I was shadowing a practitioner recently in order to give her some feedback on her communication skills with patients. We entered an examination room in the emergency department where we encountered a gravely ill gentleman and his two middle aged daughters.
One daughter sat quietly beside him with a sad countenance. Another daughter stood close by and offered his history to us. Her expression was one of sadness, fear and anxiety. Like her face, her voice quivered with fear and anxiety, but it is her face I remember. When we left the room I asked the practitioner if she made note of how anxious that daughter appeared. She shook her head, saying she had not seen it. Note that I do not say she ignored it. I think it is more likely that she could not see it. It was not a failure to note but an inability to see.
In the spectrum of disorders from Asperger’s syndrome to autism, experts seem to agree that individuals diagnosed within the spectrum lack the ability to read emotions expressed by the human face. In communicating face-to-face with people they are disadvantaged and cannot identify joy, sadness or anger. They also cannot “hear” these emotions in the voices of people with whom they are talking. I suspect that not only those within the spectrum of Asperger’s have deficit abilities in reading emotions of others. Just as some of us have perfect pitch or have better color perception than most, there are some of us who do not “read” or “hear” the emotional language expressed on the face and in the voice of the people with whom we speak.
Temple Grandin is an autism expert and animal behavior expert who is autistic herself and has written extensively about her experience. I recall that she said in an interview that she could tell more about a person’s emotional state when she was talking to them on the phone than when she was facing the person—an implication that her visual cortex was somehow trumping or cancelling out her auditory cortex in relation to evaluating the emotion of the person speaking to her.
Emotional intelligence starts with the ability to perceive and name emotions in other humans. I find most doctors are not very good at this. I suspect this is not because they cannot see emotions, but because they have no training in how to respond to them. Physicians are not taught much psychology and psychotherapeutic technique. Most physicians have no training in the cauldron of emotional studies that one finds in literature, music and the visual arts.
Thus when many physicians encounter a strong emotion in a patient or a family caregiver they tend to try to disregard it or to persuade the patient they should not have it. The problem with both approaches is that emotions—anger, fear, sadness, grief—are not chosen by the brain. The brain has them: they are not good or bad, they simply exist and they tend not to just go away. Sadness does not befall us by our own volition. Although the emotions of personality disordered patients may be very inappropriate and reflective of a wildly unrealistic world, this befalls a small minority of people and most emotions are appropriate even if their manifestations seem ugly.
Scholars of patient communication advise us to first see the emotion and then to name it. So when you come upon a patient or caregiver who has a sad appearance and affect, you can say, “You seem sad. Do you want to talk about it?” Then you can express an understanding of it: “I can see how getting sick and losing your job because of it would make you sad and anxious.” You do not need to offer any answers or solutions to the problem. You can correct the impressions of the person if they are false and causing fear or sadness: “I can see you think that this illness is going to make you die soon and I want you to understand that is not the case.” Yet you cannot get anywhere in dealing with the emotions of patients without asking about a person’s emotions.
Rhetoric that you can put into practice in the form of questions or statements:
How do you feel about what we have discussed?
Given what we have talked about, what are you most afraid of?
I can understand that you would feel this way.
Fear is an apprehension about something negative that will or might occur, often of a loss. It might be a loss of function, loss of life. We have to ask patients what they are afraid of, because it is not possible to infer it. An ill and elderly patient may be fearful and sad not only regarding the illness, but because he or she fears they will become a burden on their family.
Sadness is a reflex to a loss or to a loss that seems very likely to occur.
Anger is generated by loss and fear. Loss often generates a sense of shame and loneliness in us.
The means of comforting patients suffering from fear, sadness and anxiety stemming from the diseases we treat them for is complicated and situational. Often it entails just listening to them. Sitting beside them, assuming an engaged body posture, grasping them by the arm are often more powerful means of communication than words. In some instances an assurance to the patient or family that they will “get through this” is helpful. There are many tragedies in life which we will never get over, but most we can get through. Most people suffering very sad events also experience a sense of solitude or a sense of being alone.
Returning to the emergency department exam room and the patient and his daughters, I can say that there were things that the practitioner might have done to comfort the patient. He was lethargic, struggling to breathe beneath an oxygen mask, suffering from COPD related pneumonia, an element of heart failure and renal insufficiency. He had difficulty speaking due to a laryngectomy. In the years preceding this he had undergone cardiac surgery, cancer surgery and had become dependent on home oxygen. She might have encouraged him that he would feel better with treatment, that he would be in intensive care and that we would attend to his needs.
What about the daughters? There was a conversation needed that did not take place. What were their fears? Who had medical power of attorney? What were their goals for their father? Were they only concerned regarding his survival or were they anxious to explain that he did not want to be on a ventilator again? As a practitioner you cannot know these things until you ask. “You seem to be very anxious and fearful for your father. Can we talk about it?”
You cannot communicate properly with a patient or caregiver until you learn to look into their eyes, read their emotion and respond to it.