Wednesday, April 23, 2008
This is part one in a planned ongoing series of how to be a palliative care doctor. Why doctor and not nurse or social worker? Because I am a doctor, so I can only speak of what I know, but some of the same ideas probably apply regardless of discipline. If someone wanted to submit this from a SW or RN or other perspective, I would be willing to guest post it here.
The New York Times published an essay by a frequent NYT contributor, physician Barron Lerner about the role of emotions in caring for patients. As one may imagine the piece had much to do with working with patients diagnosed with cancer, and those who were dying, familiar arenas to an experienced palliative care doctor. The question in the essay is rhetorical: Should doctors display emotion? The answer to be found in the essay is a good one: If it fits for you and for the situation it can be powerful and potentially strengthen existing bonds. If crying in public is not your thing, don't go there.
In palliative medicine we encounter many sad, difficult and trying situations which test our emotional stamina daily. In fact for some of us, it may be that visceral connection from human to human attracting us to this specialty. I was surprised in residency when I first discovered 'breaking bad news' and 'compassionate honesty' actually led to praise and gratitude from patients and families who would cry, be angry, and eventually come to a certain peaceful but sad acceptance of dying. Using my medical knowledge to guide patients and families through this was personally rewarding and occasionally emotionally difficult, but I never cried in these meetings. In residency I would have these talks once a month or maybe once a week, but once you start doing palliative medicine full time you do this three to four times a day, sometimes 6 or 7 times.
Withdrawal of a ventilator in the ICU on an inpatient palliative consult service. The prolonged waiting of a slow decline in an inpatient hospice unit. Helping a family understand symptom control on home hospice visits. Three to five times a day you are experiencing the sadness, grief, anger, and stress of others as they approach death. Each time is not an intense 90 minute family meeting, but even if you briefly unleash those raw emotions from a patient or family, and the rest of the visit is upbeat and friendly, you as a palliative care doctor are still using some of your emotional stamina.
For some doctors crying at the bedside of a patient is acknowledgment of grief, impending loss, and the connection that has been built. If crying can restore some emotional stamina by releasing pent up negative feelings then this can be worthwhile. If crying at the bedside starts to become something you do more often than not, or start to feel as though you must or should cry, then you might need to look at other ways to replenish yourself and see if your team notices any signs of compassion fatigue/burn-out.
What a good palliative care doctor should not do is allow the crying to change the focus from the family or patient to the physician. This is a good built-in boundary check: If the family is more concerned about you then themselves, you might have gone too far. Some palliative care providers have also used their emotions to make a quick connection to the patient or family. In the guise of 'I lost my (insert relationship here) too,' the palliative care provider avoids the natural trust building and jumps right for the emotional connection. This also turns the focus away from the patient and family and to the provider. Building trust quickly is important in palliative care when you sometimes go from "Zero-to-Death and Dying in 5 minutes", but not at the expense of changing the focus away the patient/family unit.
Do I cry at the bedside? No, I don't, but have I felt a surge of sadness come to me? Sure I have and I later addressed those feelings away from the bedside. How I maintain my emotional stamina in this field is by becoming a professional chameleon, or some may say actor. By professionally adapting to the situation in front of you, your emotions can be sincere, but protected from your core by what I term a 'professional mask.' It is much like a two way mirror. Things come through the mask in both directions; I am able to outwardly display genuine compassion and concern to the level needed without compromising my emotional integrity. But when someone turns the lights on the other side of the two-way mirror, the emotions of the meeting can come through that 'mask' as well to affect me. I am sincere in my concern and compassion I display for my patients, I know because at the end of some days, I can tell my wife I don't feel much like talking and she understands. I am drained. A check of my emotional stamina is thinking about how opaque the mask is.
Is this just a guy thing? Maybe. I would like to hear what some of the female palliative care docs think of crying at the bedside. IS there a different social norm? I don't think the issue can be simplified to a male who is not allowed to show emotions or not in touch with his emotions. I am very familiar with my emotions because of palliative care, more so then I would expect without being in this field. The article also mentions the role of hugging. For me as a male physician, I don't go around giving out hugs to everyone I see, but I have pretty good Hug-dar when a family member is coming in for a hug, so I would not deny that. I am actually a big fan of free hugs from family members. So much so that if I know a family to be particularly generous with their hugs, I will make sure to take the stethoscope off my shoulders so they don't get a face full of ear pieces.
Emotions, crying, boundaries, and self-care are important to avoid burnout and depression. Newsweek recently published an article about physicians, depression and suicide risk, cheerfully titled, "When Doctors Kill Themselves." The article highlights an upcoming PBS special, "Doctors with Depression*", that features a palliative care fellow. I am hoping it highlights self-care training in his fellowship. As a fellowship director, I 'stress' self-care activities for fellows, and letting me know if they are pushing themselves too far. In a fellowship, I think it is actually a good sign if you can recognize when this happens, so don't be afraid to identify that in yourself. The work of a palliative care physician is emotionally taxing, which is why we must look out for ourselves and each other.
How do other palliative care doctors (or other disciplines) deal with emotions, depression, burnout? What is the ideal approach to outward display of emotions for our field and disciplines?
Other bloggers have posted about crying physicians here and here and here.
*Sponsored in part by Wyeth, makers of Effexor