The Importance of Empathic Inquiry in Healthcare:
An Interview
CIPC had the privilege of interviewing Ariel Singer, MPH, a community health expert who specializes in helping healthcare professionals develop and implement practical strategies for human-centered health system redesign and care delivery. In her article titled "Assessing the Feasibility of an Empathic Inquiry Approach to Social Needs Screening in 10 Federally Qualified Health Centers," Singer delves into the findings of an extensive 8-month learning collaborative. During this collaboration, she and her team worked with 10 community health centers to facilitate the implementation of a patient-centered approach to social needs screening. The approach, which they developed based on motivational interviewing, trauma-informed care, and stakeholder input, was called empathic inquiry. Our interview aimed to gain a deeper understanding of the innovative strategies Singer employed and their impact.
Q: What brought about the study and the project?
"We started to work on developing empathic inquiry at the Oregon Primary Care Association (OPCA) in 2017. OPCA was very involved with the early development of the PRAPARE social needs screening tool. It seemed like everyone was talking about the importance of social determinants of health data collection. As a Motivational Interviewing trainer, this way of talking about social determinants of health made me uncomfortable. I regard this kind of information not as data, but as the tender, sensitive, personal details of people’s lives.
The overall culture of health care focuses on meeting the needs and requirements of the system, rather than emphasizing the experience and priorities of our patients. If we are not thoughtful about how we ask such sensitive questions, we risk harming relationships and alienating the very people we are trying to help."
Q: How was the project developed?
"This project was funded by Kaiser Permanente Northwest’s community health program. To get started, we conducted stakeholder surveys, focus groups, and interviews, including speaking to several community health center patient advisory councils. We also talked with many professionals, including community health workers and their supervisors, trauma-informed care experts, motivational interviewing trainers, and clinical and operational leaders. We asked all of those people for their take on what a patient-centered approach to asking social screening questions looks like.
We summarized all of that input to develop principles for a patient-centered approach to social screening, as well as a conversation guide that draws heavily on motivational interviewing. We then conducted a learning collaborative where we provided training and implementation support for ten community health centers to test this approach. We collected patient and staff feedback as we went along."
Q: What findings or insights have emerged from the project and similar studies since?
"Since we did this work, many additional publications have been released with research on the same topic. There is a lot of consistency in what people have to say about this. Patients want clear explanations on why the questions are being asked, assurances about their privacy, respectful and nonjudgmental conversation to negate stigma, and meaningful follow-up. Even if that follow-up is just a good conversation, that can still be meaningful."
Q: What challenges do cultural constraints in healthcare present to this approach, and how can they be addressed?
"Many new levers are emerging to either incentivize or compel people to conduct this type of screening. It would be great if those levers were built into the requirements to conduct screening in a person-centered style. In Oregon, for example, the Medicaid quality metric that incentivizes social screening includes requirements that people conducting screening are trained to do it in a trauma-informed, culturally sensitive, patient-centered way. Regulations and incentives drive behavior in healthcare, so using these levers to promote person-centered care is crucial.
There’s also some evidence that individual workforce members have mixed feelings about social screening. They find the concept of social screening acceptable since they see how much social circumstances impact health on a day-to-day basis, but they may not feel comfortable and confident about asking these questions. Providing adequate workforce preparation, including training, change management, and workflow support can make a big difference.”
Q: What do you believe is the most important aspect of this work?
"It’s very easy to underestimate the emotional impact of asking people sensitive questions about their social circumstances. For many people, it is simply not neutral to be asked these questions, and we should adopt an approach of universal precautions to promote psychological safety for everyone. We won't know in advance for whom these questions will be troubling and emotionally difficult, so we have to approach everyone with proactive non-judgment,al and respect. It’s not the only way to adopt universal precautions, but patient-centered and trauma-informed communication is a great starting point."
Q: Are there aspects the paper didn’t address or things you’d want to see in future work?
"The paper was focused on empathic inquiry for social screening, but the reality is that we ask people all kinds of sensitive questions in healthcare settings. For example, asking about drug and alcohol use, weight, exercise habits, tobacco use, sexual activity, and personal identities—all of these can be very sensitive. We tend to underestimate the emotional impact of all these questions. In the era of population health and value-based care, we are expected to conduct more and more screenings for the purpose of addressing individual risks and managing population health . If we’re going to systematically ask people to divulge tender information, we need to treat it tenderly."
Q: Can you explain the difference between asking these questions in a data-focused way versus a patient-centered approach?
"If you're approaching it from the standpoint of data collection, you’re focused on building a data set. You’re looking to get your questions answered in a way that is reportable at the population level. In contrast, a patient-centered approach is about connecting with and supporting patients. It involves bringing a more relational approach to the interaction, communicating that their information is safe, that you’re not there to judge, and that your intention is to offer support. It’s about shifting mindsets and communication behaviors from extracting information to creating a meaningful conversation."
You can learn more about how to have patient-centered conversation and hear more from Ariel in our Motivational Interviewing course. Click here to learn more.
