DESCRIBE
During a recent palliative care attachment I was fortunate enough to be working with a wonderful doctor, who I will refer to as Dr. M. One particular morning we were called to the hospital to consult on one of Dr. M's patients, who had passed away a few hours earlier. This patient, who I will refer to as Emily, was a young girl diagnosed with a terminal illness 18 months earlier and had been under the care of the palliative team and Dr. M for the previous 9 months. We entered the hospital room; the family surrounded her bed. There she lay as white and perfect as porcelain. The coldness of death on such young skin was shocking. Dr. M offered his support to the family, and we left to allow them the space to grieve.
In the car driving from the hospital, Dr. M asked me what I enjoy doing in my spare time, and he described the importance of maintaining the things that are our own during our journeys as medical professionals. He described his love of music and the ocean. He said that it is inevitable that you form connections with your patients. As he described the loss that he felt in the death of this young girl for whom he had cared for so long, tears glistened in his eyes. He explained how he recognized this loss and shared with me the strategies he has developed to work through his own grief and maintain his personal well-being.
REFLECT
It is rare for a professional person to be so open with their emotions, and I was touched by how willing Dr. M was to share his experiences and the strategies he uses to manage his psychological and emotional well-being. During my time as a medical student, there have been numerous occasions when I have been deeply moved by the interactions I have had with people. Sometimes these emotions are so powerful I find myself fighting back tears or needing to step out of the room. And while I know that this compassion is human and is what makes me so captured by the field of health and the interactions it offers, I also realize that I will need to be careful with my emotional involvement not to take on grief that is not my own and become overwhelmed by it. The message that is often delivered to medical students is that you need to maintain emotional boundaries between yourself and the patients and that it is a weakness to show your emotions. In my observations of experienced physicians, I have rarely witnessed any expression of emotional involvement and exposure of the rawness inside. Talking with Dr. M validated for me that it is okay to become connected to your patients so long as you are able to identify it and have a process by which to let it go. I feel grateful for the openness and honesty Dr. M showed me and privileged to have witnessed the profound ways in which he was able to connect with his patients.
CONNECTING
My discussion with Dr. M stimulated much reflection and highlighted some areas that I wanted to further explore in the literature. I have looked at the ways that doctors engage with their patients emotionally and how this is viewed among medical professionals. I have studied the factors that influence a physician's emotional involvement with patients and the consequences of leaving these experiences unaddressed. In realizing my own potential to become emotionally connected to patients, I have explored what strategies can be used to mitigate compassion fatigue and burnout and how to optimize the interactions I have with patients to improve both the care that I offer and my own personal well-being.
The topic of patient loss and its emotional effect on a physician has been given little attention in the literature of past years, but awareness of the issue is growing. Studies have shown that physicians do indeed become emotionally involved with their patients but that there has been a lack of open discussion of this between colleagues. Factors identified that affect the emotional impact on the doctor include the level of training (doctors earlier in their training are more shocked by the death of their patients), the time spent caring for a patient, the level of responsibility for the patient felt by the doctor, being a female doctor, and the doctor's own personal experiences of loss, death, and dying (Gallagher, Reference Gallagher2013).
A study by Redinbaugh and colleagues (Reference Redinbaugh, Sullivan and Block2003), from the University of Pittsburgh Cancer Institute, examined the factors that influence the effect of patient death on physicians and the extent to which this is recognized and discussed. They reported that trainee doctors need greater emotional support than experienced physicians in dealing with the loss of patients but that this is currently not well achieved and that the lack of openness in discussion of these issues creates a disability to cope and can later present as physician burnout and impaired medical decision making.
With growing awareness of the emotional impact of the health profession on physician well-being, the terms “burnout” and “compassion fatigue” have emerged. Burnout refers to the relationship between the doctor and the work environment, while compassion fatigue refers to the relationship between doctor and patient. Burnout involves emotional exhaustion, loss of job satisfaction, and cynicism with respect to many symptoms of depression, and is associated with poorer patient outcomes and impaired delivery of care. Factors predisposing to burnout include long work hours and failure to recognize one's limitations and psychological needs, as well as personal factors such as previous mental health problems and high-achieving personality types. Compassion fatigue, sometimes referred to as secondary trauma or vicarious trauma, is described as a variant of posttraumatic stress disorder, in which the physician carries the trauma of the patient. Compassion fatigue is characterized by the three domains of posttraumatic stress disorder, including hyperarousal (e.g., insomnia), avoidance, and mentally reexperiencing an event. While compassion fatigue doesn't prevent the physician from caring for a patient, it does impair the quality of care and if not addressed can progress to burnout (Kearney et al., Reference Kearney, Weininger and Vachon2009).
Kearney et al. (Reference Kearney, Weininger and Vachon2009) examined the factors that can reduce burnout and compassion fatigue and identified a number of areas. In relation to the work environment, the main influential factor was the extent to which the physician had control over work hours. In terms of personal factors, those with spiritual or religious beliefs had better outcomes than those who employed wellness strategies in their everyday life such as reflective writing and mindfulness meditation.
As my reflection has been stimulated by my interaction with a palliative care doctor who was more emotionally engaged with his patients than I have experienced with other doctors, I was interested in exploring the relationship between palliative care as a specialty and physician connection and spirituality. A qualitative study into the spiritual journey of palliative care physicians by Penderell and Brazil (Reference Penderell and Brazil2010) identified that physician spirituality plays a significant role in the delivery of palliative care, and they sought to further unravel this connection. They described how care of the dying is associated with the spiritual growth of the physician and that this in turn improves their ability to provide compassionate care for their patients. It was also noted that in being more spiritually engaged physicians were more self-aware and more likely to participate in self-care activities.
In examining the processes of self-care and self-awareness, Kearney et al. (Reference Kearney, Weininger and Vachon2009) noted that self-care without self-awareness does not have the same positive effect and can result in doctors disengaging from their work and being less connected to their patients. Self-care activities include physicians taking the time to do the things they enjoy, reducing their work hours where appropriate, and spending time with loved ones. Self-awareness can be practiced in many ways, but the two methods that are supported with the strongest body of evidence include mindfulness meditation and reflective writing. Research into trauma therapists practicing self-care in combination with self-awareness identified that they were less likely to suffer compassion fatigue or burnout. It was found that they were in fact able to care for their patients with “exquisite empathy”—a term defined as “highly present, sensitively attuned, well-boundaried, heartfelt empathic engagement,” and that this resulted in the physicians being uplifted rather than depleted by their patient connections (Harrison et al., Reference Harrison and Westwood2009).
Reflective writing in the manner with which medical students are familiar is helpful in the ongoing journey of a medical professional. The process of describing, reflecting, and connecting with the current literature, and deciding on how this might change future practice or emotional response to experiences has been demonstrated to have long-lasting positive effects on physician well-being and in turn improve patient care. Reflective writing was developed with the concept that experiences are learning opportunities and that by taking the time to reflect on these experiences one can better understand themselves and continue their personal evolution (University of New South Wales, 2008). Reflective writing in medicine has been shown to improve physicians' ability to provide empathic care to patients due to a better appreciation of patient experiences and more sensitively attuned personal awareness (Wald & Reis, Reference Wald and Reis2010).
Mindfulness meditation can be practiced at anytime and is most successful if it is integrated into everyday life—paying attention to the feeling of the cold water on your hands while doing the 30 seconds of hand hygiene, or noticing the feel of anxiety in your body when you know you are late for something. In short, it is being aware of yourself without judgment, right now and in every “now” (Holzel et al., Reference Holzel, Lazar and Gard2011). In addition to the strong body of practical evidence on the benefits of mindfulness mediation, there is emerging research in neuroplastic changes as demonstrated by neuroimaging (Allen et al., Reference Allen, Dietz and Blair2012).
Meier and colleagues (Reference Meier, Black and Morrison2001) examined physician response to patient death and the ways in which the psychological impact can be addressed to prevent burnout and impaired medical decision making. They argued that emotional responses are normal and important in patient care and should not be considered a weakness in professional behavior, but that these responses need to be recognized and addressed. In addition to the methods of self-awareness and self-care described above, they proposed a strategy of recognition and management of emotional responses that involves a number of steps:
1. Name the feeling—draw conscious attention to the emotional response.
2. Accept the normalcy of the feeling—validate that it is normal and need not be regarded with guilt or a feeling of failure.
3. Reflect on the emotion and its possible consequences—consider what might happen if this is not addressed.
4. Consult a trusted colleague—bring your emotions to the surface and encourage openness between colleagues
This method of recognizing and addressing emotions includes the aspects of self-awareness described previously and requires ongoing attention to self. It provides a framework for diagnosis and management that doctors are familiar with in the hope that they will be more successful in implementing changes (Meier et al., Reference Meier, Black and Morrison2001).
DECIDING
My involvement with palliative care and an interaction with a palliative physician, Dr. M, encouraged me to consider the ways in which I become emotionally connected to the patients I see. I identified that already in my experience as a medical student I have had encounters with patients that have moved me deeply, and I was grateful to be pursuing a profession that allowed me to be so engaged. With the conclusion of my studies fast approaching, soon I would be a practicing doctor and would be having these interactions with patients daily. As a female, junior doctor, with all the responsibilities that involves, I have the potential to become emotionally involved with my patients, and I understand that now is when I need to develop the strategies to prevent compassion fatigue, burnout, and, ultimately, poor provision of care. While it may not be an often-discussed topic, it is normal for doctors to develop attachment and emotional connections to their patients, and it is important that I be able to find colleagues with whom I can share these experiences. By practicing self-care and self-awareness in the process of ongoing mindfulness meditation and reflective writing, I have the opportunity to be invigorated and uplifted by the meaningful connections that I have with patients, reducing the chance of compassion fatigue and burnout and allowing me to provide the highest quality and most sensitive and engaged type of care. This has been a very valuable reflection for me, and I look forward to a fulfilling future in medicine with ongoing meaningful patient interaction.
