In 1889, Sir William Osler, in his legendary Aequanimitas lecture before a graduating medical school class, said, “a certain measure of insensibility is not only an advantage but a positive necessity in the exercise of calm judgment.” The central thesis of Dr. Danielle Ofri's book, What Doctors Feel, is that this widely embraced notion is difficult to achieve at best, and potentially compromises a physician's well-being at worst. As she says, “Understanding the positive and negative influences of physician emotions in doctor-patient interactions is crucial to maximizing the quality of medical care.”
Ofri, an Associate Professor at New York University who has worked at Bellevue for more than 20 years, is a frequent contributor to the “Science Times” section of the New York Times, the New England Journal of Medicine, and the Best American Science Writing series.
It is often said that “what you see is a function of where you sit.” Much of the first half of the book is devoted to illustrating some of the many stresses that confront medical students, house staff, and young physicians as they experience medicine in the bubbling caldron that is the essence of the “Bellevue Hospital experience.” I spent part of my third-year clinical clerkship at Bellevue, and the descriptions in the book of the fear, stress, fatigue, and sense of feeling overwhelmed are captured dramatically and convincingly.
All of these negative emotional influences work against preserving empathy—what Ofri believes is the all-important emotion in medical practice. As she defines it, empathy is the ability to recognize and appreciate a patient's suffering. Doctors seem to find empathy easiest when the patient's suffering is easily understandable and not self-inflicted. This is one of the problems in any urban hospital practice with its over-abundance of drug abuse, alcohol-induced illnesses, and poorly controlled chronic diseases. Paradoxically, this is one of the positives of an oncology practice, where the disease is clearly defined, serious, and not generally self-inflicted.
Empathy, it seems, can be measured, and physicians at Jefferson Medical College have developed a one-page tool that produces a numerical measure of empathy: For example, high empathy scores are seen in physicians who enter people-oriented specialties like primary care or pediatrics rather than procedure-oriented specialties. Oncology patients experience better quality of life and less depression when they have doctors with high empathy scores.
Ofri asserts that forces working against empathetic physicians are fear, sadness, stress, and overwhelming anxiety, which doctors often characterize as a sensation of drowning. Physicians sometimes feel like circus “acrobats, where more and more spinning plates are tossed onto their pole,” she says.
Grief is another of the complex emotions that is part and parcel of medicine and has been studied in oncologists, where the pervasiveness of death often results in a persistent sense of grief. Ofri shares data from an article in Archives of Internal Medicine (now JAMA Internal Medicine) with its accompanying editorial (2012;172:964–966 and 2012;172:966–967, respectively).
In the paper Leeat Granek et al describe oncologists' grief as feelings of powerlessness, self-doubt, guilt, and failure. Apparently, the attempts to compartmentalize as a coping tool are frequently used but work surprisingly poorly. Oncologists describe “grief spillover,” where they experience difficulty separating work from their personal lives. The editorial notes that in the extreme, stress can lead to emotional exhaustion, depersonalization, and the self-perception of inadequacy—all hallmarks of burnout.
The article advocates the use of staff support groups focused on coping skills, wellness initiatives, and shared experiences, and there are numerous examples of the success of programs of this type.
Given that 56 percent of practicing oncologists and 30 percent of oncology trainees experience burnout, such programs seem both beneficial and prudent.
Ofri devotes a full chapter to the effect of shame on medical practice. Here she explores the newer attempts to encourage full disclosure of medical errors and highlights the emotional obstacles to disclosure and apology.
Guilt, shame, and failure to live up to one's image of oneself make apologies difficult for physicians. Part of the problem, Ofri suggests, is the unrealistic expectations doctors and society have about their own capacities. These perfectionist attitudes result from the physician selection process, in-training programs like morbidity and mortality conferences, and the view that there is no such thing as a “good enough” doctor. These all lead physicians to turn blame for errors inward, and the effect often lingers for years after the event.
The book also contains a full chapter on “Drowning,” which focuses on the overwhelming work load produced by increasing patient volumes, growing masses of paperwork, and increasing numbers of patients with self-inflicted illnesses. This seems to impact general internists more than specialists where one out of six versus one out of 25, respectively, leave practice prematurely.
The final chapter covers the emotional impact of our increasingly litigious society and the effect of malpractice on physicians' emotions. Ofri stresses that the emotional toll is independent of the outcome of the episode. Unfortunately, as she says, “Emotions cannot be dropped.” Lawyers maintain that we not take it personally, but she says that is simply impossible. Malpractice suits in her view are “soul-corroding events,” which linger in physicians' minds and result in defensive medicine, higher health care costs, and burnout.
Ofri believes that the doctor-patient interaction is fundamentally a human connection and that emotions affect the quality of care more than Osler suggested and more than we would like to believe. She explores this using her experience as a generalist at Bellevue with a heavy focus on early training experiences.
The book would be a valuable read for young physicians in training. The reality is that with too much work and too much medicine to learn, physicians early in their career are not likely to take the time to explore this valuable and insightful text. That would be a missed benefit.
However, there is much here for the senior physician and specialist as well. The book does touch on some of the unique challenges of oncology and certainly refers the reader to literature on the subject. For an established physician specialist, much of this book will bring back old memories of the stresses of training as well as the excitement of medicine and the great satisfaction inherent in its practice.
What Doctors Feel provides a cerebral and analytical discussion of the emotional effects on medical practice. It explores ways to enhance the positive effects and minimize those that compromise one's ability to provide high-quality care.
2013, BEACON PRESS, HARDCOVER, 232 PAGES, ISBN 0807073326; ALSO AVAILABLE IN PAPERBACK, KINDLE, AND AUDIO EDITIONSCopyright © 2013 Wolters Kluwer Health, Inc. All rights reserved.
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