Dr. Nathan Wanner is memorable for his silence.
Unlike other doctors who lighten the mood with jokes or lead off conversations with medical data, he enters a hospital room, introduces himself and then stays quiet.
"I'm not dramatic or demonstrative. … I think that listening is an extremely important skill," said Wanner, an associate professor of internal medicine at the University of Utah and medical director of the University Hospital's palliative care service.
Over the past year, Wanner has spoken often about his habit of not speaking. As a patient experience physician leader for his organization, he highlights key ways to bring empathy to the exam room, such as by being a good listener or asking patients about their pets.
"Everyone has time pressures in the hospital," he said. "But a few little comments (about) patients' lives show them that you value them as people."
Showing patients they care is increasingly on the minds of American doctors, as the patient experience (and how to improve it) is used to define quality health care. When the Affordable Care Act became law five years ago, patient satisfaction scores were linked to Medicare reimbursements, making bedside manners essential to a hospital's bottom line.
Expressing empathy, or addressing a patient's emotional needs in addition to his or her physical health concerns, is now understood by many to be a cornerstone of medical practice. And yet it's hard for some to imagine how to regulate the emotion or how to make time for small talk when doctors have few minutes to spare.
Training doctors to be more empathetic can be tricky, said Danielle Ofri, a physician at Bellevue Hospital and associate professor of medicine at New York University School of Medicine, but she maintains that training health care professionals in the skill is a key part in not just boosting patient satisfaction, but also adding meaning to a chaotic system.
"It's pretty fundamental (to the practice of medicine) to care about our patients as people. Otherwise, medicine could be practiced by a computer. You could type in your symptoms and get a prescription," she said. "There's a big difference between getting cured and being taken care of."
Emphasizing patient satisfaction
Ofri knows first-hand that empathy is easily lost in the chaos of a hospital.
A self-described "people person" who loves hearing her patients' stories, Ofri still goes entire shifts without asking anything beyond, "How are you feeling?"
"The last time I worked in the clinic, I was so busy that I hardly had time to renew medication, let alone ask questions about people's lives," said Ofri, whose book, "What Doctors Feel: How Emotions Affect the Practice of Medicine," was published in 2013.
After shifts like that, she regroups, reminding herself that being empathetic can be as simple as putting her hand on a patient's shoulder or referencing a note she made during their last visit about a family member or a knitting hobby.
"I wish I had an hour with each patient, but even just noticing if they had a haircut, got a new job or lost a few pounds is money in the bank for when you have to face bigger, harder issues," she said, adding, "It's about recognizing their life outside of the hospital. … Three or four times a year for 15 minutes they're a patient, but they're always a person."
Helping patients feel comfortable by asking about their family or giving them time to explain their concerns is quickly becoming an essential part of medical practice, said Helen Riess, director of the empathy and relational science program at Massachusetts General Hospital and chief scientific officer for Empathetics, an organization that provides empathy and interpersonal skills training for health care providers.
She said the focus on empathy is driven by health system leaders, who have a lot of money at stake in patient satisfaction scores.
The Affordable Care Act altered the Medicare reimbursement process, allowing the Centers for Medicare and Medicaid Services to withhold 1 percent of overall filings and then redistribute it based on performance and patient experience.
"Roughly $1 billion is withheld every year, and 30 percent of that amount can be earned back through good patient satisfaction scores," she said. (The other 70 percent is distributed based on clinical process and outcomes.) "There's a very large dollar amount hanging on good communication."
And it's not just national regulations driving the conversation about empathy, Wanner said, noting that today's age of online reviews and social media has raised patient expectations.
"A lot has changed in the last 10 years or so. Health care is a much more consumer-oriented field than it was in the past, because people can shop around. They have a lot of options," he said.
Barriers to change
Reimbursement adjustments and patient expectations have energized efforts to bring more empathy to the health care system.
There are providers who resist the trend, questioning whether interpersonal skills can be taught and why busy doctors — many of whom spend less than 10 minutes with each patient — should prioritize an exchange of pleasantries, Riess noted.
"Most people are pretty receptive, but there are some that still believe you can't teach empathy," she said.
This skepticism can lower the motivation to practice new techniques, even if they're as simple as maintaining eye contact and clearly explaining your role in the patient's treatment, Wanner said.
"When I work with people who aren't motivated, I can give them tips and advice, but the impact is going to be limited," he said.
According to Wanner, resistance is more common among older doctors.
"In general, there is more enthusiasm for this concept among younger physicians," he said. "I think younger folks have been trained under a shifting paradigm that involves different ways of looking at … patient issues and experiences."
However, skepticism can also be motivated by doctors' relationship to their work, Wanner noted.
"(Burnout) makes it very hard for people to show empathy and muster the energy to care as much about what the patient is feeling," he said. "When you're working 80 hours a week, listening to all of a patient's concerns takes a lot of effort."
Even health care providers who are open to enhancing their emotional intelligence can struggle because it's awkward to try new approaches with patients, noted Brian Boyle, author of "The Patient Experience: The Importance of Care, Communication and Compassion in the Hospital Room."
In 2004, Boyle, then 18, was in a serious car accident that put him in a coma for more than two months. During his recovery he worked with a wide variety of care providers, connecting with some while trying to ignore others who coldly used words like "vegetable."
"When you come into a room, the patient is engaged with your presence and body language," he said, noting how unsettling it is when a doctor seems distracted or uncomfortable. "You have to create a positive energy around the patient."
In writing and speaking about his experience, Boyle highlights the work of the best members of his care team, who practiced both quality medicine and open communication.
"They became part of my family in a lot of ways, supporting me and encouraging me," he said, noting that the bonds remain strong. Many members of his care team attended his wedding a year-and-a-half ago.
Over the past few years, Boyle has delivered more than 150 keynote presentations to health care organizations, describing his experience as a patient and helping doctors approach communication in new ways.
"The first question I had (at almost every event) was, 'Brian, what can we do differently to help patients?,'" Boyle said, noting that a willingness to be more empathetic needs to be met with helpful strategies.
At the University of Utah, Wanner combats the potential awkwardness of trying to be more empathetic by encouraging each doctor to do what feels natural for them.
"You have to use a style that works for you," he said. "Some clinicians use humor a lot, but others aren't good at that and would get in trouble if they tried. Some people are more comfortable holding the patient's hand or putting a hand on his or her shoulder.
"One of the things I tell people is that if you don't feel comfortable (using a particular strategy), you probably shouldn't be doing it," Wanner added.
Beyond his focus on being a good listener, Wanner said his empathy style involves "finding little opportunities to connect with people." He comments on a patient's shirt if it advertises a sports team he likes, or asks about "Get Well" flowers.
Through Empathetics training, Riess highlights strategies like these and equips health care providers to recognize nonverbal signals so they can form an emotional bond with a patient through a strategy that's not only natural, but appropriate.
"We do a lot of skill-building around non-verbal communication and facial expression decoding. … There's an emphasis on distinguishing whether someone looks like they understand or if they're angry or disgusted," she said.
The program also emphasizes curiosity, coaching doctors to ask open-ended questions and let patients share their experience before interrupting with data points or a potential diagnosis.
In a 2012 study published by the Journal of General Internal Medicine, Riess and her co-authors showed that just three 60-minute training sessions on empathy can boost a doctor's patient ratings. More than 90 percent of the 54 participating health care providers told researchers that the classes helped them manage reactions to challenging patients, interpret non-verbal cues and become better listeners.
Overall, the Empathetics approach is about being present with a patient, offering your full attention when you might usually be looking through medical files or updating a digital record, Riess said. It might require extra time when a doctor first meets someone, but it's designed to save resources in the long run.
"When you put in extra time and build a more solid relationship, you won't be getting phone calls or the unnecessary appointments that happen when someone feels upset or unheard," she said. By being empathetic from the beginning, doctors can enjoy meaningful, trusting relationships with each patient.
Continuing the trend
At the beginning of May, Riess stood before 5,000 leaders from the Long Island Jewish Health System in Madison Square Garden, delivering the keynote address at a conference titled "Empathy: The Cornerstone of the Patient Experience."
"This is a dream come true," she thought to her self, amazed at how awareness of the importance of empathy has grown in just a few short years.
"I saw the degree of passion and commitment and leadership going into making the whole health care system more empathetic," Riess later remembered. "It gives me goosebumps just thinking about it."
Riess experienced on a large scale what Ofri and Wanner see in individual exam rooms: the power of empathy. All three doctors were optimistic that the recent emphasis placed on patient satisfaction would continue.
It's not just health care systems and their budgets that benefit from an ongoing focus on empathy, Ofri noted. She's passionate about the way serving a patient's emotional needs adds meaning to a doctor's daily life.
"The (medical) mandate is to care for the whole person, not just the stomach or heart," she said. "We can have fun getting to know each patient."
And in the process of connecting with patients, doctors can take better care of themselves, Wanner said.
"Burnout is a major problem in health professions. The hours are long and the pace is fast," he said. "Regardless of how important you think (empathy) is for the sake of the patient, it's really important for you."
Emphasizing empathy helps a doctor do his or her job better, which enables patients to thrive, Wanner said, noting that his own effort to stay quiet and let his patients ask questions isn't revolutionary, but makes a big difference in the long run.
"It's very important for patients to feel they are listened to, respected and valued as individuals," he said. "And I think that if we don't do that as health care professionals, we're not giving patients the care they want and deserve."
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