"Good to see you. I'm sorry. It sounds like you've had a tough, tough, week." Spoken by a doctor to a cancer patient, that statement is an example of compassionate behavior observed by a University of Rochester Medical Center team in a new study published by the journal Health Expectations.
Rochester researchers believe they are the first to systematically pinpoint and catalogue compassionate words and actions in doctor-patient conversations. By breaking down the dialogue and studying the context, scientists hope to create a behavioral taxonomy that will guide medical training and education.
"In health care, we believe in being compassionate but the reality is that many of us have a preference for technical and biomedical issues over establishing emotional ties," said senior investigator Ronald Epstein, M.D., professor of Family Medicine, Psychiatry, Oncology, and Nursing and director of the UR Center for Communication and Disparities Research. Epstein is a national and international keynote speaker and investigator on mindfulness and communication in medical education.
His team recruited 23 oncologists from a variety of private and hospital-based oncology clinics in the Rochester, N.Y., area. The doctors and their stage III or stage IV cancer patients volunteered to be recorded during routine visits. Researchers then analyzed the 49 audio-recorded encounters that took place between November 2011 and June 2012, and looked for key observable markers of compassion.
In contrast to empathy – another quality that Epstein and his colleagues have studied in the medical community -- compassion involves a deeper and more active imagination of the patient's condition. An important part of this study, therefore, was to identify examples of the three main elements of compassion: recognition of suffering, emotional resonance, and movement towards addressing suffering.
Emotional resonance, or a sense of sharing and connection, was illustrated by this dialogue: Patient: "I should just get a room here." Oncologist: "Oh, I hope you don't really feel like you're spending that much time here."
Another conversation included this response from a physician to a patient, who complained about a drug patch for pain: "Who wants a patch that makes you drowsy, constipated and fuzzy? I'll pass, thank you very much."
Some doctors provided good examples of how they use humor to raise a patient's spirits without deviating from the seriousness of the situation. In one case, for example, a patient was concerned that he would not be able to drink two liters of barium sulfite in preparation for a CT scan.
Doctor: "If you just get down one little cup it will tell us what's going on in the stomach. What I tell people when we're not being recorded is to take a cup and then poor the rest down the toilet and tell them you drank it all (laughter)… Just a creative interpretation of what you are supposed to take."
Patient: "I love it, I love it. Well, I thank you for that. I'm prepared to do what I've got to do to get this right." Researchers evaluated tone of voice, animation that conveyed tenderness and understanding, and other ways in which doctors gave reassurances or psychology comfort.
Here's an instance in which an oncologist encouraged a reluctant patient to follow through with a planned trip to Arizona: "You know, if you decide to do it, break down and allow somebody to meet you at the gates and use a cart or wheelchair to get you to your next gate and things like that. And having just sent my father-in-law off to Hawaii and told him he had to do that, he said no, no, I can get there.
Just, it's okay. Nobody is gonna look at you and say, 'What's an able-bodied man doing in a cart?' Just, it's okay. It's part of setting limits."
Researchers also observed non-verbal communication, such as pauses or sighs at appropriate times, as well as speech features and voice quality (tone, pitch, loudness) and other metaphorical language that conveyed certain attitudes and meaning.
Compassion unfolds over time, researchers concluded. During the process, physicians must challenge themselves to stay with a difficult discussion, which opens the door for the patient to admit uncertainty and grieve the loss of normalcy in life.
"It became apparent that compassion is not a quality of a single utterance but rather is made up of presence and engagement that suffuses and entire conversation," the study said. First author, Rachel Cameron, B.A., is a student at the University of Rochester School of Medicine and Dentistry; the audio-recordings were reviewed by a diverse group of medical professionals with backgrounds in literature and linguistics, as well as palliative care specialists.
The National Cancer Institute funded the study.