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How to Handle Challenging Emotions — in Ourselves, Patients, and Those We Lead

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Speaker: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at stepsforward.org.

Kevin Hopkins, MD: Hello everyone, and thanks for listening. My name's Kevin Hopkins. I'm a family physician at Cleveland Clinic and a senior physician advisor for Practice Transformation at the AMA. Today on our podcast, we're joined by our guest, Dr Neha Sangwan, CEO and founder of Intuitive Intelligence, an internal medicine physician, international speaker, and corporate communication expert. You may remember Dr Sangwan from a previous STEPS Forward® podcast episode titled How to Master Communicating with the Most Challenging Personalities in Your Life. If you haven't listened to that episode, I'd highly recommend it. Dr Sangwan, thank you for being with us again today. Would you mind starting with just telling our listeners a little about yourself and your background?

Neha Sangwan, MD: Sure, great to be back. Thanks, Kevin. I'm a mechanical and biomedical engineer. Worked for Motorola back when Motorola was a thing in the nineties, went on to medical school, internal medicine residency, and then I became a hospitalist. I have since left practice in the hospital, I now have a private practice, and I now work, as well, in helping transform toxic cultures into healing organizations. I've done TEDx Talks, I've written a book called TalkRx: Five Steps to Honest Conversations That Create Connection, Health, and Happiness, and I am just finishing up my second book, which is on burnout and how do we heal it. So yeah, I'm excited to be here, and emotions and communication are my jam, so really excited to be able to talk to everybody.

Dr Hopkins: Awesome. Well, I'm excited to have our conversation today. So in our previous podcast that we did together, How to Master Communicating With the Most Challenging Personalities in Your Life, we talked a little bit about personalities, but also work style and how to help ourselves identify communication style that we tend to use, but also those we work with, live with and interact with, not the least of, which certainly is our patients, and how to identify how most effectively to communicate with one another. One of the topics we just touched on very slightly was the emotional reaction that we have to communicating with people that can be seen as challenging or challenging circumstances and situations. Since we're going to talk about how to handle challenging emotions, can you maybe give us an overview of which emotions tend to create the most significant challenges for people, either internally or with interpersonal relationships?

Dr Sangwan: Sure. Well, I mean, I think we should just start with the basics. We've all been through a lot, and so for those of us that thought, "I don't really feel emotions, emotions are a waste of time. I got lots of things to do, the world's too busy for that to all happen," well, I call what we went through in 2020 a global heart attack. The world had a heart attack, and in that moment, we went through not having what we needed. We were all challenged and stressed on different levels, and to me, it felt like we got buckled into an emotional rollercoaster. Whether you're someone who felt emotion or not, boy, 2020 was something else. And so, we can push these emotions down, but the truth is they only grow bigger. They don't go away, and the most common ones that I experience and in my 20-plus years of coaching and healing patients and talking to colleagues and working in companies, really some of the basic ones are anxiety, anger, and some form of sadness, grief, depression, loss.

Now, the most fascinating thing to me is we're in the business of life and death, and I never got Emotions 101, did you?

Dr Hopkins: Not that I recall, no. It was sort of learn on the fly on your own.

Dr Sangwan: I mean, on top of being so busy, "There's someone else in Bed 9, Dr Sangwan, a heart attack in Bed 9," it's like even if my patient just passed, the paperwork, getting on electronic medical records to take care of the death certificate, it's like, "Okay, who's next?" We don't even give ourselves time to grieve and time to process what's happening. For those of us lucky enough to have a lounge, a place where we can commune and have connection, eat together, that is one of the most valuable aspects of shared space. Not only do we get side consults, but we get to process, "Hey, I had this patient, I lost my patient today." Whatever it is, there's like a moment in time where we can understand and connect to one another.

Dr Hopkins: Are you talking about a physician's lounge of some sort? I'm not familiar with the concept. Sorry, that was sarcasm, but you can't always pick it up over audio. But yeah, those, in many places, don't exist anymore, and it was a center of community and relationship among physicians in the past certainly.

Dr Neha Sangwan: Yeah, a physician's lounge, a lot of times those have been taken away. And I also want to say, for leaders who care about the bottom line, the amount of business that got taken care of in those lounges, it may not have been on the books and tangible and documented, but I promise you, more happened in those lounges for our own healing, our own productivity, and our patients' better care. So, we're in the business of life and death, we've never had Emotions 101, unless you had a really self-aware parent or experience in your life, or a great mentor who taught you this. Emotions are put to the side, and if I think about it, there's not a single patient who didn't show up in the ER thinking they were going to die. Who comes voluntarily If you don't work there? You're coming because something has alarmed you enough that you're willing to wait as long as it takes to see someone.

And so, in that space, really what I want people to know is—why don't we just start with the basics, which is anger, anxiety, and tears? Because most people, even just starting there, have a reaction to that in themselves or in those they love and lead, or their patients. So, when emotions arise, which of those, listeners, do you want to make go away in yourself or in others? And so, notice, if you're someone who, when someone else starts getting tearful, you're like, "Where's the nearest exit? I don't know what's going on here." Or if someone starts getting angry, do you have judgments around their anger, and whether that's okay or not okay? And over the last few years, all of the pace of change that we've been through, all that we've had to improvise and makeshift, for those of you where anxiety is where you go and you worry, you worry a lot, you worry about missing something with a patient, you worry about making a mistake and getting sued. Whatever it is in that space, is it anxiety that you are most connected to?

Because I'd be happy, Kevin, to take us through those and have a bit of a discussion on those three. Let's start there.

Dr Hopkins: I think that sounds like a great place to start, Neha, and those are certainly feelings and emotions, and I'll say circumstances and situations, which make a lot of people very uncomfortable. And it wasn't even all that long ago when in medical training, we were taught that showing emotion ourselves meant weakness. And yet we know that there's certainly a valuable interpersonal connection that is engaged when we do have a genuine emotional reaction to something that's going on to our patient or to a family member or a friend. And so, I think there's so much value to be placed within those emotions and our own emotional response. So yeah, let's start there even though it might make us uncomfortable.

Dr Sangwan: Awesome. So, let's start with tears, okay? Tears, that, I mean, you were saying, "Oh, if you show emotion, it's weakness." What I will tell you is certainly tears are something I have gotten familiar with, and since I was a little girl was told, "Why do you get tearful? Why are you crying?" and, "You got to stop that. Go in your room and don't come out until you have a smile on your face." That whole experience. What I want to start with is, when you see tears coming out of someone's eyes, what does that mean? What does it actually mean? It might mean that they're sad, but what else might it mean? It might mean they're angry, and it's turned into that. It might mean that you remind them of their grandfather who passed. So, a memory, a familiarity, there might be some way in which you've touched them, they feel touched.

Another way is relief. When you give someone news, "You know what? The biopsy showed that it was benign," all of a sudden it's like tears of relief. So just because someone gets tearful, please don't assume that you know what that means. You can say something like, "I'm noticing your eyes tearing up. Tell me, what's happening? What's happening for you?" So, whenever you don't know what's happening, because you don't have to know what's happening in someone else, all that matters is you actually care and you acknowledge that it's happening so they have a space in which they can express that. People think it's going to take a really long time. In fact, avoiding it is the reason you never get to where you want to get. It's the reason that they won't agree to the plan of treatment, because they don't feel heard, because they feel like they weren't able to express their concerns. So, in fact, not acknowledging emotions actually will have you lose time, take longer, and create more passive aggressiveness.

So, the way that you do it, once again, is just state what you physically see, "Hey, noticing that your eyes got tearful. I just want to slow down and ask, what's happening?" That's it, that's how simple it is, takes no time. So, when somebody cries, and maybe this is because it's my experience of it, the way I think of it is they trust themselves enough, and they trust you enough to show you what's close to their heart, because that's an act of courage, that's not an act of weakness. But people who, in the presence of other people's tears get uncomfortable, will try to shut it down by judging it. And notice, does it make you a little uncomfortable? And so, like I said before, what you really want to do is you want to notice if you have judgments around it, you want to notice if you get uncomfortable, and so you're looking for an exit fast. And here's the big thing, did you know that tears are a biological way that the body releases stress hormone?

We have three types of tears. We have continuous tears, the ones that lubricate your eyes, have lysozyme in them, go into your nasal duct, and also keep your nose moist. But the lysozyme keeps bacteria, it's why we can open our eyes and have our eyes bare to the world, our nose has lots, it's filtering a lot, but we don't get infections there very often. Why? Because lysozyme in that fluid, the continuous tears, is taking care of that. Then there's reflexive tears, which are a different composition, more water-like. But it's when you're putting a contact in, you get dust in your eyes, and there's a different flood of emotions. The third type of tears are emotional tears. And the biochemist William Frey out of Minnesota has measured stress hormones in emotional tears and endorphins. This is biologically the body's way of releasing stress, and we're judging it, amazing. So, I think it's more about the people who don't want to feel uncomfortable themselves don't know how to handle it.

I'd ask you to do a little reflection on yourself about whether that discomfort is something you're trying to get out of, rather than you slowing down, taking those box slow deep breaths and allowing energy in motion to move through someone else and witness it or move through you. And by the way, I want to tell you that those emotional tears, yes, they have stress hormone, they also have endorphins, so I say, cry away, you're going to feel good. Endorphins are what you get when you exercise, so you're going to have a good night's sleep, and you're going to feel good. So, cry away. So, any thoughts on tears for you, Kevin?

Dr Hopkins: Yeah, it actually took me back to a time during I think my residency, so 20 years ago or more, and a very awkward interaction with a patient and one of our attendings, who, the patient started to cry, and our attending physician did exactly what you said not to do, is basically just ignored it, disregarded it, didn't ask anything about it, didn't even seem to notice. And it felt incredibly awkward and incredibly disconnected from that patient. And I just always think that patients trust us at their most vulnerable times. And I mean, you were saying that, when somebody cries in front of another person, that's a real point of vulnerability. And so, I appreciate that, and I hope that I honor that with my patient because it's a real sacred trust that we have. Patients will tell us as their physicians things they won't mention to another living soul. I never want to take that sacred trust for granted, and so that's what it reminded me of and where it took me.

Dr Sangwan: Yeah. Well, I thank you for that, because I think that's in your formative years, and we look up to our attendings, and we become them, we role model. They're role modeling for us what we should become. And you didn't forget that. And how many years ago was that? But just like that, it's right there in your memory. So how we show up in the world, we are role models to our patients, to each other, to our med students and residents. And I think we need to remember that because true strength is being able to be with what is. And the last thing I'll say about tears is a lot of times people ask me, here's the engineer in me, I take everything and make it practical, "How do I express my tears? I'm so uncomfortable. How am I going to do that?"

Three simple steps — You want to identify the emotion underneath your tears, you want to say what triggered that emotion, and you want to state what you need, if anything at all. So, it's like, "Wow, I'm so happy. That means a lot to me, we should celebrate." "Wow, I was really hurt by what you just said. I'm not sure why yet, but I need some time." "I'm relieved, at least now I know the truth of my diagnosis." "I need time to make a decision. Can we talk tomorrow?" That's how long it takes when you are well-versed in knowing yourself and knowing how to communicate. You just heard it, that's how long it takes. So, it's not going to take you more time in your emotions, it's going to take you less. So, this is going to be, you're going to be more connected, less stressed, and deeper connection with others. All right, how about you ready to take on some fire? How about some anger?

Dr Hopkins: Yeah, bring it.

Dr Sangwan: Tell me some judgements people have about anger.

Dr Hopkins: So that it's unwarranted, undeserved—

Dr Sangwan: Out of control. Yeah, so what is anger rooted in? Anger is rooted in — It's a mask emotion, it's a secondary emotion. Anger itself is not the emotion, it's rooted in hurt or fear or both. So, there's pain, someone's afraid, or they're in pain and they're afraid. So, the first question you want to ask yourself, in my book TalkRx, I call this taming the volcano within, the fire inside. So, if you know that this happens for you, or this happens with your colleagues, or with your patients, and you don't really know what to do. First notice if you have any judgments around it, and then you want to ask yourself, let's stick with you first, what are you afraid of? What are you hurt by? What just happened? So first, get to what's at the root of that, and then ask yourself too, how do you know someone's getting angry? And we talked about this a little earlier. It's like they use your full name, "Neha Sangwan, get down here right now." There's doors slamming, there's people abruptly leaving. So, there's pace of speech quickening and getting louder, pressured speech, swearing.

So, there's all sorts of way that you know anger is in the room or it's coming. And my favorite part is when you say, "Are you angry at me?" "I'm not angry. What are you talking about?" And so, people in the moment oftentimes are having such an emotional experience that they are not aware of what's happening, it's almost like it's happening to them. So, emotions are merely data telling you how you're experiencing your life in this moment. Wouldn't you want that data? That's really important data. And that's not just anger, that's tears, that's anxiety. Emotions are data. And I want us to start thinking about them as valuable data to guide us. So how do you heal anger? Well, anger, sometimes if you lose your temper or someone else has lost their temper, I want you to remember they're afraid or they were hurt by something that happened. And the way that you heal anger is through compassion and forgiveness.

And I really like Dr Kristin Neff's work around self-compassion because it's really—when you're mad at yourself for making a mistake, for doing something wrong, it's self-compassion and self-forgiveness. And so, these are the ways that you take care of that hurt and fear.

Dr Hopkins: One thing I was thinking of: ways to help diffuse a situation of somebody that you're talking to that's getting angry, they get louder, they talk faster, my natural tendency, most people's natural tendency is to go along with it, but sometimes to do the opposite, to talk softer and more slowly and more deliberate can actually sometimes help diffuse the situation as well as to keep us calm.

Dr Sangwan: What tends to happen is, so, if you're thinking there's our minds and we often have penthouses built in our minds, we've spent so much time there. I think of each of us as a human skyscraper, the very top floor, the top of your head, I think, and the outline of your body, I call that your body, your physical. You get in the elevator, you drop down to your mind, and we have penthouses built there, we spent so much time. Get in the elevator, drop down into our hearts, and when that third floor opens, there's no floorboards. Nobody goes there, there's cobwebs. And anytime something emotional happens, we run back upstairs out the fire escape to try and make sense of it or change it or whatever it is. Here's the secret, when you're in the elevator, and it opens on the heart floor for you or someone else, name it and stay there.

See them, name it. So, it's like this; "Wow, I can see how important this is to you," "Wow, I hear how upset you are about this, I hear how frustrated and annoyed and angry and devastated you are about this." Now, here's the kicker, you don't even have to get the emotion right. They'll say, "No, I'm not irritated, I'm frustrated, I'm angry." And you're like, "Awesome." By the way, don't correct them, they know what emotion it is. But when you meet them on that floor, instead of saying, "We're going to change it, how do we solve this? How do we?" and running back up to the mental level, when you don't just sit with whatever that emotion is, it gets bigger. The way to diffuse an emotion is to stay on that heart floor until they can express and bounce off you what it is.

So, allow the space for that, slow down, be with them, meet them where it is, and just be like, if you can't think of the emotion, you say, "I hear how important that is to you." Because whether someone's elated or upset, when they're emotional about something, it matters to them. Now, what I would not do is walk around to anyone who's upset and keep going, "Wow, I can see how important that is to," "Wow, I can see how important that..." Okay, when you're not genuine, they pick up that too, and that will inflame them. So be genuinely curious, be genuinely with them, and allow them to say that. And all of a sudden, when they think you've got them, boy, it diffuses right away. So that's another time-saver.

Dr Hopkins: Yeah, yeah. A great tip for how to make an empathic statement. I see that you are, or I sense that you're whatever, and name it out loud. And you're right, if you get it wrong, they'll correct you, and then at least you understand where they're coming from.

Dr Sangwan: Awesome. Are we ready to do the last one, anxiety?

Dr Hopkins: Yup. Let's go to anxiety.

Dr Sangwan: All right, let's take it away. So, anxiety, what's anxiety rooted in? Fear, it's like someone's afraid. But what are some of the judgements, common judgements we have about people who are anxious?

Dr Hopkins: That they can't handle a situation, they're unprepared, they're not tough enough. Those types of things, I think.

Dr Sangwan: Exactly. Now, what I want you to know is none of that is true. Once again, emotions are energy in motion, and they are data. Important, important data, telling us how we're connecting to the experience of our life at this moment. So why do we get anxious? Why do we get anxious? We're getting anxious and we're doing things, "What if? What if? Oh my God, my biggest fear is.” So, we're doing this whole scenario building, and we're trying to protect ourselves from something that might happen in the future or that already happened, and we don't want to happen again. So, this is what anxiety is, this is how I define it. Anxiety is a failed attempt to control the future because there's only one place that you can be in this world, and it's right here, right now, in this moment. And you can try to figure out all the things that might go wrong, but life's going to happen.

And how do you handle this? So, if somebody is spiraling out into the future, which so many of our patients do, "Oh my God, what if it's cancer? What if it's this? What if it's that?" So, we're dealing with anxiety all the time, whether we know it or not. I call this Back from the Future Tool. Step number one, if your thoughts are way out into the future, back from the future is the very first step. It's a five-step process. Number one, get present in your body. If you're with an anxious patient, ask them if you can put your hand on their back and up here just below their neck, on their chest, and then ask them to please separate your hands by breathing. Because right now, they're spiraling outward in their mind, you have to get them present. Anybody who's in their body, who can feel their feet on the ground, gravity, pulling them down and are breathing and are conscious of it, they're in their body. And the only way you can be in your body is in the present.

Number two, get them to name that fear. And this is about you too. Just write down, "What if? What I get COVID? What if my family gets sick? What if I can't do X, Y, Z? What if this patient dies? What if they're sick? What if it doesn't work? What if this new protocol doesn't work? What if they don't make it out of surgery?" Name that fear and keep writing them until you're done. But leave about two, three inches in between each of those fears. So, let's say mine is what if I get COVID? What if I get sick? Okay? Step three now. So, one was get present in your body so that you can do that with the soft belly breathing, the box breathing that Kevin taught you. Number two, name that fear, write them all down, leave some space between it. Three, expand your perspective. So, what you're doing when you write down your fears is you have to say to yourself, right here, right now, what is true?

Oh, well, I'm healthy, my immune system is strong, and I haven't been exposed to anyone that would cause that. There's no known exposure, that's right here, right now, this is the truth. The fourth step is reprogramming your thinking. So, when you reprogram your thinking, what you're doing is you're giving yourself a little affirmation that when you notice your mind doing that thing on autopilot, on repeat, you can replace it with this, so mine is, "What if I get sick? What if I get sick? Oh my gosh, what if I get sick?" I'm going to reprogram it with, "Neha. You are whole, healthy, and well," because that's the truth. I just wrote it down — I am whole, healthy, and well. So lastly, the fifth and final step in the Back from the Future Tool for anxiety is ask yourself, "What would self-trust and courage do now?" And that's how you make whatever decision you need to make.

It's a game of self-trust here, because in the areas of your life that when you're in the OR and something goes wrong, guess what? You trust your team, you trust yourself to be able to figure out what happens next. You've got a protocol, you've thought through it, and sometimes when you haven't, you do the best you know how with what you know. But there's a self-trust that happens after years of practice in all of our professions, in our relationships, in knowing what comes next. So, if you've been, let's say, unfortunately, been sued or something in the past, something went wrong, you might not trust yourself as much anymore, and that's where the anxiety might start coming in. Take this, bring yourself into your body, name the fear, name what's true in this moment, reprogram yourself, and then ask yourself, "What would self-trust and courage do now?" Because self-trust is the antidote to anxiety.

Dr Hopkins: Awesome. Great tips for us to think about because, certainly, the vast majority of the things that we worry about and become anxious about never happen. And so now we've expanded bandwidth, and brain power, and energy on things that we didn't need to worry about in the first place.

Dr Sangwan: Yeah, and you send your whole physiology down the path of experiencing it even if it's not real, because our bodies don't actually know the difference between what's real or imagined. And the way you know this is, if any of you have ever had a nightmare, you've ever been falling over a cliff, been chased in your dreams while you've been sleeping, a nightmare, when you wake up and it's pitch black, it's quiet, there's nobody breaking into your house, but your heart's racing, you're sweating, the sheets are kicked off you, your body doesn't know the difference between what's real and imagined. So, your physiology goes through these emotions over and over again. And this is one of the fastest tracks to burnout, losing emotional energy because we don't know how to practically work through it for ourselves and with our patients.

This is going to help you everywhere in your life, if you're a human being, emotions are a part of your world. You know what I'm going to do? I'm actually going to give the listeners of this podcast, I'm going to give them a free audiobook, Doctor Neha, D-O-C-T-O-R, spell out the word doctor, doctorneha.com/audiobookgift, and the code is AMA.

Dr Hopkins: Awesome. Well, thank you. Tons of great information, and I know we're just scratching the surface of what we could talk about today. But thank you so much for joining us, Dr Sangwan. And for our listeners, if you'd like to learn more about Dr Sangwan's work, visit her website, it's doctorneha.com, D-O-C-T-O-R-N-E-H-A.com. And also, be sure to check out stepsforward.org for more resources on this topic and others. And thanks again, Neha, for joining us.

Dr Sangwan: Such an honor to be with you.

Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA STEPS Forward® program is open access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, stepsforward.org.

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