Medicine frequently puts physicians in life-and-death situations, yet the emotional experience of doctoring is often overlooked. Medical schools don't teach physicians how to handle watching someone struggle and die, and television's portrayal of life in the hospital deals more with drama between colleagues than the drama of trying to save someone's life.
That's not healthy, argues Danielle Ofri, MD, PhD, FACP, an associate professor of medicine at New York University School of Medicine and an internist at Bellevue Hospital in New York City. In her new book, “What Doctors Feel: How Emotions Affect the Practice of Medicine,” Dr. Ofri examines the emotional reactions of physicians to their work and how these can affect patient care. She draws on research and personal stories to illustrate that having a plan for managing one's emotions about medical practice can be as important as having a protocol for hand hygiene.
Dr. Ofri shared with ACP Hospitalist some of her ideas for how hospitalists can access and process emotions relating to work.
Q: In your experience, do physicians talk freely to one another about their emotions regarding their patients?
A: Not so much. Doctors have internalized the idea of keeping things to themselves. If you have good friends who you see outside of work, you might talk to them, but it doesn't come to the fore in most discussions with colleagues.
Q: Should physicians talk to colleagues more about this?
A: Emotions need their due at some point, and there are appropriate and inappropriate times for that. It may be that at the moment of interaction with the patient, emotions need to be put aside, but at some point they need to be addressed. We have all seen the poorly regulated doctor who terrorizes the operating room, or has angry outbursts, and that is often the result of years of emotional experiences that have never been given their due. Doctors who were treated poorly, pimped and blamed—this gets internalized and they end up doing the same things to others that were done to them.
Q: So how can a doctor deal with emotions in a way that is helpful and not debilitating at work?
A: Talking among colleagues, especially during medical training, is an important part of this. During medical school and residency, trainees experience a deluge of emotional events. Having the senior doctor simply acknowledge them can be immensely helpful. If a patient is dying, or has been refusing treatment, or has angry family members, for example, trainees can be overwhelmed. If, when they leave the room, the attending says something as simple as, “That was a difficult time in there,” the rest of the team members will feel an immense relief that they weren't the only ones who were shaken up. Their emotional reactions were not aberrant.
Wise attendings will spend a bit of time discussing the difficult moments, perhaps sharing how they handled—or mishandled—such experiences in the past. We educators need to set the tone that this is part of medicine and talking about it is as much a part of rounds as discussing the differential diagnosis.
I recall a time on the wards when we needed to discuss with a patient that her cancer was not curable and that it was time to shift toward palliative care. Even though I've done this countless times, it was a first for this patient, and it was a first for the intern. The acknowledgment that the patient was going to die from this cancer was devastating for the patient and her family, and it was equally devastating for the intern. None of them had faced death head on before, and no matter how straightforward the clinical decision-making was, it was an undeniably tragic moment for everyone involved. When we left the patient's room, the intern was biting back tears. We stopped in the hallway and had a talk about sadness, and how it is very real in medicine. No matter how many times you've faced it, the realization that a patient will die is terribly sad, and you need to acknowledge this and give it its human due.
Q: Do you think most attendings address sad or difficult moments with their team?
A: It is getting better, but when we were trained it wasn't part of the repertoire, so it takes an effort. One thing I often do with my team is to talk, up front, about all the medical errors I have made. Most of us think of medical errors as rare and horrible, so usually they are surprised to hear all their attending's blunders. But errors are pervasive, and our gut instinct is to hide them because of the shame. Educators need to set the tone that errors, like emotions, are part of the territory in medicine. Talking openly about them is a critical first step.
Q: Is there any sort of formal effort to address the emotional aspect of medicine, in medical schools, in facilities, among organizations?
A: We are beginning to, but we have a long way to go. All of our mission statements talk about compassion and professionalism, but in the everyday practice of medicine many of these fall by the wayside. In a student's third year, a lot of this gets dispensed with among the pressures of discharge, admissions, scut, and turnover. Students see doctors dismissing patients' concerns, snapping at one another, treating nurses poorly. This has a powerful impact on trainees.
Q: In your book you say that, when teaching on the wards, it can be useful to ask a patient a question about her personal life in order to humanize her. When is this necessary?
A: This is especially helpful with “difficult” patients. Patients who complain a lot or refuse treatment, or don't seem to care about their health are particularly challenging. It can be hard to corral empathy for these patients. In particular, doctors have trouble with patients with so-called self-inflicted illness, like addiction or obesity. We are a self-disciplined lot and so we think, deep down inside, that if they tried harder and corralled themselves, they could control it. It angers us that patients do self-centered and self-destructive behavior, and unconsciously we say, “Why should I invest myself in these people?”
For these patients in particular, it is extremely helpful to humanize them by learning about them as individuals. I often ask the team, “Who is the worst patient on the service?” When we go see that patient, I will ask him or her about hobbies and passions. And everyone has—or has had—a hobby or passion in life, even the homeless, disheveled, malodorous drug addict. Suddenly, the patient comes alive for the team, and the dynamic between doctor and patient improves dramatically.
Q: One of the points you make in your book is to recognize how emotions on both sides—the doctor and patient—are affecting an interaction and, potentially, patient care. Can you elaborate?
A: I try to educate housestaff and students to pay attention to how you feel in the moment when interacting with a patient. Sometimes this can be diagnostic: we feel the weight of a patient who is depressed, we feel discombobulated in the room with a patient who is manic. When you feel yourself getting angry with a patient, the patient may have a need they can't articulate. You need to have your radar up and take what you are feeling seriously. It almost always yields diagnostic or therapeutic clues.
Q: What do you do with this awareness?
A: By acknowledging it, we can learn how to negotiate our emotions. We have to figure out how not to let our sadness or anger overwhelm a situation, even if that just means stepping out of the room for a few moments to let the emotions settle. If we've had wise teachers who have shown us how to do this, it helps us minimize our blunders. It also helps us hone in on key issues with our patients. If we are reacting to something about our patients, there is something important waiting to be uncovered.
Q: Should doctors seek to regulate their emotional life outside of work, too?
A: When we face profound emotion, as we do watching people who are sick and dying, it always comes back to us eventually. Whether it is when we are drifting off to sleep that night or when we are facing our next patient, there is a sense that something intense occurred. How we give those feelings and experiences their due has a big impact on our future abilities. We need to take time to acknowledge sadness, anger, frustration, humiliation. If we are able to air our emotions— by talking to a friend, working out, writing, playing music—we are usually more flexible and supple the next time. If we don't, we may not handle things as well in the future.
Q: What do you do personally for this?
A: I have been taking cello lessons for the past eight years. There is an intense learning curve that is rich and rewarding and demanding, similar to med school, in fact. Temperamentally, though, it is the complete opposite from medicine. Life in the hospital is frenetic and you can hardly focus, but when you haul out your cello, there is an intense focus on a single thing, finding that right note. And then it doesn't just have to be the right note, it also has to be beautiful. There is nothing practical about beauty, and that adds to my love for playing cello. It exists just for beauty.
I used to do regular sessions for Bellevue's clinic for survivors of torture on Mondays, and my cello lesson is on Tuesdays. So, often I would go from the devastation of people's lives right into an intense session on the Bach cello suites. It some ways it was an unsettling transition, but in other ways it made perfect sense. When the globe is littered with people like Assad and Mugabe and Saddam Hussein, maybe the only way to shore yourself up is with Bach.