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