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Stress Points November 2010

by Elizabeth Tillinghast’93

Balanced Caring

Elizabeth Tillinghast'93We have all heard a great deal about the need for doctors to be more humane with their patients; often these discussions focus on the behavior of doctors with dying patients.

What is not sufficiently appreciated, perhaps, is that practicing medicine poses some of the greatest emotional challenges -- and can provide some of the greatest emotional rewards -- of any field.

Medicine is a highly charged field emotionally and places great emotional demands on its practitioners. As an ex-lawyer, I can say with assurance that this is not true in the law. Although lawyers may at times feel infused with a righteous indignation when fighting for a cause they believe in, usually they are simply resolving disputes about money or property, subjects it is hard to feel passionate about unless you happen to be one of the parties involved. At times lawyers may feel angry about being attacked by an adversary or anxious about performing under the critical eye of a judge, but that's pretty much it.

Practicing medicine arouses a much greater range and depth of feeling. 

Medicine is packed with human drama. As patients and their families cope with illness, they may struggle with fear, desperation, hope, and at times tenderness for a sick relative, love, or deep sorrow.

Illness arouses a torrent of emotions in patients and their families.

It can arouse powerful feelings in doctors as well. Learning how to weather the emotions of patients while managing your own is one of the great challenges of practicing medicine.

Of course, it is impossible to think clearly if you’re too rattled emotionally; doctors learn early on to keep a certain distance so they can keep a clear head.

In addition, practicing medicine is often so physically intrusive that keeping some measure of impersonal distance from patients may almost reflect a kind of tact, or respect. It’s a little like living in NYC, where everybody is on top of each other; the most astonishing things can happen in public and nobody blinks an eye. New Yorkers see too much, so they act as if they see nothing as a way of giving each other space. Similarly, doctors may keep a kind of impersonal tone with patients as a way of compensating for other invasions of privacy that are unavoidable in their work.

Doctors keep their distance to protect themselves too. Practicing medicine can at times feel deeply jarring or even traumatic. Watching someone keel over after vomiting up coffee grounds, participating in a code that fails, telling a parent his child has died: All of this is enormously distressing. Over time, you may develop a certain toughness or sense of detachment to weather emotional assaults like this.

Sometimes just listening to someone’s story is deeply upsetting. I remember interviewing a teenage boy in the emergency room about his escape from Cuba; as I stumbled through the interview, which had to be conducted through an interpreter, I slowly realized this boy had escaped on a rubber raft with a friend and watched his friend be pulled into the ocean by a shark. The boy was certainly traumatized but I was deeply shaken as well.

Practicing medicine can be difficult as well because it disrupts your sense of yourself. At moments of high emotional tension, you may find yourself struggling with an impulse to giggle – just to shake off the sheer horror of it – or focusing on what is plainly a trivial and irrelevant part of the scene, for example, by thinking about the toenail polish of someone undergoing a code. This doesn’t mean you’re a superficial or unfeeling person; making something small which feels too big emotionally can be a way of coping with stress.

Doctors may also pull back when treating someone who is on an inevitable downhill course. We’re taught to try to fix people and often feel guilty and helpless when that proves impossible. 

Furthermore, forming an emotional attachment to someone you know you are going to lose is not easy. Yet the truth is, of course, that you can help even if you can’t cure, by relieving pain or providing comfort. Treating the terminally ill may be easier as well if you keep in mind that dying is part of the natural course of life; even doctors can’t fend off death forever.

There are many reasons why doctors withdraw emotionally, but if you pull back too much, you will deprive yourself of some of the most profound and meaningful experiences of your professional life.

Many of us were driven to become doctors because of deeply personal experiences. Some may have had a sick sibling, perhaps, or watched a loved one die. The wish to help, cure, comfort, or prove one’s own competence at moments of crisis can be deeply rooted and at times may provide the fuel needed to get through the arduous hours of medical training.

Those of us who have chosen to work with patients are not interested solely in intellectual puzzle-solving; instead, we’ve become physicians in part because we are drawn to the human elements of medical practice.

At first, many of us are intent on “following the rules” and holding tightly to a kind of professional detachment. Over time, however, as you get comfortable and confident in your role as a physician, you may adapt the role somewhat to suit your own style, so you can allow yourself to feel a bit more relaxed with patients and able to have more personal interchanges with them. You may find you share a love of baseball with one patient or admire the dignity and humor with which another faces illness. Over time, many of us become fond of certain patients.

In fact, feeling emotionally invested in our patients is often part of what keeps us going. It’s hard to see 20 patients a day, many of them with similar medical problems, on intellectual interest alone. A physician who is a young mother may feel a particular connection with a parent who has a sick child, for example, while a doctor who is caring for aging parents may develop a deeper understanding of the needs and vulnerabilities of elderly patients.

Bringing some of your own experiences to your work can make you a better doctor – but it is also bound to make your work more meaningful. As doctors, we have real opportunities to give back to others what we ourselves have received, or what we might like to receive under similar circumstances. At times, we may be able to offer patients something we were unable to give to someone closer at hand.

Keeping your balance between the personal and the professional is no easy task in medicine. It’s like balancing on a log. There is no possibility of reaching a static equilibrium. You have to pay attention. Going too far in either direction can be treacherous.

Yet you can let yourself feel stirred by patients at times, even deeply stirred, without taking on their lives and emotions as your own. If you aim for a kind of controlled empathy, you will be able to experience the emotional richness of medical practice without becoming emotionally overwhelmed.

Elizabeth Tillinghast is a psychiatrist and psychoanalyst who also has a law degree. She has published articles about how lawyers and other professionals can overcome psychological impediments to success and happiness at work. She is on the faculties of Columbia and Cornell medical schools. Contact her through et41@columbia.edu.