I'm a little down today. I've told you before that I take care of my own patients in hospice. I've also told you about watching patients and friends lose their battles with disease.
This week I had serious talks with several people about end-of-life issues (the details of which I can't really share at the moment). I've also had to tell someone about an abnormal lab result (a very bad one). In fact, the best news I've delivered all week was telling someone they had mononucleosis (rather than something worse).
I've found, in my limited experience, that terrible illnesses don't change people that much. If they were cheerful healthy folks, they tend to be cheerful (albeit appropriately sad and angry) sick folks. If they were curmudgeonly when well, they will usually be cranky when ill. Occasionally, some transformation will come over someone when they are confronted with a mortal illness, but I don't think this is the norm. When thinking about these things, it is very tempting to wonder how I would deal with such a thing myself, but if I've learned one thing in the last decade as a physician it is this:
Don't go there!
Empathy is a good thing, a necessary thing, but you cannot be an effective physician if your empathy turns into true identification. It is paralyzing. Everyone worries from time to time about what could happen to them if this or that illness struck, but doctors are in a bad position. We know too much. It's far to easy to come up with realistic scenarios of our own demise. This is especially true when dealing with ill patients who are like is, in age, education, ethnicity, etc.
We don't really talk about this much. I mean, we talk about "not going there", but we don't often acknowledge to each other what it means to "go there". As someone who teaches young physicians, I deal with their irrational fears all the time. Every lump, bump, cough, in the mind of a young doctor, is the seed of their own death. It takes a while to build up a bit of a skepticism about your own ability to evaluate your health. It also takes a while to find the right balance between empathy and identification---how to feel for the patient, without feeling like the patient.
Still some days it's harder. I was talking to a friend today (a fairly new friend, as it turns out) who is going through a particularly rough round of chemo. I grew up with her husband, she has a kid my kid's age; it's very easy to identify with her. If she were a patient, I would try to throw up that flexible fence with empathy on one side and pathological identification on the other. But she's not my patient. Where do I build my fence?
I don't. Sometimes it's possible to over-think things. She's one of the "cheerful" ones. She's not crazy, not stupid, not in denial, just a good person with a good attitude and a lousy disease. When it comes to friends and family, sometimes you've got to set aside the white coat and allow yourself to laugh and cry with someone, allow yourself to get close to someone even if you don't know where life is heading.
It's not always an easy ride, but it sure is better than the alternative.
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Many thanks for this PalMD - it has helped me identify one of things I most admire about a member of my family (she is a GP of over two decades standing.) She is a very good GP, and a very popular one: I've thought the magic quality was her *compassion* but, thinking about it in terms of your post I see it is not. While she has experienced traumatic events and very serious illness within family, she is always warmly present, insightful, the skilled & objective doctor at the ready but never occluding the person or the situation. Empathetic in her practice; compassionate with her family and friends.
Beautiful post. I've always wondered how a doctor finds that line. I've known a few physicians who take a somewhat impersonal approach, and put it down to needing to keep that distance. And that's fine, but anyone who can move that divider over to the blurry region between empathy and identification gets a little gold star in my ledger.
Also, I long ago decided that cheerful is as cheerful feels. Glad to know that applies generally even in the face of serious disease. I had known some specific examples (e.g. my father-in-law, who, while finishing off a progression of mestastasized cancers would say things like, (after a good long cough) "I'm going to have a bloody mary now, with real blood"), but your observations are closer to data than are my anecdotes.
Great post. Now can you be my doctor. Oh, wait, you do not live around here. My loss, not yours.
I think that emotional strain comes with the territory, and the fact that so many dedicated men and women voluntarily and knowingly subject themselves to that for the sake of helping others--well, let me just express to you personally the profound thanks I feel for you and everyone else who have the courage and selflessness to shoulder that kind of burden.
Nice post, dude. This is one of the things I see my own medical students grappling with as they begin their clinical rotations.
It is difficult to achieve sufficient emotional distance from their patients to allow them to function rationally, but without going so far as to dehumanize their patients. And once each physician achieves this delicate balance, it requires vigilance to maintain.
I struggle with this a lot. I used to feel sure that it would get easier to build that fence as I got more experienced, but reading this, I see that it doesn't. I'm not sure that's a bad thing--it means that it's possible to remain thoughtful and intentional about the way we empathize, and to continually reflect on the differences in our responses to patients and friends.
You're a wonderful writer, and a great role model. Thanks for this post.
In the not so distant past, I went through dealing with several doctors over an issue.
It was my family doc, who stayed after hours at her clinic to talk to me and manage the situation, that I will always respect. She didn't have to do that, but I'm grateful that she did. It made a horrible situation better.
The specialist I was referred to after? Terrible. Rude. Cold. She dropped the less than fantastic news on me, and said "why are you still in my office? why are you upset?!" I didn't want sympathy, but empathy.
And I have a friend in her final year of med school, and I watch her grapple with the same "line." I think as long as a doctor remembers that these are actual people, not "cases", it's good. My friend talks often about the highs and lows of what she does, and I think she'll be one of those amazing doctors.
I learned this lesson from my mother's doctor, when sitting in one time; young woman doctor, 90ish-year-old patient who rambled a bit, which always used to drive me crazy. And I saw the doctor's slow, genuine, full-face smile as she listened, patiently, eyes alive and attentive, to what I was dismissing as just another repetition, and realized this doctor was paying a lot better attention than I was.
I realized if I smiled the same way, I might pay attention better. And I did it --a real smile, the kind that goes all the way to the eyebrows and the ears, and my attention clicked, and I was in a brand new moment, not ignoring something I'd heard before. Ever since, each time I've needed it, it's worked. Closest thing I"ve ever had to a fast-school Zen moment.
I'm very grateful for the lesson.
Wow.../Respect
This a thing I learned while in college, tutoring other students in math and CS classes. To this day it baffles me that it works, but it certainly seems that it does.
As I am getting back into the educational swing of things, I have been trying hard to figure out where to go with it. I want to end up in psych, but I am not so sure clinical therapy is a possibility for me. And this is exactly why.
Before the baby came in December, I was still volunteering some of my time as a mentor for at risk kids (though even that was less than I used to). I really enjoyed it for the most part, as I was able to have a pretty positive impact on the lives of several kids in single parent households. The big problem that I had with it was objectivity and compartmentalization. Even after some fairly intensive training sessions and discussions with an awesome volunteer coordinator, I was unable to leave the problems of some of the kids at their front door.
I had to cut it way back when it was affecting my interactions with my own family. I actually felt relief when we got close to our due date and I finally had my last day. As much as I love working with these kids and helping them on their way through less than ideal childhoods, it was just too much for me. The straw that broke it for me, was meeting one of my kids at the jail. His mom was at work and couldn't afford to lose her job (no, she's not a neglectful mom, just poverty ridden). He was thirteen and got busted at school for smoking crack.
As much as I would love to go into clinical therapy and help others, I just can't seem to build that wall.