EMPATHY: HOW IT SHOULD BE TAUGHT IN MEDICAL SCHOOLS
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MODEL CURRICULUM
INTRODUCING THE CURRICULUM
• The main motivation for medical ethics programs is to focus
and train the new academicians, bureaucrats, and legal
experts who are needed to cater to the growing demand for
technical aspects of knowledge in bioethics.
• Whereas knowledge and competencies are the primary goals
of formal medical training, an understanding of professional
values and ethical conduct is essential for fostering the
development of a good doctor.
TEACHING MEDICAL ETHICS
• Various methodologies:
o conventional lecture method
o group discussions of case studies and narratives
o problem-based learning
o audio-visuals and films
• Sessions should be designed to be as interactive as possible
• Maximum student participation must be encouraged
• Student reactions could be summed up to highlight a principle
or compare differing viewpoints
• When medical ethics is taught by clinicians, it has an
advantage because they not only use clinical language, which
is closer to practice but is also readily acceptable by students.
TWO VIEWS OF ETHICS
• Standard ethics help to guide behavior, actions, and choices
can be viewed from two angles: normative & prescriptive.
• Normative - well-based standards of right and wrong that
prescribe what humans ought to do in terms of rights,
obligations, benefits to society, fairness, and specific virtues
• Prescriptive - the study and development of ethical
standards, as well as community ethics.
CHALLENGES
• Various ethical dilemmas and moral conflicts in both medical
care and clinical research may arise in daily medical practice
and can drastically affect medical professionalism.
• There may be number of ethical issues that can cause
physicians difficulty in clinical practice and can lead to errors
in physician's judgment in various aspects such as:
o Confidentiality
o Taking informed consent
o End-of-life care
o Breaking the bad news in difficult situations
OUTCOMES
• Studies have shown that teaching Medical Ethics can result in
improvement in physician confidence, knowledge, ethical
analysis skills and patient satisfaction.
• Studies done on practicing physicians who had completed
some training or course on Medical Ethics have also shown
that there is an increased awareness and understanding of
various bioethical issues and better management of patients
during clinical dilemmas.
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• In conclusion, it can be an expectation that teaching medical
ethics in curricula in medical schools will produce better
young doctors who will be good managers of healthcare
resources, advocate for patients and may be leaders for
organizational change.
CASE: G.R No. 203080
A complaint for grave misconduct against Dr. Idol L. Bondoc
(Petitioner) by Marilou R. Mantala (Respondent)
Marilou Mantala was about to deliver her fifth child and was
advised in Bansud Municipal Health Office (BMHO) to undergo a
cesarean section due to a macrosomic fetus and polyhydramnios.
She started labor at 7AM and was initially brought to Bongabon
Health Center before she was admitted to Oriental Mindoro
Provincial Hospital (OMPH), with referral from (BMHO), at 11AM on
April 3, 2009.
While in the delivery room, she was attended by Dr. Bondoc
accompanied by a midwife and two other assistants. The doctor
instructed to press down on the patient's abdomen while also
demonstrating how to insert their fingers into the vagina.
The doctor and his assistants left the room thereafter while the
patient labored in pain with intermittent stiffening of her abdomen.
At this time, Dr. Bondoc was operating on another patient. Dr.
Fabon, also attending this other patient, heard his remark on
Marilou's condition, saying,
"Meron pa nga kami sa DR macrosomia, polyhydramnios pa, pero
paanakin nalang 'yon. Abnormal din naman ang bata kahit
mabuhay, kawawa lang siya."
Dr. Bondoc proceeded back to the OB ward after operation.
The doctor returned later at 4PM and remarked, "Hindi ka pa
nanganak?"
The patient, intolerant of the pain, requested a cesarean section
but was DENIED.
The midwife arrived shortly and reprimanded her for not sleeping
and bracing the steel bar. Together with the assistants, the midwife
pressed down on her abdomen again which caused excruciating pain.
on her ribs. They repeated this until the baby and the placenta was
delivered.
At 8:15PM, the patient was forwarded to the OR for Emergency.
Pelvic Laparotomy with a diagnosis of T/C Ruptured Uterus. Dr. Fabon.
was also attending to the patient and again heard another remark by
Dr. Bondoc,
"Pinilit no'ng tatlong ungas, ayon lumusot pero patay ang bata,
tapos ito, mukhang pumutok."
The patient regained consciousness later in the recovery room
and learned about the operation. Not only was she depressed by the
loss of reproductive capacity but also by the news of her stillborn
baby.
She was transferred to a ward the next day. Patient noticed her
swollen vulva and an open surgical wound with liquid squirting from
it, although nurse regularly dressed the wound.
On April 9, she was discharge despite still having sutures on her
wound and an active cough. Dr. Bondoc prescribed antibiotics, cough
medicine, and multivitamins upon discharge.
Two days after discharge, the patient's surgical wound widened,
and she was brought to the Bongabon Community Hospital wherein
she was advised that the wound should be re-stitched by Dr. Bondoc.
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 On April 14, patient went back to OMPH but was attended by Dr.
Gonzales who dressed her wound which was full of pus and said
"problema ito ni Bondoc."
After undergoing a blood transfusion on April 18, Dr. Bondoc re-
stitched her wound, but Dr. Gonzales would follow-up on her
condition thereafter.
Dr. Bondoc removed all but leaving three sutures on April 27. The
day after, Dr. Bondoc said, in a threatening tone,
"lkaw ang sadyang ayaw magpa-CS!" He also introduced the
nurse on duty, "Papermahin mo si Mantala, pauuwin ko na 'yan
bukas. Tanggalin mo na rin ang tahi."
He further commented, "Huwag sana akong idemanda ni
Mantala kasi kaya ko siyang baligtarin." The patient was discharged
the following day with removal of all sutures. However, the wound
was still open and it was her sister who cleaned it.
DECISION: WHEREFORE, judgement is hereby rendered finding
respondent Medical Officer Idol L. Bondoc of L. Oriental Mindoro
Provincial Hospital (OMPH), Barangay llaya, Calapan City, Oriental
Mindoro, guilty of Grave Misconduct.
EMPATHY IN MEDICAL STUDENTS
JEFFERSON SCALE OF EMPATHY (JSE)
• 20-item test specifically developed to measure empathy in
the context of health profession education and patient care
• Administered to health professions students and practitioners
• 3 versions of the SE are available. The one that is used for
administration to medical students is the S-version.
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ASSOCIATIONS OF JSE SCORES TO DIFFERENT PARAMETERS
CLINICAL COMPETENCE
• In a study by LaNoue and Roter (2018), significant associations
were found between self-reported SE scores in third-year
medical students, and observations of empathic
communication pattern with simulated patients, where in
medical students with a higher JSE a have better empathic
communication skills as measured by the Roter Interactional
Analysis System (RIAS).
PATIENT OUTCOMES
• A study by Hojat et al. 2011, showed that patients of
physicians who scored high on the JSE were significantly
more likely to have good control of their disease
(determined by hemoglobin A1c test result < 7.0%, and LDL-C
of < 100) compared to patients of physicians who scored low
on the JSE.
• A study by Del Canale et al. 2012, records of adult patients
with types 1 and 2 diabetes mellitus and acute metabolic.
complications showed statistically significant associations
between physicians' high scores on JSE and lower rates of
patients' hospitalization.
GENDER DIFFERENCES
• In 2003, a study by Baron-Cohen showed that some,
suggested that women's behavioral style is generally more
"empathazing" than men
• Female health professions students and practicing clinicians
obtained significantly higher JSE mean scores than males.
• Several plausible explanations have been given for gender
differences in empathy, including social learning, genetic
predisposition, evolutionary underpinnings, and other
factors.
PERSONALITY MEASURES
• A study with medical students of Hojat et al. (2005) resulted
that those with higher scores on the JSE were associated with
higher scores on Sociability.
• Scores of the SE have also been linked to the "big five"
personality factors such as Agreeableness, Openness to
Experience, Conscientiousness, and Extraversion in medical
students.
• Evidence showed that a number of personal quality measures
that are conducive to relationship building were positively
correlated with JSE scores including emotional intelligence,
cooperativeness, and desirable professional behavior.
SPECIALTY INTERESTS
• In 2001, Bailey reported that medical students who planned
to pursue a career in specialties requiring extensive and
prolonged encounters with patients received significantly
higher scores on empathy measured by the IRI than those
who planned to pursue procedure-oriented specialties.
• High scorers on the JSE are more inclined to choose "people-
oriented" specialties such as general internal medicine, family
medicine, and psychiatry.
• Low scorers on the JSE would likely be more interested in
"technology/procedure-oriented" specialty such as
pathology, radiology, and surgery.
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 CHANGES IN EMPATHY IN MEDICAL STUDENTS
• A study in Turkey showed that there is a decrease in empathy
throughout the years of medical school education (Igde and
Sahin, 2017)
• The third year is typically when students often deal with
emotionally challenging and difficult situations while rotating
through various clinical clerkship, their empathy declines as a
protective defense mechanism
• However, a study in Australia showed that there were no
significant differences in empathy scores in relation to the
stage of medical training (Hegazi et al, 2017)
• Their findings suggest that there is a gender difference in the
levels of empathy, favoring female medical students, and that
empathy levels may be preserved in medical school despite
prior evidence that a decline is pervasive.
• In the study, "Revisiting the trajectory of medical students'
empathy, and impact of gender, specialty preferences and
nationality: a systematic review," 30 studies were included
and the results revealed equivocal findings concerning how
the empathy level among medical students develops across
numbers of educational years and how empathy levels are
associated with gender, specialty preferences, and
nationality. (Andersen et. al. 2020)
• Further researches should be conducted focusing on how
students' empathy is displayed in clinical settings, e.g. in
clinical encounters with patients, peers and other health
professionals.
CASE: EMPATHY IN MEDICAL EDUCATION
On December 31, 2007, 39-year old Jan Jan (pseudonym), a gay
man from Cebu, a Philippines, had a sexual encounter on his way
home from party, during which a perfume canister was inserted into
his rectum allegedly without his knowledge or consent, requiring him
to have surgery.
On January 1, 2008, Jan Jan went to the Vincente Sotto Memorial
Medical Center in Cebu where rectal surgery was performed to
remove the canister. A nursing student videotaped the procedure
and posted the video on YouTube without Jan Jan's knowledge or
consent. The videotape shows hospital personnel laughing and
making jokes at Jan Jan's expense
Jan Jan knew nothing about the video until the head of his housing
ward/district, Barangay Captain Dave Tumulak heard out about it,
investigated, approached the hospital, got the video, and showed it
to Jan Jan. Tumulak helped Jan Jan file an affidavit and found him an
attorney.
Jan Jan has been devastated by the experience. "I trusted them
and yet they ridiculed me. Was that something a professional would
do? 1 can't even walk on the streets without being laughed at by my
neighbors. I want my ordeal to end. I hope it doesn't happen to anyone
else."
The Philippines Department of Health has a standing policy that it
must pre-authorize any documentation of medical procedures on.
film, even before a patient's consent is requested. However,
Magdalena Lepiten, of Lepiten and Bojos Law Office in Cebu and
executive director of GAHUM 1 does not believe this case is about
privacy or consent. "Even if there was consent to being videotaped by
the hospital, the filming was clearly outside professionalism. It shows
clear malice. That's why even the heterosexual public is so outraged."
ALLEGATION: Unprofessional and Inappropriate conduct made
during the surgery resulted in patient's emotional distress.
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DISCUSSION
Patient
• Emotionally distressed
• Patient was in vulnerable position
• Privacy was invaded
• Patient's experience must have been traumatizing
Healthcare Worker
• Treated the patient with disrespect
• Acted Unprofessionally
• Broke the trust between healthcare worker and patient
relationship
• Insensitive towards the feelings of the patient
The healthcare workers should have "put their feet in the
patient's shoes" and thought of what the patient might have felt from
their mockery. As physicians, it is important that we are sensitive of
our patients' feelings and emotions and make them feel that they are
not being judged of whatever circumstances that they are In.
Several research demonstrate that empathic doctors tend to
diagnose diseases more accurately and patients with empathic
doctors feel more trust, participate in decision making, and show
greater adherence to medical advices. Using clinical empathy helps
put patients at ease and sets the foundation for a trusting and positive
patient-doctor relationship.
EMPATHY
• Empathy is the capacity to recognize and experience feelings
that are experienced by another.
• It is the recognition and validation of a patient's fear, anxiety,
pain, and worry and the ability to understand patients'
feelings. It facilitate a more accurate diagnoses and more
caring treatment.
• Expressing patient empathy advances humanism in
healthcare - in fact - expressing empathy in healthcare is THE
KEY INGREDIENT to enhancing the patient experience and
patient encounter.
TYPES OF EMPATHY
According to Psychologists Daniel Goleman and Paul Ekman:
1. Cognitive Empathy
• aka "empathic accuracy"
• ability to recognize emotions and feelings of others
• This makes us better communicators - it helps us relay
information in a way that best reaches the other person.
2. Emotional Apathy
• aka "affective empathy"
• ability to share the feelings of another a person.
• Some have described it as "your pain in my heart."
• This helps you build emotional connections with others.
3. Behavioral Empathy
• demonstrating behaviors that acknowledge the
emotional state of others
• In some cases, authors do not recognize this as a separate
type of empathy (from Moral empathy)
4. Compassionate Empathy
• aka "empathic concern" "Moral Empathy"
• considered highest level of empathy
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 • goes beyond simply understanding others and sharing
their feelings: it actually moves us to take action, to help
however we can.
• moral responsibility to act in accordance with the other
person's emotional state regardless of personal feelings
DECLINE OF EMPATHY IN MEDICAL EDUCATION
2017 Survey from Schwartz Center for Compassionate Care
showed is that there is a belief that there has been a significant
decline in emotional support and communication in healthcare
professionals in the past 5 years.
Studies that state various reasons why there is a decline of
empathy in medical students throughout their education, which
include:
• Elitism among medical students in prestigious schools
• Emphasis on detachment and objective neutrality in
• today's current medical education
• Focus on research
• Practice of defensive medicine
Other reasons for Empathy Erosions:
• Response to Authority
• Dehumanization - Denial of a distinctively human mind a to
another person; Used to justify slavery and other crimes
against humanity
• Deindividuation - Doctors as a sea of white coats; patients as
half-naked bodies in smocks, identified by their disease
procedure.
• Mechanization - Breaking the body into organs and systems.
• Moral disengagement - Some actions require inflicting
suffering.
TEACHING EMPATHY
FOCUS OF TEACHING EMPATHY
• Cultivating Relationships
• Use Sensitive Language
• Developing a deeper understanding of their patients
CLINICAL DETACHMENT OR DETACHED CONCERN
• is the ability to distance oneself from the patient in order to
serve the patient from an objective standpoint.
• However, research shows that patients value affective
concern as much as technical competence. Several researches
demonstrate that empathic doctors tend to diagnose diseases
more accurately and patients with empathic doctors feel
more trust, participate in decision making, and show greater
adherence to medical advices. Using clinical empathy helps
put patients at ease and sets the foundation for a trusting and
positive patient-doctor relationship.
• With these being said, it is vital for clinical empathy to be
taught in medical schools.
APPLICATION
To combat the current lack of empathy amongst healthcare
professionals, medical schools are implementing required academic
programs.
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COLUMBIA UNIVERSITY - NARRATIVE MEDICINE PROGRAM
• emphasizes the importance of patient's personal stories when
it comes to delivering comprehensive care
• recognize, interpret, and incorporate the patient's vigorous
plights and circumstances when designing a health care plan
DUKE UNIVERSITY - VITAL TALK PROGRAM
• In this program, simple advice is offered, such as maintaining
eye contact or making sure that appointments where bad
news will be delivered are scheduled at the end of the day.
• Students learn and practice delivering serious news and goals
of care conversations with seriously ill patients and their
families in a community of peers, led by specially trained
facilitators
STANFORD UNIVERSITY - STANDARDIZED PATIENT PROGRAM
• Paid actors called "standardized patients," interact with
medical students in a simulated clinical environment.
• The is program is designed to assess the students on their
communication skills, diagnosis accuracy, social and cultural
awareness, and overall level of compassion.
• This allows students to begin learning how to create crucial
connections with their patients early.
DAVAO MEDICAL SCHOOL FOUNDATION INC.
• Although face to face classes are not possible at this time, the
breakout rooms provide an avenue for the preceptors to
share personal experiences regarding their practice with the
medical students.
• Lectures on scenarios in Medical Ethics allow the students to
learn about ethical principles, morality of human acts, and
personal duties of physicians toward God, society, and fellow
physicians.
• Proper physical examination techniques as well as
appropriate doctor-patient interaction are discussed during
online meetings. Students record and perform return
demonstration videos and submit them to their mentors.
Mentors are then able to make constructive criticisms to
improve the student's competence.
EMPATHY IN COMMUNICATION AND PATIENT CARE
SIGNIFICANCE OF EMPATHY
• Main ingredient of humane, compassionate care
• According to the natl institute of health it is Defined as the act
of correctly acknowledging the emotional state of another
without experiencing that state oneself
• Builds the patient trust
• Calms anxiety
• Improves health outcome
• "Empathy: one patient at a time, advances humanism in
healthcare"
BUILDING EMPATHY IN PATIENT CARE à ACTIVE LISTENING SKILLS
• Put ourselves in the shoes of the our patient so that we can
see what he sees and feel what he/she feels
• When the patient feels understood rapports quickly built, the
client is more willing to reveal him/herself and the doctor
better understands
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 • With rapport, critical misperceptions of his symptoms that
cause emotional pain, will be revealed by the patient which
can be corrected by the doctor.
o Example: Perception of severe throbbing headache on
one side of the head due to tumor, but in reality it is
just a migraine.
• Adjunct to usual hx and PE. It allow It the doctor more
leverage and flexibility in providing not just rational and
scientific medical management but also compassionate and
empathic care
COMPONENTS OF ACTIVE LISTENING SKILLS
ATTENDING SKILLS
Refers to the way in which we use our bodies to communicate non
verbally that "I am listening to you"
Openness and Understanding
• Leaning forward
• Tilting or nodding the head or raising the eyebrows
• Maintaining eye contact
No Interest
• Leaning backward
• Looking away from the patient
• Crossing one's arms
Avoid Certain Habits of Movement
• Eg. twirling pencils, scratching our heads or tapping our feet
Distance from the patient may be negative or positive factor
• Too close may threaten
• Too far may be interpreted as unwillingness to get involved
Sitting directly in front of the patient may be threatening
• A better angle would be a 45 degree angle, which allows good
eye contact and an option of gazing away from you when the
px needs to
BRACKETING
• This is a mental skill
• Temporarily setting aside one's feelings, thoughts and
judgments in order to hear what the other person is really
saying
• Must not have biases, prejudices and preconceived notions or
assumptions about the situation the person is describing
LEADING
Indirect Leading
• Open invitation made by the healthcare provider for the
patient to talk about that he wishes
• Ex: "What would you like to talk about?" or "What can I do for
you?"
Direct Leading
• Focuses the topic more specifically
• Encourages patient to elaborate on what he is saying
• Can only be used after indirect leading
• Ex: "Kindly explain to me the circumstances that led to your
*chief complaint*"
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REFLECTING
• One way of expressing to the patient that the physician is in
his frame of reference and shares his deep concern
• Three areas of reflecting:
a. Feelings
b. Content
c. Experience
Reflecting Feelings
• Determines what feeling the patient is expressing
• Helps the patient articulate his feelings
• The patient feels understood, rapport with the doctor
increases and the patient feels encouraged to tell the doctor
more
• EXAMPLE:
o Patient: I cannot understand why am having this
headache for 3 weeks now. My grandmother also had
the same thing last year and died of it.
o Doctor: So, you're afraid that the same thing might
happen to you?
Reflecting Content
• Uses paraphrasing and perception checking
o Paraphrasing - the doctor listens and then uses fewer
but clearer words to summarize what the patient said
o Perception checking - when the doctor is not certain if
he understood the patient correctly and would like
confirmation from the patient
• Helps patient express himself clearly by giving him words to
picture out he said
Reflecting Experience
• Descriptive feedback that relates broad observations of the
patient
• The value of reflecting back the nonverbals is that these are
often done unconsciously and thus these patients are not
aware of this
• EXAMPLE:
o Doctor: I notice your hands are trembling. What does
this imply?
PROBING
• utilizes open-ended questions not answerable by yes or no
o prompts the patient to give more information or to
explore a situation that is not clear
o creates a request to become more specific in
situations that are often of an important, sensitive, or
problematic in nature.
• Examples:
o How does that make you feel?
o Can you tell me more about it?
FOCUSING
• identifying what is the most important to the patient
• enumerate the emotions felt by the patient and ask the
patient to choose which one is the most troublesome
• EXAMPLE: “So you feel angry, guilty and frustrated. Of these,
which troubles you the most or is giving you the most pain?”
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INTERVIEWING
• By using an effective interview technique, physicians can
draw out important information from the patient and can
avoid common mistakes during the process
Forms of Communication:
1. Verbal communication
• Makes use of spoken or written words to transfer
information and understanding from one person to
another
• Easier to understand since it is more natural and formal
• No to technical terms and medical jargons (should use a
vocabulary that will be easily understood by the patient)
• No to interpreting and reacting to patient's narrative
statement
• Less possibility of distortion of information
2. Non-verbal communication
• Non-spoken context expressed by other than linguistic
means
• Almost impossible to fake
• Provides important clues to our underlying feelings
• Examples of nonverbal communication:
o Eye contact: indicates sincerity
o Mannerisms: can distract the patients
o Touch: sense of personal relationship with patient
o Gesture: should be done with ease so that it
appears spontaneous and avoid distraction
o Tone of voice: should be modulated
o Posture: lean forward, backward or crossing one’s
arm
3. Symbolic communication
• Describes the external manifestations of both the
patient's and the physicians
• Found in the manner of dressing, hairstyle, lifestyle and
social distance
CHALLENGE OWN PREJUDICE AND STEREOTYPES
• Healthcare providers may encounter undesirable situations
that make them feel uncomfortable. Feeling of discomfort
and awkward situations are inevitable. We encounter
different kinds of people in the hospital and we need to
overcome them in order to do our job effectively.
• We need to challenge our own prejudice and stereotypes, set
aside these preconceived opinions to better understand
them.
• We need to be empathetic and compassionate in dealing
with challenging patients. This is through showing the
patients that we are actively listening to them through non-
verbal communication before we have even said anything.
• Some challenging patients cooperate willingly when they see
that their doctors really care for them.
BEDSIDE MANNERS
CASE 3
• 58 year-old female
• Former smoker
• Began shortness of breath over a 1-2 year period
• Her usual doctor found no abnormalities other than COPD.
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• Dyspnea rapidly worsened and became very noticeable to her
friends
• Cyanotic and severely dyspneic after walking a short distance
• Referred to a pulmonologist and a cardiologist, but to no avail.
DIAGNOSIS
• COPD was deemed the most likely cause despite the rapidity
with which her symptoms developed and despite the fact that
she had quit smoking 12 years before
• Due to lack of response from her previous doctors, she
referred herself to a medical center where a cardiac
catheterization was done
• She was then diagnosed with severe primary pulmonary
hypertension- very poor prognosis - usually only about 4
years, 2 of which had been wasted and untreated, because
her local doctors did not listen to her
TREATMENT
• Prostacycline infusion
• Only given intravenously
• Requires a battery-operated I pump to be carried with the
patient at all times.
• If the infusion stops, the patient immediately becomes
hypoxic.
• Specifically told that the IV line should never be flushed
because too much of the prostacycline would get into her
system too fast.
ER EXPERIENCE
• A few months later, her pump stopped working due to a
defective valve, she noticed the increase in shortness of
breath right away. She went to the local emergency room and
asked that they call the doctors at the medical center to find
out what to do, which they did not do.
• She begged the ER doctor not to flush the V line, which he did
anyway, causing her considerable anxiety. Her blood pressure
dropped and she became light headed immediately.
• Fortunately, her pressure responded to a large fluid bolus and
she did not die, but she could have.
• Then, after the fluid bolus, her bladder quickly filled. She
asked the nurses several times to help her to the bathroom or
to get a bedpan for her.
• 45 minutes passed, during which time she heard the staff
talking, laughing and joking just outside her room. She could
not hold it any longer and finally got up to go to the bathroom
herself. Then she was reprimanded for trying to get up by
herself.
• The ER doctors had no idea how to fix her problem, so after
she was released, she was driven by her daughter to the
medical center 2 hours away. The doctors there found that
the pump had a faulty valve. Once that was replaced, her
pump worked fine again, and she was able to go home.
PROFESSIONAL ETIQUETTE
• Professional etiquette is one of the most important factors
contributing to a successful healthcare career.
• Healthcare involves many personal interactions with a variety
of people. Etiquette in healthcare is more than just good
manners; it is about establishing respectable relationships
with patients, colleagues, and supervisors.
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 • In a medical setting, healthcare professionals must set the TEACH BACK METHOD
tone for the interaction with patients and visitors. They are • A method of assessing whether patient understands the
constantly in contact with people who will assess them based information presented to him/her
on the way they communicate, body language, and • Instead of asking "Do you have any questions", the doctor
appearance. asks questions such as:
• Being kind and empathetic goes long way in gaining a patient's o I want to be sure I explained everything clearly. Can
confidence. A visit to the doctor can be stressful enough you please explain it back to me so I can be sure that I
without having to deal with unfriendly, inattentive, and did?
disorganized medical staff. o What will you tell your wife (husband/partner/child)
• Patient satisfaction can also be improved if patients are about the changes we made to your medications
encouraged to express their ideas, concerns, and today?
expectations. o We've gone over a lot of information today about how
you might change your diet. In your own words,
PATIENT-CENTERED APPROACH please review what we talked about.
• Based on the idea that patients are active participants in o How will you make it work at home?
developing a health strategy for themselves.
IMPORTANCE OF BEDSIDE MANNERS
• This means that both physicians and patients have
responsibilities in communicating information and concerns • Growing awareness of the need for interprofessional
• Most common complaints from patients about doctors: cooperation in healthcare.
o Would not listen • Countless studies have shown that genuine teamwork and
o Would not give information team intelligence are critical to patient safety.
o Showed lack of concern or lack of respect for the • Poor communication among health care personnel is a major
patient factor in hospital errors, even more so than the level of staff
• "Healthcare staff should be friendly and open. A patient competence and experience.
should be acknowledged immediately," Wolff says. "smiling • This is why many schools for health professionals and major
and appropriate touch also lets patients know they matter" healthcare employers now promote interprofessional
education and cooperation.
Medical Model vs. Patient-Centered Model • Bedside Manners is a play about workplace relations among
Medical Model Patient-Centered Model physicians, nurses, others who work in health care, and
Patient's role is passive Patient's role is active patients-and how their interaction affects the quality of
à patient care, for better or worse.
(Patient is quiet) (Patient asks questions)
Patient is a partner in the
Patient is the recipient of C.L.E.A.R PROTOCOL
à treatment plan
treatment
(Patient asks about options) • Simple protocol to gauge Bedside Manners
Physician dominates the
Physician collaborates with the • Created by Sullivan Luallin Group, a medical marketing firm.
patient • According to the Sullivan Luallin Group: "Service performance
conversation à
(Offers options; discusses pros is as important as clinical performance; just as there are
(Does not offer options)
& cons) clinical guidelines, service protocols are necessary too"
Care is disease-centered Care is quality-of-life centered
(Disease is the focus of à (The patient focuses on family CONNECT
daily activities) & other activities) • Use the patient's name
Physician does most of Physician listens more & talks • Use a friendly, helpful voice tone
à
the talking less
• Establish eye contact and smile
Patient is more likely to adhere
Patient may or may not to treatment • Say "please" and "thank you"
à • Acknowledge immediately
adhere to treatment plan (Treatment accommodates
patient's cultures & values)
LISTEN
AMA Recommended Guidelines For Improving Physician-Patient • Maintain eye contact
Relationship • Be relaxed
• Slow down, slow down, slow down • Don't interrupt
• Create a shame-free environment, encouraging questions • Use "active" listening techniques"
• Use plain, nonmedical language • Repeat information for accuracy
• Show or draw pictures
• Use the teach-back method or show-me technique EXPLAIN
• Describe what's going to happen
• Answer questions with patience
• Let patients know about expected delays
• Speak slowly; repeat as necessary

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ASK
• "Were all your questions answered?"
• "Is there anything else l can do...?"
• "Did you understand..."
RE-CONNECT
• Check back frequently with waiting patients
• Direct patient where to go next
• End with a friendly parting comment
DEALING WITH DIFFICULT PATIENTS
• The emergency department milieu, intoxicating drugs or
alcohol, psychiatric or organic illness, or combinations of
these social and medical factors may cause unpleasant
behaviour that is uncharacteristic for that person. Therefore
it is crucial to determine the underlying cause of angry or
profane outbursts before reacting to them.
• Any person may become angry, hostile, or demanding under
the right circumstances.
• Their fear may be appropriate to their illness, or their
symptoms may have caused heightened anxiety
• In a practical approach, the issues can be divided into three
categories: rapport, diagnostic considerations, and legal
guidelines.
• Difficult Patients
o Difficult patients are defined as those who elicit
strong negative emotions from their physicians. If
not acknowledged and managed correctly, these
feelings can lead to diagnostic errors, unpleasant
confrontations, and troublesome complaints or legal
claims.
RAPPORT
• Rapport denotes a "harmonious relationship," a condition in
which communication between doctor and patient is effective
• A 1983 review by Cresswell underlines the importance of
nonverbal cues. Agitated, impatient, or hostile behaviour by
the patient should alert you to the failure of rapport thus far.
o Remain calm and verbally comment on what you have
observed. For example: "I see you're angry; can we
talk about it?"
o Form an alliance with the patient. f they are angry
with a nurse or ambulance driver, empathize with
them-get on their side.
o If the patient wants to leave, keep talking and delay
him or her-all communication is information that
helps you make an accurate diagnosis.
• If you feel yourself becoming angry, frustrated, or repulsed,
find an excuse to leave the bedside for a few minutes before
saying something you may regret later.
• Do not deny your feelings, and do not act on them; instead try
to identify what caused your reaction and formulate a
strategy.
o Ask yourself the following questions.
o Did the patient have reason to be angry?
o Are the patient's demands reasonable, at least from
his or her own standpoint?
o What is the source of the patient's anxiety
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DIAGNOSTIC CONSIDERATIONS
• The first priority is always to diagnose or exclude serious
organic disease. Never ignore the standard emergency
priorities.
• The best clues to organic impairment of behaviour are
abnormal results of mental status examination: decreased or
alternating level of consciousness, memory loss,
disorientation, or confusion
• If you are still unsure whether a patient is lucid after normal
history taking, then formal mental status testing is
mandatory.
LEGAL CONSIDERATIONS
• When communication breaks down, or before it even begins,
a patient may leave, with or without informing the staff.
• Try to convince the patient to stay until the assessment is
complete.
• If this fails, you must decide whether to restrain the patient
• If you have reason to believe patients are a danger to
themselves or others, you can detain them involuntarily
• It is your clear duty to hold the patient until complete physical
and psychiatric assessment is possible in the following
circumstances: the patient is believed to be suffering from
organic disease that impairs his or her judgement; the patient
is intoxicated, unsteady, and could fall; or patients have
uttered threats against themselves or others.
• If allowing a patient to leave against your advice, the patient
should be requested to sign a personalized release form that
is witnessed.
• Adding specific risks the patient may face to a standard form
may impress the patient you are serious (e.g., for a patient
leaving with undiagnosed chest pain you could specify the
high risk of sudden death). If the patient refuses to sign a
release document, note this refusal on the chart.
• The decision to treat against a patient's will must be made
separately from the decision to detain.
TIPS FOR EFFECTIVE PATIENT PROVIDER COMMUNICATION
WHY IS IT IMPORTANT?
• Better Patient Outcomes due to cooperation
• Less errors in providing patient care
• Job satisfaction
• Time management
• This is a critical skill to achieve patient satisfaction and
outcome of intervention, Many healthcare systems are
training their employees proper communication.
• KAISER PERMANENTE - trains physicians, therapists,
pharmacists and optometrist in its four habits communication
model
1. INVEST IN THE BEGINNING
• Establish good rapport
• Elicit patients concerns
• Plan the visit together
2. ELICIT THE PATIENTS PERSPECTIVE
• Ask for the patients ideas
• Determine his/her wanted outcome or goals
8
 • Explore the impact of the illness on his/her life
3. DEMONSTRATE EMPATHY
• Be open to the patients emotions
• Make an empathic statement as well as try to convey
empathy nonverbally
4. INVEST IN THE END
• Deliver diagnostic information in terms of the patient's
original concerns.
• Always remember to educate the patient to allow him/her
to participate in the decision-making process
• Complete the visit
BEDSIDE MANNERS IN MEDICAL SCHOOL
• Bedside manner among all medical professionals is a crucial
part of patients' recovery. Not only does it affect how patients
feel in the hospital, but also how much they learn about caring
for themselves at
• home
• The teaching of bedside manner emphasizes two important
elements: communication and empathy.
• Medical school incorporate the teaching and practice of
bedside manner into their curriculum through various
approaches to instill the value of bedside manner among
physicians
WEST VISAYAS STATE UNIVERSITY
• The practice in their school is that in 1st year, they have a
subject about Science and Art and Career in Medicine,
wherein they are taught of the fundamentals.
• 2nd year is the start of their interaction with actual patients.
By group, they will be taking history and physical exams to
patients admitted to their University Hospital. After which,
they will be doing a case presentation to their
resident/consultant which includes their differentials,
diagnostics, impression, and management.
UNIVERSITY OF MICHIGAN
• Currently, medical students are often trained in bedside
manner through role-playing with other students and actors.
• Recent study published in Patient Education & Counseling
researchers from the University of Michigan and the digital
healthcare company Medical Cyberworlds Inc. may now
change the mode of educating medical students into training
with virtual humans.
• The simulation, called MPathic-VR, is able to create real-time
responses to what actual humans say by assessing human
body language, facial expressions, and communication
strategies. It then responds in real time with either a negative
or positive response

TEACHING OF BEDSIDE MANNERS IN DIFFERENT MEDICAL SCHOOLS

DMSF
• Bedside manners are integrated with the 2nd year subject
Arts and Science of Medicine of the medicine Curriculum. The
topics are lectured first before the scheduled laboratory time
for this subject wherein the students will perform different
tests and maneuvers and are graded accordingly by their
assigned clinical preceptor.
• In the 3rd year of the medical curriculum, aside from lectures
in school, the students are also supposed to have junior
clerkship wherein they will rotate to different departments in
the hospital with their assigned clinical preceptors.

MSU ILIGAN
• In their institution, under their Community Medicine subject
in 1st year medicine, they are assigned to "purok" wherein
they will have a family under their care for 3 years. They also
teach the people in the community about healthcare which is
of great help to that community.

OUR LADY OF FATIMA UNIVERSITY

• In their 2nd year of medicine, they have a subject called
clinical medicine wherein they have lectures and warding at
the same time. In the ward, they have a patient who will act
out a certain disease and they will be graded on how they take
their history taking.
• In their 3rd year of medicine, their Internal Medicine subject
is just for 1 semester and this is also the time that they apply
what they have learned in Clinical Medicine wherein they will
already interact with patients.

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