How to Communicate with Patients in the ER: First Seek to Understand

A new patient is placed in room 18. I read the chief complaint as I sign up to see the patient: 32-year-old male seeking detox from narcotics.

Let’s be honest: most of us in emergency medicine are not thrilled to see this patient. First of all, in most cases, there is not much that we can do for him in the ED. Secondly, many of us will judge the patient before speaking to him: “He did this to himself.” “Unlike the patient with cancer or diabetes, he had a choice!” “Here is another person who thinks we are going to solve his long standing addiction problems with one visit to the ED.” These are just are some of the thoughts we might have prior to seeing them. 

Just before I walk into the room, the charge nurse approaches me and asks if I can talk to a disgruntled person in the waiting room. It seems that this person brought her 14-year-old daughter to be evaluated for a fever. They have been waiting for an hour. The mother is frustrated and anxious because a doctor has not seen her daughter. The triage nurse has seen the patient, she seems fine and there are no beds in the back. Yet another situation none of us look forward to.

Here are some of the thoughts that might run through our head: “What does this person expect? They should have called their own pediatrician!” “She arrived and was seen by the triage nurse quickly. Does she expect to be seen immediately by a doctor? We obviously have sicker patients to see first!” “It has only been an hour!”

I go see the patient requesting detox. I am ready to tell him that he doesn’t meet inpatient criteria, that withdrawing from narcotics is usually not lethal and that he can seek outpatient help. But then I begin to listen to his story. The patient served two tours in Iraq and told me that during his 2nd tour, the stress of seeing friends and colleagues being killed and the stress of constantly being under attack was too much for him and he started using drugs. He thought he could get off it on his own upon his return but he has been unable to do so. He comes today to seek help because he is about to lose his family as well as his job.

In an instant, my attitude changed. I hold the military in highest regard. Its members risk their lives for our country – something I have never done. I walked over to the psychiatric counselor and told him I really want to go above and beyond the usual protocol to try to get him some help, even if it meant bending the rules a bit. “It’s the least that we can do and we owe him at least that much,” I said to him.

Then I go to the waiting room and speak to the other patient’s mother. I was already expecting that this person was probably unreasonable and I that needed to reset her expectations. As it turns out, her daughter’s best friend died two days ago from an overwhelming infection. Apparently her daughter’s friend had a fever for a few days and then was found dead in her room. This mother is frantic that her daughter has the same thing. I certainly still needed to explain the process to the mother but hearing that story certainly made me understand her fears, her anxieties, and in her mind, the need to have immediate attention and care.

What changed my attitude? Why is the ex-soldier addicted to drugs any different than any other patient addicted to drugs? Patients can be addicted because they made bad choices. Maybe they were abused as children, maybe that was the only way to deal with depression. Do we take the time to really find out patients situations, concerns, and stressors?

Wouldn’t it make us better clinicians if we became better listeners and tried to understand before judging? Habit number five of the book The 7 habits of Highly Effective People, by Steve Covey, is: “Seek first to understand, then to be understood.”

As he puts it, “seek first to understand” involves a very deep shift in paradigm. Most people do not listen with the intent to understand; they listen with the intent to reply. Responses such as these are very common after someone tells you something:

“Oh, I know exactly how you feel”

“I went through the very same thing.”

“Let me tell you about my experience.”

In contrast, Covey writes about empathic listening – listening with the intent to understand. He uses the example of a father who once told him that he “can’t understand my kid. He just won’t listen to me at all.”

Steve Covey replied: ”let me restate what you just said. You don’t understand your son because he won’t listen to you? I thought that to understand another person, you needed to listen to him!” Steve Covey tells another story:

“I remember a mini-Paradigm Shift I experienced one Sunday morning on a subway in New York. People were sitting quietly — some reading newspapers, some lost in thought, some resting with their eyes closed. It was a calm, peaceful scene. Then suddenly, a man and his children entered the subway car. The children were so loud and rambunctious that instantly the whole climate changed.

“The man sat down next to me and closed his eyes, apparently oblivious to the situation. The children were yelling back and forth, throwing things, and even grabbing people’s papers. It was very disturbing. And yet, the man sitting next to me did nothing.

“It was difficult not to feel irritated. I could not believe that he could be so insensitive to let his children run wild like that and do nothing about it, taking no responsibility at all. It was easy to see that everyone else on the subway felt irritated, too. So finally, with what I felt was unusual patience and restraint, I turned to him and said, ‘Sir, your children are really disturbing a lot of people. I wonder if you couldn’t control them a little more?’

“The man lifted his gaze as if to come to a consciousness of the situation for the first time and said softly, ‘Oh, you’re right. I guess I should do something about it. We just came from the hospital where their mother died about an hour ago. I don’t know what to think, and I guess they don’t know how to handle it either.’

“Can you imagine what I felt at that moment? My paradigm shifted. Suddenly I saw things differently, I felt differently, I behaved differently. My irritation vanished. I didn’t have to worry about controlling my attitude or my behavior; my heart was filled with the man’s pain. Feelings of sympathy and compassion flowed freely. ‘Your wife just died? Oh, I’m so sorry. Can you tell me about it? What can I do to help?’ Everything changed in an instant.

“It becomes obvious that if we want to make relatively minor changes in our lives, we can perhaps appropriately focus on our attitudes and behaviors. But if we want to make significant, quantum change, we need to work on our basic paradigms.”

We could all improve our compassion by analyzing our attitudes prior to seeing patients and to work harder on seeking to understand, before wanting to be understood. I will try to remember the frantic mother and the addicted soldier the next time I find myself jumping to conclusions and making judgments prior to actually listening to the patient.