Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

The Swiss Army Knife


Sometimes clinicians’ wellspring of empathy runs dry. Unfolding a few simple tools—like mirroring patients’ nonverbal communication—can improve therapeutic relationships and allow us to provide compassionate care even when we are not at our best.

A few years ago, a resident I mentored was struggling in clinic. After multiple patient complaints, he admitted, “I just don’t feel empathy for my patients.”


He wasn’t burned out, depressed, withdrawn, or narcissistic. He wanted to improve but didn’t know how. I told him the good news, “Empathy isn’t a fixed trait and you’re not alone.” 


Medicine asks clinicians, who are human, to do superhuman things. Go from one room to the next listening, validating, negotiating, reconciling, comforting, apologizing, and empathizing all within strict time limits. You could be sending a patient to the ER, transitioning another to hospice, and celebrating a “win” in three adjacent rooms all within an hour of clinic. This emotional whirlwind takes a toll on doctors, no matter how mindful and/or resilient we are. No amount of “empathy training” will overcome it. So, I empathized with the resident’s experience and offered three pieces of advice which I now call the Swiss Army Knife. 

1. Be a mirror.

2. Emphasize the physical exam.

3. Tell patients, “I’m glad you came in today.”


Be a mirror 

Active listening can be challenging. Summarizing an emotion or experience by saying, “It sounds like . . .” is an advanced skill. Remember that patients are subconsciously assessing your non-verbal communication as you walk in the door. Clinicians who go straight to the computer with little eye contact have already failed the test. The best “mirror” will make appropriate eye contact and then mimic a patient’s cadence, tone, mood, or posture to help them relax and feel comfortable. For example, a smile should be met with a smile and when they lean in, you lean in too. Now they know you’re listening. 


Emphasize the physical exam 

The most sacred and sharpest tool we have in cutting through superficial relationships toward deeper connection and empathy is the physical exam. One way to develop rapport is to feel a patient’s pulse as they’re talking or listen to their heartbeat while supporting their back. Whether symbolic, ritualistic, or truly investigative (e.g., possible A fib for a chief complaint of fatigue), patients expect to be touched. Get to it early and it may just catalyze enough trust for a patient to open up about what’s really getting them down. It also may change your management or line of questioning. 


“I’m glad you came in today.” 

We may sometimes overestimate our rapport with patients and assume they share our comfort, joy, and satisfaction after a diagnostic dilemma is solved. Some patients do not. If a patient isn’t mirroring your sentiment(s), then you must dig to find out what’s nagging at them. “What’s your biggest fear?” and/or “You still seem down.”  While these “scripts” have been shown to improve patient-centered communication when applied in various settings, there’s one that universally works at the end of a patient encounter, if said with genuine intent: “I’m glad you came in today.” Those six simple words normalize fear, validate pain, and reinforce the psychological safety of your office. By saying these words, it helps patients avoid feelings of shame or inadequacy. They now know you care. 


Notice not once did any of these three tips mention emotional capacity or require the trainee to feel differently (as if empathy is some magical wellspring that some can access, and others cannot). We should outright reject this narrative. 


In the case of this resident, he stopped hearing patient complaints. As a clinician who admittedly doesn’t always show up to clinic as “my best self,” this is the value I see in the Primary Care Swiss Army Knife. 


In moments of stress, we rarely rise to our potential, ideals, or expectations but we do fall to our level of training. I find these three simple and actionable “tips” help me to provide compassionate care even when my emotional reserve is running low. 







This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.