Exploring how surgeons employ empathy in clinical practice: a qualitative study

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Despite the recognition of the value of clinician empathy (1), quantitative studies have shown that surgeons have lower empathy scores than other specialities (2–4). The reason for this is unclear, and little is known about how surgeons manage emotions in clinical settings. This study explored the role of empathy in surgical treatment and how surgeons see patients’ emotions. Methods We used an exploratory qualitative study in the Constructivist Grounded Theory tradition, utilising online individual semi-structured interviews with fourteen general surgeons. Results Surgeons described multiple discrete approaches to patients’ emotions. Participants were conscious of modulating their emotional response to patients depending on need, and systemic factors like urgency and setting. General approaches to patient emotions included emotion-facing and emotion-avoidant strategies. While the approach used was often tailored to the situation, surgeons usually had a preferred style. The degree of emotional engagement was particularly influenced by time available, and urgency. Participants described some techniques to influence the degree of emotional involvement, primarily by altering consultation times. Conclusions The management of emotions by surgeons is nuanced and affected by contextual factors. Management is not entirely automatic or subconscious, but opportunities can be created or limited by the surgeon as required to facilitate effective treatment. The results offer a new perspective on surgeon empathy in the context of the limited existing literature. Empathy Clinical skills General Surgery Consultation skills Quality of care Figures Figure 1 Figure 2 Introduction Empathy is an individual social process to deal with the emotions of others. It can be defined as the ability to understand the perspective and emotions of a patient, communicate and respond to that understanding (5). It combines perception and processing, both emotional and cognitive (1,6). While the experience of empathy is internal (1) and not entirely conscious, it may lead to outward behavioural manifestations (7). Empathy is a key characteristic of interest in healthcare. Empathy is associated with higher patient satisfaction and improved patient compliance (5,8,9), and lower rate of treatment-associated trauma and anxiety (5,10), and even improved physiological recovery from illness (11). It may also contribute to improved physician health and wellbeing (5). Procedural specialists such as surgeons, anaesthetists, and radiologists have a lower measured empathy than other physicians (9,12), but the absolute difference is small (9), and the patterns are not consistent across studies (12). The factors associated with the difference are unknown (9,12). Empathy may be confounded by specialty specific factors, such as the need to cause pain but also potentially relief and resolution, but there has been little targeted research into empathy in surgeons. Empathy research in healthcare has been hindered by inconsistent definitions (5,11,13). Investigation of cognitive and behavioural processes of empathy have been dominant (1,5,13–15), to the extent that emotional processes has been deemphasised (1,14). Most models of empathy emphasise that both cognitive and emotional processes are key components of the empathy response. However, a focus on cognitive processes in empathy research, tends to emphasize the conscious aspects of empathy and de-emphasize the more subconscious emotional response. Research has also focussed more on measurements of empathy in different demographic and specialty groups, with little exploration of the reasons for differences (13). Measures used have variable validity (5) and are mainly self-reported scales, which are prone to distortion, particularly by stress, burnout and self-image (5,11). A common response to perceived deficiencies, is to formally teach empathy skills to procedural specialists (7). This approach aligns with a hypothesis that increasing empathy will cause an improvement of patient outcomes, without any negative effect on patient or surgeon. That is, that empathy levels are independent of capacity to complete practice tasks or responsibilities. However, this is untested, as there has been insufficient research into the interaction between practice pressures and empathy, particularly in procedural specialists. This study was designed to explore and develop a theory of how surgeons experience emotions in clinical practice and how they develop and use clinical empathy. Interest will be given to the role of factors particular to surgical practice. A deeper understanding of empathy in surgeons is vital to develop a response to perceived or real deficiencies. Methods Study design This study was designed to investigate the role of empathy in patient surgeon interactions, and how surgeons respond to the emotions of patients in clinical situations. This qualitative study used semi-structured interviews with general surgeons, analysed in the Constructivist Grounded Theory (16,17) tradition. The research paradigm was constructivist, which accepts that social phenomena and their meaning are subjective and in constant revision. Actors interact with the world, and knowledge is generated as they make sense of their experiences. This study was facilitated by a group of researchers with diverse perspectives and research experience. This study was designed by Author A who works as a general surgeon and became uncomfortable with a perceived simplification of surgeons’ communication skills, particularly with respect to emotional management. She had previously completed a PhD in Surgery but has more limited experience in educational and qualitative research. Author B is a clinical surgeon with extended experience in education research. Author C is an experienced educationalist with extensive experience in qualitative and quantitative research, who has often worked with surgeons and procedural specialists. Research Assistant D is a social worker with previous research in reflective practice, who collaborated particularly on coding and analysis. A balance of subject expertise allowed differences in perspective and promoted both detailed data collection with a surgeon interviewer, but also a balanced perspective on the analysis of that data. Ethics Approval and Consent to Participate The relevant Human Research Ethics Committee[1] approved all research procedures. Informed consent was documented for all participants. Participants We chose to interview Australian general surgeons. All participants had current registration and were a Fellow of the Royal Australasian College of Surgeons (RACS). Surgeons who had ceased work more than six months prior to recruitment, or worked clinically with the primary investigator were excluded. Recruitment Participants were recruited for a semi-structured interview. The recruitment was by email sent through General Surgeons Australia (GSA), the professional body of general surgeons in Australia under the umbrella of RACS. Additional surgeons were recruited by word of mouth and personal recommendation from interviewees. 21 surgeons volunteered in response to the initial invitation. Two were ineligible for interview, as one worked with the primary researcher, and one was not in clinical practice. Four further surgeons were recruited by other means. Out of 22 eligible volunteers, 14 were interviewed, selected in chronological order of those who volunteered (Table 1). The selected interviewees represent an adequate representation of practicing general surgeons in Australia, within the limits of a small sample size. Table 1: Demographics of interviewees in context of Australian surgical workforce. Demographics of General surgeons in Australia (18) (n=3001) Participants interviewed (n = 14) Sex Male 2483 (82.7%) 11 (78.6%) Female 517 (17.2%) 3 (21.4%) Other/unknown 1 (<0.01%) 0 State NSW 821 (27.3%) 5 (35.7%) VIC 660 (22.0%) 6 (42.9%) QLD 462 (15.4%) 1 (7.1%) WA 209 (7.0%) 2 (14.3%) SA 206 (6.9%) 0 TAS 41 (1.4%) 0 Interviews All interviews were conducted by Author A using online commercial meeting software (Zoom Video Communications, Inc). The initial interview prompts and plan was designed for this project according to the research question. The interview focused on the experiences and perspectives of the interviewees on empathy in clinical practice. To avoid bias related to previous understanding of the term “empathy”, questions were focussed on perceiving and responding to the emotions of patients, and a definition of empathy was not supplied. All interviews progressed with an exploratory intent. The initial set of questions for the early interviews is presented in supplemental material. Interviews were recorded, transcribed and anonymised with alphanumerical codes based on recruitment order and initial. The median interview length was 1 hour 21 minutes. Transcripts were shared with the full research team for analysis. Interviews continued until theoretical sufficiency was reached (14 interviews total). Analysis Data analysis was conducted in the Constructivist Grounded Theory (16) tradition. Interview transcripts were analysed using constant comparative technique to identify and refine recurring themes (17). The analysis of the transcripts was performed by Author A and Researcher D. Identified codes and themes were integrated into the interview guide for future interviews. Ineffective questions were removed, and new stems aiming to explore emerging codes were added. Using a codebook, initial codes were collated into refined codes, and themes were developed. As data collection continued, themes were challenged to ensure they were representative of a wide experience. When collected data consistently fit existing themes, a theory was constructed to describe the data. This was proposed by the primary investigator and developed in discussion with all authors. After drafting the theory, three further interviews were held to discuss the theory and the contributing themes. These interviews were coded in turn and the theory was edited to encompass the new data. Analysis choices Themes developed from the data were diverse and represented topics from consultation skills and communication to personal distress and surgeon self-image. In development of a theory, a description of practice was prioritised that was value-neutral and explained both positive and negative experiences. This is compatible with the exploratory nature of the interviews, which did not attempt to determine best practice, but simply describe emotion management techniques. [1] Monash University Human Research Ethics Committee – project reference 35445 Results Our analysis demonstrated discrete strategies for approaching patient emotions in clinical settings. In some instances, responses to emotions are clearly spontaneous, but may also be conscious strategies. When describing others, interviewees could recognise that some strategies are more helpful for the patient, and in self-reflection, some could see benefits and issues with their own approach. Surgeons’ techniques may be pervasive, or they may use different approaches, depending on the situation. Conscious and unconscious approaches to empathy Empathy threshold If a clinical situation has parallels with the surgeon's own life, then the emotional response is more likely to be spontaneous and have a stronger impact on the surgeon. One interviewee called this the "empathy threshold". It is affected by previous patient interactions, one's own life experiences, and other personal biases. This leads to easier emotional engagement with some patients than with others. [W]e bring a threshold into that interaction with us... The most obvious example is … someone with a cancer diagnosis. I think society and med school and the whole thing has geared us towards that being a low threshold for developing empathy... Whereas if it was someone with something more stigmatised - mental health, addiction, obesity, ... There is a threshold that needs to be overcome. - A04 Empathy as an optional tool Participants talked about a deliberate choice to turn empathy on and off. The choice was often made around utility or efficiency. That is, surgeons can use time and energy to engage with emotions if it makes a difference in the outcome or consultation. The idea that surgeons lack empathy I think is a different one to surgeons don’t display empathy, don’t use empathy or however that should be worded. But I wonder if that’s what it is, whether empathy is something we see as a tool to use or not use depending on the situation in front of us. - A04 This idea implies that different aspects of surgical practice need different attention to emotion. Surgeons use concrete methods, such as adjust scheduling to facilitate or inhibit emotional discussions. Surgeons describe predicting the degree of emotional stress in an upcoming consultation and deliberately increasing or reducing allocated time or arranging psychological support. This also can be used to reduce emotional engagement. If it's … a situation that …, may be quite distressing for you as the surgeon... You might want to avoid going and unpacking and moving them from a patient to a person, or a condition to a person because of the costs associated with that…. So, your choice of how much you choose to engage with that patient will then influence …the depth and the richness of the empathy that actually is developed. – G08 Strategies to deal with emotions To describe the approaches of surgeons to emotions, diagnosis and treatment can be considered to have a biological component (illness) and an emotional component (emotional dysfunction), which vary in strength, depending on the pathology and patient. Strategies ranged from directly addressing patients’ emotions to completely avoiding them. “Emotion-facing strategies” diffuse emotions in some way, and “Emotion-avoidant strategies” bypass emotions and focus primarily on the biological illness. This may also encompass psychological, social, and other stressors, through their impact on emotions. Surgeons described different approaches to emotions depending on context and condition, but also on the personality and comfort level of the surgeon. For example, the interviewees felt that the emotion-facing strategies were easier in clinic consultations and that the emotion-deferred or emotion-avoidant strategies were more likely to be used in emergency or ward settings. However, many described feeling most comfortable with a particular strategy, even if they understood its limitations. Emotion-facing strategies (Figure 1) include direct and indirect approaches. Direct approaches acknowledge the role of emotions and actively seek to address them. Indirect approaches usually focus on developing a strong clinical rapport to reduce patient stress. Patient emotions may be acknowledged, but they are primarily reduced by increasing the safety and security of the clinical relationship. a. Address emotions Surgeons commonly address emotions directly. It is more common in settings where high emotions are expected, such as in cancer clinics, or metabolic surgery. The techniques included directly questioning and exploring emotions, to employing psychologists or nurses who are routinely involved in psychological care, to expanding consultation time. I think in the immediate preoperative period, one of the things that I do in the anaesthetic bay is make sure I acknowledge what I think the patient’s feeling and have a discussion about what they are feeling. - A01 Prioritising recognition of emotions improves the patient's experience. It is a way of developing rapport and maybe improving their treatment outcomes. I mean, they leave happier from an emotional perspective, but [if] I'm not going to fix them medically... some of them probably walk out happier from an emotional point of view. - K14 Unresolved emotions also inhibit the surgical treatment process. That is, dealing with emotions in some way improves the efficiency of treatment. It's a false economy to try and speed somebody out of a room because a clinic's running late, because it's actually going to take you more time in the long term. …Spending a bit of extra time, as frustrating as it can be, will actually be [more] beneficial. - A01 b. Pursue rapport (indirect) Some interviewees prioritise forming a good clinical relationship with the patient. This leads to increased trust and better understanding. After multiple interviews, it became clear that some saw this as an emotion-ameliorating technique. A good relationship may reduce some of the fear and anxiety surrounding surgery (clinical partnership) or may transfer some of the responsibility for the good outcome to the surgeon (clinical dependence). Trust and empathy go along with each other. It will be easier to build up trust if they feel that you can kind of understand what they are worried about and what their concerns are. - M02 Surgeons talk about the need for rapport as an accepted requirement for treatment. It does not seem to be consciously examined. The idea of good rapport was almost always referenced in the context of a poor treatment outcome. A good relationship is a buffer if the clinical relationship is stressed by unexpected results or complications. If you want to be selfish about it, it’s absolutely the best possible investment, ‘cause if that person has a leak or a bleed or doesn’t get the treatment effect that you want... well, you are partners, and it’s already set up and you’re already in a partnership and it’s ok. ... More importantly it’s a much more rewarding way to practice medicine. It does, it does make it more rewarding. - A04 Emotion-avoidant strategies Emotion-avoidant strategies (Figure 2) are commonly used to reduce the time taken for a consultation or encounter, or improve time-efficiency. They are common in life-threatening situations but are not always overtly signposted for patients. a. Not now strategy The “not now” strategy is pausing or deferring emotional engagement. It may be done overtly with a verbal request or explanation from the surgeon, or emotions may be simply ignored. This is a common approach in emergency settings, where there may not be enough time to deal with emotional factors due to the urgency of the physical condition. Eventually, this delay must be resolved, or it becomes a variant of avoiding emotions. I've learnt over time to say, right at this moment we need to talk about this a bit more, but I need to organise a couple of things... Can you hold that thought, write anything down that you want to ask me? I'm going to be 15 minutes and I'm going to come back and give you some time because I think this is important. - A12 Ideally, this is discussed openly with the patients as described above, but it also happens without explanation to the patient. You just have to go, "Well, if this is the path you're gonna take, you've gotta take it now. Sorry." And then I probably came across as a bitch in that situation... They're kind of circling the drain at the moment. Like we can sit here and chat about your feelings, and they're going to be dead? Like, if you want, if you really want to do this, then do this now. - K14 The benefits of deferral depend on the situation, but often relate to perceived urgency and triage. If life-threatening or urgent, the biological condition always takes priority and emotional and psychological interaction is delayed. So, I think it's incredibly important that you recognise from an empathic point of view the difficulty and the stress that they're in. But I would then argue that that's not the time for you to then stop... You would need to recognise that, and we need to put that aside for the moment or five. And I guess that's still showing empathy. - G08 b. Fix-it strategy Emotional intensity is often significantly reduced when there is a successful resolution of the biological or physical problem. Uncertainty, fear, and ongoing symptoms (including pain) are key drivers in ongoing emotional stress. Successful treatment of the underlying physical illness can completely resolve some of these emotions. This approach was described by most interviewees. Surgeons view it as particularly useful when they perceive the underlying biological condition to be straightforward and predict that the outcome of treatment will be successful. The surgeon sees solving the physical symptom as the key to successful treatment, and emotional management. I think that probably would be my response in that setting. So even if someone came in and said I am really worried about this. Don’t worry, we’ll fix it, rather than what's got you worried? - A04 c. Avoid emotions The final strategy is to ignore or avoid emotional factors. This approach seems easier to describe in others. This shows discomfort with intentionally avoiding emotions. Furthermore, when asked for examples of surgeons who were particularly poor in empathy, this was the typical approach described. That depends on what you want to be. It comes down to what the surgeon wants to be. If he just wants to be the technical expert, you can have zero empathy. - M02 Most of the interviewees were uncomfortable with the idea of avoiding emotions, and felt it delivered inadequate care for the patient. It was commonly linked with being indifferent, implying a deficiency or failure. However, it was described as a choice or technique, rather than incompetence. This did not usually equate to being an inadequate or even poor surgeon, if the approach to the underlying physical condition was correct. In technical terms, the guy who can fix you up but not necessarily talk to you about it in a way that you understand... These guys may get the respect of their patients because they can fix them up, but that is probably not the whole experience that a patient needs to overcome their condition. - M02 The perceived advantage of this approach is that it is easier and more time efficient for the surgeon. When speaking about other surgeons or hypothetically, the interviewees linked the behaviour with financial advantage due to efficiency gains. Emotional regulation of self and one's own resources was also suggested as a reason to choose this approach. Well, if you are the God who provides the care, then patients will probably not bother you as much. And if you have separated yourself from emotional engagement with the patient, then when things go wrong, it's just that things went wrong. And I don't have to engage with that distress. - S05 Value and difficulty of addressing emotions. Addressing patient emotions is seen as a functional approach. Unresolved or unaddressed emotions serve as a barrier to many of the surgeons' tasks, particularly educating patients and having a positive outcome at the end of surgical treatment. I think acknowledging an emotion, showing an understanding of emotion or even seeking out an understanding of emotion, I think that is a very powerful rapport building tool and almost to me it’s like emotion is, rather than getting in our way, it’s almost like not seeking emotions, there is an opportunity cost there. - A04 It's probably hard because I have to keep bringing it back and managing the emotion at the same time as ensuring they're actually hearing what I need them to hear. - K14 Barriers to addressing emotions The reluctance to deal with emotions directly was not ubiquitous. However, there was a general perspective from interviewees that exploration and resolution of emotions is not the core business of surgery. There were perceived barriers to dealing with emotions, which explain why some surgeons spend at least some of their clinical encounters deferring or avoiding participation at this level. The most cited barrier to dealing with patient emotions was time available or the risk of delaying other unrelated clinical tasks. Let the person talk. Find out what their real concerns are. That takes a lot of time and energy and a lot of us just don’t have that energy or the patience anymore, to just see and wait for the emotions to come and then address them. - M02 When dealing with urgent or emergency cases, the emotional load is often high, but the time before deterioration of the biological pathology is short. This is a clear conflict, and surgeons openly talk about the compromises they deliberately make in those situations. There's just less time for you to be able to deal with the emotional side of things in that setting. ... in those urgent settings you have to be even more blunt and sometimes you have to push the emotional stuff aside a little bit in order to try and get the message through. - D07 Surgeons also were not confident of their own skills at managing emotions and overwhelmed at the complex psychological and emotional situations they were exposed to. They feel confident and skilled at dealing with physical illness but feel less well-equipped to manage patients’ distress. So, I think those that those that deal with greyness … such as psychiatrists or whatever who, that is a big part of their training, I think would feel much more comfortable than the average surgeon surgical registrar. – G08 Discussion The purpose of this research was to explore empathy in surgeons and to explore how surgeons experience emotions of patients, with reference to the limits and demands of surgical practice. This data demonstrates surgeons’ perception of how they deal with emotions and the choices they make to manage their responses. As empathy is a partially unconscious process, first person interviews can’t measure or value empathy in surgeons, but this data does shed light on the pressures on empathic practice. Surgeons were able to describe their internal responses and attitudes, and strategies that they consciously adapt to respond to the emotions of patients according to clinical pressures. In addition to involuntary responses, surgeons adapt their behaviour depending on the time available, and other factors, like their own personal resources. Although able to discuss this approach, it is not necessarily selected or intentional behaviour. The aim of these behavioural approaches is often to improve treatment efficiency, and approaches are often adapted according to the degree of the patients’ emotional stress (19), which usually varies over the course of treatment. Analysis demonstrated two broad approaches to patient emotions – emotion facing or emotion avoidant strategies. These strategies were further divided into subgroups. Emotion facing strategies included addressing emotions openly and the more indirect approach of pursuing emotional and relationship rapport, and therefore improving trust and reducing anxiety. Emotion-avoidant strategies included deferral, focussing on the biological illness (fix-it strategy) and frank avoidance. Deferral is not a definitive approach and can naturally grow into avoidance if the situation is not deliberately resolved. It is tempting to rank approaches, as empathy is aspirational in our society (7) and there is a bias toward assuming that dealing with emotions openly is "correct" and avoiding emotions is "incorrect". This bias may have contributed to our current poor understanding of empathy in clinical practice. It is much more likely that all approaches to emotion have some validity in different clinical situations. Certainly, the interviewees were aware that they used more than one of these different approaches, depending on the situation. There is research showing surgeons have a variety of responses to emotions in consultations. Levinson studied responses to emotional clues in surgical consultations (20), and demonstrated that surgeons are adept at detecting emotion cues. Surgeons were more likely to respond openly to signals than primary care physicians, but inadequate exploration of emotions is common in most of the clinicians studied (20,21). Surgeons commonly missed clues, but also actively introduced emotional clues in 20% of consultations (21). Surgeons can also actively avoid facing emotions, using inadequate or partial responses, or by open denial, not acknowledging, or creating conversational blocks (20,21). Doctors are also likely to respond to emotional statements with biological or physical information (22). There is also evidence that surgeons emphasise narratives about 'fixing' problems, even in complex consultations (23). These studies reflect the strategies that surgeons are aware of in their own practice. However, the current study demonstrates that surgeons are aware of using different strategies at different times, depending on emotional need and time available, which has not previously been described. Surgeons in this study described adapting their responses to patients from consultation to consultation. Empathy can be seen as a clinical skill or a personality trait, but in this study, surgeons described empathy as an optional tool which is consistent with previous work in surgical trainees (24). The evidence contradicts this, in that a response to emotions of others is usually intuitive, immediate, and unconscious (1,25). Contemporary models of empathy describe an involuntary emotional response, with surrounding layers of cognitive modulation or processing (5,7). Based on this concept, it is unlikely that surgeons are turning off their own emotional response but may be modulating the cognitive or behavioural output. Empathy does vary in intensity (27), and there may be some component of emotional regulation (25,28) or empathy accommodation (14). However, in this instance, the surgeons interviewed are aware of the changes and describe them as voluntary. There is a nexus in the medical literature between true empathy, an internal process that is difficult to measure, and external actions that are perceived as empathy (1,7). These can be considered complex consultation or communication skills. These skills can be taught in empathy training interventions (25) but are probably distinct from the emotional/cognitive empathy response. It is plausible that surgeons describe this set of communication skills when they talk about turning on and off their empathy. That is, their underlying emotional-cognitive response is intact, but they choose whether to superimpose a compassionate communication approach on top of that, depending on the situation. This seems to match an established medical cultural trait that values detached concern, in preference to deliberate emotional involvement (14). It became clear that surgeons are conscious of patients with heightened emotional stress. Although the aim of the study was to investigate surgeon empathy, we discovered surgeons implemented conscious techniques to help them manage highly emotional situations, particularly by restricting or expanding available consultation time. Surgeons sometimes deliberately create more time in consultation when they anticipate higher emotions, like patients with life-threating conditions (32), by rearranging appointments, or booking extra reviews. Conversely, they can limit their own emotional involvement when they have limited reserve or time, by reducing the time for discussion. Without knowledge of how these approaches are perceived, we can’t comment on their effectiveness. There is evidence that focussing on emotions increases consultation time (22), but consultation time is unrelated to perceived empathy (9,33). The use of time restrictions to deliberately reduce engagement or formalise relationships has not previously been described. Limitations This study was limited to general surgeons in Australia, so the results are likely to be culturally biased. It is likely that the practice of empathy in surgeons is affected by cultural and biological factors (34,35), as well as structural healthcare factors, such as the role of surgeons in caring for patients (12). The interviewees represented varied subspecialities and geographic areas within Australia, although females were relatively over-represented (21% of interviewees vs. 17% of general surgical fellows in 2023) (18). As expected, most of the interviewees were interested in empathy and consultation skills, which limited the exploration of different perspectives. Conclusions This research has demonstrated that surgeons are aware of their responses to the emotions of patients and the need to manage them in some way. They have described approaches to either actively resolve emotions, or defer or deny emotions, to manage the impact those emotions have on clinical situations. These strategies can be used to balance urgency, time available and their own psychological resources. Surgeons may have preferred approaches to emotions, but also selectively adjust their technique according to multiple factors, which may not prioritise the patient’s wishes. These factors demonstrate the complexity of surgeon-patient interactions and the need for further research in this area. Declarations Clinical trial number: not applicable Human Ethics Approval: Monash University Human Research Ethics Committee ID 35445 Corresponding author Christine Cuthbertson, PO Box 666, Bendigo, VIC 3552, Australia [email protected] The raw data used for this study (interview transcripts) is not available publicly due to the limitations of participant consent, but can be obtained from the corresponding author on reasonable request. Funding AO Foundation, Switzerland. Fellowship in Medical Education Research References Michalec B, Hafferty FW. Challenging the clinically-situated emotion-deficient version of empathy within medicine and medical education research. Soc Theory Health STH. 2021 Nov 22;1–19. Walocha E, Tomaszewski KA, Wilczek-Ruzyczka E, Walocha J. Empathy and burnout among physicians of different specialities. Folia Med Cracov. 2013;53(2):35–42. 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Mammalian empathy: behavioural manifestations and neural basis. Nat Rev Neurosci. 2017 Aug;18(8):498–509. Levy J, Bader O. Graded Empathy: A Neuro-Phenomenological Hypothesis. Front Psychiatry. 2020;11:554848. McRae K, Gross JJ. Emotion regulation. Emot Wash DC. 2020 Feb;20(1):1–9. Quinn MA, Grant LM, Sampene E, Zelenski AB. A Curriculum to Increase Empathy and Reduce Burnout. WMJ Off Publ State Med Soc Wis. 2020 Dec;119(4):258–62. Kim KJ. Project-based learning approach to increase medical student empathy. Med Educ Online. 2020 Dec;25(1):1742965. Bearman M, Palermo C, Allen LM, Williams B. Learning Empathy Through Simulation: A Systematic Literature Review. Simul Healthc J Soc Simul Healthc. 2015 Oct;10(5):308–19. Marterre B. Surgeon-Patient Cross∼Talk: How It Happens, How to Fix It. Am Surg. 2023 Sep;89(9):3695–701. Kortlever JTP, Ottenhoff JSE, Vagner GA, Ring D, Reichel LM. Visit Duration Does Not Correlate with Perceived Physician Empathy. J Bone Joint Surg Am. 2019 Feb 20;101(4):296–301. Chopik WJ, O’Brien E, Konrath SH. Differences in Empathic Concern and Perspective Taking Across 63 Countries. J Cross-Cult Psychol. 2017 Jan;48(1):23–38. Christov-Moore L, Simpson EA, Coudé G, Grigaityte K, Iacoboni M, Ferrari PF. Empathy: gender effects in brain and behavior. Neurosci Biobehav Rev. 2014 Oct;46 Pt 4:604–27. Additional Declarations No competing interests reported. Supplementary Files AppendixS1interviewguide.pdf Cite Share Download PDF Status: Published Journal Publication published 29 Oct, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 19 May, 2025 Reviews received at journal 21 Apr, 2025 Reviews received at journal 20 Apr, 2025 Reviewers agreed at journal 20 Apr, 2025 Reviewers agreed at journal 16 Apr, 2025 Reviewers invited by journal 14 Apr, 2025 Editor assigned by journal 08 Apr, 2025 Editor invited by journal 19 Mar, 2025 Submission checks completed at journal 18 Mar, 2025 First submitted to journal 18 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6124486","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":447238279,"identity":"1de01a6f-ef3e-4fd4-9033-772ee16ded20","order_by":0,"name":"Christine Cuthbertson","email":"data:image/png;base64,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","orcid":"","institution":"University of Melbourne","correspondingAuthor":true,"prefix":"","firstName":"Christine","middleName":"","lastName":"Cuthbertson","suffix":""},{"id":447238281,"identity":"9ca9b34a-de4f-40d3-a969-33373f257c25","order_by":1,"name":"Jenepher Martin","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Jenepher","middleName":"","lastName":"Martin","suffix":""},{"id":447238282,"identity":"c0f3aa3a-a377-4718-8d11-b16425a7c595","order_by":2,"name":"Debra Nestel","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Debra","middleName":"","lastName":"Nestel","suffix":""}],"badges":[],"createdAt":"2025-02-28 01:53:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6124486/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6124486/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-08075-w","type":"published","date":"2025-10-29T15:58:36+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82133854,"identity":"ece268f0-fca0-48fd-83a8-574359dcac87","added_by":"auto","created_at":"2025-05-07 06:00:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":42715,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEmotion-facing strategies used in surgical practice\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e (E = Emotional dysfunction; B = Biological illness; R = Relationship with patient). The direct approach to emotions aims to openly diffuse any emotional stressors. The indirect approach prioritises forming a strong relationship and trust with the patient, without openly discussing emotions\u003c/em\u003e.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6124486/v1/aa35e2e96ac09ac8f7bcb190.png"},{"id":82133855,"identity":"a260b5d5-2039-41be-8638-eaccb48026db","added_by":"auto","created_at":"2025-05-07 06:00:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":56937,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEmotion avoidant strategies used in surgical practice\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e (E = Emotional dysfunction; B = Biological illness). The \"Not now\" strategy to emotions defers any resolution of emotions. The \"Fix it\" strategy focuses on resolution of biological illness to reduce overall emotional intensity, and avoid the need to deal with emotions. The Avoid strategy avoids addressing patient emotions entirely.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6124486/v1/60fc698a48c56bd20f4a1c9d.png"},{"id":95040049,"identity":"3931138a-d004-4083-9296-267c7536788c","added_by":"auto","created_at":"2025-11-03 16:08:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":726351,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6124486/v1/9393bdfe-0e2a-403c-87fa-004b049cab03.pdf"},{"id":82135431,"identity":"71759591-d9fb-4eb2-a2d9-cb83e9b8a869","added_by":"auto","created_at":"2025-05-07 06:08:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":69065,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixS1interviewguide.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6124486/v1/6a7ec85155a9ef50c903ed4f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring how surgeons employ empathy in clinical practice: a qualitative study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEmpathy is an individual social process to deal with the emotions of others. \u0026nbsp;It can be defined as the ability to understand the perspective and emotions of a patient, communicate and respond to that understanding (5). \u0026nbsp;It combines perception and processing, both emotional and cognitive (1,6). While the experience of empathy is internal (1) and not entirely conscious, it may lead to outward behavioural manifestations (7). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEmpathy is a key characteristic of interest in healthcare. \u0026nbsp;Empathy is associated with higher patient satisfaction and improved patient compliance (5,8,9), and lower rate of treatment-associated trauma and anxiety (5,10), and even improved physiological recovery from illness (11). \u0026nbsp;It may also contribute to improved physician health and wellbeing (5). \u0026nbsp; Procedural specialists such as surgeons, anaesthetists, and radiologists have a lower measured empathy than other physicians (9,12), but the absolute difference is small (9), and the patterns are not consistent across studies (12). \u0026nbsp;The factors associated with the difference are unknown (9,12). Empathy may be confounded by specialty specific factors, such as the need to cause pain but also potentially relief and resolution, but there has been little targeted research into empathy in surgeons.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEmpathy research in healthcare has been hindered by inconsistent definitions (5,11,13). \u0026nbsp;Investigation of cognitive and behavioural processes of empathy have been dominant\u0026nbsp;(1,5,13–15), to the extent that emotional processes has been deemphasised\u0026nbsp;(1,14). \u0026nbsp;Most models of empathy emphasise that both cognitive and emotional processes are key components of the empathy response. \u0026nbsp;However, a focus on cognitive processes in empathy research, tends to emphasize the conscious aspects of empathy and de-emphasize the more subconscious emotional response. \u0026nbsp;Research has also focussed more on measurements of empathy in different demographic and specialty groups, with little exploration of the reasons for differences\u0026nbsp;(13). \u0026nbsp;Measures used have variable validity\u0026nbsp;(5)\u0026nbsp;and are mainly self-reported scales, which are prone to distortion, particularly by stress, burnout and self-image\u0026nbsp;(5,11). \u0026nbsp; A common response to perceived deficiencies, is to formally teach empathy skills to procedural specialists\u0026nbsp;(7). This approach aligns with a hypothesis that increasing empathy will cause an improvement of patient outcomes, without any negative effect on patient or surgeon. \u0026nbsp;That is, that empathy levels are independent of capacity to complete practice tasks or responsibilities. \u0026nbsp;However, this is untested, as there has been insufficient research into the interaction between practice pressures and empathy, particularly in procedural specialists.\u003c/p\u003e\n\u003cp\u003eThis study was designed to explore and develop a theory of how surgeons experience emotions in clinical practice and how they develop and use clinical empathy. Interest will be given to the role of factors particular to surgical practice. A deeper understanding of empathy in surgeons is vital to develop a response to perceived or real deficiencies.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy design\u003c/h2\u003e\n\u003cp\u003eThis study was designed to investigate the role of empathy in patient surgeon interactions, and how surgeons respond to the emotions of patients in clinical situations.\u003c/p\u003e\n\u003cp\u003eThis qualitative study used semi-structured interviews with general surgeons, analysed in the Constructivist Grounded Theory (16,17) tradition. The research paradigm was constructivist, which accepts that social phenomena and their meaning are subjective and in constant revision. \u0026nbsp;Actors interact with the world, and knowledge is generated as they make sense of their experiences.\u003c/p\u003e\n\u003cp\u003eThis study was facilitated by a group of researchers with diverse perspectives and research experience. This study was designed by Author A who works as a general surgeon and became uncomfortable with a perceived simplification of surgeons\u0026rsquo; communication skills, particularly with respect to emotional management. \u0026nbsp;She had previously completed a PhD in Surgery but has more limited experience in educational and qualitative research. \u0026nbsp; Author B is a clinical surgeon with extended experience in education research. \u0026nbsp;Author C is an experienced educationalist with extensive experience in qualitative and quantitative research, who has often worked with surgeons and procedural specialists. \u0026nbsp;Research Assistant D is a social worker with previous research in reflective practice, who collaborated particularly on coding and analysis. \u0026nbsp;A balance of subject expertise allowed differences in perspective and promoted both detailed data collection with a surgeon interviewer, but also a balanced perspective on the analysis of that data.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eEthics Approval and Consent to Participate\u003c/h2\u003e\n\u003cp\u003eThe relevant Human Research Ethics Committee[1] approved all research procedures. \u0026nbsp; Informed consent was documented for all participants. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eParticipants\u003c/h2\u003e\n\u003cp\u003eWe chose to interview Australian general surgeons. \u0026nbsp;All participants had current registration and were a Fellow of the Royal Australasian College of Surgeons (RACS). \u0026nbsp; Surgeons who had ceased work more than six months prior to recruitment, or worked clinically with the primary investigator were excluded. \u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eRecruitment\u003c/h4\u003e\n\u003cp\u003eParticipants were recruited for a semi-structured interview. The recruitment was by email sent through General Surgeons Australia (GSA), the professional body of general surgeons in Australia under the umbrella of RACS. \u0026nbsp;Additional surgeons were recruited by word of mouth and personal recommendation from interviewees.\u003c/p\u003e\n\u003cp\u003e21 surgeons volunteered in response to the initial invitation. \u0026nbsp;Two were ineligible for interview, as one worked with the primary researcher, and one was not in clinical practice. \u0026nbsp;Four further surgeons were recruited by other means. \u0026nbsp;Out of 22 eligible volunteers, 14 were interviewed, selected in chronological order of those who volunteered (Table 1). \u0026nbsp;The selected interviewees represent an adequate representation of practicing general surgeons in Australia, within the limits of a small sample size. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 1: Demographics of interviewees in context of Australian surgical workforce.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eDemographics of General surgeons in Australia (18) \u0026nbsp;(n=3001)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eParticipants interviewed (n = 14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e2483 (82.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e11 (78.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e517 (17.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e3 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eOther/unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e1 (\u0026lt;0.01%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003eState\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eNSW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e821 (27.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e5 (35.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eVIC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e660 (22.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e6 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eQLD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e462 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e1 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eWA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e209 (7.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e2 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e206 (6.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003eTAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e41 (1.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch4\u003eInterviews\u003c/h4\u003e\n\u003cp\u003eAll interviews were conducted by Author A using online commercial meeting software (Zoom Video Communications, Inc). The initial interview prompts and plan was designed for this project according to the research question. The interview focused on the experiences and perspectives of the interviewees on empathy in clinical practice. \u0026nbsp;To avoid bias related to previous understanding of the term \u0026ldquo;empathy\u0026rdquo;, questions were focussed on perceiving and responding to the emotions of patients, and a definition of empathy was not supplied. \u0026nbsp; \u0026nbsp;All interviews progressed with an exploratory intent. The initial set of questions for the early interviews is presented in supplemental material. Interviews were recorded, transcribed and anonymised with alphanumerical codes based on recruitment order and initial. \u0026nbsp;The median interview length was 1 hour 21 minutes. \u0026nbsp;Transcripts were shared with the full research team for analysis. Interviews continued until theoretical sufficiency was reached (14 interviews total).\u003c/p\u003e\n\u003ch2\u003eAnalysis\u003c/h2\u003e\n\u003cp\u003eData analysis was conducted in the Constructivist Grounded Theory (16) tradition. \u0026nbsp;Interview transcripts were analysed using constant comparative technique to identify and refine recurring themes (17). The analysis of the transcripts was performed by Author A and Researcher D. Identified codes and themes were integrated into the interview guide for future interviews. \u0026nbsp;Ineffective questions were removed, and new stems aiming to explore emerging codes were added. \u0026nbsp; Using a codebook, initial codes were collated into refined codes, and themes were developed. \u0026nbsp;As data collection continued, themes were challenged to ensure they were representative of a wide experience.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen collected data consistently fit existing themes, a theory was constructed to describe the data. \u0026nbsp; This was proposed by the primary investigator and developed in discussion with all authors. \u0026nbsp;After drafting the theory, three further interviews were held to discuss the theory and the contributing themes. \u0026nbsp; These interviews were coded in turn and the theory was edited to encompass the new data.\u003c/p\u003e\n\u003ch4\u003eAnalysis choices \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eThemes developed from the data were diverse and represented topics from consultation skills and communication to personal distress and surgeon self-image. In development of a theory, a description of practice was prioritised that was value-neutral and explained both positive and negative experiences. \u0026nbsp;This is compatible with the exploratory nature of the interviews, which did not attempt to determine best practice, but simply describe emotion management techniques. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[1] Monash University Human Research Ethics Committee \u0026ndash; project reference 35445\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOur analysis demonstrated discrete strategies for approaching patient emotions in clinical settings. In some instances, responses to emotions are clearly spontaneous, but may also be conscious strategies. \u0026nbsp;When describing others, interviewees could recognise that some strategies are more helpful for the patient, and in self-reflection, some could see benefits and issues with their own approach. \u0026nbsp;Surgeons’ techniques may be pervasive, or they may use different approaches, depending on the situation.\u003c/p\u003e\n\u003ch2\u003eConscious and unconscious approaches to empathy\u003c/h2\u003e\n\u003ch4\u003eEmpathy threshold\u003c/h4\u003e\n\u003cp\u003eIf a clinical situation has parallels with the surgeon's own life, then the emotional response is more likely to be spontaneous and have a stronger impact on the surgeon. \u0026nbsp;One interviewee called this the \"empathy threshold\". \u0026nbsp;It is affected by previous patient interactions, one's own life experiences, and other personal biases. \u0026nbsp;This leads to easier emotional engagement with some patients than with others.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e[W]e bring a threshold into that interaction with us... The most obvious example is … someone with a cancer diagnosis. I think society and med school and the whole thing has geared us towards that being a low threshold for developing empathy... Whereas if it was someone with something more stigmatised - mental health, addiction, obesity, ... There is a threshold that needs to be overcome. - A04\u003c/em\u003e\u003c/p\u003e\n\u003ch4\u003eEmpathy as an optional tool\u003c/h4\u003e\n\u003cp\u003eParticipants talked about a deliberate choice to turn empathy on and off. The choice was often made around utility or efficiency. That is, surgeons can use time and energy to engage with emotions if it makes a difference in the outcome or consultation. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe idea that surgeons lack empathy I think is a different one to surgeons don’t display empathy, don’t use empathy or however that should be worded. But I wonder if that’s what it is, whether empathy is something we see as a tool to use or not use depending on the situation in front of us. - A04\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis idea implies that different aspects of surgical practice need different attention to emotion. \u0026nbsp;Surgeons use concrete methods, such as adjust scheduling to facilitate or inhibit emotional discussions. \u0026nbsp; Surgeons describe predicting the degree of emotional stress in an upcoming consultation and deliberately increasing or reducing allocated time or arranging psychological support. \u0026nbsp;This also can be used to reduce emotional engagement.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf it's … a situation that …, may be quite distressing for you as the surgeon... You might want to avoid going and unpacking and moving them from a patient to a person, or a condition to a person because of the costs associated with that…. So, your choice of how much you choose to engage with that patient will then influence …the depth and the richness of the empathy that actually is developed. – G08\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003eStrategies to deal with emotions\u003c/h2\u003e\n\u003cp\u003eTo describe the approaches of surgeons to emotions, diagnosis and treatment can be considered to have a biological component (illness) and an emotional component (emotional dysfunction), which vary in strength, depending on the pathology and patient. Strategies ranged from directly addressing patients’ emotions to completely avoiding them. “Emotion-facing strategies” diffuse emotions in some way, and “Emotion-avoidant strategies” bypass emotions and focus primarily on the biological illness. This may also encompass psychological, social, and other stressors, through their impact on emotions.\u003c/p\u003e\n\u003cp\u003eSurgeons described different approaches to emotions depending on context and condition, but also on the personality and comfort level of the surgeon. \u0026nbsp;For example, the interviewees felt that the emotion-facing strategies were easier in clinic consultations and that the emotion-deferred or emotion-avoidant strategies were more likely to be used in emergency or ward settings. \u0026nbsp;However, many described feeling most comfortable with a particular strategy, even if they understood its limitations.\u003c/p\u003e\n\u003cp\u003eEmotion-facing strategies (Figure 1) include direct and indirect approaches. Direct approaches acknowledge the role of emotions and actively seek to address them. \u0026nbsp;Indirect approaches usually focus on developing a strong clinical rapport to reduce patient stress. \u0026nbsp;Patient emotions may be acknowledged, but they are primarily reduced by increasing the safety and security of the clinical relationship.\u003c/p\u003e\n\u003ch5\u003ea. Address emotions\u003c/h5\u003e\n\u003cp\u003eSurgeons commonly address emotions directly. \u0026nbsp;It is more common in settings where high emotions are expected, such as in cancer clinics, or metabolic surgery. \u0026nbsp;The techniques included directly questioning and exploring emotions, to employing psychologists or nurses who are routinely involved in psychological care, to expanding consultation time.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think in the immediate preoperative period, one of the things that I do in the anaesthetic bay is make sure I acknowledge what I think the patient’s feeling and have a discussion about what they are feeling. - A01\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePrioritising recognition of emotions improves the patient's experience. \u0026nbsp;It is a way of developing rapport and maybe improving their treatment outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI mean, they leave happier from an emotional perspective, but [if] I'm not going to fix them medically... some of them probably walk out happier from an emotional point of view. - K14\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eUnresolved emotions also inhibit the surgical treatment process. \u0026nbsp;That is, dealing with emotions in some way improves the efficiency of treatment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt's a false economy to try and speed somebody out of a room because a clinic's running late, because it's actually going to take you more time in the long term. …Spending a bit of extra time, as frustrating as it can be, will actually be [more] beneficial. - A01\u003c/em\u003e\u003c/p\u003e\n\u003ch5\u003eb. Pursue rapport (indirect)\u003c/h5\u003e\n\u003cp\u003eSome interviewees prioritise forming a good clinical relationship with the patient. This leads to increased trust and better understanding. After multiple interviews, it became clear that some saw this as an emotion-ameliorating technique. A good relationship may reduce some of the fear and anxiety surrounding surgery (clinical partnership) or may transfer some of the responsibility for the good outcome to the surgeon (clinical dependence).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTrust and empathy go along with each other. It will be easier to build up trust if they feel that you can kind of understand what they are worried about and what their concerns are. - M02\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSurgeons talk about the need for rapport as an accepted requirement for treatment. It does not seem to be consciously examined. The idea of good rapport was almost always referenced in the context of a poor treatment outcome. \u0026nbsp;A good relationship is a buffer if the clinical relationship is stressed by unexpected results or complications.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIf you want to be selfish about it, it’s absolutely the best possible investment, ‘cause if that person has a leak or a bleed or doesn’t get the treatment effect that you want... well, you are partners, and it’s already set up and you’re already in a partnership and it’s ok. ... More importantly it’s a much more rewarding way to practice medicine. \u0026nbsp;It does, it does make it more rewarding. - A04\u003c/em\u003e\u003c/p\u003e\n\u003ch4\u003eEmotion-avoidant strategies\u003c/h4\u003e\n\u003cp\u003eEmotion-avoidant strategies (Figure 2) are commonly used to reduce the time taken for a consultation or encounter, or improve time-efficiency. \u0026nbsp;They are common in life-threatening situations but are not always overtly signposted for patients. \u0026nbsp;\u003c/p\u003e\n\u003ch5\u003ea.\u0026nbsp; \u0026nbsp;\u0026nbsp;Not now strategy\u003c/h5\u003e\n\u003cp\u003eThe “not now” strategy is pausing or deferring emotional engagement. \u0026nbsp;It may be done overtly with a verbal request or explanation from the surgeon, or emotions may be simply ignored. This is a common approach in emergency settings, where there may not be enough time to deal with emotional factors due to the urgency of the physical condition. Eventually, this delay must be resolved, or it becomes a variant of avoiding emotions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI've learnt over time to say, right at this moment we need to talk about this a bit more, but I need to organise a couple of things... Can you hold that thought, write anything down that you want to ask me? I'm going to be 15 minutes and I'm going to come back and give you some time because I think this is important. - A12\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIdeally, this is discussed openly with the patients as described above, but it also happens without explanation to the patient.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eYou just have to go, \"Well, if this is the path you're gonna take, you've gotta take it now. Sorry.\" And then I probably came across as a bitch in that situation... They're kind of circling the drain at the moment. Like we can sit here and chat about your feelings, and they're going to be dead? Like, if you want, if you really want to do this, then do this now. - K14\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe benefits of deferral depend on the situation, but often relate to perceived urgency and triage. \u0026nbsp; If life-threatening or urgent, the biological condition always takes priority and emotional and psychological interaction is delayed. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo, I think it's incredibly important that you recognise from an empathic point of view the difficulty and the stress that they're in. But I would then argue that that's not the time for you to then stop... You would need to recognise that, and we need to put that aside for the moment or five. And I guess that's still showing empathy. - G08\u003c/em\u003e\u003c/p\u003e\n\u003ch5\u003eb.\u0026nbsp; \u0026nbsp;\u0026nbsp;Fix-it strategy\u003c/h5\u003e\n\u003cp\u003eEmotional intensity is often significantly reduced when there is a successful resolution of the biological or physical problem. \u0026nbsp;Uncertainty, fear, and ongoing symptoms (including pain) are key drivers in ongoing emotional stress. \u0026nbsp;Successful treatment of the underlying physical illness can completely resolve some of these emotions. \u0026nbsp;This approach was described by most interviewees. \u0026nbsp;Surgeons view it as particularly useful when they perceive the underlying biological condition to be straightforward and predict that the outcome of treatment will be successful. The surgeon sees solving the physical symptom as the key to successful treatment, and emotional management. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think that probably would be my response in that setting. So even if someone came in and said I am really worried about this. \u0026nbsp;Don’t worry, we’ll fix it, rather than what's got you worried? - A04\u003c/em\u003e\u003c/p\u003e\n\u003ch5\u003ec.\u0026nbsp; \u0026nbsp;\u0026nbsp;Avoid emotions\u003c/h5\u003e\n\u003cp\u003eThe final strategy is to ignore or avoid emotional factors. \u0026nbsp;This approach seems easier to describe in others. \u0026nbsp;This shows discomfort with intentionally avoiding emotions. \u0026nbsp;Furthermore, when asked for examples of surgeons who were particularly poor in empathy, this was the typical approach described.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThat depends on what you want to be. It comes down to what the surgeon wants to be. If he just wants to be the technical expert, you can have zero empathy. - M02\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost of the interviewees were uncomfortable with the idea of avoiding emotions, and felt it delivered inadequate care for the patient. \u0026nbsp;It was commonly linked with being indifferent, implying a deficiency or failure. However, it was described as a choice or technique, rather than incompetence. \u0026nbsp; This did not usually equate to being an inadequate or even poor surgeon, if the approach to the underlying physical condition was correct. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIn technical terms, the guy who can fix you up but not necessarily talk to you about it in a way that you understand... These guys may get the respect of their patients because they can fix them up, but that is probably not the whole experience that a patient needs to overcome their condition. - M02\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe perceived advantage of this approach is that it is easier and more time efficient for the surgeon. \u0026nbsp; When speaking about other surgeons or hypothetically, the interviewees linked the behaviour with financial advantage due to efficiency gains. \u0026nbsp;Emotional regulation of self and one's own resources was also suggested as a reason to choose this approach.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWell, if you are the God who provides the care, then patients will probably not bother you as much. And if you have separated yourself from emotional engagement with the patient, then when things go wrong, it's just that things went wrong. And I don't have to engage with that distress. - S05\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003eValue and difficulty of addressing emotions.\u003c/h2\u003e\n\u003cp\u003eAddressing patient emotions is seen as a functional approach. \u0026nbsp;Unresolved or unaddressed emotions serve as a barrier to many of the surgeons' tasks, particularly educating patients and having a positive outcome at the end of surgical treatment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI think acknowledging an emotion, showing an understanding of emotion or even seeking out an understanding of emotion, I think that is a very powerful rapport building tool and almost to me it’s like emotion is, rather than getting in our way, it’s almost like not seeking emotions, there is an opportunity cost there. - A04\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIt's probably hard because I have to keep bringing it back and managing the emotion at the same time as ensuring they're actually hearing what I need them to hear. - K14\u003c/em\u003e\u003c/p\u003e\n\u003ch4\u003eBarriers to addressing emotions\u003c/h4\u003e\n\u003cp\u003eThe reluctance to deal with emotions directly was not ubiquitous. \u0026nbsp;However, there was a general perspective from interviewees that exploration and resolution of emotions is not the core business of surgery. There were perceived barriers to dealing with emotions, which explain why some surgeons spend at least some of their clinical encounters deferring or avoiding participation at this level. \u0026nbsp;The most cited barrier to dealing with patient emotions was time available or the risk of delaying other unrelated clinical tasks.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLet the person talk. Find out what their real concerns are. That takes a lot of time and energy and a lot of us just don’t have that energy or the patience anymore, to just see and wait for the emotions to come and then address them. - M02\u003c/em\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen dealing with urgent or emergency cases, the emotional load is often high, but the time before deterioration of the biological pathology is short. This is a clear conflict, and surgeons openly talk about the compromises they deliberately make in those situations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThere's just less time for you to be able to deal with the emotional side of things in that setting. ... in those urgent settings you have to be even more blunt and sometimes you have to push the emotional stuff aside a little bit in order to try and get the message through. - D07 \u0026nbsp; \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSurgeons also were not confident of their own skills at managing emotions and overwhelmed at the complex psychological and emotional situations they were exposed to. \u0026nbsp;They feel confident and skilled at dealing with physical illness but feel less well-equipped to manage patients’ distress.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSo, I think those that those that deal with greyness … such as psychiatrists or whatever who, that is a big part of their training, I think would feel much more comfortable than the average surgeon surgical registrar. – G08\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe purpose of this research was to explore empathy in surgeons and to explore how surgeons experience emotions of patients, with reference to the limits and demands of surgical practice. This data demonstrates surgeons’ perception of how they deal with emotions and the choices they make to manage their responses. As empathy is a partially unconscious process, first person interviews can’t measure or value empathy in surgeons, but this data does shed light on the pressures on empathic practice. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSurgeons were able to describe their internal responses and attitudes, and strategies that they consciously adapt to respond to the emotions of patients according to clinical pressures. \u0026nbsp;In addition to involuntary responses, surgeons adapt their behaviour depending on the time available, and other factors, like their own personal resources. Although able to discuss this approach, it is not necessarily selected or intentional behaviour. \u0026nbsp; The aim of these behavioural approaches is often to improve treatment efficiency, and approaches are often adapted according to the degree of the patients’ emotional stress (19), which usually varies over the course of treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnalysis demonstrated two broad approaches to patient emotions – emotion facing or emotion avoidant strategies. These strategies were further divided into subgroups. \u0026nbsp;Emotion facing strategies included addressing emotions openly and the more indirect approach of pursuing emotional and relationship rapport, and therefore improving trust and reducing anxiety. \u0026nbsp; Emotion-avoidant strategies included deferral, focussing on the biological illness (fix-it strategy) and frank avoidance. Deferral is not a definitive approach and can naturally grow into avoidance if the situation is not deliberately resolved. \u0026nbsp; It is tempting to rank approaches, as empathy is aspirational in our society (7) and there is a bias toward assuming that dealing with emotions openly is \"correct\" and avoiding emotions is \"incorrect\". This bias may have contributed to our current poor understanding of empathy in clinical practice. \u0026nbsp;It is much more likely that all approaches to emotion have some validity in different clinical situations. \u0026nbsp;Certainly, the interviewees were aware that they used more than one of these different approaches, depending on the situation.\u003c/p\u003e\n\u003cp\u003eThere is research showing surgeons have a variety of responses to emotions in consultations. \u0026nbsp;Levinson studied responses to emotional clues in surgical consultations (20), and demonstrated that surgeons are adept at detecting emotion cues. Surgeons were more likely to respond openly to signals than primary care physicians, but inadequate exploration of emotions is common in most of the clinicians studied (20,21). \u0026nbsp; \u0026nbsp;Surgeons commonly missed clues, but also actively introduced emotional clues in 20% of consultations (21). Surgeons can also actively avoid facing emotions, using inadequate or partial responses, or by open denial, not acknowledging, or creating conversational blocks (20,21). Doctors are also likely to respond to emotional statements with biological or physical information (22). There is also evidence that surgeons emphasise narratives about 'fixing' problems, even in complex consultations (23). \u0026nbsp; These studies reflect the strategies that surgeons are aware of in their own practice. \u0026nbsp; However, the current study demonstrates that surgeons are aware of using different strategies at different times, depending on emotional need and time available, which has not previously been described.\u003c/p\u003e\n\u003cp\u003eSurgeons in this study described adapting their responses to patients from consultation to consultation. \u0026nbsp;Empathy can be seen as a clinical skill or a personality trait, but in this study, surgeons described empathy as an optional tool which is consistent with previous work in surgical trainees (24). \u0026nbsp;The evidence contradicts this, in that a response to emotions of others is usually intuitive, immediate, and unconscious (1,25). \u0026nbsp;Contemporary models of empathy describe an involuntary emotional response, with surrounding layers of cognitive modulation or processing (5,7). Based on this concept, it is unlikely that surgeons are turning off their own emotional response but may be modulating the cognitive or behavioural output. \u0026nbsp;Empathy does vary in intensity (27), and there may be some component of emotional regulation (25,28) or empathy accommodation (14). However, in this instance, the surgeons interviewed are aware of the changes and describe them as voluntary.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere is a nexus in the medical literature between true empathy, an internal process that is difficult to measure, and external actions that are perceived as empathy (1,7). These can be considered complex consultation or communication skills. \u0026nbsp; These skills can be taught in empathy training interventions\u0026nbsp;(25)\u0026nbsp;but are probably distinct from the emotional/cognitive empathy response. \u0026nbsp; It is plausible that surgeons describe this set of communication skills when they talk about turning on and off their empathy. That is, their underlying emotional-cognitive response is intact, but they choose whether to superimpose a compassionate communication approach on top of that, depending on the situation. \u0026nbsp;This seems to match an established medical cultural trait that values detached concern, in preference to deliberate emotional involvement\u0026nbsp;(14).\u003c/p\u003e\n\u003cp\u003eIt became clear that surgeons are conscious of patients with heightened emotional stress. Although the aim of the study was to investigate surgeon empathy, we discovered surgeons implemented conscious techniques to help them manage highly emotional situations, particularly by restricting or expanding available consultation time. \u0026nbsp;Surgeons sometimes deliberately create more time in consultation when they anticipate higher emotions, like patients with life-threating conditions (32), by rearranging appointments, or booking extra reviews. Conversely, they can limit their own emotional involvement when they have limited reserve or time, by reducing the time for discussion. \u0026nbsp;Without knowledge of how these approaches are perceived, we can’t comment on their effectiveness. There is evidence that focussing on emotions increases consultation time (22), but consultation time is unrelated to perceived empathy (9,33). The use of time restrictions to deliberately reduce engagement or formalise relationships has not previously been described.\u003c/p\u003e\n\u003ch2\u003eLimitations\u003c/h2\u003e\n\u003cp\u003eThis study was limited to general surgeons in Australia, so the results are likely to be culturally biased. \u0026nbsp;It is likely that the practice of empathy in surgeons is affected by cultural and biological factors (34,35), as well as structural healthcare factors, such as the role of surgeons in caring for patients (12). The interviewees represented varied subspecialities and geographic areas within Australia, although females were relatively over-represented (21% of interviewees vs. 17% of general surgical fellows in 2023) (18). \u0026nbsp;As expected, most of the interviewees were interested in empathy and consultation skills, which limited the exploration of different perspectives.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis research has demonstrated that surgeons are aware of their responses to the emotions of patients and the need to manage them in some way. \u0026nbsp;They have described approaches to either actively resolve emotions, or defer or deny emotions, to manage the impact those emotions have on clinical situations. \u0026nbsp;These strategies can be used to balance urgency, time available and their own psychological resources. \u0026nbsp;Surgeons may have preferred approaches to emotions, but also selectively adjust their technique according to multiple factors, which may not prioritise the patient’s wishes. These factors demonstrate the complexity of surgeon-patient interactions and the need for further research in this area.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eClinical trial number: not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHuman Ethics Approval: Monash University Human Research Ethics Committee ID 35445\u003c/p\u003e\n\u003cp\u003eCorresponding author\u003c/p\u003e\n\u003cp\u003eChristine Cuthbertson, PO Box 666, Bendigo, VIC \u0026nbsp;3552, Australia\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eThe raw data used for this study (interview transcripts) is not available publicly due to the limitations of participant consent, but can be obtained from the corresponding author on reasonable request. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eAO Foundation, Switzerland. Fellowship in Medical Education Research\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMichalec B, Hafferty FW. Challenging the clinically-situated emotion-deficient version of empathy within medicine and medical education research. Soc Theory Health STH. 2021 Nov 22;1\u0026ndash;19.\u003c/li\u003e\n \u003cli\u003eWalocha E, Tomaszewski KA, Wilczek-Ruzyczka E, Walocha J. Empathy and burnout among physicians of different specialities. Folia Med Cracov. 2013;53(2):35\u0026ndash;42.\u003c/li\u003e\n \u003cli\u003eHojat M. Change in empathy in medical school. Med Educ. 2018 Apr;52(4):456\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eTariq N, Tayyab A, Jaffery T. Differences in Empathy Levels of Medical Students Based on Gender, Year of Medical School and Career Choice. J Coll Physicians Surg--Pak JCPSP. 2018 Apr;28(4):310\u0026ndash;3.\u003c/li\u003e\n \u003cli\u003eMalbois E, Hurst-Majno S. 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Available from: https://www.surgeons.org/Resources/reports-guidelines-publications/workforce-activities-reports\u003c/li\u003e\n \u003cli\u003eHogikyan ND, Kana LA, Shuman AG, Firn JI. Patient perceptions of trust formation in the surgeon-patient relationship: A thematic analysis. Patient Educ Couns. 2021 Sep 1;104(9):2338\u0026ndash;43.\u003c/li\u003e\n \u003cli\u003eLevinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA. 2000 Aug 23;284(8):1021\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003evan Hoorn BT, Menendez ME, Mackert M, Donovan EE, van Heijl M, Ring D. Missed Empathic Opportunities During Hand Surgery Office Visits. Hand N Y N. 2021 Sep;16(5):698\u0026ndash;705.\u003c/li\u003e\n \u003cli\u003eBeach WA, Dozier DM. Fears, Uncertainties, and Hopes: Patient-Initiated Actions and Doctors\u0026rsquo; Responses During Oncology Interviews. 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Nat Rev Neurosci. 2017 Aug;18(8):498\u0026ndash;509.\u003c/li\u003e\n \u003cli\u003eLevy J, Bader O. Graded Empathy: A Neuro-Phenomenological Hypothesis. Front Psychiatry. 2020;11:554848.\u003c/li\u003e\n \u003cli\u003eMcRae K, Gross JJ. Emotion regulation. Emot Wash DC. 2020 Feb;20(1):1\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eQuinn MA, Grant LM, Sampene E, Zelenski AB. A Curriculum to Increase Empathy and Reduce Burnout. WMJ Off Publ State Med Soc Wis. 2020 Dec;119(4):258\u0026ndash;62.\u003c/li\u003e\n \u003cli\u003eKim KJ. Project-based learning approach to increase medical student empathy. Med Educ Online. 2020 Dec;25(1):1742965.\u003c/li\u003e\n \u003cli\u003eBearman M, Palermo C, Allen LM, Williams B. Learning Empathy Through Simulation: A Systematic Literature Review. Simul Healthc J Soc Simul Healthc. 2015 Oct;10(5):308\u0026ndash;19.\u003c/li\u003e\n \u003cli\u003eMarterre B. Surgeon-Patient Cross\u0026sim;Talk: How It Happens, How to Fix It. Am Surg. 2023 Sep;89(9):3695\u0026ndash;701.\u003c/li\u003e\n \u003cli\u003eKortlever JTP, Ottenhoff JSE, Vagner GA, Ring D, Reichel LM. Visit Duration Does Not Correlate with Perceived Physician Empathy. J Bone Joint Surg Am. 2019 Feb 20;101(4):296\u0026ndash;301.\u003c/li\u003e\n \u003cli\u003eChopik WJ, O\u0026rsquo;Brien E, Konrath SH. Differences in Empathic Concern and Perspective Taking Across 63 Countries. J Cross-Cult Psychol. 2017 Jan;48(1):23\u0026ndash;38.\u003c/li\u003e\n \u003cli\u003eChristov-Moore L, Simpson EA, Coud\u0026eacute; G, Grigaityte K, Iacoboni M, Ferrari PF. Empathy: gender effects in brain and behavior. Neurosci Biobehav Rev. 2014 Oct;46 Pt 4:604\u0026ndash;27.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Empathy, Clinical skills, General Surgery, Consultation skills, Quality of care","lastPublishedDoi":"10.21203/rs.3.rs-6124486/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6124486/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch3\u003eIntroduction\u003c/h3\u003e\n\u003cp\u003eEmotions are key factors in surgical disease and treatment, both in the surgeon and in the patient. Despite the recognition of the value of clinician empathy (1), quantitative studies have shown that surgeons have lower empathy scores than other specialities (2–4). The reason for this is unclear, and little is known about how surgeons manage emotions in clinical settings. This study explored the role of empathy in surgical treatment and how surgeons see patients’ emotions.\u003c/p\u003e\n\u003ch3\u003eMethods\u003c/h3\u003e\n\u003cp\u003eWe used an exploratory qualitative study in the Constructivist Grounded Theory tradition, utilising online individual semi-structured interviews with fourteen general surgeons.\u003c/p\u003e\n\u003ch3\u003eResults\u003c/h3\u003e\n\u003cp\u003eSurgeons described multiple discrete approaches to patients’ emotions. Participants were conscious of modulating their emotional response to patients depending on need, and systemic factors like urgency and setting. General approaches to patient emotions included emotion-facing and emotion-avoidant strategies. While the approach used was often tailored to the situation, surgeons usually had a preferred style. The degree of emotional engagement was particularly influenced by time available, and urgency. Participants described some techniques to influence the degree of emotional involvement, primarily by altering consultation times.\u003c/p\u003e\n\u003ch3\u003eConclusions\u003c/h3\u003e\n\u003cp\u003eThe management of emotions by surgeons is nuanced and affected by contextual factors. Management is not entirely automatic or subconscious, but opportunities can be created or limited by the surgeon as required to facilitate effective treatment. The results offer a new perspective on surgeon empathy in the context of the limited existing literature.\u003c/p\u003e","manuscriptTitle":"Exploring how surgeons employ empathy in clinical practice: a qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-07 06:00:39","doi":"10.21203/rs.3.rs-6124486/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-19T09:59:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-21T16:45:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-21T02:06:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133153094508872215124876499921987621522","date":"2025-04-21T00:57:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306925432890734014397737605567579665466","date":"2025-04-16T10:50:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-14T04:57:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-08T17:18:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-19T05:22:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-19T02:48:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-03-19T02:47:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4457b7b6-1564-4329-9d25-daf513dada3c","owner":[],"postedDate":"May 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-03T16:03:23+00:00","versionOfRecord":{"articleIdentity":"rs-6124486","link":"https://doi.org/10.1186/s12909-025-08075-w","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-10-29 15:58:36","publishedOnDateReadable":"October 29th, 2025"},"versionCreatedAt":"2025-05-07 06:00:39","video":"","vorDoi":"10.1186/s12909-025-08075-w","vorDoiUrl":"https://doi.org/10.1186/s12909-025-08075-w","workflowStages":[]},"version":"v1","identity":"rs-6124486","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6124486","identity":"rs-6124486","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}