Background    It is normal for clinicians to experience an array of emotions when interacting with ill patients and their families.  Although positive emotions such as joy and satisfaction are rarely problematic, negative emotions such as anger or sadness may interfere with your ability to communicate empathically or even to provide appropriate medical care. This Fast Fact focuses on clinicians’ emotional responses to patient care.  See Fast Facts #59, 167-170, and 172 for more on responding to anger, clinician burnout, and professional boundaries.      

Sources of Emotion    Some of the emotions we experience are direct reactions to what the patient is saying or doing (e.g. an angry patient may trigger our own anger). Difficult emotions may also arise when patients do not act in ways that we like (e.g. feeling frustrated when a patient is not taking medication as prescribed).  We may feel sad, helpless, or even guilty when we cannot prevent a patient from further illness or death. We may also experience emotions triggered by our own past experiences, such as a patient who reminds us of a family member (e.g. grief, longing).

Strategies for managing difficult emotions    Dealing with one’s emotions is a learned skill. Like all skills it takes time and practice.  Be patient and keep practicing – look at each experience as a learning opportunity. 

• Prior to an interaction you anticipate will be difficult specifically identify what is causing your emotional response.  Was it the patient’s health behavior, their behavior towards you, their intense emotions, or your own sadness about their condition?  If your emotional response is based on your past, acknowledge this and put it aside during the upcoming interaction. 
• Practice the interaction ahead of time. Imagine the most likely ways that the patient will react and how you will respond.  
  • Clarify your goals.  It is unrealistic to expect that you can prevent or control patients from experiencing difficult emotions, especially anger and grief.  Acknowledge this and focus on realistic goals: being empathic, listening, disclosing medical information, talking patients through options, and validating their emotions.
  • Don’t go it alone.  Bring along a colleague or team member who can help if you have trouble controlling your emotions and can give you feedback on what might work better next time.
• During the interaction recognize when your emotions are impacting your thinking/communicating:
  • Increased heart rate; feeling flushed, sweating; shallow, rapid breathing; increased muscle tension; speaking rapidly or loudly; repeating yourself; or realizing you are not listening.
• If you are experiencing intense negative emotions:
  • Give yourself and the patient time to allow emotional intensity to subside.  Listen, rather than speak; allow silence.
  • Validate the patient’s experience by naming their emotions (‘You seem frustrated’).  If you are not sure, pose it as a question (’Are you feeling frustrated?’). Besides being empathic, simply naming what is happening may attenuate your own emotional response.
  • Naming your own emotions is appropriate as long as it does not divert attention from the patient’s needs or put blame on the patient.  For example you might say, “I am feeling frustrated that there is not more we can do to help you.” 

• If you are feeling overwhelmed, it is appropriate to say, “Please excuse me for one moment” and then step outside the room; resume your interaction once composed.
  • Most patients appreciate certain displays of clinician emotion (e.g. tears), if they occur at appropriate times and are consonant with the tenor of the interaction.
  • However, losing control of one’s emotions, including grief (sobbing), is never appropriate in front of patients and clinicians should excuse themselves prior to doing so.
• Afterwards, debrief with a trusted colleague or team member about what happened, how you responded, and how you might do it differently next time.  A less emotionally involved person can often see things in the interaction that you cannot.  Students and residents might ask faculty to come with them the next time they interact with the patient.  Repeated episodes of emotional instability may be a sign of burnout and/or need for mental health counseling.

References

1. Meier D, Back A, Morrison RS. The inner life of physicians and care of the seriously ill.  JAMA. 2001; 286(23):3007-3014.
2. Halpern, J. Empathy and patient-physician conflicts. J Gen Int Med. 2007; 22(5):696-700.
3. Back A, Arnold R, Baile W, Tulsky J, Fryer-Edwards K. Approaching difficult communication tasks in oncology. CA, A Cancer Journal for Clinicians. 2005; 55:164-177.

Version History:  Originally published May 2008.  Version copy-edited in June 2009; then again July 2015.