The emotional parent: Why empathy matters

Consider the following scenario in an outpatient clinic:

Doctor: Mrs. Johnson, we need to talk about the results of your son’s echocardiogram, It didn’t turn out exactly as I hoped it would. The echo indicates your son has a hole in his heart called a ventricular septal defect. There are a number of things we need to do now. First, we need to get you in to see a cardiologist or heart doctor. While this could turn out to not be a big deal, we need to consider multiple alternatives. Your son might need medication, a procedure performed by the cardiologist I am going to send you to, or the cardiologist might refer you to a surgeon to repair the problem surgically.

Parent: I love the way you talk, doc. My son might be OK or he might have a really serious heart problem! You are basically telling me my son has a serious heart condition, right? This might be nothing or he might need a bunch of treatments and even surgery. Could he 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?

The medical profession is emotionally overloaded by its very nature and the range of emotions experienced in a single day can be tremendous. Pediatricians can experience great sadness when giving bad news and great joy in telling patients and parents a suspected condition is not present or is now under control. Receiving a diagnosis, actions leading up to a diagnosis, and apprehension over future health may all have different emotions for parents and patients.

Emotions affect communication, comprehension, and the ability to take action based on the knowledge provided by the pediatrician. As much as 80% of the medical information provided to patients cannot be recalled in the short term. Additionally, patients and parents often “remember” information that is incorrect.^1,2 When patients or parents are presented with a new diagnosis or prognosis that provokes emotions, it is not surprising that recall is poor and desired actions are not taken. However, clear and empathetic communication can improve a number of important outcomes including patient safety, self-management behaviors, and satisfaction.

The potential impact of emotions on different aspects of care leads to a number of important questions:

• Are emotional reactions common in practice?

• What happens when the emotional needs of patients and parents are not met successfully?

• What are the consequences of failing to meet the emotional needs of parents and patients?

• How can pediatricians better deal with the emotional patient or parent?

• How can comprehension and adherence be improved?

How common are emotional responses in medical practice?

Negative emotions are common when receiving an undesirable diagnosis or dealing with patients experiencing a chronic medical condition. Depression, anxiety, and posttraumatic stress are common among patients and parents with advanced disease as well as in those hospitalized with general medical conditions.^3,4 Emotional responses may persist for some time and even may be prolonged by use of negative coping strategies such as denial, venting, and self-blame.³ Cardiac patients have been found to continue to display emotional and psychological problems as long as 4 months after receiving a diagnosis.⁵ Because many children and their parents experience significant emotional distress prior to obtaining medical care, during diagnostic testing, or in getting a diagnosis, the emotional responses physicians see in their offices may be compounded.

What if emotional needs are unmet?

Residents and students sometimes ask if parents’ and patients’ emotional responses really matter. They are often surprised that there is an actual evidence base to support addressing the emotional issues of patients and parents in the same way that asthma symptoms or a diabetic’s HbA_1C is addressed.

Common emotional reactions parents and patients experience as part of receiving a diagnosis or dealing with a chronic illness are associated with poorer health outcomes. For example, psychological distress is much greater in the mothers of preterm infants compared with mothers of full-term infants. Emotions such as anger, stress, and sadness are associated with increased risk of depression and posttraumatic stress disorder.⁶ More commonly studied in adult patients, addressing the emotional needs of patients is associated with a long-term mortality benefit in adult cardiac patients.⁷ Similarly, improvement in clinical outcomes such as length of stay and disease-specific quality-of-life scores are seen for a wide range of hospitalizations, including cancer, asthma, and postoperative care.^7-11

At a more basic level, patients and parents need to remember and act on information about treatments and appointments. When strong emotions are injected into healthcare, patients and parents tend to remember central themes (eg, your son has a hole in his heart) and may not recall treatment options or appointments.¹ Additionally, there is evidence that patients tend to recall information best when in the same “physical state” in which the information is received. Given this, it is not surprising that a parent may not be able to explain to a spouse everything discussed during a stressful conversation in the pediatrician’s office when they get home to a more supportive environment.¹

How might emotional responses impact a pediatrician’s practice?

There are also practical concerns regarding patient emotionality that must be considered in addition to providing the best possible care for patients and parents. In areas experiencing high penetration rates of capitated care, emotionally laden care may result in more utilization and greater cost of medical services.¹² When pediatricians fail to meet the emotional needs of parents and patients, parents may seek care from another hospital or practice.¹³ Finally, failure to appropriately handle emotionally laden care situations may increase litigation risk whereas effectively dealing with these situations decreases risk of litigation.¹⁴

Addressing emotional distress in practices

What can a pediatrician do when patients or parents display emotion in reaction to an unwanted diagnosis or inappropriate handling of a chronic illness? By putting the following suggestions and strategies into practice, pediatricians demonstrate empathy that may result in higher satisfaction and understanding of important health messages:

Make sure pediatrician and patient/parent are on the same page. If a pediatrician does not know exactly what a patient or parent understands and misunderstands, addressing their emotional needs is problematic. Unfortunately, patients and parents impacted by chronic illness often receive mixed messages. Misunderstanding is a common etiology or root cause for emotionally laden interactions with patients/ parents. As a result, understanding what a patient is thinking and his or her reactions to what you are saying is important. For example, this more commonly occurs when patients see multiple physicians or subspecialists. A patient’s nephrologist may say that the patient’s kidney function is worsening at the same time the rheumatologist is happy the symptoms of the patient’s arthritis are improving. Receiving a positive message from one specialist and a negative message from the other specialist may lead to significant patient emotions in your office. Pediatricians can make a tremendous impact for their patients by mitigating these sometimes-conflicting messages.

Be empathetic. Patients and parents may leave the office with the impression their doctor is uncaring if the pediatrician fails to acknowledge emotionally laden topics when they occur.¹⁵ Further, once patients or parents have expressed these emotions, the pediatrician should explore them with the patient and parent. Empathetic communication is most effectively accomplished by using questions that acknowledge and explore the topic. Following up with questions about the chief complaint for an office visit or the “real symptoms” does not demonstrate empathetic communication and may lead to the patient not sharing similarly in the future.¹⁶ See the Table for examples of communication strategies that express concern and empathy for the emotional patient.¹⁷

Slow down. Office-based practice can be very fast paced and pediatricians may not take time to slow down, but delivering information slowly and deliberately gives parents and patients the ability to better comprehend and more opportunities to express emotions and develop questions about what is being said.^16,18 Simply pausing after delivering bad news or another emotion-provoking topic is an effective method to make sure parents and patients receive the message and provides them an opportunity to react, ask questions, or comment on what the pediatrician has just said.¹⁶ Additionally, asking the patient or parent to summarize the discussion provides the pediatrician with information about whether or not the message was understood as well as how the patient or parent is interpreting what was discussed.

You do not necessarily have to refer. Referral to a social worker or psychiatrist may be appropriate if patients experience emotional distress following a new diagnosis or have coping problems with a chronic illness. However, patients often neither expect nor want the referral, sometimes because of social stigmas, and most patients and parents want to discuss these issues with their primary care physician. Further, most patients are more than willing and happy to accept a referral when directly asked by their pediatrician.¹⁹ Some patients will benefit from and/or desire treatment with psychotropic medications if symptoms are severe. Others will just want you to listen, to acknowledge, and to talk about their problem. In the end, most patients want to be truly heard rather then rotely referred.

Improving patient comprehension after emotional distress

Showing empathy for patients is essential in developing rapport and trust. However, patients will often have multiple appointments to complete a workup and need to follow a complicated treatment regimen. Although close follow-up in a short time interval may be appropriate after a new diagnosis or to follow a chronic patient experiencing problems, this may significantly stress a pediatrician’s already hectic schedule and could possibly inconvenience or delay a patient’s treatment. The following 4 tips will help you improve patient comprehension and adherence with your treatment plan following a new diagnosis or emotional encounter:

1. Speak in simple language and be specific. Specific information is seen as more valuable than general information.¹ For example, telling a parent or patient ”You need to set up a bedtime routine” will not be remembered or acted upon as well as telling them “Turn off the TV 2 hours before bed, no caffeinated drinks after dinner, shower, brush teeth, and read a book.”

2. Organize your patient messages. Developing systems to categorize or organize health information can also improve parent’s and patient’s information retention and adherence. One successful strategy suggests improving patient comprehension by explicitly telling the patient²⁰:

• What is wrong or what the problem is;

• Which diagnostic tests will be performed;

• What patients can expect to happen;

• Necessary treatments; and

• Self-management activities.

While an office practice can be very busy, parents and patients are more likely to be adherent and remember this information if they hear this message from their pediatrician. Having office staff reinforce the physician’s message before leaving the office will further increase understanding and adherence.

3. Written materials increase compliance. Written materials increase adherence with treatments, appointments, and other things you need parents and patients to remember when home.²¹ Pictographs and cartoons are useful among parents or patients with limited reading abilities.^21,22

4. Use teach back. Teach back is a specific skill that allows confirmation of a parent’s or patient’s understanding of whatever has been discussed. Understanding is confirmed when they explain back to you, in their own words, what you have just told them. You can watch a 5-minute video learning how to apply the teach back technique at http://nchealthliteracy.org/teachingaids.html.

Patient emotion is present every day in a pediatric practice. Because most of us never received training in medical school or residency in dealing with patient emotions in everyday practice, implementing some of the tips discussed here will increase your patients’ satisfaction with your practice and increase the likelihood that they will follow the treatment plan you and your patient establish.

REFERENCES

1. Kessels RP. Patients' memory for medical information. J R Soc Med. 2003;96(5):219-222.

2. Anderson JL, Dodman S, Kopelman M, Fleming A. Patient information recall in a rheumatology clinic. Rheumatol Rehabil. 1979;18(1):18-22.

3. Franck LS, Wray J, Gay C, Dearmun AK, Lee K, Cooper BA. Predictors of parent post-traumatic stress symptoms after child hospitalization on general pedaitric wards: a prospective cohort study. Int J Nurs Stud. 2014;pii:S0020-7489(14)00168-0.

4. Virtue SM, Manne S, Mee L, et al. The role of social and cognitive processes in the relationship between fear network and psychological distress among parents of children undergoing hematopoietic stem cell transplantation. J Clin Psychol Med Settings. 2014;21(3):223-233.

5. Dixon T, Lim LL, Powell H, Fisher JD. Psychosocial experiences of cardiac patients in early recovery: a community-based study. J Adv Nurs. 2000;31(6):1368-1375.

6. Shaw RJ, St John N, Lilo E, et al. Prevention of traumatic stress In mothers of preterms: 6-month outcomes. Pediatrics. 2014;134(2):e481-e488.

7. Denollet J, Brutsaert DL. Reducing emotional distress improves prognosis in coronary heart disease: 9-year mortality in a clinical trial of rehabilitation. Circulation. 2001;104(17):2018-2023.

8. Devine EC. Meta-analysis of the effects of psychoeducational care in adults with asthma. Res Nurs Health. 1996;19(5):367-376.

9. Devine EC. Effects of psychoeducational care for adult surgical patients: a meta-analysis of 191 studies. Patient Educ Couns. 1992;19(2):129-142.

10. Devine EC, Pearcy J. Meta-analysis of the effects of psychoeducational care in adults with chronic obstructive pulmonary disease. Patient Educ Couns. 1996;29(2):167-178.

11. Devine EC, O'Connor FW, Cook TD, Wenk VA, Curtin TR. Clinical and financial effects of psychoeducational care provided by staff nurses to adult surgical patients in the post-DRG environment. Am J Public Health. 1988;78(10):1293-1297.

12. Koopmans GT, Donker MC, Rutten FH. Length of hospital stay and health services use of medical inpatients with comorbid noncognitive mental disorders: a review of the literature. Gen Hosp Psychiatry. 2005;27(1):44-56.

13. Kent G, Wills G, Faulkner A, Parry G, Whipp M, Coleman R. Patient reactions to met and unmet psychological need: a critical incident analysis. Patient Educ Couns. 1996;28(2):187-190.

14. Spector RA. Plaintiff's attorneys share perspectives on patient communication. J Healthc Risk Manag. 2010;29(3):29-33.

15. Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA. 1997;277(8):678-682.

16. Travaline JM, Ruchinskas R, D'Alonzo GE Jr. Patient-physician communication: why and how. J Am Osteopath Assoc. 2005;105(1):13-18.

17. Lo B, Ruston D, Kates LW, et al; Working Group on Religious and Spiritual Issues at the End of LIfe. Discussing religious and spiritual issues at the end of life: a practical guide for physicians. JAMA. 2002;287(6):749-754.

18. Ambuel B, Mazzone MF. Breaking bad news and discussing death. Prim Care. 2001;28(2):249-267.

19. Brody DS, Khaliq AA, Thompson TL 2nd. Patients' perspectives on the management of emotional distress in primary care settings. J Gen Intern Med. 1997;12(7):403-406.

20. Ley P. Memory for medical information. Br J Soc Clin Psychol. 1979;18(2):245-255.

21. Blinder D, Rotenberg L, Peleg M, Taicher S. Patient compliance to instructions after oral surgical procedures. Int J Oral Maxillofac Surg. 2001;30(3):216-219.

22. Delp C, Jones J. Communicating information to patients: the use of cartoon illustrations to improve comprehension of instructions. Acad Emerg Med. 1996;3(3):264-270.

Dr Bass is chief medical information officer and associate professor of medicine and pediatrics, Louisiana State University Health Science Center–Shreveport. The author has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.