Empathy and boundary turbulence in cancer communication

•In cancer communication, empathy was rare; affirmation and acknowledgement were frequent.•Physician-centered transparency, self-disclosure, and projection were common.•Physicians expressing empathy were more likely to use projection and not-useful transparency.•Well-intended physicians who provide empathy and transparency may be at risk for boundary turbulence.•Clinical communication training in empathy should include boundary management strategies. To describe and deepen our understanding of patient-centeredness, empathy, and boundary management in challenging conversations. Previous studies show frequent physician self-disclosure, while empathy and boundary management are infrequent. Three standardized patients (SPs) portrayed cancer patients consulting a new community-based physician, resulting in 39 audio-recorded SP visits to 19 family physicians and 20 medical oncologists. Transcripts underwent qualitative iterative thematic analysis, informed by grounded theory, followed by directed content analysis. We further defined the identified communicative categories with descriptive and correlational calculations. We identified patient-centered physician response categories--empathy, affirmation, and acknowledgement; and physician-centered categories—transparency, self-disclosure, and projection. Acknowledgement and affirmation responses were frequent and empathy rare. Physician transparency and self-disclosure were common. Useful and not useful self-disclosures were highly correlated; empathy, useful and not useful transparency, and projection were moderately correlated. Most physicians used self-disclosure but few of these were judged patient-centered. Physicians expressing empathy and patient-centered transparency were also more likely to use projection and physician-centered transparency, thus engaging in communication “boundary turbulence.” Patients may benefit from physicians’ improved use of empathy and boundary management.