The different faces of empathy in cancer care: From a desired virtue to an evidence‐based communication process

Empathy lies at the heart of cancer care but historically has been seen as an art, not science, lacking a clear operationalization and evidence base. In the current issue of Cancer, Sanders et al furnish the building blocks of empathy from a patient perspective by presenting the results of a qualitative study into cancer patients’ perceptions of empathy. This important endeavor has not yet received much explicit attention. Sanders et al describe tangible empathic behaviors, including clinicianpatient “relationship sensitivity” (eg, listening), “focus on the whole person” (eg, asking what matters most), “communication” (eg, smiling but also clear information provision), “clinician attributes” (eg, being friendly), and “institutional resources and care processes” (eg, teamwork and being on time). Although the simplicity of the survey design chosen by Sanders et al is elegant, it also has its limitations. First, we cannot rule out that patients described attributes of a “good doctor” rather than specifically of “empathy. ” The validity of the results would have been strengthened by indepth qualitative followup interviews. Second, although the study revealed patient perceptions, it remains unclear whether the perceived behaviors affected patient outcomes. Observations of consultations and postconsultation patient evaluations might have demonstrated the effect of empathic behaviors on patientreported outcomes. That being said, some of the empathic behaviors found in this study by Sanders et al are already advocated and taught by leading communication platforms such as Vital Talk and Ariadne Labs, and they have indeed been shown to improve patientreported outcomes. According to a recent systematic review, clinician empathy training should teach 1) verbal statements of acknowledgment and validation (“this has been hard for you”), 2) nonverbal caring behaviors (sitting vs standing and eye contact), and 3) detecting and responding to patients’ cues (for which the NURSE acronym can be helpful: naming, understanding, respecting, supporting, and exploring; eg, “tell me what is going through your mind”). Indeed, empathic behaviors mentioned by Sanders et al, such as attentive listening, eye contact, and responding to emotions, can improve patientreported outcomes such as satisfaction and information recall (eg, Visser et al, Hillen et al, and Uitterhoeve et al), whereas sitting can positively influence patients’ perceptions of time and of the consultation. Two empathic behaviors mentioned by Sanders et al deserve special attention. First, paying attention to what matters most to an individual patient is perhaps the most important empathic expression in cancer care. In advanced illness, this is seen as the route to truly patientcentered care and as an effective way to decrease patients’ anxiety levels. Second, and relatedly, offering support and continued care is crucial. Patients confronted with a serious illness can fear abandonment by their clinician, especially when the illness progresses. Reassuring statements about nonabandonment, such as “We will do, and will continue to do, our very best for you,” decrease feelings of anxiety and uncertainty and are advocated by the American Society of Clinical Oncology communication guideline. We, therefore, did not share the surprise of Sanders et al at their finding that patients perceived declarations of accessibility as empathic. However, we do share the authors’ concern about the keeping of such promises in busy clinical practice. For patients, little is as harmful as the breaking of promises of continued care. One way to ensure nonabandonment might be to designate a key provider (eg, a specialized nurse) who is continuously involved in the cancer trajectory. In addition to highlighting several empathyassumed behaviors, the study by Sanders et al seems at first sight to challenge a distinction between informationoriented communication and clinician empathy– oriented communication. Patients are thought to have 2 distinct needs in medical consultations: a need to know and a need to feel known. These needs can be satisfied by the provision of information and empathy, respectively. In the study in question,