I still do not know death. As a physician, I am taught to identify it, to delay it, but when confronted by it, I struggle with how to process it. This unrest becomes most apparent when I speak with a patient and their family about end-of-life care. "Your mother is dying," I have told a son. "How do you feel about focusing her care on comfort and dignity?"
Amidst the crying and the silence, I considered how I would feel if I lost my mother, and I grieved alongside him.
Afterwards, having unconsciously, but naturally, given part of myself to the moment, I left the room exhausted. Despite all my years of training, I have not received formal instruction on dealing with such palpable heartache -- felt strongly at the time of the encounter and carried with us long after the event ends. This grief remains with me and simply avoiding it is not a sustainable solution.
An Emotional Burden
So much has been written in recent years about shifting patient attitudes toward death and dying and how physicians can support these decisions through palliative care. But often ignored is the other half of the emotional coin: How do these conversations, and ultimately their outcomes, make the physician feel? A physician's duty to speak honestly and empathetically with a dying patient is not one all of us carry evenly or even train for, yet it's a duty many of us must perform. And amidst this duty is an emotional burden that frequently goes unrecognized, with little guidance on managing it.
Unfortunately, under a culture of medical stoicism, we subdue or ignore our emotions.
But learning to embrace them goes beyond the individual and has profound effects on the patient-physician relationship. As one senior physician told me, "If you don't talk about these feelings they come out in weird ways." What he was referring to was the concept of countertransference, originally used by Sigmund Freud to describe how a therapist responds to the patient's influence on his unconscious feelings. Today, its definition has been broadened to include all of the emotional response of the health care provider toward the patient. The physician is inevitably affected by the patient and the patient’s reaction to a diagnosis, treatment or entire medical experience.
Especially in the emotionally charged setting of end-of-life care, one can see how countertransference is pervasive.
Feelings Emerge In 'Weird Ways'
Why should patients care about the physician’s inner self? When negative or even positive countertransference goes unidentified, it can emerge in “weird ways,” causing miscommunication, appearing nonverbally or, worse, resulting in bad patient outcomes.
As one study of junior physicians at the University of Pennsylvania demonstrated, almost half of participants identified personal feelings toward the patient as a source of medical error. Such events can spiral into provider burnout, which can present as blunted compassion and cause patient blaming or scapegoating.
Reciprocally, patients may decry the perceived lack of empathy and care from providers who are emotionally spent. One friend confessed to me that despite her patience, she felt anger when her patient was non-compliant with the care plan and relief when he died. At the same time I questioned how they both arrived at that state, I fearfully conceded that it could happen any of us.
Professionals who work in challenging environments use debriefing, or the process of emotional and psychological reflection, with colleagues to help them observe, respond, monitor and integrate their countertransference. As I mature in my budding clinical practice and talk with more patients and their families about palliative care, I wonder why we do not debrief more.
End-of-life planning and associated discussions can bring up past experiences or feelings that may project into the present. In my case, I often feel guilt that I have not spent enough time with my friends and family. Other providers, after encounters that did not go as planned, felt frustration with caretakers and patients for choosing aggressive care in a situation where the physicians did not feel more medical care would be beneficial. Talking about our emotions not only names them but also provides perspective. Why does this particular situation induce feelings of guilt or frustration? Are these feelings shared by our patients, and if so, why? How are our feelings causing our patients to react?
Helping Doctors Debrief
Thankfully, more educators and hospitals are recognizing this need and starting programs to help physicians debrief with each other. And early evidence suggests that over a period of time, these programs are helpful in reducing physician stress and burnout. But more importantly, they begin to change our current culture and normalize the reflection and sharing of challenging thoughts and feelings.
And the refrain from physicians should not be "we have feelings too!" but rather "how can we understand our patients better?” This understanding creates opportunities for healthy conversation with our patients and allows shared decision-making to organically evolve.
In our radically changing health care system, improving patient-physician rapport should be in the forefront of any change. It seems at each encounter, patients and physicians alike voice more complaints about declining quality time spent together and increasing depersonalization.
Recognition of the shared emotional landscape is the first step in protecting and maintaining these unique relationships.
For me, after telling a son his mother was about to die, I was tired. I thought about my parents, called them, and went to bed, only to wake up a few hours later to tell another that her sister was going to die as well. I want to say that I took my own advice and debriefed with colleagues, with anyone, but I just laid in my bed that night, waiting for rest that never came.
Isaac Chan, M.D., is a resident physician in internal medicine at Boston Medical Center and will be starting his oncology fellowship at Johns Hopkins Hospital in July. Follow him on Twitter @ithinkichan.