Patient—Doctor Interactions: Emotional Cues and Discussing Prognosis

Overtly expressed feelings and emotions

Patients may show obvious emotions during the consultation. These may be expressed, for example, through crying (grief) or anger (shouting). In such situations, the doctor should make an ‘accepting response’, which acknowledges the patient's feelings and helps build rapport as the patient and doctor share understanding of the patient's perspective (Silverman et al., 2004). The patient's reaction should not be ignored (Box 1). It may be easy for the doctor to recognize the emotion; it is also easy to carry on with the doctor's agenda of telling the patient what will happen next without responding.

Indirectly expressed feelings and emotions

Covert emotional cues or non-verbal cues (Box 2) are more difficult to recognize. They occur frequently and they are often ignored. The use of open questions and listening attentively helps patients express their emotions. If the doctor establishes rapport and appears interested in the patient, the patient will usually give cues to his or her emotions during the attentive (active) listening phase of the consultation.

Doctors ignore such cues for various reasons. They may not wish to respond because they are unsure of how to, because they feel under pressure for time and/or because they are distracted by the information they wish to impart. When patient emotions are recognized, the doctor should acknowledge them. For example: ‘I can sense that you are angry by what I have just said—am I right to think that?’ and ‘You appear to be very anxious about what I have just said. Would you like to tell me about what you are thinking?’

Skills involved in eliciting and responding

For those doctors who have been trained to be objective and not become emotionally involved with their patients, it will be difficult to acknowledge patients’ feelings and in particular to know how to respond. GPs develop their own style, through observing their role models and feedback from patients, and from experience but should reflect on this and ensure that they are communicating effectively and empathically. Certain doctors would never respond to a patient who is crying by holding a hand, but have other ways of responding to grief such as by active listening and empathic responses. GPs should not do anything that makes them feel uncomfortable; however, they should be aware of the effect of their behaviour on their patients. The skills that doctors should employ when dealing with patients’ feelings include responding to non-verbal cues (Box 3).

When the doctor feels that it is time to move on to the next stage of the consultation, he or she should thank the patient for discussing emotions: ‘Thank you for sharing how you feel with me. Do you feel able to discuss what is going to happen next now?’

Empathy

Empathy is the identification with and understanding of another's situation, feelings and motives. However, doctors need to be careful of confusing what they would feel in a certain circumstance with what the patient is actually feeling. This tendency has been called ‘pseudo-empathy’ (Rosenfield and Jones, 2004). For example, a fit and healthy unmarried doctor cannot understand completely what a mother with three young children is feeling when she is diagnosed with breast cancer, so saying ‘I know how you are feeling’ may be met with anger. A more helpful interaction would be: ‘this must be very difficult for you’.

Empathy is a natural attribute that may be heightened by personal experience of illness or traumatic events, though even if a doctor has had a similar experience to a patient's, it will only be similar and not the same. Empathic statements such as ‘I can see that you are angry’ help develop rapport. Ways of expressing empathy may be learnt. It may be thought of as a two-stage process:

The understanding and sensitive appreciation of another person's predicament or feelings

Empathy may be expressed both verbally and non-verbally. Non-verbal communication is used to show that the doctor is sensitive to the patient's feelings and may include lowering the voice, moving closer to the patient, touching the patient's hand or being silent.

The anxious patient

Patients will usually be anxious when attending for test results, even though they may be expecting them to be normal. Their anxiety will be heightened if they have to wait a long time for these or if on the day of their appointment the doctor is running late and they have to sit for a while in the waiting room. When the patient enters the consulting room, the doctor should apologize if necessary for running late. If the patient appears anxious — his or her hands are shaking, there is evidence of sweating or agitation — this should be acknowledged: ‘waiting for these results must have been difficult for you. How are you feeling at the moment?’

Sharing bad news with a patient is a difficult task. If the patient is anxious, this becomes even harder. How to ensure that the patient is able to understand what is being said? The doctor may signpost the bad news: ‘I have the results of the tests. I want you to listen very carefully to what I have to tell you now. It is important that you concentrate on what I am about to say’.

The patient may become physically distressed due to anxiety, for example the patient may start to hyperventilate, speak rapidly or obviously switch off from listening. In such cases, he or she is unlikely to take in any more information. The doctor should employ techniques to reduce such physiological effects. The patient could be invited to lie down and/or to take deeper and slower breaths. Sometimes the offer of a cup of tea will help (though of course this all takes time and is likely to add to the GP's own anxiety).

Interacting with patients with a diagnosis of cancer will also involve employing skills of dealing with anxiety. Exploring ideas and concerns will help the doctor understand the specific anxieties that each patient has. It is easy to assume that patients are scared of dying but this may not be the uppermost concern of an individual. A mother may be worried about how she will tell her daughters the news; a man may be concerned about how his condition and treatment may affect his future fertility. While patients have genuine causes to be anxious, some of their specific concerns may be unfounded. When anxieties are expressed, the doctor should acknowledge these and advise the patient that such concerns and emotions are to be expected. The GP should reassure as necessary but not give false reassurance. Reassurance should be based on fact.

Because the GP may know the patient well and have knowledge of previous reactions of personal illness or illness in a family member, he or she can remind the patient of how anxiety has been coped with in the past. If the GP is not that familiar with the patient, he or she can explore how the patient has dealt with stress and reinforce the fact that there are coping mechanisms that will work. To help manage anxiety at home or at work, the GP can explain stress-relieving techniques such as simple relaxation, breathing exercises, the use of soothing music and other attention diversion exercises.

Anxious patients will find it harder to understand what they are being told, as their concentration will be impaired. Information should be repeated and summarized in order to help patient recall. It can be reinforced with written material. Patients should be asked if they have any further questions and follow-up arranged to deal with any unresolved questions that may be remembered after the consultation.

The distressed patient

Distress is a natural result of being told bad news, though patients will manifest this in different ways. The first signs of distress within a consultation should be acknowledged: ‘I can see that this is very distressing for you’. Patients who apologize for crying should be ‘given permission’ to cry; providing tissues is one way of doing this. The GP should not attempt to discuss information when the patient is crying and should not be afraid of silence and leaning forward. Certainly, the doctor should not be focused on a computer screen or be writing while the patient is distressed — the patient needs the doctor's full attention.

Distress and crying should prompt the doctor to explore ideas and concerns once the patient is able to talk. The doctor should invite discussion but acknowledge that the patient may not wish to explore his or her feelings at this point. ‘I can see this is very distressing for you. Would you

like to tell me how you are feeling or would you rather discuss this at a later time?’ Again, false reassurance should not be given. If the GP is unable to address particular concerns about drug treatment or prognosis, this should be said and a promise made to find out the relevant information or if the patient is to see a specialist, the GP may say: ‘You will be seeing Dr X in a few days. She will be able to discuss this with you’. In such cases, the GP should ensure that the patient has adequate support until the specialist appointment.

The angry patient

Patients become angry for various reasons. They may believe that their diagnosis is the result of delayed investigations or that their previous care has been inadequate. They may have no precipitating reason but anger may be a way they deal with strong emotions, rather than crying for example. They may feel guilty because of their lifestyle, for example smoking/drinking heavily, and this is demonstrated by lashing out at loved ones or professionals.

GPs have to deal and defuse a patient's anger, but they must also be sure to protect themselves if the anger becomes physical and abuse is likely. Fortunately, anger is common but aggression is rare. Signs that a person is becoming angry include an increase in respiratory rate, speech becoming louder, facial flushing and obvious tension in the neck and shoulders. If a patient becomes angry, it is important to acknowledge this and to explore the reasons for the emotion while not invading the patient's personal space. Empathic statements are helpful such as ‘I can see that you are angry’. Other strategies for dealing with angry patients are listed in Box 4.

As GPs, we all make mistakes in diagnosis and treatment. If there has been a delay in diagnosis, then the GP should acknowledge this and explain to the patient what has happened. Being honest is usually the best way to proceed. However, if the patient is making rash statements about what has happened, these should not be challenged or criticized, but neither should they be accepted. ‘I can see that you are angry. Perhaps you would like to sit down and tell me what has upset you and let's see together what we can do about it.’

The depressed patient

GPs are in a good position to recognize patients who become depressed during their illness journey if they see them regularly. This is more difficult if patients see different GPs due to rotas and holidays. Obviously, no patient is likely to be happy following the initial diagnosis of cancer or human immunodeficiency virus, but some adapt and take a positive attitude to treatment. Other patients will become depressed and depending on the manifestation of their mood may need treatment and/or referral. A patient who has a history of depression is more likely to react in this way. It is important to recognize and treat depression appropriately as co-morbid psychological problems may affect the patient's response to treatment, in particular depression may cause an increased incidence of drug side effects, anxiety and tiredness.

The symptoms of depression are well known but some of them overlap with symptoms expected during cancer treatments, e.g. anorexia, malaise, insomnia and weight loss. While GPs will be quick to recognize overt symptoms such as crying and those volunteered by patients, they may miss more subtle symptoms such as lack of interest without asking the patient directly. Non-verbal clues are lack of eye contact, change in mood (a GP who knows the patient well may see a change in affect and self-care) and hesitant speech.

Open questions should be asked first: how are you feeling? Followed by more focused questions as necessary: how are you sleeping? How is the appetite? How did you enjoy your daughter's wedding — you mentioned last time that she was getting married last week? Empathic statements are also useful: this must be really difficult for you. You look tired. GPs must consider the possibility of self-harm and ask if the patient has any thoughts of this. Certain patients are more at risk of depression than others (Box 5) and again the GP is often in a good position to make a risk assessment.

Patients who have cancer with depression should be involved in decisions about treatment for their depression as much as possible. They should be offered the same treatments as other patients. They need to be reassured that depression is common and that it can be treated. Anti-depressants are not always necessary. Cognitive-behavioural therapy and stress management techniques have therapeutic value. If the GP does not feel skilled enough to manage the patient, referral is necessary. Whether referral is made or not, the GP should see the patient regularly for support and monitoring.

The communication of prognosis within general practice

GPs may not be involved in the communication process dealing with prognosis. Indeed, GPs should approach with caution the desire to give a prognosis. The most appropriate person is often the specialist, particularly in relation to cancer diagnoses, as treatments change and survival rates alter. In most cases, patients will be referred to a specialist for confirmation of diagnosis plus further management. GPs may become involved if they are confident of the diagnosis at the ‘breaking bad news’ stage and the patient asks for information or following the specialist consultation if the patient asks for clarification of that doctor's discussion. Patients have a need for information about prognosis and how likely this is to be accurate. They want to know about life expectancy, the chances of cure (Lobb et al., 2001) and the effect of cancer on their lives (Butow et al., 1996) and they feel it is important to be able to refine their understanding about prognosis as the disease progresses. But they also want the provision of hope and express a need for hopeful messages at all stages (Kirk et al., 2004).

Types of information about prognosis

Prognosis may be discussed in different ways, for example with numerical data or with descriptive words. Such discussion should be related to the patient's desire for the level of information and not to the doctor's level of comfort.

Patients, when ready, should be given all relevant information, including details about probability and risk in a form that promotes understanding. Doctors should also remember that prognostication is not an exact science and is based on statistical probabilities. Most clinicians can give examples of occasions when prognoses were wrong.

Doctors are often reluctant to discuss prognosis because of their beliefs that patients cannot understand the information and that it may destroy hope (Beisecker et al., 1994). This is a form of paternalism that removes a patient's ability to plan for whatever future remains. And of course the onus should be on doctors to ensure that their communication skills facilitate the patient being able to understand the information presented. Again, the patient-centred approach is the most appropriate process for discussing prognosis — with the doctor exploring the patient's ideas, concerns and expectations as necessary.

The language of risk and prognosis

Communicating prognosis involves the language of risk. This discussion involves the open two-way exchange of information and opinion about risk, which should lead to better understanding and better decisions about clinical management (Edwards et al., 2000). Helping patients understand risk in the context of decision making is fundamental to the process of ensuring that patients make the correct decision in relation to their treatment in partnership with their doctors. Patients understand different methods of presenting risk to varying extents and these differences need to be taken into consideration when considering the way to present information. Overall, patients prefer information that is balanced and includes a careful and honest assessment of the advantages and disadvantages of treatment including risk. They do not want false reassurance. Examples of different ways of framing risk are shown in Box 6. Prognostic information of this kind may also be given with the help of diagrams, including graphs and the ‘100 faces/circles’ method (Fig. 1).

OPEN IN VIEWER

Figure 1.

Use of 100 circles to represent quantitative data. A 70% chance of cure or seven in 10 women as represented by the shaded circles.

Patients’ preferences for the content of the discussion of prognosis

Risk is generally defined as numerical odds or probabilities, yet research has shown that patients find such terms difficult to understand and that their understanding is affected by their age, educational level, health status and recent experience of illness (Mazur and Merz, 1994). However, research that looks at information retention and understanding of patients following such consultations cannot always distinguish whether patient recall is poor because of lack of understanding due to the words used, their emotional state, their being overwhelmed with detail or simply not being told enough.

In regards to prognosis, the important information that patients want is the probability of cure, the chances of any treatment being successful and 10 year survival figures with and without treatment after any surgery. Patients have individual preferences for how this information is framed. Patient preferences for written material, including diagrammatical representations of prognosis, also vary.

Doctors’ communication behaviour relating to prognosis

Doctors appear to vary the way they frame prognosis depending on the severity of the patients’ disease, rather than basing this on patients’ preferences (Hack et al., 2005). This may be because doctors have their own psychological need to protect patients from bad or negative news, with the underlying intent of giving patients hope and enhancing their well-being. However, in the long term such behaviour, however well intentioned, can result in confusion and increased anxiety. If the doctor concentrates on giving information about diagnosis and prognosis, without discussing treatment, patients are more likely to feel despair. However, GPs are often not in the best position to discuss treatment options except in general terms. Strategies for discussing prognosis are shown in Box 7.

The importance of hope

Patients need to have hope and this is helped by the doctor being willing and able to talk, while providing emotional support. In interactions with patients with cancer, GPs must also portray an optimistic attitude. The patient—doctor relationship is important, and GPs are in a good position to offer this, as they may already have a good relationship with the patient.

Involving relatives

GPs are often in the position where they know a family and indeed are often the whole family's doctor as well as the patient's. This may cause problems in that a family member has access to the doctor and may ask for information about the patient without the patient being present or even knowing of the consultation.

On the whole, patients prefer openness with their family but only with their consent (Benson and Britten, 1996). They do not want their family to influence what information they, the patient, are given. Patients consider that their needs take priority over the needs of their family members. There may be pressure from relatives not to give the full diagnosis — this should be avoided. Indeed, relatives should not really be informed about the medical condition before the patient, except in special circumstances. If relatives do ask for the patient not to be told, the GP needs to explore the reasons for this request. The doctor needs to remember that such collusion is because the relatives love the patient and want to spare him or her from extra distress.

Cultural differences

Family involvement in illness is often greater in certain cultures than others. Indeed, there is a strong predilection to close

relatives’ knowing the diagnosis and prognosis in more detail than the patient. The head of the family takes control over the passage of information. If a doctor comes from a culture where non-disclosure to the patient is normal, this doctor may take this approach in consultations. The underlying message is not to assume but to explore the cultural expectations and overall take the patient's preferences into account.

Conclusion

Consultations are often emotional interactions. GPs need to be able to recognize emotional cues and to respond to these; they also need to be able to acknowledge and deal with their own emotions. Debriefing following ‘difficult’ consultations is important.