A team of researchers looked at how HIV healthcare providers responded to the emotions of their patients living with HIV during routine clinic visits. Through several analyses, they found that there are racial disparities in how HIV providers respond to patient emotions and cultural differences in how people express their emotions. Also, providers who describe themselves as high in empathy don’t actually respond more empathetically to patients.
Health outcomes are heavily influenced by the relationship and communication between patients and their providers. In previous studies, effective communication has been shown to improve patient satisfaction, treatment adherence, and health outcomes. Good patient-provider communication positively impacts retention in HIV care, and people living with HIV who feel their provider knows them as a person are more likely to be prescribed and be adherent to antiretroviral therapy and more likely to be undetectable.
To better understand the dynamics of emotional communication in HIV care, Jenny Park and a team of researchers from John Hopkins School of Medicine did an observational study on visits between people living with HIV and their HIV providers who were enrolled in the Maximising Respect and Improving Patient Outcomes in HIV and Substance Abuse (MaRIPOHSA) Study. MaRIPOHSA audio records visits between HIV care providers and patients in two HIV specialty clinics in Baltimore, Maryland and Portland, Oregon.
Eligible providers were physicians, nurse practitioners, and physician assistants who provided both HIV and primary care to people living with HIV. Eligible patients were English-speaking adults with HIV who had been in care at list six months, seeing their regular provider for a routine visit.
The study included 41 providers and 342 patients. The average age was 46 for providers and 53 for patients. Most (66%) of the providers were female, while most (64%) of the patients were male. Most providers (66%) were White, followed by Black (15%), Asian (10%), Hispanic (5%), and other race (5%). Most patients (77%) were Black, followed by White (20%), other race (3%), and Asian (1%).
Patient expressions of emotional communication
Emotional communication, which includes patient emotional expressions and provider responses were coded with the widely used Verona Coding Definitions of Emotional Sequences (VR-CoDES).
Most (67%) visits contained at least one emotional expression (average 3, range 0-24), and there was a total of 1,028 expressions among all visits. Most (77%) were initiated by the patient, rather than being elicited by providers. Around half of expressions (51%) were mentioned only once, while the rest were repeated twice or more.
Around half (53%) were medically related, focusing on HIV, other illnesses, tests, treatment, symptoms, and substance use. The remaining expressions were about non-medical concerns, like general life events, living situations, and people.
Patients expressed emotions explicitly and implicitly through concerns or cues. Concerns, defined as “a clear and unambiguous expression of an unpleasant current or recent emotion where the emotion is explicitly verbalised”, accounted for 27% of expressions. Patients most often (73%), used cues, defined as “a verbal or non-verbal hint which suggests an underlying unpleasant emotion but lacks clarity.”
Cues were divided into subcategories, with the most common (29% of all expressions) being verbal hints to hidden concerns, often by emphasising unusual words or phrases. The next most common category (22%) was neutral expressions of stressful situations and life events that didn’t flow with the conversation. Non-verbal expressions of emotion (>1% of all expressions) were hard for researchers to detect since they had only transcripts, however they were able to identify some through silence, gasps, sighs, and crying.
Healthcare provider responses fell into four broad categories depending on whether they responded explicitly (44% of total responses) by referencing the patient’s emotional circumstance and whether their response provided space for the patient to elaborate (81% of all responses).
Around half (49%) of responses non-explicitly provided space, through responses such as mostly non-verbal signs of active listening (known as 'back channelling’, 33% of all responses), or acknowledging using moderate verbal encouragement (9% of responses). Thirty-two percent of responses explicitly provided space, through responses such as asking follow up questions (18% of responses), or acknowledging the circumstances that gave rise to the emotions (10% of responses).
Providers explicitly reduced space in 12% of responses, most frequently by giving information/advice (11% of responses), or, rarely, through switching the subject or postponing the conversation. Providers also non-explicitly reduced space (7% of responses), which they did through responses such as ignoring the emotional expression (5%) or by providing non-explicit information or advice (e.g. “everything will be fine”, 1%).
Researchers looked at how these provider response types impacted visit length in another study. In adjusted analyses, the only significant finding was that provider responses that explicitly focused on the patient’s emotion by acknowledging it, asking about it, or providing explicit empathy, were associated with shorter visits, by an average of 4.11 minutes (95% CI).
Racial disparities and differences
An earlier study by the same researchers looked at emotional communication between providers and patients new to HIV care. It found that Black patients were 58% less likely to be given responses that provided space for them to elaborate their emotions than patients of other races. Black patients were 52% less likely to be given responses that explored their emotions, and the odds of their emotional expression being blocked, or actively avoided, by their provider were six times greater.
Troubled by these unexpected findings, the researchers searched for racial disparities in the larger dataset of people who’d been in care for at least six months. They noted that one might expect the “distance” between patients and providers to be lessened in the context of routine visits between established patients and providers, since the first study covered initial visits.
"Providers explicitly reduced space in 12% of responses, most frequently by giving information or advice."
To identify racial disparities and differences, researchers looked at how providers responded to Black patients compared to patients of all other races, including White patients. They also looked at how providers responded to White patients compared to patients of all other races, including Black patients.
The racial disparities uncovered in the first study persisted, albeit presenting in slightly different ways. After adjusting for other factors, the researchers found that providers were 56% more likely to explicitly refer to the emotional expressions of Black patients compared to any other race, and 35% less likely to provide explicit responses to White patients compared to all other races.
Providers were 44% less likely to respond in a neutral or passive way to Black patients compared to other races, and 76% more likely to give White patients a neutral or passive response compared to other races. As in the first study, providers were more likely to block the emotional expressions of Black patients, doing so over twice as much than they did with patients of other races. White patients were 60% less likely to be blocked by their provider compared to all other races.
The larger sample size in the second study also allowed researchers to look for racial differences in how patients expressed emotions. To do so, they looked at how Black patients expressed emotions compared to patients of all other races, including White, and looked at how White patients expressed their emotions compared to patients of all other races, including Black.
After adjusting for other factors, researchers found that Black patients were twice as likely have providers elicit the emotional communication compared to all other races, whereas White patients were 57% less likely to have providers elicit their emotions. This means that White patients were more likely to spontaneously express emotions whereas Black patients were not.
When expressing emotions, Black patients were over three times as likely than other patients to use cues involving repetition by using the same or very similar words of something they’d already said, often by repeating a neutral phrase. For example, “I ain’t even that, that old, you know, but I feel old,” followed by “That’s what it is. I feel real old”. In contrast, White patients were 72% less likely to use cues involving repetition compared to other races.
"Black patients expressed their emotions more subtly and were less forthcoming with providers compared to other patients."
Considering the differences found between the smaller study and this study, researchers note that the findings suggest that over time, familiarity and comfort between providers and patients may increase more for White patients compared to Black patients.
Overall, these findings illustrate that Black patients expressed their emotions more subtly and were less forthcoming with providers compared to other patients. When Black patients did express their emotions, they were more likely to be blocked and less likely to receive responses that allowed or encouraged them to elaborate or continue expressing themselves compared to patients of other races.
The authors suggest several possible explanations for these findings. Provider racial bias, whether conscious or unconscious, may be playing a role. Cultural differences in how emotions are expressed may mean that the providers (largely White in this study) were less able to recognise the subtle emotional communication of their Black patients and therefore more likely to miss cues and move on to other topics.
Regardless of the underlying cause, these communication patterns may become a mutually reinforcing dysfunctional cycle. Black patients, having had their emotional issues ignored or closed off by providers, become less forthcoming and direct. Providers, less able to recognise the emotional cues their patients are sharing, may not provide an affirming response, which can make their patients even less likely to open up.
Impact of provider empathy
One facet of communication is empathy, understood in this context as a provider’s ability to recognise and understand a patient’s emotional state and respond in a way that eases negative emotions. Provider empathy has been shown to be particularly significant to patient satisfaction, treatment adherence, and positive clinical outcomes in many settings.
For example, previous research has shown that the patients of HIV providers who self-reported higher scores on the empathy subscale of the Interpersonal Reactivity Index (IRI) had greater odds of reporting the highest medication self-efficacy. Yet the same study found that the providers actually had less emotional communication and conveyed more information to patients.
Providing information or advice is generally regarded as a missed opportunity for empathy, so these findings suggest a possible causal relationship between provider empathy and HIV outcomes that doesn’t necessarily operate through what is traditionally considered “empathic” communication. Researchers were eager to explore this further in hopes of gaining conceptual clarity in how to interpret these results.
The team also wanted to separate the two concepts that are both referred to as empathy. The first is empathic concern, also known as affective empathy, or how much emotional resonance a person has with another person’s experience. A question from the IRI measuring empathic concern is “When I see someone being taken advantage of, I feel kind of protective towards them.”
The second concept is perspective-taking, also known as cognitive empathy, or the ability to understand the experiences of another person. A question from the IRI measuring perspective-taking is “I try to look at everybody's side of a disagreement before I make a decision.”
Out of 28 total possible points, the average provider empathic concern score was 22, with a range between 14-27. The average perspective taking score was 19.9, ranging between 8-27 out of 28 possible point. The correlation between empathic concern and perspective-taking was significant (0.96, p = <0.001). There was a trend towards greater empathic concern among female providers, but no differences in perspective taking.
"Providers who rated themselves highly in empathy or perspective-taking did not engage in more emotional communication with patients."
Patients expressed fewer concerns with providers as provider self-rated empathic concern increased (β −0.06; 95% CI −0.10, −0.01), and there was a similar, yet not significant trend for perspective-taking. Providers were more likely to give any information or advice for each one-point increase on the empathic concern scale (10% greater odds) and the perspective-taking scale (6% greater odds).
Overall, few provider responses displayed empathy. Only 5% of all responses were classified as showing any empathy, and only 4% of total responses explicitly focused on the patient’s emotion, including by providing explicit empathy.
Providers who rated themselves highly in empathy or perspective-taking did not engage in more emotional communication with patients. Rather, they were more likely to give advice or information. The authors hypothesised that providers with greater empathy may be attempting to alleviate emotional distress by offering solutions, and that those providers who experience distress when faced with another’s unpleasant emotions may find it more difficult to stay present.
Patients made fewer emotional expressions to providers who rated highly in empathy. It could be that the patients weren’t looking for advice or information, so they subsequently share fewer emotions. On the other hand, providers with greater empathy and perspective-taking may rightly perceive that information or advice would be helpful. If patients are satisfied by their provider’s response, they may feel less need to repeat themselves.
The researchers offered a range of practical tips and advice resulting from the study and subsequent analyses.
They urge providers, and those who train them, to be more cognisant of racial and cultural differences in emotional expression, and of potential biases or blind spots providers may have in discerning emotional cues and responding appropriately. More effective communication can bridge the social distance between providers and patients, which may in turn improve health outcomes and reduce racial disparities.
The authors suggest that providers with more empathetic tendencies be aware of impulses to give their patients information or advice, and to assess whether this response would actually be helpful. They also call for further research on the relationship between provider empathy, emotional communication, and clinical outcomes, while urging other researchers to use precise measures of empathy, which is often used as a broad, catch-all concept.
Park, J et al. Racial disparities in clinician responses to patient emotions. Patient Education and Counseling 103: 1736-44, September 2020.
Park, J et al. Are clinicians’ self-reported empathic concern and perspective-taking traits associated with their response to patient emotions? Patient Education and Counseling 103: 1745-51, September 2020.