Be emotionally intimate with your patients

Be emotionally intimate with your patients

A new patient calls for an appointment. I ask, “What would you like to come in for?”

“Depression. Two weeks ago my doctor put me on antidepressants.”

“Why don’t you see your current doctor?” I ask.

“I feel weird discussing my emotions with someone who doesn’t have any.”

When doctors are fully present, vulnerable — even emotional, patients are more likely to be honest, transparent, and open. Sexual intimacy is, of course, inappropriate between patients and physicians, but emotional intimacy is essential in any healing relationship.

What patients really need is a human being who is being human, a whole person who sees the patient as a whole person. On her way out, a new patient says, “I feel like I just got a physical, met with a marriage counselor, and had a spiritual awakening.” We could all have comprehensive, personalized care, but here’s the paradox: We resist what we most desire: Intimacy. Intimacy means “in-to-me-see.” It’s when we see so deeply into another, that we find our own reflections and discover ourselves.

Beatrice, an elderly woman calls for a Prozac refill. I remind her of my office policy: no refills between appointments. She screams, “None of my other doctors made me come in. What’s wrong with you?” Upon arrival for her appointment, she’s fuming. After thirty minutes, Beatrice breaks down and shares how difficult it has been since her husband died last month. She feels isolated and scared. With tears in her eyes, she hugs me and then thanks me for getting her out of the house.

It’s Friday night when Christie calls for an antidepressant. I pick up on the second ring. “Hello, how can I help you?”

“This is the doctor? It’s almost midnight and you answered the phone!” Frazzled, Christie tries to explain herself. “Things are kind of tough right now, Pamela. I was just calling so you could prescribe me some antidepressants.”

We talk about her mother’s death and the challenges of raising her autistic child.

“Christie, I’m happy to see you Saturday morning.”

“I just can’t believe you answered the phone. I’m so excited, I don’t feel depressed anymore.”

Being emotionally available and accessible is healing. Sometimes I think maybe I am the antidepressant.

Pamela Wible pioneered the community-designed ideal medical clinic and blogs at Ideal Medical Care. She is the author of Pet Goats and Pap Smears.

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  • Sarah Smith

    Thank you for this article, Dr. Wible. (And yes, you are a big part of the antidepressant : )

  • DoubtfulGuest

    Thank you, Dr. Wible. A great reminder that we’re not automatons and all need a human connection. The doctor patient relationship is difficult in that it’s the patient’s job to trust right away. In reality, many people need time to get to know others and feel comfortable at all. This seems to be true for a majority of doctors I’ve seen, and it applies to me, outside doctor’s offices. What I’d really like from doctors here, is some advice about how to navigate the social aspects of a visit. You’re all so different in your preferences and expectations!

    For example, when discussing upsetting symptoms or family history with past physicians, I’ve tried to be matter of fact. I thought I should compartmentalize as a courtesy to the doctor…knowing they don’t have much time and need to conserve emotional energy. This ultimately led to accusations of malingering, even though I was later found to have a progressive neurologic disease. Inappropriate affect? On the other hand, “anxiety” is not well-received, even when it’s a genuine reaction to a distressing situation. I didn’t think I was extreme in any of my reactions. With each doctor I saw, I meant to be polite above all else. I’ve seen a lot of medical literature saying that communication problems during a visit are mainly because the patient has a personality disorder. Did anyone ever think it’s just…awkward and hard for lots of people? We know doctors are human, you all have feelings, and that’s important. But we don’t know what to do with that information under the constraints of a typical health care visit. Like I said, you all seem to want different things, and we only find out what you wanted after we’ve really stepped in it…

    • PamelaWibleMD

      The foundation of health care IS the relationship between doctor and patient. As in any good relationship, mutual respect is key. Truly appreciating your doctor will go a long way. It’s always helpful to ask:

      1) “Can I call you by your first name?” I don’t mind, but some docs do.

      2) :Can I have a hug?” I don’t mind, but some docs do.

      3) “Do you have time to hear one more problem I am having?” I generally have longer visits and so have more time than most docs. Be aware of timing. When you and 28 other patients that day ask the same question at the end of your visits, it can be extremely taxing emotionally for the doctor.

      Realize that doctors get empathy burnout after about 10-12 patients. Many docs see more than 28 patients per day. If you need a high dose of empathy schedule your appointments in the beginning of the day.

      Realize that you may not be well matched sometimes and may need a different doctor.

      • DoubtfulGuest

        and 4) Doctor, would you please not bite my head off?
        Sorry… :) Really – this is helpful, thanks so much, Dr. Wible. I’m sure that no small number of patients are breaking boundaries left and right with doctors. It’s just that I was never so presumptuous as to use a doctor’s first name or initiate a hug. We’d get stuck below the minimum level of courtesy, and “May I please finish giving factual information?” On the time issue, why is it that in many offices, only the doctor is positioned to see the clock? Would it be okay to look at our watches or supposed-to-be-turned-off cell phones the whole time? Doctors’ offices can be quite disorienting, some of us have cognitive problems. We should follow your advice even so. I’d just love to see doctors help us stay on track without getting angry. As for personality mismatches, that’s true, but it’s getting harder for patients to switch doctors with health care reform. Also, doctor shopping makes a poor impression… some people need specialized care (less choice of docs). So it really makes sense for us to try to salvage the relationship, and for doctors to let us do so wherever possible.

        • PamelaWibleMD

          Give feedback in a letter to docs whom you feel could benefit. We are practicing medicine and we are always learning how to do things better. Your words matter.

          • DoubtfulGuest

            I have – thanks so much, although it’s not been well received. Another thing that might be helpful to cover here, in case it could help someone else not have the same experience I did, is to talk more in-depth about appropriate boundaries, as you mentioned before. Many doctors have legitimate concerns that patients are going to “try something”, an unwanted hug being the mildest example. They should do whatever they need to do to protect themselves. But please remember how easy it is for there to be misunderstandings, and don’t anchor your impression of a patient unless you get a lot more evidence.

            An example involves one of the doctors in the situation I mentioned. At the first visit, after the history-taking, he handed me a gown and said something like “Take off shirt, pants, socks, and shoes, put this on and I’ll be back in a minute”.

            One feature of my disease (that was not diagnosed at the time) is a mild hearing loss. On top of that, I have some central hearing loss and word recognition difficulty. So, I heard “…shirt, pants, hwanh hwanh, hwanh hwaaah.” (like the grown ups in the old Peanuts cartoon). I was also very tired that day, so my thought process went like: okay, take off four items…shirt….pants…socks? oh, shoot, I’m not wearing socks, did he say…

            To make matters worse, I was not yet an experienced medical gown-wearer.

            “So, you said leave on underwear, right?”

            This did not go over well. For all I know, he was just feeling pressed for time, but given what happened later with my care, I tend to think he assumed I was being inappropriate. For any doctors who might read this, before making assumptions, please try “Do you get confused sometimes? Any trouble hearing things people say?” Do whatever you need to do to protect yourselves, but give the patient the benefit of the doubt until you’re sure what’s going on.

          • rbthe4th2

            Wow yes! I prefer written down instructions, etc. The docs who give me a couple of short lists, I check those things off, like a honey do list (WHOOPS no one say that to the spouses!!).
            The problem is that docs think you want to sue them when you ask for that. Actually, when some of us take a couple of days to get the specific store you want us to go and find a particular supplement, and there’s ALL sort of variations, having something written helps us to know we need to ask you more questions on what is appropriate to follow your instructions.
            Which most docs don’t ask about – we’re just “non compliant” or ask too many questions.
            You can also judge on what patients are going to respond to your written instructions too. My suggestion is that docs take a copy of it and then keep it in the record. After a couple of times, they don’t follow thru, its easy to figure out who to spend the time on and who not too.
            Randy

          • DoubtfulGuest

            Yes. So often they are way off in their estimate of whatever we’re doing. I’m talking about a neurologist in this incident. Hello! Even without a hearing loss, people are going to miss stuff because they’re nervous, adjusting to a new environment, and so on. The part I missed was because the doctor turned slightly away, or was rustling papers, or there was a noise in the hallway or something like that. It amazes me how many doctors get irritated when you ask them to repeat something. A generic “What?” does not go over well, either. They might be running right over a diagnostic clue there. I could be wrong about his reaction, I suppose. We were behind schedule, which was my fault. But you never know what kind of stuff they remember and then go back and reinterpret in a negative way. Especially when they’re unsure of the diagnosis.

    • DoubtfulGuest

      btw, “stepped in it” means nothing other than what I described elsewhere in this post. Oh, wait…one other time I might have smiled too much.

  • Thomas D Guastavino

    When I was in training I first noticed that the best surgeons were the ones that were considered to have the most abrupt and abrasive personalities. Not always, of course, but over 25 years later and that has continued to be the case. If I ever needed treatment for depression or anxiety then going to the provider to whom I could have the best emotional connection makes sense. However, If I ever need major surgery then point me to the surgeon with the most abrasive personality because that surgeon is surviving on their skills.

    • PamelaWibleMD

      Yes. There are specialties that attract certain personalities for a reason.

      • Thomas D Guastavino

        I cant agree with you more.

    • Duncan Cross

      Speaking as someone who has had multiple surgeries with several surgeons involved (and consults with others), the best surgeons I’ve had were also the nicest. The abrasive ones only care about the technical aspects of their trade, not about the lives their patients lead. That might work if the surgery is straightforward (appendectomy, maybe?), but for anything complicated you want a surgeon who is making decisions with your interests in mind, and not according to his own sense of technical perfection. I wouldn’t let a jerk with a knife anywhere near me — much less in a hospital.

      • PamelaWibleMD

        Holistic approach to patient always best, but skill supercedes everything in say, a lung transplant.

        • Duncan Cross

          When I had a (‘best’) surgeon insist that I needed a procedure, he had nothing to say about what my life would look like afterwards, and very little info on the risks involved. That made him a bad surgeon. I can imagine a ‘best’ surgeon insisting his patient needs a lung transplant – without any consideration for what the patient’s life looks like afterwards, nor explaining the 50% 5-year survival rate – resulting in a technically proficient procedure that the patient regrets intensely for the last few years of his life. I don’t regret my surgery, but I didn’t let the abrasive guy do it.

          • PamelaWibleMD

            A holistic approach with technical skill can’t be beat.

          • DoubtfulGuest

            Did abrasive guy even give you a chance to ask those questions? Sometimes they just have a different mindset and aren’t thinking about what we need to know. If he didn’t let you ask, that is a problem.

          • Duncan Cross

            I was a little shell-shocked. It was the first time anybody had mentioned surgery, and he mostly just yelled at me about how I needed it done.

          • DoubtfulGuest

            Oh.
            ….Yeah, I see the problem. Glad you went with the other guy.

        • Geoffrey Koerner

          ….and under general anesthesia, I wouldn’t be around to hear the surgeon, but I’d sure hope he/she’d be kind to the rest of the surgical team.

      • Thomas D Guastavino

        You may choose any surgeon you wish. There is a difference between abrasive and arrogant and condescending . Given what appears to be an over emphasis on people skills while taking technical skills for granted, all else being equal, I will go with abrasive. As stated, that surgeon is getting by on their skills, not their personality.

        • EmilyAnon

          If a surgeon is short tempered and abrasive with the patient, you can only imagine the tantrums and verbal abuse that goes on in the operating room toward his team. This could indicate hubris rather than skill.

          • DoubtfulGuest

            Run, don’t walk, from a short-tempered doctor, yes. I’ve had some great docs that didn’t do anything rude per se…they were just lacking any warmth or pleasantness. I think a well-kept secret is that some of these abrupt doctors actually feel their patients’ pain and fear the most. They keep it inside instead of showing it. It can be very hard for them, and it doesn’t mean they care any less. Others are more science-y and not emotionally involved, but they still keep the patient’s welfare at the top of their priorities. Works for me…

          • DoubtfulGuest

            Abrasive docs with a sense of humor are also fine, provided they use these qualities to help the patient. I was telling the anesthesiologist before one procedure that ten years prior with my wisdom teeth surgery, I had a 9/10 headache right before falling asleep, and I wasn’t sure if I would be okay with anesthesia. He gave me some serious reassurance that the field had come a long way since then, that he would be using different, better drugs. But also: “And what did they use for anesthesia in your home town back then, pray tell? A hammer? Perhaps a rock on a string? No wonder you had a headache.” :)

          • Thomas D Guastavino

            Abrasive is not the same as short-tempered. If I may, let me explain my impressions of the best surgeons I ever knew.
            These surgeons were of a commanding presence. They made decisions based on common sense and rational thinking. They were problem solvers who quickly analyzed the task put before them. Their ability to move quickly from diagnosis to planning to resolution were sometimes looked upon as intimidating, gruff and impatient but they had to be given the task put before them, especially when dealing with emergencies. They were happy to answer a patients questions but their answers did tend to short and more technically oriented and they were rarely wrong. Since they tended to think in terms of black and white they had little patience for pretension. In the OR they took command, as they should. Without that commanding presence chaos can ensue. When they lost their temper most of then time it was justified. Believe me, I know.
            In the OR where chaos and catastrophe can quickly get out of hand this is the kind of person you want in command.

          • EmilyAnon

            I have no credentials to challenge your account of what goes on in the operating room. Or what makes a good surgeon tick. But what I do know is when a patient first meets a surgeon, they are scared, and most likely hurting. OK, I can see where “commanding presence” can indicate confidence. But if that is combined with abruptness or impatience with naive patient questions, then to me the message is that this doctor doesn’t like patients, or maybe me in particular. It’s easy to confuse perception with reality. Since we have no choice but to trust blindly, it certainly lightens our anxiety to have a positive first encounter.

            Along with Dr. Pamela, you are one of the few doctors that respond to patients here. Thanks Dr. Guastavino for taking the time. I can only think you are generous with your real patients as well.

          • Thomas D Guastavino

            Your Welcome. I try to be generous but in todays environment it has become increasingly difficult.

          • PamelaWibleMD

            So Thomas (and others) ~ Do you feel emotional intimacy is more essential is certain specialties? Like, say, primary care. Less essential in surgeons? And maybe potentially dangerous in, say, psychiatry?

            Thoughts?

          • Thomas D Guastavino

            First things first. What is your definition of “emotional intimacy”?

          • PamelaWibleMD

            Making a deep emotional and spiritual connection with one another. Often both parties are sharing emotional content though in the context of a doctor’s visit there would be more focus on the patient than the doctor. I don’t really have a well thought out definition. It is more of a feeling. You know if you are willing to be seen (in to me see) and if you are seeing the other person for who they really are in the world. You know – the “connection feeling.” Does this make any sense?

          • Thomas D Guastavino

            So, you really dont have a well thought definition but you believe all physicians should have it? Fair enough, we will play in your ball park. Under your definition, the importance of emotional intimacy would depend not so much on the specialty but on the condition being treated. As stated before, if I were depressed, even suicidal, then having an emotional connection to my provider would be key to my recovery. However, if I were in a bad car wreck I would want a surgeon who knew what they were doing and could care less about making an emotional connection with them.

          • PamelaWibleMD

            I’m likely coming from the primary care angle. Seems most essential to have a high level of emotional connection there.

          • Thomas D Guastavino

            As I said, we each serve in our own way.

          • DoubtfulGuest

            Maybe just like the Good Enough Mother, there’s also the Good Enough Doctor. Something as simple as “Let’s see if we can get you feeling better” goes a long way.

          • DoubtfulGuest

            I like all this except for the yelling part.

          • Thomas D Guastavino

            When I was in training as a surgical resident there was this attending surgeon that fit my above description. The first time I scrubbed with him I was intimidated out of my mind. I prepared as much as could but no amount of studying can prepare you like actually operating.
            I very quickly got lost and nearly went into a panic when this surgeon said to me in a stern voice. “What are you doing?” Frightened out of my mind, I described the surgical approach and what I was looking for but I just could not find it. He looked at me with piercing eyes and said “OK, its looks like you tried to be prepared, let me show you some tricks” The procedure went well after that.
            Several weeks later I was once again scrubbed with this surgeon only this time there was another resident who was operating. This resident also got lost and once again the surgeon said in a stern voice “What are you doing?” This time it was obvious that the resident had no clue what he was trying to do and was totally unprepared. Frustrated, the surgeon lost his temper and yelled at this resident to get out the room. Everyone else in the room agreed that it was justified.

          • DoubtfulGuest

            Fascinating stuff! I see what you mean…I’m not opposed to people raising their voices in an emergency, like you don’t politely whisper to get someone to “Call 911″. That resident surely needed to leave the room and a stern approach was justified. It’s just that loss of temper to me equals loss of control, so it goes against the otherwise admirable qualities in these people. Strict and stern with consistent expectations is one good way to handle things…taking out frustrations on people is not. In my first summer lab job ages ago, the professor constantly shouted at me. I couldn’t focus on doing things right because my stress response was always switched on. I’ve read this often happens during medical training, only much worse. The next year, I worked for someone who knew how to mentor and teach. She was also very kind and patient, but just the not yelling was enough for me to do much better. Toughness is fine, and patients sometimes do well with these doctors. I know the type you mean, and I don’t mind them a bit. I surely can’t imagine all different scenarios that a harsher approach might save someone’s life. I don’t know where the line is between reasonable and abusive behavior in all circumstances, but it’s an interesting question.

          • PamelaWibleMD

            Speaking of toughness . . . there were some surgical residencies that used to brag about their 90% divorce rate among residents. Anyone remember this?

          • DoubtfulGuest

            You mean the program…bragged…?!?!?!? Tell us more?

          • PamelaWibleMD

            Yes. Bragged. That’s all I know. As in the program is SO good they have a 90% divorce rate.

          • DoubtfulGuest

            Was this during the time period you were in training? I can’t even imagine what that would be like.

          • PamelaWibleMD

            I first heard this in the early 90s and it was confirmed again this evening as a hung out with 3 surgeons at a medical society function.

          • DoubtfulGuest

            Thank you for checking on that. What a horrible situation.

          • Thomas D Guastavino

            I believe that psychiatry is the specialty with the highest divorce and suicide rate. It is also higher for female over male physicians depending on what study you read.

          • querywoman

            The Texas Medical Board seems to discipline a very high rate of female docs.

          • DoubtfulGuest

            Any idea why?

            I read that most “physician help” programs are actually disciplinary or lead to discipline. That’s shady. I don’t like it that doctors can be punished for having depression or anxiety. Of course there are a few bad apples, but it would be in patients’ best interest for there to be an actual support system for doctors.

          • querywoman

            I suspect that women get in trouble more due to greater sensitivities. It seems like some of them get involved in some kind of love entanglement, like stalking.
            Look at Dr. Angela Siler-Fisher, who recently broke into the home of another doctor with whom she believed her husband was cheating.
            She wrote, “wh0re,” and, “homewrecker,” in red lipstick on the bathroom mirror and scattered condoms on the staircase.
            A man would have never garnered the sympathy she did.
            Her employer released a statement that, “It’s a private matter.” No, it’s not. That’s a crime against society.
            Her brains went out the window with the text messages she sent the other woman. That’s a prosecutor’s dream.

          • DoubtfulGuest

            Women get away with all kinds of stuff we shouldn’t, but then I wonder if the boards are letting men off easier for certain things. Who knows? I make no excuses for those who commit crimes, I just don’t like to see a system designed to break doctors. It’s unsustainable.

          • querywoman

            I feel confident you are right. Medicine is a still a good ole boy network.
            I think the problem is Dr. Brandon Fisher, Dr. Angela’s husband.
            Angela’s rage target, Dr. Marcelle Mallery, denied having a sexual relationship with him
            Dr. Angela is in charge of a busy public ER. You know she has treated domestic violence victims.

          • PamelaWibleMD

            Doctors need a nurturing educational and work environment (if we are to be nurturing with our patients). How can we give what we do not receive?

          • PamelaWibleMD

            I do not believe women docs complete suicide more than men. Women are more likely to ask for help when they are suffering, Women tend to m=be more relational. Men, on the other hand, don’t even like to ask for directions when they are lost in a car. To ask for mental health help as a male doctor is a biggie. Easier in America to grab a gun or some lethal dose of meds.

          • querywoman

            I agree with you here.

          • NormRx

            The reason men don’t ask for directions is most of the time the people giving directions are wrong. Most women can’t read a map so they have to ask for directions. Give me a GPS and a good map and I am good to go.

          • DoubtfulGuest

            “Most women can’t read a map…”. I thought you didn’t like stereotypes? Wasn’t that you? I’m an excellent map reader.

          • NormRx

            It is not a stereotype if is true, then it is a fact. I knew one woman that had a tremendous sense of direction, better than me and better than most guys I knew. What I commented on was why men don’t ask for directions and I said most, not all women.

          • DoubtfulGuest

            “Most” + “can’t” = stereotype.

            It’s a bit more complicated:

            http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909401/

            http://www.neurolab.ca/2008(8)_Palermo.pdf

            http://www.sciencedirect.com/science/article/pii/S0023969013000350

            Hey, at least I’m consistent.

          • PamelaWibleMD

            Doctors, police, firefighters all need to have access to weekly counseling for free and part of their job. No stigma. Available to all.

          • PamelaWibleMD

            Nobody is tracking these stats so it is hard to get accurate numbers. We’ve lost surgeons, anesthesiologist, and primary care docs in my town. No psychiatrists that I know of. All suicides were men. And there have been many.

          • Thomas D Guastavino

            If nobody is tracking these stats then where did you get your information that surgical residencies have a 90% brag rate for divorce? Google “physician suicide” or “physician divorce” Lots of interesting stats. You, yourself, had a post here on physician suicide last May that started “A psychiatrist in Seattle went to a bridge….” FYI, it is true that more men actually commit suicide but more women attempt it.

          • DoubtfulGuest

            I have to agree. I like Dr. Wible a lot and she does a lot of important work. But lots of other great doctors are being punished or insulted because patients don’t always know good care when we see it. Of all the ones I’ve seen, it’s pretty much an even 50/50 male/female split on how well they treated me. But I recognize good care even without much of an emotional connection. A general and consistent sense of goodwill from the doctor is enough for me, though it seems okay for there to be more of a connection over time if it develops naturally.

          • PamelaWibleMD

            I’m not down on men. I have a lot of respect for all doctors, In fact, anyone who can make it through med school deserves kudos. Keeping one’s soul alive is the key.

          • DoubtfulGuest

            I didn’t think you are down on men. I’ve had female docs who were gruff and judgmental. I’ve had male docs who were kind and sensitive. And the other way around. I don’t care about the gender of my doctors. I’m right in the middle of the road myself, in terms of emotion vs. reason. But I wonder if Dr. Guastavino and others might legitimately feel or think that some styles of doctoring are promoted as more valuable than others. Patients are socialized to look for an emotionally approachable doctor. And you are a great doctor! But if we look at online reviews of other wonderful doctors, they get torn down by patients who expect a more personal relationship than that doctor can give. But the surgery may be perfect, the doctor may be perfectly polite and care about patients a lot in his/her own way. Their souls are just fine, their focus is just not on emotional intimacy.

          • PamelaWibleMD

            Agree.

          • PamelaWibleMD

            Oh, I am not demonizing anyone. Don’t think any one way of doctoring is better than another. Docs deserve to be happy. If doctors are victims, patients learn to be victims. If doctors are discouraged, patients learn to be discouraged.

            The 90% divorce rate is what I keep hearing from surgeons. I can’t confirm the accuracy.

            I think states should track #s of doc suicides. Not happening yet. I believe the numbers are higher than what is reported in med journals. Doc i town has lost 7 colleagues. We lost 3 in 18 months to suicide in my town alone and both men I dated in med school died by suicide.

            Have read more women make attempts. More men complete.

          • DoubtfulGuest

            I would like to see wider media coverage about the physician suicide problem. Your column was a great start. Another discussion on this blog at some point could take it to the next level, to understand the issue better.

          • PamelaWibleMD

            I covered physician suicide in my TED talk just released on 1/31/14. Check it out here:

            http://www.youtube.com/watch?v=5cvHgGM-cRI

          • Thomas D Guastavino

            Not demonizing?
            “Women are more likely to ask for help when they are suffering. Women tend to be more relational. Men, on the other hand, don’t even like to ask for directions when they are lost in a car. To ask for mental health as a male doctor is a biggie”
            Half truth?
            “I do not believe women docs complete suicide more then men”
            Repetitive pure speculation?
            “The 90% divorce rate is what I keep hearing from surgeons. I can’t confirm the accuracy”
            Can at least give us some of the names of the surgeons who are making this claim? I have been a surgeon for over 25 years and have never heard this.

          • PamelaWibleMD

            Name of surgeon I spoke to at med society meeting the other night:
            Harris Waters, MD I believe it was.

            I’m just speaking from experience when it comes to asking for directions when lost. I have had many, many boyfriends berate me for asking for directions. I stopped asking because it was easier to avoid the arguments in the car afterwards. . . .

            I am just sharing my personal experience. Not the be-all-end-all truth.

            Don’t mean to offend.

          • DoubtfulGuest

            Maybe we could look at gender socialization without stereotyping people? Do we really know why anyone feels they can’t ask for help? There are probably lots of different reasons.

          • PamelaWibleMD

            A great research project. I would love to know more.

          • DoubtfulGuest

            Touché…I’m actually not sure how to design a study like that. I just meant there are probably lots of different factors. We all start from personal experience as a reference point. I had a male friend in high school who loved to ask for directions! Boyfriends ‘berating’ you doesn’t sound good at all. Are there any large anonymous surveys for doctors? Reasons to not ask for help would have to be self-report, I suppose. I was thinking about this the other day…to keep it ‘doctors only’ the physician would have to somehow ID themselves, right? That’s a dilemma. Do you know any way around this? I’m sure that gender is a factor…I just wonder what else might be going on, too. I should delve into the research myself. And I will watch your video…thanks

          • Geoffrey Koerner

            Residencies that bragged about 90% divorce rate among residents? How horrible. No wonder PTSD and suicide is so high among doctors. I’m horrified and saddened that anyone would be treated to such professional emotional abuse, especially in the field of healing. As we have Holocaust Remembrance Day, perhaps we should also have Abused Healers Remembrance Day, too.

          • DoubtfulGuest

            Better yet, change the system so doctors don’t get abused. It’s still going on in different ways.

            Step 1: The public stops expecting perfect care.

          • Kristy Sokoloski

            I agree with that about step 1. And Step 2 would be stop expecting that the diagnosis is going to be made within one visit as sometimes that does not always happen. Step 3 would be stop abusing the staff that works for your doctor.

          • PamelaWibleMD

            Abuse trickles down. Where does it start? My opinion: medical education.

          • EmilyAnon

            Equally important is where abuse might end. On patients, family, then finally on themselves. What a terrible cycle.

          • PamelaWibleMD

            Yep!

          • PamelaWibleMD

            I think most abuse begins internally within med school. Docs picking on other docs. Cynics telling idealistic young med students their dreams are impractical. Bullying on rounds. Cut throat and competitive environment. Reductionist medicine mind-body split. Mental health deteriorates in med school. I don’t think the abuse originates in patients’ maltreatment of doctors.

          • DoubtfulGuest

            I see…but then how did medical education get that way? What’s the basis for it?

          • PamelaWibleMD

            Allopathic medicine has always been reductionist.
            That means a mind-body split is part of the training. Perfectionist med students witness a high-volume of human drama and trauma. Workaholics are admired. Vulnerability is weakness.

          • DoubtfulGuest

            I hadn’t thought about that…thanks. I just wonder how much society’s expectations of doctors come into play as well.

          • Kristy Sokoloski

            The divorce rate among medical marriages is quite high. At least as of several years ago it was. And it wasn’t just the surgeons just like Dr. Pamela mentioned. There were several reasons for why the rates were so high, but I don’t remember what the percentages are when it comes to exact numbers. However, I know it affected multiple specialties.

            There are other reasons for why the suicide rate among doctors is so high, and that is just one of them.

          • PamelaWibleMD

            Easy to burn out one’s spouse while trying to process the trauma of the day’s events.

          • PamelaWibleMD

            Just fact checking this evening. While speaking at the medical society event in Salem, Oregon, I hung out with a few surgeons who confirmed that all surgical residencies have high divorce rates.

    • querywoman

      I have not had good luck with any doc with poor bedside manner. My mama had a gentle, easygoing topnotch general surgeon.
      I went to a vascular surgeon like him him after cellulitus, but he was the wrong doctor for me. We both agreed that I needed a dermatologist.
      I hope I never need him, but I’d refer anyone to him in a quick minute.

    • Suzi Q 38

      This is my be true if the surgeon ends up doing the surgery.
      At the teaching hospital, maybe your surgeon is really his “fellow.’ Maybe the fellow actually performed the surgery.

    • Lisa

      My ortho sugeon has a very poor bedside manner; however he is a good surgeon. Luckily, I do like the practices PA.

      • Thomas D Guastavino

        The beauty part is that, well at least for now, you have the right to evaluate and choose whatever provider you wish. You just have to make sure you are making the right choice for the right reasons.

        • Lisa

          I disagree with your statement that I have the right to evaluate and choose whatever provider I wish. While my current insurance allows me to go outside their network, I would pay a large premium (50%) to do so.

          I chose my ortho surgeon for two reasons: His reputation in the community and the fact that he uses the approach I preferred for hip replacements. I talked to my PCP and I talked to friends who are physical therapists to see how his patients fared. I think I made the right choice.

          • Thomas D Guastavino

            Hence the “well at least for now” clarifier. Loss of the right of choice will be just another in a long list on unintended consequences of current models of health reform. Congradulations on doing your due diligence and finding a surgeon that you feel you can trust.

  • Kristy Sokoloski

    Dr. Pamela,

    What an amazing piece. And after I read it and some of the comments you left to the other posters it made me think of the doctor who I have as my Primary Care Physician right now. He’s been taking care of me for almost 2 years. What you describe with this piece is not only a doctor but a “friend” (in an appropriate way of course). And that’s one of the reasons why I thought about my PCP because he’s also trying to be my friend. Thanks for sharing this.

    • PamelaWibleMD

      The way I try to practice medicine reminds me of this quote by a zen poet:

      A person who is a master in the art of living [insert art of medicine here] makes little distinction between his work and his play, his labor and his leisure, his mind and his body, his education and his recreation, his love and his religion. He hardly nows which is which. He simply pursues his vision at whatever he does, leaving others to decide whether he is working or playing. To him he is always doing both.

    • PamelaWibleMD

      There is a lot of talk about integrated medicine. The first thing we need to integrate is ourselves.

      • Kristy Sokoloski

        Dr Pamela,

        I agree with you about integrating ourselves. One of the things that I learned when I was doing additional research in to Osteopathic Medicine was the way that they also look not only at the emotional aspect of things but also the spiritual. And while I was in Nursing School (I am not right now but hoping to get back to there) I learned that sometimes spirituality also has to play a bit of a role in the Nursing profession when called for.

        My search about Osteopathic Medicine also caused me to understand further about holistic care. It was amazing how much more I understood as a result of that research.

        • PamelaWibleMD

          On my intake form (after the standard health history questions) I ask patients:

          1) What are your health goals?

          2) What is your life purpose?

          3) Anything else you want to share?

          With one gentleman we spent the entire session on #2. Knowing why our patients are here (not just for the appointment but why they are here on the planet) matters. It helps us create appropriate treatment plans if we have a grasp on who people really are.

          • Kristy Sokoloski

            Dr. Pamela,

            That’s a great idea about asking on the intake form about the health goals. However, what if someone doesn’t know what kind of goals they have for their health? The reason I ask that is because I know for myself I don’t have really have any specific goals for my health. And in previous years under other PCPs no one has ever asked me that. So I am sure I can’t be the only person who doesn’t know how to answer question #1.

          • PamelaWibleMD

            That is exactly why the question is there. To get people thinking about why they come to the doctor and the broad possibilities for their life and health. There is no right or wrong answer. To never ponder the question is a problem.

          • Kristy Sokoloski

            Interesting because I don’t know. I guess you just made me think as well. :)

            It’s one of the reasons I frequent this blog. I learn a lot here. I may not always agree with everything I read when it comes to some of the posts but yep it definitely makes me think. Thanks.

        • querywoman

          I like osteopaths a lot, but they also have some baddies!

          • Kristy Sokoloski

            So do doctors that have MDs behind their names. Three of the doctors that have taken care of me have been very good Osteopaths. My PCP the one of course I see the most.

          • querywoman

            No need to keep rehashing it. I’ve been to many more BAD MD’s than DO’s.
            There are good and bad chiropractors, etc.

    • DoubtfulGuest

      This is fantastic, Kristy. Yesterday I tried to post a link to a nice article on doctor-patient friendships. It didn’t get through moderation. If anyone’s interested, it can be easily found online: What To Do When Patients Become Friends, by Mark Bernstein, MD. It covers the ethical issues well and comes down on the side of, friendship is natural and okay as long as it doesn’t interfere with medical care. In the case discussed, the doctor and patient are actually socializing outside the office as the friendship develops over many years. Of course there are many degrees of friendship and the “unconditional positive regard” that’s supposed to exist between doctor and patient. So glad to hear it’s working out for you in real life. Friendship is one of life’s greatest treasures, as they say.

      • Kristy Sokoloski

        There was an article that came out one time through the AMA (not sure if you can still find it online or if it’s the same one you are thinking of) where it talked about some of the ethics of doctor-patient relationships and touched on areas of friendship and dating. And it said that as far as the issue of being friends that is up to the doctor and the patient if they choose to do that, but as far as the issue of dating if the doctor wants to date the patient then they must end the relationship. The patient must then find another doctor to care for their needs. It was quite interesting.

        • PamelaWibleMD

          Correct. Never date patients. Never cross sexual boundaries with patients.

          in small towns where there is one family docs for the entire town, it may be quite likely that dating options will be limited since everyone is or has been your patient!

  • guest

    Nice piece but I’m hoping that that isn’t actually a picture of you???

    • PamelaWibleMD

      It is.

      • Kristy Sokoloski

        Nice picture.

        • PamelaWibleMD

          Thanks! 46th birthday trapped in a blizzard on the Oregon coast in the honeymoon suite at my favorite hotel.

      • guest

        Well… it IS a very cute pic!

        • DoubtfulGuest

          You know, it all went right over my head the first four or five times. Just did not compute…

        • PamelaWibleMD

          Thanks!

  • Rhea

    I had gone to my doctor for nearly 10 years but never expected her to be
    interested in my emotions. So I would read the questions on my list and report
    any concerns, While she always asked me questions, my answers were very factual
    and unemotional. I thought that’s the way you talked to doctors.

    When she finished my check-up recently, it occurred to me to ask her
    how SHE was. She looked like she wasn’t used to having anyone ask how SHE was
    going. She hesitated for a moment and then said, “It’s not been my best day.” I
    sighed and said, “Gosh, things must not be going well.” She lingered by the door
    and told me that her teenage son was being bullied in his school and it was
    hard for her to drop him off at school that morning and come to the office. I
    said I was sorry and told her I’d say a prayer for him.

    When I got home, I wrote the prayer in a card and sent it to her office. I
    was surprised a few days later to receive a beautiful handwritten Thank You card
    saying my prayer touched her and your family. She had never received a “love
    note” like that from a patient before. She signed her card, “Your Friend,
    Victoria.” I know my next visit to her office will be different.

    • PamelaWibleMD

      That is such a beautiful thing you did for your doctor!! Love heals doctor and patient alike.

    • Kristy Sokoloski

      I am glad that you did that with your doctor. I do this with my doctors as well whenever I can get the chance to do that.

  • Jill Mardin

    I would totally agree with this except that I had a doctor that I thought I had an emotional connection with and I did until I had a crisis and was told by that doctor that she didn’t have the time or energy to “hold my hand ” while in crisis. I found another doctor but the aftermath of feeling abandoned by a doctor I trusted so much devastated me in a major way so I think it’s a bad idea to have that kind of intimacy unless the doctor can sustain it.

    • PamelaWibleMD

      Totally understand. Any abrupt change in a relationship can be damaging. Also emotional intimacy may not be appropriate in all situations. Psychiatrists, for example, have very clear boundaries in this area.

    • DoubtfulGuest

      Compassion fatigue is a big problem. Doctors with the highest emotional intelligence and self-awareness are least likely to give patients mixed messages. I swear sometimes they don’t know what they want. I’m terrible at recalling where I heard things, but someone did an informal “study”, for a radio show or something? in which people pretended to be patients and recorded their doctor visits (I hope with permission!). Anyway they looked at how much doctors talked about themselves and it was A LOT. Their “conclusion” was that many doctors are lonely, and looking for as much human connection during visits as the patients are. Especially with the long hours they work, they barely get to see their regular friends. So, it’s possible for patients to feel a bit used, not being sure if the doctor actually enjoys talking with them, or is just desperate to talk to, you know, anybody.

      Years ago I saw a specialist for a disease I turned out not to have. It was a reasonable experiment, but this doctor was starting to think that if I didn’t have *his* disease, I must not having anything major going on at all. It turned out to be something just as bad, in a different specialty area. This doctor was as kind and nice as anyone could be, for someone who never listens to a word you say. Because his son went to the same university as me, that triggered some connection in his mind, and he sort of ranted to me on two occasions about his frustrations with his slacker offspring.

      Me: “Oh, that’s great. What’s his major?”

      Dr.: (shaking his fist) “His MAJOR? Wine, women, and song, I guess. He’s dropping out. I’m so MAD at him.”

      I actually didn’t think this was over the line, and I’m a friendly person, but ultimately my medical needs didn’t get met. I kind of felt like I was paying him to be his therapist. Drove two hours each way to see him, too. So, yeah, I agree with you…

      • PamelaWibleMD

        I think doctors should have some type of therapy available (balint groups with other docs are a great example). Seeing 30 patients per day without lunch or bathroom breaks can lead to unhealthy relationships with one’s patients, spouse, even oneself.

  • Sheri

    “The secret of the care of the patient is in caring for the patient.” Francis Peabody

  • PamelaWibleMD

    Can I quote you?

    • PamelaWibleMD

      On my office brochures? Website? You are cracking me up, Benton.

      But it IS true. Most people yearn for intimacy (which is not necessarily sexual. And sex is not necessarily intimacy for that matter) and many people never feel safe enough to reveal themselves 100%–to anyone. Doctors have to hear the entire story and see the whole person to make the best diagnosis. That in and of itself requires intimacy.

  • Freddie Thiemer

    Spot on as always Pamela. My Mom is a retired RN so I grew up hearing about how much doctors had to learn. I’m greatful that you are creating the dialog to address this issue. You’re the best.

  • PamelaWibleMD

    Many! And doctors often call for help too. I’m here for them as well. In fact, doctors are more shocked than patients that someone would care for them!

  • DoubtfulGuest

    An example of great medical care with no emotional intimacy:

    In my travels through the system to get a diagnosis, my PCP at the time referred me to a specialist. “He knows his stuff, but be aware some of my patients don’t like how he relates to them”.

    The problem? “Well, he types…on his laptop.”

    “Does he type what you actually say? Does he listen? Is he at least polite?”

    “Well, yes…”

    “So, is he condescending?”

    “No…but he doesn’t make eye contact! Patients need eye contact!”

    “But he’s typing what you tell him, he knows his stuff?”

    “Yes….”

    “So, what’s the problem?”

    Long story, this doctor helped me with some things and then I went back to him for an alternate opinion, after specialists A and B who had been helping me turned against me and accused me of faking my symptoms. I was desperate at that point.

    So, I told him what I’d been through, and he cried with me.

    No, he didn’t.

    What he said was “Hmmm…”

    “They decided I’m malingering.”

    “Oh! Huh….”

    “…and I really think I need another neurologist’s opinion but I wanted to ask if you think this other disease that you treat is really ruled out for now and if it’s okay to do that, or am I just totally crazy or should we watch and wait some more…”

    “Hmmmm…”

    Days later, through his office, I had an appointment set up with the specialist who correctly diagnosed me and who still takes care of me, years later. You bet I wrote this guy a thank you letter, for breaking the cycle of doctors misjudging me. And you know what? He wrote back — shortest letter in the west, but I knew my letter cheered him up.

  • CouldSleepAMillionYears

    While I would agree that many physicians have become too ‘corporate’, a situation caused mostly by the system, btw, I think this is somewhat naive. If you give too much, even if you maintain proper boundaries, you will almost inevitably end up being hammered for it. Idealization progresses to devaluation very quickly, and the greater the idealization, the greater the fall.

    What seems nice and human can quickly turn into a huge nightmare for the physician. Beware.

    Also, all this talk about intimacy – I get what you’re saying, but I think you’re over-sexualizing your approach. The photo too. I’m not a suit and tie doctor. Far from it. But you’re treading dangerous water there and I’m not sure you know it.

    We don’t live in the good ol’ days. We live in an era where medical boards and corporations and bureaucracies rule. They don’t care if you were the nicest kindest and fairest doctor on earth. If they perceive you as someone who’s broken a rule or regulation, you’re done for.

    • DoubtfulGuest

      Hammered by patients, or others? What would you suggest is a good middle ground for patients who want to get along with their doctors but still be appropriate? We don’t have a reference point in everyday life, and I think this causes lots of problems.

      I don’t know that it’s fair to say someone has a sexualized approach unless it’s clearly intentional. Dr. Wible makes it clear she knows the rules. I can see how it would be confusing for patients, who, again, have little reference point for what’s correct. Women are socialized to be nice. There are huge penalties in society if we’re not “nice” enough, like female professors often get bad evaluations if they’re not downright maternal toward their students. What concerns me is that should Dr. Wible’s approach be more widely adopted, it could potentially lead to missed diagnoses — especially for complex cases. Like a patient who has a weird disease, but also psychosocial problems that are not causing the disease. I know from experience that hand-holding is no substitute for a good diagnostician.

      • PamelaWibleMD

        Sometimes the diagnosis is best identified by having a deep relationship over time. So important to have an inquisitive primary care doc who can see the big picture and also at the same time be trusted to pick un on what may appear to be inconsequential details of a patients’ personal life. Patients have disclosed things to me that they have never told other doctors. Everything is a clue.

        • DoubtfulGuest

          I agree, Dr. Wible. I really admire you and your work. I just think that other approaches can be equally valuable. My own diagnosis required, let’s see…quaternary care? Super-specialized care with multiple referrals in the same teaching hospital. I had a very kind, well-meaning doctor dismiss my exercise intolerance since early childhood, as a non-organic failure to thrive. I had a difficult home situation, yes. But that didn’t cause my disease. The more doctors focused on it, the further we strayed from an accurate diagnosis. I’m getting better now, at least for the foreseeable future, but that couldn’t happen until the biochemical basis for all my symptoms was identified and treated. Does that make sense? I didn’t mean to be critical. I just want to give equal credit to other doctors who step back from the emotions and focus on the hard science part of medicine. That can save lives, and those doctors care just as much in a different way.

          • PamelaWibleMD

            Yes. I agree. There is no one-size-fits-all doctor – or patient. Each is unique and requires unique skills and approach.

          • DoubtfulGuest

            Dr. Wible, your columns always get such a nice turnout. It seems a lot of people here are interested in doctor-patient communication and boundary issues. Maybe an idea for a future post of yours? I would like to see patients learn to appreciate a wider variety of doc personalities, and for doctors to get a better understanding of where patients are coming from. Thanks for another great post this time. I always enjoy reading your work.

          • PamelaWibleMD

            Aw. . thanks! I’d like to do one on professional closeness soon (vs. the more commonly accepted notion of professional distance)

  • Geoffrey Koerner

    At least two of them. When my wife was having trouble breathing very late one night, Pamela answered her phone and guided me to an easy, at-home solution. If we’d have gone to the ER and hit with an armload of paperwork and invasive questions, I think I would have have been so distraught that I might have done some very un-good things to the hospital staff.

  • Geoffrey Koerner

    For interested physicians and med students (I think), Pamela holds workshops for healers to create their own ideal medical practices that work for the well-being of both patients AND doctors.

  • Geoffrey Koerner

    I’m so glad to see so many people entering into the conversation. As I’ve been one of Pamela’s patients for a number of years, the experience of working with her is like that of having a good coach, albeit a very holistic one. The choices of what to do are always mine, as contrasted to the traditionally paternalistic, “My doctor told me to do this;I don’t know why, and I’m too stupid to understand” sort of mindset. Because of her approach, I’ve become a far more responsible person regarding my health and other areas of my life.

  • Dale Howard

    Love is patient and kind. Love is not jealous, it does not brag, and it is
    not proud. Love is not rude, is not selfish, and does not get upset
    with others. Love does not count up wrongs that have been done.
    *
    Someone posted this on my Facebook page and I thought to myself computers must be booted in order to function properly. Wouldn’t it be interesting if the human mind could go through a booting process to download positive affirmation(s) first thing in the morning. I did the next best thing I printed this out, bought a $1 frame at the $tore and placed it in the bathroom!

  • Karen Ronk

    There are difficult, insensitive and abrasive personalities in every profession. The difference is that doctors can make such a huge difference, for good or bad, in our lives. And I feel it is not so much about the spoken words from a doctor, but rather the innate feeling that this person cares about you. Perhaps there should be some type of empathy test added to standard medical training. Those that flunk that test should be encouraged to go into research or administration.

    I do agree that it is a two way street and patients should also care about the well being of their doctors. There are things going on in their lives that effect them just as our medical issues effect us and we need to be mindful of that. Unless of course, he or she is just a bad doctor, and then we need to move on.

    • PamelaWibleMD

      Unfortunately studies have revealed that empathy decreases during medical training. Not sure taking an empathy test will reverse this. There are deeper issues at play. We need to have a more nurturing and less competitive environment in medicine.

    • DoubtfulGuest

      I agree w/Dr. Wible that an empathy test is not the way to go. Otherwise you are spot-on, Karen. Great contribution to this thread.

  • buzzkillersmith

    Wow, it’s been a while since I read something like this from a doc.

    I was told long ago by a good old doc that a doctor should be friendly but not a friend. That’s good advice.

    There are many problems with too much intimacy:

    1. It can lead to very inappropriate behavior, especially among certain docs and pts.

    2. Some day we all have to tell people bad things like, “Sorry, but there’s no good treatment for this.”

    3. People need shamans, and we are the shamans. Intimacy destroys this kind of magic.

    4. Emotions can mess up clinic judgment, our stock in trade. Why we’re here. Treating your family is a bad idea.

    5. Overly intimate docs risk burning out themselves. See number 2 above.

    That said, you have to do right by people and help them, especially when they need it.

    • DoubtfulGuest

      Finally…I was hoping for some input like this. I see what you’re saying. I think occasional doctor and patient can develop a platonic friendship over time. But they’d have to consciously check themselves with all these factors you mention. You make good points. I’ve read that sometimes doctors would not do as much workup on a patient they really like because they want that person not to have a bad disease. Like a denial thing. I had a bad experience with a #5 doc. Nothing creepy, just a missed diagnosis as I described above. I can’t agree with #3, because I had to figure out a good portion of my diagnosis myself, and the testing just confirmed it. I think the shaman thing goes against people taking responsibility for their health, which we really should do. You make a lot of sense, though.

      • buzzkillersmith

        You’re right.

      • PamelaWibleMD

        Interesting. I don’t think I have ever becomes friends with a patient, but I do have friends who have later become patients. Living in small towns docs are often friends with their patients I suspect.

        • DoubtfulGuest

          Well, I guess it comes down to, what does ‘friends’ mean? I posted the title of a paper that talks about a case in which doctor and patient socialize outside the office. They openly discuss the ethical concerns and there will be a point that the patient will have to find a new surgeon if he wants to stay friends with his current surgeon. How could anyone make life or death decisions with/for a friend or family member? It would be so difficult as to be unworkable, I’d think.

          There are some doctors and patients who do not socialize, but they share interests and enjoy chatting if they have an extra minute here and there. This is nice in many ways, but how does one avoid being distracted from the patient’s medical situation? Not easy.

          I have friends with whom I’m not emotionally intimate. They are work friends. Even emotional intimacy, there’s a matter of degree. What does it mean for you, in terms of sharing about yourself? I think patients do need to see the doctor is human. One way doctors can show this but still maintain boundaries, is to share some feelings about being a doctor. What’s your philosophy of care? What do you like about working with patients? What can patients do to help you help them? What do you wish you understood about the patient’s side of things?

          It’s hard for patients to open up and say embarrassing things, like about bowel habits. It’s not fun and can leave us with a weird feeling when we leave your offices. It would help if more patients could say “I’m intimidated by all this” and more doctors could say “No need, because I am here to help”. I would like more practical examples like that to be discussed on this blog. Different ways that patients and docs of various personality types could get along and work together.

    • querywoman

      Buzz, I used to attend a large church with doctors, lawyers, other professionals, and the homeless.
      I did not socialize with the doctors and lawyers, etc., because most of them had children, and I do not.
      I wanted to be with single people.
      My church was full of gynecologists. Some women in the church used them, but I, like many others, refused to spread my legs for a church member.
      I taught children’s Sunday school with a medical doctor. Poor dear! Couldn’t shut up about being a doctor!
      I tried to keep my personal health issues private around him.
      I would not want a personal relationship most of my doctors. I do consider a Nurse Practitioner who used to come my home a friend, but she sold her house and moved away to be with her daughter and grandchild.

      • buzzkillersmith

        Well done.

        • querywoman

          Some more jewels for you, Buzz. As you know, people harass doctors and lawyers socially for advice.
          I have an attorney friend who is ignoring an email about Kentucky estate law. He’s an immigration lawyer.
          I haven’t seen many doctors who I think qualify as shamans.
          But, you need time away from your jobs like everyone else. Therefore, if I keep my distance from my doctors, I’m not tempted to harass them in their time off.

          • PamelaWibleMD

            Ah, yes. I have many relatives who enjoy asking me about aches and pains during family get-togethers.

          • querywoman

            Yes, Pamela, and you let us all know that you are lax about the boundaries.
            You have to take care of yourself, too.
            Two ushers took me out of the service once for being wobbly and got a church doctor to assist me.
            Once, during a service, the senior pastor noticed a woman struggling in her pew and requested that a doctor assist her. He had it made it part of the service.

    • querywoman

      Once I had too much of a relationship with one of my welfare clients.

  • DoubtfulGuest

    I know just a little about this. I think it’s a combination of clinical hardening — actually working with patients and seeing so much death and suffering, and the way they themselves are treated during that time. Long hours, little sleep, and often verbal abuse from anyone who is ranked higher than them.

  • PamelaWibleMD

    Yep. Often patients see naturopaths (rather than MDs) just to have someone spend the time listening to them.

    • querywoman

      Patients are supposed to love it when chiropractors, “lay their hands on them.”

  • PamelaWibleMD

    Many students graduate medical school with PTSD and are traumatized by the way they are treated by superiors (hazing, bullying) and, of course, they witness immense human suffering, and they are not supposed to show their emotions or seek help as that would be a sign of weakness. I could go on . . .

  • PamelaWibleMD

    Karen, please read the comments on this physician suicide blog to understand the severity of the trauma inflicted on med students:

    http://www.idealmedicalcare.org/blog/why-physicians-commit-suicide/

  • http://www.CommunicatingWithPatients.com/ Edward Leigh, MA

    Your posts are always insight, inspiring and educational. In teaching healthcare professionals patient engagement skills, I often hear people complain that they don’t have time for empathy. Empathy could literally take seconds. How long does it take to say, “Sounds like you are having a rough time?” Keep up the great work! We need to clone you! Best, Eddie

    • PamelaWibleMD

      The problem arises not for lack of interest in empathy, but because there is nothing left to give when one is traumatized through one’s medical training. Hard to pass a test on empathy (as one commented suggested we give med students) when one has PTSD. How can one give what one does not have?

  • http://www.CommunicatingWithPatients.com/ Edward Leigh, MA

    I often hear about doctors with “poor bedside manner” who are technical experts. I have heard people say, for example, “Well, his people skills are awful, but he is a great surgeon.” What people don’t realize, even if someone is technically sophisticated, if they are not excellent listeners, they can miss vital pieces of information. Taking an excellent history and listening carefully are vital to patient safety. Thanks again for the outstanding article! Best, Eddie

    • PamelaWibleMD

      Exactly.

  • PamelaWibleMD

    Why traumatize future doctors?

  • PamelaWibleMD

    My TED TALK on intimacy with patients:
    http://www.youtube.com/watch?v=5cvHgGM-cRI

  • Mylene Stehouwer

    What a great title !! but what a wrong picture! Why the comparison with sexual intimacy ??
    I was in tears when I thought a patient was suffering because of a mistake I made. it was seen by family end they were shocked. A doctor crying ?? Then the mistake (of course I told them about it) must be terrible ! Their first thoughts were that it had to be about that; how could a doctor just care that much for their mother ?
    The management convicted me because I was open about it, because I embraced it. Let the inspection come and read what the care-takers, the nursus and we doctors write down, I said: then they will see how loving and caring everyone is. How could I know they would just be interested in rules and protocols. Of course they did’t come…
    I left the hospital because I really think it is insane that we have only 10-15 minutes for a human being that is worried or suffering. Especially in oncology, it is a disgrace ! There should be a holistic approach. Traditional medicine should work hand in hand with the spiritual world (especially in psychiatry !)
    When will they see that !!??

    • DoubtfulGuest

      So sorry…I have been a big proponent here of doctors being honest about mistakes. Awhile back, I was also accused of having inappropriate intentions for seeking medical care, when I actually have quite a serious disease that needed to be diagnosed. Thank you for stopping in. We could all be having lots more serious discussions about these topics. Could save many folks a lot of pain down the road.

      • PamelaWibleMD

        Honesty always best policy. If your needs are not being met, speak up.

        • DoubtfulGuest

          Thank you, I’ve spoken up repeatedly in my own situation. This is the non-existent malpractice suit I keep mentioning. The doctor apparently feels we’re embroiled in some legal battle. The fact that I’ve never contacted an attorney hasn’t sunk in, I guess. This doctor is preparing to defend….nothing. He’s on a whole different planet, where things don’t make sense. None of my well-intentioned, normal-person words have had any effect on him.

          • Rob Burnside

            Some mountains won’t move, DG. Better to walk around them.

          • DoubtfulGuest

            Haven’t made contact since September. But should we ever stop expecting someone to come around and do the right thing? Doctors are human…it’s a package deal.

          • Rob Burnside

            I’m with you, but it’s possible we’ve both seen too many “Casablanca” re-runs.

    • PamelaWibleMD

      Agree. The photo, btw, drives home the point that sometimes we confuse emotional and sexual intimacy.
      Good hook too.

      • DoubtfulGuest

        It sounds like Dr. S. had a very stressful situation. Hopefully she(?) will come back and participate more on this blog. I thought it’s a nice photo, if a bit informal. I didn’t notice anything that other people were noticing, for quite some time. The emotional vs. sexual intimacy, though is a pretty darn serious issue that cannot be skipped lightly over. I’m sure lots of other people were reading who were too uncomfortable to discuss anything, and that’s too bad. I can understand what some other doctors here were saying. It’s a very serious issue and I don’t think it’s stuffy or conservative to say people have to be careful. Patients sometimes make undeserved complaints if they misinterpret something. Doctors may unjustifiably terminate a patient. Or let an innocent misunderstanding influence their medical judgment. All kinds of things can go wrong. That said, I think depending on how you define it, some degree of non-sexual emotional intimacy is important. It’s very complicated.

        • PamelaWibleMD

          Intimacy synonym: close. How about professional closeness? I like that term.

          • DoubtfulGuest

            That’s somewhat better…If I understand correctly what I think you’re promoting is what many people would call ‘emotional connection’ or ‘talking about feelings’ instead? I suspect much of the problem here has been lack of agreement about definitions?

  • PamelaWibleMD

    YES!!!!!

  • PamelaWibleMD

    Overleaf Lodge in Yachats is best on Oregon coast.

  • DoubtfulGuest

    I like your cashier example. I have mixed feelings about all this, but I had hoped for a more substantive discussion with answers to some very reasonable questions.

    • PamelaWibleMD

      Forgive me is I have not answered your questions. What are they? Happy to give it my all.

      • DoubtfulGuest

        Thanks so much. I understand you’re very busy. I had also hoped for more input from other doctors, and it seemed like some other patients were wondering things, too. Some people just wanted to state their opinion and then they were done. But there was this visitor from Europe (I think?) who seemed quite upset and I also felt that the concerns of the other doctors were not addressed. About boundaries and such. I always wonder about unusual situations. Like how might you handle things with a patient who has medical reason to be more easily confused…cognitive difficulties, mental illness and so on? I’m sure everyone is different, and you can’t get too specific with any of our situations. But it seemed like me and at least a couple of other people had some very upsetting doctor-patient miscommunications that would sort of complicate what you’re encouraging people to do. I’m very open to your ideas, actually, and I completely agree that doctors and patients need to have stronger relationships. And patients should care about doctors’ welfare. Our society has done a terrible job of looking after its doctors recently. There are just a lot of different things to consider with intimacy, professional closeness, or whatever you like to call it. Thanks for your time.

        • PamelaWibleMD

          1) Boundaries – I aim to treat all patients the same. So no special favors. For example, no refills between appointments. That is for everyone. Even if a patient who is a friend begs. I still will not do it. Yet . . . I also aim to be compassionate so that when a patient’s car breaks down and he/she is the last patient of the day, I do drive that person home.

          2) handling patients with cognitive disorders, mental illness. Same way as #1. I try to be as compassionate as possible. Example, I have a patient with traumatic brain injury who has shown up at my house and has called me more than most. I a compassionate and continue to redirect her to follow office policy. She is a dear woman. requires more hand holding and support than most. It is ok.

          3) Key is clear communication and being consistent. Like raising a child or a puppy. The minute you loosen the leash, they are off and running.

          Every case is individual.

          Does this help?

          • DoubtfulGuest

            Clear & consistent communication is also best for adults. :) That helps a bit. Patients are like kids in that we’re vulnerable and don’t always know what’s going on. But then many of us are adults with varying degrees of competency that need to be respected. Do you have any thoughts about what the other doctors said? I don’t think the photo is offensive…it’s still G-rated. I’m not sure there’s an issue with emotional sharing itself, or just how it’s being talked about? I can’t tell. I would say that it could potentially be most respectful of people’s emotions to be very careful with them. I don’t want doctors to be cold or uncaring, but I feel like they’re actually protecting me if they keep a bit of distance and objectivity. Because the focus is on fixing my medical problems as best they can. I need a lot of specialist care and I’m the last person really qualified to assess a family practice situation. So please take my thoughts with a grain of salt. But I can see different sides of the issue.

  • PamelaWibleMD

    Intimate means: Relating to or indicative of one’s deepest nature; essential; innermost. These are words that describe the conversations that many patients have with their doctors. They often tell us things that they have never even shared with their spouse. Medicine involves emotional intimacy.

  • Rob Burnside

    We all need some degree of connection with other human beings somewhere in our lives. More than anything else, it makes us feel human, and alive. Too many of us suffer, and even die, for lack of this thing called “intimacy.” This is unnecessary and unwarranted, and I’m very glad you’re doing something about it, Dr. Wibel. Your last sentence says it all. Three cheers, and march on!

    • PamelaWibleMD

      Thanks Bob! How can we heal one another if we are content to remain facades of ourselves. Two characters playing the roles of doctor and patient in an exam room can only evolve so far. For healing we need to be real.

      TED Talk on emotional intimacy is now live:

      http://www.youtube.com/watch?v=5cvHgGM-cRI

      • Rob Burnside

        In a word–brilliant!

        • PamelaWibleMD

          Thanks SO much for your support. Holding a vision can be lonely at times. Like the company. :)

          • Rob Burnside

            Your vision gives us reason to hope that healthcare will survive its harsh winter of discontent, and perhaps be better for it. Your company makes the journey seem possible, and the path less painful. We can’t thank you enough, Dr. Wible. I only wish you had more peer support.

          • PamelaWibleMD

            Ah, I do have peer support. But being visionary has been lonely at times and I have been misunderstood. It’s a journey of the heart. Pilgrimage of the soul. In medicine. The journey inward is solo by nature. And deep inside all of us are the answers we have been so desperately searching for . . .

          • Rob Burnside

            “If you bring forth what is within you, it will save you; if you do not bring forth what is within you, it will destroy you.” -Gnostic Gospel of Thomas

    • PamelaWibleMD

      Thank you Rob. Much appreciated. Please share widely.

  • DoubtfulGuest

    Will do, thanks.

  • DoubtfulGuest

    Bruce, I have a thought…you make many good points here and I’m in ~75% agreement with Dr. Wible’s approach…but in my personal experience the psychosomatic approach to care can be taken too far and actually backfire on the patient. I’m one of the 10%, if you will, although I wonder how many other people might have a similar experience. My ATP synthase has a manufacturing defect and causes lots of problems. Of course, as with all of us, stress makes my symptoms worse. But the disease has a strong cellular/biochemical/genetic basis. We are social animals and all need to be treated kindly by others. Certainly when my doctors are nice to me, I feel more motivated to do my part of treatment (taking several medications multiple times a day), eat well, exercise, and so on. And knowing that I have such caring people looking out for me does help me feel better about any other stresses that might crop up in my life. But that can’t cure the disease, or even really treat it. Before I was diagnosed, I had a few doctors get very angry with me. They pretty much said “Here I have been kind to you whenever you come in, treated you with compassion, and you’re not responding normally to it. You are still sick! So, that means there’s something wrong with you as a person, your character is sick instead of your body”. At one point, they were not using any objective evidence to support the notion that I am a bad person. I can’t begin to describe the extent of harm that caused me. It’s just something to consider, especially when we look at compassion fatigue. Almost everything has an ugly side when taken too far.

    • PamelaWibleMD

      Being nice is not a replacement for being a good diagnostician.

    • Bruce

      I think you are right: “the psychosomatic” approach can be abused. And, yes indeed, pushing (a) kind(-ness) too far can turn that kind(-ness) into the opposite (of) kind(-ness).

      It is a cop-out — and worse — for a healer to turn their nice-ness into its opposite — into blame-the-patient mean-ness — just because the patient’s illness does not clear in response to nice-ness alone, a nice-ness delivered together with insufficient applied scientific knowledge, and insufficient medical-technical skill.

      I think that Dr. Wible has been clear that, in her view, mere nice-ness is no substitute in a medical practitioner for highly-trained diagnostic and other technical medical-care skills.

      Indeed, “bedside manner +” is itself also a kind of additional medical care skill, but one that requires heartfelt sincerity — that cannot be “faked” if it is to be effective.

      Since ATP [Adenosine Tri-Phosphate] is the fully-charged variant of the master-molecule of all cellular biochemical energy, having a dysfunction in the enzyme that synthesizes it, from ADP [Adenosine Di-Phosphate, the energy dis-charged variant], sounds, to me, like it could impact every aspect of a person’s life energy and bio-molecular vital processes.

      Someone with any such issue would need medical practitioners with advanced bio-scientific training, it seems to me.

      Professional closeness and kindness, alone, would not suffice.

      But professional kindness and closeness, along with technical acumen, on the part of a scientifically-advanced doctor, might also help the healing process, vis-a-vis an ice-cold interaction with a scientifically-advanced, but emotionally-retarded, or emotionally-suppressed, or intimacy-fearing doctor.

      I notice so often — in this column, not to mention in life in general — that the better way is so often a third way: It is not one kind [emotional intimacy without diagnostic and technical skill, expecting emotion to do all of the healing work], nor its other kind [diagnostic and technical skill, delivered with cold "professional distance"], but BOTH, the integrated combination of the two [diagnostic and technical skill, delivered in the mode of heartfelt "professional closeness"] — the most difficult, MOST SKILLFULL of the three, I admit — that is the best option among the three.

      • DoubtfulGuest

        Thanks for your kind thoughts, Bruce. I expect we are of like mind on this for the most part. Any differences of opinion are probably based in 1) semantics and 2) a matter of degree. I know some doctors are just not comfortable with much emotional expression and that’s okay with me. I do want my doctors to feel relaxed and comfortable with no fear of lawsuits. I expect them to be honest and ethical. For my part, I accept mistakes, as long as they’re followed by sincere apology and explanation. I value my relationships with doctors. When I ask how they’re doing, I really want to know. When they’re tired, having a bad day, bereaved, etc. I’d want to show some extra consideration. I think many ‘emotionally suppressed’ doctors could benefit from a bit more openness. Often, gradual changes are helpful in these cases. You do make me wonder how often this is just someone’s basic personality/character vs. trauma and fallout from medical training (i.e. something they’d like to change if they knew how)? Or some combination of both. I try to respect people’s boundaries and not put pressure on them. But I absolutely see doctors as human beings — they should be treated as such by our health care system and society in general. Thanks for the book rec, I look forward to checking it out.

  • PamelaWibleMD

    Please share the TED talk. It tells the story of ideal care and how we can save one another. Can’t bear losing another colleague. Thanks Bruce!

  • Rob Burnside

    And with Vitamin S, we can change the course of a mighty river? Yes!

    • Bruce

      Yes, Indeed: with “Vitamin S”, we can even change the course of the mighty river of human history itself — right now wrong-headed — if enough of us put our hearts, minds, and souls into it!

  • Rob Burnside

    Right on, Bruce!

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