By Asking, “What’s the Worst Part of This?” Physicians Can Ease Suffering

Dec. 22, 2015
Ron Epstein, M.D.

When patients suffer, doctors tend to want to fix things and if they cannot many doctors then withdraw emotionally. But by turning toward the suffering, physicians can better help their patients and find more meaning in their work, wrote University of Rochester Professor Ronald M. Epstein, M.D., in the Journal of the American Medical Association’s weekly essay, “A Piece of My Mind.”

As a national and international keynote speaker and investigator in medical education, physician burnout and mindfulness, Epstein is concerned about a lack of attention to suffering. It doesn’t often fit neatly within the hurried, fragmented, world of clinical care, he said.

The essay was co-authored by oncologist Anthony L. Back, of the University of Washington. Epstein and Back conducted a literature review on how doctors address suffering. Despite the ubiquity of suffering, they discovered few articles in the medical literature—most of which were published in journals rarely read by practicing clinicians.

“Physicians can have a pivotal role in addressing suffering if they can expand how they work with patients,” the article stated. “Some people can do this instinctively but most physicians need training in how to respond to suffering—yet this kind of instruction is painfully lacking.”

The authors provide an example of how doctors can address suffering more effectively using a story of a patient who went years without a diagnosis, despite pain and disability. Surgery and medical treatments were not enough. Only after her physicians became truly curious about her experience, listening to her, looking at her, and bearing witness, were they able to help the patient heal.

Epstein and Back offered two clinical approaches to suffering to complement the familiar “diagnosing and treating.” These are referred to as “turning toward” and “refocusing and reclaiming,” and the authors suggest that doctors use these approaches routinely.

Turning toward suffering means to, first, recognize it. It requires physicians to ask patients about their experience of suffering, through questions such as “what’s the worst part of this for you?” Sometimes doctors feel helpless in the face of suffering, and in those situations their own discomfort can be a useful wake-up call.

To refocus and reclaim involves helping patients reconnect with what’s important and meaningful in their lives, especially when suffering and its underlying causes cannot be eliminated. Sometimes that requires physicians to be supportive of a patient’s efforts to become more whole. In the case described, the patient separated from her spouse and re-established a professional identity. By making those changes she saw past her suffering and again viewed herself as a complete human being.

Asking physicians to engage as whole persons in order to address patients as whole persons “is a tall order,” Epstein and Back wrote, “yet, it strikes us as more feasible than ever because of evidence that programs promoting mindfulness, emotional intelligence, and self-regulation makes a difference.”

Epstein’s published work is among the most widely cited in the scientific community; earlier this year four of his medical education articles were ranked by Academic Medicine as among the top cited in the last century.  Back has also published numerous articles on patient-physician communication and palliative care.