Empathetic Listening

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Learning Objectives:

Identify the benefits of listening with empathy
Demonstrate best practice techniques to listen for underlying feelings, needs, or values
Apply empathetic listening techniques to build trust and improve patient experience

Introduction

Expressing empathy is a key ingredient to enhancing the patient experience. In fact, 65% of patient satisfaction has been attributed to physician empathy.¹

The feeling of being understood by another person is intrinsically therapeutic. It bridges the isolation of illness and helps to restore the sense of connectedness that patients need to feel whole. The foundation of empathetic communication is based on accurately understanding the patient's feelings and effectively communicating that understanding back to the patient so the patient feels understood.²

In this current era of COVID-19 with unprecedented levels of uncertainty and anxiety, it is even more crucial that clinicians employ empathetic listening to understand and allay patients' fears and concerns.

Empathetic listening is a simple yet powerful approach

Empathy begins with “engaged curiosity about another's particular emotional perspective.”³ Empathetic listening builds on the concept of being attentive to better understand another person's experiences. Empathy is also described as the capacity to put one's self in another's shoes to feel what that person is going through and share their emotions; the recognition and validation of a patient's fear, anxiety, pain, and worry; and the ability to understand patients' feelings to facilitate more accurate diagnoses and more caring treatment.¹ By connecting with empathy, you can help to alleviate fears and convey that you and your care team are listening to their concerns.

Quiz Ref IDTangible and intangible benefits to listening with and demonstrating empathy include³:

Greater therapeutic efficacy
Increased patient trust, which may increase the amount of information the patient discloses and improve adherence to treatment
Improved communication between patient and practitioner, which may decrease patient anxiety and improve the patient's and physician's abilities to cope in emotionally charged interactions

Patients who feel understood are often more open and responsive to their physician's advice. In return, physicians may have an improved sense of professional satisfaction and joy in work.

Five STEPS to Listening With Empathy

Connect with Empathy by Honoring the First “Golden Moments”
Listen for Underlying Feelings, Needs, or Values
Remain Present When You Are Listening
Look for Cues to Speak Versus Listen
Reflect on Your Experience

STEP 1 Connect With Empathy by Honoring the First Golden Moments

In a clinical situation, the first few minutes of the encounter are precious. During the initial patient visit, you may feel pressured to dive into the various clinical tasks that need to be completed. However, if you leap into these tasks without listening to the patient, you may miss critical information. Take the time to honor the first “golden moments” of the visit by setting aside distractions such as charts, computers, phones, alarms, and pagers. Giving the patient your full attention at the start of the visit prevents important issues from surfacing at the end and will allow you to better understand the patient's concerns or symptoms. While the first few minutes of a visit are important, you should continue to be fully attentive throughout the interaction to ensure that you capture any concerns that may be revealed later in the visit.

Practice Scenario 1:

A new patient presents for a routine preventative visit. At the beginning of the visit, she asks, “What do you think of hydroxychloroquine?” As a clinician, it may be instinctive to answer swiftly and directly and continue on with other “routine” tasks. When practicing empathetic listening, it is advisable not to answer immediately. Instead, ask her about the underlying reasons for asking the question. For example, you can respond, “Are you worried and looking for something that'll help you prevent infection with COVID-19?” This opens up the door for her to express any additional underlying concerns and creates trust between the two of you during the first golden moments. On the other hand, a quick response of yes or no, agree or disagree, usually shuts the patient down for the remainder of the visit.

Practice Scenario 2:

A patient presents with persistent neck pain. During the interview, she says, “My neck was fine until the car accident, but it's been getting worse ever since. Now I can't sleep, I can't do chores around the house, and my boss is really getting upset about all the days I've missed at work.” It may be tempting to jump in with additional questions, such as, “How would you rate the pain on a scale of 1 to 10?” However, a response like this does not effectively show the patient that you are listening to what she is saying. An empathetic response would be to echo her words by saying, “I understand. The neck pain is affecting many aspects of your personal and professional life.” After the patient has finished speaking, you can summarize what she said by saying, “So to summarize, you didn't have any neck pain until the car accident, but it's been getting progressively worse ever since and it is having a major impact on your life.” Alternatively, you can invite her to share more in an open-ended way, such as “Can you tell me more about your neck pain?”

Practice Scenario 3:

A patient is scheduled for a preventive health visit. The office recently developed an electronic note template designed to help physicians navigate preventive health guidelines and recommendations. You start the visit facing the computer and ask the patient how he is doing. The patient responds with a brief, “Fine, thank you.” In recognizing that you have not given the patient your full attention, you turn away from the computer to ask, “How are you doing today?” The patient's response is more complete. Seeing that you are fully attentive, the patient feels free to express the anxiety he has been experiencing related to a conflict with his work supervisor. Through your conversation, it also comes to light that he hasn't been sleeping well lately. Together, you decide to include difficulty sleeping on his visit agenda.

Q&A

Quiz Ref IDHow can I use body language to show empathy right away?
You can show empathy by:
- Sitting next to or near the patient
- Leaning in their direction
- Maintaining eye contact
- Making sure your arms are not crossed
- Not focusing solely on a computer keyboard or screen with your back to the patient
- Periodically echoing or summarizing what the patient is saying

STEP 2 Listen for Underlying Feelings, Needs, or Values

Sometimes feelings may be right on the surface, but at other times they can be hidden. Patients often mention emotional situations, and then wait for a practitioner's cue that it is okay to continue. As the patient explains the situation, watch for feelings hidden in body language, facial expressions, or other non-verbal cues. As your interaction continues, take your own emotional temperature and note your own internal feelings like anxiety, sadness, or frustration. Use the patient's non-verbal cues to assess if this is an opportunity to switch from medical questioning to empathetic listening. To switch to empathetic listening, allow for a brief pause in the conversation, soften your tone of voice, and ask a question that is directly related to your interest in the patient's feelings. This strategy invites the patient to express their concerns, and allows you to address the patient's unique needs.

Identifying Underlying Needs (520 KB)

This tool will help you gain a deeper understanding of the underlying needs we all have but may not openly or knowingly express, with examples of how needs may be expressed in conversational language.

View All Downloadable Resources

Practice Scenario 4:

While seeing a patient in your office, he complains about mask mandates and states that rebreathing carbon dioxide is bad for him. In this situation, you may be tempted to try to correct and educate the patient right away. Instead, listen without interrupting, and then reflect back the patient's feelings and needs. For example, say, “You'd like to be safe and you'd like the freedom to make choices that you feel are safe.” Empathy is possible without agreeing with the patient. It is important to separate out patient education from empathic listening.

Once the patient seems to feel heard, you can give information about best practices for disease prevention and debunk common myths.

Practice Scenario 5:

A patient with cyclic vomiting syndrome comes to the clinic. During her visit, you mention that she needs to stop using marijuana. You notice a sudden grimace on her face. This expression could mean many things. It could reflect anger because she thinks she's being judged about drug use, it could indicate worry if marijuana is the only thing that has alleviated her symptoms, or she could be confused if a previous physician told her marijuana use was unrelated to her vomiting. She might also be embarrassed to talk about her marijuana use in front of others, even confidentially with her physician.

In a situation like this, you should try to ascertain what the grimace means. To do so, you might lower your glasses or shift position to make direct eye contact with the patient and say softly, “You seem to be concerned,” then pause to allow the patient to elaborate.

The patient explains her concerns and indicates that she is worried she might not be able to find anything else to alleviate her nausea. With further insight into the patient's emotions, you can express interest in learning more about her underlying needs or values by saying, “It sounds like it's important that we make sure you're comfortable.” The patient may respond with, “Yes! And I want to have the freedom to help myself be comfortable.”

Upon reflection, you might realize that the patient perceived your earlier suggestion to stop using marijuana as a threat to her comfort and autonomy. By inviting the patient to share more about her feelings and needs, you can establish a common understanding of her needs. The focus of the visit can then shift to discussing other methods for the patient to alleviate her symptoms.

We all have common needs, but different ways of acting in response to these needs. When we focus on needs and values, we can identify ways in which we are the same. During empathetic listening, focus on the patient's underlying needs, rather than their communication style or behavior. You may not know what the need is at first—be open and ask questions until you reach a common understanding.

There might be situations where you may not be able to identify the feeling that the patient is experiencing. In those circumstances, it is important to emphasize that you are interested in hearing about the patient's experiences. Expressing interest invites more expansive conversation, and increases the probability that the patient will reveal underlying feelings.

Practice Scenario 6:

You are running late in clinic, enter a patient room, and promptly apologize for the delay. Despite the apology, the patient mutters a half-hearted greeting and avoids eye contact. Noting this response, you respond, “I sense that you are angry with me.” The patient replies, “Yes, I am angry but also embarrassed.” Before continuing to discuss the reason for the visit, you ask, “Can you help me understand why you're feeling that way?”

The patient expresses that he can no longer drive and is dependent on his daughter to bring him to his appointments. “She's out in the waiting room now. She has a job and kids and I have become such a burden on her. This only makes things worse—the wait, that is.” You pause, and respond, “It sounds like you really value respect—both for your time and for your daughter's time. Did I get that right?” The patient expresses a sigh of relief and says, “Yes… and independence. I just wish I could be more independent.”

Q&A

What is the difference between empathetic listening and being a caring and compassionate physician in general?
Caring is a natural part of the patient-physician relationship. Empathetic listening reinforces the care that you have for your patients, and that you are fully invested in listening to and understanding their emotions. Empathy is not a character trait, but a skill that allows you to have meaningful interpersonal connections with your patients. Your patients may know that you care about their health outcomes, but they may share more information and develop better trust if you are attuned to verbal and emotional messages.

STEP 3 Remain Present When You Are Listening

Give patients an opportunity to express their feelings to completion, without interruption. Their feelings and values will surface if they are given ample time to express themselves in a welcoming environment. Focus on moments when the patient seems to display the most energy around a topic (eg, more rapid speech, change in facial expressions, more pronounced gestures) as these signs can provide clues to what the speaker values most. Embrace silence to allow for a compassionate experience.

“With empathy, we don't direct, we follow. Don't just do something, be there.”
—Marshall Rosenberg, PhD, Founder and Director of The Center for Nonviolent Communication

Practice Scenario 7:

You notice that your colleague is not smiling and seems distracted. You ask your colleague, “Everything OK?” and he responds, “Oh, my 3-year-old is home with my mom and she won't stop vomiting. Every 15 minutes.” You show concern through your face, pause, and let your colleague continue. “I'm also thinking about that little girl who came in yesterday with leg pain. Her labs are back, and it looks like she has leukemia.”

As your colleague ducks into another exam room you reflect on your own dismay about the young patient's diagnosis. You realize that your colleague could be experiencing anxiety, weariness, or a feeling of being overwhelmed. You wonder if he might need an opportunity for balance, or perhaps just a chance to be sad about not being with his daughter while she's ill. Later that morning, your colleague shares that his mom called and his daughter has been feeling a little bit better. Instead of looking relieved, he still looks concerned. Picking up on facial expressions, you say, “You're still worried?” and your colleague replies, “Oh, I know she'll get better. I am a little worried that my mom will get this bug. But I'll tell you what. I just keep thinking about how that little girl's dad doesn't know if his daughter will get better.” This time, your colleague is speaking with a little more speed and energy. You listen while he expresses his need for safety for his child.

By the time these clinicians need to move on to their next patients, they both feel better knowing that someone at work cares about what they are experiencing.

Practice Scenario 8:

A 36-year-old patient asks you for a medical necessity note to work from home because her employer is starting to have people go back into the office. She does not have any high-risk medical comorbidities for COVID-19, and she states her office is taking appropriate safety precautions, but she would feel more comfortable working from home. “You said you'd feel more comfortable working from home. Tell me more.” As she speaks, the physician can listen for feelings and needs. In this situation, the feelings might include fear, hopelessness, or being overwhelmed. The obvious need is safety, but other needs might include respect, autonomy, and understanding. Giving the patient words to help understand what she is seeking can help her to gain perspective and be empowered to create solutions with her employer.

Q&A

How do I give a patient my full attention when I have a responsibility to keep the electronic medical record (EMR) updated?
When using an electronic health record system (EHR), there is a natural temptation to multitask during the encounter by typing while listening to the patient. A more effective strategy is to alternate between working on the computer and communicating with the patient. In moments where empathy is called for, remove your hands from the computer completely and turn to face the patient. If you do need enter something into the EHR, you can announce the transition by letting the patient know that you need to put some information into the computer. It may be helpful to turn the screen towards the patient so that you can review the information together.
I have a habit of keeping a professional distance. Will this impact my ability to engage in empathetic listening?
Communicating with empathy involves emotionally engaging with the speaker, but it does not mean that you have to lose your professional boundaries. Empathetic listening does not demand that you become responsible for resolving all feelings or needs expressed by a patient or co-worker, but that you listen with focused attention. As you continue to practice empathy, you may become more comfortable listening to the needs and feelings of others as you discover that empathy facilitates more effective relationships.
I communicate with my patients frequently through a secure web portal. Is it possible to show empathy in my typed responses?
Empathy is different in a written conversation than in a live conversation, since non-verbal cues of facial expression, body language, and intonations are absent. Acknowledging the patient's emotional experience in writing can still be beneficial. It is possible to demonstrate empathy by responding in a way that shows you recognize the underlying feelings and values the patient is trying to communicate in their message.
If a patient is communicating something emotionally charged, the physician can go out of her way to say something like, “I read your message carefully.” Responses can include language that acknowledges the limitations of this form of communication. For example: “What I'm understanding is…” or “If I'm understanding you correctly, then…” Always include an invitation to talk on the phone, over video, or in person.

STEP 4 Look for Cues to Speak Versus Listen

Quiz Ref IDThere are opportune moments for verbal responses to what the patient is sharing. Cues might be a decrease in emotional intensity, a deep sigh, or a shift in the focus of the conversation. At this point, it may be natural to respond to their message and attend to the medical care needed. Verbal reflection may be helpful for conveying empathy when you need more description or explanation from the patient, or when you sense the patient would like confirmation that you are listening and understanding.

When you respond, keep this question in the back of your mind:
“Is the patient feeling [this emotion] because they have this particular [value or need]?”

As you respond, it is important to speak naturally and be yourself. At this point in the dialogue, the focus is still on listening and it is not the time to share your experiences or opinions. Listening with empathy has a reflective quality that allows the patient to reach a deeper level of self-understanding.

You may also want to be mindful of actions that suggest a lack of empathy. These include:

Interrupting or finishing the patient's sentences
Challenging the patient's feelings
Speaking in a manner that sounds patronizing
Describing what the patient ought to think or feel
Lack of emotional acknowledgement by changing the topic and proceeding with medical questions

Identify and Overcome Deflective Listening (51 KB)

Use this tool to understand and overcome barriers to empathy.

View All Downloadable Resources

Practice Scenario 9:

A patient requiring a dilation and curettage (D&C) procedure after a miscarriage awoke in recovery before her husband arrived. She felt sad, defeated, and disappointed. Her OB/GYN came to see her, stood next to her, and intuited that she wasn't ready to talk about the procedure or how she was feeling. Instead, the doctor allowed her to speak of unrelated subjects—her college experience, her last vacation, her husband—and connected to her physically by holding her hand. In this instance, the OB/GYN didn't follow a specific sequence of steps or a protocol for demonstrating empathy.

A few days later, the patient described her experience to a colleague, “My doctor was with me, and that is what I really needed in that moment. No one was going to have the right words to say to make me feel better in that moment. I didn't need to feel better. I needed to be sad, and to know that it was ok to feel that way.”

Practice Scenario 10:

Your patient appears on screen for telehealth visit. He is middle-aged, overweight, and with a history of heart failure. He is lying in bed. The lighting is poor, and it is difficult to see him. After walking around to find his medicines to work on his medication list, he lays back down and tells you that his brother recently died from COVID-19. He starts crying and is soon overcome with emotion. His brother had a history of alcoholism, had been sober for a while and then relapsed. This summer, he contracted coronavirus and died. Your patient tells you that his brother was his best friend, and he was unable to be with him in his final days.

Your patient is crying loudly while looking away from the camera. You wait for a bit while he cries. You may be wondering what to say. Give your patient time to express himself. During a quieter moment, you might repeat back the sentiment he expressed about his brother, “He was your best friend.” Your patient says, “Yeah, he was my best friend,” and began to cry again. He then took a deep breath and calmed down a bit. He said, “I lost him twice!” You may echo a few other things your patient says as he works through his thoughts.

The visit may continue like this for several minutes. Give your patient time to grieve and don't assume that he expects you to do anything about the situation. Once it feels appropriate, you might ask, “Do you feel comfortable continuing the conversation about your medical care, or would you like to talk more about your brother?” This allows your patient the opportunity to confirm when he is ready to move on.

Note: Empathetic listening skills can be helpful in situations like this that otherwise could have been very uncomfortable. The physician and patient were so distant. But listening to the patient in this way put the physician at ease. It can make the physician feel good to let the patient express themselves, especially when many patients may be disconnected from other supportive resources. Empathetic listening and training give the tools that could help console a person, even at a distance. The physician should have the confidence to be patient, knowing that the patient on the screen would eventually be ready to move on. Not only can empathy help you handle the situation, it makes the patient feel heard and not be embarrassed.

Q&A

How can I make it feel more natural when reflecting feelings back to the other person?
Adopt a tone of curiosity and openness. Consider starting your response with⁴:
- “I imagine you might feel…”
- “I am wondering if you feel…”
- “You sound…”
- “You seem…”
- “Is it important to you that…?”
- “Let's see if I have this right…”

STEP 5 Reflect on Your Experience

Quiz Ref IDAs you reflect on a conversation in which you listened with empathy, begin to think about how you are feeling. Is there anything you are grateful for in this specific interaction? Is there anything you would do differently next time? Offer yourself a chance to be heard and understood for your own experiences.

You can use empathy to reflect on your own underlying feelings and experiences using the same steps outlined here. For emotionally charged situations, writing narratives about your experience can be helpful. Find a listening ear for yourself, and if you want, request that they listen without offering advice or solutions to problems. It may also be helpful to seek trusted colleagues and mentors with whom you can share some of the emotional impact of patient care.

There are many venues in which you can safely share these emotions, you may consider these or others:

Worksheet for Self-Reflection (48 KB)

Use this worksheet to restore yourself for the next time you listen with empathy

View All Downloadable Resources

Q&A

I'm already busy managing my patients' medical conditions, how do I make time to acknowledge their emotions as well?
Strengthening the patient–physician relationship will lead to more effective and efficient clinical care. Physicians can responsibly budget appointment time, and select a moment to transition to medical management.
For example, a woman comes for a check-up and, knowing that her husband is very ill, the physician may ask, “Would you like to talk about your husband?” She responds, “Yes, it has been so difficult.” She speaks of her responsibilities caring for him. The physician encourages her to talk about these feelings and listens closely. While the physician doesn't have the capacity to change the situation with her husband, she may feel better after being heard by someone she trusts and respects.
After letting her express herself, the physician may then pivot with a statement like, “It's important for me to understand what you're experiencing in your personal life. Thank you for helping me understand. With your permission, I'd like to use the rest of our time addressing your medical needs.”
The patient responds, “Yes, absolutely.” She has a need to be understood, but also to get her medical needs met.
Listening with empathy does not necessarily require the majority of the appointment time. With practice, it can be woven in and out of a day.

Conclusion

Listening to others with empathy is a skill that can foster trust in the patient–physician relationship, increase collaboration among co-workers, and enhance personal well-being. Focusing on a patient's underlying feelings demonstrates that you are committed to understanding their experience, and your choice of language and other non-verbal responses is key to drawing out their feelings and values. In a clinical setting, patients are more likely to hear you and be open to your counsel if they sense your empathy.

Empathetic Listening: Additional Reading and Resources (789 KB)

This document lists articles and resources recommended for more details on empathetic listening.

View All Downloadable Resources

AMA Pearls

It is a privilege to listen to a patient's experience—a moment of human connection and understanding that makes you a wiser, humbler person
Listening with empathy is a skill, and like any skill requires practice, reflection, and more practice to refine
Knowing how to listen with empathy gives you confidence that you can handle emotionally charged situations, which is critical during COVID-19 and other times of crisis

Resources

Identify and Overcome Deflective Listening (51 KB)

Use this tool to understand and overcome barriers to empathy.

View All Downloadable Resources

Identifying Underlying Needs (520 KB)

View All Downloadable Resources

Identifying Underlying Feelings

(54 KB)

Worksheet for Self-Reflection (48 KB)

Use this worksheet to restore yourself for the next time you listen with empathy

View All Downloadable Resources

AMA Wire - Listening with Empathy

(278 KB)

Empathetic Listening: Additional Reading and Resources (789 KB)

This document lists articles and resources recommended for more details on empathetic listening.

View All Downloadable Resources

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

CME Credit Renewal: August 22, 2019

References:

Menendez M, Chen NC, Mudgal CS, Jupiter JB, Ring D. Physician empathy as a driver of hand surgery patient satisfaction. J Hand Surg Am. 2015;40(9):1860–5.e2. doi:10.1016/j.jhsa.2015.06.105 Google Scholar Crossref

Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA. 1997;277(8):678–682.Google Scholar Crossref

Halpern J. Empathy and patient-physician conflicts. J Gen Intern Med. 2007;22(5):696–700. doi:10.1007/s11606-006-0102-3 Google Scholar Crossref

Leebov W, Rotering C. The Language of Caring Guide for Physicians: Communication Essentials for Patient-Centered Care. 2nd ed. Language of Caring, LLC; 2014.

Stone J. The Importance of Empathy in Healthcare: Advancing Humanism. MedicalGPS. 2019.Google Scholar

Disclaimer: AMA STEPS Forward^® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward^® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward^® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward^® content.

Empathetic ListeningHonor the Patient Experience During Crisis

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AMA Pearls

Resources