Physicians who are able to feel compassion

Here’s a true story from the operating room:

Surgeon: Intern, what is the story behind this patient?

Resident Intern: Patient is a 51 year old female with breast lump on the left side, and 17 out of 20 lymph nodes positive for cancer.

Surgeon (speaking in a rather ‘as a matter of fact’ tone): Oh, she’s F_ _ _’d.

Resident Intern: shocked, frozen and unable to respond.

“How do some physicians become so stoic?” I was once asked by a frustrated student. In one of my recent posts, Breaking Up is Hard to Do, I wrote about feeling sad in regards to saying goodbye to my patients, despite this unsettling feeling that somehow I was not “supposed to” allow myself to feel.

It wasn’t until one of my favorite physician bloggers, Dr. Synonymous, wrote a comment in response that made me think about why I felt that I was not supposed to get attached to my patients. This is what he said:

Dr JAT, You KNOW you don’t believe the above comment about “refrain from getting attached.” In family medicine, We are SUPPOSED TO GET ATTACHED to our patients. That is the definition of compassion. That is what separates our specialty from many others.

Family physicians are stereotyped for being a rather pleasant, friendly, and compassionate bunch (in general). But there is still this underlying unspoken culture amongst some physicians (not all) across all specialties, including primary care, that perhaps frown upon the notion of allowing yourself to express emotions in your practice.

However, it is often necessary for physicians to build this rather concrete wall around their true feelings as a coping mechanism, in order to be able to function optimally in their careers. Because truly, after seeing patient after patient, if you allow yourself to feel too much it can wear you down in a big way.

Imagine this: you are a physician with approximately twenty patient encounters a day. Several of those twenty are very ill or dying. A couple of others are with major depression entrenched in helplessness, and perhaps contemplating suicide. And then another one or two who get angry at you for not prescribing them the medication that is driving their addiction. Several may be frustratingly non-compliant, and don’t take their medications like you prescribed, and now their health is deteriorating irreversibly as a result. Then, there are a few more that really make your heart sink, because frankly, they are the nicest people you have ever met, and there is something very serious going on with their health, and it is so unfair.

Now multiply that by a minimum of 5 days a week, 52 weeks a year, which comes to 260 days a year.  This gives perspective as to why some physicians may appear to be stoic on the outside.  It’s about survival of the fittest in this profession.  Because how else can we function otherwise?

When were we all first taught of this unspoken ideology encouraging us not to feel? Is it passed down from generation to generation as a culture while in training?  While contemplating Dr. Synonymous’ remarks, I can recall as far back as my Gross Anatomy class. I remember in the very beginning of the course, my small group was forced to confront our first real deceased human being lying before us. He was so real. He had a tattoo on his arm, with presumably his significant others’ name on it, and many surgical scars. Who was he? How did he pass and leave this world? Who did he leave behind? We all contemplated the answers to these mysterious questions while we respectfully dissected our cadaver as a team.

When the course commenced, we had a sort of a required “support group,” in which all medical students were randomly assigned to a small group with an instructor, in order to discuss how we are dealing with actually knifing through deceased human flesh.

I remember the instructor asking, “What are your thoughts on dealing with this issue?” I was relieved to hear this question, because I had heard some students discuss their struggles (whether it was spiritual, religious, or personal) with the challenge of a face-to-face encounter with a body that was once alive. However, when we went around the room, no one voiced their thoughts. No one spoke. I knew that even though several had shared those difficulties with me in private, they were perhaps afraid to voice their emotions in an atmosphere where “sharing your feelings” is not encouraged. How can you blame them?

Finally, there was one student whose words I will never forget. He expressed that he personally tried to view the cadaver as an “object” and that it was only when he looked at his cadaver’s hands that it seemed so “real” to him. “You do a lot with your hands,” he stated. He too was struggling to feel.

But there is something about going through the medical school and residency training process that begins to harden your soul, in preparation for protection against the potentially emotion-draining life as a physician. Is it a bad thing? I don’t think so. Perhaps it is a necessary, hardening process to experience in order to survive mentally.

At the same time, however, I think it is very important to maintain compassion. There has to be some balance. It’s a primal instinct to want to be loved and cared for, and physicians who are able to feel and convey this compassion may have much more influence over their patients’ health. And it ultimately makes us much better physicians if we just allow ourselves to feel once in a while.

“Jill of All Trades” is a family physician who blogs at her self-titled site, Jill of All Trades, MD.

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  • http://www.changingaging.org Kavan

    Thanks for offering the doctor’s point of view, I can imagine it’s a difficult transition to prepare yourself for the rigors and emotionally-draining demands of being a physician. But I would have liked to see an even more passionate defense for the importance of compassionate care giving. Too often a cold, clinical approach is used as a shield to avoid making the patient the center of medical decisions. You need to truly see the human being to treat the human body.

  • BladeDoc

    I cry when it’s time to cry. I hug families at the appropriate times, I am a vigorous advocate for compassionate and palliative care. When it’s time to stop the bleeding, sew the perforation, cut out the tumor — it’s time to focus. Having a long heartfelt discussion with the members of the treatment team, all of whom know that the “patient is f—’d” on how sad it is, is not useful for the patient or really anyone else. Does talking about it in the euphemism of “dismal prognosis” or “essentially negligible 5 year survival make anyone feel better at the end of the day?

    • richard scottr

      so true. How we work and survive in the o.r. is not how we deal with patients and families. … there are those, however, who do talk to patients in that way. Our ethics committee not long ago censured a senior doc for telling his patient who was complaining about his food a similar thing…”why should you care,” he said, {you are f—d with lung cancer, anyway.” In this case the family complained; in others, however, patients speak like that and the euphemisms do not work

  • http://secondbasedispatch.com Jackie Fox

    Dr. Jill,
    You are one of my favorite bloggers and this is so beautiful. In Omaha, we have the University of Nebraska Medical Center School of Medicine and Creighton University Medical School. One or both of them, forget which, has a prayer service/blessing for the cadavers. I think that is so moving and humane.

    P.S. Your compassion always shines through in your writing.

  • Medical student in FL

    Jackie–

    Most schools actually have some type of cadaver ceremony. Some make a bigger deal out of it than others, but nonetheless it is an important part of the first year medical curriculum.

    • http://secondbasedispatch.com Jackie Fox

      Good to know! It’s a respectful thing to do.

  • http://drsynonymous.blogspot.com Dr Synonymous

    Dr JAT,
    Thanks for the reference and the thought provoking post. After 30-some years in Family Medicine, I’m still challenged to connect with the suffering of patients and maintain a reasonable workflow. Howard Brody, MD, PhD is one of my favorite authors in describing our challenge as physicians in The Healer’s Power (1992, Yale U. Press). In a chapter titled, “The Physician’s Character”, Dr. Brody beautifully leads into aspects of the patient-physician relationship that create a situation in which “the physician must constantly struggle against …obstacles in order to practice compassion”, which he describes as a “virtue instead of an obligation or duty (which) must become internalized as a habit of character before it can truly be called compassion at all.” He further suggests that the physician adopts “an instinctive attitude of openness and vulnerability” or she can’t overcome the barriers to compassion. “To be compassionate in response to the suffering of the patient is therefore one of the most powerful things a physician can do; but this is possible only to the extent that the physician is willing to adopt a position of relative powerlessness, to acknowledge that the patient’s suffering has incredible power over him and that he cannot remain unchanged in the face of it. This…irony of the physician-patient relationship, in which a sense both of one’s own healing power and of one’s necessary humility forms a synthesis of the apparent contradiction of power and powerlessness.”
    In light of the patient numbers with significant problems mentioned in your post, this attitude of compassion and vulnerability that forms a major element of our physicianly power requires time to develop and practice with mentorship to hone, but our patients deserve it as does our profession. Blog on!

  • Molly Ciliberti, RN

    Funny, as an old figuratively and actually ICU/CCU nurse, I would say those who are reluctant to show compassion and emotion provide the least effective care. They don’t care for the whole patient and their family and friends. When we found a nurse distancing herself from the patient and her own emotions, becoming hardened; we knew she was at burn out and was not at her best.

  • http://drpauldorio.com Paul Dorio

    Great post and great topic. Thanks.

    In my opinion, empathy and professional detachment can and should coexist without issue. When I leave the hospital at the end of the day I pretty much let the day’s events dissolve behind me. I don’t know how it happens, but by the time I get home to my wife and three kids, the only thing on my mind are those hugs I have been looking forward to all day.

    But when I am at the hospital, I stop long enough with each patient to make them know that I care about their well-being, even when I am unable to help them in any meaningful way.

    Each of us deals with adversity in our own way. Keeping in mind that doctors and patients are “only human” is an essential component of what we do as health care professionals. Separating the emotional involvement just enough so that we don’t internalize it all and take it home with us is what enables us to function over the long term. Some of us do it better than others, but again that’s where understanding comes into play.

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