Author: Danielle Ofri
This book sets out to uncover the relatively shrouded subject of doctors’ feelings, and to debunk ‘the conventional stereotype that doctors are fairly emotionless‘ (page 3). The author examines the complex emotions that doctors experience in the performance of their work, dissecting the wide range of painful and pleasurable feelings that are intimately associated with medical practice. She appraises the impact of emotions on the performance of physicians, and the effect emotions have on the doctor-patient relationship. The book demonstrates the beneficial effects of positive emotions on health outcomes, at the same time illustrating how emotions, when poorly managed, may compromise patient safety.
Empathy is the key emotion the book addresses, pointing out how deficient it is in day-to-day patient care. The author, a physician herself, traces the erosion of empathy to medical school where students ‘seem to lose prodigious amounts of empathy as they progress along the medical training route’ (page 30). She blames ‘the hidden curriculum of medical school’ for depleting empathy, and she asserts that it does this by inculcating in medical students a ‘whatever-it-takes-to-get-it-done‘ attitude (pages 33-36). She appraised several habits which also distance doctors from their patients, for example the ’empathy-sapping’ terminologies and the gallows humour which typify their conversations about patients (page 36-37). She makes the painful admission that doctors generally don’t feel empathy for certain patient groups such as those who are smelly, dirty, nauseating, hostile, manipulative, entitled or arrogant (pages 10-12). She goes further to argue that doctors are notoriously contemptuous of alcoholics, drug addicts, and the morbidly obese, and ‘they often make little effort to conceal it’ (page 18).
The book goes beyond empathy and addresses a broad range of emotions that doctors experience throughout their careers. One prevalent example is the dread of harming patients, an emotion that is so pervasive that the author says ‘being a doctor means living with that fear, incorporating it into one’s daily life’ (page 93). Another ubiquitous emotion she explores in detail is grief, ‘one of the most commanding of human emotions’, capable of spilling into the personal lives of doctors, and ‘depleting their inner reserves of strength’ (page 107). The book also explores anxiety, an emotion that is the consequence of the uncertainty that characterises medical practice, and sorrow, an emotion that manifests even in ‘mundane daily medical encounters’ (pages 92 and 119). All these negative emotions, if poorly managed, take their toll on physicians, and the book discusses several devastating consequences such as disruptive behaviour, substance abuse, burnout, medical errors, and even quitting the medical profession (pages 158-160). Almost as a postscript, the author reviews the positive emotions that doctors occasionally experience, and these include joy, pride, gratitude, and love (page 210).
The author enriched her free-flowing narrative with anecdotes from her own personal emotional experiences as a physician. In this way, she graphically illustrated how emotions affect both the clinical practice, and the personal lives, of doctors. She was particularly courageous in how she openly and honestly discussed her clinical errors, and the shame she felt subsequent to these. A striking example is the guilt she felt when, two weeks after completing internship, she ‘proceeded to nearly kill a patient’. She attributes the excessive feeling of shame doctors endure to the culture of perfection in medicine which she says ‘fosters a strictly binary analysis: either you are an excellent doctor or you are a failure‘ (pages 124-129). The book particularly examined the feeling of shame that accompanies patients’ complaints and malpractice suits, situations that evoke other emotions including ‘anger, depression, cynicism, and wariness towards patients’ (page 137). She contends that the destructive shame that permeates medical practice arises because the healthcare system does not condone human error, and senior doctors do not openly acknowledge their own mistakes (page 136). The book explored the complex relationship of guilt, shame, and blame, making reference to Aaron Lazare‘s excellent book, On Apology (page 128).
The author employed several pertinent patient anecdotes to illustrate her arguments. The most cogent and gripping is probably the emotional roller-coaster narrative of Julia, her patient who ‘fell off the Starling curve‘ when her heart failure became terminal, and who battled all odds in her endeavour to secure a heart transplant (page 23, 142 and 170). Another patient story is of Betty Wilton, ‘the classic worried-well type of patient’…’who can overwhelm a doctor, quickly siphoning off reserves of time, clinical reasoning, and empathy‘ (page 86). The author also drew on the tragedies of other doctors to illustrate the impact of emotions on clinical practice. An example is the story of medical intern Curtis Climer who developed overwhelming anxiety from the stress of medical practice, and this ‘brutally’ impaired his clinical decision making (pages 69-76). Another tragic story, the harrowing decline to alcoholism of Joanne, illustrated ‘the purest form of disillusionment‘, and this is ‘frustration with the actual essence of taking care of patients, the feeling that many patients can’t be helped or don’t deserve to be helped’ (page 150).
The author made many recommendations for doctors on how to create an empathetic relationship with their patients. A key suggestion is for doctors to inculcate the ‘culturally aware‘ clinical practice of older physicians who ‘examined each patient… with a thoroughness that in itself exuded respect‘ (page 53). This approach, she argues, ‘serves to appreciate the dignity and uniqueness of each patient and his or her illness‘ (page 53). She maintained that ‘the very act of taking a patient and her story seriously… is the basis of empathy’ (page 54). The book suggested changes to the medical education curricula which may help inculcate empathy in healthcare, for example the use of the Jefferson Scale of Empathy to predict which students may become exemplary and successful doctors (pages 48-50). The author advised doctors to learn how best to manage their emotions, suggesting, for example, that doctors should not suppress their grief since this may result in ‘a numb physician who is unable to invest in a new patient’ (page 121).
This book is a very powerful advocacy for openness in all aspects of medical practice, from emotions to errors. The author makes strong arguments for empathetic patient care, stressing that this is an inherent component of each patient interaction. The book illustrated how emotions may make or mar the clinical encounter, from history taking to physical examination. The author supported all her arguments with cogent and appropriate clinical examples, and it is instructive that many of these are from her own personal experience.
This book has brought to the open a subject that is not readily acknowledged in medicine. The author reviewed the whole spectrum of feelings all doctors experience every working day, and in doing so, successfully debunked the myth of the unemotional doctor. The book makes a strong case for doctors to openly acknowledge their emotions, and it outlines measures to deal with these appropriately. It is an excellent book and I highly recommend it to all doctors.
Publisher, Place, Year: Beacon Press, Boston, 2013
Number of Chapters: 7
Number of Pages: 224
Rating: 5 stars