HOW TO ACCESS THE HUMAN SIDE OF MEDICINE

A patient presents with respiratory distress and COPD. She is very dramatic in her gestures, very upset and emotional. The first time you saw her you had given her lorazepam and sent her home. It turns out she frequently gets that. You and your colleagues eventually set boundaries on that but she continues to present daily for respiratory distress. This case turns out to involve the deeper human side of medicine. How do you access that?

 

How do we not only know medicine but know the human condition? Read Shakespeare? Go to bedside medicine skills sessions with actors? Do an ED fellowship in emergency psychiatry?

 

I particularly enjoyed reading the articles by Frederick Platt from the University of Colorado. He was an internist who would put on workshops on difficult patients/encounters. In role playing, the clinician would learn to recognize strong affect, stop, and name the affect. “I sense you are feeling…upset…scared…angry…etc.” The patient then is invited to explain their fears and concerns.

 

Emotions, as the Latin root “motere” tells us, serve to “move” us. They motivate us and impel us to action. They are faster and more intuitive than verbal language. But they are not enough for us. We need to move the patient from nonverbal to verbal expression.

 

“I sense you are feeling scared.”

 

The patient starts crying. You ask why she is scared.

 

She is afraid of dying.

 

You then address that fundamental concern with her. You write “fear of death” as the diagnosis, knowing that future providers can at a glance review the primary diagnosis for each visit. As your colleagues and you empathetically address her concerns, the visits drop from daily to weekly to a couple times a year. She starts taking care of herself better and gets off the sedatives.

 

TAKE HOME POINTS

-if there is strong affect, stop, name it, and inquire about it

-transition the patient from nonverbal to verbal communication

-identify the concerns and needs behind each visit with a question like “what concerns you the most?”

-review the post on agenda setting for related suggestions

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DENIAL? IT’S ABOUT HOPE

A patient presents with a scalp hematoma from a remote fall. When you press on it, it feels very soft but is not swollen. You are confused, and order a CT, which shows complete lysis of the bone,. Further workup suggests metastatic renal cell carcinoma. The patient is avoidant on history and keeps explaining away the findings and concerns. Hours later, while he is awaiting a bed upstairs, he reveals that a year ago his doctor suspected renal cell carcinoma but he refused a workup.

 

This patient suffers from denial. Whether that is a perfect term is debatable. In this case it is severe but so often denial seems to overlap with avoidance, perhaps even procrastination. It is at times the unwillingness to address an unpleasant reality. In medicine all too often we judge “denial” as a break with reality but we need to understand it as a human experience. Denial is the way some patients try to grasp onto hope. Go read Arthur Miller’s Death of a Salesman if you want a literary exploration of denial and hope.

 

We shouldn’t always oppose denial. Don’t argue over code status. If they want to be full code don’t gripe about them at the nurse’s station. They are dying. If knowing they will get 30 minutes of CPR in the end gives them comfort then let them have that consolation. If the patient-centered reasons aren’t enough, remember that practicing code situations only makes you better at it.

 

The literature is accumulating articles portraying denial as a positive thing. Denial mitigates terror and allows patients to continue to function. But in the emergency department we sometimes see patients at an earlier stage, where denial gets in the way of potentially curative treatment. So what should we do?

 

Accentuate the positive

Without distorting the truth, emphasize the safety and efficacy of your recommendations.

 

Build a relationship of trust by genuinely connecting as people

Spend some time getting to know them as people. Share anecdotes of those who have had good experiences, which not only illustrates safety but also displays your connection to patients. As emergency physicians we will not get long-term rapport, so build it for your consultants, whose expertise and caring we should commend to the patient (assuming we can do so truthfully).

 

Tools of persuasion – allowing an “out” lowers the cost of an “in”

Finally, point out that they can always choose to stop treatment later. That way they can say yes without feeling stuck. By giving them an “out” you are lowering the cost of going “in.”

 

Ultimately, denial is their choice. We will not be able to convince everyone to face the unpleasant reality but we should use the skills and techniques that best address their frame of feeling.

 

Take Home Points:

-Denial is often a way for the patient to have hope

-Give such patients hope through emphasizing the positives of treatment

-Connect on a genuine, human level

-Remind them they can change their minds later