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“Through empathy-based training, physicians and other health care providers learn the skills to have honest informed consent discussions without causing undo fear, while also preparing patients for all possible outcomes. Empathic skills make for better physicians, better communications, and better conversations for all outcomes.
With a strong alliance, a reduction in medical professional liability claims is the result of increased trust, better understanding and expectations of all possible outcomes, and knowledge that physicians deeply care about their patients, because, when it comes to health care, empathy matters.”
Helen Riess is a psychiatrist and author of The Empathy Effect: Seven Neuroscience-Based Keys for Transforming the Way We Live, Love, Work, and Connect Across Differences.
She shares her story and discusses her KevinMD article, “The role of empathy in improving patient care and decreasing medical liability.”
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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today we welcome back on the show Helen Riess. She’s a psychiatrist, and she’s the author of the book The Empathy Effect: Seven Neuroscience-Based Keys for Transforming the Way We Live, Love, Work, and Connect Across Differences. She wrote the KevinMD article “The role of empathy in improving patient care and decreasing medical liability.” Helen, welcome back to the show.
Helen Riess: Thank you for having me.
Kevin Pho: So for those who didn’t get a chance to listen to our first episode, can you just briefly share your story and journey to where you are today?
Helen Riess: Yes. So I’m a psychiatrist, and my research focus at Mass General and Harvard Medical School has been the science of empathy. I became interested in this because I was seeing the effects that the lack of empathic care was having, not just in our state but around the country. And it led me to really want to answer the question: Can empathy be taught, and can people improve if their empathy skills and feelings are diminishing?
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Kevin Pho: So we’re going to get into that article in a little bit, but we are speaking towards the end of January now, and health care workers are going through yet another wave of the pandemic. Just in general, through your observations as a psychiatrist, what are you seeing among health care workers as it relates to their empathy and perhaps their mental state?
Helen Riess: Well, Kevin, I am seeing that we are truly in a parallel pandemic, or at least epidemic. The health care workers that I speak with are really suffering. As recently as yesterday, I led a class of residents who are just reporting noticing a lack of empathy, because they are really not able to take care of themselves, and there’s very little permission in the medical community to prioritize self-care.
But we’re seeing more than ever that if people don’t have self-empathy and try to fill the tank, and really try to notice and make the most of positive moments in their day that can actually refresh and reinvigorate, a downward spiral can take place. And I think the most alarming statistics are that depression and anxiety are really escalating in our health care workers, and the incidence of suicidal ideation and completed suicides is really on the rise. So I think it’s incredibly important for people to realize that their health care workers need a lot of support right now, that the empathy flow is not just one way, but it really has to be bilateral.
Kevin Pho: Now, when you were talking to this class of residents and they were giving you stories about burnout and decreasing empathy because of the pandemic, what kind of advice did you give them? What kind of messages did you give them?
Helen Riess: Well, first I wanted to normalize that our empathy is not a fixed quotient. Our empathy rises and falls based on the kinds of encounters we’re having, and based on the kinds of support that we experience from our friends, our families, and in this case, from our institutions. I know that many institutions are trying to prioritize wellness, but it is so ingrained in medical training that you sacrifice yourself and that you put the patient first. And I think that what we’re realizing is we can’t get good care out of people who are exhausted, depleted, and whose morale is declining.
And so the advice was to share some moments where they actually did feel they were making a difference, and that actually perked a lot of the residents up, to realize there are still some good moments. And to really emphasize the importance of taking care of their physical and emotional needs, and really giving permission to share when they’re stressed and when they need outside help.
Kevin Pho: All right, let’s talk more about that KevinMD article that you wrote. It was titled “The role of empathy in improving patient care and decreasing medical liability.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?
Helen Riess: I wrote this article because many people think that medical liability and malpractice claims are the result of medical errors or omissions, and they don’t realize that communication errors are actually the biggest drivers of whether or not a claim will be filed against a physician or nurse. These communication failures can be avoided. They can be corrected. If they go unchecked and unapologized for, they can actually be the deciding factor between whether somebody decides, whatever error happened, that they’re going to complain about it, or whether they’re going to have a forgiving attitude, or an attitude of “nobody’s perfect, mistakes are going to happen.” And of course, I’m not talking about severe injury or severe neglect or things like that, but things where a patient or family can decide, “You know, this thing went wrong, and I really didn’t like that person’s attitude.”
And so I felt it was really important to emphasize that empathic care is not only the right thing to do for the patients, because it’s what everybody wants when they are a patient. They want to feel cared about. They want to feel that they’re treated as a human being who matters. But it also is protective for the physicians and nurses who are caring for patients.
So when people are not aware that there are some basic failures that lead to people being angry enough to file a claim, I think it’s important that people are aware of these, so that they can be self-monitoring and also help their colleagues if they see them falling into these kinds of traps.
The first is, any airs of arrogance, superiority, or callousness are going to come back to hurt you. So have a demeanor of expertise with humility, realizing we never really know everything that’s going on in a person’s mind or heart or their physical condition. And so have a curious and humble approach, really knowing that the patient is really the greatest expert on what is going on with them physically. We need to listen to that.
The second failure is communication failures, where we’re not listening, where we’re interrupting. There’s much research that says that patients get about 17 seconds into their narrative before they’re cut off, and someone starts telling them what they ought to be doing or what tests they’re going to order. And not being clear about our availability: If we know we’re going to be away, and we’ve just done surgery or we just saw a psychiatry patient for the first time, we better be sure they know that we’re not available and who’s going to be covering.
Interestingly, another failure of communication is disparaging previous care that patients have received. So patients don’t want to hear you put down some decision that another physician made, or take potshots at someone who recommended something. If you disagree with something, you can say, “Well, that’s not the approach that I take,” or, “I have a different approach here.” But really putting down or diminishing somebody else’s expertise, who that patient may have had confidence in, can also come back to hurt you.
One of the other big failures is not learning what patients are expecting. We have to manage their expectations, not what we expect. So if we prescribe something or suggest a procedure, and we know what the outcome is likely to be, we could be very happy with that outcome. But if we haven’t asked patients, “What do you expect, and what kind of functioning do you expect you’ll be having after we do this?” they may be very disappointed when we think the outcome was quite good.
And lastly, informed consent conversations are difficult. No one really wants to be recommending something and having to tell a patient that they could lose a limb, lose vision, lose their hearing, or potentially lose their lives. And so these informed consent conversations are often done quickly, or with “I’ve done a hundred of these before, you don’t have to worry,” and a lot of reassurance. But of course, if something does go wrong and a patient can say, “I was never told this,” that really opens us up to potential litigation or claims.
And so at Empathetics, which is the company that I founded that provides empathy education, we actually have a separate course on an empathic informed consent conversation. Because we have to be very careful about recommending something that we truly believe is going to help someone while being honest about what the potential risks are. And when these conversations are done with empathy, and with putting ourselves into the shoes of the person receiving this, they take a much different tone, and patients will usually be able to decide whether they are willing to take the risk or not, if we can be honest and clear about what can happen.
So these are some of the obvious tips about where we can fall down, and it’s not as simple as just saying, “Oh, OK, I’ll have those conversations in a better way.” We really need to learn how to perceive, and open our perception to what patients are experiencing. When do they look confused? When have we fallen into medical jargon, where we know what we’re talking about, but we’re not checking to make sure that the person understands what we’ve just said? Having greater self-awareness and also greater perceptive abilities, to be sure we’re meeting people where they are emotionally, will help them and help us, and helps to preserve the relationship.
Kevin Pho: Now, you mentioned a connection between these communication failures and potential litigation. Can you talk in more detail about that connection?
Helen Riess: Well, yes. I can put a few numbers on the risk that these failures lead to. So over 80 percent of malpractice claims that are filed are due to these communication failures, have to do with appearing or coming across as arrogant and superior. Another 35 percent have to do with just not listening, interrupting, and not being clear about how people can reach you. Seven percent have to do with disparaging previous care, and the rest is about failure to learn and manage patient expectation.
Kevin Pho: We’re talking to Helen Riess. She is a psychiatrist, and she’s the author of the book The Empathy Effect: Seven Neuroscience-Based Keys for Transforming the Way We Live, Love, Work, and Connect Across Differences. And she wrote the KevinMD article “The role of empathy in improving patient care and decreasing medical liability.”
Helen, without taking your entire course, what are some simple ways that physicians can use an exam room to have more empathetic conversations with patients, and perhaps avoid these communication failures? Because I know you said that it’s not as easy as just thinking about it and saying, “I’m going to have better conversations.” But what are some actionable things that physicians can do?
Helen Riess: So my book is about the seven keys of empathy, and most of them are nonverbal. So some of the tips are: Start with making eye contact with the person you’re talking with before you just start firing away at questions or looking at the computer. The advantage of sitting down at eye level, instead of standing over people, just cannot be overestimated. It is so important, if you’re trying to create rapport, that you are not standing over someone in a dominant position. Because if airs of superiority and arrogance are one of your greatest risks for making patients feel uncomfortable and angry, starting with a seated position means we are talking person to person. Even though you have more medical expertise and knowledge than the patients are likely to have, it doesn’t mean that you’re a superior person.
So eye contact, sitting at eye level. And our training teaches how to decode facial expressions, because our studies show that the physicians who were not trained were quite unskilled in discerning the difference between anger, disgust, fear, surprise, and sadness. These microexpressions do require some training.
And then just being conscious of naming what you think that person’s emotion is, so that your awareness is raised. If somebody is anxious, maybe you modify your tone of voice, or you ask more questions about whether they understand what you’re talking about, and try to hear the whole. And importantly, use your own body as an instrument to measure how comfortable this interaction is going. Because when things are going well, both people usually feel good, and when things are not going well, we start to get internal signals that we’re unsettled, or that our own anxiety has increased. So those are some of the basic tips in how we can connect better.
Kevin Pho: Over the last few years of the pandemic, a lot of clinicians are donning PPE, or we’re speaking to patients via Zoom or some type of virtual setting. How has that affected empathetic communication with patients?
Helen Riess: That’s a fantastic question, because when we talk about noticing facial expressions, and half of our faces are covered, it makes it really challenging. Fortunately, most of our emotions are actually conveyed through the eyes. We all know that people can fake a smile, but it’s really hard to fake genuine happiness, because your eye muscles get involved.
So not to diminish the challenges of speaking with people that are covered up to here, but it does call us to really focus on meeting people’s gaze, and trying to measure their emotion based on what we’re seeing. And then also having the comfort to say, “How are you doing? It’s hard for you to see me through my mask, and it’s hard for me to see you fully through yours.” So maybe we have to ask that extra question, instead of just thinking we’re accurate in reading their emotions.
Kevin Pho: And my final question: What are some take-home messages that you want to leave with the KevinMD audience?
Helen Riess: The first message is, really figure out what you need to take care of yourself. Find moments every day where you can feel grateful for some interaction you had, either with a colleague or with a patient. Find something positive, because every intentional awareness of what’s going well fills the tank a little bit. If we don’t take those moments, we can get completely drained.
Recognize that we are all in this together right now. This is a time when everybody is stressed and anxious. And learn to ask for help, even if you just need to debrief an interaction you had with somebody, whether it be positive or negative.
And the whole point of this particular podcast about medical liability, this is probably the last thing people are thinking about today, but just remember that how we comport ourselves is actually self-protection too, because things are going to go wrong. All these burned-out clinicians are going to make mistakes. It’s just a given. But if we can maintain as positive a connection as possible with our patients, they will see that we are truly doing the best we can, and are less likely to retaliate.
Kevin Pho: Helen, thank you so much for coming back on the show and sharing your time and insight.
Helen Riess: Thank you for having me.
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