Danielle Ofri, MD, physician, writer and editor, often turns her pen along with her focus to the emotional complexities that accompany a career in medicine. Her book, What Doctors Feel: How Emotions Affect the Practice of Medicine, is an honest sharing of what many healthcare professionals are often processing behind a mask of false bravado and confidence. The book, a must read for every medical education program in the country, can prepare and provide a realistic perspective of the road medical students can travel, to know they are not alone when doubt or disillusionment creeps in. It also can serve as an instruction manual of sorts for patients to better understand the person who provides the care. In just the Introduction, she writes:
There has been a steady stream of research into how doctors think…In…How Doctors Think, Jerome Groopman explored various styles and strategies that doctors use to guide diagnosis and treatment, pointing out the flaws and strengths along the way. He studied cognitive processes that doctors use and observed that emotions can strongly influence these thought patterns, sometimes in ways that gravely damage our patients. “Most [medical] errors are mistakes in thinking,” Groopman writes. “And part of what causes these cognitive errors is our inner feelings, feelings we do not readily admit to and often don’t even recognize…
…The emotional layers in medicine…are far more nuanced and pervasive than we may like to believe…they can often be the dominant players in medical decision-making, handily overshadowing evidenced-based medicine, clinical algorithms, quality-control measures, even medical experience. And this can occur without anyone’s conscious awareness…
…This book is intended to shed light on the vast emotional vocabulary of medicine…how it affects the practice of medicine at all levels.
It was the recent reporting of two young physicians taking their own lives at a time they should be celebrating academic and professional milestones that prompted this post. While we are not privy to what contributed to these terrible losses, the frequency with which similar lives are lost among the healthcare ranks speaks to what can often be a Grand Canyon-sized gap in the expectations and the reality of a career in medicine–as well as what is often left untreated or acknowledged within the profession: mental health and wellness of the healthcare professional. As Ofri writes in a recent article for Slate Magazine, The Tyranny of Perfection:
…it is clear that a career in medicine also brings on tidal waves of pain, confusion, stress, self-doubt, and fear. The eddies nip at our ankles from our first step into anatomy lab, gathering in force and ferocity over the years of training and practice. During medical school, at least half of students experience burnout, and some 10 percent contemplate suicide.
So much of medicine is a tyranny of perfection. Medical students are asked to absorb an immense body of knowledge…Yet, we act as though this perfection of knowledge is a realistic possibility. No wonder nearly every student feels like an imposter during his or her training….We’ve been asked for a perfection that is unachievable, yet the system acts as though the expectation is eminently reasonable. It’s no surprise that disillusionment is a prominent feature in the medical landscape today. It’s also no surprise that such burnout is associated with unprofessional behavior and more frequent errors.
Each year (since 2010) we gather medical, nursing and health science students, and resident physicians together for the Telluride Patient Safety Summer Camps in Telluride, CO (now Napa, CA and the Washington DC area as well) for week-long educational sessions, discussing patient safety related topics such as the need for open, honest communication in medicine, the need to honor the patient’s voice, and in the past, the bullying that goes on in the healthcare culture. The hope is that we can empower young change agents that will put a more realistic, positive spin to a culture that seeks to heal versus harm one another, or patients, yet continues to fail on both accounts far too often. The students and residents that take time out of their ever-increasing busy schedules to spend a week of vacation focused on making care safer are some of the most interesting, well-intended and accomplished young people. They have big hearts and the energy to climb the healthcare administrative and cultural mountains required when choosing to open their eyes to the challenges that lie within the healthcare culture. What steps can be taken by those leading today, to clear a safer, more well-rounded path, for their training and well-being? The thought of any one of our Telluride alum experiencing what Ofri and others describe is untenable–as is the thought that there are people posing as healthcare leaders that would allow this to continue.
Today is the day to commit to do things differently. To act upon what your gut is telling you. Today is the day to protect those you lead as they learn!
Lucian Leape’s words from the 2009 Telluride Patient Safety Educational Roundtable and Student/Resident Summer Camps tend to come back to me at random times. Not only was it amazing to sit in small group breakout sessions with him, discussing patient safety topics like a culture of disrespect in medicine, but to be in the classroom as he taught was something I’ll never forget.
Recently, his words on bullying in the healthcare workplace rang true and clear. In Danielle Ofri’s July 18 NYTimes Well blog piece, In a Culture of Disrespect Patients Lose Out, the topic was highlighted yet again. Unfortunately, this healthcare challenge remains alive and well. (See also ETY posts What Doctors Feel, and Bullying: Just Say No).
What struck me about Ofri’s NYTimes piece wasn’t that disrespect in the medical workplace was being linked directly to patient safety. That is just common sense. If your workforce is being bullied or treated poorly, how will those same individuals feel when going to do their job — which in this case, is care for patients? It was the following that was a reminder of the responsibility we all have to stop disrespectful behavior:
…This shift in perspective was a shock to the system. When we tolerate a culture of disrespect, we aren’t just being insensitive, or obtuse, or lazy, or enabling. We’re in fact violating the first commandment of medicine. How can we stand idly by when our casual acceptance of disrespect is causing the same harm to our patients as medication errors…
How can we continue to stand idly by? Bullies need to be called out. Period.
As we embark on yet another wonderful week of “Educating the Young” and move Telluride east to the Georgetown University campus for the first time, I hope that those of us able to stand up for students, residents and those we are charged with leading, continue to do just that — to stand up, to not stand idly by, and as Ofri says, view respect for one another…as common decency, something we should do because it’s simply the right thing to do.
For more information, see Leape et al in Academic Medicine July 2012.
In a recent post, What Doctors Feel, I referenced the work of Danielle Ofri MD, author, Associate Professor of Medicine at NYU, and practicing internist at Bellevue Hospital in NYC, whose research, and book by the same title, examines how emotions affect those providing care. Ofri’s website (found here) provides a number of related articles, as well as the following interview with colleague Oliver Sacks. Sacks is also a physician, and a well-known author whose work includes the 1973 memoir, Awakenings, later made into an Academy Award nominated film starring Robert DeNiro and Robin Williams.
Sacks has long believed in the value of sharing the stories of his neurologically impaired patients, as well as working to make them whole again. The compassion and empathy he feels for each of the patients whose story he shares is palpable.
Please enjoy his story over the holiday week–we will be back online July 9th!
I came across a post last week on Slate, The Darkest Year of Medical School, revisiting the idea that medical students lose not only empathy during their medical education, but according to author and NYU physician, Danielle Ofri, “altruism…generosity of spirit, love of learning, high ethical standards—are eroded by the end of medical training.” On June 4th, Ofri also published What Doctors Feel: How Emotions Affect the Practice of Medicine, having performed numerous interviews to draw her conclusions. I read some of the comments on her blog post above–many sharing “medical school was great”. Yet research–past and present– shows many students are not having that experience.
Ofri’s post and newest publication caught my eye as we embark upon the 9th year of the Telluride Patient Safety Educational Roundtable and Resident/Student Summer Camps. This will be my third year in Telluride. The first year I attended, I had the privilege to share a breakout discussion with Lucian Leape and a group of students in the shadows of the San Juan mountains. Throughout that week, Lucian emphasized the need to get a handle on the bullying that occurs in medicine, and instead, instill a greater respect for all in the medical workplace. He shared that unless we are able to do this — treat one another with respect — patients would pay the price, as well as healthcare providers and students.
Having not yet read Ofri’s book, I wonder if medical students who report enjoying medical school overall, were safely ensconced within a workplace with the culture of respect that Dr. Leape refers to as being so very important to patient well-being. It is safe to assume just how empowering a culture of respect would be for students, making them feel competent, part of a team and confident in their newly acquired skills. It’s also safe to assume how students who were bullied might feel (see Bullying in Medicine: Just Say No).
For more information on a culture of respect, and how to create one, see Lucian’s papers: