Emotional Patient

Posted on Jul 27, 2010 in Patient Care | 2 comments

The Emotional Patient

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Consider the following scenario in an outpatient clinic:

Doctor: Renee, we’ve got to talk about the results of your stress test. It didn’t turn as I hoped it would. Your test indicates you may have serious heart disease. There are a number of things we need to do now. First, we need to get you in to see a cardiologist. While this could turn out to be nothing, we need to consider the other side too. You could need a stent or even bypass surgery.

Patient: I love the way you talk doc. I might be ok or I might have a really serious heart problem. You are basically telling me, “You’ve got heart disease. You’re going to need a bunch of treatment and I might even die?” Is that what you’re really trying to tell me? Once you remove the euphemisms isn’t that what you are really trying to say?

By its very nature our profession is emotionally laden–our patients will experience emotion related to concern over their future health and are affected by events leading up to the initiation of care or receiving a diagnosis. Emotions not only impact our ability to communicate with patients, but also our patients ability to understand and act on the information we provide. Forty to eighty percent of the medical information we give patients is forgotten immediately, and significant amounts of remembered information is incorrect.[1, 2] This is even before patients’ emotional state impacts on their ability to recall or act upon information we give them. Ultimately, communicating clearly and empathetically with our patients can improve–

• Patient safety
• Patient self-management
• Patient satisfaction

Our patients’ emotions can affect many aspects of care and lead to a number of important questions that we need to answer:

1. How common are emotional responses in our practices?
2. What are the implications for patients when their emotional needs go unmet?
3. What are the implications for us if we fail to meet this patient care need?
4. How can I better deal with the emotional patient?
5. How can I improve patient comprehension and adherence with an emotional patient?

How Common Are Emotional Responses In Our Practices?

Patients commonly experience negative emotions in receiving a diagnosis or dealing with their chronic medical condition. Depression, anxiety, and posttraumatic stress disorder are common among patients with advanced disease as well as those hospitalized with general medical conditions.[3,4] The emotional responses, in fact, may persist for some time. Cardiac patients have been found to continue to display emotional and psychological problems for months after receiving a diagnosis.[5]

What Are The Implications For Our Patients If Their Emotional Needs Go Unmet?

As an educator I am sometimes asked by residents and students if patients’ emotional responses really matter as we care for them and I am often shocked at my learners’ surprise at our discussion. When I discuss an actual evidence base to support dealing with emotional issues of patients in the same way address a post-MI patient’s LDL or a diabetic’s HBA1C, my learners are often taken aback.

Common emotional reactions our patients experience as part of receiving a diagnosis or dealing with a chronic illness are associated with poorer health outcomes. For example, emotions such as anger, stress, and sadness are associated with increased risk of death and additional myocardial infarctions among patients with coronary heart disease. This increased risk occurs even after accounting for individual disease severity.[6] There is also evidence that specifically addressing the emotional needs of patients has a long-term mortality benefit among cardiac patients.[7] Reductions in length of stay and improvement in other clinical outcomes are seen among hospitalized patients with a number of different conditions including cancer, asthma, COPD, and postoperative care.[7-11]

At a more basic level for us in day-to-day primary care practice, we need patients to remember information about treatments and appointments. When emotions are interjected into care, patients tend to only remember the central message (eg, you have cancer), and may not remember discussions related to treatment options, self-care strategies, or appointments.[1] Additionally, patients tend to remember information when in the ‘physical state’ they received the information, possibly explaining why patients forget information received in a stressful hospital or office environment once they have gotten home to a more supportive environment.[1]

How Might Patient’s Emotional Responses Affect Our Practices?

In addition to our concern for patient welfare and trying to provide effective care, there are other practical concerns regarding patient emotionality that we must consider. If you are practicing in a capitated environment, significant levels of patient emotion may result in increased utilization and cost of medical services.[4,12] The unmet emotional needs of our patients may contribute to our patients seeking care from a different hospital or another practice.[13] Finally, poorly dealing with patients’ emotional reactions can increase our risk of litigation while effectively dealing with our patients’ emotion can decrease chances of litigation.[14]

Dealing With Our Patients Experience Emotional Distress?

So what can we do in our practices when patients display emotion in reaction to a diagnosis or in dealing with a chronic illness. Consider the following 4 tips that will demonstrate to your patients that you care, and, as a result, improve their satisfaction and hopefully comprehension of your important health messages.

1. Make sure you and the patient are on the same page. Knowing exactly what your patient understands or potentially misunderstands is key to dealing with his or her emotions. When following a patient with chronic medical conditions, the patient may sometimes receive mixed messages. Emotions can arise from misunderstanding, so it is important to understand what your patient is thinking. For example, a patient’s nephrologist may tell him his kidney function is worsening, while the cardiologist is happy with his symptom control from congestive heart failure. The confusion created for the patient when one doctor is giving a positive message and the other doctor a negative message can cause significant patient emotions in your office.
2. Be empathetic. Failure to acknowledge your patient’s emotions and his or her impact may leave your patient feeling that you are uncaring.[15] Further, once identified, these emotions should be explored with the patient. You should not follow up with questions about her ‘real symptoms,’ but focus on statements that demonstrate empathetic communication.[16] See Table 1 for some suggestions for communication strategies that express concern and empathy for the emotional patient.[17]
3. Slow down. Delivering information in a slow and deliberate fashion not only allows your patient to better comprehend what you are telling him, but allows time for him to express emotions and develop questions.[18] When delivering bad news simply giving the bad news and then pausing is an effective method for making sure the patient and his family receive and understand what you have said.[16]
4. You don’t have to refer. While our first inclination may be to refer to a mental health professional after our patients experience emotional distress following a diagnosis or when experiencing problems with a chronic illness, our patients often do not expect or want this. Most want to discuss these issues with their primary care clinician and are more than happy to do so when directly asked.[19] If experiencing significant symptoms, some patients may want treatment with psychotropic medications, while others may just want to talk with you about their problem. I find that after talking with patients and getting a full understanding of their situation, most patients are accepting if I decide they need a consultation with a mental health professional.

Improving Patient Comprehension When They Experience Emotional Distress

In addition to displaying empathy for our patients, we often need them to keep multiple appointments or follow complicated treatment regimens. While bringing a patient back to the office in a short time period after a new diagnosis to discuss a treatment is always an option, this creates more office visits for your already busy schedule and may significantly inconvenience or delay your patient’s treatment. The following 4 tips will help you improve patient comprehension and adherence with treatment plan following a new diagnosis or emotional encounter.

1. Speak in simple language and be specific. Patients perceive specific information as more important than general information.[1] For example, telling a patient, “You need to rest your back” will not be remembered or acted upon as well as telling him, “No lifting of boxes more than 10 pounds for the next 2 weeks.”
2. Organize your patient messages. How we categorize or organize health information for delivery to patients can also improve patient’s information retention and adherence. One successful categorization strategy suggests you can improve patient comprehension by explicitly telling the patient[20]:
   • What is wrong or what is the problem
   • Which tests will be performed
   • What you expect to happen
   • Needed treatments
   • Specific self-management activities to help himself or hersel

   While we are all very busy, patients are more likely to be adherent and remember this information if they hear this message from you. Having your staff reinforce the message you deliver before the patient leaves the office will further increase understanding and adherence.

3. Provide written materials in addition to talking with your patients. Written materials can increase adherence with treatments, appointments, and other things you need your patients to remember when home.[21] Pictographs and cartoons are useful among patients with limited reading abilities.[21,22]
4. Use teach back. Teach-back is a specific skill that allows you to confirm a patient’s understanding of what you have told your patient. Patient understanding is confirmed when the patient can explain back to you, in his own words, what you have just told him. You can watch a 5-minute video learning how to apply the teach-back technique here. http://nchealthliteracy.org/teachingaids.html

Patient emotion is present every day in each of our practices. While most of us never received training in medical school or residency in dealing with patient emotions in our every day practice, implementing some of the tips discussed here will increase your patients’ satisfaction with your practice and increase the likelihood of following the treatment plan you and your patient establish.

What are your communication techniques?

 

Pat F. Bass III, MD, MS, MPH
Louisiana State University Health Sciences Center
Published on July 27, 2010

References

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3. Hotopf M, Chidgey J, Addington-Hall J, Ly KL. Depression in advanced disease: a systematic review Part 1. Prevalence and case finding. Palliat Med. 2002;16:81-97.
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