Clinical communication
How Are You Feeling? I Mean Emotionally, How
Are You Feeling?
Frederic W. Platt, MD, and James T. Hardee, MD
M
ost doctors tend to undervalue emotions,
those in themselves and those in their
patients. We tend to assume that we and
our patients are rational creatures, driven by ideas and
articulated values. We prize thoughts over feelings [1].
Yet many studies have shown that human beings
tend to feel first and think afterwards. Most of our
actions are primarily motivated by our emotions. As
patients we need our feelings to be ferreted out when
obscure, and acknowledged whether they are obscure
or obvious. As clinicians, our primary goal must include
that ferreting out and that acknowledgment [2,3].
Consider:
Clinician: So I see that you have been suffering with
chest pain and want me to find it and fix it, eh?
Patient: Well yes, Doctor. I’ve been pretty scared by
all this. I think it could mean … (silence)
Clinician: OK, let’s talk about the chest pain. Exactly
where is it and what brings it on?
Not a rare sort of clinical conversation. This clinician
correctly focuses on the symptom (chest pain) and tries
to further define it. Since symptoms are the gold of the
clinical interview, the clinician is focusing aptly [4]. But
what about that business of being scared? What did the
patient leave off saying?
Clinicians often hear but do not recognize or
acknowledge voiced feelings by the patient. Levinson
et al reported that the patient often gave clues to help us
understand how he had been feeling but less often voiced
the full story. The clinician then missed the opportunity
to search out the full story and failed to probe further.
The clues were missed more often than caught [5].
The Levinson et al study was published 13 years ago.
Have we improved much in that time period? Hsu et al
think not. They studied empathic opportunities in 47
visits with HIV-infected patients. Half the empathic
opportunities were missed [6]. Similarly, Adams et al
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reported 79 patient encounters wherein the patient
expressed negative emotion; in only a third of these interviews did the clinician show any empathic response [7].
Smith and his colleagues insist that our most therapeutic action in patient interviews is to seek out emotion
and respond with evidence that we have heard it and
understood it [8]. If that is true, we have a real challenge:
not to miss the key symptoms and the story attached to
them, but yet to recognize the patient’s strong emotional
responses and offer empathic summaries to close the gap
between patient and clinician.
What are the usual strong feelings that patients
experience and will tell us about? Mostly they are the
big 3: fear, sadness, and anger. Anger, often dreaded by
clinicians, is itself usually a secondary feeling and stems
from fear (anxiety, worry, fear, terror …) or from sadness
(unhappy, loss, grief, hopelessness …) Patients often tell
us of these feelings, and if they don’t make them explicit,
we can ask [8].
This patient has presented his clinician with a real gift,
a name for the emotion (fear), and offered to tell more
about it. All the clinician needs to do is invite further:
Clinician: I want to hear more about the pain, exactly
where it is and what brings it on, but first tell me
more about being scared. What are you worrying
about mostly?
Patient: Oh gosh, Doctor, I guess I think it might
be my heart and it could be a sort of messenger of
death. Maybe this is the end of me.
Clinician: I see. So you’re concerned that this could
be your heart and so a really serious problem. I
imagine that you want me to get right at sorting
it out.
Patient: Exactly!
Is this little divergence worth pursuing? It takes a
few seconds, perhaps half a minute, but investigation
and clarification of the patient’s concerns alleviate the
Vol. 20, No. 12 December 2013 JCOM 555
How are you feeling?
possibility that the patient thinks we really haven’t been
listening and do not understand the depth of his concern.
Patients who feel unheard or incompletely understood
tend to be dissatisfied with their care, more likely to
complain, and less likely to follow their treatment plan.
Of course, a patient may deny emotional material,
thus making it more difficult to discover. Many people
who tend to intellectualize their situation will explain
with their ideas but omit their feelings. What to do when
a patient does not voice an emotional connection or even
denies having any feelings?
Clinician: So how have you been feeling, emotionally, while all this is going on?
Patient: I dunno, Doctor. I don’t think feelings have
anything to do with it.
This patient, a professional colleague, seemed to never
recognize his own feelings and seldom those of anyone
else. But he was available for prompting:
Clinician: Well, still I’m curious. Most people with
chest pain like yours do have feelings associated with
the problem. They may feel worried or sad or even
angry. How about you?
Patient: Well, I don’t think the feelings caused the
pain or my breathing difficulty.
Clinician: Probably not. But tell me anyway.
Patient: I guess I am worried and now I’m worried
that you are trying to blame the pain on my worry.
I don’t come here for psychotherapy.
Clinician: I see. So chest pain, short of breath, a
little worried, and now I’m making it worse by inquiring into the feelings.
Patient: OK, you got me. Yeah, I’m worried. Concerned might be a better word. Maybe a little scared.
one will be angry and might even initiate a lawsuit, and
perhaps angry with the patient for not having followed
our recommendations more precisely. Then our patients
suffer and die. The death leads often to grief. We grieve.
Ofri says:
Grief tugs insistently at doctors. We form relationships—like all humans colliding in this world—but
our partners in these relationships die off with a regularity that isn’t common elsewhere. A thread of sorrow weaves through the daily life of medicine, even
during the mundane and pedestrian encounters. It is
disease, after all, that we are dealing with, not misdemeanors, philosophies, or building foundations.
So in the end, it is not only our patient’s feelings
that we must find and respond to, but our own strong
and sometimes disabling emotions need recognition and
care. We all need someone to share our grieving with;
we all need to be debriefed and understood. Otherwise
we become wounded healers and are dysfunctional with
our patients.
Much of doctor discontent and burnout seems linked
to strong unrecognized emotions. If we are disillusioned, perhaps bored, and convinced that our lives are
not what we were promised, we will function less well
and may end up leaving medicine entirely. If we address
these emotions we might still have a life in this chosen
field.
The clinical action that we are contemplating is usually called empathy. Our patients need it and we do them
a disservice if we withhold such a response. Yet clinicians
often explain the lack of empathic responses with stereotyped explanations [10]:
I don’t have time for those responses. I only get 10
minutes with a patient and there is just not enough
time to respond to their feelings.
Clinician: I see. OK, let’s go back to the chest pain
and sort that out a little better.
I never got any training in being empathic. That’s
for social workers and psychiatrists. I’m a doctor. I
don’t do psychotherapy.
What about our own strong negative feelings? Often
omitted in medical curricula, they do exist and we do suffer with them. Ofri offers quite a list in her powerful book,
What Doctors Feel [9], a list that includes anger, fear,
embarrassment, guilt, shame, disillusionment, sadness,
loss, grief, frustration, boredom—the list goes on and
on. When patients suffer unanticipated and unfortunate
outcomes, we may feel guilty, perhaps fearful that some-
I knew something needed to be said, but I just
couldn’t find the words.
556 JCOM December 2013 Vol. 20, No. 12
I’m not convinced that it would help. My responding with understanding might lead the patient
to pour out distressed feelings and I’d be overwhelmed. Asking about feelings would open a
Pandora’s box of powerful emotions that I am not
equipped to handle and have not the needed time.
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Clinical communication
If I did that, I’d have nothing left for my family at
the end of the day. Maybe I’d start drinking again.
It would be a sure track to burnout. I’d want to quit
medicine.
Why bother simply rephrasing what the patient has
already told me? He knows what he said. It’s just a
waste of time.
These excuses have some validity, of course. But
responding empathically takes little time and comforts
the clinician as well as the patient. We simply cannot
afford to be without this essential clinical tool. Our
patients need it. The last explanation is simply altogether
incorrect. Summarizing what the patient has told us and
letting him know that we heard and understood is a
powerful therapeutic step and that, after all, is our goal in
medicine, to listen to the patient and help him feel better.
The techniques needed seem simple even though they
are far from ubiquitous. The clinician must pay attention.
Then he or she must listen well and allow his/her imagination room to play. Finally, the clinician should give the
patient evidence, usually a brief summary of what has
been heard and understood, that he/she was indeed alive,
conscious, and listening. That should do it.
Of course those same listening tools serve well with
the physical symptoms of the illness.
Patient: I’ve been feeling weak and maybe a little
bit feverish for a couple of weeks. But Friday I went
swimming. I usually swim half a mile once a week.
Friday I couldn’t swim. I sank.
Clinician: You sank?
Patient: That’s right. I couldn’t float anymore. I sank.
Clinician: OK, I see. What I think I’m hearing is
that you have been ill for a couple of weeks with fatigue and maybe a little fever, but then what got you
in to see me was a problem with your swimming.
You had lost your buoyancy; you sank.
Patient: Exactly. I sank!
This very real patient presented with an uncommon
chief complaint: “sinking.” Further examination showed
that she had a large unilateral pleural effusion caused
by an unsuspected lymphoma [11]. The doctor’s use of
careful attentive listening and a short summary prevented
the common syndrome of a “Patient who tells the same
story over and over,” created trust, and speeded up the
diagnostic interview.
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A more common sort of story might go this way:
Clinician: Tell me the story of this illness.
Patient: I’ve been feeling punk for a month or so.
Then I got nauseated and lost my appetite. Finally
last week I noticed that my eyes look yellow and my
urine is darker. So I called to make an appointment
with you.
Clinician: I see. Punk for a month, nausea and loss
of appetite and then jaundice. (That’s the yellow you
noticed in your eyes.) Anything else?
Patient: Nope, that’s about it.
Of course that is almost never quite “it.” This patient,
when asked about his idea of what might be causing the
trouble had more to say.
Clinician: What do you think caused this trouble?
Patient: Well, I don’t know, but I did have a trip
to Mexico. I was in Yucatan for 2 weeks about 2
months ago. Maybe I caught something.
Yes, he did catch something. Hepatitis A.
This addition reminds us that we must listen intently
and summarize our hearing not just about those distressing
feelings but also about the patient’s symptoms, the patient’s
ideas about causation, and the values behind the feelings
we’ve unroofed. In fact, it is fair to say that the clinician’s
discovery process includes hearing the patient’s physical
symptoms, the patient’s emotional responses, the patient’s
ideas (about causation, about further treatment, about
future worries), and the patient’s values that tend to underlie feelings. Those 4 categories of data stand out in our
work. And, of course, the power of effective listening and
summarization lies in their therapeutic effect: the patient
gains trust and confidence in the doctor and will likely
follow suggestions better, be more satisfied, and less likely
to run away or complain of his treatment in your hands.
Looking for and summarizing symptoms seems
straightforward. Feelings and ideas seem almost as easy
to ferret out. All we have to do is ask. “How have you
been feeling about all this; I mean emotionally, how have
you been feeling?” and “What ideas have you considered
about this illness? Cause? Treatment? Further tests or procedures? What were you expecting me to recommend?”
But sorting through the patient’s values may seem more
difficult. It helps to remember that values underlie feelings
[12]. Our conversation might go something like this:
Vol. 20, No. 12 December 2013 JCOM 557
How are you feeling?
Clinician: So I understand that you’ve been feeling
punk, nauseated, no appetite, and then jaundiced.
You’ve been thinking that you might have caught
something in Mexico. How are you feeling about all
this; I mean emotionally?
Patient: Well, a little bummed out, I guess. I had
big plans for a climbing trip and I think I won’t be
able to go.
Clinician: Tell me about that.
Patient: Oh, my 2 buddies and I were going to try the
east face of Long’s Peak. It’s a big climb and pretty
hard. I was really looking forward to it. We three have
climbed before and I hate to disappoint them. But of
course falling off the mountain would be a downer too.
What if we just omit all this stuff and stay with the
physical symptoms. Sometimes that’s enough:
Patient: My dog ran in front of me, and I tripped
over him, and I fell and twisted my ankle. I think I
sprained it. Would you look at it?
Looking at the ankle, maybe an x-ray, maybe a splint,
might be quite enough. But another time we might ask
how the dog came to run in front of him. Maybe he was
not watching the dog, instead ogling the cute girl down
the block. Maybe he’s been terribly lonely since he broke
up with his previous girlfriend. Maybe he’s been drinking
more. Maybe …. Maybe there is more to discover. To do
that we have to ask the right questions.
Clinician: So, sounds like, you were planning a
tough climb and you hate to disappoint your climbing friends.
Corresponding author: Frederic W. Platt, MD, 396 Steele
St., Denver, CO 80206, [email protected]
Patient: That’s it. It’s really important for me to come
through with my promises. I hate to renege on them.
REFERENCES
Clinician: Keeping your promises is really important
to you.
Patient: Yeah.
Clinician: OK, let me sort of summarize what I’ve
heard so I’m sure I haven’t gone astray. You’ve
been under the weather for a couple of weeks, then
jaundice appeared. You think it might be from your
Mexico trip and you’re feeling sad because it is really important for you to keep your promises and
you had promised y our buddies to join them in the
Long’s Peak climb. Did I miss anything?
Patient: Nope. You got it, Doc.
OK, that part of the dialogue is an imagined
sequence, including my favorite response from a patient,
that “You got it, Doc.” But the sequence should be clear.
Sort out the physical symptoms, then the emotional
ones, and finally look for the underlying value that fuels
the emotional symptoms. And, on the way, discover and
recognize the patient’s thoughts on the matter.
A few caveats: In ordinary English, people often use
“I feel …” to mean “I think ….” So if we ask our patient
what his ideas about causation are, he might respond,
“I feel that perhaps I have some sort of liver problem,
maybe hepatitis.” No need to argue about grammar; he’s
really saying, “I THINK perhaps I have ….”
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Copyright 2013 by Turner White Communications Inc., Wayne, PA. All rights reserved.
558 JCOM December 2013 Vol. 20, No. 12
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