Compassionate Communication Starts with Listening

Abstract

This reflective narrative explores the profound impact of compassionate communication in healthcare from the author's personal experiences as a caregiver and teacher. The author recounts 2 pivotal encounters: one with an oncologist who delivered devastating news with clarity, empathy, and patience, and another with a cardiologist whose brusque, impersonal approach led to confusion and distress. These contrasting experiences underscore the critical importance of slowing down and truly listening to patients and families. The article highlights research demonstrating that compassionate communication improves patient outcomes and supports clinician well-being. Through her experience as a patient and caregiver the author advocates for training healthcare professionals in these essential skills. Ultimately, the narrative calls for a renewed focus on empathy, attentive listening, and human connection as foundational elements of effective patient-centered medical care.

Introduction

Thanksgiving weekend 2005, my dad called. My mom had lost 10 pounds in 3 weeks, couldn’t eat, and had started to vomit. They were going to the emergency room. I flew home immediately. A tumor, detected a year earlier as a small spot on a CT scan and ignored, had overtaken her belly. They inserted a feeding tube and tried chemo. About 3 weeks into her stay, her condition wasn’t improving, and I came to the hospital early in the morning to meet her oncologist. He was just coming out of her room and gestured us into a conference room, where we sat. “My dad and I came up with a list of questions,” I said smiling, trying to be efficient at 6am. He paused and looked at me so kindly. He knew we were living in different realities, and that he was about to upend mine. He reached across the table and held my hand so I wouldn’t feel alone. He spoke slowly as he told me that the feeding tube was not feeding my mother—it was feeding her tumor. The most humane thing was to remove the feeding tube. He paused for me to absorb this news. Time stopped. I looked at my list. None of my questions made sense anymore. His last statement echoed in my head: “remove the feeding tube, remove the feeding tube…” Reality was still out of reach for me. I said, “So, she won’t be able to eat?” There was something about the way he said it. He was clear. “No. It's not a bad end. It is the least painful thing we can do.” He looked me right in the eye and waited for me to catch up. That took a while. My whole life had just changed. I choked out the question, “So… my mom is going to starve to death?” He nodded as the room spun. More echoes in my mind: “my mom is going to starve to death, my mom is going to die…” The only words I could muster aloud, “How long does that take?” He held my shoulder. “Probably two or three weeks.” He was right. Mid-January, on a crystal-clear morning, she died with my dad and me by her side.

Despite the fact that he was telling me such difficult news, this oncologist remains one of the best medical communicators I have met. In each of the 3 encounters I had with him, he made me feel like I wasn’t alone. He was clear. He was direct, but not abrupt. He held my hand firmly, like a friend would do if you were scared, or lost, or both. Most of all, he waited for me to catch up to an unimaginable story.

Perspectives Practical

I don’t remember this doctor's name, but I will never forget him. Twenty years later, I find myself teaching doctors and nurses to do what this physician did for me. I am a teacher and communication leader for mid-career doctors and nurses. This is a humbling position. I’m not a clinician. I am a theatre professional, and I have never had to deliver news like this in real life. The lines I’ve uttered in performance or directed onstage are a pale comparison. Two doctors in my life have delivered profoundly graceful and compassionate “performances” in the face of my own imminent suffering. First, when I was 15-years-old facing my 21-year-old brother's death from aggressive cancer, and years later the encounter with my mom's oncologist. I come to work with them held in my heart: my brother, my mom, and their doctors.

I am in a unique position as a patient, caregiver, and communication facilitator. I work in partnership with my longtime colleague and dearest friend, Dr Evonne Kaplan-Liss, and palliative care physician Dr Gary Buckholz. We run a 60-hour compassionate communication fellowship and to date we have graduated 100 doctors and nurses who all emulate the kind of clinician we want beside us as we navigate confusing diagnoses and impossible decisions. ¹

I’ve also been on the receiving end of poor communication. When my dad was 92, we went to a new cardiologist (a covering doctor for the cardiologist he had known for 20 years) expecting to get his medications refilled. The new doctor, sitting behind his computer screen, bluntly informed us that my dad needed a TAVR (trans arterial valve replacement) or he would be dead in less than a year. In less than 2 min, with no greeting or eye contact, he launched an acronym we had never heard before, said “dead in less than a year,” and suggested we watch a YouTube video so we could understand the procedure. We left the appointment confused, scared, and angry, which my dad shared with his tablemates at assisted living. They insisted he needed a second opinion, which needlessly lost us precious time of nearly 2 months. We faced an additional 2-month delay because my father faced another health challenge. Finally, my dad had the TAVR, quickly regained his stamina and vigor and he recently celebrated his 95^th birthday. While the new cardiologist was clinically correct, his lack of communication derailed what could have been a much easier path. Because time wasn’t taken in the room, it wasted months after the visit.

Recommendations

We all have stories of communication gone wrong. In their groundbreaking book Compassionomics, Steve Trzeciak and Anthony Mazzarelli refer to it as a “compassion crisis” with burned out clinicians losing their compassion by depersonalizing their patients and themselves. ² They quote a study from the University of Chicago published in JAMA where even “our primary care physicians missed 79% of emotional clues from patients and opportunities to respond with compassion.” ³

The secret sauce to good healthcare communication is nuanced, but it often comes down to 2 things: slowing down and listening. It may sound impossible when a primary care doctor is expected to see a patient every 18 min. This time constraint results in communication habits that include an average of 11 seconds for a physician to interrupt their patients’ story. I was teaching a group of residents recently who bemoaned their patients going on and on. “Why can’t they just get to the juicy stuff,” one complained. The “juicy stuff” to a doctor is the clinical problem, whereas to a patient it might be how that problem is impacting their ability to sleep, to work, or care for people they love. On average it takes a patient about 60 to 90 seconds to come to a natural conclusion in their story. ⁴ That story may not contain all the clinical “juice,” but if left uninterrupted, it often does contain important information about what a patient understands and doesn’t, what they care and worry about the most. This crucial information provides the doctor with a broader perspective of the person they are treating, not just their disease—and it provides the patient with the feeling that the doctor cares.

I think about my own experiences and how I’ve described them in this writing. “Time stopped” with the news of my mother. “In less than 2 min” with the news for my dad. As a medical educator, I am interested in helping clinicians become more attuned to a patient's perspective on the receiving end of unexpected news. Timing is taught in performance. Actors are taught to “hold for the laugh” which means wait until the wave of emotion in the audience begins to subside before you speak again so they don’t miss what comes next. Because every audience is different, you can’t predict the length of that hold: you must feel it. You must connect with the energy of the audience and ride the wave with them—just like my mom's doctor did with me. Some have that ability instinctively—and others need to learn to listen more deeply to the emotion in the room and not fight it. We enjoy laughter, so riding that wave is fun. But when we are faced with suffering, our fight or flight clicks in, and we want to leave—or make it better—or rush past it like it didn’t happen. Rushing through serious news may feel better to the person delivering that news, but to a patient the story we have been living is disrupted to such a degree that we don’t recognize the pattern anymore. Grief takes longer to process, to put the pieces back together, to reconcile the echoes in your mind, to breathe again. My mom's doctor recognized the time I needed to catch up, whereas my father's doctor didn’t. It's significant that the worst clinical outcome of the two is the one I attribute the best communication. And from the distance of 20 years, I can imagine now that the feeling I had, of time “stopping” really didn’t last all that long. As an educator, I wish I could share a formula: grief = time squared. Unfortunately, it doesn’t work that way. There is no standard formula, other than connection.

Our fellows share the techniques they employ in these moments—breathing together, finding the rhythm. Like actors, they are grateful for the chance to rehearse these tragic scenes in a safe space, to cry together, to have permission to step away when the roleplay hits too close to home. Their grief is present, and so is their love shouldering the stories of favorite patients.

Conclusion

Over the last 15 years, Dr Kaplan-Liss and I have asked doctors to describe their best experience with a physician. We always hear the same stories—“he listened,” “she cared about me as a whole person,” “they treated me like a member of their family,” “she explained things clearly,” “he was honest…” What never makes the list? Education. Medicine. Clinical outcome. Of course, those things matter—that's what we expect from our doctors. But the things that stick with us, the vehicle that carries the message, good or bad, comes in more humanistic form. The way I experienced with my mom's doctor.

He waited for me to catch up to a story I never wanted to hear. He waited. And that made all the difference.