Robert A. Buckman, M.D., Ph.D.
Adjunct professor, Behavioral Science
The University of Texas M. D. Anderson Cancer Center
In all of the patient care modules of the I*CARE Web site, we've been stressing the value of acknowledging the emotion of the patient, however briefly and simply. In this module, we're going to look at why this is actually the most useful and the most practical way of dealing with a strong emotion. And we--we have to face it. A lot of us often find ourselves thinking why bother, why should I say something like, "This is obviously a shock to you." I mean why shouldn't I just say, "Oh, come on, it's not that bad really," or even "Pull yourself together." Well, this module on the Web site is actually different from all the others because in this module, we're going to answer that very question, the "Why bother?" question.
What we're going to do here is to show you how some of the other options might play out and why acknowledging the emotion always leads the interview along a more productive and supportive path. So it's not a matter of what you should do, for moral or ethical or even legal purposes, it's about what you can do to achieve a better outcome for the relationship between you and your patient. So in this module, what we're going to do is to show you that there are times in interactions that basically represent a crossroads between you and the patient, a crossroads where there are options for different types of responses. And we're going to show you how different responses would have taken the interview in different or less productive directions.
Now, just for the purposes of illustration in this module, we're going to use 4 different types of responses and then of course, there are probably dozens or maybe hundreds. What we're going to do is, first of all, we're going to illustrate what would have happened if you made a direct response, a response that aims solely at addressing the factual content of what the patient says, such as for example trying to reassure the patient when they're really upset, "It's not all that bad really." And I think I'll give you a quick non-oncological example. Suppose you are a physician in the ER and the patient comes in with chest pain, the ECG shows a small inferior MI, it's a small infarct, and you tell the patient that they've had a small heart attack. The patient then says "Oh my gosh, that's terrible." Okay, okay, now a direct response to the factual content of what our patient said might be to say, "I did say it was a small heart attack, you know." Now that is a direct or factual response, and I've actually heard clinicians respond exactly like that. That kind of direct or factual response usually leaves the patient thinking that the clinician is actually insensitive because it doesn't acknowledge the emotion. On the other hand, worse, if you happen to be very short tempered or you're under great pressure, you might make a response that starts an escalation, and this starts a conflict such as, "Come on, there's no need to overreact you know." Now that's escalationary because it's likely to increase the emotions, it escalates the emotions, and in a negative way, making the other person for example defensive or even angry or hostile, so that's the second type. And the third type that we're going to illustrate here, and it's very rarely wrong, it's almost never wrong actually, is to ask, to explore, to better understand what the patient is actually thinking or feeling.
Now one way of making an exploratory response is to ask an open-ended question, a question that could be answered in any way that the patient feels. So, if a patient has just heard about a recurrence of her disease, let's say, and she says, "How am I going to tell my husband?" You could respond to it with an exploratory response by saying, "Tell me more about that." The exploratory response invites the patient to expand on how they are thinking or feeling or what their major concern is about. Another way is just to repeat the last word or phrase that the patient says, so in that case--but with a rising intonation. So in that case if the patient says, "How am I going to tell my husband?" You might say, "Tell your husband?" Now, when you don't have a good idea of really what the emotion is, what the patient is feeling, explore, ask, ask or explore. It's not prying, it's clarifying. And the patients largely will be grateful for your interest in them, that's the third type.
The fourth type, the empathic response, that's the type that we'll be illustrating here and we've been stressing in almost every other part of this Web site, and that's the one that is always most productive. It's most productive when you do it because when you frame an empathic response, you basically align yourself with the patient, and you validate what he or she is thinking or feeling. It's a very, very powerful form of nonjudgmental acceptance and support at a time when the patient may well be feeling vulnerable. It's basically saying, "Hey, I'm with you on this one." The empathic response, as we've discussed in the basic communication section of this--in this whole series, consists of 3 steps. Number 1, the clinician identifying the strong emotion, the visible emotion, the anxiety or stress or whatever is, and sort of naming it to your self. I am stressed, upset, whatever it is. Then identifying the cause of that emotion, the source of it, what triggered it, and then responding to show specifically to the other person that you've made the connection between the emotion and the source of the emotion, between those 2 points. So in the case of that infarct for example, an empathic response could be something like, "Obviously that's a major shock to you," or "Clearly that's very upsetting," or "This must feel awful" or something like that, or any of the dozens of ways in expressing the same acknowledgment of the patient's distress. The words don't matter, the function of acknowledging does matter.
So, what we're going to do in this module is to show you an extract of an interview in which bad news, in this case recurrence of the woman's breast cancer, is shared with the patient. And at 4 points during that interview, points that we call the crossroads, we're going to show you how 4 options, the 4 different types of responses, direct, escalation, exploratory and empathic, actually would look like, and how each of those options would have worked out in a given scenario. And as you'll see, when we come to one of those crossroads, we're going to show you how the interview might have progressed for a short while after each of those types of responses, direct, escalationary, exploratory and empathic. And you'll be able to see how the way you respond to your patient is a matter of choosing your reply, and how the various consequences or outcomes of that reply play out. And we're going to do this in this way. First of all, you're going to see the entire interview straight through. And when we come to the crossroads, the four of them, we're going to, as it were, mark them, okay. So you'll just see now these are the crossroads. Then we're going to show you those crossroads again, and this time we're going to show you how each of those 4 choices that the physician could have made, direct or factual, the escalationary, the exploratory and the empathic, and what would have happened, how the interview would have gone over the next 3 or 4 exchanges after that. And I think by doing this exercise, you're going to see the value of the empathic response, why it's so often worth choosing.
Okay, so let's start by describing our patient's situation. Mrs. Simpson is a woman of 55 who was diagnosed with primary breast cancer just over 10 years ago at another hospital. The primary was node positive and also estrogen and progesterone receptor positive, ER-positive, PR-positive. So, Mrs. Simpson had adjuvant chemotherapy then she had 5 years of hormone therapy. She moved into your geographic area about a year ago and transferred to your care for routine follow up. She remained completely well for just about 5 years after completing her endocrine therapy until about 3 weeks ago. Then she suddenly developed low back pain which her physician told her was probably muscular in origin. She telephoned your office, and by your primary care nurse, you arranged a bone scan to be done this morning and for her to be seen by you this afternoon, okay? The bone scan shows multiple boney metastases. So now you're ready to see that interaction between you and Mrs. Simpson. Watch for the points in the interview that we've highlighted as crossroads, they're places where a choice of response is particularly important.
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