Tessie W. October, MD, MPH

An analysis of audio-recorded care conferences between physicians and pediatric patients’ family members found that physicians acknowledge family members' emotions in about three-fourths of all interactions.

A qualitative study of 68 recorded conferences in an urban, pediatric critical care facility reported that physicians missed the opportunity to respond to the emotions of their patient’s family in 26% of all interactions. The study also found that instances where physicians responded with open empathy and with time to allow family members to respond resulted in more important information being shared, from family to physician.

Led by Tessie W. October, MD, MPH, of the George Washington University School of Medicine’s Department of Pediatrics, researchers conducted a cross-sectional, qualitative phenomenology study of the interactions between 30 physicians and 179 family members of 68 children treated in a pediatric intensive care unit (PICU). The care conferences between the 2 parties are generally held to review a critically ill patient’s condition, prognosis, and plan-of-action—often being held when the patient’s condition has worsened, researchers noted.

In order to properly categorize and code physician empathetic statements, researchers used the published NURSE pneumonic (naming, understanding, respecting, supporting, exploring). They coded physician statements which were followed by a pause allowing family members time to respond as “unburied,” and statements which involved medical talk or a closed-ended remark as “buried.”

Family member responses to such statements were categorized by either being a continuation of emotion (alliance), medical talk (cognitive), or no response. Researchers also tracked for missed opportunities for physician empathetic response. Family alliance response was subcategorized into instances of deepened emotional discussion, expressed gratitude, or agreement with the physician.

Physicians acknowledged families’ emotional cues in 74% of all instances, responding with 364 empathetic statements. Among the NURSE responses, ‘understanding’—or empathy for the family’s emotional response—was the most frequently reported, in 110 (30%) of all statements. ‘Respecting’ (n= 90; 25%) and ‘supporting’ (n= 83; 23%) were also used in at least one-fifth of all responses.

Physician empathetic responses were also more likely to unburied (n= 224; 61.5%) than buried (n= 140; 38.5%). In 160 (71%) of unburied statements, families responded with alliance—the most likely response being a continuation of emotion, at 59% of all alliance responses. Just 7 (3%) of all unburied statements were met with no response from patient’s family.

However, buried statements were most likely to result in a family’s cognitive response (n= 69; 49%) or no response at all (n= 54; 39%). Researchers noted physicians most commonly buried empathetic statements with complex medical talk, or by contradicting their empathy through frequent use of the conjunction ‘but’ to return to technical talk.

“We suspect physicians use medical talk or “but” to quickly attempt to address the emotion, then return to what is most comfortable,” researchers wrote. “For families, using “but” may make that clear and lead them to move away from the emotion and stay in medical talk.”

In an essay accompanying the analysis, Robert D. Truog, MD, MA, of the Harvard Medical School’s Department of Global Health and Social Medicine, gave notice to the study’s demographics—24 (80%) of physicians were classified as white while 43 (64%) of the patients were classified as black.

Though the disparity is common in large, urban hospitals, Truog suggested health care providers take consideration to the effect race, ethnicity, and culture may have on the dynamic between physicians and patients family members.

Truog also pointed to the fact that bedside nurses were present for just 35% of all PICU conferences—despite commonly playing a critical role in debriefing the family following the physician’s exit. Non-clinician care providers were also more likely to provide unburied, empathetic statements to the families—but they only spoke in 5% of all observed conferences.

The concept that such conferences are strictly held to conversation between physicians and families is not optimal, Truog wrote.

“Systems that place a high priority on ensuring that nonphysician clinicians are able and expected to attend and that use proactive huddles before meetings to encourage the participation and involvement of everyone on the team are likely to do a better job of supporting families overall,” Truog wrote.

Researchers concluded by noting that the incorporation of empathy into communication has been linked to improved patient satisfaction and health outcomes, as well as a reduction in physician burnout.

“Limiting medical talk, using open-ended questions to explore emotions, and reducing physician-to-physician interruptions can provide opportunities to learn new information about patients and their families,” Truog wrote. “Most importantly, listening to patients and their families allows physicians to avoid missing opportunities to deepen the discussion.”

The study, "Characteristics of Physician Empathetic Statements During Pediatric Intensive Care Conferences With Family Members," was published online in JAMA.