As Dr. Becker entered the room, she could tell her patient was agitated. After exchanging pleasantries, Dr. Becker inquired about Mr. Karapati’s cough, which her computer listed as his chief complaint. But Mr. Karapati kept talking about how worried he was about his children’s school performance and about an orthopedist he met with who was disrespectful toward him.
Dr. Becker tried to steer the conversation back to Mr. Karapati’s cough, but it was like sailing a small boat through a storm: Mr. Karapati kept talking about his life instead of his cough, and sulked when Dr. Becker forced the conversation back to his chief complaint. Dr. Becker sighed inwardly. This was going to be one of those encounters.
There is a better way.
It begins with understanding one basic concept: when a patient is experiencing a strong emotional charge (such as fear, anger, sadness, or even joy), they cannot process what you say. This is because the emotional charge seeks to be released, and can only do so when it is received by someone or something else.
Until then, the emotional charge generates intense internal noise and obscures the external world. If you try to take control of the conversation (by asking questions or by providing new information) during this time, it will not only be counterproductive, it might also hurt your relationship with the patient.
But as we all know, you’ve got a short timeframe for each appointment and there is a lot of material to cover. So what you should do when a patient has a strong emotional charge that needs to be released? Address it. These steps and videos explain how:
- Listen Deeply: Give your undivided attention to your patient. This requires applying all the principles of good body language that you are familiar with (facing your patient, making eye contact, etc.), as well as eliminating physical distractions (we call this “One-Tasking”, to help us remember not to multi-task) and minimizing cognitive distractions (engaging mindfully in the conversation). See video
- Paraphrase, aka WIG (“What I Got”): Paraphrasing, or WIGing, is a wildly under-appreciated relational activity. By simply saying back what you got from the other person, without adding any interpretation, you communicate that you appreciate their point of view, respect their experience, are not trying to change them without their permission, and care about them. As you earn your patient’s trust by showing them they have your attention, they may disclose more personal (and often more important) information. As they continue talking, you continue WIGing, and their emotional charge continues to drop. See video
- Summarize: When you believe the patient has released enough emotional charge to be able to process what you have to say, it is time to summarize in order to bring closure to this part of the conversation. A summary is like a big WIG, in which you say back the entire story the patient shared with you, from start to finish. Sometimes your patient will have more to add after your summary but it’s likely that soon they will confirm you understood correctly and have nothing more to add. This will be your sign to begin leading the conversation (ideally by asking permission) so you can start asking questions and talking about diagnosis and treatment options. See video
Each of these steps requires discipline and focus, but the behaviors themselves are not complicated, and will be immediately helpful. So next time you notice your patient has a strong emotional charge, don’t try to push through it. Stop, relax, listen, WIG, and summarize. You will be doing both of you a favor.
Eran Magen, PhD, completed post-doctoral training in population health as a Robert Wood Johnson Health & Society Scholar, after earning his PhD in psychology from Stanford University. Eran is the scientific director of the Center for Supportive Relationships, which provides relational skills training for medical students and medical providers (@SUPR_Medicine), as well as for public school districts (@SURP_Education).
