Showing you care: An empathetic approach to

doctor–patient communication
Mitchell J. Lipp, Christopher Riolo, Michael Riolo, Jonathan Farkas,
Tongxin Liu, and George J. Cisneros

Our College recently convened a series of retreats bringing together faculty,

administrators and employees to identify common concerns. Stakeholders
working independently in small groups separately and collectively agreed
that our major organizational concern was communication. This theme
played out in various ways. From not knowing what was going on beyond an
individual’s immediate work area to broader interpersonal challenges. Some
felt a lack of caring or appreciation. Often the word, “respect,” was used.
Perceived deficiencies extended to students, faculty, administrators, staff,
and most troubling, to patients. Communication skills are recognized as
essential to professional competence by the Commission on Dental
Accreditation, the American Dental Education Association, and the Inter-
professional Educational Collaborative. It is a theme that crosses disciplines
and is foundational to patient-centered care. As scientifically driven evidence-
based healthcare and technologies progress, the emotional, psychological,
social and cultural needs of patients may be neglected. Communication skills
centered on empathy and showing you care, yield benefits to both the doctor
and patient in terms of satisfaction, compliance, and treatment outcomes.
(Semin Orthod 2016; ]:]]]–]]].) & 2016 Elsevier Inc. All rights reserved.

Introduction emphasize “patient centered care” in a “human-

istic environment.” This article will focus on
mpathy is part of being human. Through
E empathy we connect to others and share in
their felt experiences. Science is responsible for a
the role of empathy in the doctor–patient
relationship.
It is without question that communication
remarkable transformation in health care. Yet
skills are necessary to succeed in orthodontic
there is increasing recognition that filtering a
practice. Many studies in health care suggest that
human being through tests and images and
communication between the doctor and the
making objective evidence-based decisions is
patient positively impacts on satisfaction,
somehow incomplete. The emotional “truths” that
decreased malpractice claims, and improved
propel people through life have been largely
health outcomes.1–4 One article in the ortho-
excluded from the process. Health professional
dontic literature reported a dramatic decrease in
groups, including The Commission on Dental
treatment time when greater attention was paid
Accreditation and the American Dental Educa-
to communication.5 While dental and medical
tion Association, include standards that
education programs regard communication as a
core competency, it appears infrequently (or is
Department of Orthodontics, NYU College of Dentistry, New York,
under reported) in the orthodontic literature.
NY; Department of Orthodontics, University of Washington School of The consequences of miscommunication can
Dentistry, Seattle, WA; Department of Orthodontics, University of be dire, like the 71 million dollar malpractice
Detroit Mercy School of Dentistry, Detroit, MI. settlement when emergency health care workers
Address correspondence to Mitchell J. Lipp, BA, DDS, Department mistranslated the word “intoxicado” to mean
of Orthodontics, NYU College of Dentistry, Room 683 W Dental
Center, 421 First Ave., New York, NY. E-mail: [email protected]
intoxicated instead of the intended meaning of
& 2016 Elsevier Inc. All rights reserved.
“feeling sick to the stomach” that caused a delay
1073-8746/12/1801-$30.00/0 in making the correct diagnosis resulting in a
http://dx.doi.org/10.1053/j.sodo.2016.04.002 potentially preventable quadriplegia.6

Seminars in Orthodontics, Vol ], No ] (), 2016: pp ]]]–]]] 1

2 Lipp et al

The doctor–patient relationship is deeper experience of the patient, hence deepening the
than a transactional relationship. Communica- empathetic relationship.9
tion in this area goes beyond the exchange of Empathy is rooted in our biology, in our
information. Orthodontists need to understand brains and in our bodies. It has been observed in
the complete set of wants and needs of the various species including rats.8 In the last
patient; often going beyond objective findings in decade, more attention has been focused on
order to consider psycho-social dimensions that the role that mirror neurons play in empathy.10
affect care. Empathy is a discrete and complex Mirror neurons are cells in the brain that fire
phenomenon that has subtle and foundational when we observe someone performing an action
influences in the doctor–patient relationship. in the same way that they would fire if we
Because empathy affects the information that the performed that action. The primacy of mirror
patient discloses, this fact alone may significantly neurons in empathy has more recently been
affect diagnosis, treatment planning, practice brought into question. However, their
management, and other related skills and contribution to a neuronal understanding of
behaviors that lead to a more trusting relation- empathy remains under investigation. Empathy
ship between the doctor and patient. is also modified by external factors such as
social–cultural considerations and socio-
economic status.11
Empathy
Empathy is the experience of understanding
A patient-centered environment
another person’s condition from their per-
spective by placing yourself in another’s shoes Doctor–patient relationships are affected by the
and feeling what they are feeling. Empathy is various aspects of the health care process and
known to increase prosocial (helping) behaviors. environment. These physical and social compo-
Researchers have differentiated between the two nents inherent in this environment begin as early
types of empathy. “Affective empathy” refers to as the first phone greeting or online contact.
sensations and feelings—an emotional response. Once inside the physical office, the environment
This may include mirroring what a person is includes structural elements like location, décor,
feeling, or anticipating what they may feel. For furnishings, equipment, cleanliness, order, and
example, a guttural shriek when witnessing a soundscape. This environment is further sup-
person falling and possibly getting hurt. “Cog- ported in part by the entire orthodontic health
nitive empathy,” sometimes called “perspective care delivery team in that (1) each patient should
taking,” is the mental act of projecting oneself feel as if they are the center of the universe with
into another person’s perspective, and through their wants and needs as the primary focus; (2)
this process being able to identify and under- the environment promotes the feeling of safety
stand another person’s emotions. In the example and confidentiality; and (3) the staff exhibit
of seeing someone fall, this would equate to caring and positive attitudes.
appreciating the embarrassment and frustration Implicit in this team centered office envi-
that person may feel. ronment is a congenial supportive team that
There is some disagreement concerning the emulates empathetic communication practices.
value of affective empathy in training health Effective and empathetic communication is not
professionals. Some feel that by becoming too only useful in patient management but also in
emotionally invested in a patients’ personal managing team member relationships. If the
perspective, objective based health advice may be orthodontist intends to lead the team, each
compromised.7 Others stress that the key communicative interaction should be designed
component of empathy is the emotional to increase awareness of the empathetic role
connection with the patient, and without this each team member should display. All of the staff
affective bond, behavioral attempts at empathy, involved, whether engaged in support services or
that is, “acting” as if you are really concerned, involved with direct patient care should be
would not be as productive.8 Dr. Rita Charon has employing a “Show You Care” communication
advocated the use of narratives, literature, shared style thus reinforcing that the primary concern is
stories as methods to reveal the felt emotional the patient’s welfare.
 Doctor–patient communication 3

Table. A Framework for Showing You Care

Attitudes Interpersonal Skills Behaviors

Building Rapport Verbal Giving a direct phone line

Patience Avoid interrupting Making follow-up calls
Respect Avoid too quick of an interpretation Escorting patients
Being fully present Partnership statements Coordinating referrals
Connecting on a Appropriate language Position self in relation to patient
human level (proximity, level, bearing, etc.)
Nonjudgmental Normalizing: recognizing emotional reactions that Introduces names and positions of all
anyone would have health care team members present
Taking patient Giving feedback Establishes an environment of safety
seriously and confidentiality
Cultural competence Eliciting patient concerns Asking permission before touching or
Recognition of Language terminology relating to the patient's illness, intruding on one's privacy or
differences like clearly describing one's condition, the treatment plan personal space
ethnicity or gender, proposed and associated risks and benefits
Cognition Articulation
Humor Vocal placement (timbre, tone, color, etc.), volume, and
size
Tactfulness Pace of speaking
Enthusiasm Varying one's delivery approach (pitch, pace, rate, and
Relating emphasis)
Reflective listening
Provides appropriate wait time after asking questions.
Responding to questions.
Clarifying
Paraphrasing
Acknowledging
Nonverbal
Eye contact
Tone of voice
Body posture
Facial expression
Appropriate touch
Allowing crying
Mirroring patient's body language. Checking for
nonverbal signs (understanding)
Integrations
Integrating verbal with other communication modes
(visual, aural, kinesthetic, etc.)
Note the overlapping boundaries and integration of empathetic skills with other communication skills. In our framework, we
proceed from a theatrical or actor's perspective. Mastering the role begins with understanding the attitudes and attributes of an
empathetic doctor. After understanding the role, we proceed to awareness of the skills required to effectively communicate and
experience/express empathy. Finally these skills need to be integrated and regularly applied in daily living.
4 Lipp et al

Despite all good intentions we live in an explaining things while minimizing technical
imperfect world, largely because we are imper- jargon, and quickly defining any word which
fect. Things do go wrong and when they do, it is may cause confusion. Visual aids can be helpful
essential to acknowledge the fact and move to demonstrate procedures and appliances and
ahead. Do not hesitate to say, “I’m very sorry this overcome language barriers. Techniques such as,
has happened. We will continue to do everything tell, show, and do can be very useful for younger
we can to resolve (the issues under discussion) as patients. However, overcompensating or over-
well as any others that may occur as we proceed using any approach or aid in this area can
with your care.” The practitioner needs to keep become problematic as sometimes the patient
staff included, supported, and supportive. A team (or parent) can perceive oversimplified
that shares ownership for the patient’s welfare is explanations as a form of condescension. Care
the ultimate goal. Opportunities for training must be taken to gauge the mental capacity of the
(and re-training) in communication skills, with patient (or parent) possibly using education level
role-playing and scenarios may be helpful. Much as a guide. Adjusting to match cognitive and/or
like exhibiting empathy towards one’s patients, language levels of your audience (patient and
the orthodontist should express the “Show You parents) is another part of the challenge in
Care” communication styles to all team members. communication.
Orthodontic treatment of younger children
occasionally requires effective communication
Empathy in clinical practice not only with the patient but also with the parents
Generally, empathy has been studied using surveys as well. A guiding principle in building empa-
or rating forms in which patients or observers rate thetic relationships is to strive to understand the
the practitioner relative to response options. Most unique needs of each individual and modulate
scales focus on ultimate outcomes and not isolated communication skills and behaviors accordingly.
skills or behaviors. One study took a novel approach
by having medical educators work with professional Active listening
theater educators that adapted actor-training tools
incorporated in the health care setting12. This tool, Engage the communication process by first,
unlike other empathy scales, offered insight into asking open-ended questions; and second, by
the observable methods a doctor may use to keeping the number of your interruptions to the
improve communication and convey empathy. minimum. Allow patients to do most of the
From this tool and other sources, we have talking. Whenever possible, only interject at
attempted to isolate skills and behaviors that are appropriate points, using open-ended questions,
associated with demonstrating empathy (Table). to elicit additional information allowing you to
If the perspective toward building empathetic “funnel down” into more focused questions.
skills stems from the realm of theater, perhaps Patients need to feel heard. Ask prompting
the clinical orthodontist should begin by questions like “Is there anything else?” or “Tell
understanding the role-internalizing core values me more about that” and then pause to listen to
like altruism and beneficence; as well as attrib- the response. Phrases such as “I can imagine how
utes such as, approachability, nonjudgmental that made you feel,” or even remaining silent can
attitude, and expressing an active interest in the be effective as long as the patient feels encour-
patient. After understanding the role of the aged and is assured that she is being heard. If
empathetic doctor, one should then focus on appropriate, take notes while the patient is
skills that effectively lead to establishing and speaking. This conveys the aura of active listening
encouraging an empathetic relationship. and supports the patient’s perception of being
heard. Once again, be careful about overdoing it.
Losing focus by taking too many notes can be
Key themes distracting and thwart the impression of actively
listening to the patient.
Educating and communicating
Framing statements convey the intention of
A significant fear for any patient is fear of the obtaining an accurate understanding.14 Phrases like
unknown.13 This can be mitigated by calmly “Let me see if I understood everything correctly…”
 Doctor–patient communication 5

demonstrate actively trying to understand the front desk staff treats the new patient. Main-
patient’s situation. Giving back to the patient what taining eye contact, within a comfortable prox-
you think they have stated not only makes the imity to the patient, inclined forward to hear
patient feel understood but also provides what they have to say conveys interest and not
opportunities for clarification. Listening to and only helps the listener to really hear the patient
repeating or rephrasing the patient’s words can but provides the patient with the feeling that they
help orthodontists recognize the patient’s feelings are truly being heard. Asking the patient if they
from their perspective.15 It allows the doctor and the have any special requests or needs is another
patient to bridge perspectives moving toward mechanism that can be used to enhance their
empathy. Patients that feel understood tend to experience. Whenever the doctor is with the
reciprocate by trusting their health care provider. patient, the patient needs to receive the practi-
The benefits of empathy are tangible and tioner’s full attention regardless of other people
measurable resulting in improved treatment being in or near the treatment area. This concept
adherence, quality of care, decreased health care also includes the idea that whenever possible, the
costs, and decreased psychological distress.16 doctor should not be interrupted by members of
the staff to attend to other needs within the office
until the patient encounter is completed.
Body language
Active listening continues by sustaining an
The nonverbal communication an orthodontist open body position—never appear to be closed
conveys is a crucial element in patient under- off by folding your arms across your chest.
standing and satisfaction.17 In one study, physicians Respond nonverbally by nodding your head
were asked to disclose medical errors to patients, by while remaining engaged in the conversation.
contrasting error disclosure with or without Smiling is a very powerful type of body lan-
nonverbal involvement such as, appropriate guage. Interestingly, but not surprisingly, a
touch, personal space proxemics, forward leaning, randomized controlled trial demonstrated a
body orientation, prolonged gaze, vocal animation, significant negative effect on perceptions of
attentiveness and interest, affirmative head nods, an empathy when doctors wore facemasks while
numerous other nonverbal communicative interviewing patients.19 The orthodontist
techniques. When nonverbal communication was should also be aware that some patients may
absent, physician’s apologies were interpreted as be anxious just being in a clinical setting, the
being less sincere and remorseful.18 The study so-called “white-coat syndrome,” which has
demonstrated how nonverbal involvement been found to elevate the patient’s blood
facilitated more accurate patient understanding pressure (a key measurement of anxiety).
and assessment of the medical error as well as its Establishing an empathetic doctor–patient
consequences on the patient’s health and their relationship can modulate this anxiety.
quality of life.
Body language needs to be open, not con-
Match patient’s nonverbal style
strained, and includes such acts as pausing, nodding,
all while maintaining eye contact.14 Starting with Language matters but the manner in which we
body positioning and hand gestures, creating a say things has been shown to be powerful,
welcoming safe environment for the patient in order sometimes more powerful than what we actually
to share information and be made to feel at ease is say. For instance, one’s tone of voice, volume,
important. For example, maintaining focus and and pacing of speech, all play a role.13 This
proximity to the patient while leaning forward to paralanguage skill is most effective when used to
hear the patient’s narratives conveys interest and mirror the patient’s own tone. In fact, it has been
helps the practitioner better understand the shown that when practitioners attune to patients
patient’s wants, needs, and expectations regarding nonverbally, patients feel more comfortable and
treatment. give fuller histories.15 Tone should never be
As noted previously this impression starts the uncaring, apathetic, express frustration, or stress.
minute the patient enters the office. Thus the Modulating your tone of voice can markedly
proverbial “you never get a second chance to modify the patient’s behavior and reduce
make a good first impression,” starts with how the agitation; a key factor in managing the child
6 Lipp et al

patient. Used pointedly, tone can help the doctor during the early phases of one’s professional career
take charge of a situation, but it must be used in and with continually gained experience, by virtue of
moderation. practice and repetition, the maturing practitioner
approaches the final phase,” unconscious com-
Expressing empathy petence.” This final phase, somewhat synonymous
with expertise, reflects the seamless and facile
Perhaps the clearest way to demonstrate empathy is integration of knowledge and complex cognitive
to validate the patient’s emotional target. The two and procedural skills without much conscious
steps in accomplishing this process are first, finding effort. Like driving a car—at first it requires con-
the target; and second, empathizing with the centration and effort, after enough practice; it
patient. An ideal target is one that is close to the becomes an almost automatic response. Commu-
other person’s emotional epicenter. It could be nication skills, both verbal and nonverbal, that lead
mirroring back the other person’s rationale of how to empathetic doctor–patient relationships follow a
they are seeing things and why they feel the way the similar pathway. This essay was intended to bring
way they do. It could be picking up on secondary this subject of empathetic communication and its
elements that they are experiencing which are true, associated skills and behaviors into the practi-
and offering confirmation of that fact. There is little tioner’s consciousness. By developing an under-
empathy in saying “I’m sorry thumb sucking makes standing of this subject the doctor can begin to
you feel bad.” It’s more empathetic to say “After apply these concepts and techniques into clinical
hearing that your friends are making fun of you, I practice.
understand how embarrassing thumb sucking is.” Some of us may recall a time, prior to today’s data
driven era when, “chairside manner” counted.
Considering that empathetic behavior results in
Conclusion
higher patient satisfaction, better patient perceived
Clinicians should be prepared and ready to outcomes, a lesser tendency for the initiation of
recognize and react appropriately to the emo- malpractice claims, happier offices, and less doctor
tional needs of their patients by showing genuine burnout this subject should be given greater
sensitivity and compassion. Empathy must flow attention in both the educational and clinical
naturally from the professional and his/her staff orthodontic environments.
to the patient in order to “Show You Care” and
acknowledge that you have a stake in their well-
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