Author’s Note: This story is about a special and difficult encounter I had with a patient during my first year in medical school, and all the questions it provoked after: should doctors display emotions or stay reserved at the bedside? How about holding a patient’s hand or hugging a patient who is crying? This brief encounter highlighted the difficulties that arise in the medical profession, especially when it comes to how doctors should or should not display emotions.
Although empathy, objectivity and professionalism are emphasized in our medical training, we tend to avoid talking about doctors’ emotions. My encounter with this patient highlighted to me more than ever that I cannot avoid asking difficult questions. I also cannot be empathetic without showing some form of emotion. Saying “oh this must be hard for you” without feeling it or putting myself in the patient’s shoes is not empathy. False reassurance is not an option either. So, holding his hand would have been the best non-verbal way of communicating my empathy! But that approach may cross the blurry line of professionalism in some cases.
I would argue that empathy is the most important part of a doctor’s job, and the most tricky. It is not easy to figure out what to say and/or do with different patients’ stories. But being a ‘detached observer’ and repeating the same sentence with each patient to remain objective and professional is not easy either!
I remember my first experience with a patient crying. I was interviewing a pleasant elderly gentleman, 2 days post his heart bypass surgery. The patient had a past medical history of cardiovascular disease, arthritis and diabetes. Our interview took place in Mr. M’s hospital room at a cardiovascular centre in the city. Mr. M told me his chief complaint, history of presenting illness, symptoms and complex past-medical history. But the interview took a sharp turn I did not anticipate when I asked him “So, what is your biggest concern?” A typical question we were taught to ask relatively early on in the interview protocol to focus on the patient’s chief complaint and major concern(s). Heavy silence covered the room. Mr. M’s facial muscles tightened. He clenched his fists and his kind eyes immediately filled up with tears. “My biggest concern…. is that I am going to DIE,” Mr. M said while choking back tears. Tears dropped down his cheek. I did not see that coming and felt really bad for asking that question! I looked at him, nodded and nervously wrote down on my notepad.
“My daughter is getting married next month. I am afraid I will not make it to her wedding. She got me these arthritis pain-relief orthotic shoes to wear for the wedding, so I can walk her down the aisle,” Mr. M. explained. I guess I tried to comfort him a little because I murmured something along the lines of, “Hopefully you will get better soon, wear the shoes and walk your daughter down the aisle.” I honestly wanted to get up and hold his hand or give him a hug, but I remained seated and continued to nod. This new approach of what seemed like a ‘detached concern’ was totally foreign to me. But my mind was racing with many thoughts ranging from “you are a first year medical student now. You are the professional and you have limits” to “you started this, so maybe you should just remain quiet and give him space!”
I managed to maintain my composure and completed the interview successfully. He even smiled a little at the end and wished me good luck. But I never forgot that experience. His tears, his frustration, the silence in the room and my panic! I blamed myself for asking such an “insensitive question.” As I walked home, I kept on thinking about how it all started with one question. Duhhh… of course his main concern is going to be dying. He just had a major operation for God’s sake!
I could not help feeling uneasy about asking other seriously ill patients that question again. I wondered why ask pre or post-op inpatients in a major cardiology centre to express their main concern? Why evoke fear and strong emotions from them? If the goal is to ensure addressing patients’ main concern among the different symptoms they describe and to obtain a differential diagnosis, wouldn’t it be better to ask “what symptom worries you the most?” The word “concern” is emotionally loaded, especially to someone in a vulnerable position like a cardiac inpatient. So why not replace the question “what concerns you the most?” with “what symptom worries you the most?”
With more reflection, I wondered if I was missing the point all together. I made the question specific, but maybe it was meant to be open-ended. Two important aspects of patient-centred communication are learning to draw out a patient’s true concerns and then identifying which ones to address first. The crying patient’s strong emotional response to the “what is your main concern” question made me aware of the question’s complexity. It made me reflect that maybe the question is not about addressing the patient’s main physical concern and/or prioritizing symptoms, but it expands beyond that to getting the patient to open up about his fears, including fear of dying. This question is at the heart of building rapport and being a patient’s sounding board, while appearing on the surface as a mere attempt at prioritizing patients’ symptoms.