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02 Dec 2013

When time is pressing and the waiting room is overflowing, it can be tempting for doctors to skim over a patient’s emotional concerns, or put off such discussions until the end of the consultation.

But the advice of Professor Stewart Dunn is “don’t”.

Years of experience, backed by empirical evidence, has shown that putting the discussion of emotional concerns first – particularly in high-stakes consultations like those involving the diagnosis of cancer - not only improves patient experience and confidence, it also saves doctors’ time.

“It is often thought that talking about the emotional side of things will be long and open-ended, will crowd out talk about medical issues, and lead to longer consultations,” Professor Dunn, Professor of Psychological Medicine at Sydney Medical School and Royal North Shore Hospital, said. “But the opposite is actually true.”

A study Professor Dunn co-authored in 2001, based on a randomised trial involving 400 cancer patients, found that consultations where emotional concerns were addressed first reduced patient anxiety by a third, their recall of information provided during the consultation doubled, and the duration of such consultations was on average almost four minutes shorter than those where emotional issues were not discussed first.

He said the findings underlined the importance for doctors of addressing both the medical and emotional needs of their patients.

Identifying and being upfront about emotional concerns, especially in the case of cancer, was the best approach for both patients and doctors, he said.

“These are often difficult discussions around such questions as, ‘Am I going to die?’, ‘Is treatment going to cure me?’, and ‘Are there things I can do to prolong my life’,” Professor Dunn said.

He said that, when they started their studies, medical students usually had high-level social skills, but the development of these was often overlooked during the following four to six years of very demanding and intensive study of technical medical knowledge and skills.

“This is good for patients, because you want your doctor to be very responsible and able in clinical management, but you also want them to be responsive on the emotional side of things,” Professor Dunn said.

He said it often took years of experience for doctors to be able to attend to a patient’s medical issues while also paying regard to their emotional needs.

The trick, he said, was to address emotional concerns and provide support while remaining clinically objective.

 “When you ‘lean back’ you maintain objectivity about the disease, and you don’t get too caught up in the patient’s emotional state, but you want to ‘lean in’ enough to make the patient understand that you acknowledge their emotional concerns,” Professor Dunn said, adding that it often took doctors “years of experience” to develop the judgement and skills to achieve this.

He said increasing attention was being paid during doctor training to the development of social skills, and Sydney Medical School ran simulation exercises, often involving professional actors, to teach students how to address and manage this important aspect of practise.

Professor Dunn said the problem was not that doctors lacked empathy, but a proportion was uncomfortable talking with patients about their emotional concerns, and such training gave them an opportunity to develop their social skills and understanding.

He said this was not just an issue for doctors, and that patients also needed to make sure they were better prepared when seeing their doctor.

In a public lecture he delivered on 20 November, Professor Dunn said the wealth of medical information that was now publicly available meant that both doctors and patients often came to consultations with an “enormous overload” of information, and important emotional concerns might be overlooked by technical discussions.

While doctors had a responsibility to manage the conduct of the consultation, he suggested patients should come prepared with questions about their condition and possible treatments, take notes or ask for permission to make a recording of the consultation, and not hesitate to ask for more information.

Adrian Rollins 

Published: 02 Dec 2013