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INTRODUCTION
Caring for the ‘whole person’ in a holistic
manner is at the foundation of primary
care and is regarded as a basic expertise
for GPs.1 ‘Whole-person care’ means
‘…
integrating a biomedical, psychological,
social, cultural and holistic knowledge of
the patient and community and applying this
understanding to practical care planning
through person-centred approaches …’
.2
However, this person-centred approach
is under pressure nowadays. Over the
past decades, priorities in doctor–patient
communication in everyday practice have
shifted, from focusing on listening and
empathy to task-oriented communication.3
As a result of protocol-based guidelines,
daily practice has become increasingly
technical and somatically oriented.4 A
biomedical mainstream of care may be
life-saving and health-promoting but it
risks neglecting the patient’s experiences
of illness; understanding this is essential
to ensure shared decision making based
on the individual patient’s perspective,
preferences, and needs,5–9 and contributes
to effective health care.10
The emphasis in general practice on
evidence-based and protocol-driven care,
and the observed reduction in viewing the
patient as an individual, has caused an
ideological debate.6,11,12 To achieve insight
into different factors playing a role in GP–
patient communication, models of the
medical consultation were constructed.9,13
In these models, empathy was regarded
as an important tool to establish a person-
centred approach. By empathy the authors
mean that a physician:14,15
• understands the patient’s situation,
perspective, and feelings;
• communicates that understanding and
checks its accuracy; and
• acts on that understanding in a helpful,
therapeutic way.
Empathy implies a morally valuable
aspect, namely the recognition of the other
as the centre of their own experience.16
The effectiveness of empathy on specific
clinical outcomes for patients has been
widely proven17 and GPs view empathy as an
important element during consultations.18
However, so far there have been no thorough
studies into what barriers GPs experience in
applying empathy in daily practice and how
they manage these barriers, especially in
the light of the aforementioned changes in
communication in the medical consultation.
Therefore, this study aims to examine
barriers to GPs expressing empathy and
how they manage these barriers.
METHOD
Study design
This study was carried out in the
Netherlands where primary care is
Research
FAWM Derksen, GP, Department of Primary and
Community Care, Gender and Women’s Health;
TC olde Hartman, MD, GP, Department of Primary
and Community Care; ALM Lagro-Janssen, MD,
PhD, GP, Department of Primary and Community
Care, Gender and Women’s Health, Radboudumc,
Nijmegen, the Netherlands. JM Bensing, PhD,
professor, Department of Psychology, Faculty
of Social and Behavioural Sciences, Utrecht
University, NIVEL, Netherlands Institute for Health
Services Research, the Netherlands.
Address for correspondence
Frans Derksen, Department of Primary and
Community Care, Gender and Women’s Health,
Radboudumc, PO Box 9101, 6500 HB Nijmegen,
the Netherlands.
E-mail: Frans.Derksen@radboudumc.nl
Submitted: 3 April 2016; Editor’s response:
20 June 2016; final acceptance: 8 July 2016.
©British Journal of General Practice
This is the full-length article (published online
11 Oct 2016) of an abridged version published in
print. Cite this version as: Br J Gen Pract 2016;
DOI: 10.3399/bjgp16X687565
Frans AWM Derksen, Tim C olde Hartman, Jozien M Bensing and Antoine LM Lagro-Janssen
Managing barriers to empathy in the
clinical encounter:
a qualitative interview study with GPs
Abstract
Background
Current daily general practice has become
increasingly technical and somatically oriented
(where attention to patients’ feelings is decreased)
due to an increase in protocol-based guidelines.
Priorities in GP–patient communication have
shifted from a focus on listening and empathy to
task-oriented communication.
Aim
To explore what barriers GPs experience when
applying empathy in daily practice, and how
these barriers are managed.
Design and setting
Thirty Dutch GPs with sufficient heterogeneity
in sex, age, type of practice, and rural or urban
setting were interviewed.
Method
The consolidated criteria for reporting
qualitative research (COREQ) were applied. The
verbatim transcripts were then analysed.
Results
According to participating GPs, the current
emphasis on protocol-driven care can
be a significant barrier to genuineness in
communication. Other potential barriers
mentioned were time pressures and
constraints, and dealing with patients
displaying ‘unruly behaviour’ or those with
personality disorders. GPs indicated that it can
be difficult to balance emotional involvement
and professional distance. Longer consulting
times, smaller practice populations, and
efficient practice organisation were described
as practical solutions. In order to focus on
a patient-as-person approach, GPs strongly
suggested that deviating from guidelines should
be possible when necessary as an element
of good-quality care. Joining intercollegiate
counselling groups was also discussed.
Conclusion
In addition to practical solutions for barriers to
behaving empathically, GPs indicated that they
needed more freedom to balance working with
protocols and guidelines, as well as a patient-
as-person and patient-as-partner approach.
This balance is necessary to remain connected
with patients and to deliver care that is truly
personal.
Keywords
empathic behaviour; empathy; patient-centred
care; primary health care; protocol-driven care;
shared responsibility.
1 British Journal of General Practice, Online First 2016
delivered by a GP and where patients are
registered on their practice list. Most GPs
cooperate in first-line health centres where
they often help out with other GPs and
health professionals such as specialised
practice nurses, with practice assistants.
After medical school and internships, GP
residents follow 3 years of postgraduate
vocational training. Since 1989 the Dutch
College of GPs has published more than
100 standardised protocols on different
diseases prevalent in primary care.19
For this study GPs were interviewed
between June 2012 and January 2013.
In-depth interviews were performed because
they enable experiences in daily practice
and the meanings interviewees attribute
to them to be explored. Furthermore, they
clarify participants’ opinions about their
own priorities.20,21 The consolidated criteria
for reporting qualitative research (COREQ)
were applied.22
Preparation and participants
Thirty-one interviews were conducted.
To establish the appropriateness of the
questions, four test interviews were
performed by three authors before the
interviews; these were audiotaped and
discussed by the first author within the
research group.
Participants were recruited using a step-
by-step procedure. To avoid the possibility of
interviews taking place between people who
knew each other, a statistical employee
performed a systematic random sampling
from the NIVEL (Netherlands Institute for
Health Services Research) GP register
(which includes all practising Dutch GPs).
To produce a maximum variation sample,
characteristics such as age (<45, 45–55,
>55 years), sex, practice type (solo, being
one GP in a practice and duo being two, or
a group practice), and grade of urbanisation
were taken into account. A total number of
147 GPs were selected and approached by
letter, explaining the subject of the study and
the duration of the interview. Some weeks
after this letter was sent, the GPs were
contacted by telephone. After 100 telephone
calls, 31 GPs with sufficient variety in
the aforementioned characteristics had
consented to take part and signed an
informed consent form. The 47 GPs who
were not telephoned were placed on a
reserve list (Figure 1). Appointments were
made with the 31 GPs; anonymity and
confidentiality were guaranteed.
Data collection
The interviews were held face to face at
the GPs’ own practices and lasted between
45 and 70 minutes. All fieldwork was
conducted by one author with a background
in general practice who was an experienced
interviewer.
The interviews were based on an interview
guide formulated by the lead author and
based on literature and expert opinions
(Appendix 1). No repeat interviews were
carried out. At the end of each interview
the interviewee was given a short summary
and was asked if they agreed with it. All
interviews were recorded on audiotape
and transcribed verbatim (in Dutch). After
the first eight interviews, the interviewing
style was analysed. After this, more open-
ended questions were introduced to achieve
more probing interviews and more room for
reflection.
After 20 interviews it became clear that no
new issues were arising. Although the first
20 interviews approached various aspects
of empathy, the issue of barriers to empathy
and how to manage these turned out to be
the topic that came up the most. Therefore,
the final 10 interviews were used to focus
even more on the barriers GPs experienced
in applying empathy during consultations
and the way they managed these barriers.
Data analysis
To analyse the data, iterative content
analysis was employed.23 The systematic
examination of transcripts was undertaken
by the interviewer and two doctoral medical
students trained in qualitative analysis. This
team of researchers was formed to minimise
the influence of personal characteristics on
How this fits in
Priorities in GP–patient communication
have shifted from focusing on listening and
empathy to task-oriented communication
and protocol-driven care. The effectiveness
of empathy on specific clinical outcomes
for patients has been widely proven and
GPs appreciate empathy as an important
element during consultations. There are
limited data concerning what barriers
GPs experience in applying empathy in
daily practice and how they manage these
barriers. This study indicates that GPs use
different ways to manage barriers in order
to preserve the role of empathy in GP–
patient communication. For example, GPs
may deviate from the recommendations
described in the guidelines, to deliver high-
quality person-centred care and to show
genuine interest in their patients. More
work is needed to resolve the barriers
experienced by GPs.
British Journal of General Practice, Online First 2016 2
the analysis and thus the possibility of
bias. Atlas.ti (version 7) was used to assist
with registering, searching, and coding the
data. The researchers, independently of one
another, read and re-read the transcripts,
and met regularly to discuss the subjects
and interpretations. In addition, after the
third, twelfth, and thirtieth interview, the
coding process was discussed with one
author acting as supervisor. By using axial
and selective coding, codes and super
codes were attributed to text segments.
Codes referring to the same phenomenon
were grouped in categories and significant
themes were made explicit. These themes
formed the structure of the final result;
quotations were used to explicate the
themes. The original quotations were in
Dutch and were translated into English with
the help of a native speaker.
RESULTS
Overview of the results
Thirty-one GPs participated but, because
one recording failed, the study was based
on 30 interviews. The demographics of the
participants show variability concerning sex,
age, degree of urbanisation, and practice
type (Table 1). An algorithm showing the
procedure by which participants were
recruited and information about those GPs
not willing to participate is presented in
Figure 1.
GPs indicated that they encounter barriers
when they apply empathic behaviour in daily
practice. However, because they consider
empathy in the clinical encounter to be
very important, they emphasised ways to
manage these barriers. Four main barriers
were distinguished:
• a conflict between protocol-driven care
and showing genuine interest;
• a tension between professional distance
and emotional involvement;
• patients’ behaviour threatening
connectedness within the GP–patient
communication; and
• a conflict between time pressures
and constraints and the GPs’ need for
personal space, peace, and need to
regroup after each encounter.
These barriers and the ways that GPs
manage them so that they can continue to
show empathy are described below.
Protocol-driven care versus showing
genuine interest
GPs considered empathy to be an important
prerequisite for humane care. However,
they found that guideline-driven care results
in a disease-centred emphasis rather
than a person-centred way of thinking
and working. The increased number of
guidelines and bureaucratic requirements
were seen as significant barriers to behaving
empathically during the consultation.
Six GPs also mentioned that therapeutic
regimens and ‘programmed asking’ (a
list of standard questions) from evidence-
based guidelines and protocols hamper
Data
147 GPs selected and sent a letter
100 GPs were telephoned
47 GPs put on reserve list
31 GPs consented to participate
and 30 interviews
were recorded
Drop out
13 GPs did not call back
19 GPs had no time for participation
2 GPs no affinity for the subject
2 GPs bad health
33 GPs wrong address or
telephone number
Figure 1. Participants flowchart.
Table 1. Characteristics of the
participating GPs
Characteristics of the 31a
participating GPs
N
(%)
Sex
Male 14 (45)
Female 17 (55)
Age, years
<45 13 (42)
45–55 10 (32)
>55 8 (26)
Practice type
Sole 8 (26)
Two partners (duo) 14 (45)
Group 9 (29)
Urbanisation
Rural area 12 (39)
Urban area 19 (61)
Mean experience as GP, 16 (2–33)
years (range)
a
Thirty-one GPs participated but, because one
recording failed, the study was based on 30
interviews.
3 British Journal of General Practice, Online First 2016
genuine reactions, interest, and creativity,
thereby reducing the effectiveness of their
empathic behaviour. This programmed way
of working in the current medical system
was identified as an external barrier to
providing empathic care:
‘… that we’re working in an extremely
protocolised way, in fact being the doormat
of the health insurance companies,
that when I witness a resident doing a
cardiovascular risk protocol, reading out
30 questions to the patient and looking at
the computer screen all the time, and I tell
them they were doing that, they will hate it
as much as I do, but that is the danger of
working with protocols … and it causes you
to completely miss out on contact with the
patient, and empathy suffers enormously, I
think.’
(GP 12, male, age 40 years)
‘In my experience, the more you’re doing
your own thing, like I want this and I need
that, the more you’re doing that, the less
you really listen. That way you run the risk
of missing things in a patient and later you
think, if I had just kept quiet for a moment
and listened, if I had just taken a little bit
more time, I would have picked up on things
that would have changed the situation and
the patient would have been more satisfied.’
(GP 3, male, age 58 years)
‘People with diabetes, for instance, they
have to record about 73 items in a list …
and I thoroughly dislike that, because you’re
spending most of your time looking at the
computer screen instead of at the patient,
so, yes, the increase in administrative tasks
does influence my communication …’
(GP 2,
male, age 40 years)
To maintain their humane, empathic
behaviour, GPs suggested that it is more
effective and natural to combine the
recommendations in the guidelines with
questions about the patient’s personal
situation. GPs indicated that they considered
patients as equal human beings, and that
they wanted to treat them with respect
and to show genuine interest, for example,
by telephoning patients proactively in case
of hospital admissions or life events, or
by reflecting on previous situations.
Furthermore, according to GPs, it helps
to mutually value each other’s expertise:
the GP with regard to medical knowledge
and the patient with regard to their specific
situation and illness experiences. This
patient-as-person approach contributed, in
their view, to an innately humane form of
contact, enhancing mutual understanding,
shared responsibility, and commitment, and
it helped to develop a trusting relationship:
‘Empathy also means asking further
questions: how are the kids, or if you know
the husband is recovering from an illness,
how is your husband doing? When the
woman is visiting you to have her blood
pressure checked, it is interesting to let go
of protocol for a minute and ask after her
husband, thereby showing interest in her
context and broadening the picture; I can
see that it’s greatly appreciated, and it also
gives me a lot of information about how
she’s doing.’
(GP 13, male, age 37 years)
‘Empathy also involves a certain disposition,
an outlook on how you want to deal with
a person … I believe that patients can put
forward their own expertise, to which I add
mine, and together we can then explore
the problem and get to work … it’s like
building a foundation for cooperation with
the patient.’
(GP 23, female, age 55 years)
Professional distance versus emotional
involvement
The risks of getting too close to and
emotionally involved with patients emerged
during the interviews, with GPs concluding
that such relationships may interfere with
their objective judgement with regard to
diagnosis and treatment. At the same
time, GPs stated that they needed a certain
level of involvement in order to behave
empathically. Furthermore, according
to GPs, when involvement becomes too
intense, they risk developing burnout:
‘That sometimes you start to cry when
something is really tough, that has
happened to me a few times. It makes me
think less clearly and that is not good, so
for me that’s a boundary I don’t want to
cross. I think it’s fine to be sympathetic with
someone, but I shouldn’t start blubbering
along, that’s not what I’m there for and I
don’t want to go there, and I think I can be
more empathetic when I’m not eaten up by
it.’
(GP 9, female, age 55 years)
GPs mentioned ways to protect their
professionalism, for example, by setting
clear boundaries and creating distance in
their doctor–patient contact by behaving in
a business-like way.
Furthermore, they were convinced that
intercollegiate counselling groups offer an
excellent opportunity to discuss this issue
in depth:
‘Of course, there are moments when
British Journal of General Practice, Online First 2016 4
there is a lot of pressure, for example
during palliative care … when a different
connection with someone develops, you
must try to remain professional, which is
quite difficult and I try not to show that to
my patient. When necessary I can show
my emotions to my partner at home or
during counselling with colleagues.’
(GP 17,
female, age 36 years)
‘There is a boundary and I can work with
that. I think it’s OK to have emotions, as
a GP it’s OK to show you have feelings
and you’re not a business-like person, you
can express your feelings, but there is a
boundary and that is your professionalism.’
(GP 18, female, age 34 years)
Patients’ behaviour threatening
connectedness within GP–patient
communication
GPs indicated that certain patients’
characteristics can hamper GP–patient
contact and complicate spontaneous and
honest empathic communication. GPs
specifically mentioned problems with the
‘unruly behaviour’ of some patients, such
as those who argue aggressively with
the reception staff, patients who keep an
emotional distance, those with personality
disorders, or patients who cross moral
boundaries such as actively engaging in
sexual abuse or drug dealing:
‘They sometimes fend it off, they build up
a wall, like “What is it, what do they want.”
That occurs pretty regularly here, with older
men of the rough-diamond type, they don’t
say much but do come, and I think that can
be tough, but if you approach them more
quietly, you do sometimes get through to
them, but I do find it tough sometimes.’
(GP
17, female, age 36 years)
‘When I get the feeling … it does happen
that you have to deal with someone and you
just don’t click. “You can’t please them all.”
So there are people you just don’t get along
with, but that usually filters itself out, people
switch to another GP and so they should.’
(GP 5, male, age 65 years)
As a prerequisite for empathic behaviour
in these situations, GPs emphasised that
they need to be able to communicate in
a free and honest way. They stated that
their residency training in communication
styles and intervision courses (Balint
groups or coaching groups) help them to
stay on speaking terms with these patients,
preserving a trusting doctor–patient
relationship:
‘Really wishing the other person to have
a good consultation, even if they enter all
grumpy. It can be pretty tough in a situation
like that to find out what is bothering them.’
(GP 23, female, age 55 years)
‘What I want to say is that it doesn’t simply
happen by “switching on”, so yes, I’m all for
supervision and intervision for GPs. In my
opinion it is very important to experience
personal growth, you could say that
“growing and pruning” is my motto.’
(GP 8,
female, age 37 years)
Everyday time pressures and constraints
versus GPs’ personal space and peace
GPs indicated that it is more difficult to
pay empathic attention to the patient when
the consultation schedule is overloaded.
Overcrowded waiting rooms and large
numbers of patients get in the way of empathy.
Disturbance to the consultation itself, for
example, because of incoming telephone
calls, has a negative influence on GPs’
attention and communication. Furthermore,
GPs indicated that personal factors also play
an important role in hindering empathic
attention. For example, reduced physical
fitness, personal difficulties, or a recent night
shift can result in a decrease in a GP’s ability
to show empathy:
‘Well, it is affected by how you feel, how
well you’ve slept … you do have an off-day
sometimes, and if you’re doing consultations
with a splitting headache, you know, it can
be difficult to be really empathic; so yes, it
does have to do with the condition you’re in
yourself.’
(GP 29, female, age 64 years)
‘Being distracted, someone entering …
when you’re distracted it’s hard to focus on
a conversation, whether it be from being
tired, or busy, or having all sorts of thoughts
running through your head, there are phone
calls and messages all the time. I think all
those things can interfere.’
(GP 9, female,
age 45 years)
To manage these barriers, GPs stated that
they try to plan longer consultation times for
specific patients. In addition, they indicated
that having a thoughtful and committed
practice assistant who predicts patients’
required consultation times helps them
apply empathy. Furthermore, optimising
the organisation of the consultation hours
by structured deliberations between GPs
and practice assistants was regarded by
some as useful. Others saw a reduction
in the number of registered patients as an
opportunity to create extra time:
5 British Journal of General Practice, Online First 2016
‘Wouldn’t it be an idea to switch to smaller
practices and to spend 15 minutes on each
patient, while keeping your income … that
way you’d actually facilitate empathy by
keeping incomes at the same level … I
think there’s certainly a case for setting
a 15-minute consultation time for many
complaints.’
(GP 12, male, age 40 years)
‘So that is an important prerequisite, you
know, having peace of mind, things running
smoothly in the practice. Your staff need to
understand when they can interrupt you and
when they cannot, and that some questions
are worth an interruption and others are
not; that’s a matter of fine-tuning things.’
(GP 16, male, age 45 years)
DISCUSSION
Summary
This study describes the barriers GPs
encounter when applying empathy in
daily practice and how they manage these
barriers. GPs perceive the current emphasis
on protocol-driven care with guidelines,
bureaucratic requirements, pay-for-
performance, and quality-of-care indicators
to be an important barrier to remaining
genuinely patient-oriented during the
consultation. Although the government is
not driving these changes, health insurance
organisations use, for example, blood levels
(an HbA1c value from the diabetes protocol)
as quality-of-care indicators.
To manage these barriers GPs try to
combine a patient-as-person approach with
the recommendations given in the guidelines.
GPs mentioned overcrowded office hours
and disturbances in consultations as
factors hampering empathic behaviour.
Longer consulting times, smaller practice
populations, and efficient practice
organisation were described as practical
solutions. Furthermore, GPs argued that
approaching patients as partners with
mutual expertise can result in shared
responsibility. Conversely, they described
how having to deal with transgressive
behaviour in patients, those exhibiting
unruly behaviour, those with personality
disorders, and those keeping an emotional
distance presented a barrier to displaying
empathy in a spontaneous way. GPs also
discussed their own internal difficulties
in balancing emotional involvement and
professional distance.
Strengths and limitations
GPs’ experiences with barriers to
empathetic behaviour and the ways they
manage these barriers during consultations
are, to the best of the authors’ knowledge,
hitherto under-researched aspects of GPs’
everyday practice. Previous studies have
explored the views of GP trainees, medical
educators, and hospital specialists, or have
approached the subject theoretically.9,24
Being interviewed by a colleague has
possibly affected the data collection.25
Negatively, it could result in a lack of
objectivity and possible bias, and, with
respect to the participants, the possibility
of them providing ‘desirable’ answers.
Positively, being interviewed by a trustworthy
colleague may have led GPs to give more
personally detailed information.
Empathy can be considered a ‘container’
concept. Some interviewees merged it
with aspects of general communication or
patient-centredness. Qualitative studies are
limited in their generalisability. However,
compared with quantitative studies, they can
provide richer insights. By using a cyclical
and iterative way of collecting and analysing
data, ‘progressive focusing’ on the barriers
that GPs encounter and on the way these
barriers are managed was realised. The
GPs who participated did so as volunteers.
Accepting a time-consuming interview may
imply that GPs had some sympathy with
the subject and may have under-exposed
negative thoughts. Therefore, caution
should be taken in generalising conclusions
beyond this study.
Although the qualitative method is
appropriate to explore and clarify GPs’
opinions, it does not provide insight into
the GPs’ actual behaviour. However, tape-
recording the interviews, multiple coding
during analysis, and member checks added
to the rigour of the study.
Comparison with existing literature
Previous research has pointed out that
communication styles of GPs have changed
from focusing on listening and empathy
towards task-oriented communication.26 It
can be assumed that this task-oriented
communication originates from the ever-
expanding numbers of standardised
protocols and guidelines. Recently, health
insurance companies have focused on the
GP guidelines — which were not intended
to be used in this way27 — in order to define
quality-of-care indicators for primary care.
These indicators are mostly somatically
oriented. Van Os and colleagues pointed
out that merely following guidelines is not
enough to deliver good-quality care.28 The
best outcome will be gained when doctors
follow the professional guidelines and are
able to build a trustful and personal doctor–
patient relationship with their patients as
well. Therefore, evaluating the quality of
British Journal of General Practice, Online First 2016 6
health care simply by measuring adherence
to the guidelines is not appropriate at all.10,29
This explains the tension GPs face when
they try to deliver good-quality health care.
It is also in line with what patients expect:
they count on a humane and personal
approach from their GP, who shows an
affective attitude and who is aware of the
latest evidence available, and who takes the
needs and consequences of their illness
into account.10,30,31 In this regard patients
have previously identified certain types
of non-verbal behaviour of GPs, such as
being occupied by the computer screen, as
negative.31
Furthermore, this study highlights that
empathy helps GPs to consider patients as
so-called cooperating experts, an approach
with shared responsibility and expertise,
enabling tailor-made solutions. Previous
research has defined the mutual-expert
approach as partnership-building, a working
alliance, or as achieving collaboration.9,32,33
To choose the best course of action for
the individual patient, Greenhalgh and
colleagues argue that evidence-based
medicine should reintroduce its founding
principles, that is, a strong interpersonal,
humanistic, and professional relationship,
empathetic listening, and a collaboration
between an expert physician and an expert
patient.34 GPs expressed exactly the same
opinion in this study.
Preserving a more emotionally
involved GP–patient relationship does
have consequences. GPs in this study
experienced tension between behaving
empathically and remaining professional.
They described how engaging empathy
brings with it a need to create a balance
between involvement and preserving some
distance. The authors are not aware of
recent general-practice-oriented studies
analysing GPs’ experiences regarding these
aspects. Ethicists such as Gelhaus point
to the depth of emotional participation
of GPs in enabling adequate empathic
understanding.35 Previous theoretically
oriented studies describe similar ideas
about working on the boundary of self–
other awareness. It is stated that mental
flexibility, self-critical analysis, and self-
knowledge help in maintaining a clear self–
other separation. Self-knowledge allows
one to have a controlled, balanced, and
efficient regulatory process of empathy-
related responding.35–37
Implications for research and practice
Given the results of this study, there is a
need to get quantitative insight into the
prevalence and relevance of barriers to
empathic behaviour in daily practice. The
consequences of overly biomedical protocol-
driven care especially should be studied in
depth, as well as the influence of the role
of health insurance companies on patient-
centred care.38 The urgency of resolving the
barriers experienced by GPs should also be
determined. Further research in this area
may be helpful to convince policymakers
and health insurance companies to take
action and to stimulate positive conditions
for empathic behaviour in GPs. Because
patients are considered important judges
on healthcare issues,39,40 and research into
patient outcomes has been performed,41
the authors advocate more detailed
research into patients’ experiences and
opinions with regard to GPs’ empathetic
behaviour. Insight into patients’ points of
view gives physicians the opportunity to act
on them.42
According to GPs, empathy is a requisite
for high-quality person-centred care, GP
education should then focus on this to
show students and residents the added
value of empathetic behaviour. Teaching
and practising this behaviour should be
embedded explicitly in the current teaching
models on GP–patient communication.
A focus on personal development and
the introduction of humanities within GP
education and residency may preserve
and strengthen empathy as a humanising
communication skill in general practice.43
Furthermore, continuous medical education
and organising intercollegiate counselling
groups may help GPs in preserving an
effective GP–patient relationship and in
managing involvement with patients, while
at the same time maintaining professional
objectivity.
GPs described different kinds of barriers
to their empathetic behaviour. They pointed
out different ways to manage these barriers
to preserve the role of empathy in GP–
patient communication. In a healthcare
system in which protocol-driven care and
quality indicators have become increasingly
important, GPs consider empathy as a
fundamental tool in their patient-as-
person and patient-as-partner approach.
GPs in this study also stated that it is
sometimes necessary to deviate from the
recommendations described in the
guidelines, in order to deliver high-quality
person-centred care and to show a genuine
interest in their patients.
Funding
This research received no specific grant
from any funding agency in public,
commercial, or not-for-profit sectors.
Ethical approval
Interviewing healthcare professionals with
respect to professional beliefs does not
require approval of an ethics committee
according to Dutch legislation.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing
interests.
Acknowledgements
The authors thank the participants who were
interviewed and the two medical students,
Sascha Kuiper and Milou Van Meerendonk.
The authors also thank Judith Tijman,
translator, and Rosamund Havardre, native
English speaker.
Discuss this article
Contribute and read comments about this
article: bjgp.org/letters
7 British Journal of General Practice, Online First 2016
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British Journal of General Practice, Online First 2016 8
Appendix 1. Interview guidelines
Introduction
My name is Frans Derksen and I am a retired GP. I conduct scientific research on empathy in GP–patient communication. As I mentioned in my letter of introduction,
I am interested in the personal opinions, experiences, and perceptions of both GPs and patients on the role of empathy during consultations. This part of my research
focuses on GPs; in a later phase the opinions of patients will be investigated. I have chosen face-to-face interviews as the method to collect the data for this research.
Names and addresses of GPs to approach were obtained through taking a sample from the NIVEL GP file. You were in that sample and you have shown yourself
willing to get involved with this research. Thank you for that. In the interview I would like to talk to you about the following topics: background information about your
practice, your views on general practice, your views on empathy in communication with the patient, and, finally, the conditions you believe play a role when working with
empathy. I would like to stress that in this interview there will be plenty of space for your thoughts. My aim is to let the interview take up to about 1 hour (15 minutes per
topic). As we have agreed, I will audiotape the entire interview and I will make some notes and check my list of questions. Everything you say is strictly confidential; the
research findings will be anonymised.
Do you have any questions at this point?
Some questions to gain background information on your practice: Do you work in an urban or a rural area? When did you start working as a GP? Do you train GP
students? Could you tell me something about your practice organisation (sole, two partners, group) and about your patient population?
A. First your own general views on general practice:
1. At some point in your life you chose to become a GP. How did you come to that choice?
2. What aspects would you describe as the core of your job?
3. What important developments have you noticed during the time you have been a GP?
4. What do you think of these developments?
5. How do you feel now about your choice to become a GP, taking into account the developments that you just outlined?
B. Now I would like to talk to you about empathy:
1. What does the concept of empathy mean to you as a GP?
2. Can you specify the way you use it? How do you use it? What do you find difficult or easy? Do you feel capable of providing it and are you skilled at it? Can you give me
any examples? How do you experience empathy yourself?
3. Does the special feature of the GP with its longstanding contact with the patient play a role in the implementation of empathy?
4. There is a lot of talk about sex differences in the use of empathy. Do you have any opinion on that?
5. How much importance do you attach to the use of empathy in your relationship with your patients? Can you indicate this on a scale of 1 to 10? What if you relate it
specifically to evidence-based medicine and/or protocol-based medicine?
6. Can you give any examples of your personal experiences with empathy during the consultation? Were they positive or negative?
7. In general, GPs are highly esteemed by their patients; if they complain about anything it is a lack of communication skills and empathy in their GP. Do you recognise
this? Can you tell me anything about that?
8. How do you think patients experience empathy?
C. Preconditions and barriers to empathy:
1. Do you think there are preconditions and barriers to being empathic? If so, what are they?
2. Is it possible to facilitate its use? How? Can GP training play a role in this? What was it like during your own training?
3. Do health insurance companies and the government show enough interest in the role of empathy in your opinion?
4. Is there enough, or too much, attention being paid to empathy in medical literature, during refresher courses, and by professional associations? If so, how could this be
improved?
D Final question:
1. We have talked at length about your views on general practice and empathy. Would you like to add anything, anything that we have not covered, but that in your view is
important in this context?
These were the questions I wanted to put to you. Thank you very much for replying and for your cooperation.
9 British Journal of General Practice, Online First 2016
