Florence Gelo
Philadelphia, Pennsylvania, United States

Communication skills are essential for medical professionals. High-quality care depends not only on accurate diagnosis but also on recognizing how illness is experienced and communicated. Much of a patient’s suffering is expressed nonverbally. Clinicians therefore need to develop the ability to recognize emotional distress, reflect on what they observe, and respond with empathy.

As a behavioral science faculty member who observes physician–patient interactions, I have seen how challenging this can be. Patients may not say they are frightened, overwhelmed, or in pain. Instead, emotion emerges through facial expression, posture, movement, silence, or tone. Recognizing these signals requires clinicians to pause, consider what they are seeing, and reflect on what the patient may be experiencing.

Suffering is ubiquitous in clinical practice, but it is not always spoken. Clinicians encounter frightened patients, overwhelmed families, and devastating news delivered at the bedside. These encounters can carry an immediate emotional intensity, a silent scream.

Edvard Munch’s The Scream helps one recognize this visual language of suffering before one encounters it at the bedside. It depicts fear, anguish, and isolation. The central figure—wide-eyed, mouth open, hands pressed against the face—embodies overwhelming distress. Although exaggerated, the expression captures emotions clinicians encounter every day in subtler forms.

When teaching family medicine residents, I use The Scream to explore how emotional suffering can be recognized through the face and body. I begin by projecting a cropped image focused on the figure’s face and ask a simple question: “What do you see?”

Careful observation is a foundational clinical skill that extends beyond the physical examination to the patient’s emotional experience. I ask residents to notice both the image and their own responses to it. I then ask:

• What emotions are expressed here?
• What aspects of this expression feel familiar?
• Have you seen this in a patient?

After reflecting individually, residents share their observations and recall clinical encounters in which they witnessed similar distress.

Their examples are striking: a patient with severe abdominal pain and shortness of breath; a young woman battered and bruised after an assault; a child struggling to breathe; a young man awaiting surgery after a gunshot wound. Despite different diagnoses and circumstances, each encounter shared a common feature: profound distress communicated as much through expression and posture as through words.

As residents describe these encounters, they often recognize nonverbal signs they had previously overlooked: trembling hands, an averted gaze, a clenched jaw, a change in voice, rigid posture, or the tight grip of a stuffed animal. These behaviors can communicate distress before patients are able, or willing, to put their experience into words.

This realization raises a fundamental challenge for medical education: If suffering is often communicated without words, how can clinicians recognize what is expressed but not said? And once they recognize it, how are they to understand their own emotional responses to another person’s suffering?

During one session, a physician recalled a patient she had cared for early in her career. The patient had consented to a procedure that proved more extensive than expected, resulting in ongoing complications, interventions, and pain. Physically fragile, even small movements caused discomfort. The patient said that, in hindsight, had she fully understood the recovery, risks, and complications, she would not have agreed to the procedure. Yet she rarely spoke about the extent of her suffering. Instead, it revealed itself in small but unmistakable ways: a pause before moving, a grimace during repositioning, and instinctive bracing before touch. Her clenched jaw and tightly shut eyes communicated what words did not.

The physician reflected, “In that moment, I realized you can recognize suffering even when a patient never says a word.”

Her reflection illustrates an important distinction between observing distress and recognizing suffering. The former requires attention; the latter requires emotional understanding. Reflective empathy begins when clinicians ask themselves not only, “What am I seeing?” but also, “What might this mean for this patient?”

The final step in the exercise is often the most difficult. I ask: “What was your patient trying to tell you?”

The question shifts the task from observation to emotional recognition. It asks learners to move beyond identifying behavior and consider its meaning within the patient’s experience. A clenched jaw may signal pain, fear, or both. Avoiding eye contact may reflect shame, grief, mistrust, or exhaustion. A rigid posture may communicate apprehension before a patient ever says, “I’m afraid.”

Such interpretation requires reflective empathy, the capacity to recognize another person’s emotional experience while also becoming aware of one’s own response to it. Clinicians bring their own histories, assumptions, discomfort, and emotional reactions to encounters with suffering. Learning to recognize these responses is part of learning to understand patients.

Many clinicians have experienced powerful emotions during patient care that they have never fully processed or named. A patient’s fear may evoke our own anxiety; another’s helplessness may make us want to move quickly toward fixing the problem. Suffering may create discomfort that leads us, consciously or unconsciously, to look away. Reflection creates an opportunity to notice these responses rather than allowing them to interfere with attention to the patient.

The exercise creates a reflective space that is often absent from clinical training. The goal is not to produce perfect communicators. Rather, it is to cultivate a habit of attentive curiosity: to notice emotional cues, consider what they might mean, reflect on one’s own response, and remain open to the patient’s perspective.

The Scream is particularly effective because its exaggerated expression makes the underlying emotion unmistakable. It gives learners a shared visual language for discussing fear, anguish, and isolation, and helps them recognize quieter manifestations of those same emotions in clinical practice.

Art cannot replace clinical experience, but it can cultivate the habits that make clinical experience more perceptive: slowing down, looking carefully, recognizing emotion, and reflecting on what we see. It can help clinicians move from noticing a patient’s distress to wondering about its meaning and responding with greater empathy.

To care well for patients, clinicians should recognize what remains unspoken. Emotional recognition is the beginning. Reflective empathy is what allows recognition to become understanding, and, ultimately, clinicians more compassionate when providing care.

Acknowledgement

The author thanks Marah Mattheus-Kairys, MD, a family medicine residency faculty member, for sharing her ideas and perspectives, which helped enrich this article.