measures The Empathy scale of the BLRI may be an appropriate measure because high scores on the c l i e n t form of the BLRI have been associated with treatment gains i n counselling (Barrett-Lennard, 1962). 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(4) How confident were you i n your responses? 1 2 3 4 5 6 7 not at a l l somewhat extremely What would you have l i k e d to have done or said d i f f e r e n t l y ? (5) How h e l p f u l did you f e e l when interact i n g with this person? 1 . 2 . 3 4 5 6 7 not at a l l somewhat extremely What f e e l i n g s did you have during this interview? What are you f e e l i n g now? ••1-8.0-- Appendix B Outline of Empathy Training Sessions Outline of Empathy Training Sessions Session I I n t r o d u c t i o n s Overview and o u t l i n e o f t r a i n i n g R e l a t i o n s h i p b u i l d i n g : I d e n t i f y i n g f e a r s and e x p e c t a t i o n s D i s c u s s i o n o f s i m u l a t i o n s L e c t u r e t t e : Empathy - What i t i s - Why i t i s i m p o r t a n t i n p h y s i c i a n - p a t i e n t r e l a t i o n s h i p s M o d e l l i n g Empathy and A c t i v e L i s t e n i n g P r a c t i c e o f M i c r o s k i l l s ( i n P a i r s ) - a t t e n d i n g ( i m p o r t a n c e o f SOLER) - a c t i v e l i s t e n i n g - p a r a p h r a s i n g c o n t e n t and f e e l i n g u s i n g communication l e a d s P r o c e s s o f a c t i v i t y i n whole group C l o s i n g Session II Opening Comments and r e a c t i o n s r e p a r a p h r a s i n g Empathy f o r m u l a : "you f e e l . . . . because. . . . " G u i d e l i n e s f o r f a c i l i t a t i v e feedback P r a c t i c e o f empathic r e s p o n s e s u s i n g communication l e a d s ( dyads) Overview on t o p i c o f emotion o f " f e a r " D e m o n s t r a t i o n ( m o d e l l i n g ) o f d e m o n s t r a t i n g empathy i n s i t u a t i o n s i n v o l v i n g f e a r "Round R o b i n " r o l e - p l a y e x e r c i s e Empathy p r a c t i c e u s i n g " n a t u r a l " communication l e a d s V i d e o t a p e o f p r a c t i c e i n t e r v i e w s i n v o l v i n g emotion o f f e a r .182 Processing of taped interview Closing Session III Introduction Overview of topic of emotion of Anger Tape on Anger and discussion Demonstration of using empathy i n anger simulations Practice and videotape of practice interviews involving emotion of anger Presentation and discussion of the "Patient-Centred" Model Lecturette: Non-verbal cues to emotion (e.g., voice tone) Practice and discussion of non-verbal cues to various emotions Closing Session IV Introduction Overview of topic of emotion of Grief Tape on Grief and discussion Demonstration of the use of empathy i n g r i e f s i t u a t i o n Practice and videotape of practice interviews involving emotion of g r i e f Further practice on responding to emotionally intense si t u a t i o n s Feedback on empathy program Termination exercise and cl o s i n g 183 Appendix C Case D e s c r i p t i o n s P r e s e n t e d t o t h e M e d i c a l S t u d e n t s , and T r i g g e r Sentences Used by S i m u l a t e d P a t i e n t s i n F e a r , Anger and G r i e f T e s t i n g O c c a s i o n s 1 8 4 Case Presented to Physician-ln-Traininq Patient i s a 30 year old male/female who has noted lumps in his/her neck. The surgeon to whom your partner referred him/her has recommended biopsy. The patient thinks this means he/she has cancer. He/she i s seeing you today for the f i r s t time because your partner is away. You have 15 minutes during which time you are to explore the nature of the problem, recognizing the limitations of your length of training to date. There is no "one right way." Trigger Sentences for Simulated Patient "I want to have the biopsy immediately—I can't stand not knowing." "My mother had cancer and she died in great pain." "What w i l l happen to my two children i f anything happens to me?" "How can I possibly break this news to my husband/wife?" -1.85 Case Presented to Physician-In Training Patient i s a 35 year old teacher who enjoys sports as a hobby and who had a knee injury about 2 years ago. She/he continues to have knee pain and was sent by your partner, her family physician, who i s away temporarily, to an orthopaedic surgeon, Dr. S t i l l w e l l , whom you both consult frequently. The patient arrives i n your o f f i c e , a f t e r having seen the s p e c i a l i s t . You have 15 minutes during which time you are to explore the nature of the problem, recognizing the l i m i t a t i o n s of your length of t r a i n i n g to date. There i s no "one r i g h t way." Trigger Sentences for Simulated Patient "That s p e c i a l i s t you sent me to, Dr. S t i l l w e l l , he took a l l those X-rays over again! I thought X-rays were bad for you! " "He hardly even talked to me, just jerked my knee around and gave me some p i l l s ! I t o l d him what was wrong with my knee and he didn't even answer me! "That man ju s t wants to operate so he can make a l o t of money! I thought doctors were supposed to help a person." "It's been 2 years Doctor! I haven't been able to play sports or keep up with my family." 18 6 Case Presented to Physician-ln-Traininq Patient i s a 35 year old married man/woman. Patient comes to you complaining of tightness i n h i s chest, sporadic d i f f i c u l t y breathing and insomnia. You have 15 minutes during which time you are to explore the nature of the problem, recognizing the l i m i t a t i o n s of your length of t r a i n i n g to date. There i s no "one r i g h t way." Trigger Sentences for Simulated Patient* "I wake up at 4:30 A . M . and I can't breathe." "It's l i k e I'm i n a fog." "I know my husband/wife blames me." "I should have watched him/her more c a r e f u l l y . " * I t was explained to the simulated patient during r o l e t r a i n i n g that the g r i e f reaction was due to the fact that his/her 5 year old c h i l d was struck by a car and died two months e a r l i e r . This was to be revealed by the simulated patient during the interview.

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