The Power of Feedback
The Power of Feedback
In this multimedia series, sponsored by the William and Flora Hewlett Foundation, voices from the social sector will offer tactics, tools, and advice gleaned from the grassroots to encourage nonprofits and foundations to make listening to their constituents—and acting on what they hear—a smart norm for any organization committed to improvement.

Interrupting is a powerful urge. We want to quickly find out what we need to know and are eager to steer conversations in that direction. While this isn’t necessarily bad, most of us want people to listen to us when the tables turn. When that doesn’t happen, human nature leads us to stop talking altogether or to crank up the volume.

As a neurologist and chief experience officer at Cleveland Clinic, one of the most powerful things you can do for people is to ask about insights and feelings, reflect what you hear back to them, and then do something about it. This not only makes an impact in one-on-one conversations, but can also improve program and process design. I call this concept “empathy operationalized.” Although I view this issue through a healthcare lens, the reflections are universal. Ultimately, soliciting and applying someone’s feedback is fundamental to making that person feel seen and valued.

Training for Empathy

Many people who choose careers in medicine or at nonprofits are intrinsically motivated to serve others. And yet most of us haven’t received any training to hone our ability to empathize; we just do our best. If we expect every healthcare professional to empathize with every patient, we must provide training. Working in hospitals is tremendously stressful: Doctors-in-training have to learn to work on a team, document their actions extensively, take on sleep-depriving schedules, and begin to take responsibility for the health of their patients. They may see death for the first time. They must learn to stand in the midst of suffering, field questions they don’t know the answers to, and parse medical jargon. As they become more senior, they may travel back and forth from outpatient to inpatient settings. They may miss their kid’s soccer game to comfort a patient who is contemplating their own mortality. Amidst all of this, studies show that physician empathy levels decline throughout training, and rise again only later in a doctor’s career.

In 2011, I helped design a communication training program for all Cleveland Clinic physicians that included approaches to listening to and building empathy for our patients. We thought we would just teach some skills, but we soon realized we also needed to listen to the physicians themselves. Many were grappling with challenging conversations and feeling isolated by their unacknowledged struggle. We quickly changed the curriculum to allow physicians time to share their stories. Tales tumbled out—stories of abuse and loss, of witnessing humanity at its best and worst. Creating this space made room for their pain; it helped the healers heal.

Adopt Reflective Listening Techniques

But empathy requires more than just listening and moving on. Listeners have to communicate—through words or actions—a deep understanding of what someone is going through. This is called reflective listening, and it's the difference between these two conversations between friends:

  • Conversation One
    Laura: “Hey, great to see you. How are things?”  
    Doug: “Oh hi. Good to see you. Things are ok—I haven’t really been sleeping very well.”
    Laura: “Yeah, I’m pretty worn out from working two jobs. How’s that new puppy you rescued?”
  • Conversation Two
    Laura: “Oh hi. Good to see you. Things are ok—I haven’t really been sleeping very well.”
    Doug: “You sound exhausted. Tell me what’s going on?”
    Laura: “Thanks for asking. My mom just passed away.”

In the first example, Laura could leave the conversation not even knowing Doug’s mother has died, and he also made the fatigue about him. In the second example, Doug reflects back the emotion he is hearing when he says, “You sound exhausted.” Naming the emotion serves to check that he heard the feeling correctly. He then follows with an encouraging statement, so that Laura feels comfortable enough to share what’s really going on.

Reflective listeners hear and then articulate the emotion or message back to the speaker. If the message is emotional, the reflection is a statement of empathy. If the message is information, then the listener states facts or data. When this happens, people feel heard and understood. A relationship begins.

Medical researchers Mary Catherine Beach and Thomas Inui describe relationship-centered care as having four features:

  1. Both patient and medic share a common goal, ideally the patient’s health.
  2. They both value each other’s expertise in reaching that goal. The patient has expertise in their disease; doctors have expertise in the science and medicine.
  3. As patient and clinician listen to each other, their relationship influences both sides. They call this reciprocal influence. In other words, the patient might actually tell the doctor he isn’t taking his medicine. The doctor might stay late to give him a call.
  4. The relationship is therapeutic on both sides, but it’s not friendship.

Human beings behave differently when they are in relationships, and we can be intentional about building relationships through reflective listening.

The Cases for Empathy

Being empathic is self-perpetuating. In healthcare, reflective listening and empathy can lead to behavior change, fewer malpractice claims, and less burnout–that feeling you get when your emotional bucket is empty and it’s hard to keep going.

University of Chicago researcher Nicholas Christakis studied the power of social contagion—one person influencing another to adopt a behavior like smoking or eating habits leading to obesity. He found that social contagion also applies to empathy. If I'm empathic to you, you’ll be empathic to the next person, and they to the next.  

Fascinatingly, listening and empathy may be doctors’ greatest tools in reducing financial, physical, and emotional harm. If you look at why people file malpractice claims, the number-one cause isn’t inappropriate medical management, but a lack of human connection. Such shortcomings translate into millions of dollars in claims. In recordings of doctor-patient interactions that did not result in malpractice claims, the physicians use humor, let the patient talk, and explain what will happen during the visit.

Empathy and effective communication also increase physician retention, leading to additional economic benefit. We studied 1,500 physicians who participated in our communications courses as well as their patients, and found we had both enhanced their patients’ experiences and reduced physician burnout. At Cleveland Clinic, burned-out physicians are twice as likely to leave as those who remain engaged and satisfied, and it takes significant time, energy, and dollars to replace them.

Even in human-centered fields like medicine, social services, and development work, we often think that skills like reflective listening and empathy are soft, fluffy, and optional. The truth is, they are the only skills that can make another human feel cared for and connected—they just take some intentional practice.

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