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Several years ago, I was sitting at the gate in a Washington, D.C., airport when I got a call on my cell. A close friend of one of my patients wanted to let me know that Lara (not her real name) had died after a long and difficult course of throat cancer.
Lara was relatively young, a kind, brilliant and incredibly thoughtful woman, and I'd had a deep patient-physician relationship with her, given all that she'd been through and how open and honest she was about her experience. And no matter what was going on with her disease and in her life, she unfailingly asked about me and my family.
I was one of many clinicians who had the pleasure of working with her. Her dying process was incredibly difficult because of her tumor type and location, and the degree of her pain. We all worked hard on controlling her pain. But Lara was the mother of young children and she was determined to remain alert and functioning. Also, I think she resisted palliative care because she saw it as a defeat. I always wish that I could have convinced her to receive more comfort measures.
When I got the call, I put my head down, covered my hands with my face and sobbed. Silently. But apparently visibly enough that a young man sitting across from me, likely in his 20s, placed his hand on my shoulder and asked if I was OK. I told him that one of my patients had died. He was taken aback.
“I never thought doctors would get that upset about their patients,” he said incredulously.
“We sure do,” I replied. If you only knew how much, I thought.
Another patient affected me deeply but in a different way. This patient was an elderly man with multiple medical problems and a complex condition that required surgery. I have expertise performing the surgery to fix this condition, so he was referred to me. We discussed risks and benefits of various treatments during our first visit. Later, I performed a minimally invasive laser procedure through his mouth.
Unfortunately, the procedure left a small throat perforation. Any hole in the throat lining can allow saliva to leak into the neck, causing a serious neck and chest infection. It is a known complication of this technically challenging operation, but it had never happened to any of my patients. I felt horrible: Instead of helping this patient, I had, at least temporarily, made him much sicker. Yes, I had discussed this possible complication and obtained preoperative consent from him for the procedure. But it wasn’t what he signed up for, or what he thought would happen. And it isn’t what I expected when I became a doctor. I am supposed to heal, not harm.
Doctors Risk Emotional Trauma
Intellectually, we all know that there are no guarantees of good outcomes, in surgery or in life. But emotionally, most of us expect perfection -- both of others and of ourselves. Physicians have a particularly hard time accepting our fallibility. Robert Helmreich studied the culture of medicine and aviation and found that “both stress the need for perfection… and a deep sense of personal invulnerability.”
So when something goes wrong, we are uniquely unprepared for the emotional fallout. And the fallout can be massive. There is ample evidence that some physicians suffer serious consequences -- burnout and even suicide -- when patients suffer injuries related to their care rather than their disease, especially when these involve errors.
The two patients whose lives particularly affected me are examples of the degree to which, as caring professionals, we are vulnerable to emotional stress in our work. As we should be. We have the honor of being present in the most challenging times of our patients’ lives: when they are sick. It is precisely because of our humanity that we care so deeply. But over time, without support and strategies to help us cope with these emotions, we are at risk for emotional trauma that affect us, our families, and ultimately, our future patients.
Help From Those Who Have Been There
This is what prompted us to establish the Center for Professionalism and Peer Support at Brigham and Women’s Hospital. The guiding principle is that we need to attend to the well-being of caregivers, educators and researchers, so that they in turn can give their best to our patients and to society. Peer support, one of our center's core programs, begins when a trained peer support colleague reaches out to anyone involved in potentially emotionally stressful situations -- caring for trauma victims, making a mistake, having an ill colleague, or mourning the death of a beloved patient. We found that most of us want to speak with colleagues who have “been there” and can understand how we feel. We have also helped many institutions, both nationally and internationally, develop and sustain peer support programs.
If I am the designated peer supporter alerted that a clinician has been involved in a potentially emotionally stressful event or set of circumstances, I contact him or her. I explain that we reach out to anyone involved in such an event because many of us have found it helpful to talk to a colleague. This way we try to normalize the process and de-stigmatize any negative emotions. The offer for peer support is an invitation, not a requirement.
The peer support itself involves both empathic listening and some sharing of the peer supporter's experience. In addition, the supporter asks open questions to help the peer connect with his or her own wisdom and strategies for resilience.
We do a day of intensive training to become a peer supporter. It is countercultural for clinicians to be in a position where they are not fixing problems. The training also teaches balancing tensions such as listening versus sharing or the peer's coping strategies versus the peer supporter's strategies.
We initially set the program up so that the peer needed to contact us for support. But we didn't receive a single call. We should not have been surprised. Our research had uncovered multiple barriers to physicians' asking for help.
For peer supporters, it is intensely gratifying to support colleagues and to help ease their pain. Nothing is more important to us than relieving the suffering of our patients. And it is precisely so we can do that work that we ourselves must be whole and supported.
Dr. Jo Shapiro is the director of the Center of Professionalism and Peer Support at Brigham and Women’s Hospital. She is also the chief of the Division of Otolaryngology in the Department of Surgery.
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