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Page 1: Exploring the Emotional Aspects of Patient Care

COLUMN: LITERARY RESOURCE

Exploring the Emotional Aspects of Patient CareDanielle Ofri: What Doctors Feel: How emotions affect the practice of medicine. BeaconPress, Boston, MA, 2013,978-0-8070-7332-2, 224 pages; $24.95 (hardcover)

Mary K. Morreale & Richard Balon

Received: 21 January 2014 /Accepted: 22 January 2014# Academic Psychiatry 2014

Even as psychiatrists who are trained to recognize emotionalresponses to patients, it is likely that many, if not all of us,have experienced situations in which we found it challengingto maintain emotional neutrality. The teaching of neutrality inour field is likely rooted in Freud’s work. In “Recommenda-tions to physicians practicing psychoanalysis,” [1] he wrote,“The doctor should be opaque to his patients, and like amirror, should show them nothing but what is shown tohim.” This objective is certainly not limited to psychiatrists.As Danielle Ofri, a practicing internist and essayist, writes inWhat Doctors Feel: How Emotions Affect the Practice ofMedicine, Sir William Osler also spoke of it in a speech titled“Aequanimitas” [2] given to medical graduates in 1889: “Acertain measure of insensibility is not only an advantage, but apositive necessity in the exercise of calm judgment.”

Ofri’s book, her latest in a series of works examining med-icine and the doctor-patient connection, explores the disconnectbetween the teachings of insensibility and opacity and the“flood of emotions that even the most distant, aloof doctor”experiences (p. 4). InWhat Doctors Feel: HowEmotions Affectthe Practice of Medicine, Ofri illuminates the breadth of physi-cians’ feelings and describes how emotions influence the prac-tice of medicine. Ofri writes “The emotional layers in medicineare far more nuanced and pervasive thanwemay like to believe.In fact, they can be the dominant players in medical decision-making, handily overshadowing evidence-based medicine,clinical algorithms, quality control measures, even medicalexperience” (p. 3). Using true stories based on her experienceas a medical student, resident and attending physician, andthose of several additional physicians, Ofri uncovers the emo-tional experience of practicing medicine. Through the analysisof these emotions, Ofri believes medical care can improve.

She begins the book by discussing empathy. Empathy tendsto come naturally when “patients’ suffering seems to makesense…or when patients seem deserving” (p. 10). Becauseidentification with a patient is the “first step towards empathy”(p. 12), it can be hard to empathize with those who have poorhygiene or even with patients who are severely disfigured.Empathy can be difficult when we perceive that patients arecontributing to their illness, for example, in those who abusesubstances or are obese. Unfortunately, Ofri believes our cur-rent system of training physicians endangers the developmentof empathy. From the language of medicine (e.g., GOMER, getout of my emergency room [3]) to gallows humor, medicalstudents are distanced from patients. The overwhelming work-load and fatigue contribute as well. “Sure it’s wonderful to havean in-depth conversation with a patient” (p. 34), but the jobmust get done. Although Ofri mentions curricular changes thatfoster empathy, she feels that the primary responsibility forpromoting empathy lies with attending physicians who clini-cally supervise student and residents. “If the commandingdoctor at the top of the heap has no issues about being humblewith a patient, then it is okay to do” (p. 55).

The book continues with a chapter discussing various typesof fearful situations that physicians may encounter. Ofri be-gins with a description of an “acute stress reaction” (p. 73) inan intern whose mind freezes after an overwhelming day on-call. Although Ofri’s example of this phenomenon may notmatch DSM criteria, it is apparently quite common and po-tentially devastating for both physician and patient. Ofri goeson to describe her own fear after making a medical mistake:“There’s no easy answer about how to proceed onward indaily medical life with that ongoing churn of anxiety and fear,and certainly no research to guide us. Each doctor has to cometo terms with it and negotiate an individual emotional armi-stice” (p. 93). Because the stakes are high in our field, somefear is necessary.

In our opinion, the most moving stories in this book arecontained in the chapter titled “A Daily Dose of Death.” Ofri

M. K. Morreale : R. Balon (*)Wayne State University School of Medicine, Detroit, MI, USAe-mail: [email protected]

Acad PsychiatryDOI 10.1007/s40596-014-0047-5

Page 2: Exploring the Emotional Aspects of Patient Care

tells the story of Eva, a pediatric resident, who faces multipletraumatic experiences with no psychological support. Evastates, “All of residency seemed to be an exercise in stuffingtraumatic experiences way down into consciousness” (p. 102).Eva leaves pediatrics for psychiatry, but unfortunately ends upemotionally disconnected from her patients. Ofri writes of adefining moment in Eva’s career when she is examining analcoholic who had fallen and possibly sustained a head injury.“I really didn’t give a f*** whether he was bleeding in hishead” (p. 105). Eva had suppressed grief to the point ofnumbness and per Ofri’s accounts, PTSD.

Ofri continues with a chapter on shame. She makes a pointof distinguishing guilt from shame, utilizing a definition from“On Apology” [4] by Aaron Lazare, a psychiatrist and formerdean of the University of Massachusetts School of Medicine.“Guilt is associated with a particular incident and can dissipatewhen the issue is resolved. But shame reflects a failure ofone’s entire being. While guilt often prods a person to makeamends, shame induces a desire to hide [4].” It is shame, Ofriposits, that makes it difficult for doctors to apologize for theirerrors. “Either you are an excellent doctor, or you are a failure”(p. 129). Ofri mentionsWinnicott’s “good-enoughmother” (p.129) and notes that there is no room for this concept in thefield of medicine. Again, Ofri believes senior faculty can helptrainees recognize shame and process medical error. It is themwho can “talk publicly about their own errors and specificallyaddress how they dealt with the shame” (p. 136). “Error can bean aspect of oneself, not the defining characteristic” (p. 136).

In a chapter titled “Drowning,”Ofri tells the story of Joan, anemergency medicine physician who turns to alcohol as a way ofcoping with the disillusionment she experienced in clinical med-icine. Ofri uses Joan’s story as a sounding board for physiciandisillusionment as a whole. Caring for patients who are entitledor neglect themselves, time pressures, work-life balance, paper-work, and even boredom—all can contribute to disillusionmentand, ultimately, burnout. Ofri discusses the risks this imposes onphysicians, including substance abuse, depression, andabandoning one’s job and uses Florida Hospital in Orlando as asuccessful example of an institution that is actively working toenhance physician wellness, thus minimizing burnout.

Finally, Ofri discusses the emotional toll of litigation. Sheshares her own experience and, among others, that of a youngpsychiatrist whose borderline patient suffered serious injuriesafter jumping from a rooftop. Ofri describes lawsuits as “soul-corroding” (p. 190) for physicians, with little benefit for patients.“Most cases never go to trial, and of those, patients don’t usuallywin. But the lawyers always benefit financially, no matter whatthe outcome” (p. 189). In this final chapter, Ofri also speaks toquality indicators and reviews by patients. Ofri criticizes theformer: “these sort of metrics don’t give a full measure of quality;they simply measure what is easy for administrators to measurebut do not necessarily add up to the totality of goodmedical care”(p. 195). Regarding online reviews by patients, Ofri writes,

“There are many who feel that choosing one’s doctor shouldrequire slightly more sophisticated thinking than choosing atoaster oven or a Mexican restaurant” (p. 196).

Woven through the book is the story of Ofri’s patient Julia,an undocumented immigrant in need of a heart transplant.Ofri’s relationship to Julia incorporates many of the emotionsdescribed in this book, including deep connection, empathy,frustration with the system, and dealing with loss. It is by wayof multiple true stories like this that Ofri keeps the readerengaged and keeps this book from reading like a rant againstour current educational and clinical systems.

Despite systems that fail to support empathy or help phy-sicians to process fear, grief, and shame, we found hope inOfri’s description of the connection between doctors andpatients. What Doctors Feel: How Emotions Affect the Prac-tice of Medicine is a book that can “normalize” medicalstudents’ and residents’ emotions and can open them to theprocess of examining their feelings. For attending physicians,particularly those involved in education, this book serves as areminder of the struggles of medical school and residency andwill, we hope, stimulate ideas to assist trainees. As a final noteand reminder, a charming passage, from a conversation Ofrihad with a senior physician, that encapsulates her sentimentsregarding opacity and insensibility follows:

“When I brought up Osler’s speech, about doctors keep-ing an emotional distance from patients, he gave a snortof derision. ‘Garbage wrapped in tinsel is still garbage.And what did Osler know anyway? He was a puppathologist from the Canadian prairies. He learned hisbedside manner on cadavers’” (p. 56).

Implications for Educators

• Despite the goal of maintaining emotional neutrality, physiciansexperience a wide range of feelings.

• The current system of physician training does not adequately supportthe processing of emotions and empathy.

• Educators need to pay attention to trainees’ “emotional” careerdevelopment.

Disclosure The authors have no conflicts to disclose.

References

1. Freud S. Recommendations to physicians practicing psycho-analysis.The standard edition of the complete psychological works of SigmundFreud, Volume XII, 1912.

2. William Osler, “Aequanimitas” speech, Celebrating the Contributionsof William Osler, website, Johns Hopkins University; 1889. http://www.medicalarchives.jhmi.edu.

3. Shem S. The House of God. New York: Berkley Books; 1978.4. Lazare A. On apology. New York: Oxford University; 2004.

Acad Psychiatry