Death & Dying: Unlearning What You Learned in Medical School

Written by on August 30, 2013 in Insight - No comments

Dealing with death and dying—it’s among the most stressful experiences most humans encounter, but one would never know it from the demeanor of some of the physicians treating them.  One of the first lessons taught in medical school is not to care too much.  Emotionalism is viewed as unprofessional and thought to interfere with patient care.  While that may be changing in some schools, for most physicians currently in practice, this is still the norm.

To master this unstated curriculum, medical students have historically developed an emotional armor that both shielded them from feeling too much and disguised any depth of any emotion they experienced.  Dark humor is an antidote many medical students use to overcome their revulsion at dissecting cadavers—ghoulish anecdotes surrounding pranks with corpses are common grist of the medical school humor mill.

Referring to patients by their condition—the “gallbladder in room 4”—rather than by their names is another way physicians maintain emotional distance.  By the time they graduate from medical school, physicians have gained experience with death and dying patients.  Studies show that they are far less apprehensive about communicating with dying patients and their families than first year students, but their degree of empathy has dropped.

Given the extent to which physicians are trained to repress emotion, it’s not surprising that they’re reluctant to admit they’re having strong feelings about a dire prognosis or patient death.  Indeed, a recent qualitative study on the impact of grief and loss on oncologists found that by far, the most common impact—and coping strategy—was “compartmentalization” with over half also reporting feelings of burnout and emotional exhaustion as an impact.  Many also noted a spillover of grief into their personal lives.

Detachment In Practice:

How Physician Empathy Affects Patient Care

While a certain amount of emotional detachment is necessary, how much is too much?   Studies conducted over the past 20 years suggest that the emotional detachment that physicians work so hard to develop isn’t necessarily helping patient care and outcomes:

  • Numerous studies suggest that patients who perceive their doctors as emotionally distant when giving a cancer diagnosis are less apt to adhere to their treatment plans and seek subsequent care.
  • In a 3‐year study of 891 diabetic patients, patients whose physicians had high scores on the empathy scale were significantly more likely to have good control of hemoglobin A1c (56%) than were patients of physicians with low empathy scores (40%).
  • In a 2010 study, when patients perceived their clinicians as empathetic, the severity, duration and objective measures of the common cold significantly changed.
  • In the 2012 study on oncologists referenced earlier, physicians reported distraction, distancing or withdrawing as patients are closer to death, as well as impacts on treatment decisions

What about the health and wellbeing of the physician?  Are caring and empathetic doctors at a higher risk for burnout and “compassion overload?”  The research suggests not:

  • In a recent study of palliative and hospice‐care clinicians, frequent exposure to death and dying was largely a positive experience that added meaning to their lives.
  • In a 2009 study, participation in a mindful communication program was associated with short term and sustained improvements in well being and attitudes associated with patient‐centered care.
  • A 1995 study found that oncologists who expressed an inability to communicate with patients had greater stress and more symptoms of burnout.
  • In the oncologist study, positive impacts included a motivation to improve patient care, and gaining a greater perspective on life and what is important.

We have found that physicians often underestimate the toll that the death and dying of their patients takes on their emotional health and wellbeing.  Just because they often say they “don’t have time” to think about their emotions doesn’t mean they aren’t experiencing them.

Experiencing Grief & Loss:

It’s Not All Sadness

In many instances, it’s not only the intensity of the emotions that he or she is experiencing that upsets a physician, it’s also the nature of the emotions that disturbs them.  In addition to sadness over the loss of a patient, most doctors feel a wide mix of emotions, including anger and guilt.  It’s not unusual for them to lose confidence, blame the patient, worry that they did something wrong, or worry about getting blamed for something they couldn’t have prevented.

Even though those reactions are quite commonplace, it’s also quite normal for physicians to think they’re “the only ones” that ever experienced them.  Physicians are typically somewhat competitive with their colleagues and concerned about appearing less than competent.  It’s not unusual for them to isolate and suffer in silence.

Helping Oneself While Helping Patients:

Improving Communication and Empathy Skills

Few physicians are entirely comfortable with delivering bad news to patients or dealing with the emotional aftermath.  Given how hard they’ve worked to repress their own emotions, it’s often very difficult for them to communicate with patients and family members who are in emotional distress.

The most important step physicians can take is to allow themselves to experience the emotions of grief.  This can be accomplished in several ways, including:

  • Approaching the subject of patient loss with a trusted colleague or physician peer coach
  • Participating in a spiritual retreat
  • Putting thoughts and feelings into writing, such as through journaling

Some studies suggest that physicians who have undergone communication training are perceived as more empathetic by their patients.  One interpretation of those findings is that, in order to improve their communications skills, physicians often become more aware their own feelings as they learn to watch for and understand emotional cues given by their patients.

Unfortunately, given the demands of their jobs, attending communication workshops isn’t a top priority for most physicians. The good news is that communication and empathy are skills that can be built—on the job—with coaching and commitment.

It can be helpful to “rehearse” how they’ll approach delivering a bad diagnosis with an objective listener.  In other instances, physicians may find a debriefing after the death of some patients with other members of the care team, or with a peer coach, to be helpful to access and work through emotions.  This may be especially helpful after the loss of some patients, such as children or young people, or those who have had especially valiant struggles, and to whom the physician and other members of the team become especially attached to or affected by during their course of treatment..

Another good way to prepare for difficult conversations is for physicians to take better care of themselves.  In a 2005 study from Mayo Clinic, residents who had a greater sense of wellbeing received higher empathy ratings from patients.

Over time, most physicians find that a relatively small investment of time spent improving the way they communicate with their patients and co‐workers can make their work significantly more rewarding.  If it also helps them confront and deal with feelings of grief and loss more effectively, the benefits to themselves and their patients can make it an even more worthwhile investment.

References:
Granek, L, Tozer, R, Mazzotta, P, Ramjaun, A, Krzyzanowska, M. “Nature and Impact of Grief Over Patient Loss on Oncologists’ Personal and Professional Lives,” Archives of Internal Medicine (2012).
Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonella JS. “Physicians’ empathy and clinical outcomes for diabetic patients,” Journal of Academic Medicine (2011).
Kasket, E. “Death and the doctor,” Journal of the Society for Existential Analysis (2006).
Krasner, MS, Epstein, RM, Beckman, H, et al. “Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians,” JAMA (2009).
Ramirez AJ, Graham J, Richard MA, et al. “Burnout and psychiatric disorder among cancer clinicians,” British Journal of Cancer (1995).
Rakel, D, Barrett, B, Zhang, Z, Hoeth, T, Chewning, B, Marchand, L, Scheder, J. “Perception of empathy in the therapeutic encounter: Effects on the common cold,” Journal of Patient Education and Counseling (2011).
Shanafelt TD, West C, Zhao X, Novotony P, Kolars J, Habermann TM, Sloan JA. “Relationship between increased personal well‐being and enhanced empathy among internal medicine residents.” Journal of General Internal Medicine (2005).
Sinclair, S. “Impact of death and dying on the personal lives and practices of palliative and hospice care professionals,” CMAJ, (2011).

By Liz Ferron, MSW, LICSW
Physician Wellness Services

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