USDA Photo by Lance Cheung | flickr
Telemedicine usage has accelerated rapidly in much of the world because of the COVID-19 pandemic. The urgency of this transition has sometimes meant that making virtual care patient- and family-centered has not always been a top priority. Silvia Perez-Protto, MD, MSc, FCCM, is a critical care physician and the medical director of the Cleveland Clinic’s End of Life Center. She has been a virtual care provider for many years, and was a member of the IHI Lucian Leape Institute's expert panel that contributed to the Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care white paper. In the following interview, Perez-Protto discusses ways to express empathy through a virtual platform and why expressing empathy matters for both patients and health care providers.
What do you mean when you talk about the need for empathy in the context of telemedicine?
Let’s start with defining empathy. For me, empathy means the ability to recognize and respond to another’s emotions or perspectives. There’s a capacity to recognize and understand the other person’s emotions and then expression of this awareness. The behavior change or response is the capacity to communicate that effectively and do something about it.
In person, let’s say I’m giving bad news and a family member starts crying. I may naturally try to do something like put my hand on their shoulder to show that I care and have some understanding of their emotions. We need to recognize the barriers to expressing empathy during a virtual encounter.
How does showing empathy benefit both patients and providers?
Empathy helps the patient or the family member to decrease the distress and intensity of emotions. If we ignore their feelings, we can make it more difficult for the patients or the family members to listen to us, or follow our recommendations. It is demonstrated across the literature that empathy improves health outcomes, improves the patient experience, and lowers patient anxiety or stress.
For caregivers, when we have a good interaction in which we are open and reachable — even if it’s a hard or sad conversation — and we see that showing empathy decreases the distress of our patients or their loved ones, this helps us as well. It helps us to walk away from that conversation in peace.
How does this fit with what is sometimes accepted as conventional wisdom that clinicians need to maintain emotional distance from patients to be effective?
When I was first trained years ago, I was taught that if you are too emotional, you cannot be a doctor. Dr. Rana Awdish talks about this in her book, In Shock. I think our thinking has evolved since [I was first trained] to understand that showing your vulnerability and caring helps patients to heal. We are not only here to treat diseases. As Dr. Wes Ely says in his book, Every Deep-Drawn Breath, we are here to heal. To navigate difficult situations together, even the process of dying, we have to give support and clinical knowledge and also show that we are human beings healing other human beings.
What are some of the potential risks of not conveying empathy?
If we don’t convey empathy, we are at higher risk of burnout because we are departing from our vocation. Whether we are a nurse, doctor, or respiratory therapist, or any other health care provider, if we lose our deep connection to humanity, we are losing touch with why we are in health care.
What are some tips for how to effectively express empathy through telemedicine?
At the Cleveland Clinic, we believe that empathy is a trainable skill, and you can convey it through a virtual encounter. We think of it as paying attention to a range of nonverbal cues and verbal responses:
- Sit (or stand) in an open posture. Lean forward.
- Use facial expressions to convey caring, concern, and curiosity.
- Do your best to maintain eye contact by looking at the camera and not the image of the patient on the screen. (It feels more natural to look at the person’s face, so this takes practice. Sometimes I fail to do it, and I do not want to get distracted, so I sometimes explain what I’m trying to do and why.)
- Use open-ended questions to provide the opportunity for patients to express themselves.
- Use a gentle tone and slow down, especially if you tend to speak quickly.
- Embrace pauses in the conversation, especially if you’ve made a statement or asked a question. Give patients time and space to react or respond so they don’t feel rushed.
- Consider nodding or doing things like putting your hand to your heart to connect your actions to what you’re saying.
- Remember [the mnemonic] SAVE to help with how you approach the interaction verbally:
- S for support — Let’s work together to figure out what to do next. I’m here to answer all your questions. How can I help?
- A for acknowledge — You look like maybe you have questions. I can see that this is hard for you.
- V for validation — Many people feel that talking like this can feel a little awkward. Let’s try to make it work.
- E for emotion naming — You seem worried. Help me understand how you feel right now.
As a general rule, refrain from trying to fix the situation or rushing to reassure. It may be tempting to say, “Everything is going to be fine.” It’s better to acknowledge what is happening: I’m here to do everything I can to help. I know this has been hard for you. I wish I had other news to give you and that there were better alternatives. Anyone in your position would be upset.
These are ways to support, acknowledge, validate, and name emotions without trying to “fix” the situation. By doing these things, you indicate you are open to however the patient is feeling.
We need to adapt to this new technology in the best ways we can. We have to learn how to manage it in order to make the experience good for our patients and their loved ones. Our goal is to heal others, and to do that it’s important to acknowledge how hard the pandemic has been for everyone and be open to listening with empathy.
Editor’s note: This interview has been edited for length and clarity.
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IHI white paper: Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care
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