Navigating Complex Cases With Empathetic Communication

Recently, a young and healthy patient in their 40s entered the clinic for an initial evaluation of an abnormal paraprotein and unexplained anemia. The patient was seen by their primary care provider (PCP) a month earlier for a routine physical, and the PCP was concerned about their moderate anemia (hemoglobin 10.3 mg/dL; normal range 13–17 mg/dL). A colonoscopy was performed, and the findings were normal. The anemia labs (ferritin, total iron binding capacity, iron, reticulocytes, and vitamin B studies) were also normal, hence the referral to hematology.

I met with the patient and explained that there are many causes for anemia and that additional testing would be needed. The patient had no “red flag” symptoms of unexplained weight loss, new back or bone pain, fatigue, or other worrisome findings. They had normal organ function. I reassured them that while I was not worried about the anemia and hoped there was an underlying nutritional cause, we needed to proceed with the appropriate testing to rule out a hematologic malignancy, including labs and radiologic exams to start.

Later that afternoon, I was called by the hematopathologist, as the patient was found to have 12% circulating plasmablasts in their peripheral blood. I phoned the patient and asked them to return to the clinic to discuss the findings in person.

I explained that while we found only a small amount of abnormal protein in the blood, plasma cells should live in the bone marrow but were seen in the peripheral complete blood count test, which is worrisome. Based on the circulating cells, they were diagnosed with plasma cell leukemia and required immediate treatment to prevent kidney, bone, or other organ damage. I emphasized the many “normal” organ function tests seen again in today's labs and the normal X-rays obtained that day. I gave them time to ask questions and reassured them that I would collaborate with colleagues to recommend a plan of care that would be best for them. Unfortunately, our discussion went from an optimistic, “Hopefully, there is an easy and correctable explanation for your anemia,” to a more serious “You need immediate treatment for blood cancer.” Despite my years of experience, breaking bad news to patients and their families is never easy.

PATIENT COMMUNICATION

Numerous clinical studies have been conducted and papers written on effective communication. Empathetic communication, defined as responding to emotions and actively appreciating others' points of view, is associated with better outcomes for patients and families. Some benefits include decreased anxiety and depression, and improved coping strategies. Empathy also leads to improved patient satisfaction in care (Kelley et al., 2014). Patients are more satisfied with the outcome if they feel that providers validate their feelings and take even 1 additional minute in the patient encounter (Childers et al., 2023; Lis et al., 2009).

My preferred communication method to start a patient encounter is “Ask-Tell-Ask” combined with the NURSE (Name, Understand, Respect, Support, Explore) method (Back et al., 2005; Table 1). This strategy can be used as a guide and when interacting with patients and families over time. It also does not need to be reserved for bad news. Validating and allowing time to discuss patients' feelings, then providing a solution to their concerns through this method, fosters effective communication and can help deflate a tense situation.

Table 1. Ask-Tell-Ask and NURSE Strategies for Empathetic Communication.

Ask-Tell-Ask

NURSE

Ask, “What brings you here today?” to learn about what the patient understands about why they are seeing you. Tell the patient in plain language important information in small, digestible parts. Ask the patient about what they understand from the conversation.

Name the emotion you observe. For example, “I can see that you are surprised by this diagnosis. Unexpected news can be overwhelming.” Understand what they may need. For example, “I think a little more information can be helpful. Let's talk briefly about what this diagnosis means and what our first steps to treating this should be.” Respect the patient. For example, “There are quite a few things we need to go over today about your health. Do you need time to take a break, or can I get you some water or something else to drink?” Support the patient. For example, “You came to the visit alone today. Is there someone else you want me to call so we have another set of ears listening to what we are discussing? I can also bring the social worker in to speak with you.” Explore their concerns. For example, “You and I have discussed a lot today. What are your concerns about the next steps?”

IN THIS ISSUE

In this issue, several articles discuss situations in which empathetic communication can be employed by advanced practitioners (APs). The article on the psychosocial impact of ostomies highlights issues of loss of bodily control and altered body image that patients face. Osburn and colleagues review the impact of remote interventions on reducing distress in caregivers of stem cell transplant patients. Communication strategies that employ empathy should be integrated into training programs. Clermont and colleagues reported their experiences implementing a malignant hematology education intervention.

In addition, learn about how physician assistants dealt with increased burdens at work and at home during the COVID-19 pandemic. Brooks and colleagues discuss screening and preventive practices for adult allogeneic transplant patient survivors. Read about primary and secondary toxicities of CAR T-cell therapies, the creation of a high-risk breast cancer clinic, and a case study of untreated aplastic anemia in this issue.