doctors and feelings

Is Your Model of Physician Behavior Out of Date?
As a physician, you are a product of medical culture; in that culture, there are unspoken manners and mores that its members are expected to note and assimilate.
In dealing with patients, for example, the historical model has been for physicians to remain cool, calm, and collected at all times. Your approach is to be strictly scientific: logical, objective, methodical, precise, dispassionate, the very embodiment of the term “clinical.” This, medical tradition has it, is in the best interest of doctors and patients alike.

That’s been the model since Sir William Osler, the father of modern medicine and a paradigmatic figure for generations of doctors, called on his colleagues and students to demonstrate “imperturbability,” which he defined as “coolness and presence of mind under all circumstances.”[1]
“A rare and precious gift,” Osler added, “is the art of detachment.”
But today, an attitude of detachment is often a double-edged sword for physicians. In many ways, it can be useful and necessary. It insulates and protects you from the powerful emotions that patients display in your presence: anger, frustration, bewilderment, grief, rage. And it insulates patients from the roiling emotions that you may at times feel toward them.
However, a detached attitude also insulates you from empathizing with patients. A doctor/patient relationship may technically exist, but it’s often too perfunctory to matter. The detached doctor talks in language that is over patients’ heads, assumes that they understand what was said, and keeps her eye on the clock. That, research shows, can have a negative impact on clinical outcomes.
Is Detachment Necessary?
Physicians may justify this aloofness by framing it as necessary for efficient doctor/patient interaction, believing that with people in the doctor’s personal life, there will be a different, more intimate standard of behavior — one that is more empathic, outgoing, revealing, and vulnerable.
Unfortunately, it doesn’t often work that way. Detachment is not like a light switch that you can turn on and off to suit the situation, experts maintain. It has a tendency to seep into all your relationships. It becomes a personal style of distancing yourself from the world — not just from patients, but also from colleagues, family, friends, and even yourself.
The result can be unhealthy for physicians and patients alike.
Bottled-up Feelings Can Lead to Burnout
Burnout is a good example of what can happen when physicians avoid their own feelings. In a Medscape video lecture on the subject, cardiologist Seth Bilazarian, MD, defines burnout as a physical or mental collapse caused by overwork or stress.”
Burned-out physicians tend to ignore their frustrations and not reach out for help, says internist Alan H. Rosenstein, MD, MBA, Medical Director for Physician Wellness Services in Minneapolis, which works with hospitals and practices to help physicians manage stress.
“These doctors are used to working autocratically and often lack emotional sensitivity,” Rosenstein says. “They may not be aware of what is happening to them, and if they become aware, their first reaction is, ‘I can handle it myself.'”
Burnout seems to be at epidemic proportions. One widely cited study found that almost one half of physicians experienced at least 1 symptom of serious burnout.[2] In another survey, almost 87% of physicians felt moderately to severely burned out, and almost two thirds said it was worse than 3 years ago.[3]
As to whether burnout adversely affects patient care, the evidence is mixed. One study found that burned-out physicians commit more surgical errors,[4] while 2 others indicated that quality was not affected.[5,6]
But there is evidence that burnout harms physicians’ lives, says Herdley O. Paolini, PhD. Paolini is a psychologist who, as director of the Florida Hospital Physician Support Services program at Florida Hospital in Orlando, treats some 35 doctors per week for burnout.
Burnout “has to do with depersonalizing yourself and others,” Paolini says. “Doctors face a lot of trauma, but the trauma doesn’t make them sick. It’s their inability to process the trauma. They just tough it out, even if makes them physically sick.”
Problems That Spring From Physician Detachment
Society puts physicians on a pedestal, and medical culture grooms doctors to assume that role. Is it any surprise that some doctors view themselves as special and above others? But it’s lonely at the top, and when a doctor falls, such as when a serious medical error is made, it’s a long way down. It’s made longer by the fact that many doctors choose to suffer in silence.
Rheumatologist Dennis J. Boyle, MD, a physician risk manager for COPIC, a malpractice insurance company based in Colorado, observes that physicians don’t like to discuss their mistakes. “Many physicians believe in the myth of perfection,” he observes. “They don’t tend to deal well with errors. It’s hard for them to talk about it.”
In addition, many doctors keep any knowledge of errors to themselves, fearing a lawsuit or hospital approbation.
But any sort of error can have a profound, emotionally destabilizing effect on physicians, Boyle warns. A 2007 survey of physicians who committed medical errors found that 61% reported anxiety about the possibility of making future errors, 44% felt a loss of confidence in their medical judgment, 42% encountered sleeping difficulties, and 42% experienced reduced job satisfaction.[7]
After making an error, “you can become unnecessarily cautious, which can result in the overuse of tests and procedures and distracted clinical decision-making,” Boyle says. A survey of orthopedic surgeons found that 96% practiced defensive medicine, accounting for $100,000 a year in extra costs per surgeon for tests and other services.[8]
Coping With the Reality of Imperfection
Even when a poor outcome is not the result of medical error, many physicians may have difficulty coping with his or her own perceived imperfection. Being emotionally isolated doesn’t help. Although they may take pains not to show it, doctors often feel very bad over a patient’s lack of improvement or death. In a 2010 study, physicians treating chronic pain reported feeling guilty when treatment outcomes were less than expected.[9] They also frequently feel self-doubt over a patient’s death.[10]
“Many doctors have not been taught to face a negative situation that should just be accepted,” Paolini says. “When a patient is dying and you don’t want to deal with your grief, you just keep on going” with heroic measures to try to save that individual. This leads to higher costs and lower quality of life in the patient’s final months, she says.
Doctors also have a hard time expressing regret over errors or poor judgment, even though sometimes an apology can reduce their risk for a malpractice lawsuit.
“Usually the only person who knows about the error is the doctor, and the only way anyone finds out is when the doctor comes forward,” says Danielle Ofri, MD, Associate Professor of Medicine at New York University School of Medicine and author of What Doctors Feel: How Emotions Affect the Practice of Medicine (Beacon Press, 2013). In a 2012 survey, about one third of physicians did not completely agree that they needed to disclose serious medical errors to patients.[11]
Ofri believes that physicians need to recognize that they have emotions too. “The doctor/patient relationship is still primarily a human one,” she says. “And when humans connect, emotions by necessity weave an underlying framework” of interaction, empathy, and concern that are important for healing both patient and doctor.
1. Osler W. Aequanimitas. 1889. Accessed June 6, 2013.

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