Frederic W. Platt, MD, and James T. Hardee, MD
Most doctors tend to undervalue emotions, those in themselves and those in their patients. We tend to assume that we and our patients are rational creatures, driven by ideas and articulated values. We prize thoughts over feelings . Yet many studies have shown that human beings tend to feel first and think afterwards. Most of our actions are primarily motivated by our emotions. As patients we need our feelings to be ferreted out when obscure, and acknowledged whether they are obscure or obvious. As clinicians, our primary goal must include that ferreting out and that acknowledgment [2,3].
Clinician: So I see that you have been suffering with chest pain and want me to find it and fix it, eh?
Patient: Well yes, Doctor. I’ve been pretty scared by all this. I think it could mean … (silence)
Clinician: OK, let’s talk about the chest pain. Exactly where is it and what brings it on?
Not a rare sort of clinical conversation. This clinician correctly focuses on the symptom (chest pain) and tries to further define it. Since symptoms are the gold of the clinical interview, the clinician is focusing aptly . But what about that business of being scared? What did the patient leave off saying?
Clinicians often hear but do not recognize or acknowledge voiced feelings by the patient. Levinson et al reported that the patient often gave clues to help us understand how he had been feeling but less often voiced the full story. The clinician then missed the opportunity to search out the full story and failed to probe further. The clues were missed more often than caught .
The Levinson et al study was published 13 years ago. Have we improved much in that time period? Hsu et al think not. They studied empathic opportunities in 47 visits with HIV-infected patients. Half the empathic opportunities were missed . Similarly, Adams et al reported 79 patient encounters wherein the patient expressed negative emotion; in only a third of these interviews did the clinician show any empathic response .
Smith and his colleagues insist that our most therapeutic action in patient interviews is to seek out emotion and respond with evidence that we have heard it and understood it . If that is true, we have a real challenge: not to miss the key symptoms and the story attached to them, but yet to recognize the patient’s strong emotional responses and offer empathic summaries to close the gap between patient and clinician.
What are the usual strong feelings that patients experience and will tell us about? Mostly they are the big 3: fear, sadness, and anger. Anger, often dreaded by clinicians, is itself usually a secondary feeling and stems from fear (anxiety, worry, fear, terror …) or from sadness (unhappy, loss, grief, hopelessness …) Patients often tell us of these feelings, and if they don’t make them explicit, we can ask .
This patient has presented his clinician with a real gift, a name for the emotion (fear), and offered to tell more about it. All the clinician needs to do is invite further:
Clinician: I want to hear more about the pain, exactly where it is and what brings it on, but first tell me more about being scared. What are you worrying about mostly?
Patient: Oh gosh, Doctor, I guess I think it might be my heart and it could be a sort of messenger of death. Maybe this is the end of me.
Clinician: I see. So you’re concerned that this could be your heart and so a really serious problem. I imagine that you want me to get right at sorting it out.
Is this little divergence worth pursuing? It takes a few seconds, perhaps half a minute, but investigation and clarification of the patient’s concerns alleviate the possibility that the patient thinks we really haven’t been listening and do not understand the depth of his concern. Patients who feel unheard or incompletely understood tend to be dissatisfied with their care, more likely to complain, and less likely to follow their treatment plan.
Of course, a patient may deny emotional material, thus making it more difficult to discover. Many people who tend to intellectualize their situation will explain with their ideas but omit their feelings. What to do when a patient does not voice an emotional connection or even denies having any feelings?
Clinician: So how have you been feeling, emotionally, while all this is going on?
Patient: I dunno, Doctor. I don’t think feelings have anything to do with it.
This patient, a professional colleague, seemed to never recognize his own feelings and seldom those of anyone else. But he was available for prompting:
Clinician: Well, still I’m curious. Most people with chest pain like yours do have feelings associated with the problem. They may feel worried or sad or even angry. How about you?
Patient: Well, I don’t think the feelings caused the pain or my breathing difficulty.
Clinician: Probably not. But tell me anyway.
Patient: I guess I am worried and now I’m worried that you are trying to blame the pain on my worry. I don’t come here for psychotherapy.
Clinician: I see. So chest pain, short of breath, a little worried, and now I’m making it worse by inquiring into the feelings.
Patient: OK, you got me. Yeah, I’m worried. Concerned might be a better word. Maybe a little scared.
Clinician: I see. OK, let’s go back to the chest pain and sort that out a little better.
What about our own strong negative feelings? Often omitted in medical curricula, they do exist and we do suffer with them. Ofri offers quite a list in her powerful book, What Doctors Feel , a list that includes anger, fear, embarrassment, guilt, shame, disillusionment, sadness, loss, grief, frustration, boredom—the list goes on and on. When patients suffer unanticipated and unfortunate outcomes, we may feel guilty, perhaps fearful that someone will be angry and might even initiate a lawsuit, and perhaps angry with the patient for not having followed our recommendations more precisely. Then our patients suffer and die. The death leads often to grief. We grieve. Ofri says:
Grief tugs insistently at doctors. We form relationships—like all humans colliding in this world—but our partners in these relationships die off with a regularity that isn’t common elsewhere. A thread of sorrow weaves through the daily life of medicine, even during the mundane and pedestrian encounters. It is disease, after all, that we are dealing with, not misdemeanors, philosophies, or building foundations.
So in the end, it is not only our patient’s feelings that we must find and respond to, but our own strong and sometimes disabling emotions need recognition and care. We all need someone to share our grieving with; we all need to be debriefed and understood. Otherwise we become wounded healers and are dysfunctional with
Much of doctor discontent and burnout seems linked to strong unrecognized emotions. If we are disillusioned, perhaps bored, and convinced that our lives are not what we were promised, we will function less well and may end up leaving medicine entirely. If we address these emotions we might still have a life in this chosen field.
The clinical action that we are contemplating is usually called empathy. Our patients need it and we do them a disservice if we withhold such a response. Yet clinicians often explain the lack of empathic responses with stereotyped explanations :
I don’t have time for those responses. I only get 10 minutes with a patient and there is just not enough time to respond to their feelings.
I never got any training in being empathic. That’s for social workers and psychiatrists. I’m a doctor. I don’t do psychotherapy.
I knew something needed to be said, but I just couldn’t find the words.
I’m not convinced that it would help. My responding with understanding might lead the patient to pour out distressed feelings and I’d be overwhelmed. Asking about feelings would open a Pandora’s box of powerful emotions that I am not equipped to handle and have not the needed time.
If I did that, I’d have nothing left for my family at the end of the day. Maybe I’d start drinking again. It would be a sure track to burnout. I’d want to quit medicine.
Why bother simply rephrasing what the patient has already told me? He knows what he said. It’s just a waste of time.
These excuses have some validity, of course. But responding empathically takes little time and comforts the clinician as well as the patient. We simply cannot afford to be without this essential clinical tool. Our patients need it. The last explanation is simply altogether incorrect. Summarizing what the patient has told us and letting him know that we heard and understood is a powerful therapeutic step and that, after all, is our goal in medicine, to listen to the patient and help him feel better.
The techniques needed seem simple even though they are far from ubiquitous. The clinician must pay attention. Then he or she must listen well and allow his/her imagination room to play. Finally, the clinician should give the patient evidence, usually a brief summary of what has been heard and understood, that he/she was indeed alive, conscious, and listening. That should do it.
Of course those same listening tools serve well with the physical symptoms of the illness.
Patient: I’ve been feeling weak and maybe a little bit feverish for a couple of weeks. But Friday I went swimming. I usually swim half a mile once a week. Friday I couldn’t swim. I sank.
Clinician: You sank?
Patient: That’s right. I couldn’t float anymore. I sank.
Clinician: OK, I see. What I think I’m hearing is that you have been ill for a couple of weeks with fatigue and maybe a little fever, but then what got you in to see me was a problem with your swimming. You had lost your buoyancy; you sank.
Patient: Exactly. I sank!
This very real patient presented with an uncommon chief complaint: “sinking.” Further examination showed that she had a large unilateral pleural effusion caused by an unsuspected lymphoma . The doctor’s use of careful attentive listening and a short summary prevented the common syndrome of a “Patient who tells the same story over and over,” created trust, and speeded up the diagnostic interview.
A more common sort of story might go this way:
Clinician: Tell me the story of this illness.
Patient: I’ve been feeling punk for a month or so. Then I got nauseated and lost my appetite. Finally last week I noticed that my eyes look yellow and my urine is darker. So I called to make an appointment with you.
Clinician: I see. Punk for a month, nausea and loss of appetite and then jaundice. (That’s the yellow you noticed in your eyes.) Anything else?
Patient: Nope, that’s about it.
Of course that is almost never quite “it.” This patient, when asked about his idea of what might be causing the trouble had more to say.
Clinician: What do you think caused this trouble?
Patient: Well, I don’t know, but I did have a trip to Mexico. I was in Yucatan for 2 weeks about 2 months ago. Maybe I caught something.
Yes, he did catch something. Hepatitis A.
This addition reminds us that we must listen intently and summarize our hearing not just about those distressing feelings but also about the patient’s symptoms, the patient’s ideas about causation, and the values behind the feelings we’ve unroofed. In fact, it is fair to say that the clinician’s discovery process includes hearing the patient’s physical symptoms, the patient’s emotional responses, the patient’s ideas (about causation, about further treatment, about future worries), and the patient’s values that tend to underlie feelings. Those 4 categories of data stand out in our work. And, of course, the power of effective listening and summarization lies in their therapeutic effect: the patient gains trust and confidence in the doctor and will likely follow suggestions better, be more satisfied, and less likely to run away or complain of his treatment in your hands.
Looking for and summarizing symptoms seems straightforward. Feelings and ideas seem almost as easy to ferret out. All we have to do is ask. “How have you been feeling about all this; I mean emotionally, how have you been feeling?” and “What ideas have you considered about this illness? Cause? Treatment? Further tests or procedures? What were you expecting me to recommend?” But sorting through the patient’s values may seem more difficult. It helps to remember that values underlie feelings . Our conversation might go something like this:
Clinician: So I understand that you’ve been feeling punk, nauseated, no appetite, and then jaundiced. You’ve been thinking that you might have caught something in Mexico. How are you feeling about all this; I mean emotionally?
Patient: Well, a little bummed out, I guess. I had big plans for a climbing trip and I think I won’t be able to go.
Clinician: Tell me about that.
Patient: Oh, my 2 buddies and I were going to try the east face of Long’s Peak. It’s a big climb and pretty hard. I was really looking forward to it. We three have climbed before and I hate to disappoint them. But of course falling off the mountain would be a downer too.
Clinician: So, sounds like, you were planning a tough climb and you hate to disappoint your climbing friends.
Patient: That’s it. It’s really important for me to come through with my promises. I hate to renege on them.
Clinician: Keeping your promises is really important to you.
Clinician: OK, let me sort of summarize what I’ve heard so I’m sure I haven’t gone astray. You’ve been under the weather for a couple of weeks, then jaundice appeared. You think it might be from your Mexico trip and you’re feeling sad because it is really important for you to keep your promises and you had promised y our buddies to join them in the Long’s Peak climb. Did I miss anything?
Patient: Nope. You got it, Doc.
OK, that part of the dialogue is an imagined sequence, including my favorite response from a patient, that “You got it, Doc.” But the sequence should be clear. Sort out the physical symptoms, then the emotional ones, and finally look for the underlying value that fuels the emotional symptoms. And, on the way, discover and recognize the patient’s thoughts on the matter.
A few caveats: In ordinary English, people often use “I feel …” to mean “I think ….” So if we ask our patient what his ideas about causation are, he might respond,
“I feel that perhaps I have some sort of liver problem, maybe hepatitis.” No need to argue about grammar; he’s really saying, “I THINK perhaps I have ….”
What if we just omit all this stuff and stay with the physical symptoms. Sometimes that’s enough:
Patient: My dog ran in front of me, and I tripped over him, and I fell and twisted my ankle. I think I sprained it. Would you look at it?
Looking at the ankle, maybe an x-ray, maybe a splint, might be quite enough. But another time we might ask how the dog came to run in front of him. Maybe he was not watching the dog, instead ogling the cute girl down the block. Maybe he’s been terribly lonely since he broke up with his previous girlfriend. Maybe he’s been drinking more. Maybe …. Maybe there is more to discover. To do that we have to ask the right questions.
Corresponding author: Frederic W. Platt, MD, 396 Steele St., Denver, CO 80206, email@example.com
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