What Doctors Feel: How Emotions Affect the Practice of Medicine

Empathy--the ability to identify with someone else's suffering--is certainly a prerequisite for a genuine apology.

Thus, whatever the medical student has been taught, and even genuinely believes, about the ideals of medicine, the primacy of empathy, the value of the doctor-patient relationship--all of this is swamped once he or she steps into the wards. [...] It's no wonder that empathy gets trounced in the actual world of clinical medicine; everything that empathy requires seems to detract from daily survival.

Fear is a primal emotion in medicine. Every doctor can tell you of times when she or he was terrified; most can list more episodes than you might wish to hear. [...] It may be sublimated at times, it may wax and wane, but the fear of harming your patients never departs; it is inextricably linked to the practice of medicine.

Burnout also leads to a large swath of physicians who aren't as empathetic toward their patients as they could be.

But I realized that not only did I need to keep tuning my skills as a doctor, I also had to figure out a way to live with the uncertainty of medicine and its attendant anxiety.

To empathize with these patients, to put yourself in their shoes, may be a bit too existentially disconcerting. And so doctors unconsciously try to protect themselves by widening the moat between their own good health and their patients’ dauntingly mortal conditions

Neuroscientist Antonio Damasio describes emotions as the “continuous musical line of our minds, the unstoppable humming.

But at the most basic level, doctors need to be able to come forward with their errors and near-misses, otherwise we will never know where the problems lay.

The very fact that these doctors continuing to be doctors--highly successful ones--despite their errors and their accompanying assaults on their self-definion would itself be a potent lesson to the students and interns. It is possible to hold one's head up after an error, to admit that errors are part and parcel of human existence, even in medicine. It is possible to see the error as an aspect of oneself, not the defining characteristic of oneself.

How the sadness is handled by the physician has a powerful impact on the medical care received by the patients. If the grief is relentlessly suppressed--as in Eva's experience during residency--the result can be a numb physician who is unable to invest in a new patient. This lack of investment can lead to rote medical care--impersonal at best, shoddy at worst. At the other end of the spectrum is the doctor who is inundated with grief and can't function because of the overwhelming sorrow. Burnout is significant in both these cases, and that erodes the quality of medical care.

Grief ate at these doctors, distracting them from both their families and their patients. Many reported withdrawing from emotional involvement with their patients and that their patients had noticed they weren't fully present.

What these older physicians exhibited is termed clinical curiosity. They stroke to understand their patients in order to elucidate the underlying medical conditions. This thoroughness, patience, and dogged curiosity may have been ingrained in them because they trained at a time when they were no rapid CTs or MRIs. But even now, when these diagnostic tools are at their fingertips, these physicians maintain this approach to patients, one that serves to appreciate the dignity and uniqueness of each patient and his or her illness.

But while the patient does bear some responsibility, I believe that the onus falls more heavily on the doctor to be attuned to the factors--cultural, ethnic, or just personal style--that influence how patients present their symptoms.

I sometimes wonder whether doctors are more shame-prone than most people, or whether the medical profession itself is more shame-prone than other professions, though shame is, of course, a universal emotion. Given that we do not accept the idea of the good-enough doctor, that physicians are always striving for and expecting perfection, every doctor feels that he or she falls short to some degree. Perhaps shame and self-blame are built into the system because of an unrealistic and pervasive expectation of perfection.

These younger doctors are the immediate interface with clinical medicine for the students. The students trail their interns and residents every waking minute and absorb from them how medicine is done—how it is spoken, thought, written, performed, attired, and equipped.

Most medical students desperately want to help out on the wards—to ease some of their guilt, to “pay back” the interns and residents who are teaching them, to do some good for the patients in need they see all around them. But it’s hard to know where to start when your skills are minimal and everything is moving at breakneck speed with a paradoxically anarchic efficiency that you are sure to jam up. Indeed, the help that medical students earnestly offer often slows things down, a point that is painfully obvious to all parties involved. Although medical students eventually acclimatize somewhat to the clinical tumult, most retain that awkward sense of feeling useless, of being a constant fifth wheel. This difficulty in finding purpose, in finding a justified place in the beehive, can cause many students to unconsciously curtail their desire for engagement and hence their empathy.

Residents and interns are the grunts of the medical profession, tasked, simply, with getting everything done. The practical side of the clinical buck stops with them (even if the ultimate clinical and legal responsibility rests with the attendings), and the house staff do whatever it takes to get everything done. With their scut lists in hand, their coat pockets doubling as supply cabinets, they are the embodiment of the pragmatic. While many still retain their interest in the theories and mechanisms of disease, the overriding modus operandi is utilitarian, because unlike the electricians, housekeepers, therapists, technicians, orderlies, dietitians, even the nurses and senior doctors, their job description has no bounds.

For the researchers, sympathy is an emotion, actually feeling the patient’s feelings. Empathy is a cognition, a thought process that allows you to understand the patient’s feelings while not necessarily feeling them yourself. In fact, maintaining your own sense of self is a key part of empathy. The empathy definition might thus be reworded as the ability to stand in another’s shoes without actually leaving your own shoes. And of course the empathic doctor needs to be able to clearly communicate that understanding.

These derogatory terms, by definition, serve to distance doctor from patient, and this directly detracts from the ability to be empathic. While some of this slang seems merely callous, a lot of it derives from fear. Some of the states in which our patients live—or die—are downright terrifying. To empathize with these patients, to put yourself in their shoes, may be a bit too existentially disconcerting. And so doctors unconsciously try to protect themselves by widening the moat between their own good health and their patients' dauntingly mortal conditions.

Suddenly, I was plunged back into an avid learning environment, starting at the bottom and working my way painstakingly up the mountain. The thrill of learning and accomplishing stimulated me so much that the work was pleasurable.

Hospital life--with its byzantine array of moving parts layered atop the unpredictable rhythms of illness--is a permanent state of flux.

It can be rough going to maintain both composure and empathy in these situations, but a doctor's failure to do that is probably the number one reason why patients feel dissatisfied with their physicians and end up doctor-shopping endlessly.

In general, empathy is easier the more we can identify with someone. When we can genuinely envision ourselves in a situation, it's possible to intuit what that person's suffering might feel like.

Empathy requires being attuned to the patient's perspective and understanding how the illness is woven into this particular persons' life. Last--and this is where doctors often stumble--empathy requires being able to communicate all of this to the patient.

Neuroscientist Antonio Damasio describes emotions as the "continuous musical line of our minds, the unstoppable humming." This basso continuo thrums along while doctors make a steady stream of conscious medical decisions.