The difficulties of determining a patient's needs (1,2) and developing a working alliance (3,4) are magnified in the emergency department, where patients and clinicians often contend with unfamiliar levels of anxiety. Clinicians are pressed for time, patients are frequently overwhelmed, and the intensity of the emergency department tends to promote skill in triage and disposition rather than in connection and understanding. The need to evaluate and treat people who are at best highly ambivalent about receiving help further taxes the clinician's ability to quickly form a working relationship.
This column describes four common pitfalls that interfere with effective clinician-patient collaboration. Avoiding these pitfalls is especially important when dealing with patients who have little or no interest in receiving treatment and with whom one may have no second chance for connection if the interview gets off to a rocky start. For less challenging patients, avoiding these errors generally expedites and enhances diagnosis and treatment.
Failure to acknowledge the patient's affect
Customary openings for the clinical interview such as "How can I help you?" and "What brought you to the hospital today?" are most useful if the patient in fact wants help and was not forcibly taken to the hospital by the police. However, for the large number of patients whose chief priority is a speedy departure, such openings may serve only to delay the opportunity to make effective contact. These patients can often be identified by their angry or aggrieved facial expressions or the leather restraints that they are straining against.
Such patients' conviction that "this is all a big mistake" must be quickly addressed, as the best chance to connect with them may be to acknowledge their sense of outrage and allow them to express it. A simple way to start might be to say "You look very upset. Tell me what's happened, and let's see what I can do to sort things out." By starting with what the patient is experiencing at that moment, the clinician sends the message that the primary goal is to understand what is happening from the patient's perspective, even if that perspective is distorted (5). Unless aggrieved patients have the opportunity to release some steam at the beginning of the interview, there may be little subsequent chance for collaboration. Once patients know that the clinician knows how upset they are, they have less need to communicate this feeling by other means, such as overturning the gurney, bolting, or threatening to kill someone.
Clinicians generally have a clearer idea of the goals of the interview than do patients, whose perception and judgment are often impaired by the atmosphere of crisis and urgency. Clinicians may think, "Will this patient kill himself or anyone else? Can't he see that I'm just trying to help?" Patients may in turn be thinking, "Who is this person, and why does he keep asking me if I can keep myself safe, whatever that means?"
In other words, the clinician's agenda—history taking and safety assessment—may be quite different from the patient's—leaving as soon as possible or settling a grievance. A stalemate may ensue unless the differing agendas can be harmonized. One solution is to reframe the clinical encounter to ensure that patients have a clear idea of what is wanted of them. Reframing is particularly important when patients are angry, uncooperative, or elusive. It may be quite effective in addressing the escalating sense of frustration and anxiety of both parties.
For example, the clinician might say, "You've made it very clear to me that you feel fine and would like to go home. You were brought here because some people have been concerned that you've been thinking about killing yourself. Perhaps, as you say, they were overreacting. Before you can leave, you and I need to have a conversation about any suicidal feelings that you may have been struggling with. The sooner we can do this, the quicker we can settle things."
This reframing approach is helpful for two reasons. First, it gives patients a clear idea about what they need to do. Second, it shifts the task into a more collaborative mode: the goal is for two people to do something together—to have a conversation about suicidal feelings.
This approach helps with a variety of potential impasses, such as concerns about confidentiality or homicidality.
"I understand you don't want people to know you're here and that this all feels like a big mistake. The reason I would like to speak to your [family member, friend, therapist] is only to be sure that I haven't missed something that might end up jeopardizing your safety. If there are things you would not like me to share with that person, we can discuss it."
"From what you've told me you have no history of being violent to other people. You were clearly very upset when your girlfriend told you she was seeing someone else, and you said you felt like killing her. People often feel like killing someone. What we need to figure out is whether you're actually thinking about doing it."
When this approach is used, the patient may more easily grasp that the clinician's intention is to be an ally rather than an inquisitor and to negotiate and explore rather than make demands (6). The act of clarifying the purpose of the evaluation process may itself be therapeutic (7) and often helps in developing the basic rapport that makes data gathering easier and more meaningful.
Missing the bigger picture
Patients are often less interested in their signs and symptoms than are clinicians. It won't be useful to have fully catalogued all neurovegetative features and inquired about talking TV sets and broadcasted thoughts if the clinician has missed the fact that a patient's parent is near death or that his eviction date is a month away. Patients often do not volunteer information about relevant stressors, and without deliberate questioning a clinician may gain little insight into a patient's difficulties. The obvious risk in not asking about current stressors is that patients sense—often accurately—that the real pain in their lives is somehow less compelling to the clinician than their symptoms.
Curiosity and common sense, not abstract theory, are helpful here. One can develop a "psychosocial review of systems" (8) that covers home life, work, family matters, and relationships. Questions might be as general as "Are there any illnesses in your family?" "Any problems with your children?" "Do you have any conflicts at work with your boss or your colleagues?" "Are you and your husband able to make ends meet?" "How hard has it been to accept the fact that you have cancer?" Such an approach helps in several ways. First, it helps the clinician get quickly to patients' relevant issues; second, patients will recognize that the clinician is as interested in them as in their symptoms; and third, it is much more interesting for the clinician. A good tactic is to lead with the psychosocial inquiry and then cover the relevant signs and symptoms.
Patients who are feeling particularly angry or afraid often manage to say things that elicit similar feelings in the clinician.
"You look much too young to be a doctor."
"Hospitalize me and I'll make sure you never practice medicine again."
"I told this whole story to the first idiot who talked to me. Don't you jerks communicate with each other?"
Here the clinician must maintain equanimity and avoid responding in kind (9). Few patients in these circumstances are making a deliberate effort to be manipulative or difficult. Instead, finding themselves in an intensely anxiety-provoking situation in which they feel powerless, they try to regain control by replacing negotiation with intimidation and humiliation.
Two maneuvers can help clinicians avoid taking the proffered bait. First, keep a clear eye on the fact that the patient's reaction is not personal. Second, help the patient focus on the shared task at hand rather than retaliating or even responding to the challenge. The clinician might respond to the three challenges described above with the following remarks:
"However I look, our job now is to figure out why you took all those pills."
"Before we even discuss hospitalization, we need to get a better understanding of why your wife was so worried about you."
"Unfortunately, the communication here is sometimes not ideal. Let's try to move past that and come up with a good solution to all this."
If the patient were more skilled at communicating his pain and enlisting help for it, he might have avoided the emergency department altogether. The interpersonal difficulties mentioned above are usually integral to the presenting problem rather than peripheral to it, and keeping this fact in mind tends to increase the clinician's patience.
The issues raised in this paper are familiar to all clinicians working in emergency departments. Why are these pitfalls so common? In part, it may be that making even basic empathic contact with challenging patients in the emergency department often means realizing how much one is feared or even hated by them. This realization is stressful for caregivers in general, who are "just trying to help," and for trainees in particular, whose lack of experience and confidence make it difficult not to take patients' hostility personally. The result is often a kind of clinical disengagement that can lead to misdiagnosis and lost opportunities to provide what patients want or need. Recognizing the pitfalls described above may help clinicians sort out a patient's projections, acknowledge the truth in the patient's anxiety, and maintain the kind of curiosity that cuts to the heart of the patient's predicament.
The author thanks Michael C. Miller, M.D., Jennifer Schreiber, M.D., and Harvey Ginsberg for helpful comments.
Dr. Kahn is affiliated with the department of psychiatry at Beth Israel Deaconess Medical Center, Rabb 2, 330 Brookline Avenue, Boston, Massachusetts 02215 (e-mail, firstname.lastname@example.org). He is also an instructor in psychiatry at Harvard Medical School. Douglas H. Hughes, M.D., is editor of this column.