While our entire training program painstakingly enumerated complications in weekly Morbidity and Mortality Conference, we never talked about the impact a particular case had on us or shared the way we felt knowing we had caused a complication that might have led to a patient’s injury or even his death. It was up to us to find our own way through those experiences. These behaviors led to the accretion of thicker emotional armor: with no formal training in how to manage the emotional impact of our job on ourselves and others, this became a necessary, reactive survival tool.
Another problem with medical training is that physicians are generally quite poor communicators. Dr. Mary Buss, chief of Palliative Care at Harvard Deaconess, observes that surgeons receive excellent technical educations but are poorly trained in communicating with patients and families. They have virtually no education or practice in discussing the withdrawal of life-sustaining treatments, and these conversations often occur without supervision. “Physicians,” she says, “are terrible in assessing their own communication skills.”
As physicians, do we connect emotionally or do we defend ourselves? We cultivate detachment and emotional distance as a coping mechanism against the pain of grief, loss, and failure. Yet our attempts to protect ourselves ultimately intensify feelings of loss and deprive us of resolution. I have come to see that these unresolved feelings contribute directly to professional burnout.
Before Victoria’s illness, I didn’t even realize I was doing this. Since then, I have come to recognize the armor doesn’t ultimately serve me and is in fact a liability. Once I understood how it interfered with the intensity of my perceived experiences, I saw it as a hindrance, blocking emotional connections I have come to cherish. Removing the armor requires deliberate effort. Admitting to mistakes and feelings is difficult and feels unnatural at first, but in the end, it is liberating.
Dr. Buss notes that physicians are afraid of, and avoid, feelings of sadness. We reason, mistakenly, that being open to pain and loss could damage us; we fear losing our composure and appearing vulnerable. Yet accepting vulnerability is what most closely connects us with our patients. This is what they remember in the end, after all the tests and treatments are done. Patients crave acceptance, appreciation, and acknowledgment; we all want this for ourselves.
It intrigues me that compassion fatigue does not come from exposure to too much sadness. If it did, then palliative care physicians would be the least happy and most burned out physicians of all, yet in reality, they are some of the most satisfied of any specialty. It is not exposure to sadness that is the problem, but the way we respond to it and how we are affected by it. By opening ourselves to experiencing heartache, we allow ourselves to become more vulnerable.
Brené Brown describes the importance of allowing ourselves to be vulnerable and holds up the surgeon as an example of someone who is exempted from this by the technical nature of their work. Yet, as I have come to appreciate, it turns out no one gets a pass. Surgeons and pilots, those whose work requires high levels of technical skill with direct responsibility for the lives of others, have to be able to flex, operating at different levels of vulnerability, but the ability to access their vulnerability is still crucial. Doing so connects them with the privilege and seriousness of their enterprise.
Surgeons who try to reduce surgery to a purely technical exercise flounder as physicians. The best surgeons maintain their humanity and their vulnerability. The opposite—a pose of distance and imperviousness—leads us to dehumanize and objectify patients and is a recipe for disaster. We can see the pitfalls of this behavior everywhere in medicine. Mechanical metaphors abound in surgery. “He’s a machine” is an admiring way to describe a colleague who puts aside his own needs and feelings to work unflaggingly. “Productivity” refers to doing lots of surgery and generating revenue. But these descriptions dehumanize both physician and patients: A person who is a machine is one who is not feeling. Productivity is a reflection of the diminishment of the patient: no longer a human being in need of help, the patient has been reduced to a body part in need of repair and assigned a monetary value.
Dehumanizing patients can lead to indifference in physicians. It is a privilege to be trusted to take care of every patient we encounter, yet we can lose sight of this and begin to see our patients as a burden, or as units of work, rather than as individuals. When people cease to matter, we cease to care. This is the precipice of burnout and invites mistakes and poor behavior, such as cutting corners or pushing the envelope by exposing patients to excessive risks.
Often, physicians hold themselves to unachievable standards of perfection. No surgery is ever perfect, yet we expect perfection from ourselves and from our colleagues. Partly the result of training, these unrealistic standards also interfere with emotional connection or empathy. Complications are an inevitable part of the work we do, yet physicians often lack self-compassion. We tend to be unforgiving of ourselves (and of our colleagues). Self-compassion is a crucial component of emotional flexibility; unrelenting self-criticism does not promote learning or modification of maladaptive behaviors.
As the brother of a patient, I discovered how it felt to be on the receiving end of care lacking in compassion and became determined to connect more deeply with my patients and my own emotions. Yet I wondered, how could I balance connection and detachment as a neurosurgeon? Did engaging emotionally with my patients mean I could no longer detach enough to be an effective surgeon? Would it be better to become a technician and leave the emotions to others?
I found the solution to this conundrum through a conversation with Helen Riess, author of The Empathy Effect. Dr. Riess explains that through the process of self- and other-empathy, emotional armor can be replaced by “emotional agility.” Intrigued, I went on to read Susan David’s Emotional Agility, which characterizes this healthier stance.
A key to developing emotional agility is a willingness to embrace our vulnerability. Emotional agility enables us to move easily between powerful emotions, recognizing feelings without becoming bogged down by them, to move fluidly through the demands of life without becoming stuck or overwhelmed. Emotionally agile people are dynamic: They derive power from facing, not avoiding, difficult emotions, recognizing that “life’s beauty is inseparable from its fragility.” Thus, physicians become better able to connect more deeply with our patients and ourselves, increasing our satisfaction and engagement while staving off burnout. Achieving emotional agility gave Dr. David “the power of facing into, rather than trying to avoid, difficult emotions.”
In my own life, I have discovered that the tremendous power of emotional connection is an antidote for compassion fatigue, burnout, and despair. This has meant becoming more flexible and resilient. By being less defended, I have become more, rather than less, available. But make no mistake, this requires constant effort. Just as with the emotional armor of practicing physicians, we all use defenses against perceived threats—as David illustrates in her book, our natural inclination is away from agility. By “unhooking,” “showing up,” and “stepping out,” we put aside these maladaptive defenses and create new, and ultimately self-reinforcing, patterns of behavior. The pleasure of seeing with greater clarity and the creation of meaningful connections are their own reward. I liken the feeling of this transition to going from seeing in black-and-white to suddenly seeing in color: the increased richness is intoxicating and becomes its own reward. I don’t want to go back.
Dr. Riess has studied the neurobiology of empathy, as outlined in The Empathy Effect. “Some people must turn down the dial on their emotional empathy to become objective enough to do their jobs. Think of firefighters, or surgeons, who must focus on the technical tasks to complete a successful operation and not be distracted until the operation is complete.” She has created a validated program to increase empathy through training for medical practitioners, based on increasing the perceptual awareness of others centered on the seven keys of “E.M.P.A.T.H.Y.” In this acronym, E stands for “eye contact”; M
for “muscles of facial expression”; P for “posture”; A for “affect”; T for “tone of voice”; H for “hearing the whole person”; and Y for “your response.”
Not only do practitioners need to be trained to have increased empathy and awareness of self and others, they also need to learn how to move between different states of empathetic responses with patients, as the need arises. Dr. Riess observes that:
… emotional empathy must also be kept in balance with self-regulation to help manage excessive loads of emotional arousal that can lead to blurred boundaries and personal distress. If you are exposed to too much pain and suffering every day, such as a day in the life of an oncologist or social worker or prison guard, excessive emotional empathy can lead to depression, anxiety, and burnout. The sharp edge of empathy would soon become dull, and you’d start to distance yourself from the human experience. In the medical profession, we call this “compassion fatigue.”
Emotional agility allows the surgeon to operate with dispassionate objectivity one moment and move toward intimate connection the next, as the situation demands. Without emotional agility, these transitions can be difficult to make.
Dr. Alan Davidson, an ER attending, was a colleague of mine for over twenty years. He had recently retired. One Saturday while I was on call, he presented to the ER as a patient, with right-sided numbness. Initially designated “code stroke,” a CT scan instead suggested a brain tumor. An MRI suggested a glioblastoma, so I was consulted. I fearfully faced my friend, upset for him and his wife. When I told them the likely diagnosis, he replied, “Well, then I’m going to die, aren’t I?” We both knew his prognosis was poor.
Aware that he entrusted me with his life, I took him to surgery a few days later. I warned him he might be more numb or weak after the procedure. When he awoke, Alan and I were pleased that he was no worse than before his operation. The postoperative MRI scan showed we had removed almost the entire tumor.
I met with Alan, his wife, and his son when the pathology results came back. I sat on the edge of his bed and told him his diagnosis. Neither of us was surprised by the results. But he choked up as he expressed gratitude for his care. Holding back tears, I told him I felt honored he trusted me enough to take care of him. In the past, I would never have allowed myself to acknowledge my gratitude to Alan or the depths of his gratitude to me: I would have truncated the conversation and pushed these feelings away. We spoke for quite a while until I had to return to the operating room for another case.
As I left, Alan noted that my work seemed to fill me with energy and joy. I was surprised to realize I did not feel depleted, but rather that I felt privileged to witness both the beauty and fragility of life. At that moment, I knew I had discarded my irreparably damaged suit of emotional armor. In its place I had substituted something far more powerful: emotional agility.
Later, Alan was readmitted to the hospital with increasing numbness on his right side. I read him a draft of an essay I was writing about him. He sat in his bed, unable to control his phone or computer, yet emotionally attuned and intellectually forceful. He was pleased; he wanted me to tell his story. He felt strongly this message must be shared, agreeing that doctors often are burdened by perceived failures and private grief.
As we sat together, we reminisced about his life. We spoke of his worries for his wife, children, and grandchildren. He told me of professional mistakes that haunted him, yet he also spoke proudly of the thousands of patients he had cared for. Their individual stories and faces were no longer distinct but flowed through him. Just as Alan needed to recognize and admit his failings, he also needed to let them go. This is true for all of us: we must celebrate our victories, admit our failings, and forgive ourselves and each other. The connections we established did us both a world of good; he needed them, as did I.
I have described emotional armor, truncated communications, and barriers to emotional connection from the physician’s point of view. But how does this feel to the patient? Through speaking with my sister and later from reading her journal, I learned what it felt like to be on the receiving end of these kinds of communication. Fear and a profound desire for connection were driving forces for Victoria. Most of her interactions with her physicians were positive, yet some communications increased her fear and her anxiety, causing her considerable stress. Two experiences stand out in her journal entries. The first was from a legalistic physician explaining the risks of different types of radiation to kill off her bone marrow in preparation for her bone marrow transplant. This was extremely frightening for Victoria, who didn’t want to hear details, but instead wanted support, of which she felt little.
Once I found my way to radiation, I found myself wondering how I could possibly have requested this particular method! The consult began with chatting with one somewhat junior doctor about the efficacy of targeted vs. whole-body radiation, and I couldn’t follow a darn thing he said. I don’t think it was me. It was a circuitous, utterly confusing discussion. After what felt like half an hour, I heard him say, “The TMI vs. TBI [I believe that is total marrow irradiation, versus total body irradiation] was likely no worse and possibly better re: secondary cancers.” I felt like I was talking to a “lawyerdoc” or a “docyer.”
—MARCH 21, 2015
Earlier, she described how terrified she was upon being transferred from St. John’s, where she felt supported, to City of Hope, which felt harsh and clinical in comparison. Her intake interview, which occurred late in the evening after a long day of travel through snarled traffic on LA freeways, did not inspire comfort. That the admitting doctor referred to her previous treatment as a “failure” caused her to doubt the care she had received previously and made her feel that it was somehow her fault. She described her reactions to that discussion in her journal, which I cited in the chapter on her diagnosis.
But Victoria spoke and wrote about Dr. Fischer in glowing terms. She did not feel judged by him but reveled in his positivity. She adored him.
When talking with Dr. Fischer, he once again, reminded me that he is CONFIDENT I’m going to do great—that I have so much going for me: intelligence, determination, an amazing support team, my family and friends. He also remarked how not everyone does anywhere near as well as I have done with the ARA-C. He said the transplant will not be a cakewalk but he is certain I’m going to do great.
This would horrify Dr. Fischer but several of us agreed that he is the real “Dr. McDreamy.” He is an excellent doctor, who happens to be highly attractive. And he is a kind man. I was listening to an interview with Dr. Bernie Siegel talking about how many doctors go into medicine because they are interested in the science aspect, less the idea of working with patients. Dr. Fischer does both and he would never call my chemo a “fail!” In fact, he said he would have preferred the term “sub-optimal,” which delivers a very different message, one of hope, not of failure … From the very beginning, he set a positive picture in place and I have followed his lead.
When he first told me I had leukemia, he said, “This is life-threatening but not a death sentence.” That was very clear and an upbeat way to look at it. The message being: this will be hard, you have your work cut out for you, but you can do this. He has never wavered in his support. Even when I was at City of Hope, he was emailing me, seeing how I was doing and he’d always finish with, “You’re going to do great.” One time, I commented that perhaps the supplements I took with regularity have helped me do so well. He replied, “Or maybe it’s just you.”
—FEBRUARY 21, 2015
When I spoke with Dr. Fischer, I told him I struggled with the implications of her diagnosis and how to relay this to Victoria, who made it clear to me that she did not wish to talk about dying or the concept of her own mortality. I wondered how this had affected the difficult conversations he had with Victoria and Pat and if he had also found it challenging.
After doing this for some time, and you probably know this yourself, you deal with each individual differently. I felt like Victoria’s
personality type was one I was familiar with. Such individuals thrive on the positive and avoid the negative. I felt like she wanted as little information as possible so that she could focus on the kind that would help her achieve very short-term goals.
“Hey, what can we do to get my bone marrow into remission? What can we do to mitigate side effects? What can we do to allow me to get home faster?” My understanding in speaking with her was always that she got it. It wasn’t that she didn’t want to know. She did know, but she didn’t want to acknowledge it in her mind because it would take her to a dark place. I think she needed that positive energy to hold on to, and to get her through the day-to-day, week-to-week struggle of all of the treatment and the side effects, and the dealing with having young kids.
There were times where we would sit down and she would let that guard down and say, “Look, this is what we are going to have to do.” I think she would take it in and kind of reset and start again where she would focus on short-term things, and not start thinking about transplants and donors. I think it was more, “All right, so I am going to have my bone marrow next week. Okay, I am going to stay positive and hope that my bone marrow is negative, and hope that I don’t need a platelet transfusion tomorrow, and hope that I don’t get nausea or vomiting …” We focused a lot less on the big picture with her, at least up front.
With Victoria, I viewed it as purely a defense mechanism. She needed to be strong for her children. I think everybody is different in how they approach it, and this was something that she created for her own mental well-being as a barrier to insulate herself, and maybe say to Pat, “You deal with some of these bigger things like insurance issues, and scheduling, and appointments, and visitors, and family.” She told me, “I am going to focus on what I can do immediately, short-term.”
She got it, she understood, and I think it wasn’t denial. I think it was acceptance, but it was a very muted acceptance. She understood the gravity of the situation. She understood that it was a very serious, potentially life-threatening disease. Once she acknowledged that, she did not want to revisit it: “We are not going there again. We are going to take care of business. We are going to get to the place where I have the best opportunity to be cured and focus on all things positive.” And that is what she did.
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