Patient Education and Counseling 88 (2012) 359–363

Commentary

‘‘I am worried, Doctor!’’ Emotions in the doctor–patient relationship

Arnstein Finset *

Department of Behavioral Sciences, University of Oslo, Oslo, Norway

A R T I C L E I N F O

Keywords:

Communication

Doctor–patient relationship

Emotions

A B S T R A C T

Objective: To review research on emotional communication in medical interviews regarding predictors,

physiological correlates and effects of clinicians’ responses to patients’ cues and concerns and individual

differences among patients.

Methods: A selective review of research literature on emotional communication in medical interviews

was conducted.

Results: Four questions regarding emotional communication were explored: What factors predict how

clinicians respond to emotional cues and concerns? What happens in the brain and the body of both

patients and clinicians during emotional talk? Are there individual differences in patients’ responses to

emotional talk in medical interviews? Do clinicians’ responses to emotion affect health outcome?

Conclusion: Building on evidence reviewed, research on predictors of clinician responses, physiological

correlates of behavior, individual differences and effects on outcome should be further pursued.

Practice implications: In communication skills training programs, better understanding of the

phenomena described could have implications for training clinicians to handle emotions in clinical

interviews.

� 2012 Elsevier Ireland Ltd. All rights reserved.

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Patient Education and Counseling

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1. Introduction

In many medical interviews patients present their hopes anduncertainties, feelings and worries. But most often patients do notexpress their distress as directly as indicated in the title of thisarticle. Rather, negative feelings are often expressed as indirecthints about underlying emotions, often referred to as cues [1,2] orclues [3]. However, feelings may also be expressed more explicitly,labeled in the literature for instance as concerns [1] or empathicopportunities [4].

Fig. 1 presents a model of the consultation starting with thepersonality of the patient as well as the clinician (trait), the state ofthe participants in the encounters and characteristics of thesituation. In the actual interchange of information there are manyelements which could be included in the model [5], but here theemotional communication is emphasized, in terms of theclinician’s eliciting of patient emotions, the cues and concerns ofthe patient and the clinician responses. The model also includes afeature often neglected, namely the biological processes takingplace in the consultation. Finally, the model includes the outcomesof the consultation in terms of intermediate outcomes and effects

* Correspondence address: Department of Behavioral Sciences in Medicine,

Institute of Basic Medical Sciences, POB 1111, Blindern, 0317 Oslo, Norway.

Tel.: +47 2285 1435; fax: +47 2285 1300.

E-mail address: arnstein.finset@medisin.uio.no.

0738-3991/$ – see front matter � 2012 Elsevier Ireland Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.pec.2012.06.022

on health and quality of life of the patient as well as the clinician. Inthis paper we will mostly concentrate on patients’ cues andconcerns and their reactions to how clinicians have responded towhat patients have expressed.

A crucial element of the model is the clinician’s response to thepatient’s cues and concerns. In the present commentary I suggestsome potential areas of future research on emotional communica-tion in medical encounters by posing four questions, all withemphasis on the responses of clinicians to patient emotion (seeFig. 1): What patient, clinician and interaction factors predict howclinicians respond to emotional cues and concerns? What happensin the body and the brain during emotional talk? Are thereindividual differences in patients’ responses to emotional talk inmedical interviews? Do clinicians’ responses to emotion affecthealth outcome?

In this commentary the discussion of the four questions issupported by a selective review of research literature, often withreference to papers from our own group, when relevant. A morecomprehensive discussion would require a systematic review ofthe literature.

2. What factors predict how clinicians respond to patients’emotional cues and concerns?

Studies show large variations in how health professionalsrespond to patient emotion. For instance, Mjaaland et al. found in a

Fig. 1. A model of the medical consultation, with reference to topics of the present paper.

A. Finset / Patient Education and Counseling 88 (2012) 359–363360

study of medical interviews in a general hospital across specialtiesthat physicians provided room for further disclosure in response toabout half of all emotional cues and concerns, but more often withreference to the medical than the affective content of the cue orconcern [6]. Similarly, Butow et al. reported that oncologistseffectively identified and responded to the majority of informa-tional cues; however, they were less effective in addressing cuesfor emotional support [7]. In another study from cancer care Pollaket al. found that oncologists responded with empathy to 29% ofpatients’ expression of negative emotion [8]. A number of studiesreport similar results, indicating that the emotional aspect ofpatients’ messages are overlooked and not responded to byphysicians [6,9–11]. Rather than follow up on emotional cues,physicians often, but not always, respond with biomedicalquestioning and information giving or rather nonspecific acknowl-edgment or premature reassurance [9–12].

The responses of nurses to cues and concerns have also beeninvestigated. The results vary. In a study from a surgical oncologyclinic Uitterhoeve et al. found that nurses explored or acknowl-edged 45% of patients’ emotional expressions, but more than half ofthe expressions were met with distancing behaviors [13]. Eideet al., on the other hand, found that 75% of all emotionalexpressions were met with implicit recognition, whereas another13% were explicitly recognized in a study of admittance interviewsto a pain clinic [14]. The differences between findings may be dueboth due methodological differences and different clinical tasksand settings in the respective studies.

There is little knowledge on what different factors actuallyinfluence clinicians’ responses to the feelings and worriesexpressed by patients in medical interviews. In earlier studiesemphasis has been more on which physician behaviors influencethe likelihood of subsequently expressed cues and concerns [15–18] than on characteristics that may influence the response. Weknow that female clinicians engage in more emotionally focusedtalk than male clinicians do [19]. Other studies have reportedassociations between patient attributes as well as situation factorsand clinician empathic behavior [8,20]. However we know littleabout the communicational dynamics, what interaction factors

predict how clinicians respond to emotions. Potential communi-cation variables include the source of the expression of concern; i.e.whether the cue or concern is initiated by the patient or by theclinician (e.g. by asking a question, or providing a facilitativeremark); characteristics of the content of the cue/concern, such asthe emotional explicitness of the expression; and the timing of theemotional expression in the consultation [1].

One recently developed approach to study emotional commu-nication in clinical encounters is the Verona Coding Definitions ofEmotional Sequences (VR-CoDES), developed by a network ofresearchers who have met annually at the University of Verona todevelop this coding system [21,22]. The VR-CoDES system includesspecifications of both the patient cue or concern and the clinicianresponse, and should be well suited for an analysis of the dynamicsbetween patient and provider expressions.

Applying the VR-CoDES we recently published a study based onanalyses of video recordings of 196 consultations in cancer care,interviewed by oncologists or nurses [23]. In that paper the unit ofanalysis was the consultation, as opposed to individual utterancesand responses. In a subsequent paper the unit of analysis was theindividual cue/concern sequence at a ‘‘turn’’ level (N = 580),making it possible to study the dynamics of the basic sequencesof cues and concerns in terms of the timing within the consultationand the associations between timing, source, explicitness andresponses [24]. The dependent variable was whether the clinicianacknowledges the cue or concern and opens up for furtherelaboration or not, referred to as providing room for furtherdisclosure, a basic dimension is several methods for classifyingclinician responses to emotions. The clinician may provide roomfor disclosure for instance by an inviting silence, by a back-channeling remark or by an explicit acknowledgment or explora-tion of the cue or concern [22].

We found that nurses in admittance interviews in in-patientunits were five times more likely to provide space for furtherdisclosure of cues and concerns than oncologists in out-patientfollow-up consultations. Moreover, both oncologists and nursesacknowledged cues or concerns initiated by themselves morefrequently than cues and concerns initiated by patients. Similarly,

A. Finset / Patient Education and Counseling 88 (2012) 359–363 361

Del Piccolo et al. found recently that psychiatrists in their study ofpsychiatric consultations provided space for further disclosure of aconcern more frequently when the concern had been initiated bythe psychiatrist in the first place [25]. The providing of space forfurther disclosure was also dependent on the explicitness andtiming of the cues and concerns [24].

These findings indicate that clinicians’ provisions of space forfurther exploration do not occur at random. A number of factors,regarding clinician characteristics as well as features with theongoing interaction, influence whether or not the clinicianacknowledges the emotion by providing room for furtherdisclosure. In future studies it might be fruitful to supplementdata regarding the quantitative analyses of cues and concerns andclinician responses with qualitative analyses of the content of thecommunication.

3. What happens in the brain and the body duringemotional talk?

All emotional behavior has obviously physiological correlates.There is a small, but growing literature on psychophysiologicalactivation during medical encounters [26]. Psychophysiologicalmethods have for instance been applied to measure cortisolresponses of medical students in difficult consultations withpatients [27,28] and a delayed cortisol response in patients 24 hafter a consultations was observed [29]. With its strong associationwith the sympathetic activity electrodermal activity (EDA) isanother physiological marker of emotion which has been appliedin studies of medical interviews [26].

In regards to clinicians’ responses to cues and concerns, we havelittle knowledge about the psychophysiological activation patternsin patients following the clinician’s response to patients’ expres-sion of emotion. Will an empathic acknowledgment of emotionsstimulate further emotional activation or will an empathicresponse rather buffer and down-regulate patient emotion? Thiswas the question we asked in a recent study on the effect ofempathic statements on psychophysiological responses. Forty-eight patients with fibromyalgia were given arranged interviewswith a research assistant trained in responding to patients’expression of emotion, who systematically varied her degree ofempathy in her responses [29]. We found that high empathy wasassociated with increased electrodermal activity in the patient,probably due to the fact that interviews with more empathicstatements also contained more expressions of patients’ emotionsdue to the eliciting effects of empathic remarks.

But emotional communication in medical interviews, includingcommunication involving empathic statements, is often associatedwith feelings in both individuals involved, not only in the patient.The contagion effect of emotions, when an individual shares theemotional experience of a person with whom he or she interacts, isassociated with activity in areas of the frontal brain known to becrucial for emotional processing and often suggested as the mainfocus for subjective experience in emotional processing, suchventromedial prefrontal cortex [30–32]. Matthews et al. havedescribed such moments of shared affect in doctor–patientrelations as ‘‘connexions’’, where the doctor feels an intenseemotion and sense of sharing with the patient [33].

Physiological correlates of reciprocal patterns of behavior interms of synchronous patterns of autonomic activation have beenreported both in interaction between mothers and infants (withmore synchrony in harmonious mother–infant interactions) [34],between spouses [35], and in a few studies also between doctorand patient [36], most often investigating concordance betweendoctor and patient heart rate during psychotherapy [37,38]. Morerecently Marci and colleagues reported a synchronous pattern inelectrodermal activation in a study of therapist–patient interaction

in psychotherapy sessions. A high degree of reported empathy inthe interaction was associated with higher electrodermal activa-tion [39].

In the studies just mentioned the expression of emotion isassociated with increased levels or synchrony of psychophysio-logical activation. But there is also indirect evidence thatverbalization of emotion may regulate psychophysiologicalactivation. In an early study of this phenomenon Hariri andcollaborators exposed their subjects to threatening and fearfulnon-face stimuli derived from the International Affective PictureSystem (IAPS) [40]. Under one condition they were given thestimuli without specific instructions. Under another condition theywere told to verbalize the emotion that was elicited from seeingthe pictures. Functional magnetic resonance imaging (fMRI)revealed that whereas just seeing the stimuli was associated witha bilateral amygdala response, cognitive evaluation of these samestimuli, with a verbal labeling of the emotion, was associated withattenuation of this amygdala response and a correlated increase inresponse of the right ventrolateral prefrontal cortex and theanterior cingulate cortex, indicating that higher centers in thefrontal cortex overruled the more primitive affective ones.Moreover, this pattern was reflected in changes in electrodermalactivation, a marker of sympathetic activity. Other researchershave reported similar results. Applied on clinical communication,these findings could possibly indicate that by eliciting patients toexpress cues and concerns and through adequate responses thedoctor might actually help the patients to a better regulation ofemotional processing in the brain, by a downregulation ofamygdala activation and relief of stress, confirmed also by thechanges in electrodermal activation. Although it is difficult to applybrain imaging technology to clinical communication research,further studies should investigate how different clinician responsepatterns to patients’ cues and concerns could be associated withspecific activation patterns in the brain.

4. Are there individual differences in how patients respond toemotional talk in medical interviews?

People are different in how they perceive and respond toemotional stimuli. However, in the research literature there is littleemphasis on individual differences in emotional responses. Weknow little about how different patients react to clinicians’responses to patients’ cues and concerns.

We have in our group investigated responses to interviewingstyles which were quite different in terms of emotional expression.In a first study students with high and low trait anxietyvolunteered to take part in an arranged consultations with aphysician. They were instructed to bring up any medical complaintthat had in the present or had suffered in the past, or a medicalconcern regarding their parents or other close relatives. Theinterviews were performed according to two different experimen-tal conditions. During one condition, labeled as patient centered,the physician attended to psychosocial topics and respondedexplicitly to emotional concerns. In the other condition, labeledphysician centered, the physician concentrated strictly on themedical complaints and largely ignored psychosocial issues andemotional concerns. Dependent variables were affective responsesas measured with the Profiles of Mood States (PONS) and cortisolresponses. We expected stronger emotional responses to theconsultation in patients with high state anxiety. Moreover, weexpected that patients with high state anxiety would respond withattenuated emotional activation in the patient centered condition.However, in contrary to expectation, we found more arousalamong high anxiety patients in the patient centered condition [41].

In a subsequent study we looked at physician-patient interac-tion in arranged consultations with patients with fibromyalgia

A. Finset / Patient Education and Counseling 88 (2012) 359–363362

with and without difficulties in identifying and expressingemotions (alexithymia). Similarly to the study of high and lowanxiety students we found that fibromyalgia patients withalexithymia reported more confusion, less vigor and higher heartrate activation in arranged consultations with a ‘‘patient centered’’communication focus on psychosocial aspects as compared to a‘‘doctor centered’’ symptom focused communication style [42].These patients reported to be more satisfied with many empathicstatements from the doctor [43]. When the patients later viewedthe videos of the consultations, patients with alexithymiadisplayed more confusion, less vigor, increased EDA and a feelingof less control over the consultation in consultations with apsychosocial emphasis. In contrast, for patients without problemsof emotion regulation the ‘‘patient centered’’ psychosocial focus inthe communication style was associated with reduced electroder-mal activation and a feeling of more control in the consultationthan was the case for the condition with a focus on symptoms [42].The findings indicate consistent and potentially predicablepatterns of individual differences in how patients react toemotional content in medical consultations, characterized by anapparent hyperreactivity to emotional talk by some patients withproblems in emotion regulation.

5. Do clinicians’ responses to emotion affect health outcome?

In medicine the bottom line will always be effects on healthstatus. Does it really matter how clinicians respond to the cues andconcerns of patients?

The association between communication behavior and healthoutcome is a difficult one to study. Street et al. have recentlydiscussed a number of issues regarding the effects of communica-tion on outcome. They suggest careful analyses of potentialpathways of proximal, intermediate steps on the pathway to healthendpoints [44]. Yet, there are some studies which suggest thatopening up for patient emotions and providing empathicresponses may be associated with positive patient outcome interms of reduced distress [45,46], patient adherence [47,48] andsymptom resolution [49,50]. For instance, in a large Danish studydistress, self-efficacy, and perceived control were assessed prior toand after the consultation by 454 patients attending an oncologyoutpatient clinic. After the consultation, the patients also rated thephysicians’ communicative behaviors by completing a patient–physician relationship inventory (PPRI), and the physicians wereasked to estimate patient satisfaction. The overall results showedthat higher PPRI scores of physician attentiveness and empathywere associated with greater patient satisfaction, increased self-efficacy, and reduced emotional distress following the consulta-tion. [46]. Although a few studies are promising, there is need formore careful research to entangle the relationship between howclinicians respond to patient emotion and health outcome. Assuggested by Street et al. proximal outcomes should be identifiedas the first step in a pathway leading to actual health outcomes[44]. Proximal outcomes in relation to the effects of clinicianresponses to patients’ cues and concerns could be the experience ofthe patients after the consultations as to whether importantconcerns were met or not, as investigated by Eide et al. in a study ofadmittance interviews to a pain clinic [51].

6. Conclusions

I have suggested four areas of particular interest for furtherresearch on emotional communication in medical interviews.These areas concern further investigation into the predictors,physiological correlates and effects of clinicians’ responses topatients’ cues and concerns, and individual differences in have

patients react to clinicians’ responses to their emotional state-ments.

First, recent studies indicate that clinicians’ responses toemotional cues and concerns do not occur at random. Futurestudies are needed to clarify the dynamics of interaction patternsthat are associated with the different types of clinician responses toemotion.

Second, even if we know that emotional talk in the consultationevokes psychophysiological activation, we still have too littleknowledge on the specific activation patterns. More studies areneeded to better know when clinicians’ responses to patient cuesand concerns evoke or buffer patient activation and when theactivation patterns of patients and clinicians are synchronous ornot.

Third, there are individual differences in how patients respondto emotional talk. In a few studies we have seen an interactioneffect between individual traits and communication style,indicating that some patients with problems in emotion regulationreact with increased emotional activation to a communicationstyle which opens up for emotional talk. We need more research totest these associations, preferably in natural settings.

Fourth, we certainly need more research on how clinicianresponses to emotion may impact on health outcome. For instance,we sometimes seem to presume that providing room for furtherdisclosure is always the best way to respond to cues and concerns.But such assumptions need empirical testing in carefully designedstudies, which include investigation of proximal outcomes andpathways from proximal outcomes to health end points.

7. Practice implications

In the present paper the emphasis has been on suggestions forfurther research rather than practice implications. But cliniciansshould also be aware of some of the predictors, correlates andconsequences of emotional behavior in the medical interview.Moreover, in designing communication skills training programs, abetter understanding of the phenomena discussed could haveconsequences for approaches and techniques in training cliniciansto handle emotions better in clinical interviews.

Conflicts of interest

None.

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