Most of the essays I write about communication have one common core discord. It is the fact that often the emotional level of each participant is not the same. When one person is focused on the emotional content of a conversation and the other is focused on the procedural or analytical content, not only is it unlikely to lead to a positive outcome but can often lead to frustration and arguments.
In reading this, one might assume that the clinician is the “rational” one and the patient is the “emotional” one. While this is not always the case, I will lean on this stereotype in this essay. This doesn’t mean that clinicians need to be more in-tuned with their emotional side. In fact, I would argue that matching the emotional level doesn’t usually help things. This can feel patronizing to the patient and exhausting to the clinician.
Before continuing, it is important to call out that a few concepts used here have various definitions and carry various connotations that can make common understanding difficult. Forgive me if this is pedantic, but this is how I am defining these terms.
Empathy is the ability to understand and feel another’s emotions, often including the sharing in the other person’s distress or emotion. Some may call this emotional empathy or affective empathy.
Compassion contains the ability to understand another person’s struggle, but also includes some sense of separation, or a solution orientation. Some people call this cognitive empathy.
Hyper-Rationalism is a focus on ‘just the facts.’ It tends to disregard any emotional weight and focus on the process. While some may call this being judgmental, it is better understood as the desire to clear the emotional smoke to get a better look at the reality.
You can certainly challenge these definitions; we can all grab a beer and play linguistic games over definitions and connotations someday. For the moment, though, please accept that I don’t present them as the only true definition, so much as how I plan to use them in this essay. Consider this illustration.
I live on a small lake that at this time of year is covered with ice fishermen and you come to visit me. If, sixty yards out, you see a fisherman go through the ice, what would you do? An emotional empath puts themselves in fisherman’s shoes. If it were them, they would want someone to try and rescue them, so they would run out on the ice themselves and dive in. It is possible that they may be successful, but it is also possible that they will fall through the ice themselves or once diving in, lose sight of the hole, and likely drown themselves.
A cognitive empath would certainly feel the same connection to the fisherman but would also realize that their best solution is to call 911, alert others on the lake that the ice is unsafe and consider how to get out to the accident site safely using a ladder or other weight-displacing tool. This approach will take longer and challenges the survival rate, but they are also likely to not make things worse and even might create collateral benefits by alerting others around to the danger.
A hyper-rationalist will realize that given the distance, the temperature, and the fact that, once under ice, people get disoriented and cannot find the hole they fell through. Therefore, it is unlikely that they will be successfully recovered. Further, if they are, hypothermia will claim them before health professionals arrive.
This paints with a big brush and doesn’t account for any other variables, like familiarity with the lake, training in rescue or CPR, and whether the victim is a stranger, family member or dog. The point is simply to illustrate the concepts. Perhaps it is easier to think of this as a spectrum, where being an empath is at one end of the scale, compassionate in the middle and being hyper-logical at the other end. This essay is not meant to be disparaging to the empath or the hyper-logical. It is examining what happens in a conversation where the two people are at different places in the spectrum.
I have been to over 100 conferences and heard countless patients talk about their experiences, often with traumatic diagnoses. All these stories contain a common element. In the moment when they receive the news of how their life has inexorably changed, they hear absolutely nothing after that. While the doctor is talking about prognoses, potential courses of care, or clinical meaning, they are in a swirl of the impact that this will have on their daily life, their loved ones, and even their own mortality. The moral of their story is that clinicians need to be aware of this disconnect. This is the point where you really want everyone to be aligned but is also the first of many times when they are not.
I was with a family member (I will call her “M”) when she got a diagnosis of multiple sclerosis. I was with her when she had this diagnosis confirmed with a second opinion. What amazed me was that NEITHER of the rooms where this news was delivered contained a single box of tissues. I don’t expect clinicians to have a high emotional IQ, but to not be equipped with a first-level obvious need struck me as startling. Again, we need to be aligned as we make care decisions and at this first step, the neurologist didn’t understand what the patient needed. Having learned my lesson in the first instance, at least I came prepared with tissues at the second opinion consult.1
As part of work I was doing with a hospital system across the Chicagoland area, I met with a group of doctors one morning. I was talking about how to build a good patient experience and I had a doctor interrupt me and say, “I tell people they have cancer all day long, no one is giving me a [top-box score.]” I responded, “Well, yeah, if you tell them like that.” He later confessed that if the case was too “sticky” he would just refer them to the city and save himself the effort.
I have no idea if this doctor was clinically talented, but it was clear that he and the two neurologists2 could have paid more attention to the compassionate side. We expect our doctors to be an anchor in the strong winds, but we also need to know that they care about the outcome. That cancer patient does not see themselves as an odds ratio that can be tweaked with the right intervention, so that is not how they want their doctor to look at them.
But patients don’t want empathy, either. M didn’t want or need the doctors to cry with her. Patients and family members certainly will respond well to a meaningful look, or silent pause. Some will appreciate a comforting touch or hug, and I have read letters from those who appreciated it when the nurse prayed with them. But the patient and family are emotional and often find it intrusive if the care team is emotional with them.
The patient is processing the “present” and reflecting on the “past” (to use language from my last essay). They need you to acknowledge their current situation, but they don’t need you to FEEL it with them. In fact, that can be off-putting. They need you to be cognizant of the current situation and not barrage them with new information. But they still need you to have a plan for the “future.” Crying with them sends the tacit message that, yeah, you are doomed. They need you to say, “Yeah, this sucks, but people get through this and you can too.”
All of this is equally important for the care team. Being too distant can create an obstacle between the patient and the care team. This obstacle becomes more problematic when the next-steps conversation gets very complex, full of dense language and lots of numbers.3 On the other side of the spectrum, there is a lot of discussion, especially coming out of the pandemic, of “empathy fatigue.” Care teams are confronted by heartbreak all the time and without some attention or relief, they become numb to it. This can make it difficult to process emotions with their own family or become insensitive to their patients. The need here, as with most things, is to find a balance. Being compassionate, understanding the family’s heartbreak without participating in it, is the key. This, though, is easier said than done.
The best advice I can give on this is that you don’t need to feel your patients’ responses, but you need to acknowledge them. This is difficult because there are two things that pull you away from being present for your patients. Both are unavoidable, but by acknowledging them, you improve your chances of staying in the same room with the patient, metaphorically speaking.
- You already knew the diagnosis. You internalized it. You researched best courses for care. You even thought about the conversation with the patient and, perhaps, imagined how it would go. You guessed whether this patient was going to go the stoic route or the emotional route. You wondered if the friend/family member/advocate was going to be more helpful or hurtful. The point is that you were already in the MIDDLE of the conversation. When I must have a serious conversation with a team member, I will think about how I want to start and will consider how to address any possible responses. This helps me be present for the conversation. Sometimes, though, I will go down the rabbit hole. I start having the conversation with the person in my head. I think, I will say this and they will say that and then I will say this and they will call me a bad word and I will say that there is no call for that and they will say… So, by the time they show up, I am in the middle of the conversation, and they are at the beginning. Nothing good happens here.
- You have a full day. Whether it is having a full slate of appointments on your schedule, or a full set of patients on your unit, this patient is one stop along the day. Trying to engage in this conversation while your brain is considering all the other things you should be doing, or the fact that you are already running behind means that you feel like you don’t have time to reach the end of this conversation. As much as I will mock the “I tell people they have cancer all day long” doctor or the exasperated nurse who shouts, “You are not my only patient!” I do understand where this comes from since the day seems more like a day of tasks than a day of patients.
The reality is that these things will never change. Even with patients accessing their test results via the portal, you will still know the diagnosis and the end of the story before the patient does. Even if you didn’t have a clinic manager or a system medical group breathing down your neck to book more patients in shorter appointments, you still don’t have the luxury to curate every step of their seven stages of grief.
The best thing to do is lean into your biggest strength which is that this is not your first day. You know the broad framework of this journey. I am not saying that you should hop to the middle or end of the conversation, but simply that you know the broad categories that people fall into—the stoic, the person being brave for their family members, the emotional, etc. By being aware of this, you know what questions to ask, or how long to pause before moving forward with the next bit of information. This isn’t useful just for the patient, but also for the clinician, as it prevents the team from having to duplicate work and helps the team find the zone between mirroring the emotional release of the patient and appearing unmoved or uninterested in it.
1For those who are surprised by the fact that she cried at the second opinion, I think the second opinion is worse than the original diagnosis. In the original diagnosis, the doctor mentions the need for a second opinion and the patient clings to that reed in the rushing river, hoping that the consult will reveal that it is all just a bad dream. When the news comes a second time, that is the real crushing blow.
2Truth be told, M’s neurologist was a great doctor who was thoughtful and attentive. He read all the articles she gave him and reviewed her list of quack cures. It talked with great compassion. He just didn’t have any tissues. I mentioned it to him and it was rectified on our next visit.
3I did a grand rounds presentation to the residents on how to talk about numbers with patients. I will revisit that presentation here at some point.
PX Matters with Joseph Snipp 
Leave a comment