41. Cognitive Reframing | Shifting the approach with addiction, end of life, and catastrophizing

We have a choice in how we perceive and act on any situation. Using that knowledge in an intentional way to shift perspective is at the core of cognitive reframing. Epictetus, the great Stoic philosopher, said it best, “It is our attitude toward events, not events themselves, which we can control.”

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We discuss:

Reframing, a psychological technique which involves thinking about something from a different perspective [04:30];

While reframing doesn’t change the situation, it does change your mindset.
Reframing empowers you to choose to decide how you want to look at an event that happened.
It is a powerful way to transform the way you think and to change your perspective.

How reframing can be used in the emergency department when you’re engaging with a patient or a patient’s family member who is hostile and upset [07:50];

Perhaps they’re reacting to a long wait or to feeling like they’ve been slighted or treated rudely.
While you can’t change the fact that this person is upset, you can choose how you respond and the perspective you take regarding their situation.
You can choose to escalate with them, taking on their energy and ramping up your sympathetic nervous system. You can get indignant and let it irritate you.
Or, you can choose to look at them through a different frame. You can look at this person and wonder what led up to this anger and frustration.
If we’re able to separate ourselves from the emotional, reactionary place and be the objective and compassionate, we can just be present with them as their physician.

Discussing comfort measures with the family of a dying patient [12:12];

It is not uncommon for us to feel that dying patients are best served with aggressive comfort measures, but the family may be angry, believing that we’re doing nothing for their loved one.
By helping the family understand what comfort care is and putting it in a new perspective for them, you’re framing that we care about their loved one’s quality of life.

‘Status dramaticus’ — the loud, demonstrative patient who catastrophizes their (often relatively minor) symptoms, triggering irritation for many providers [14:30];

Reframing can help when dealing with status dramaticus.
Critical to handling these patients is recognizing that this is a problem for you. Take a deep breath and try to frame them in a way that they have come to you for help.
You might not be willing to give them the kind of help they think they need (ie. opiates), but you can find other ways to connect with them. This will help your sanity and job satisfaction.
Being overly dramatic is not protective for disease. So, the patient may actually have something significant going on, medically or due to mental illness.

Reframing when treating patients who suffer from addiction [16:30];

By better understanding what’s going on with the addict and how they came to addiction, the irritation one might feel during the encounter can change to compassion.
One school of thought is that addiction is a treatment for whatever pain the addict has experienced (such as childhood trauma or an initial painful injury). This was explored in a previous ERcast interview with Joe Polish.
Try to get the origin story, to see the person that they were before their addiction. Sit down in a chair, treat them like a human being, and ask “How did you get here?”
By treating the addict with compassion, you can change their life and put them on a different path.

“You can be the first domino in the patient’s healing”.

Ways to reframe yourself and your job to offset burnout [20:00];

People who are feeling burnt out at work benefit from reflecting on what they really want to be doing at work and with their time. Knowing what you’re doing and why you’re doing it increases job satisfaction.
When Jaime started to burn out at work, she put four corners around the frame of her career. She decided she had four roles in her job: as a public safety officer, a resuscitationist, a diagnostician, and a patient advocate.

“It is important to feel that you have ownership of your career, and not simply that you’re a renter of your job. When you are truly the owner of your career, you want it to be amazing.”

Advice to first year medical students [25:40];

Patients are not impressed in the slightest by your grades in medical school or high test scores.
What they care about is do you care. Did you listen to them as a human being?