| Monday, January 01, 0001
Think about some of the career archetypes in our culture. We expect our police officers, firefighters and other armed servicemen to be bold, selfless and willing to sacrifice their own safety for that of others. We expect our clerks and sales representatives to be prompt, friendly and helpful, our teachers to be knowledgeable and our technicians and tradesman to be competent. These are all classic, broad-brush definitions for how we evaluate these individuals as members of a community, as well as keen indicators for job proficiency.
Now, think about a physician. What's the "classic" doctor archetype? Calm and collected? Able to make life and death decisions (sometimes literally), to deliver harrowing news and to call upon delicate surgical prowess, even under extreme duress? How about emotive and warm? Approachable? Emotionally competent and able to reach out and fully connect with patients? Indeed, the modern physician must be a veritable combination of all these traits.
To understand much of physician culture we can look to Sir William Osler, the father of modern medicine, for examples. Osler said physicians should "demonstrate imperturbability," or more plainly "coolness and presence of mind under all circumstances." Essentially, the embodiment of the term "clinical." However, it's what Osler says next that has some re-evaluating the paradigm for physician behavior. "A rare and precious gift, is the art of detachment."
Late 19th and early 20th century biases aside, there's still much truth to what Osler said. But how much? In many cases, detachment is a profoundly beneficial defense mechanism for physicians under stress. When important diagnoses must be delivered, feelings, fears and emotions can run at elevated levels. It takes a practiced physician to maintain poise and cool in and to develop an action plan with a patient – without being drawn into a detrimental emotional tail-spin.
But while some level of detachment can be necessary, detaching too far can have negative consequences. In his recent article Is Your Model of Physician Behavior Out of Date?, Leigh Page suggests that many physicians justify their detachment, or aloofness, under the banner of "efficiency." They insist that such levels of detachment are necessary for proper patient-doctor interactions, and prove ultimately most beneficial to both parties.
He also calls this act a "double edged sword" in that the types of detachment which insulate physicians from anger, rage and hostility under potent circumstances, may also be insulating them from having real and important connecting experiences with patients down the line. Furthermore, it may have an eroding effect on their personal lives.
"Detachment isn't like a light switch that can be turned on and off to suit a specific situation," he says. "It has a tendency to seep into all relationships. It becomes a personal style of distancing oneself from the world, not just from patients but also colleagues, family, friends and yourself."
Overly detached attitudes can prevent physicians from truly empathizing with patients, impeding their ability to cultivate compliance and ongoing doctor-patient trust. Detached doctors can speak in a way which is over the patient's head, and can fail to check for understanding, becoming fixated on external stimuli, like the clock or the back of patients in the waiting room.
The precursor to burnout
Physician burnout is a condition defined by Cardiologist Seth Bilazarian, MD as "physical or mental stress, or mental collapse, caused by overwork or stress."
Physicians reach dangerous levels of burnout when they ignore their own frustrations, stay separated from their own feelings and don't reach out for help. It's a rising tide, too. One widely cited survey found that 50% of physicians will suffer at least one symptom of serious burnout this year. Another comparable survey finds that 87% of physicians felt moderate to severe burnout, and 66% claimed that the phenomenon has become more prevalent than it was only three years ago.
Physician burnout most certainly has adverse impacts on patient care. One study finds that burned out physicians commit more surgical errors than those who aren't. Herdley O. Paolini, PhD is a psychologist who works as a director of the Florida Hospital Physician Support Services Program at Florida Hospital in Orlando, and ends up treating an average of 35 physicians each week for burnout and burnout related symptoms.
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."
Breaking the detachment-burnout cycle
While physicians may have difficulty coping with their own perception of imperfection, emotional isolation can further exacerbate the situation. Taking great pains to mask discomfort, to secretly nurture the feelings of guilt over a patient's lack of improvement or even death, or the continued belief that by keeping emotionally distant from patients they can protect themselves from trauma, can germinate into severe levels of burnout and less effective patient care and greater ancillary costs.
Paolini says that some situations, even negative ones simply need to be accepted. In her book What Doctors Feel: How Emotions Affect the Practice of Medicine, author Danielle Ofri, MD, an Associate Professor of Medicine at New York University School of Medicine, notes that, for example, medical errors have a tendency to get blown out of proportion, doing more damage to the physician than the patient. "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."
Like everyone, physicians have emotions. To deal with the demands and stresses of the job, which at times can be extreme, physicians must acknowledge their own feelings, especially when they're negative. Perhaps this means channeling them in positive ways like writing them down in a journal, consulting a trusted medical mentor or even something as innocuous as exercise. The treatment is often much simpler than the symptom; it's just important that it is acknowledged.
The doctor to patient relationship is primarily a human one. When humans connect on an emotional level, they "weave an underlying framework of interaction, empathy and concern" which goes a long way towards healing both patient and doctor (What Physicians Feel, Orfi).
All things should be taken in moderation and extremes in any belief tend to do more harm than good. The key isn't to get too emotionally invested, nor is it to detach too much. Doctors need to care for their patients in a genuine way that doesn't violate any boundaries, and this means processing trauma in healthy ways. In today's modern medicine, the human factor is still what helps heal patients. Detached physicians may think they're doing something responsible in the immediate stages, but in the long run they may be doing more damage to themselves and to their patients.
Grappone, Amy. "Uncertainty and the Doctor-Patient Relationship."
Countingupfromzero.com. N.p., 8 June 2013. Web. 14 July 2013.
Orfi, Danielle. "Uncertainty Is Hard for Doctors."
Blogs.nytimes.com. New York Times, 6 June 2013. Web. 14 July 2013.
Ofri, Danielle. What Doctors Feel: How Emotions Affect the Practice of Medicine.
Boston: Beacon, 2013. Print.
Page, Leigh. "How Doctors' Feelings Affect Their Patients' Care."
Medscape.com. Medscape, 20 June 2013. Web. 14 July 2013.
Dylan Chadwick is a graduate of Brigham Young University where he earned a Bachelor of arts in English and a minor in Spanish. Though spending his formative years in Cardiff Wales, he came to adolescence in Elizabethtown Kentucky, and considers it his home. He received the Eagle Scout Award, served a voluntary humanitarian mission to inner-city Los Angeles from 2007 to 2009, and once met Alan Alda on a golf course. He's an avid writer who cut his teeth contributing to student papers and continues writing for various print magazines, blogs and web resources. A ravenous fan of baseball, rock music and Dan Aykroyd-era Saturday Night Live, he plans on one day utilizing these interests in a Masters degree in American Studies and Literature. He also maintains a freelance illustration company on the side.