Thursday, 29 March 2012

Emotions, intelligence, and medicine

The NYT's article below outlines the conditions in which pretending we do not have emotions and suppressing our own reactions is unhelpful. Rather than seeing emotions as a sign of weakness, there is a lot of good evidence (particularly in the psychology literature) that the best decisions are made when we couple our rational (left-brain) to our intuitive (right-brain) and use BOTH together. I often get the impression that for many in medicine the "ideal" is to be 100% left -brain and to ignore those right-brain emotional messages. My own n-of-1 trial (i.e. my life) thus far has shown me that combining intuition & emotional-awareness in addition to rational cognition makes both me and those around me happier. That is true only of course, when I can actually do all that!

Doctors Have Feelings, Too


It was a little bit like looking in the mirror. We were the same height and build, the same age — mid-30s — and both of us had two young children at home. In another world, had we been friends, we could have easily shared clothing. But today it was me with the white coat, and her with the death sentence.

Except she didn’t know it yet.

It was the morning of Julia’s discharge from the hospital, and we were going through the array of cardiac medications stacked on her bedside table. She asked the same question about each bottle: “Will this medicine make my heart better?”

I squirmed painfully around the question, weaving ever more elaborate explanations about controlling symptoms, enhancing breathing, minimizing fluid imbalances, improving exercise tolerance. I told every truth about every medication, but I could not bring myself to tell her the ultimate truth — that a roll of the genetic dice had doomed the fibrils of her heart, that her only chance was a heart transplant, that because she was an undocumented immigrant this was nigh impossible. That her children would grow up motherless.

Last month, an article in the journal Health Affairs made headlines in the news media — “Physicians Are Not Always Open or Honest with Patients.” A vast majority of the nearly 2,000 doctors surveyed agreed that physicians should be fully open and honest in all their communications with patients, as the Charter on Medical Professionalism requires, but more than one in 10 had specifically told a patient something that was not true within the past year. Almost one in five had not revealed a medical error. More than half had framed a prognosis in a more positive light than was warranted.

The authors expressed concern that doctors were not fully living up to the charter; patients worried that they couldn’t trust what their doctors said. I also found the data disturbing, but for different reasons. I don’t think that doctors are generally a dishonest bunch. Yes, there are a few utter miscreants out there, and many more who could use a tune-up on their communication skills. But I suspect that the dishonesty that is being uncovered in a study such as this — and frankly, I was amazed that the number of less-than-truthful instances was so low — reveals more about the diagnosis of being human than anything else.

When Julia walked out of our hospital without full knowledge of her prognosis, I had been derelict in my duty as her physician. I was fully aware that my job was to have “open and honest” communication with her, in a “patient centered” manner. But I couldn’t. I couldn’t bring myself to tell this young mother that she was going to die.

It could be that I over-identified with my patient, or that I let my emotions get the better of me, or that I was an out-and-out wimp. No doubt all played some role, but I wasn’t the only doctor who struggled with the truth. Everyone responsible for her care — intern, resident, medical attending, cardiology fellow, cardiology attending — independently fell short of the Charter on Medical Professionalism. Young, old, male, female, touchy-feely, egotistical, blustery alike — not one of us could say those words to her face.

When it comes to medical error, doctors have an even harder time coming out with the truth. There is, of course, the well-founded fear of malpractice litigation. Momentum is growing for legislation to protect doctors who acknowledge error and apologize. But beyond the fear of malpractice, there is the larger issue of shame at failing at your job, of letting a patient down, that makes you want to hide. It took me two decades to speak publicly about my first major medical error.

I was one week out of my internship at the time, and my patient was admitted nearly comatose with what is called diabetic ketoacidosis, from a severe lack of insulin. After we’d brought him back from the brink and could finally turn off the intravenous short-acting insulin drip, I committed the cardinal error of neglecting to inject him with long-acting insulin. He promptly barreled downhill again. A senior resident rescued him before he had a cardiac arrest, then screamed her lungs out at me in front of the entire emergency room staff.

I never mustered the courage to tell the patient what happened. So great was my shame that it was 20 years before I could begin the “open and honest” communication that the situation deserved.

Are doctors simply cowards? Do our own existential fears paralyze us? Human beings, by nature, prefer to avoid horrible truths, and denial may be our most powerful survival skill. Doctors are no more nor less immune to this, and to the basic human drives of empathy and pity, than anyone else.

By now, even the most hard-core, old-school doctors recognize that emotions are present in medicine at every level, but the consideration of them rarely makes it into medical school curriculums, let alone professional charters. Typically, feelings are lumped into the catch-all of stress or fatigue, with the unspoken assumption that with enough gumption these irritants can be corralled.

The emotional layers in medicine, however, are far more pervasive. Emotions have been described by the neuroscientist Antonio Damasio as the “continuous musical line of our minds, the unstoppable humming ...” This basso continuo thrums along, modulating doctors’ actions and perceptions, while we make a steady stream of conscious medical decisions that have direct consequences for our patients. Emotions can overshadow clinical algorithms, quality control measures, even medical experience. We may never fully master them, but we must at least be conscious of them and of how they can sometimes dominate the symphony of our actions.

Julia did eventually get the truth of her diagnosis, at her first post-discharge clinic visit. The actual moment was — as expected — horrible. It took several tries for us to get the words on the table. Voices choked, eyes brimmed — and that was just the doctors. Julia was more stoic. She nodded slowly, very slowly, as she pieced it all together. The quiet that followed felt like a licking of the wounds for all parties. All wasn’t sunny and optimistic, but there was a sense of reality, and now the planning could begin.

Why did it take us so long to tell her? It might have been that we doctors first had to come to terms with the diagnosis ourselves — however selfish that might sound. Perhaps, unconsciously, we were trying to give Julia breathing room. But all this may have been mere justification to make us feel better. The fact is that we didn’t tell her the whole truth, up front, as we should have.

I’d like to say that I’d handle the situation better now, with another decade of clinical experience under my belt, but I’m not sure. Today, at least, when my medical team faces the prospect of giving bad news or admitting a medical error, I try to help my students and interns pay attention to the basso continuo running underneath. I try to point out when our emotions might be impeding us, and when, as sometimes happens, they might be assisting us in caring for our patients. Doctors can’t — and shouldn’t — eradicate the emotions that grease the wheels of patient care. But being alert to them can help us minimize where we fall short, and maximize where we succeed.

Danielle Ofri, an associate professor at New York University School of Medicine, is the editor of the Bellevue Literary Review and the author, most recently, of “Medicine in Translation: Journeys With My Patients.”

Thursday, 15 March 2012

Medicine with a Heart

There is an entire website and related discussion-groups based on "Remembering the Heart of Medicine" (check it yourself at that is a call to meaning and re-discovering the depth in the everyday. 

This pausing to ask "what matters?" and "where is the heart in this?" is not just for doctors to need to do (although as a group perhaps we need to be reminded even  more than most, due to both internal & external forces that lead us away  from the heart). 

Stumbling across the poem below was just such a moment's pause for me today, and now perhaps for you too?

Alice Walker 

My desire
is always the same; wherever Life
deposits me:
I want to stick my toe
& soon my whole body
into the water.
I want to shake out a fat broom
& sweep dried leaves
bruised blossoms
dead insects
& dust.
I want to grow
It seems impossible that desire
can sometimes transform into devotion;
but this has happened.
And that is how I've survived:
how the hole
I carefully tended
in the garden of my heart
grew a heart
to fill it.

Saturday, 3 March 2012

Nothing to do, nowhere to go, nothing to achieve

Why do I write these posts? (Other than to meet some of my ego’s needs).

My intention is the possibility that you, dear reader, may come across it at just the time you need to hear it. The proverb “When the student is ready the teacher will appear” has been true at important times in my own life. I remain grateful to many for putting stuff out there so that when I was ready it was right there for me.
Of course that also means that not everything is for everybody (and that’s where the delete button comes in real handy).

What follows is by no means an explanation of suicide or even of depression. It is rather an attempt to make sense of things out of my own experiences. So it may not ring true for you and is not meant as an explanation of anyone else’s behaviour.

Growing up with a depressed and suicide-attempting dad (he is still alive) has made me ask myself “how can I learn not to end up depressed and a victim of my own thoughts?” (and keep in mind that I chose to work in pediatric palliative care!)

Does any of this sound familiar?
·        You get married and think “I will never be lonely again!”
·        You get a job promotion and a raise and think “now everything is going to be perfect!”
·        After years of trying you finally have a child and now “life is finally complete!”

If only.

You know how foolish it is to think that any one thing is ever going to make “everything just perfect”.
Without the mythic and impossible promise of “everything will be perfect when…” the advertising industry would grind to a halt in a heartbeat!
Does any of this sound familiar?
·        You lose your job, and now your life is ruined!
·        You get a frightening diagnosis and now your life is over!
·        Someone you love dies, and now your life will never have a good moment again.

Are any of these thoughts true?
Even if they feel really true at the time just how long do they last? Forever?

Things happen, we can’t control most of it, and we decide, on the spot, that they are great or terrible.  But when you look back at what you thought was bad it rather turned out to be good, and  what was supposed to great and long-lasting was not so.
·        I would not wish this diagnosis of cancer on anyone but it has changed my life and I have grown”.
·        “Losing everything I had thought I needed to be happy has turned out to be the best thing that ever happened to me”

What to make of all this?
Not only do we not know what is going to happen next, but our initial judgements about what is good or bad are often wrong, or at least it is often more complicated (the good/bad judgement) than we initially thought.
All these things that happen are descriptions of our life situation, but not of our LIFE.
Things happen to us and we get buffeted around by them like a balloon in the wind – Sometimes we are up and sometimes down – and all that is still not our LIFE but is rather our life-situation.

So what is our LIFE if it is not all these things that happen?
Is it possible that LIFE is what is experiencing all these things?
This LIFE (versus life-situation) is what we sense when an island of calm opens up in those spontaneous moments where thinking abates and we just are – We all get these moments  from time to time –
·        Watching your 8 year old eat an apple;
·        Diving into a calm lake;
·        Sitting quietly and watching the snow falling just outside the window.

So what's the big deal about the difference between LIFE and life-situation?

If you believe that your life situation is the same as your LIFE, if you believe that your self-worth is hinged on this or that, then you are vulnerable to losing your “reason for living”.

Do you really need any justification for being alive?
Does any form of life need to “do something” to justify its existence? Does a flower or a bird need to justify its own existence to itself or to others?  

There is no judgment of good or bad in “LIFE” but lots of judgements of good and bad in “life-situations”.
As far as your LIFE is concerned there is nothing to do, nowhere to go and nothing to achieve.
By all means go ahead and do, go, and achieve, just see them as choices to make and not as necessary justifications for your LIFE.

If you believe that what happens to you is the same thing as your LIFE, as who you really are, then the thought “I do not deserve to live” can become a wrong thought believed.
And that can be a fatal mistake.