The most important theme of emotions within the context of the patient-doctor relationship is how they influence decision-making. Barbara Mellers explored this in the book Bounded Rationality. The Adaptive Toolbox, where she noted that at least eight emotions influence our decision-making, and these are anger, sadness, joy, fear, shame, pride, disgust, and guilt. Mellers explained that these emotions sway our judgments through what she called the ‘which-feels-the-best heuristic‘; this emotion-driven cognitive bias drives us to make decisions depending on how we feel and how we want to feel. She argued that we tend to make decisions that make us feel ‘good‘, and, conversely, how we feel turns us away from making certain decisions. Daniel Fessler, writing in the same book, illustrated this with the example of how shame predisposes us to make high-risk short-term decisions, but low-risk long-term decisions. He asserted that ‘given emotion’s central role as the motivator of action…it is unlikely that normal individuals are ever completely free of the influence of emotion’. It is therefore clear that doctors are not immune from the effect of emotions in their work, and to avoid diagnostic and therapeutic errors, they must recognise the mood they are in when they make decisions.
The authors of the book Heuristics and Biases: The Psychology of Intuitive Judgment trace the impact of emotions on decision-making to their effect on the way we think, and on the memories we recall. They explained that the emotions we are experiencing at any time determines which cognitive bias will dominate our thinking – a phenomenon they called the how-do-I-feel-about-it heuristic. For example, they said people experiencing sadness are more likely to deploy the anchoring heuristic in making their decisions (as I discussed in a previous blog post, the perils of cognitive biases, anchoring is the tendency for the first information we gather to determine the judgment we finally make). With regard to the influence of mood on memory recollection, the authors maintain that ‘information is more likely to be recalled in the same mood it was learned‘ – and they labelled this concept ‘mood congruent memory‘. Undoubtedly, this will affect the diagnostic and therapeutic processes in no small way.
For doctors, the most important decisions they make follow from their interaction with patients, and it is not surprising that emotions play a dominant role in this relationship. Exploring this theme in a paper titled A model of empathic communication in the medical interview, Anthony Suchman and colleagues pointed out that patients rarely verbalise their emotions to their doctors, preferring instead to offer clues. The authors therefore asserted that it is up to physicians to invite their patients to express their emotional concerns ‘directly‘. Unfortunately, the authors found that in most patient-doctor exchanges, physicians frequently failed to recognise the clues offered by their patients, and even when the patients directly express their emotions, the physicians often declined to acknowledge the emotions, preferring to focus on ‘the diagnostic exploration of symptoms‘. They therefore concluded that the failure of physicians to acknowledge the direct and indirect expressions of their patients’ emotions ‘poses a threat to the patient-doctor relationship’.
The emotion that perhaps plays the most critical role in healthcare is that of empathy, and this was the subject addressed by Stewart Mercer and colleagues in their paper titled The consultation and relational empathy (CARE) measure: development and preliminary validation and reliability of an empathy-based consultation process measure. Referring to empathy as ‘a basic component of all therapeutic relationships’, the authors stressed that it is ‘a key factor‘ in how patients judge the quality of care they receive. They go on to show that empathy enhances the patient-doctor relationship, improves patient enablement, and contributes to ‘patient and doctor satisfaction in clinical encounters’.
In their own view of the role of empathy in the doctor patient relationship, Communication tips. Feeling understood: expression of empathy during medical consultations, they demonstrated the two-way dimension of empathy when they said ‘we only really become empathetic toward patients…when we succeed in communicating our understanding to them and in having them confirm it’. They went on to outline the ways by which healthcare providers can better understand the emotions of their patients, and these include: depicted it as ‘a psychological strategy enabling care-givers to offer support to patients grappling with strong emotions such as anger or sadness‘. Writing in a paper titled
- Remaining calm
- Adopting a neutral stance
- Obtaining as much information as possible about the patient
- Avoiding misunderstanding the patient’s message
- Abstaining from judging the patient’s behaviour
It is important to appreciate that empathy in the patient-doctor relationship is beneficial not just to the patient, but to the doctor as well. To illustrate this, Lussier and Richard listed the following advantages of an empathic relationship to both physicians and patients:
- It helps doctors better understand their patients
- It helps doctors to better manage their patients’ emotions
- It helps doctors to better support their patients
- It comforts patients to feel they have been understood by their doctor
- It helps patients to reflect on their emotions and put them in perspective
Danielle Ofri is a physician who has written most graphically about the impact of emotions on doctors, and consequently on their patients. She explores the whole panoply of how the emotions of doctors, both positive and negative, impact on patient safety and physician welfare. You may read my review of her brilliant book, How Doctors Feel, on my other blog called The Doctors Bookshelf. This will put you in good stead for the next post in our exploration of emotions – physician burnout.