NURS and PEARLS
Awkward is normal
SADNESS FEAR ANGER
RESPOND to EMOTIONS
Video Demo 1
Video Demo 2
Video Demo 3
Video Demo 4
|THE DEMO VERSION DOES NOT FEATURE THE DOCCOM ASSESSMENT QUESTIONS NOR THE LEARNING MANAGEMENT SYSTEM|
|Welcome to DocCom Module 13:
Responding to strong emotions: Sadness, Anger, Fear
|by Tim Gilligan, MD and Barry Egener, MD
Facilitator Guide of this module for DocCom Residency Doctoring Curriculum
|ACCREDITATION AND DISCLOSURE|
|Respond to strong emotions|
|Barry Egener, MD |
Legacy Health System
Tim Gilligan, MD
Length: 45 min
|Disclosure|| Dr. Egener has no commercial relationships to disclose. |
Dr. Gilligan has no commercial relationships to disclose.
Dr. Clark has no relationship to disclose.
Dr. Novack has no relationship to disclose.
Dr. Saizow has no relationship to disclose.
|Commercial Support||None; This project was made possible through the generous support of the Arthur Vining Davis Foundation.|
|Unlabeled Uses||Each faculty person presenting is requested to disclose any product that is not labeled for the use under discussion or that the product is still investigational. There are no off label uses.|
During the medical interview patients' strong emotions tend to elicit strong emotions in their clinicians. Depending on clinicians' skill and self-awareness, those emotions can lead to productive exploration of important clinical issues, or they can threaten therapeutic relationships. This module will describe concepts and skills that help you to respond to patients' intense expressions of sadness, fear, or anger in ways that not only promote patients' healing, but also enhance your own self-awareness and growth as a clinician.
|The Patient's View|
|The Doctor's View|
|Questions for Reflection:|
Prompt verbal and nonverbal acknowledgment of emotions, particularly the strong emotions of anger, fear and sadness, builds trust and strengthens relationships.
Emotions are always present in healthcare encounters, because health and illness are emotionally charged issues. On the one hand, emotions are not good or bad, but simply facts, like the weather. On the other hand, learning to perceive patients’ emotions and to elicit and respond to them are critically important clinical skills. Often we notice them, but sometimes we do not. Perhaps we are too caught up in an interaction to track patients’ emotions or are distracted by trying to make a diagnosis or develop a treatment plan. Sometimes we only recognize or respond to patients' emotions (or our own emotions) when we look back on interactions or notice the residual impact on ourselves. Increasing our awareness of our own emotions helps us avoid reacting to them in counterproductive ways.. Increasing awareness of our patients’ emotions opens opportunities to understand patients better and to express our care for them. If we do not notice patients’ emotions, they may feel that their experience is invisible, that they as people have not been seen.
Empathic responses demonstrate your active interest in understanding patients’ experiences, their hopes and fears. Every patient is suffering, a little or a lot, and empathic responses to their emotional cues, clues and statements not only lessens the suffering, but encourages them to participate productively in diagnostic and therapeutic decision-making.
The strong emotions of sadness, fear and anger each originate in the experience or anticipation of loss - for example loss of function, life, relationship or independence.
Exploring your emotions that arise in patient care promotes your professional growth. Most of us are sensitive to certain emotions and less sensitive to others. You can become a more effective clinician by being more aware of your own "hot buttons" and "blind spots."
Studies in social and biological sciences as well as extensive commentary in literature, philosophy and the arts make it clear that human beings are wired for empathy and that without this wiring we would not survive.
At a practical level, empathy refers to imagining or vicariously experiencing another person’s emotional state. As human beings, this experience happens whether we are conscious of it or not. We can never know precisely what another person experiences and what it feels like to be them, but it is the willingness to imagine that matters in clinical settings. “What,” we might ask ourselves, “does it feel like to be that patient, to live in their body, to view the world through their eyes?”
Seeking to comprehend patients’ emotional experience helps us overcome the feeling that patients are a challenge. It helps us to feel that our patients and we are together on the same side of the table, facing the challenges of their experience on the other side. Empathic responses show that we understand that the illness is the problem, not the patient. Distinguishing between the patient’s behavior and the patient as a person creates professional objectivity, whereas seeing the patient as the source of our discomfort can make a therapeutic alliance difficult. Our caring instincts are kindled when we see patients’ sadness, anger or fear as an expression of their suffering rather than the source of our own unpleasant feelings.
When emotions make us uncomfortable or if we lack confidence in our ability to respond to them, we may try to ignore them or distance ourselves or try to make the emotion go away, instead of trying to understand patients’ experiences. Exploration of patients' emotions enables us to understand and increases our capacity for caring. Exploration is the main tool in overcoming our own discomforts or lack of confidence in charged situations
When we respond empathically to patients’ emotions, we make a therapeutic intervention of fundamental importance, one which enhances healing as well as patients’ capacities for hope and for taking effective action.
You do not need to actually feel what patients are feeling in order to be therapeutic. The interview itself can become a healing experience because being understood is therapeutic. Data from many sources within medicine, across diverse cultures and in fields such as psychology, education and the arts demonstrate that when we fail to respond to strong emotions in an empathic manner, patients feel they are not understood or not cared for by the listener, or worse, not valued as persons.
You show interest in comprehending patients’ emotions and experiences by making empathic statements that acknowledge those emotions or experiences. Your empathic responses communicate and demonstrate that you care about patients’ experience and your interest builds trust and safety into the relationship. In turn, trust helps patients join with us both to explore their illness stories and to generate therapeutic options more efficiently and effectively.
To be sure, people debate about how much emotional connection between patients and clinicians is optimal. Too much detachment risks loss of rapport, but “getting too close” or losing one’s boundaries causes a loss of therapeutic agency. However, when we do experience emotion in a patient encounter, it is useful to become curious about why this is so (see "Professional growth" below).
Situations in which patients respond negatively to an empathic statement suggest that provision of good clinical care requires use of additional skills, such as providing information, containing chaos or negotiating alternative approaches to the dilemmas presented. Many situations are illustrated in later DocCom Modules’ texts and videos. Back and Arnold and Salmon cogently discuss some differences between “skilled communication” and “communication skills.”
|NURS and PEARLS statements|
Practical experience and research suggest several categories of response in situations where emotions are strong, situations that might be described as “high-stakes.”
Empathy skills are the same in simple situations and in emotionally intense ones. Many learners worry that the purpose of empathic responding is manipulative, an attempt to maneuver patients into another state or perspective that the clinician desires. Unequivocally, this is not the case! The purpose is to express authentic caring and to forge a genuine therapeutic relationship with patients by building alliance, safety and trust that will benefit them.
Staying in relationship lessens the isolation patients inevitably experience when they face health problems. Our effort to imagine their circumstances and their experience conveys the authenticity and depth of our investment in their well-being. Patients cannot infer empathy from their clinicians and need to hear empathic statements spoken aloud. Nonverbal gestures may not be sufficient in the usual healthcare settings, unless relationships are solidly established as trustworthy. Clinicians powerfully signal their genuine concern when they respond to emotion with empathic statements. This is most emphatically true when pain is significant, whether it is physical pain or psychic distress, or when diagnosis is elusive or treatments are of uncertain efficacy. All DocCom Module authors stress this dynamic and the fundamental importance of relationship building to successful healthcare outcomes. Nonverbal empathic behaviors are also critical, but may not be sufficient in the usual healthcare settings, unless relationships are solidly established as trustworthy. By the same token, empathic statements accompanied by non-empathic body language will generally be perceived an inauthentic.
Clinicians powerfully signal their genuine concern when they respond to emotion with empathic statements supported by empathic nonverbal behavior. This is most emphatically true when pain is significant, whether it is physical pain or psychic distress, or when diagnosis is elusive or treatments are of uncertain efficacy. All DocCom Module authors stress this dynamic and the fundamental importance of relationship building to successful healthcare outcomes.
The need for clarity during discussion of the complex biomedical aspects of illness often distracts clinicians from responding to patients’ emotions. Two mnemonics can help clinicians find words with which to respond in stressful situations where complicated or urgent biomedical features are prominent. NURS and PEARLS help learners to remember various effective empathic statements that build trust and relationship. The mnemonic NURS includes Name, Understand, Respect, and Support, while PEARLS includes Partnership, Empathy, Appreciation (and Apology), Respect, Legitimation and Support. We present specific examples of empathic statements in brief clinical vignettes in the pages below.
|Awkward is normal|
Whatever your words, and however awkward or unskilled you feel, if you are genuine in your intention to comprehend and appreciate patients’’ situations, your attempts will be helpful.
Many learners initially feel that these responses are faked, foreign or phony, but in the context of improving interview skills they find the mnemonics to be extremely useful. It is important to remember that the goal is not to act as if you care, but rather to show the patient that you do care. Any skill is initially awkward - think of your first time dribbling a basketball, playing a musical instrument, or speaking a foreign language. Increasing the range of situations in which you can respond with empathy is a process that is essential throughout your career, from student to seasoned clinician. Both beginning and advanced clinicians report that feedback from their patient interviews convinces them that practice with NURS / PEARLS eventually results in greatly improved relationships. More practice enables them to respond to emotions in a nuanced and increasingly effective and personalized manner. As with suturing, reading x-rays and many other zmedical tasks, performance improves with practice.
The illustrations in this module are informed by evidence-based sources. Whatever your words, and however awkward or unskilled you feel, if you are genuine in your intention to understand, your attempt will be helpful. First, your empathic nonverbal cues (DocCom Module 14) will be apparent to patients. Second, if you are misunderstood, patients are likely to give you another chance to clarify and express your caring, either by telling you directly or sending nonverbal signals of perplexity. If your goal were to manipulate, the skills would be inflammatory; if your goal is to communicate genuine interest and feelings, no matter how awkwardly expressed, patients are likely to be appreciative.
|Sadness, Fear, and Anger|
The emotions of sadness, fear and anger have origins in the experience or anticipation of loss.
In the medical interview, each of these emotions can have their source either in the patient, the clinician or in their interaction. We don’t generally associate anger with loss, but if you are feeling angry, you can uncover this association by asking yourself the question, “What might this person (or situation) cause me to lose?”
What do we know about the biology and functions of empathy?
Our reasoning is governed by our emotions and desires much more readily than our emotions and desires are controlled by logic or rationality. We consider ourselves rational beings, but human behavior is often driven more by emotion than logical thought. And when people are in highly emotional states, their ability to use cognitive reasoning is compromised. Expressions of empathy, both verbal and nonverbal, and of an authentic desire to understand people who are experiencing strong emotion are the most effective ways to connect with them..
People and other primates have evolved the capacity to “read” others’ emotions, a fact that implies that empathy provides a survival advantage. Research in wild chimpanzees demonstrates advantages to the ability to read emotions, as well as disastrous social consequences of the inability to do so. Other research indicates that complex neurobiological mechanisms and neuroendocrine activation underlie the phenomenon of empathy. In the brain‘s cortex "Mirror neurons" register another person’s behavior and allow people to imaginatively experience that observed experience. In fact, “emotional intelligence” (EQ) may correlate better with job and marital success than intelligence quotient (IQ).
Awareness of emotions and their recognition in other people confers the power to react mindfully, rather than reflexively. Thoughtful and empathic responses are productive for patients and satisfying for clinicians, whereas reflexive responses usually retard rapport and limit healing. One way of understanding this is that an empathic imagining of what a patient is going through and active expression of this empathy allow us to stay with patients where they are emotionally. In contrast, our reflexive reactions tend to be responses designed to guide us away from emotion because we find strong emotions uncomfortable. The patient cries, we find it uncomfortable to witness their distress, so we reflexively try to “help” them stop crying rather than remain present with them in their grief.
Exploring your own emotions that arise in treating patients promotes your professional growth. Most of us are very sensitive to some emotions, and less sensitive to others. You can be a more flexible and effective clinician by becoming more aware of your own blind spots and "hot buttons".
Emotions are “contagious”
Clinicians may resonate with patients’ anger or sadness and thus feel the same emotion. Or a patient’s emotion may evoke a different emotion in a clinician, e.g., patient sadness may induce clinician anger. Also, a clinician may experience an emotion when the patient is not manifesting any emotion.
The range of responses to patients is as rich as the diversity of human experience, upbringing, culture, and personality. While our own emotions may provide clues to what the patient is feeling, there is nevertheless a differential diagnosis of clinician emotion – just as the emotions may have many sources in the patient, the same may be said of the clinician. These factors combine to attune us differently to emotions – there is no “correct” or “best” response.
|Responding to Sadness, Anger or Fear|
Exploring emotions enables accomplishment of all the major functions of the medical interview: data gathering, relationship-building and collaborative planning for diagnosis and treatment.
In this section, the following are discussed::
Studies have shown that addressing emotions helps shorten interviews and builds trust, in both surgical and primary care visits. Unfortunately, clinicians commonly disregard emotions. Sometimes clinicians think they lack the skills to manage the flow and timing of the interview, and sometimes they cannot shift their focus from biomedical aspects back to the person.
The timesaving effects of acknowledging emotions lie in enhancing patients’ trust in their clinician. Skillful use of patient centered skills allows clinicians to integrate caring for the person with caring for the biomedical diagnostic and therapeutic goals. Patients who see that their communication of important personal needs, values, concerns and beliefs is welcomed by clinicians are more likely to cooperate and partner with clinicians in discussing, planning and carrying out diagnostic and treatment plans.
Of course clinicians use judgment in deciding how to respond to emotions when they arise, but choosing not to explore strong emotions will hamper the therapeutic relationship. Regardless of the clinician’s intention, ignoring patients’ feelings creates the impression that the clinician does not care about the emotions or considers them not important. Patients may feel that the clinician has failed to perceive their experience and their suffering. This perception diminishes the clinician’s therapeutic effectiveness (DocCom Module 3).
Giving the patient control over whether and how to discuss sadness will also give the patient some control of the emotion.
Let’s look at an example using the mnemonics. Sadness may be non-verbally apparent when a clinician approaches the patient’s bedside or enters the patient’s room. A patient may be crying, withdrawn or staring at the floor. The clinician cannot initially know whether these gestures relate to a health concern, a social issue, depression or something else.
Thus it can be empowering for a clinician to simply Name the apparent emotion.
|“You seem sad (upset, down or perhaps pensive) today.”||
Name (or mirror, echo or reflect)
Some clinicians worry that an incorrect naming would be off-putting for patients and inhibit relationship building and trust. On the contrary, all people value attempts to comprehend their situation, and usually respond with either grateful appreciation or a more accurate naming of their emotion. This is especially true in healthcare situations. As with all emotions, patients do value thoughtful attention and attempts at fine-tuning. For example, for a patient who is withdrawn, Naming “you seem sad” brings the emotion into the interview and signals that you intend to address it. However, for a patient who is sobbing, the emotion is already present and the statement above is too tame. Thus, inviting the patient to explain the sadness would be a better approach, perhaps Naming “upset” and saying something like: “Can you tell me what is upsetting you?”
Some explanation will follow. When the clinician has some notion of the cause, Understanding, Rspecting (or Legitimizing) the patient is the appropriate next step and demonstrates the clinician’s willingness to understand the reason for the emotion.
Here are some statements that illustrate use of the skills of Respect, Understand and Legitimize.
|“I’m impressed with how you’ve coped with such a devastating loss.”||Respect|
|“Losing your job when your husband has been out of work must be very scary.”||Understand|
|“Losing a child is the worst thing most people can imagine. It can be hard to imagine how to go on living.||Legitimize|
|“The last few months of your wife’s illness have been really hard.”||Understand|
|“I’m impressed with how you’ve coped with such a devastating loss.”||Respect|
Support / Partnership statements align the clinician with the patient, emphasizing that the two are on the same side and working for a shared goal of improved health.
|“I’m concerned about you and want to help you feel better. I’m hoping we can work together on that.”||Support|
|Sadness: additional considerations|
Many (but by no means all) people who suffer a significant loss or illness will develop clinical depression. Whenever strong sadness is present, the clinician should screen for the presence of major depression. In extreme sadness, the clinician should explore the patient’s capacity for self-care (or intent for self-harm) and access to a support system: friends, relatives, faith and other practitioners. (DocCom Module 27)
When talking with someone who is angry, the most effective strategy for navigating a way forward toward a more productive dynamic is to acknowledge and try to understand their anger.
Anger is a normal response to an injury or perceived threat and can be counter-productive when it alienates those who might help or unnecessarily escalates a conflict. Many of us have difficulty responding in a productive manner to anger due to our fear of escalating anger, conflict and potential retaliation. This fear can lead to defensive statements or questions which have the undesired effect of increasing the other person’s anger. Ignoring their anger, changing the subject or trying to persuade them not to be angry tend only to escalate the anger. Remember: you can express your understanding without agreeing with the other person.
Patients may express anger toward clinicians for many reasons, including:
Click the picture above to see a movie portraying poor communication with an angry patient.
Click the picture above to see a movie portraying better communication with an angry patient.
Most clinicians find it difficult to verbally understand and to express empathy with patients by whom we feel attacked, but the same skills useful in other situations are equally useful here. As with sadness, stating your empathy with angry patients may require calibration. For example, when the patient is “simmering” with anger, but doesn’t feel that it’s appropriate to reveal the anger, Naming will help bring the upset into the interview, where it can be addressed:
|“You seem angry. Have I done something to upset you?”||Name|
However, the same statement would seem foolish, sarcastic or belittling to a patient who is yelling at the clinician. Here, there is no need to bring the emotion into the open, since it is already present. Understanding or Legitimizing would be more appropriate:
|“Anyone would be upset after being kept waiting in a cold room dressed in a flimsy gown.”||Legitimize|
Clinicians are often reluctant to Understand or Legitimize a patient’s anger for fear of “adding fuel to the fire.” But especially because not feeling heard often arouses patients’ anger, Understanding / Legitimizing the feeling is helpful, not harmful. Using this language does not mean that you agree with patients, only that you have heard them. Here are two Understand / Legitimize examples:
|“I can Understand that you would be upset with me for not prescribing the Vicodin®, when that’s the main reason you came in today.” “It’s difficult to care so much and feel that you have so little control over what happens.”||
Support / Partner statements that affirm the clinician’s investment in helping the patient can also help in these circumstances. Here are three Support / Partner examples:
|“I understand that you are angry and I want to help.”||Support|
|“I hear what you are saying about how much pain you are in and I want to help you feel better. I don’t think that Vicodin® is a good option for you and I’m committed to working with you to develop a better plan for managing your pain.||Support|
|“Let’s see if there’s another way I can help address your concerns; or perhaps others on the health care team can assist us.”||Support|
One challenge of anger is balancing empathy with enough “detachment” to remain professional. The patient’s anger may not be directly towards us personally, but feeling personally attacked can make us defensive. And responding in a defensive manner - “You did not hear what I said” – usually worsens the situation, because it implies that the other person is at fault, somehow. Sometimes it helps to remind ourselves that although patients’ anger may be directed at us, its origin lies in the patients’ circumstances.
In other words, the anger is usually not about us and we’re not responsible for the patient’s anger or for “fixing” it. However, we do help patients when we take the time to become mindful of their pain or loss and genuinely attempt to make an empathic statement despite feeling attacked.
|Anger: additional considerations|
There are times when you would choose not to empathize, when it is more appropriate to place boundaries on the patient’s anger. For example, when patients are so upset that they cannot listen, when they have lost control or when they threaten the safety of others. The best way to place limits is to describe the conditions in which you are willing to continue to engage with them. Importantly, speaking at low volume and with non-aggressive postures is very helpful. (see DocCom Module 14 about non-verbal aspects of this situation.)
This gives the patient the choice of whether to de-escalate and continue to be heeded or, alternatively, to lose the audience and certain other freedoms:
|“I’m willing to continue this conversation so long as you exhibit the same respect towards me that I am giving you.”|
If disregarded, your own limitsetting should escalate:
|“If you continue to disrupt our ability to conduct care safely, I will need to call Security.”|
If patients continue to be disruptive, it’s best to disengage. Continued discussion usually only “fuels the fire.” It is appropriate to leave the room, to hang up the telephone or to call Security.
Your own safety takes precedence over being therapeutic. Your own gut feeling about personal safety is generally reliable, and being attuned to a sense of danger is but another aspect of self-awareness.
Exhibitions of extreme anger are unusual and may signal other feelings or diagnoses. For example, intense anger may be a way of insulating oneself from intense fear, such as that presented by a lethal diagnosis or a threat to one’s child. Anger that might have been more moderately expressed can be disinhibited by alcohol and other drugs. Personality disorders and delusional thinking can manifest as extreme anger, so such demonstrations should prompt consideration of substance abuse, sociopathy or schizophrenia.
Being the target of intense anger is always upsetting, and you are likely to feel shaken. Take a few moments to center yourself after such an encounter before moving on to other tasks and reflect on the experience, which may offer opportunities for growth. You could ask yourself or discuss this with a trusted colleague:
Medical events such as a motor vehicle accident or a worsening clinical situation precipitate intense fear. Assist patients who experience fright by helping them bring fears into the interview where you can show your understanding.
Resist invoking false reassurance – on the one hand, the falsehood usually helps only minimally, and on the other, trust is jeopardized and the therapeutic alliance is undermined when the falsehood is uncovered. That alliance is what provides the leverage for supporting patients. However, you should never diminish hope, even when death, the most dire outcome, is certain. Hope is available in the manner or management of dying, in spiritual domains and in the people and accomplishments left behind.
Starting with Naming what you observe may objectify an emotion that patients were unaware of:
|“You seem apprehensive.”||
Name / Reflection
After patients respond, Support / Partner with them by exploring the causes:
|“What worries you most about this illness?”
“What help would you like in order to deal with [whatever issue patients name]?”
“What worries you most about leaving [their significant other] behind?”
“Have you spoken to them about your concerns? Are there ways you could provide for them?”
Your initial response to concerns patients name should be to make an empathic statement. Sometimes simply Naming the fear or hearing that particular concerns are Understandable/Legitimate rather than extraordinary, diminishes fear.
Often a lack of control over future events, or the idea of facing the unknown alone drives the intensity of fear, so taking any positive action, such as assuring patients of your Support can confer a sense of control.
Feeling unattractive or tainted by illness can increase a sense of alienation. Sometimes the patient’s specific fears are realistic and terrifying, such as the diagnosis of a lethal disease. In these situations, the expression, “I wish it were different,” Supports patients by communicating caring, and sharing their perspective. (DocCom Module 33 discusses “bad news” in detail)
Knowing that you have worked with other patients in the same position can help. Here are some examples:
|“The experience of chemotherapy is always scary.”||
Understand / Legitimize
|“You’re dealing with a lot right now, and you’re doing very well with it.”||
Respect / Appreciate
Alleviate the sense of isolation by offering to refer to a counselor, to a support group or simply by proffering your own constant presence:
|“Whatever struggles you’ll face with this illness, I am here to help and I hope you will reach out when you need something.”||
|Fear: additional considerations|
Fear becomes paralyzing for some patients, preventing them from making constructive steps. While the psychobiologic consequence of fear, anxiety, can mobilize a patient to prevent or mitigate a feared event, severe anxiety may require psychiatric consultation or medication. If appropriate, a benzodiazepine can give the patient relief and a sense of control. (DocCom Module 26) Remember to screen for alcohol or other substance abuse before you offer this option.
All caring professionals live with feelings of isolation, guilt, inadequacy and uncertainty, at least occasionally. No clinician is immune to the experience of patients’ suffering and death that bring us to confronting our own existential fears. In everyday patient care, you also bump up against your own limitations, which can precipitate a professional crisis. Many clinicians in certain specialties encounter these challenging issues every day. Reflect on these issues with colleagues in order to bring fears into the open and prevent burnout. (DocCom Module 4) Remember to share feelings with your colleagues and your team; their listening will help you at the same time it helps them.
Patients regularly confront both real and apparent life-changing medical events that threaten them with a loss. Every day clinicians will regularly encounter their patients' fear, sadness and anger, as well as their own emotional responses. Emotions are neither good nor bad – they are simply facts, like the weather.
However, patients and clinicians can become stuck in strong emotions and overwhelmed by their force. At these times we must maintain our professional equilibrium and use the skills that we have practiced (in less challenging circumstances,) particularly empathic ones that communicate interest in the patient as a person. NURS and PEARLS statements serve as reminders of simple, clear and effective empathic responses for most situations.
The intensity of emotion-charged moments generate proportionately strong and rewarding relationships with patients, who will benefit greatly from experiencing your attention, empathy and compassion. Such events present important professional challenges while simultaneously engendering personal and professional growth.
|Tim Gilligan, M.D., Barry Egener, M.D.|
|Dennis Novack M.D., Bill Clark M.D., Ron Saizow M.D.|
|Christof Daetwyler M.D.|
Standardized Patient (Mr. Hardisson):
Standardized Patient (Ms. Fuller):
Angry Father of sick child:
Physician on camera:
|Barry Egener, M.D.|
Physician dealing with angry father:
|Dennis Novack M.D.|
Video Director and Producer:
|Christof Daetwyler M.D.|
Video Camera, Light and Sound:
|George Zeiset B.A.|
Video Assoc. Director:
|Dennis Novack M.D.|
|4.0 - 2/01/2016 revision by Tim Gilligan
3.0 - 12/20/2011 enhanced with MP4 videos and HTML5 code
2.1 - 5/24/2011 Revision by editor
2.0 - 7/8/2009 upgrade to doc.com version 4.0
1.2 - 7/1/2009 revision by Barry Egener
1.1 - 6/10/2007 revision by Geoffrey Gordon
1.0 - 6/27/2005
13: Responding to strong emotions - by Tim Gilligan, MD and Barry Egener, MD