SCOTTSDALE – Reasoning with patients can be challenging when they are demanding, have unrealistic expectations about their treatment, are emotionally reactive, or are seeking prescriptions for narcotics, Dr. David Gullen said. “These patients tax our patience and often our clinical skills, because they often don’t respond to the usual logic or presentation of treatment options,” Dr. Gullen said at a symposium sponsored by the American Headache Society.
But by switching the focus from logic to empathy, clinicians can transform relationships, even with very difficult patients who are dealing with migraine and other types of chronic pain, said Dr. Gullen, an internist who teaches communication skills to faculty, fellows, and residents at Mayo Clinic Arizona, Phoenix. Using empathy and other skills to improve relationships enhances physician and patient satisfaction, increases compliance, and improves clinical outcomes, he said.
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Dr. David Gullen
“The question is, can the patient join you on a cognitive level?” Dr. Gullen concluded. “Often they can’t, but they may be able to join you on another level. It’s a noncognitive way of responding to them.”
Relationship building can also help clinicians heal the patient when they “don’t have a lot of medical options,” Dr. Gullen added. “I think that’s something our forebears knew 200 and 300 years ago,” he said. “Healers in the past had to use this approach because they didn’t have a lot of the tools we have today.”
To build relationships with patients, clinicians can use the mnemonic PEARLS – which stands for partnership, empathy, apology/acknowledgment, respect, legitimation, and support, Dr. Gullen said. For example, when seeing a new patient with migraine who has already tried and “failed” numerous medications, the clinician can use a partnership statement, such as, “I really want us to work on this together.” This approach increases the odds of creating a working relationship with the patient, he said.
“Empathy is probably the most important of all, because it’s your ability to convey to the patient that you understand their position,” Dr. Gullen emphasized. “Showing empathy for a patient’s perspective is not the same as endorsing it,” he added. “They may misunderstand what you’re telling them, or you may disagree with them. By showing that you understand their perspective, you’re not saying it’s correct, but you are saying you understand.”
An apology or acknowledgement could simply mean apologizing for running behind schedule or acknowledging a patient’s frustration with a treatment outcome.
Respecting a patient’s efforts to cope with the pain, and legitimizing the emotional response by letting the patient know it is normal and understandable also helps build trust. “Be aware of when you’re emotionally activated, so that you can use some of the PEARLS or respond with empathy, and take time to calm yourself down,” Dr. Gullen added.
How something is said to a patient matters as much as the words used, he said. “Think of a time in your life when you got a piece of advice that was really important for you to hear, but when you first heard it, it landed on you really badly,” he added. “Now think about getting that advice from someone you thought did not understand you or did not have your best interests at heart, compared with someone who you thought got you and really understood you. That’s why we emphasize the importance of relationship.”
Dr. Gullen declared no financial disclosures.