In general, the students commented on both the worry and the anger/frustration situations in the recall interviews. All students mentioned both the factual details about the patient’s situation and the patient’s emotional reactions to the events the patient had gone through. When asked about their own experiences during the medical interview however, students often found it difficult to remember or articulate what their own emotional reactions were. Generally, the patient’s situation was described in the recall interviews with more general terms such as “understandable” or “recognizable” and students only occasionally reported having shared the patient’s emotional experience or having felt empathic concern for the patient such as being touched, being moved, feeling sorry for, or feeling compassion or sympathy. Most students remarked how the patient was easy to talk to and that she was willing to share. Many of the students thought that the patient’s emotional concerns were uttered because the patient had a need to vent her feelings. The patient’s willingness to share was in most cases interpreted as a sign of trust or good chemistry.
Through our analysis of the students’ perceptions, experiences, and reflections in the recall interviews, the six following key themes emerged: (1) Giving priority to medical history taking, (2) Interpreting the patient’s worry as lack of medical information, (3) Conflicts between empathy and professional identity, (4) Empathy as a technical communication skill, (5) Striving for a professional form of empathy and (6) Disagreements on whether communication of empathy must be heart-felt. The results presented below are structured according to these themes. Since there is some overlap between the themes, some results could be presented/categorized under more than one theme.
3.1. Giving priority to medical history taking
Some students reported that their attention was primarily directed at remembering and completing the different tasks of the medical history taking and that they therefore were disrupted from or became inattentive to the patient’s ECs. This included focusing on the list of mandatory questions in a medical interview such as questions on hereditary diseases; finding out what to ask for next and covering all the different parts of the standard medical interview. Susan reported during an interview that she thought to herself:
…medical history, medical history, medical history, now suddenly I’m a doctor [ …] I was actually a bit preoccupied with remembering what I should ask about. And when she started bringing up the thing about the father having cystic kidney disease, it was sort of an OK transition into asking about hereditary diseases.
Sometimes, the patient’s emotional concerns were interpreted as information relevant for further medical interviewing. James told how “the student or professional in me woke up” when the patient told of bad sleep lately. As it is a typical symptom of depression, he started thinking about a scale for diagnosing depression. This distanced him a bit, he felt. He tried to do the right thing in asking about her emotional or mental health. Consequently, he felt like he dealt with the situation a bit more schematically and rationally, rather than being open and empathic, and he hoped that the patient wouldn’t notice the change in him.
3.2. Interpreting the patient’s worry as lack of medical information
When interviewed about what influenced their responses to the patients, students often reported having interpreted the patient’s emotional worry as a concern which could be handled with medico-professional help or advice. Students tended to think that the patient’s concern about the future was caused by a lack of medical information. Consequently, they saw it as their primary task to offer expert information or advice or offer reassurance in response to patient’s emotional worry. This interpretation of their role influenced student responses in a number of ways.
Some refrained from providing medical information or advice as a response since they felt they lacked medical competence, knowledge on prognosis, or were not yet in the proper professional role. Hannah wanted to say to the patient that she might not experience the same thing as her father but thought that she did not know enough about the disease to do so. She did not know how far she could go in reassuring the patient without doing this on false premises. Instead, she said she protected herself by saying as little as possible.
Others used themselves as a reference and provided advice or reassurance the way they would have liked to receive it themselves, if they were the patient. For example, Susan felt that the patient was not informed sufficiently well and did not know what was going to happen next. She herself would have wanted more information. Consequently, she replied to the patient: “Maybe it will be better once they start a proper treatment and you become more aware of the situation”. Later in the mini interview she added that she was very aware about not answering about things like prognosis. She felt that she was on thin ice and did not want to say anything wrong.
A few students considered themselves competent enough to give medical information. Jack found an opportunity to give advice. At a point in the interview, he felt that the patient was conveying worry about potential transplant surgery, but also uncertainty about what surgery meant. He felt a need to clear up her expectations in that situation and provided her with information on how not everyone with PKD will need transplant surgery. Still, he did not want to go to deep into the matter since he did not feel like he had the professional competence. He said that this way she can take this information with her to her primary care physician and discuss it with him.
3.3. Conflict between empathy and professional identity
Most students talked about how the frustration scenario placed them in a conflict between identifying with the patient’s perspective and that of the primary care physician. This seemed to result in more limited responses from the students towards the patient in these situations.
Some students identified themselves primarily with the primary care physician. Susan remembered thinking that she was sitting there as a physician. And as a physician she could imagine that such a thing might happen in a busy professional life. She instinctively felt the need to protect the primary care physician, but shortly after realized that that was not what the patient needed. It was better to just receive the patient’s frustration instead of opposing it. Hannah on the other hand, was unsure and curious about whether a mistake had been made or not. She further reflected on whether she really had to know the truth to express agreement with the patient - maybe she should just agree without knowing.
Other students identified more with the patient. Daniel remarked that her version did sound frustrating, but that he himself did not feel that he had enough knowledge to become angry himself. He did not feel like he could take part in frustration towards a physician he had never met and did not have a personal relationship with. Michael mentioned that he recognized the picture she was painting; he had heard similar stories before. Michael however, felt that that this was not right, it was not supposed to be that way, and that affected him. Emma mentioned how she recognized the situation the patient was in from her own life. She herself had experienced how it is to have a sick father. This made her more able to understand the situation the patient was in. She added that she would have asked more about whether the patient’s experience affected her trust in the health-care system if she had more time or was her actual physician.
3.4. Empathy as a technical communication skill
When commenting on attempts to communicate understanding or interest back to the patient in the videos, students usually used technical terms to describe how they responded to the patient such as through active listening and facilitation. It was important for them to find ways to let the patient talk about her feelings and show to the patient that they indeed had understood what was being said to them. Susan told of how she in one situation, when the patient spoke of her father’s condition, tried to be supportive without saying too much, to “facilitate” the patient a bit. She remarked that she mostly just nodded and said “yes” and was trying to seem “professionally understanding”. According to her experience, as long as you show that you understand – even very briefly - it is ok - and she hoped that the patient saw that she listened. She adds that maybe you do not have to verbalize too much, and that often if you do that can be awkward. Emma described facilitation as a good conversational technique since you can show empathy without really feeling anything yourself. She added that there isn’t necessarily anything wrong in that, since there is no way to tell that the patient knows that you are being honest or not. She herself thought that all physicians were honest and sincere before she started medical school and learnt about conversational techniques and facilitation.
Other students talked more of empathy as a tool or technique in clinical practice. Michael claimed that as a clinician you use empathy consciously as a tool to achieve something. In real life, i.e., as a “normal” fellow human, empathy is more real. He mentions that maybe you use it a bit artificially in clinical situations even though you are supposed not to. And although you might do a bit of play acting and is extra understanding to achieve something - to provide the feeling of safety or to get more information - he says it is important that it does not turn fake either.
3.5. Striving for a professional form of empathy
Many students were critical of their own behavior. Students often said that they would try to show more understanding or empathy if they had the opportunity. Many students told of difficulties knowing what to say and especially what would be the right things to say as a professional, and this uncertainty seemed to result in the students being more reticent towards the patients. Mary remarked that the patient was trying to say that she was not happy about her father’s physician since her father’s diagnosis came too late and was worried that the patient had already lost trust in the health care services. The student thought “[name of clinical communication skills teacher], what do I say now?”, and wondered how she was supposed to convey to the patient that she understood what the patient was saying. Hannah reported that she did not know if she was allowed to ask the patient the questions, she was really curious about, since she was afraid these questions would be too personal. This made her feel like a coward, like she was tied up. She felt this was not right, but at the same time she could not cross the line over to the more personal level like she wanted to, and say that this is going to work out, maybe even touch her physically with her hand, and say things like “you seem like a strong woman”. She chose to suppress these impulses because she felt like she had to be professional. She said that she has learnt in medical school that if you freak out, then the patient will freak out as well. She further adds that you are supposed to be sensitive and empathic in a professional manner, but that she does not know how, since she has never been professionally empathic in her life.
3.6. Disagreements on whether communication of empathy must be heart-felt
When interviewed more generally on the role of empathy after the video-stimulated recall session interviews, students disagreed on whether one really had to be authentic or sincere to communicate empathy. Susan said she thinks patients catch onto “fake empathy” very quickly – i.e., the physicians who do not feel any kind of empathy but still say they do. This will, according to Susan, only be attempts at empathy, but not real empathy, more like a “textbook”-form of empathy. She further added that the empathy must be real-felt- you have to feel that the person cares and understand – both emotionally and cognitively. If not, it does not matter what you say. You are supposed to try to understand the patient and want what is good for the patient - that must always be a core concern. James reported that he feels guilty when he does not react emotionally. He thinks it is a virtue to meet patients with an adequate level of empathy and compassion and express it. On the other hand, he also claimed that it does not matter to the patient what the physician feels. Mary reported that she is afraid to say things that sound “made up” since you contradict yourself in saying that something is sad to hear and then just move on by changing the topic of the conversation.
Finally, a few students found it ok to communicate empathy unrelated to what they themselves experienced. Jack claimed that you can think whatever you want inside your head as long as you respond and act in a way that shows you are trying to understand, even though you do not. Susan said she found the patient’s story sad when reviewing it, but when asked if she could remember what she actually felt during the medical interview, she revealed that she entered a role – she distanced herself and did not feel the reality of it there and then.