Decatastrophizing Patient Fears

IF WE’RE brutally honest with ourselves, we’ve all acted like Henny Penny at some point in our lives. Like the frantic bird catastrophizing the end of the world in the classic children’s book Chicken Little, we imagine the worst possible outcome when faced with something that could fundamentally change our lives. In stressful situations, it’s difficult to regulate our emotions — and sometimes we’re incapable of regulating them at all.

Unlike Henny Penny’s fear, however, patients’ fears are grounded in reality. Whether facing a routine checkup or major surgery — or even visiting a friend in a hospital setting — clinical environments and the unknown cause significant discomfort. For example, a blood draw can hurt, and waiting for a diagnosis or wondering if a treatment will work is nerve-wracking. Add to this discomfort a sterile, sometimes cold, tech-ridden environment and being touched by strangers who use “foreign” tools such as blood pressure cuffs, EKG wires, IV needles and betadine and it’s no wonder patients struggle to keep their feelings in check. But your demeanor can help them ease their anxiety and move forward more calmly.

Fundamentals of Medical Anxiety

The fear of doctors, or iatrophobia, and “white coat syndrome” are real phenomena. In fact, experts estimate that 15 to 30 percent of patients whose blood pressure appears high in a clinical setting experience white coat syndrome.¹ But what, more specifically, is behind these patients’ — and other patients’ — fears? Reasons why patients catastrophize their fear are much more nuanced than merely being afraid of pain.

A patient survey by The Empathy Project, a program at New York University’s (NYU’s) Langone School of Medicine, found that top patient fears are infection, incompetence, death, cost, medical mix-ups, needles, rude doctors and nurses, germs, diagnosis/prognosis, communication issues and loneliness.² The survey undoubtedly found more factors than physical discomfort. Most fundamentally, patient fears can ultimately be reduced to two realms: fear of loss of control (of body and lives) and fear of depersonalization.^2,3 As a provider, how can you help ease these fears?

What Not to Do

Looking at examples of what not to do is a good place to start. Examples of ways providers behave poorly help highlight ways you may be contributing to patient fears. Here are two patient stories shared with The Empathy Project to consider:

• Alicia Flaum, director of the CBS show “60 Minutes,” shared the story of when her doctor informed her of a cancer diagnosis. “I went to my primary care physician, and my blood counts came back. One of them was low. He sent me to a hematologist, and eventually, after going through a couple of hematologists and a little bit of an ordeal, I was diagnosed with myelodysplastic syndrome. I said, ‘How long will I be out of work?’ And he said, ‘Probably about six months. At least six months.’ And I said, kind of to myself, but out loud, ‘Gee, I hope they’ll hold my job for me.’ And he said to me, ‘Well, I mean you’ve had a good run, right?’”² The doctor’s words seemed to dismiss Flaum’s understandable concerns.
• Social worker Jordana Schein-Levi experienced a lack of concern from physicians as well. During a crisis situation, several doctors explained what her newborn daughter’s serious heart condition entailed and the procedures necessary to address it immediately. When they finished an efficient but cold explanation, the doctors left the room, leaving her feeling lost, apprehensive and incapable of thinking clearly.² “I didn’t know what to do. I felt like, you know, ‘Do I breathe? Do I move? Do I pick up the phone?’ I didn’t even know what questions to ask. I didn’t know what half the words they used meant. And I was really frozen.”² Schein-Levi’s doctors gave her clinical information, but their lack of compassion made a difficult situation harder to deal with.

Put Yourself in Their Shoes

Part of developing a more helpful approach starts with realizing that you have been a patient yourself, or you certainly will be a patient in the future. Supporting your patients involves considering your own need for empathy and recognizing your patients need it too.

“Words matter. Tone matters,” says Jon LaPook, MD, chief medical correspondent at CBS News and medical professor at New York University (NYU) School of Medicine.² What you say matters, but how you say it matters, too. Your attitude carries as much weight as your attention. As Dr. LaPook explains, “Empathy is when the doctor’s not just in the room, but really with you. It should be at the core of everything we do in medicine.”²

At The Empathy Project, instructors teach medical students to imbue their work with humanity and treat their patients as people, not just a diagnosis. “It’s not about teaching empathy directly all the time, but reminding people to bring themselves to the work that they’re doing,” explains Richard E. Greene, MD, MHPE, medical professor at NYU. “I think the students who you don’t always notice empathy in first think that they’re going into medicine to be scientists [rather than caring professionals who invest in patients].”²

Certainly, learning how to balance empathy with professional distance is part of learning how to relate well to patients. “I think you become a master of being present and connected, but having that monologue in the back of your head that tells you what’s appropriate and what’s not appropriate,” Dr. Greene says.² Empathy may not come naturally, but as Dr. LaPook and Dr. Greene explain, learning to be empathetic comes down to being your best self: “Who you are and the person you bring into the room is your most therapeutic tool in your arsenal. To show up and be present and to make eye contact and to listen and to not be afraid of the patient’s reactions, of the patient’s questions. And don’t be afraid to say, ‘I don’t know.’ And don’t be afraid to say, ‘I’m sorry.’ And don’t be afraid to be human in the room.”²

Developing empathy also involves recognizing hidden thoughts and feelings patients may have about their condition. For example, some patients might feel self-blame and condemnation because their personal habits and behaviors could have contributed to it. It might be difficult to avoid silently (or subconsciously) judging a patient for their poor health management, but your patients need your empathy to help them cope. Recognizing and understanding your thoughts about your patients and their situation can help you set aside your judgments and prioritize their feelings. Look at the situation through their eyes, and treat them the way you would want to be treated.

Your Words Have Weight

Schein-Levi’s negative encounter caused her to think about what doctors should have said, and consider what the best way to deliver bad news to patients and their families might be. “There needs to be an awareness that you as a doctor are about to change someone’s life,” she says. “And whoever you [the recipient of bad news] were five minutes before those words come out the doctor’s mouth, you’re no longer that person. [Doctors] have got to have this awareness, that you are at the beginning of a very long journey in someone’s life. You’re the gatekeeper. The moment you say these words [of diagnosis, procedures and prognosis], you change their life. So you [the professional] gotta work at that.”²

Schein-Levi described a more positive interaction with a different physician who was treating one of her other daughters that demonstrated an effective, professional and compassionate way of delivering difficult news. Instead of receiving cold, aloof comments that left Schein-Levi bewildered and afraid, this interaction helped her accept the circumstance and move forward with confidence. “So they called in one of the top docs to take a look at her,” she explains, “and he came into my room and he said to me, ‘You know, this can be OK. Hi. I’m Dr. So-and-So. Let me tell you what I’m doing here, and let me tell you what I think’s going on with your daughter.’ And I was so struck by the fact that he was willing — and I use this language only because it was my sense that he took a risk that other people weren’t willing to. That they thought, somehow, by talking to me in a way that you would talk to a friend or just not start off with the clinical piece, but human to human, and take the risk of saying, ‘Hey, this can be OK.’ He wasn’t promising me that she would be cured, or that my life would be wonderful. He was saying to me: Sometimes in life, even bad things can be OK because you as a human being can deal with it. And I was so struck by that, that he was willing to do that. It didn’t in any way diminish his clinical expertise or anything that was going to happen from that moment forward. And he had me. And I trusted him.”²

Flaum had a more positive experience that helped her move forward as well. After asking doctors many questions, watching her healthcare team seemingly evade questions and finally receiving answers she could not understand, a different doctor extended humility and compassion that comforted her. Flaum explains that this doctor took the time to explain the complex series of tests Flaum would need and why she would need them, and when the doctor saw her struggling to understand, said, “You know what? We don’t really understand it either.”

“And I loved that,” Flaum said. “I thought that was so honest and great, and I’ve really come to love her.”²

Putting It All Together

No one wants to face difficult news only to be devalued, ignored or dehumanized, and fear can quickly escalate when patients aren’t treated with some measure of compassion when they seek medical care. Engendering a level of deep trust in patients, whether you are a physician, nurse or any other healthcare provider, should always be one of your professional goals. Your support and empathy help patients cope and recover faster. Make the effort to grow in empathy. Adjust your thinking and behavior, if necessary, to reflect who you are — and who you want to be as a professional. You alone have the power to continue to improve your skills accordingly, and it’s an exceptionally worthy endeavor.