By: John Ragsdale, MD, MS, assistant professor, Division of Hospital Medicine, Department of Medicine, University of Kentucky College of Medicine
You can learn a lot just by observing. As clinicians, we frequently diagnose and assess just by paying careful attention to our patients. We see the signs of impending respiratory failure in the patient with asthma who’s not improving. We note subtle signs of developing encephalopathy in the patient with cirrhosis. We learn to differentiate the critically ill patients from the stable ones. In some way, this is all part of the physical examination, and we hone these skills with experience. But when we’re first learning these skills, we need someone to teach us to see as a clinician sees, to know which details to focus on and how to put those in context. This is also true in learning to recognize emotion in our patients. We must be taught to see the subtle signs of emotion, to recognize the facial expression details that suggest the “emotional diagnosis.” Interpreting facial expressions is a physical examination skill much like recognizing the signs of a stroke or a thyroid disorder.
This is why my co-authors and I began to study this skill (described in our recent Academic Medicine article) and chose to teach it, first as faculty development to other educators and later to other faculty, residents, and students. We believe the skills are applicable in practice and present an opportunity to provide better, more humanistic care to our patients. As I have taught and practiced these skills the last few years, I’ve found that I use them in many emotionally-charged situations. I’ve also found that they have raised my general awareness of emotion in situations in which I was not anticipating it. I have picked up on a fleeting expression that might otherwise have passed by and used that opportunity to address the underlying emotion, resulting in more meaningful connections with patients and their families. Last month, I was rounding with my team in the room of an elderly patient with a hip fracture. The resident was leading the discussion with the patient and her son and adeptly explained all of our plans and answered their questions. Reassured we had met their needs, our team turned toward the door as the son turned toward the window. In that moment, for a brief second, I saw signs of sadness on his face. I turned back, took his arm, and asked if he was OK. He broke down in tears explaining how worried he was about his mom. We talked through his fears and reassured him of what to expect. His concerns and worries might have been realized in future conversations or been addressed in other ways, but in that moment his facial expression was the clue that opened the door to have the conversation with him we needed to have.
In the end, it all comes back to meeting the patients where they are and finding a way to help them. And that means recognizing and treating their emotional needs right alongside their physical ones. That sounds daunting, but the encouraging results from this study (and from my own experience) are that these skills can begin to be learned in a relatively short time. Just like other physical examination skills, it may take time to hone them, but we can begin to reap the benefits with patients as we do.