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Although empathy is not generally considered a therapeutic tool, discussion of emotional issues can be therapeutic. An empathic relationship is crucial in psychotherapy and enhances the power of all therapeutic relationships. The following sections show how to talk about emotions using specific skills. A premise of this discussion is that biomedical aspects of disease cannot be effectively addressed without considering their emotional consequences. Emotions, whether related to physiologic dysfunction or psychosocial issues, color the discussion in the examining room, and may be so distracting that the patient cannot fully concentrate on other issues until the emotions are addressed.
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A clinical scenario helps to illustrate the usefulness of the emotion-handling skills described in this section.
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CASE ILLUSTRATION 1
While you are on call for admissions from the emergency room for patients without a primary care physician, a 45-year-old man is admitted because of concern that his 2-week history of chest pain may represent unstable angina. Although the emergency room physician acknowledges that it is a “soft admission,” the patient has a history of elevated lipids, a family history of cardiac disease, and his blood pressure in the emergency room is 180/95. The patient describes a sharp substernal chest pain that occurs at rest, when working in the yard, and while trying to fall asleep at night. He does not smoke or have diabetes. On examination, he appears anxious, his blood pressure on the cardiac floor is 160/90, and he is 5% over ideal body weight. The rest of his examination, laboratory tests, electrocardiogram, and chest X-ray are normal, except for his low-density lipoprotein cholesterol, which is 160 mg/dL.
You greet the patient with outstretched hand:
Doctor: Good morning, Mr. Swenson, my name is Dr. Bergen. I’ll be taking care of you while you’re in the hospital.
Patient: Well, Doctor, am I having a heart attack?
Doctor: You haven’t had a heart attack. I can tell from your blood tests and electrocardiograms.
Patient: Well is the pain coming from my heart?
Doctor: I don’t think so.
Patient: But you’re not sure?
Doctor: Nothing in medicine is certain, but your age, the character of your pains, and the fact that antacids help somewhat reassure me that the problem is most likely acid indigestion or muscular pain.
Patient: Don’t you think we should do more tests to be sure?
Doctor: Although you are at low risk for having coronary artery disease, I think it would be prudent to do an exercise stress test as an outpatient just to be sure.
Patient: What if I have a heart attack in the meantime? I’m still worried.
Doctor: You don’t need to be. Besides, you were admitted under “observation status” to make sure you didn’t have an unstable cardiac condition, and we have done that. By standard protocols, you fall into the low risk category, and your insurance will not allow you to remain an inpatient for further risk stratification. Don’t worry, you’ll be all right.
Patient: Well, okay, if you say so.
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Despite a diagnosis of non-cardiac chest pain, providing good information, and attempts to reassure the patient, something goes awry in this interaction. The patient still does not seem satisfied. Let us look at the effect empathic skills might have.
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The techniques discussed in the following sections are adapted from a three-function model of the medical interview. The goals of the interview are described as gathering medical data, building a relationship with the patient, and educating and motivating the patient (see Chapter 1). The following emotion-handling skills are related to the second function, building relationships with patients (Table 2-2).
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The term reflection refers to naming the emotion the doctor sees and reflecting it back to the patient. Reflection communicates the physician’s understanding of the patient’s experience. It also has the effect of making the feelings behind the patient’s behavior or words explicit, so that they can be dealt with directly.
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For example, when a patient greets a doctor who is 20 minutes late with, “My time is as valuable as yours,” the doctor might say, “I’m sorry I’m late. You seem pretty angry with me.” The patient might then ventilate about the doctor’s lateness or his treatment at the hands of doctors. He might even deny his anger, since many patients might view an expression of anger at their physicians as unacceptable. In any case, the doctor has a chance to deal with the emotion directly and then proceed with the interview, rather than trying to work with a patient who is angry and has not had a chance to express his anger.
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After reflecting an emotion, the doctor should stop talking and see how the patient responds. Although the patient will usually elaborate, if the physician keeps talking the exploration may be prematurely ended.
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Sometimes it is clear that a patient is feeling a strong emotion, but it is not clear what that emotion is. It is perfectly acceptable (and perhaps preferable) to treat the emotion as having a differential diagnosis and test a hypothesis as one would for any other medical entity: “I’m wondering if you’re upset,” or, more tentatively, “It seems that you’re feeling something strongly, but I’m not sure what it is. Can you help me out?”
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Validation informs the patient that you understand the reason for the emotion. This has the effect of normalizing the emotion and making the patient feel less isolated. For example, to a somatizing patient who has been to several doctors to find a cause for her abdominal pain, you might say, “I can understand how frustrating it’s been to be no better after seeking so much help.” Some physicians are reluctant to validate emotions in difficult patients for fear of adding fuel to the fire. If reflection is the empathy skill that opens Pandora’s Box, then validation is the skill that closes it—it is difficult to remain upset with a person who understands how you feel. You do not have to agree with patients to express an understanding of their feelings. For example, to a patient with chronic low back pain who has responded angrily when informed that you will not prescribe narcotics, you might say, “Even though I see it differently, I can understand why you would be angry with me.” Although disagreeing with the patient, such a statement allows you to offer support and enhances your chances of continuing a therapeutic relationship. Validation of feelings emphasizes that the patient and doctor are equals in the human condition, although they have different roles in the therapeutic relationship.
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An expression of support tells patients that the physician cares about them and is willing to be present to their emotion. The expression can be verbal or nonverbal. Examples of nonverbal expression are handing the tearful patient a tissue or touching the patient. In judging whether touching a patient will be perceived as supportive, invasive, or inappropriate, the physician should consider such factors as culture, age, gender, sexual orientation, previous experience of abuse, and the presence or absence of psychiatric symptoms, such as paranoia. In general, putting a hand on the patient’s hand or arm will not be misinterpreted. Many physicians prefer taking the lead from the patient by matching the patient’s non-verbal behavior.
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Some verbal expressions of support are “It’s pretty normal to get angry with children when they act out” and “A spouse’s death is one of the most difficult life transitions.” Again, these responses are not an attempt to suppress, eliminate, or fix the emotion, but rather an offer to help patients, to reassure them that they are not alone with an uncomfortable emotion. These three skills—reflection, validation, and support—are the most important of the emotion-handling skills and will be involved in most of the work physicians do in this area.
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Partnership implies a team approach, in which the patient and doctor work together toward the same goal. Doctors support and are partners with patients in many ways, but in the context of this chapter the word partnership makes it explicit that you would like to help the patient with the troubling emotion. An advantage of partnership is that it may help motivate patients to take an active role in their improvement and may lay the foundation for a contract for behavior change. This is consistent with the notion, especially important when illness results from patient behaviors, that physicians facilitate the patient’s healing rather than curing disease in the passive patient. The physician’s use of the pronouns we and us expresses partnership, as in “Perhaps we can make a plan to help you feel better” or “Let’s figure out a way to help you deal with this difficult diagnosis.”
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This skill honors the emotional resources within a patient. The doctor might say “You’ve been through a lot” or “I’m impressed with how well you’re holding up under the circumstances.”
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Physicians may not always know what it would be like to be the patient, but they can acknowledge the patient’s experience nonetheless: “I’m not a parent, so I can only imagine what it would be like to lose a child. I can see you’re feeling the loss quite deeply.” On a happier occasion, she might say “What a joy it must be for you to see your grandchild’s birth!”
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Although it often makes sense to use reflection or validation first when addressing emotion, these skills can be used in any order, and it may be best to go through the sequence several times at different points in an interview.
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CASE ILLUSTRATION 1 (CONTD.)
Let us return now to the scenario of the 45-year-old man with chest pain to see how that interaction might be improved with a physician who uses empathic skills. The empathic skills used are listed in parentheses.
Doctor: Good morning, Mr. Swenson, my name is Dr. Bergen. I’ll be taking care of you while you’re in the hospital.
Patient: Well, Doctor, am I having a heart attack?
Doctor: You’re understandably worried. (validation) I can tell from your lab tests and electrocardiogram that you haven’t had a heart attack.
Patient: Then why do I have this pain?
Doctor: Our tests don’t seem to have reassured you very much. (reflection)
Patient: Wouldn’t you still be worried if you thought you were working up to a heart attack?
Doctor: I certainly would be. So you’re worried you’re going to have a heart attack. (reflection)
Patient: That’s what happened to my father. He was raking leaves and just keeled over. I’m the one who found him.
Doctor: That must have been horrible. (support)
Patient: You can’t imagine how awful it was. Every time I think of it I get upset. Sometimes it even brings on this chest pain. I’ve been thinking about him more and more lately, especially when I go to sleep at night. It makes me afraid to fall asleep. I’m afraid I’m not going to wake up.
Doctor: Is there a reason why you’ve been thinking about him more lately?
Patient: Yeah. I thought I got over his death. But this is the time of year he died. Just raking leaves, which I do every weekend, makes me think of him. Then I get this chest pain and worry about myself. Heart disease runs in families, I don’t have to tell you.
Doctor: I’m sorry about your father. (support) It sounds as though there’s a pretty strong connection between thinking about your father and the chest pain.
Patient: Yeah. I thought maybe being upset stressed my heart. Do you think maybe this is all in my head?
Doctor: I’m sure you really feel the pain, and I suspect your heart still aches for your father-even if only figuratively. It’s pretty hard to lose a father. Now, you know there’s a pretty strong connection between the body and the mind, and if you’ve been worrying about your own health, this could be your way of making sure you take care of yourself. (respect)
Patient: I never thought of it that way. What you say makes a lot of sense, and I think you’re probably right. But I still have this nagging worry in the back of my mind.
Doctor: That’s understandable. (validation) How about this? Let’s work together to reduce whatever risk factors you do have for heart disease to make sure you don’t have a problem down the line. (partnership) Although you are at low risk for having coronary artery disease, I think it would be prudent to do an exercise stress test as an outpatient just to be sure. I’m going to give you my card so that you can call my office to set it up when you get home. Any time in the next few weeks would be fine. And in the meantime, if the pain gets worse or changes in any way, give me a call. Right now you’re having some pretty strong feelings about your father, and if that is the source of your chest pain, it may not go away right away. We’ll talk more about it when I see you in the office.
Patient: That seems reasonable to me. I appreciate your listening to me.
Doctor: Okay, then, I’ll see you in a few weeks. And remember, if the pains get worse or you get new symptoms along with them, call me immediately; don’t wait till the next day.
Patient: Thanks, Doc. See you in a few weeks.
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Patient satisfaction, as indicated by the patient’s responses toward the end of the interview, seems much greater than in the first scenario. Although this scenario is longer than the first, using empathic skills added only approximately 1 minute to the interview, and if that additional minute prevents unnecessary visits by allaying the patient’s concerns, the time is well spent. Early in the interview the doctor does very little talking, and what he does say primarily addresses the patient’s charged emotional state. He initially resists the patient’s invitation to confirm conclusively that this is all in his head, and, instead, allows the patient to continue to explore his feeling state. There is uncertainty at the end of the medical interview, but it seems to be an uncertainty that both the doctor and patient can accept comfortably, with a sense of partnership.