Empathy for Clinical Exams

This post may seem a bit random given that I’m still on my BSc year. I’m currently tutoring a group of students in the year below in OSCE skills and I’m doing a much-requested session on empathy, since all I do is complain that they are as empathetic as tea-cups when we practice taking histories. (I’ve actually never said this, but will do so next session, now that I’ve thought it up.)

So, empathy is a really important aspect of patient interaction that my medical school likes to bang on about. During our pre-clinical communication skills teaching there was an emphasis on showing empathy towards the patient and in our clinical exams, there are marks for showing empathy. There is an absolute need for every medical student to make at least one ’empathetic statement’ during a patient interview.

This is something that I had trouble with. That’s not to say that I’m not empathetic, but it can be quite hard to show empathy in the right way, and you need to be able to choose the right words in which to express it.

Also, showing empathy towards a real patient that is really suffering with their health is different to pretending to feel sorry for someone that you know is only faking abdominal pain for exam purposes.

So, here are some tips* on displaying empathy and generally niceness- mainly for history-taking during clinical exams.


 

ICE– this is an acronym that is ubiquitous in my medical school (probably others too).

 

Ideas do you have any thought as to what might be causing this?

Concerns is there anything that is particularly worrying you?

Expectations- is there anything in particular you’d like for us to do for you today? (close the interview with this)

 

-This does not have to be done at a particular point in the history. I usually like to do it after exploring the history of their presenting complaint, so I don’t forget. But if they mention a concern or worry earlier, then you should definitely probe that as soon as they do.

 

Worried Patient: The cough started last week. It hasn’t stopped since. It’s really worrying me.

Nerdy Student With No Social Skills: Okay, and do you cough anything up?

Still Worried Patient: Some phlegm and one time a bit of blood.

———————————————————————————

Worried Patient: The cough started last week. It hasn’t stopped since. It’s really worrying me.

Empathetic Student: What in particular is worrying you?

Worried Patient Who Feels Listened To: It’s just that, I was reading online to see what this cough could be, and I read that a long-lasting cough and coughing up blood are signs of lung cancer.

 

Responding to their concerns– this can be difficult to put into the right words when you are put on the spot, but it is important to reassure the patient. They might say they are worried that they have lung cancer and you can’t just hear that and say nothing.

 

Here is a speech I wrote out, and I used variations of this during my history taking:

I understand that this is something that is troubling you and that you are worried and thank you for sharing that with me, but you did the right thing is coming in today. We’re going to do our best to do the necessary investigations to get to the bottom of this and deal with whatever it may be. But in the meantime, I’d like to ask some more questions about your health, so I can get a clearer picture of what might be going on and then we’ll take things from there. Is that ok?

 

Responding to a request for an instant diagnosis- a lot of patients will share what they think they have and then they will ask you, the poor medical student without a clue of what this wretched cough means- do you think it is cancer? This is a trick question. Do not answer.

 

Worried Patient: Do you think it is lung cancer?

Nerdy Student With No Social Skills And An Inability To Interpret Humour: I will not answer.

 

Not what I meant.

But seriously, if you say no, the patient is happy but there is still a chance that they will have cancer, even if you think it is miniscule, and then they will be very angry at you for giving them false hope. If you say yes, you completely scare them and they may not actually have cancer. Now, unless you have super X-ray vision, you don’t know. So, convey all that to the patient as empathetically as possible.

 

Worried Patient: Do you think it is lung cancer?

Empathetic Student: Whilst I do understand that this is something that you are worried about, there are lots of things that may cause a cough and it would be wrong of me to make a guess at this stage as to what you may have without us carrying out all the necessary tests to give us more information. But rest assured, whatever you have, we will ensure you get the appropriate treatment and are properly looked after.

 

Responding to death- often patients will talk about deaths of loved ones. It can sometimes feel awkward when they do, and you might not know exactly what to say.

 

Things you can say:

I’m sorry to hear that.

Would you like a minute? (if they seem visibly upset and you want to move on with questions)

I’m sorry to have to bring things up and I understand that this may be difficult for you to discuss, but if you don’t mind me asking… (If you need to ask for further details)

 

With responses, you need to somehow judge how impactful the death was. You don’t want to overdo it for an uncle that died twenty years ago of a heart attack in comparison to a parent that died the previous year.

 

Responding to pain- sometimes patients may be in a lot of pain when you are talking to them and this also needs to be treated empathetically.

 

Things you can say:

Always check for pain at the start of the interview/examination 

Before we begin, are you in any pain today Katie?

Offer analgesia

Would you like any painkillers for that or are you ok to continue?

Let them know they can stop any time

If the pain gets too much or you feel uncomfortable for any reason, just let me know and we can stop and do something about it.

If they are talking to you whilst in pain:

I do appreciate that you are in a lot pain at the moment and I’m really sorry about that, but if you could try your best to answer my questions, this will help us get a clearer picture about what’s going on.

 

Exploring sensitive/personal information- that is things like weight, sex, menstrual cycles, recreational drugs etc. And also slightly gross topics like vomit, bowel and urine habits.

 

Things you can say:

Always signpost the questions

I appreciate that these questions may be a bit sensitive/uncomfortable but if you could answer as best as you can that will be very helpful.

If you don’t mind me asking, I’d like to ask you a bit about your weight.

This may be a bit personal, but could I ask whether you have had any recent change in sexual partners?

 

General communication points:

 

-Check for their preferred name at the start and use it throughout

-Do not interrupt them (I am very guilty of this)

-Use pauses and silences effectively i.e. pause when they share sensitive information such as concerns

-Tone and body language can also help convey empathy

-Try not to talk too fast (again, guilty)

 

That’s not to say that you should fake the whole thing, but for exams, especially when you are so focused on making sure that you ask all the right questions and that you can get the diagnosis, it can be easy to forget to connect with the patient. Especially, when you know they are not real patients and the information they give you is an act.

In all honesty, the whole exam is pretty much an act. The history patients are professional actors with scripts. If you do get real patients for examinations, the situation under which you examine them is still an act. So, as a medical student your task is to do a very good job at being an actor.

You need to act like a confident medical student that really cares about these fake situations. Some students are better at this than others. When I OSCE tutor, two students** will say the exact same thing. ‘I’m really sorry to hear that.’ One sounds really flat and practised and the other sounds genuinely sorry to hear that. You can’t just say the words, you need to say them like you mean them. Empathetic tone. Empathetic body language.

 

*These are all examples of the types of responses you can give. Not exactly model answers, just things that I find work for me. I would suggest thinking out your own responses for these situations. 

**If my OSCE tutees ever stumble across this blog, I am not saying who is who. Don’t even ask.

 

 

 

 

 

 

 

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