March, 2012. All of us have memory moments that seem indelible—scenes from our professional lives that are easily recalled and linked to strong emotions, either pleasurable or painful. One curious image on the painful side that remains with me is the face of a woman on the cardiology service of the county hospital in Houston when I was a medical student at Baylor. I was on my surgical clerkship, hustling with my classmates to keep up with the flying white coattails of the great Michael E. DeBakey and his fellow surgeons, as we made 5 a.m. surgical rounds. In and out of each room, at the speed of light, checking vitals, labs, and clinical status. The woman I remember in particular was in severe congestive heart failure. Even sitting up, her breathing was labored, and she had severe dependent edema. She looked at us with a pleading and desperate expression, saying very little since it made her short of breath to talk. She was told that things looked about the same and that the team would check on her again the next day. After leaving the room, we were told, in short, that she was dying and that nothing more could be done. This was one of my first really hard lessons in medicine, and the image of her struggling either to live a while longer, or entreating us to end her misery (I couldn’t tell which) has never left me. It never occurred to me until much later that the intensity of my reaction to this patient was related to the fact that my father was, at the same time, slowly dying of cancer.
A second painful image is that of a young new mother referred to me early in my career for postpartum depression. She was from another culture, and though stoic by nature, she was unable to conceal her depression and hopelessness. With the support of her husband, she reluctantly agreed to be hospitalized, and with medications, team support, and regular visits by me, she improved and was discharged after about 2 weeks. Tragically, she suicided the following week, leaving a motherless infant, a bereft husband, and a bereft psychiatrist. I worried that I had discharged her too soon, and for some time my professional confidence was shaken. In retrospect, I wonder if I overlooked key cultural factors (the patient was from a culture routinely deferential to physicians) that reinforced my wish to believe that she was stable and no longer at risk for suicide.
All of us have had experiences like these, or if not, we will have them in the future. The practice of medicine is about helping people, but it is not simple. Try as we may to make the right decisions with our patients, sometimes we fail. And sometimes there are no right decisions, when the savage nature of the illness prevails. In psychiatry, loss of a patient is, thankfully, a fairly rare event. But the nature of our profession demands that we get to know our patients well, so it stops us in our tracks when losses like these still occur. In this issue of the Journal, Scocco and colleagues discuss psychiatrists’ emotional reactions to a patient’s suicide, or to suicidal behavior and risk, based on a survey of practicing psychiatrists as well as psychiatry trainees. They discuss the grief experienced after a patient’s suicide, especially overwhelming for trainees, and the need for mentorship and support. Often such an event can reactivate strong emotions from prior experiences of personal loss such as the death of a family member, and the potential for confusing countertransference can be high. Also in this issue of the Journal, Aggarwal discusses the Psychiatric Cultural Formulation. Among many thoughtful insights and recommendations relevant to this important topic, the author emphasizes that the “Cultural Formulation asks clinicians to consider ‘cultural transference and countertransference’ in communication, rapport, symptomatology, diagnosis, and treatment.”
I am pleased to announce the winning paper of our 2011 Resident Paper Competition, highlighted in this issue of the Journal: “Medical countertransference and the trainee: Identifying a training gap,” by Jiménez and Thorkelson. I would like to congratulate Drs. Jiménez and Thorkelson for submitting this excellent winning paper, which provides valuable insight into types of countertransference reactions that can develop in clinical teams on the consultation/liaison service. Often overlooked, shared attitudes toward patients can reflect personalized antipathies interfering with a sustained, objective, and therapeutic view of the patient and the illness. In the broad sense of the term, countertransference is a regular and predictable ingredient in our clinical work, yet it all too often goes unrecognized.
John Oldham, MD