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What Doctors Feel

Doctors are often accused of being unfeeling technicians who treat their patients like cases of disease rather than people (think Dr. House). We were taught in medical school to remain detached, not get too close to patients, and not show our emotions. That attitude was epitomized in William Osler’s essay Aequanimitas. But doctors have feelings like anyone else, and no one is Spockishly rational. A patient might reasonably say “I don’t give a damn how my doctor feels as long as she gets me better,” but emotions affect everything we do, influencing clinical decisions and patient outcomes. This subject is investigated in a new book, What Doctors Feel: How Emotions Affect the Practice of Medicine, by Danielle Ofri, MD, PhD, an associate professor of medicine and an accomplished writer who has written extensively about her experiences in medicine.

She tells anecdotes from her training to give the reader a feel for what it was like to be in an extremely stressful situation with time pressure, conflicting duties, lack of sleep, life-or-death responsibilities, the highest expectations, and the impossibility of both getting everything done and doing each thing well. It reminded me of times in my own training when I desperately wanted to just somehow survive the day and not kill anyone. Medical residency can be almost as stressful as a war zone, and has its own PTSD victims, complete with flashbacks.

Part of the stress is being suddenly immersed in a new culture with its own tribal customs, slang, in-jokes, and a foreign language: “82WM w/PMH of CAD, CVA, MIx2, s/p 3V-CABG, c/o CP, SOB 2 wks PTA. BIBA s/p LOC. No F/C/N/V/D.”

Empathy for patients tends to diminish during training. And it’s important: in one study the diabetic patients of high-empathy doctors had 40% fewer complications.

Everyone makes mistakes. Ofri candidly confesses some of her own mistakes and near-disasters and the emotional impact they had on her. When doctors make mistakes and a patient is injured or dies, or almost dies, it takes a terrible toll: guilt, shame, fear, defensive practice (ordering unneeded tests and getting rid of rude, demanding, or noncompliant patients), and soul-corroding damage to their core sense of self.

And then the lawsuits! 75% of doctors in low-risk specialties (pediatrics, dermatology, psychiatry) will be sued for malpractice by age 65; in high-risk fields (neurosurgery, cardiac surgery, obstetrics) it’s 99%. Fully 19% of neurosurgeons face a lawsuit each year. Not even a seemingly perfect doctor/patient relationship can prevent lawsuits. She tells about a family doctor who delivered a child with cerebral palsy and remained close to the family as he cared for them over 20 years. He was devastated to be sued for obstetrical malpractice at the 20 year mark even though he understood the financial motivation: the parents were afraid there wouldn’t be enough resources to care for their son after their death. Even if the suit is frivolous and the doctor has not made a mistake, the legal process is emotionally draining and can last for years.

Doctors who have been sued are more prone to burnout, depression, and suicidal thoughts. In a recent Medscape report, 23% of doctors characterized their lawsuit as “Horrible. One of the worst experiences of my life.” 39% of lawsuits lasted between one and two years; 11% dragged on for more than 5 years. On the upside, 57% resulted in no monetary award to the plaintiff. The long-term effects? 29% said “I no longer trust patients; I treat them differently.” And some of them practiced defensive medicine.

Ofri discusses problems with American medicine: the increasing burden of paperwork, the decreasing time for patients. Hospitalists spend only 18% of their time on direct patient care. Patient outcomes are better when doctors are happy in their jobs.

She describes the emotional ups and downs she experienced over many years with a favorite patient, a plucky single mother with progressive heart failure. As an illegal immigrant, she was ineligible for the heart transplant list. Finally she got a green card and a heart. Dr. Ofri describes her own joy at hearing the news; but then she has to describe her sorrow when the patient promptly dies of surgical complications.

The “system” often sets doctors up for failure and helpless frustration. She reports a trivial but telling example: residents were required to be in a conference that lasted until 1 pm, and also expected to arrive promptly at 1 pm in the clinic a quarter of a mile and 2 slow elevators away. A simple change to a 1:15 pm clinic starting time solved that problem.

More serious problems of burnout and lack of sleep are being addressed by limiting hours on duty and facilitating discussions and group support efforts. Much more can be done, such as allowing more time with patients, and Dr. Ofri’s insightful book can help guide us in the right direction. Acknowledging the role of emotion in medical practice will be a critical factor.

Osler wrote his Aequanimitas in 1889. In 1927 Francis Peabody wrote:

One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.

Ofri is clearly a Peabody-type doctor but she also embodies some of the best qualities of the Osler-type doctor. An ideal mix, I’d say. It was a privilege getting to know her through this book.

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20 thoughts on “What Doctors Feel

  1. “Empathy for patients tends to diminish during training. And it’s important: in one study the diabetic patients of high-empathy doctors had 40% fewer complications.”

    In a community of skeptics, this statement seems quite bold. Assuming there are no problems with the study (Okay… No study is perfect), we still don’t know if empathy is simply correlated with more positive outcomes.

    1. Egstra says:

      ” we still don’t know if empathy is simply correlated with more positive outcomes.”

      My guess is that both are correlated with other variables, such as greater patient willingness to talk to empathic MDs, empathic MDs taking more time, and so forth.

  2. Carl says:

    Part of the stress is being suddenly immersed in a new culture with its own tribal customs, slang, in-jokes, and a foreign language: “82WM w/PMH of CAD, CVA, MIx2, s/p 3V-CABG, c/o CP, SOB 2 wks PTA. BIBA s/p LOC. No F/C/N/V/D.”

    Dr. Hall finally reveals the full content of her tribal arm band tattoo.

  3. Thor says:

    I agree with JP: not only that statement, but the article itself is bold. Thanks, Harriet, for your candor and braveness, knowing full well what fodder this may be for proponents of ‘integrative medicine’. It underscores SBM’s (and science in general) willingness for correcting itself, for improvement—in direct contrast to CAM, which will never admit to any weakness or fallacious claim. It is, indeed, a complicated world, and medicine is no exception; the challenges it faces are daunting. Sadly (and dangerously), this leaves the door open to the wonderful world of CAM. Patients are attracted to the prospect of receiving more personal attention, more time, more care. CAM practioners have the luxury of offering these, since that is basically all they can offer. But, mixing sugar into a cake made of dung in no way makes it a good recipe, and ultimately leaves the diner unfulfilled and/or sick.

  4. hat_eater says:

    To see the other end of the spectrum visit Poland, where doctors are routinely acquitted by a jury of their peers and a case of six doctors who (independently) failed to diagnose and treat a developing widespread infection in a three year old boy ended with slaps on the wrist and only recently has been turned to the criminal court under media pressure.

  5. hat_eater says:

    Sorry – I didn’t mean to imply that suing your doctor for any real or imagined infraction is the solution (even if I think it’s preferable to near-total impunity). I wish the situation was more reasonable in both countries and all over the world. Here, too, doctors bear the emotional cost of responsibility, smoke and drink more often, die sooner.

  6. anthro49 says:

    I’ve been up in the woods with no internet and this is a very welcome, and somewhat timely post to come back to. I was with someone who sees docs but plays around with a lot of woo-ish ideas, if not the actual practitioners. She changes docs frequently, insists on unwarranted tests (and then grudgingly pays out of pocket for them) for “peace of mind”. If the docs (or me) attempt to reason with her, we are accused of all the standard tropes. She cannot understand why the doctors won’t address her “thyroid condition”, her “adrenal exhaustion”, her “drug sensitivities”, and so on. She won’t take a statin, get a flu shot (“I got one once and felt awful”, “my neighbor got one and then got the flu”, “I’m not anti-vax, but surely kids get too many too soon”, “they have formaldehyde in them”). The dose makes the poison had NO effect.

    This person is well-educated, bilingual, taught school for many years and gets most of her “information” from Dr. Oz and her son who is just starting–ready…..

    medical school :-(
    (He sees a “holistic” doctor and a chiro, eats tons of protein in the form of red meat (grass fed and therefore good for you), and absolutely no evil GLUTEN).

    I’m considering reading this book and then passing it on to her. She talks of doctors as though they are mere servants who are not following orders. I remain hopeful that there might be a way to reach these kinds of people and perhaps a book about the emotions of doctors, rather than a “but science tells us…” approach might work better.

    Lastly, can anyone tell me how to find a friend who isn’t into some level of CAM? Sorry to rant, but I’ve had this nonstop for three days and nights.

    1. windriven says:

      Anthro, your friend is a classic hypochondriac. She always has something, the doctors can’t diagnose it, and what prescriptions the doctors give don’t work.

      “This person is well-educated, bilingual, taught school for many years… ”

      I’ve struggled with this for years: people with plenty of schooling who are nonetheless sorta dopes. My suspicion is that some people approach education as an accumulation of facts without ever really internalizing the underlying concepts, much less learning to apply those concepts broadly and across disciplines.

      “I’ve had this nonstop for three days and nights.”

      What a way to defile the outdoor experience. You have my sympathy. I’m going to hike Marmot Pass in the Olympics in a few weeks. My companion will be my yellow Lab. She doesn’t subscribe to any sCAMs that I’m aware of and if she does she keeps it to herself ;-)

      1. Thanks windriven–that helps a bit. I told this woman point blank that I prefer to travel alone in future, which seemed to surprise her. As this is not the first time this sort of thing has happened, I think I’ll be following your example and just taking the weenie dog from now on. She’s not much of a hiker, but I can put her in a backpack when she poops out (but not when she poops).

        It is truly amazing how stupid some educated people are and how much you can agree on many basic things, and then it always seems to come back to how much they love Dr. Oz or whomever has drug them down the sCAM path.

        goodnightirene, aka anthro (it has been such a struggle to get my screen name right with this new WP thing)

      2. mousethatroared says:

        “your friend is a classic hypochondriac. She always has something, the doctors can’t diagnose it, and what prescriptions the doctors give don’t work”

        Or she is like many of the women in the Lupus (and mixed or undifferientiated connective tissue disease) board that I read, many of whom went years seeing doctors for symptoms and not getting answers.

        Hypochondria is supposed to be diagnoses of exclusion. Just having been seen by a doctor does not exclude the possibility of disease. Who knows if the doctor or doctors actually ran the appropriate tests and evaluated them within the current guidelines or just ran a CBC and BMP offered reassurances when they didn’t turn up any obvious clues?

  7. Sasha says:

    Doctors see their patients like cases and not like people suffering from pain, its so that they are trained in such a way that there will be no space for empathy for their patients.

    1. Harriet Hall says:

      If you believe all doctors are like that, you really need to read Dr. Ofri’s book.

    2. windriven says:

      Would it be correct for me to say: people named Sasha are short-sighted whiners?
      No? Then how can you assert that all doctors lack empathy?

      If you have a problem with your physician, first have a look at yourself and how you manage your half of the doctor-patient relationship. Discuss it with your doctor. And if you still aren’t satisfied, as of 2010 there were about 209,000* primary care physicians practicing in the United States. Try another one.

      *http://www.ahrq.gov/research/findings/factsheets/primary/pcwork1/index.html
      Apologies if you don’t live in the US but I’m sure there are plenty of primary care physicians wherever you do live. You shouldn’t spend less effort choosing a PCP than you do picking the new paint color for your living room.

    3. Pareidolius says:

      All people called Sasha are anti-intellectual, ear-candling, woo-addled, neo-hippies who smell of patchouli see channelers regularly and get most of their information from naturalnews.com. How close was I?

  8. mousethatroared says:

    My experience doesn’t lead me to believe that unfeeling medical practitioners create problems in healthcare at all. To be honest, If one could outfit a computer with the ability to do a physical exam I’d take an emotionless (but well designed) computer program over several of the bored, (or annoyed, impatient, defensive, frustrated) doctors I’ve seen over the years. This is not to say I haven’t seen my share of positive empathetic doctors as well.

    It’s just that I think that providing medical care must be a real day to day grind, that the doctors have a human need to feel like they’ve accomplished something. I think that humans tend to pay more attention to projects that are emotionally gratifying and that this might be at odds with caring for people who sometimes have unexciting, non-life threatening illnesses without a lot of dramatic treatment options. Computers, they can run their programs forever, without getting bored (frustrated, ect). They don’t preference interesting or exciting projects over boring or inclucusive project, unless they are programmed to.

  9. “And then the lawsuits! 75% of doctors in low-risk specialties (pediatrics, dermatology, psychiatry) will be sued for malpractice by age 65; in high-risk fields (neurosurgery, cardiac surgery, obstetrics) it’s 99%. Fully 19% of neurosurgeons face a lawsuit each year. Not even a seemingly perfect doctor/patient relationship can prevent lawsuits.”

    I’m curious where these numbers come from. For obvious reasons (perhaps to arm us for future dinner parties), the plaintiffs’ bar publishes some variant of the following link every year or so. http://www.nytimes.com/2009/09/23/business/economy/23leonhardt.html?_r=0

    Disclaimer: I sued a doctor once. He was a psychiatrist who groomed, then screwed, a very vulnerable patient. The father of another client was an OB/GYN in Canada who practiced for decades but had never been sued. I suspect treatment of malpractice suits plays a role, but strongly suspect that when injured parties do not have to worry about future health care costs due to medical error, they have much less cause to sue.

    1. Stella B says:

      One of my co-workers got a phone call from an ex-patient once. As a young physician he had diagnosed some life-threatening problem and felt that he had taken care of her well. She had sued him which had really crushed his enjoyment of the job for years. About 25 years after the suit she started a 12 step program and called him as part of making amends to the people she had wronged. She told him that she had just needed the money. I did a Pap on a 3 pack per day smoker and was sued 4 years later when she developed … wait for it … lung cancer. She sued the 7 primary care docs who had seen her for various problems over the previous five years. That incident really helped me decide to retire. Both suits were dropped.

      1. This is one of the saddest and most troubling things I’ve read in a while, but thank you for sharing anyway. It seems incomprehensible that someone would sue because she “needs the money” and what kind of lawyer signs on to such a thing (it’s a rhetorical question)?

        1. Young CC Prof says:

          There are really only 2 reasons individuals sue, either because they are angry, or because they desperately need money and see no better way to get it.

          A better health system and social safety net might help with the second issue, but that’s a nonstarter these days. For medical malpractice specifically, I’m a fan of health courts, which could offer RAPID verdicts by specially trained judges, with standardized settlement amounts. Rapid resolution of a lawsuit is better for both plaintiff and defendant.

  10. Mark says:

    Interesting. My previous doctor, I can honestly say made me feel like I was “just a case”. However, I do not think this is the case in a majority of situations. I recently started seeing a new doctor, and it is the complete opposite. I feel so appreciated and warm going for a visit, and this is how I believe everyone should be treated. Thanks for sharing your thoughts on this with us!

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