What is empathy? Oncology patient perspectives on empathic clinician behaviors.

BACKGROUND: Oncology patients and physicians value empathy because of its association with improved health outcomes. Common measures of empathy lack consistency and were developed without direct input from patients. Because of their intense engagement with health care systems, oncology patients may have unique perspectives on what behaviors signal empathy in a clinical setting. METHODS: As part of a cross-sectional study of patient perspectives on clinician empathy at an academic cancer center in the northeastern United States, the authors solicited up to 10 free-text responses to an open-ended question about what clinician behaviors define empathy. RESULTS: The authors categorized open-ended responses from 89 oncology patients into 5 categories representing 14 themes. These categories were relationship sensitivity, focus on the whole person, communication, clinician attributes, and institutional resources and care processes. Frequently represented themes, including listening, understanding, and attention to emotions and what matters most, aligned with existing measures of empathy; behaviors that were not well represented among existing measures included qualities of information sharing and other communication elements. Patients also associated clinician demeanor, accessibility, and competence with empathy. CONCLUSIONS: Oncology patients' perspectives on empathy highlight clinician behaviors and attributes that may help to refine patient experience measures and may be adopted by clinicians and cancer centers to enhance patient care and outcomes. High-quality communication skills training can promote active listening and paying attention to the whole person. A system-level focus on delivering empathic care may improve patients' experiences and outcomes. LAY SUMMARY: Oncology patients' responses to an open-ended question about empathic clinician behavior have revealed insights into a variety of behaviors that are perceived as demonstrative of empathy. These include behaviors that imply sensitivity to the clinician-patient relationship, such as listening and understanding and attention to the whole person. Participants valued caring communication and demeanor and clinician accessibility. Perspective taking was not common among answers. Many existing measures of clinical care quality do not include the behaviors cited by patients as empathic. These results can inform efforts to refine quality measures of empathy-associated behaviors in clinical practice. Cancer centers can use skills training to improve elements of communication.

Compassionate and Clinical Behavior of Residents in a Simulated Informed Consent Encounter.

BACKGROUND: Compassionate behavior in clinicians is described as seeking to understand patients' psychosocial, physical and medical needs, timely attending to these needs, and involving patients as they desire. The goal of our study was to evaluate compassionate behavior in patient interactions, pain management, and the informed consent process of anesthesia residents in a simulated preoperative evaluation of a patient in pain scheduled for urgent surgery. METHODS: Forty-nine Clinical Anesthesia residents in year 1 and 16 Clinical Anesthesia residents in year 3 from three residency programs individually obtained informed consent for anesthesia for an urgent laparotomy from a standardized patient complaining of pain. Encounters were assessed for ordering pain medication, for patient-resident interactions by using the Empathic Communication Coding System to code responses to pain and nausea cues, and for the content of the informed consent discussion. RESULTS: Of the 65 residents, 56 (86%) ordered pain medication, at an average of 4.2 min (95% CI, 3.2 to 5.1) into the encounter; 9 (14%) did not order pain medication. Resident responses to the cues averaged between perfunctory recognition and implicit recognition (mean, 1.7 [95% CI, 1.6 to 1.9]) in the 0 (less empathic) to 6 (more empathic) system. Responses were lower for residents who did not order pain medication (mean, 1.2 [95% CI, 0.8 to 1.6]) and similar for those who ordered medication before informed consent signing (mean, 1.9 [95% CI, 1.6 to 2.1]) and after signing (mean, 1.9 [95% CI, 1.6 to 2.0]; F (2, 62) = 4.21; P = 0.019; partial η = 0.120). There were significant differences between residents who ordered pain medication before informed consent and those who did not order pain medication and between residents who ordered pain medication after informed consent signing and those who did not. CONCLUSIONS: In a simulated preoperative evaluation, anesthesia residents have variable and, at times, flawed recognition of patient cues, responsiveness to patient cues, pain management, and patient interactions.

Nonverbal Communication.

The field of nonverbal communication (NVC) has a long history involving many cue modalities, including face, voice, body, touch, and interpersonal space; different levels of analysis, including normative, group, and individual differences; and many substantive themes that cross from psychology into other disciplines. In this review, we focus on NVC as it pertains to individuals and social interaction. We concentrate specifically on ( a) the meanings and correlates of cues that are enacted (sent) by encoders and ( b) the perception of nonverbal cues and the accuracy of such perception. Frameworks are presented for conceptualizing and understanding the process of sending and receiving nonverbal cues. Measurement issues are discussed, and theoretical issues and new developments are covered briefly. Although our review is primarily oriented within social and personality psychology, the interdisciplinary nature of NVC is evident in the growing body of research on NVC across many areas of scientific inquiry.

A meta-analysis of the relationship between emotion recognition ability and intelligence.

The ability to recognise others' emotions from nonverbal cues (emotion recognition ability, ERA) is measured with performance-based tests and has many positive correlates. Although researchers have long proposed that ERA is related to general mental ability or intelligence, a comprehensive analysis of this relationship is lacking. For instance, it remains unknown whether the magnitude of the association varies by intelligence type, ERA test features, as well as demographic variables. The present meta-analysis examined the relationship between ERA and intelligence based on 471 effect sizes from 133 samples and found a significant mean effect size (controlled for nesting within samples) of r = .19. Different intelligence types (crystallized, fluid, spatial, memory, information processing speed and efficiency) yielded similar effect sizes, whereas academic achievement measures (e.g. SAT scores) were unrelated to ERA. Effect sizes were higher for ERA tests that simultaneously present facial, vocal, and bodily cues (as compared to tests using static pictures) and for tests with higher reliability and more emotions. Results were unaffected by most study and sample characteristics, but effect size increased with higher mean age of the sample. These findings establish ERA as sensory-cognitive ability that is distinct from, yet related to, intelligence.

How Do Different Ways of Measuring Individual Differences in Zero-Acquaintance Personality Judgment Accuracy Correlate With Each Other?

OBJECTIVE: This research compares two different approaches that are commonly used to measure accuracy of personality judgment: the trait accuracy approach wherein participants discriminate among targets on a given trait, thus making intertarget comparisons, and the profile accuracy approach wherein participants discriminate between traits for a given target, thus making intratarget comparisons. We examined correlations between these methods as well as correlations among accuracies for judging specific traits. METHOD: The present article documents relations among these approaches based on meta-analysis of five studies of zero-acquaintance impressions of the Big Five traits. RESULTS: Trait accuracies correlated only weakly with overall and normative profile accuracy. Substantial convergence between the trait and profile accuracy methods was only found when an aggregate of all five trait accuracies was correlated with distinctive profile accuracy. Importantly, however, correlations between the trait and profile accuracy approaches were reduced to negligibility when statistical overlap was corrected by removing the respective trait from the profile correlations. Moreover, correlations of the separate trait accuracies with each other were very weak. CONCLUSIONS: Different ways of measuring individual differences in personality judgment accuracy are not conceptually and empirically the same, but rather represent distinct abilities that rely on different judgment processes.

Accuracy of Judging Affect and Accuracy of Judging Personality: How and When Are They Related?

OBJECTIVES: The present research is concerned with the relation between accuracy in judging targets' affective states and accuracy in judging the same targets' personality traits. In two studies, we test the link between these two types of accuracy with the prediction that accuracy of judging traits and of judging states will be associated when fundamental affective qualities are shared. METHOD: In Study 1, affective states and personality traits of 29 targets were rated by 124 judges whose individual accuracy was scored as the correlation between their ratings and target criterion scores (across targets). In Study 2, a comparable analysis was done using 30 different targets and 330 different judges. RESULTS: Accuracy in judging distressed affect was significantly positively correlated with accuracy in judging Neuroticism in both studies, as well as in a meta-analysis across the two studies. Accuracy in judging positive affect was significantly positively correlated with accuracy in judging Extraversion in one of the two studies, with the meta-analysis across the two studies being significant. CONCLUSIONS: These findings provide preliminary evidence for a new model (State and Trait Accuracy Model) that outlines when concordance in accuracy across traits and states should be expected.

Nonverbal Communication as a Pain Reliever: The Impact of Physician Supportive Nonverbal Behavior on Experimentally Induced Pain.

Despite the evidence for the potential of supportive communication to alleviate physical pain, no study to date has assessed the impact of supportive nonverbal behavior on the objective and subjective experience of pain. This analogue study examined the impact of an actor-physician's supportive nonverbal behavior on experimentally induced pain. Participants (N = 205) were randomly assigned to interact with a videotaped physician conveying high or low supportive nonverbal behaviors. Participant pain was assessed with subjective and objective measures. Participants interacting with the high nonverbal support physicians showed increased pain tolerance and a reduction in the amount of pain expressed compared to those interacting with the low nonverbal support physicians. For subjectively rated pain, a gender difference existed such that for men, high physician nonverbal support decreased pain ratings and memory of pain, but for women, high physician nonverbal support increased pain ratings and memory of pain. These results highlight the importance of nonverbal communication in altering pain with broad implications for clinical care.

Individual Differences in Accurately Judging Personality From Text.

This research examines correlates of accuracy in judging Big Five traits from first-person text excerpts. Participants in six studies were recruited from psychology courses or online. In each study, participants performed a task of judging personality from text and performed other ability tasks and/or filled out questionnaires. Participants who were more accurate in judging personality from text were more likely to be female; had personalities that were more agreeable, conscientious, and feminine, and less neurotic and dominant (all controlling for participant gender); scored higher on empathic concern; self-reported more interest in, and attentiveness to, people's personalities in their daily lives; and reported reading more for pleasure, especially fiction. Accuracy was not associated with SAT scores but had a significant relation to vocabulary knowledge. Accuracy did not correlate with tests of judging personality and emotion based on audiovisual cues. This research is the first to address individual differences in accurate judgment of personality from text, thus adding to the literature on correlates of the good judge of personality.

A Lens Model Approach to the Communication of Pain.

Two studies examined the expression and detection of suppressed, genuine, and exaggerated pain. In Study 1, videotaped participants underwent an acute laboratory pain stressor and completed pain ratings. In Study 2, the lens model examined the cues encoders displayed while in pain (facial expressions of pain and viewers' global impressions), the cues decoders used to infer pain in the videotaped encoders, and decoders' accuracy in making judgments of pain. Results revealed expression differences between the suppressed, genuine, and exaggerated pain such that exaggerated expressions contained more tightened facial expressions while genuine expressions of pain contained more open facial expressions of pain. Decoders were accurate at detecting pain only in the exaggerated pain expressions. These results highlight the need for improving providers' accuracy in detecting pain intensity for suppressed, genuine, and exaggerated pain displays. Trainings should focus on teaching providers that patients who appear more agitated and less composed may be suppressing pain, while patients who appear more tense and determined may be exaggerating pain. Finally, patients who seem to not be in that much pain because they are not showing tightened facial expressions may actually be experiencing higher intensities of genuine pain.

How patient-centered do female physicians need to be? Analogue patients' satisfaction with male and female physicians' identical behaviors.

Previous research suggests that female physicians may not receive appropriate credit in patients' eyes for their patient-centered skills compared to their male counterparts. An experiment was conducted to determine whether a performance of higher (versus lower) verbal patient-centeredness would result in a greater difference in analogue patient satisfaction for male than female physicians. Two male and two female actors portrayed physicians speaking to a patient using high or low patient-centered scripts while not varying their nonverbal cues. One hundred ninety-two students served as analogue patients by assuming the patient role while watching one of the videos and rating their satisfaction and other evaluative responses to the physician. Greater verbal patient-centeredness had a stronger positive effect on satisfaction and evaluations for male than for female physicians. This pattern is consistent with the hypothesis that the different associations between patient-centeredness and patients' satisfaction for male versus female physicians occur because of the overlap between stereotypical female behavior and behaviors that comprise patient-centered medical care. If this is the case, high verbal patient-centered behavior by female physicians is not recognized as a marker of clinical competence, as it is for male physicians, but is rather seen as expected female behavior.

Clinically relevant correlates of accurate perception of patients' thoughts and feelings.

The goal was to explore the clinical relevance of accurate understanding of patients' thoughts and feelings. Between 2010 and 2012, four groups of participants (nursing students, medical students, internal medicine residents, and undergraduate students) took a test of accuracy in understanding the thoughts and feelings of patients who were videorecorded during their actual medical visits and who afterward reviewed their video to identify their thoughts and feelings as they occurred (Test of Accurate Perception of Patients' Affect, or TAPPA). Participants' accuracy scores were then correlated with participants' attitudes toward patient-centered care, clinical course background, recall of clinical conversation, evaluations of clinical performance made by preceptors, evaluations of interpersonal skill made by standardized patients in clinical encounters, and independent coding of behavior in a clinical encounter. Accuracy in understanding patients' thoughts and feelings was significantly correlated with nursing students' clinical course experience, clinicians' favorable attitudes to psychosocial discussion, standardized patients' evaluations of medical students' interpersonal skill, independent coding of medical students' patient-centered behavior while taking a social history, and undergraduates' more accurate recall of what an actor-physician said on video. Accuracy in perceiving patients' thoughts and feelings can be objectively measured and is a skill relevant to clinical performance.

Smiling in a job interview: when less is more.

Two studies examined the effect of applicants' smiling on hireability. In a pre-test study, participants were asked to rate the expected behavior for four types of applicants. Newspaper reporter applicants were expected to be more serious than applicants for other jobs. In Study 1, participants were randomly assigned to be an applicant or interviewer for a newspaper reporting job. Smiling was negatively related to hiring, and smiling mediated the relation between applicants' motivation to make a good impression and hiring. Hiring was maximized when applicants smiled less in the middle of the interview relative to the start and end. In Study 2, participants watched Study 1 clips and were randomly assigned to believe the applicants were applying to one of four jobs. Participants rated more suitability when applicants smiled less, especially for jobs associated with a serious demeanor. This research shows that job type is an important moderator of the impact of smiling on hiring.

How women's sexual orientation guides accuracy of interpersonal judgements of other women.

This research examines how women's sexual orientation guides the accuracy of judgements of other women. One hundred ten judges (67 straight and 43 lesbian women) watched videotapes of 9 targets (4 straight and 5 lesbian) and made judgements about the targets' thoughts, emotions, personality, and sexual orientation. Accuracy scores were created for each judge by comparing judgements to criterion data gathered about targets. Straight judges were significantly more accurate at judging thoughts and marginally more accurate at judging emotions compared to lesbian judges. There were no significant differences in judging personality. Straight targets' thoughts and personality were more easily assessed than lesbian targets' while lesbians' emotions were more easily judged than straight targets'. Lesbian judges were more accurate at judging sexual orientation regardless of their tendency to categorize women as lesbian compared to straight judges. Findings support past research on the accurate perception of sexual orientation and contribute to understanding how sexual orientation guides person perception.

On the proliferation of the empathy concept in healthcare and medical education research.

OBJECTIVE: To offer a critique of empathy concept usage in healthcare and medical education research. METHODS: Analysis of current usage and suggestions for authors and researchers. RESULTS: Empathy is often undefined or inconsistently defined, and "empathy" as represented in research covers an unmanageably wide and varied range of intentions, attitudes, emotions, and behaviors. The ubiquitous use of "empathy" as a vague and often undefined umbrella term hinders comprehension and, therefore, scientific progress. Patients are rarely asked directly about empathy; instead, measures of so-called perceived empathy contain descriptive items that could as well be called quality of care, patient-centeredness, or patient satisfaction. CONCLUSIONS: Although "empathy" in medical care is widely valued by researchers, educators, and practitioners, the empathy concept as used in the published literature is overused and unclear, and potentially damaging to scholarship, medical education, and ultimately healthcare. The vague term empathy should be replaced as much as possible with concrete descriptions of what is actually measured, experimentally manipulated, or taught. PRACTICE IMPLICATIONS: Identifying patients' own empathy definitions will improve medical education and medical care through clarifying what clinical behaviors will best fulfill patients' needs and desires. This approach allows for greater specificity and personalized care delivery.

Exploring Actual and Presumed Links between Accurately Inferring Contents of Other People's Minds and Prosocial Outcomes.

The term "empathic accuracy" has been applied to people's ability to infer the contents of other people's minds-that is, other people's varying feelings and/or thoughts over the course of a social interaction. However, despite the ease of intuitively linking this skill to competence in helping professions such as counseling, the "empathic" prefix in its name may have contributed to overestimating its association with prosocial traits and behaviors. Accuracy in reading others' thoughts and feelings, like many other skills, can be used toward prosocial-but also malevolent or morally neutral-ends. Prosocial intentions can direct attention towards other people's thoughts and feelings, which may, in turn, increase accuracy in inferring those thoughts and feelings, but attention to others' thoughts and feelings does not necessarily heighten prosocial intentions, let alone outcomes.

Can naive viewers put themselves in the patients' shoes?: reliability and validity of the analogue patient methodology.

BACKGROUND: Analogue patients (APs) are untrained viewers given the task of viewing and rating their impressions of a medical interaction while taking on the patient role. This methodology is often used to assess patient perceptions when using real patient (RP) populations is unethical or impractical. OBJECTIVES: This study examines the reliability and validity of the AP methodology and its optimal implementation. RESEARCH DESIGN: Forty-six videotaped interactions of RP-physician interactions, where RP satisfaction scores existed, were viewed by 216 APs, who rated satisfaction. Interrater reliability for AP satisfaction scores was evaluated. AP and RP satisfaction scores were compared with each other and correlated with the physician's observer-coded patient-centeredness. MEASURES: RP satisfaction was measured with a 15-item scale after the whole interaction. Physicians' patient-centered behavior was coded with the Four Habits Coding Scheme. AP satisfaction was measured after viewing the entire interaction with a single satisfaction question, a 4-item satisfaction scale including that single item, and the original 15-item satisfaction scale used by the RPs. RESULTS: AP satisfaction ratings were reliable (=0.70 for 4 APs). AP satisfaction was a significant predictor of RP satisfaction (r=0.29, P=0.05), especially when the analysis was limited to the RPs who reported being less than perfectly satisfied (r=0.65, P=0.002). AP satisfaction was a better predictor than RP satisfaction of providers' patient-centered behaviors in the interaction. CONCLUSIONS: The AP methodology is a valid and reliable approach to gathering patient perception data about provider-patient interactions. Results suggest practical advice for researchers using the AP methodology.

The relation between intelligence and religiosity: a meta-analysis and some proposed explanations.

A meta-analysis of 63 studies showed a significant negative association between intelligence and religiosity. The association was stronger for college students and the general population than for participants younger than college age; it was also stronger for religious beliefs than religious behavior. For college students and the general population, means of weighted and unweighted correlations between intelligence and the strength of religious beliefs ranged from -.20 to -.25 (mean r = -.24). Three possible interpretations were discussed. First, intelligent people are less likely to conform and, thus, are more likely to resist religious dogma. Second, intelligent people tend to adopt an analytic (as opposed to intuitive) thinking style, which has been shown to undermine religious beliefs. Third, several functions of religiosity, including compensatory control, self-regulation, self-enhancement, and secure attachment, are also conferred by intelligence. Intelligent people may therefore have less need for religious beliefs and practices.

Specialist physicians' sensitivity to patient affect and satisfaction.

BACKGROUND: Studies indicate that physicians do not respond adequately to patients' emotional issues. Physician sensitivity to patient affect has not been much explored. OBJECTIVES: To describe specialist physicians' sensitivity to patient affect and satisfaction. RESEARCH DESIGN: Cross-sectional study of physicians' and patients' postvisit questionnaire statements about patient affective states and satisfaction. SUBJECTS: A representative sample of 71 physicians covering nonpsychiatric clinical specialties in a general teaching hospital were observed during 497 encounters with patients (outpatient, inpatient on rounds, emergency room, maximum 8 encounters per physician). MEASURES: Standardized correlations between physician and patient statements. RESULTS: Physician statements about patient negative affect were moderately correlated with patient self-report of negative affect [r=0.379 (0.301; 0.452)]. Physician statements about patient positive affect and patient satisfaction were weakly correlated with patient self-report of positive affect [r=0.238 (0.153; 0.319)] and satisfaction [r=0.219 (0.134; 0.301)]. Internists [r=0.300 (0.161; 0.428)] were significantly less sensitive to negative affect than surgeons [r=0.500 (0.360; 0.618), P=0.038] and neurologists [r=0.621 (0.432; 0.758), P=0.007]. Physicians previously known by the patient were significantly more sensitive to negative affect than those who were not known [r=0.509 (0.391; 0.611) vs. 0.293 (0.189; 0.390), P=0.006]. We could not find differences in affective sensitivity between male and female physicians. CONCLUSIONS: Specialist physicians have moderate ability to identify patient negative affect and poor ability to identify patient positive affect and patient satisfaction.

Empathy, an important but problematic concept.

The concept of empathy as it is used in scholarly discourse has been challenged for over 50 years, yet the same ambiguities and controversies associated with the concept persist and, indeed, have accelerated with the accumulation of definitions, subconstructs that are included under the empathy umbrella, and measuring instruments. In this article we address the following interrelated problems: many definitions, authors not offering definitions, authors using instruments that do not match their definitions, authors not specifying definitions and measurements in cited studies, the jingle-jangle problem, and the persistent need for more construct validity research. In this Special Issue on empathy and its problems, authors bring new theoretical insights, creative research designs, and a critical focus on the empathy concept itself.