Month: May 2013

The Onion Cellar: crying at work, crying at home

onioncellar

 

Have you cried at work? Do you show the depth of your emotions when faced with tragic clinical circumstances? I have never cried, and it is unusual for clinical situations to even moisten my eyes. Although I have been tempted to hug patients when they appear emotionally broken, I am far too inhibited to break through that force-field of unfamiliarity. A gentle hand on the shoulder or leg is about as intimate as it gets really.

This is not true for all doctors – some are much more comfortable with displays of sympathy or warmth…but we are all different. How do we describe doctors who admit to being moved to tears? Sentimental? A sentimental person is predisposed to be moved or swayed by emotions; it is a normal characteristic, but one that is repressed to a greater or lesser extent in most working lives. The empathetic doctor on the other hand will feel sadness and grief when they see their patients cursed by nature’s caprice, and will allow this to inform their own understanding. The sentimental doctor will reflect and display those emotions, and be visibly affected. If we accept that a continuum exists which encompasses these two characteristics, knowing where, or how, to draw the line is a huge challenge. Particular circumstances may pull individual doctors over that line now and again. When that happens, we cry. This tendency must be balanced with cool professionalism, for if sentimentality reigns there may be a deficiency of dispassionate thought.

So what lies at the other end of that continuum? How do we describe those who appear to feel no emotion at all? Does their stony facade hide inner turmoil? Are they likely to suffer from a build up unresolved mini-traumas? Or can they function indefinitely without releasing those emotions? Well, perhaps the key word here is ‘appear’. We can only know as much as we can see, and the profundity of their feeling may well be hidden from us.

In To Cry or Not to Cry: Physicians and Emotions at the Bedside by Navneet Majhail and Erica Warlick, an account is given of a bone marrow transplant physician who cried when a young patient whom she knew well discussed the likelihood of death.

All agreed that she would not want to continue with aggressive measures and allowing her to die peacefully would be in her best interest. At an emotionally intense moment, her primary BMT physician’s eyes began to water, and she shed a few tears prior to regaining composure and continuing the conversation. As the team left the room, the medical student asked, “Is it OK to cry in front of a patient?”

In response to this an informal survey of other physicians’ attitudes to the display of emotion was undertaken. The selection of responses is fascinating, and very measured. For instance:

“I think that it is totally fine not to cry … If that is not in your nature … a physician should express some genuine sympathy/empathy for a grieving family, but it can be done with words or mannerisms.”

“I think it is a problem if the emotional moment is primarily about the physician’s feelings … But if the context is about the patient or the family’s feelings then I think it is good to show empathy. … If the “primary gain” is to make the family or patient feel better … then it is OK … whereas if the primary gain is to make the physician feel better … then that is not OK.”

“I think it is acceptable to break down the austerity of the medical relationship at times … when families and patients need someone they trust the most (eg, endof- life crisis), the emotion we show only helps bridge the divide that we’ve built within medicine.”

And this one reflected my own thoughts very closely:

“There can be a fine line between being compassionate and empathetic versus allowing emotions to adversely cloud recommendations for patient care.”

A 2008 New York Times article by Barron H. Lerner explored the question At Bedside, Stay Stoic or Display Emotions?. He (and the fact that he is a ‘he’ becomes relevant) contrasts the behaviour of two physicians. There is Dr Benita Burke, who was in the habit of,

‘…skipping lunch to spend extra time with her cancer patients. They dubbed this time ‘mental health rounds,’ during which they could address issues that were not strictly medical. Many times, Dr. Burke would wind up in tears or giving an embrace.’

I find that behaviour remarkable – in fact I find it uncomfortably eccentric. In contrast, according to the article, Dr. Hiram S. Cody (acting chief of the breast cancer service at Memorial Sloan-Kettering Cancer Center) adjures his staff,

‘to understand, to sympathise, to empathize and to reassure…not to be emotional and/or cry with my patients.’ The writer of the article then comments, ‘whether because of my personality or my being a man, I, too, have never cried in front of a patient.’ (Phew. I am not the only unfeeling man out there!)

In 2006 I wrote an article called The Absence of Sadness: Darker Reflections on the Doctor-Patient Relationship’, which began with a paradox – recognition that I felt sadder when patients whom I barely knew died, rather than those I had watched suffering for days or weeks on the ward. I was moved (moist eyes, nothing more) by the love shown to a dying man by his family:

In this case my sadness derived not from torn attachment, but the juxtaposition of familial devotion with death. The brief sketch of his life, drawn during our first interaction in casualty, contained only positive images. My appreciation of him as a person was unchallenged, our relationship unsullied by the more complicated emotions that can accumulate on the ward.

Then, having described various threats to the patient-physician relationship, I conclude,

The tensions created by sudden, severe or incurable illness settle on the most vulnerable aspect of our experience with patients; not our medical proficiency, not our energy, not our commitment to advocacy…but our sense of attachment.

So, if emotion cannot be explored (by some of us) at work, where can it be resolved? I have read some very emotional medical accounts recently. One example is Elin Lowri’s beautiful blog post about the importance of love in the inevitable progress of death. A number of commentators have admitted that they were moved tears. I certainly felt emotional, and that is saying a lot, for me! I asked myself how it is that someone like me can be moved by such well-written words at home, while being in little danger of sniffing back tears in the workplace. Then I was reminded of the Onion Cellar.

In The Tin Drum, by Gunter Grass, people who have been deprived of the opportunity to display emotion pay good money to meet in an onion cellar.

“…It was this drought, this tearlessness that brought those who could afford it to Schmuh’s Onion Cellar, where the host handed them a little cutting board – pig or fish – a pairing knife for eighty pfennigs, and for twelve marks an ordinary, field-, garden-, and kitchen-variety onion, and induced them to cut their onions smaller and smaller until the juice – what did the onion juice do? It did what the world and the sorrows of the world could not do: it brought forth a round, human tear. It made them cry. At last they were able to cry again. To cry properly, without restraint, to cry like mad. The tears flowed and washed everything away.”

I wondered, thinking about the right place and the right time for displays of emotion, whether a sentimental reaction to accounts of patients and their illnesses, read outside the workplace and in relation to people that we have never seen, may provide that access of emotion that we cannot readily, or safely, tap into on the awards. Perhaps there is a place for vicarious emotions, whereby the feelings that we probably should be feeling on the wards, as normal, feeling men and women, can be experienced in abstract, at a distance, through the words of others. So please keep those blog posts and articles coming…they are healthy!

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Medical relativism: on prioritisation, excuses and kindness

In a recent Clinical Medicine article, ‘Doctors and others: reflections on the first Francis Report(£) Professor John Saunders writes, ‘People do not go into careers in healthcare to be cruel…’ and yet, ‘many experienced commentators…have witnessed an absence of kindness: an attitudinal change that resulted in substandard care.’ How does this happen? How do we explain the spectrum of kindness shown to patients that results in some coming away from hospital impressed by medical staff and some feeling neglected, as though they were a bother or a burden?

The explanation must lie in factors related to medical staff and patients. Patients come as they are of course, and there is little point analysing their characteristics in the quest to understand the spectrum of kindness. So, what of medical staff? They are human, and they vary. Some express kindness better than others, but even the poor ones are nice some of the time. Some respond better to quiet, unassuming patients who appear grateful, while others show their best side to those who are more demanding and articulate. Some engage fully only when they recognise some special factor – a common link, a mutual acquaintance, an especially tragic set of circumstances, or the perception of professional risk. Some doctors warm up only when the disease in question fires their intellect. None of these psychological explanations are defensible…all patients should receive the same amount of kindness. However, for some reason, some patients appear to deserve more kindness than others. It is the perception of deservingness that I wish to focus on, especially its root in the unavoidable practise of medical relativism.

I remember working in A&E departments (in the mid 1990’s) where waiting rooms teemed with dozing patients and red LED displays routinely flashed << 8 hours >>. By the time patients were seen their agitation had transformed to resignation, crushed by a sense of powerlessness. On the part of the doctors, a ‘warzone’ mentality seemed to foster a ‘Don’t complain, you’re lucky to get seen…’ attitude. In this environment indifferent care could be delivered, or witnessed, but ignored. That was the just the way it was. Kindness did flower, because there were good people, but the pressure on the system did not allow those flowers to cover the ground.

I wonder if the embers of that attitude smoulder in the minds of older doctors (myself included) whose behaviours were patterned by a sense of continuous battle. I certainly feel it rekindle now and again…for instance when a patient complains for reasons that appear unfounded (about a delay, a lack of explanation, an early discharge). I feel sure that they had good care, and find myself thinking, ‘What are they on about? We did pretty well by them. It was incredibly busy, there were people on the ward who were far sicker, we were a doctor down…’ I have fallen into the trap of medical relativism, making comparisons between one patient’s predicament and another’s.

We make comparisons between patients every day. It is part of being a responsible doctor. It absolutely necessary to prioritise, to treat the sickest first (and more intensively) while leaving the less unwell for longer. However, patients arriving in emergency departments, or those waiting to speak to medical teams on the ward, are concerned about their own problems. They do not see the complete picture…and why should they? They are anxious and preoccupied. Given this, is it surprising that they begin to feel hard done by if our explanation for their delay in treatment or attention includes a comparison, between their situation and that of another. The nurse answers the bell 30 minutes after it was pressed, to find a soiled patient;

“I’m so sorry, I was just finishing the drug round…”

So it seems the drug round was more important that their comfort. Perhaps it was, who knows? But the patient won’t see it that way. Or a family attends the ward to discuss end of life care with the medical registrar, who is ninety minutes late;

“I do apologise, I got held up with a emergency downstairs. I asked the ward sister to let you know….”

So the sick patient in the high dependency unit is more important than the dying patient on the ward, or the family members who gathered together in the relatives room nearly two hours ago, tense, expectant, not knowing what to say. What are the family to think of this?

One simple solution is to avoid making overt comparisons. Some of us may do this already, because it feels like we are making excuses if we go on about our other duties. It doesn’t feel completely professional to explain why we are late, or distracted, or less than focussed…because we know that our stress isn’t their concern. The danger in this policy of concealment is that patients see only the instance of neglect, but not the context in which that neglect arose. We may have justified our less than excellent performance by medical relativism, but the patients only see the end result. They develop a sense of de-prioritisation, and are not impressed.

I wonder if unchecked relativism might contribute to the kind of rationalisation and dismissal that allowed poor care to thrive at Mid Staffs. For senior hospital doctors whose careers have seen patients progress from timid supplicants to consumers of services with enhanced autonomy (and very different expectations), it is vital that we make a psychological leap – one that should come easily to anyone who has ever had to receive hospital treatment. Patients don’t care what the man or woman in the adjacent bed has; they are concerned about their own problems. They must be reassured the solution to those problems is at the centre of your, their doctor’s, thoughts, and not being forever shuffled and de-prioritised by the constant influx of more ‘deserving’ patients.

I started to write this post before the inflammatory word ‘warzone’ surfaced in the media once again. On May 9th 2013, Dr Cliff Mann, registrar at the College of Emergency Medicine, used it to describe the current situation in UK A&E departments. As the rising pressure in A&E is transmitted to the wards, maintaining an impression of patient centrality, of an importance that is intrinsic and not dependent on the needs and demands of those around them, will become harder and harder.