Neurologists Need to Better Empathize With MS Patients
Researchers in Italy conducted a study to measure patient expressions of emotion during outpatient consultations and neurologist responses to those expressions. Patient and neurologist characteristics likely to affect both outcomes were also explored. Levels of anxiety and depression were measured in 88 patients with MS (or suspected MS) before an initial consultation with a neurologist. Consultations with 10 neurologists at four MS Italian centers were recorded and later analyzed for patient expressions of emotional cues or explicitly expressed concerns, spontaneous or elicited, and doctor response.
During the 88 consultants, patients expressed 492 cues and 45 concerns (median 4 cues and 1 concern per consultation). The most common cues were verbal hints to hidden concerns (41%), followed by neutral expressions referring to stressful life events/situations (26%). Patient anxiety was directly associated with emotional expressions, while older age of patients and neurologists, and second opinion consultants, were inversely associated with patient emotional expression.
Most of the time neurologists reacted to patient expressions of emotions by reducing the opportunity to explore the emotion (by changing the subject, ignoring the content of the cue, or giving medical advice) for 58% of cues and 76% of concerns. Doctors were more than twice as likely to give these ‘space reduction’ type responses when speaking with anxious patients.
Emotional cues and concerns
‘Concerns’ are clear, unambiguous verbalizations of unpleasant current or recent emotions, with or without an indication of their importance. ‘Cues’ are hints (verbal or nonverbal) which suggest an underlying unpleasant emotion. Cues/concerns can be expressed spontaneously by the patient or elicited by the healthcare provider. When a patient expresses cues/concerns spontaneously, the aim is often to bring up topics that have been neglected, or not adequately explored.
Cues can be divided into seven sub-categories:
- Words or phrases in which the patient uses vague or unspecified words to describe his/her emotions.
- Verbal hints to hidden concerns (emphasizing, unusual words, unusual description of symptoms, profanities, exclamations, metaphors, ambiguous words, double negatives, expressions of uncertainties and hope).
- Words or phrases which emphasize (verbally or non-verbally) physiological or cognitive correlates (regarding sleep, appetite, physical energy, excitement or motor slowing down, sexual desire, concentration) of unpleasant emotional states. Physiological correlates may be described by words such as weak, dizzy, tense, restless, or by reports of crying, whereas cognitive correlates may be described by words such as poor concentration or poor memory.
- Neutral expressions that mention issues of potential emotional importance which stand out from the narrative background and refer to stressful life events and conditions. This applies to non-verbal emphasis of the sentence, abrupt introduction of new content, pauses before or after the expression, or to a patient-elicited repetition of a previous neutral expression in subsequent turns.
- A repetition, with very similar words, of an expression said in a previous turn by the patient.
- Non-verbal clear expressions of negative or unpleasant emotions (crying), or hints to hidden emotions (sighing, silence after provider question, trembling voice, frowning, etc.).
- A clear and unambiguous expression of a concern, e.g., a previous mental state, a previous worry or fear, referring to a past episode, of more than four weeks ago or without a clear time frame.
Patient-doctor communication and patient-centered care
Communication between patient and physician improves when the physician recognizes and responds empathically to patient concerns. When communication is effective and the patient’s physical and emotional needs are addressed, patient outcomes are improved.
Patient: “I’m so lacking in energy. I can’t get up, I feel so low...”
Doctor: “That’s strange. Cortisone usually picks you up. You shouldn’t be feeling so low.”
Unfortunately, 75% of patient expressions of concern in this study were met by responses that limited further discussion or disclosure, particularly for anxious patients. Neurologists often switched the topic, devalued emotions, ignored the emotion, or gave generic reassurance.
Patient: “I often wonder why this had to happen to me. It’s horrible.”
Doctor: “Yes, but, it’s not the end of the world. It may seem serious, but I have many MS patients who lead normal lives.”
Giving information and advice (analyzed as reduction of space) is at the heart of the medical consultation. Nevertheless, authors state that helping patients to verbalize their feelings facilitates emotion regulation, predicts competent coping, generates greater patient satisfaction with interpersonal care, and increases collaboration.
Results from this study suggest that MS neurologists need to be empowered with better communication and shared decision-making skills. An integrated approach that combines evidence-based medicine with shared decision-making, arising from empathic listening, is essential for quality health care and should be taught at all levels of medical training.1
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