"By medicine life may be prolong'd, yet death will seize the doctor too."

April 2, 2007 12:41 PM

Medical professionals: how do you intellectually and emotionally cope with disease and death?

I'm working on a large project involving researching medical and psychological disorders across a wide spectrum. I don't have any medical training, just a decent life sciences background. Prior to this I worked with a handful of specialty groups; this is the first time I've ever done such broad research. As the project progresses I am overwhelmed by the variety of diseases afflicting humanity, particularly the genetic disorders. It's made me wonder how physicians and other medical professionals 1). organize such a huge amount of material in their heads coherently enough to make intelligent decisions and diagnoses and 2). emotionally (philosophically? spiritually?) cope with their deep knowledge of the sheer amount of stuff that can kill or deform people. As in, drive despite knowing what a closed head injury looks like. As in, have babies despite knowing what can go awry merely with their fingers. Thanks for any books or articles on the subject that you can suggest or general insight you can offer.

posted by melissa may to science & nature (20 comments total)

You might find some help in a similar (but not identical) question I asked recently (for which, if you'll allow me a brief hijack, I never thanked the contributors - and I'd like to do that now, if any of them pop their heads in here.).
posted by granted at 1:18 PM on April 2, 2007

I don't have an answer, but I'm interested in the emotional coping as well. I shared an apartment with my sister during her residency as an ER tech. She'd come home with all these great stories, ranging from the guy who got his hand caught in the packaging machine to the associate who had to call the school to tell two kids that their parents had been killed in a car wreck.

I had to ask her to stop sharing these stories with me. Even if I could handle the profession intellectually, no way could I deal with this, emotionally, on a daily basis.

Ironically enough, and to your point of "what can go wrong", two out of three of her children were born with an incredibly rare brain defect that renders them profoundly retarded -- unable to even swallow or focus their eyes properly, much less learn to walk or talk. One of them died last winter. It would seem that healthy doses of family support + religion + SSRIs are what help her get through the day.
posted by LordSludge at 1:22 PM on April 2, 2007

1. As a family doc, there is essentially no limit to the things that people can walk in the door with so the organization of information is important. There is certainly a lot of memorization and regular review of the literature but it also takes a lot of natural curiosity. Further information is always within reach if you need it, you just can't be lazy about what you think you know. I also have developed a healthy sense of "what's normal or benign and not worth worrying about" and "this is dangerous or will be an ongoing problem and we need to get to the bottom of it."

2. This one's more difficult. It never really seemed to be an issue with me. I've definitely seen my share of road kill and healthy people turned horribly ill, but I have never really projected these things onto my own life. It's been pretty easy to separate the role I play with patients from my personal life -- somehow the things they are going through are different. It becomes personally very difficult for me when those different roles intersect, for instance when a friend is in the hospital or I run into a patient at the grocery store so I suppose there is an on/off switch that I activate regularly. I once ran into a woman at the grocery store who gave me a huge hug and exclaimed "Dr. Bartfast, so great to see you!" When my lack of recognition was apparent to her, she had to remind me that I had delivered her baby 3 weeks earlier. Oops.

I think that switch I flip probably shields me from thinking of all the things that could go wrong when I go skiing, hiking, or eating a cheeseburger. It also probably makes me a little less naturally empathetic in my personal life ("Oh, you lost your job today? Let me tell you about this guy I just diagnosed with lung cancer.") I think most doctors have to be a little more conscious of their emotions or they really risk becoming hardened.

A really dark sense of humor helps a lot, too.

I hope you get a lot of responses to this question, this is just my opinion, blah blah blah. Plus, I'd like to know who the other health care providers are around metafilter.
posted by Slarty Bartfast at 1:48 PM on April 2, 2007

This recent thread (and the linked article) might also be interesting to you. Some nice discussion about how doctors mentally organize information.
posted by occhiblu at 1:55 PM on April 2, 2007

My thoughts are basically the same as Slarty Bartfast - its never really been an issue. And I think the point about a dark sense of humor is totally true... I've yet to meet a EMT, Nurse or Doctor who didn't have one.
posted by blaneyphoto at 1:57 PM on April 2, 2007

(IANAP, but my husband is, and his inability to cope with the emotional aspect was a major factor in him becoming a pathologist - he rarely has to deal with patients. So not everyone gets over it.)
posted by gaspode at 1:58 PM on April 2, 2007

It helps to have very little ego. The best thing I ever learned was how to say, in so many words, in so many ways, "I don't know". And also, "I can, I could, but I won't."

It helps to remember how foreign the body is to most people, and how scary any disease is.

Beyond that, every one is different. Most doctors I know probably are better and worse off for having such intimate contact with illness. I never get used to watching young people die of bad diseases, or of seeing someone who has lost a spouse.

It may not be healthy, but I am [almost] constantly aware of the possibility of myself or a loved one dying. For me it just makes me appreciate my family more and not care as much about a lot of trivial irritations.
posted by docpops at 2:25 PM on April 2, 2007 [1 favorite has favorites]

Doctors, at least the ones I've known, handle these questions in a great variety of ways.

As for #1, false modesty aside, I've always been good at this. People have been telling me I displayed an unusual talent for retaining and organizing information since I was 7 years old. My folks nurtured it, paid for the best schooling money could buy, and here I am. It's not even particularly difficult for me; by now, acquiring new knowledge has become a habit, and it has always been a pleasure. The four years of med school were probably the happiest years of my life, for just this reason - fascinating knowledge to acquire, in near-infinite quantity and detail, and a good reason to bother doing so. (Probably worth pointing out that folks who really can't do this, just no ability for it, don't get into medical school, or if they do, they wash out. There are years of careful filtering before you're ever turned loose in a decision-making capacity.)

#2 is harder. The reality of the world is severe injustice, everywhere that you look. If you have a great thirst for knowledge of reality, then you learn about these things and you come to feel, in a way, "yes, this is how it is, the saccharine endings of TV shows are false. The Buddha (for instance) was correct when he proposed the first noble truth: all of life is suffering." If you are a person who values truth, then the truth of these, well, truths, serves as some kind of justification for facing them, even when they cannot be justified.

You look to history, religion, the history of religion even, for examples of how others have handled this. You see how your colleagues handle it, the good and the bad. It may or may not come as a surprise to you that my greatest source of inspiration - the one I can rely on in my lowest times - is the recall of certain patients that I have known and been privileged to care for.

Not all patients, to be sure. But some patients' lives are examples of compassion, of optimism, of faith and good cheer and courage and heroic virtue, even in the jaws of unending pain or of impending death. Those are the stories I think back on when I am feeling overwhelmed. They never fail to comfort me.
posted by ikkyu2 at 3:04 PM on April 2, 2007 [2 favorites has favorites]

It may or may not come as a surprise to you that my greatest source of inspiration - the one I can rely on in my lowest times - is the recall of certain patients that I have known and been privileged to care for.

seconded
posted by docpops at 3:10 PM on April 2, 2007

This is a nice, thought-provoking question. Like ikkyu2, I'm going to take the two questions that you asked separately. To frame what I'm saying, know that I mostly deal with pediatric oncology patients.

First, in terms of organizing large amounts of material, that for me has come with the years of training and practice. Most of the first couple of years of medical school are devoted to assimilating and organizing large amounts of information. I found, for myself, that as I progress in my career, I have become more of an information filtering device, moreso than an information storage device. While I'll have some things memorized out of convenience (that is, differential diagnoses or statistics that I frequently rely upon), for things that I use less commonly, it's easier for me to memorize information location (journals, books, on-line resources, etc.) so that I know where to find what I need.

The second question can be answered in many ways. The way that I cope with the difficult things that I see stems from realizing that what I see in the hospital is a distillation of what's out there in the world. That is, in a children's hospital you're going to see very high concentrations of very bad things that happen to children. Take my specialty - brain tumors. I see these patients regularly and the mortality rate is fairly high. However, there are maybe 4000 new diagnoses of pediatric brain tumors per year in the US. That's it. Considering that a birth cohort (# of children born per year) is about 4,000,000, you're talking about a relatively small fraction of kids out there. There is, fortunately, in many cases an inverse relationship between degree of horribleness and frequency. Thus the worst things I've seen (horrible-looking fetal brain tumors) happen very, very rarely.

The other way that I cope is by realizing that is life. It doesn't have any guarantees. Never has, never will. There's no reason that the person squished by that bus couldn't have been me. But I still need to cross the street. I try to control the few variables that I have access to: look both ways, don't drink and drive, wear your seat belt, try not to stand too close to the radiation source. Outside of that, I try to enjoy life so that in the event that it comes to a screeching halt in a manner similar to those of patients I've seen in the ED, then at least I'll have died happy and satisfied.

I smiled when I read ikkyu2's answer citing the Buddah. I've thought that to myself hundreds of times over the years. Life is suffering. It's not just in human life - it's in all life. Watch the Planet Earth series that's being broadcast on the Discover Channel. Life is hard, brutal and for many organisms, short. Once you accept that as your baseline, you come to appreciate health, longevity and comfort as the gravy in life, and not something owed to us.

One of the best things about my job is that I get to witness, daily, the resilience of children in the face of disease. Seeing how they manage to continue to find reasons to smile despite being bald, immune suppressed, vulnerable, and sometimes dying, is an inspiration.
posted by scblackman at 3:26 PM on April 2, 2007 [2 favorites has favorites]

ikkyu2 and docpops (and other MeFi medical professionals), I'm sure you are ethically constrained in telling those stories here but if you've ever read published accounts similar to what you recall, I'd love to know about them. This project has me awash in clinical descriptions of immense suffering and it would be great to read a "non-saccharine" account of this dynamic between doctors and patients. Sincere thanks to you and others who have responded so far.
posted by melissa may at 3:26 PM on April 2, 2007

melissa may - this guy says it better than I ever could.
posted by docpops at 3:34 PM on April 2, 2007

Who says they cope?
posted by kisch mokusch at 3:53 PM on April 2, 2007

Also, check out this book: Final Exam by Pauline Chen.
posted by Xurando at 4:48 PM on April 2, 2007

Some of us blog.
posted by gramcracker at 4:58 PM on April 2, 2007

"But some patients' lives are examples of compassion, of optimism, of faith and good cheer and courage and heroic virtue, even in the jaws of unending pain or of impending death. Those are the stories I think back on when I am feeling overwhelmed. They never fail to comfort me."

Very true, and worth repeating. Many of us remember the positive outcomes and it touches us greatly when we've had the opportunity to make a differences in someones life.

We see some shit that words cannot describe.

Having a dark sense of humor really does help. Many other folks don't understand it, but it helps us get through some difficult times.
posted by drstein at 10:19 PM on April 2, 2007

Melissa May, you might start by searching PubMed for my old professor Rita Charon's work. She has written a lot about the construction of the narrative as a vehicle for doctors to learn and to experience empathy. I had always felt myself to be in agreement with her but it was something that was never talked about much in school; she has made it very explicit and named the various parts of it so that doctors can have dialogues about these issues.

Or you might just email her; it's not hard to find her email address.
posted by ikkyu2 at 10:34 AM on April 3, 2007

Harvard Magazine's also been running stories over the last few years about the Med School's push for more "emotional training," I guess, in its doctors. This article has a bit more.
posted by occhiblu at 10:46 AM on April 3, 2007

I've been working as a street EMT since 1991. I'm currently in my paramedic internship. When I began, I was 18 years old, with almost no exposure to the realities of death, let alone violent and/or unexpected death.

One of my very first calls was for a classmate of mine at college: his girlfriend broke up with him, he borrowed a friend's Kawasaki Ninja, and catapulted himself into a telephone pole at high speed, doing an immense and eventually fatal amount of damage.

I handled it poorly, by trying to white-knuckle it out and keep the other firefighters from seeing my emotional reaction, which was extremely visceral. I was not resilient enough to flex and rebound: I bent, and was reshaped, and recovered, which is not the same thing.

I've found that different people handle things different ways: some people wall themselves off, others try to cope by being fully in the present, still others use a hybrid of the two.

I tried walling myself off, and it led to what I can only describe as a near-nervous-breakdown. I took a short break, and then tried engaging fully, and that was, to be brief, too intense and too painful.

After 16 years at this, I now manage by partially walling aspects of myself off and fully engaging other aspects of myself, as ikkyu2 memorably described.

When I go on duty, I am no longer married with a young child: I'm a guy doing his job, without context. That keeps me from seeing my own son in every pediatric call, and my own wife in every female patient, from seeing my father or mother or friends in the horrific situations to which we get called.

At the same time I'm doing this, however, I try to open myself compassionately to my patients with the understanding that for many of them this is the worst thing that has ever happened to them, and that treatment can be as simple as holding their hand or as complex as an advanced cardiac intervention.

Either way, they are human, they are often terrified, and in my experience the best treatment for those two issues is sometimes simple human connection: treating them with respect, controlling the chaos of the situation, and doing everything within my power to help them for the fraction of their life with which I am involved.

I have nothing but contempt for the school of thought that says healthcare workers should be distant and even harsh to their patients. As far as I'm concerned, if patients annoy you so much, get the hell out of medicine. Patients are, first and foremost, people, and people make incredibly shortsighted, stupid decisions routinely.

When I hear paramedics complaining about their idiot patients, I want to start laying about me with a two-by-four, because our job is not to judge: it is to provide succour for the wounded.

Finally, I remain keenly aware of what a privilege it is to be given the chance to work in medicine, where my actions can have a directly positive, fundamental affect on someone's life, and to be allowed into my patients' lives at what are often supreme moments of intimacy.
posted by scrump at 12:39 PM on April 3, 2007 [1 favorite has favorites]

scrump, that was a beautiful comment. Thank you all so much for all your leads on things to read and think about. You all helped me immensely.
posted by melissa may at 4:47 PM on April 3, 2007