Dealing with psychological stress of being a doctor

Dealing with psychological stress of being a doctor

Chatting with some med students, a good question was raised: how do we, as doctors, deal with the emotional baggage we encounter in our profession? It’s high stress, we see disturbing things, and sometimes we make mistakes that can result in harm to patients. The pressure and responsibility can be very hard to handle.

These stresses, if unmanaged or poorly managed, can carry severe consequences for physicians. Burnout is rampant among docs (and trainees, too). Doctors have high rates of divorce, substance abuse and have the highest suicide rate of any profession.

A normal day at my job is hard: I’m running nonstop for 8 to 12 hours, I’m constantly interrupted, I have patients making demands of my attention and empathy, I’m saturated with information and need to make rapid decision without adequate information, and I know that if I make an error or miss some important piece of information, the human, professional and financial consequences can be disastrous. It’s a pressure cooker.

And that’s a day where things go well. A bad day can be very bad indeed. Sometimes it’s just the emotional strain of dealing with particularly difficult patients. Maybe you go through a run of giving out terrible diagnoses. Maybe you deal with the death of a child. Or a patient who pulls at your heartstrings in some unique and personal way. Maybe someone dies on you unexpectedly. Worse, maybe someone dies on you and you’re not sure if it was your fault or not. Perhaps you know you made an error, and that you’re going to have to face accountability for it.

These are the days that drive physicians over the edge. I’ve had them, and I remember them so vividly even years later. There was the one lady with a gallbladder attack on Thanksgiving, many years ago. She had classic signs and I saw gallstones on my bedside ultrasound. She crashed and died right in front of me from a ruptured thoraco-abdominal aortic aneurysm. Her abdominal aorta had looked normal on my scan; the aneurysm was in the chest and ruptured into the thorax, which is very unusual. That didn’t make it any easier to go home and sleep that night.

So I guess my take on the question is not how do we deal with the psychological stress but how should we? I am not an expert, but here are my thoughts.

The first step, which most practicing professionals have already accomplished, is to learn what is called “professional detachment.” This is an unnatural skill in which you must suppress your innate sympathy for the suffering experienced by a fellow human being, pain which you may be personally inflicting. The first time you stick someone with a needle, it’s probably as traumatic for you as for the patient. More advanced applications involve you ignoring someone’s pain or personal tragedy while trying to figure out the hidden life threat. This is a necessary skill if you are to function in the medical environment.

Another way to think of the same skill is to maintain a sense of distance. Remember, an older teaching physician once told me, the patient is the one with the disease. This helps you remember that the patient’s condition is not your doing (usually) and their outcome, if negative, is the result of their disease and not necessarily a reflection on your care.

While this detachment is useful and necessary, it can be maladaptive if taken to extremes. First of all, as a physician you do need to express empathy and compassion. It’s part of the job. But the emotional demands will be overwhelming if not governed in some fashion; we have limited capacity for caring. My solution is to dole out my compassion and empathy in measured doses, as appropriate to the case and my own mental state. This is not a license to be callous and uncaring in other cases, but rather to be polite, professional and reserved, emotionally.

Furthermore, you need to understand that the professional reserve does not equate to repression of emotion. You suppress it, in the moment, set it aside to get the job done, but that doesn’t mean it never happened. For minor stuff it probably is okay to suppress it & forget it.  But the bad things — they won’t go away on their own, but will fester and bubble up at the most inopportune moments. You need to take some time, when appropriate, to unpack the experience and re-live the emotions to deal with them. Maybe it will be just turning the case over in your head the next day. Maybe it needs to be more immediate. We’ve sent docs home after bad pediatric arrests when it was clear they were so upset they needed some time. It’s essential, in any case, to explore the disturbing feelings so you can come to a resolution and move on.

Many institutions will have formal critical incident debriefings for the entire team, for particularly awful events. While this doesn’t need to be performed formally for routine events, it’s a good idea to informally debrief with a trusted partner, superior or mentor. Talk through the case, review the medicine and the science, review your actions and outcomes, and your emotional response to the situation. It is helpful to do this with someone you respect, so he or she can give you valuable feedback. This can be over coffee or a beer or three; possibly better that way.

There can be a lot of shame involved when there was a bad case, even when well-handled, but especially so when you know that you made an error or may have. A lot of docs like to bury these as deep as possible. But these in particular are helpful to talk about, and the more publicly the better. This is not easy, but can be invaluable. We instinctively shy away from openly talking about our mistakes, but when you do you will probably receive a lot of support from your colleagues, many of whom have done the same or understand that “there but for the grace of god go I.” An additional benefit is that your mistakes may have been due to a system error or a cognitive bias and by reframing the discussion in an educational light, by seeking out the root causes, you can improve the quality of your own care and that of your partners.

Keep a sense of perspective, and try to stay positive. When the job is really getting you down, take a break, go out to the ambulance bay, take a few deep breaths and try to remember the big picture. We have a great job. It’s a privilege and an honor to be allowed to care for patients. We can sometimes make a huge difference in people’s lives. We have respect and status in society, and are quite well paid for it. Many people would give their right arm to be where you are. Yes, seeing the 10th drug seeker of your shift is a drag, but damn, it’s still better than sitting at a desk and moving numbers from column A to column B.

Sublimation is a defense technique that is particularly valuable in the ER. It is a form of displacement where the negative feelings are transformed into something positive, or at least more-or-less acceptable. The most common form it takes is “gallows humor.” Tragedy and comedy are deeply linked, and a morbid witticism can provide a lot of relief of the emotional tension that builds up in a clinical setting. Others may channel these feelings into art or literature. To each their own. If this is not your thing, find an outlet. I practice karate, and there’s nothing like pounding the hell out of the heavy bag — or a white belt —after a bad day.

Finally, and possibly most importantly, when you know you screwed up, when you know there was an error that harmed or may have harmed a patient: forgive yourself. You are human, as are we all, and we make mistakes. Take the time to understand it, do your best to learn from it, and forgive yourself. Let go of it, file it away, and move on. If you don’t or can’t, self-doubt and self-hate will paralyze you and in the end it will sink you.

One last thing: if you are really having trouble, get professional help. If you’re self-medicating, or if you are bringing work home to the point it’s affecting your family, be humble and realize that doctors can benefit as much as (or more than) any other patient from psychological counseling and support. Many hospitals have a confidential Physician Assistance Program, staffed by professional counselors trained to deal with the issues doctors struggle with. I’ve seen doctors torpedo their careers with behavior and substance issues, and I’ve seen programs like these successfully rehabilitate physicians who were in a downward spiral. Check with your medical staff office and use the resources that they offer.

“Shadowfax” is an emergency physician who blogs at Movin’ Meat.

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  • karen3

    Shadowfax, this is a really good post. Really insightful. I am puzzled with one thing.

    “Finally, and possibly most importantly, when you know you screwed up, when you know there was an error that harmed or may have harmed a patient: forgive yourself. You are human, as are we all, and we make mistakes. Take the time to understand it, do your best to learn from it, and forgive yourself. Let go of it, file it away, and move on.”

    Where is the part about making things right with the patient? Apologizing. Making restitution. Making sure they get the care they need? Telling what you did to make sure you do not repeat the mistake. Isn’t that an important part of the equation. I think that a large part of the burn out comes from unresolved guilt and if you keep doing wrong and not resolving it with those who you have wronged, you will never really be able to “forgive yourself” and move on. There is a biblical description of it – it is called having a seared conscience. The medical community calls it burn out. It means that you chose not to feel the rather dealing with the unsettling feeling that you have mistreated someone and then walked away. Where is that?

    • Suzi Q 38

      So true.
      The problem is they don’t teach the doctors about telling the truth to save the patient in medical school. i am not saying that there aren’t those doctors that would tell the truth; i am just stating that they are so few and far between. Why?

      Too much is at stake. They worked too hard, for too long to get where they are today.

      Never mind that the patient is now experiencing partial but permanent paralysis, or worse yet, full paralysis eventually.
      Of course, they would not accept this for themselves, they would demand and apology, or some form of acknowledgement of the error…or DARE I SAY IT??? payment for their medical bills or the fact that they can no longer work in the capacity that they used to before the misdiagnosis or lack thereof.

      I think I need to call the patient advocacy department at the teaching hospital that I was treated at for the last 2 years. I need to tell my sad story, with reluctance, anger, and a “heavy heart.”

      I have gathered all the medical records proof that I need to show the “hot potato” game that they played with me, their patient, who trusted them to help me. Insisting all the while that my care was being handled competently. I asked for obvious tests, but they declined. Had they done them when I asked, or had chosen not to trust them, I would be fully walking today.

      Now, there obvious errors have come to light, and they are very concerned for not only their reputations, but their jobs.

      I have a heavy heart because I realize that for the original doctor it was not his specialty, but I sent him a letter in writing asking for help
      at a time that could have been crucial to my care.

      The main doctor in trouble is the neurologist, who ignored my requests for diagnostic tests (a series MRI’s of my entire spine)
      and the advice of the physical therapist at the facility who wrote that my condition was more serious than previously thought, way back in November of 2011. I gradually and slowly declined from there. the neuro still did not think it was serious, as I was walking.

      I have two “heros” to talk to the advocacy board about; one that was a gastro and the one that listened to my describe my symptoms in great detail. He told me where the problem was, and told me I had to tell my neuro. When I asked him to talk to the neuro directly as he thought I was a hypochondriac, he got angry and told me to tell him that HE said so (he was Chief of staff).
      The other “hero” was the neurosurgeon, who saw me crying with relief but anger when he told me that I had a blockage in my spine that needed to be treated or face permanent paralysis.
      When I told him my story, he was red in the face with anger and disbelief; I at that point trusted no one at that hospital, much less a surgeon to cut into my spine. Sadly, I could not choose him to do my surgery as the others had earned my mistrust and distain.

      He called out the original doctor, who called personally to not only apologize, but begged me to allow them to do the surgery ASAP. Since I could not trust them, I had to go to yet another teaching hospital and start all over again. That doctor had to listen to my tirade for an hour, and then go home to his family bringing the sadness of our day for the weekend.

      I finally received my much needed surgery on Friday, 1/18, after I begged the surgeon to book me sooner as I was loosing mobility ever so slightly each day. I was lucky. It could have been far worse.

      I know that I can sue. Anyone can sue for anything, some for far less, some for far higher stakes.

      I have the education, the money, and the legal connections to make the hospital and these two uncaring doctors miserable for awhile.
      I can also complain to my insurance company, who can hold off any payments until my problem is resolved.

      I dream of first going after the hospital itself, because the hospital allowed a system by which I had no navigator to help me with my minor and weird symptoms when first discovered, over a year ago.
      Had they discovered and treated it aggressively sooner, I would not be almost paralyzed today.

      I realize now that they probably didn’t want to treat because they thought that it might be the surgery, so a year needs to go by so that I lose my window of opportunity to sue. Just guessing.

      So many errors were made, that I don’t know where to start.
      Part of me does not want two fairly decent doctors to have to answer to my complaints and possibly lose their jobs.

      I looked up their CV’s, and this is the first big job that they were given at a fairly famous teaching hospital. My paralysis may improve with time, but the fact that it had to be at all is sad.

      I realize too, that I can report it to the medical board of our state, demand a hearing of their peers in order to get some answers as to why they didn’t try harder, much sooner, to get me care.
      If the hospital chooses not to reprimand them, I can also place a complaint to the Joint Commission of Hospitals.

      if there is no action after that, I guess my lawyer will have to do my talking for me.
      Even doctors hire lawyers. They aren’t all bad.

      My son and I had a long talk about this today.
      He doesn’t want me to do this, as it will disrupt two doctor’s reputations.
      How about my quality of life? I asked him.

  • buzzkillerjsmith

    Don’t work just before holidays. Most last pt of the day one Wednesday before Thanksgiving showed up with jaundice due to breast Ca metastatic to the liver. She was dead in 3 months.

  • Suzi Q 38

    I read this article.
    Nice, but how was the patient supposed to “declare himself???”
    Since you are doctors (a “team” of them, I might add), wouldn’t it be your job with all the medical information to be an advocate for that patient?
    Maybe the patient was like me, and was impressed that so many “brain trusts” were caring for him.
    He finally relaxed that he had made it to THE teaching hospital, probably one of the best in the area, and there would be SOMEONE there that would treat him to the best of their ability.

    As a patient, I can only study about my own condition so much.
    Besides, don’t you destain patients that do so?? You are the expert.
    It is not my job to save my own life, it is yours. You are the one with the medical degree(s). Why would I Have to know when it is time for me to have my surgery?

    I imagine that the patient in question told many, many doctors and declared himself many, many times before you. You just were not there.

    This is why when I went in for my anterior discectomy with fusion, you can bet I knew that if I had OPLL (cervical ossification of the posterior longitudinal ligament), the posterior approach may or may not have been preferred. That I needed a CT scan and an Xray of my neck in order to diagnose or rule this out. That I needed to take the tests at least a couple of days before the surgery, and that a neuroradiologist rather than radiologist should read the pictures write the report, and make the diagnosis.
    I shouldn’t have to study like that. After paying $850.00 a month, in addition to the $1K per month that my employer pays, getting the best treatment is your job.

    I was stupidly lulled into a false sense of security, which could have been my physical “downfall” no pun intended, as my condition involved paralysis in both legs. After all, I was under the care of all these highly regarded specialists who had an average of 15 years of medical training each.

    I had to make it my business because I am right: doctors these days are just too distracted to cover some very important “bases.” Decisions that will impact whether I live or die; whether I am in a wheelchair or not. I have learned that with the series of glaring mistakes that I endured.

    I tried to “declare myself” several times, once, in front of a medical student. The doctor was so embarrassed, that he rushed out of the room with more concern for his own embarrassment than his patient….me.

    I was passed off as a hypochondriac that wanted to make trouble. Thank goodness I was move vocal than most and notified as many doctors that I could of the errors, then informed the doctor of my condition in writing. The only thing I did not do was send it to him by registered mail. I guess I could have written it in the sky at his teaching hospital.

    You signed up for that awesome responsibility that comes with dragging and impressing a bunch of medical students, interns, and residents around. How about ignoring what the students are learning and focusing on the patient and whether or not a surgery may or may not have a chance to save his life?

    I am sure that he would have agreed to it, if given the opportunity. Ditto for his family.

    What was it, a phone call to you, or an official consult with the surgeon in question?

    Now doctors have to explain what they are doing for me and why they are doing it. I look it up in the interent to make sure that this is the most common protocol, and also to see if there are other options to consider.

    Why? Because doctors are human. They make mistakes.
    Too bad I am not a car or a cup of coffee. Too bad that you have the M.D. next to your name and I don’t.

    I have decided to get more involved and aggressive with my own care because you simply have too many patients and don’t listen to me.
    I don’t know why you wouldn’t listen; these words are valuable “free” clues to my condition and the “keys” to “unlock” the best formula for treatment.

    Some of us know our own bodies and how they feel now vs. how they used to feel.

    Sorry everyone. I just unloaded on all of you.

    • jknapp

      Thank you for replying and reading the article. The Case Study is important in its entirety, and as to your comments, Number 5 is very relevant.

  • Sara Stein MD

    Magnificent post. I would add that physicians of all ages and stature benefit from being able to debrief confidentially with an experienced psychiatrist or therapist colleague – sometimes running and yoga are not enough, and it beats drinking as an outlet. M&M’s can be helpful or can crucify an individual doctor – the examination of what went wrong is essential, but not always pain alleviating for the doctor (and most M&M’s are patient disease, not error). Sometimes it takes a psychiatrist to listen and say, “you’re not God, you didn’t have as much control as you believed.” We are doctors against disease…it’s a war, and we don’t always win the battles.

  • SBornfeld

    Wow, I’m reaching for the benzos–and you didn’t even mention managed care!

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