Doctor, How Do You Feel?

I was terrified and excited in equal parts. It was the first month of my third year of medical school, and I was bright-eyed and bushy-tailed. Our team was on afternoon rounds, and I was busy trying to impress my residents with my fledgling clinical skills -- until the patient next door to us coded. That is, his heart stopped and a "code blue" was called for immediate assistance from the nearest team of physicians. That meant us.

The senior resident on my team asked me if I'd ever participated in a code blue before -- I hadn't. He all but pushed me into the room and within minutes, I was doing chest compressions on the patient. The adrenaline surge was indescribable. I had entered the world of clinical medicine merely weeks before, and now this man's life was literally in my hands. When my compressions noticeably weakened, a surgical resident in the assembly line quickly took my place. I stood by and watched as the critical care physicians placed intravenous lines, injected the patient with epinephrine and attempted to shock his heart back into a normal rhythm -- a scene so perfectly orderly despite the outward chaos.

After 30 minutes of shocks and compressions, he was pronounced dead. "You did a great job," my resident told me as we exited the room. We finished rounding on our patients and parted our separate ways. My resident's comment was the extent of our emotional readout that day, which unfortunately has become the standard in modern medicine. We never debriefed as a team.

I didn't know this patient -- I had never spoken to him before, and I had no ties to him whatsoever -- so why did it bother me so much? I think it was the disconcerting realization that death could be so mundane and unfeeling. Where were his family members? Who would call them to break the news -- and what would they say? Even though this patient had not been under the care of our team, the disregard for his humanity seemed like an injustice. In particular, it felt like a betrayal to walk away from him so cavalierly because my own father had also died in a hospital. There was undoubtedly a powerful role for countertransference here.

The effect of emotions on clinical practice has gained increasing attention over recent months and years. It is well-known to the public that it can be difficult for physicians -- particularly in fields such as oncology or critical care medicine -- to manage grief without experiencing burnout or becoming emotionally stunted. Dr. Danielle Ofri of NYU recently published an entire book dedicated to the topic, titled What Doctors Feel: How Emotions Affect the Practice of Medicine. In it, she notes that "medical students seem to lose prodigious amounts of empathy" as they advance in their careers, "and it is in this demoralized state that we send them into residency." She argues that this is primarily due to the disruptive and chaotic nature of the third year of medical school: the ever-changing rotation schedules, the difficulty of finding a meaningful place on ward teams and the close interaction with overworked residents who have neither the time nor the energy to provide mentorship.

Beyond this, the unspoken culture of medicine plays a role in discouraging the open acknowledgement of emotion. Emotions are a waste of time, or worse, a show of weakness. Although we interface directly with the very real physical and emotional vulnerabilities of our patients on a regular basis -- by examining their bodies within minutes of meeting them or probing fearlessly into the nitty-gritty details of their social lives -- we are distinctly hesitant to reveal even the slightest vulnerability within ourselves. This pressure to rein in feelings may be partly well-intentioned, as emotional distance theoretically promotes clinical objectivity.

Why is all of this important? To be fair, I'm not still reeling from what I witnessed on the wards a year ago. But I do find it frustrating that this potential teaching moment was completely lost. Can we really expect medical students to retain their empathy if we don't show them how? In these formative years, students are like sponges, constantly absorbing clues from their superiors on how medicine should be practiced. A simple five-minute debriefing with an attending physician, the team leader, could go a long way in developing young minds and hearts.

During my second year of medical school, each student was required to observe an autopsy at the medical examiner's office in D.C. as part of our pathology curriculum. Notably, our deans and professors recognized the profound impact that the autopsy can have on the wellbeing of its students, and they arranged an optional discussion forum for shared reflection following the experience. My three roommates and I had signed up for the autopsy together, unaware that we would be assigned to the case of a two-year old boy who had been physically and sexually assaulted. We watched as the medical examiner slowly identified each and every one of the injuries that resulted in his death: cigarette burns on his chest, multiple rib fractures, anal canal trauma and ruptured blood vessels in the eye and brain, termed retinal hemorrhages and subdural hematomas, respectively. We had read about this: it was, "shaken baby syndrome." One of my classmates, whose nephew was also a two-year old, exited the room and excused herself for the remainder of the case.

Taking the time to debrief, process and exchange thoughts was essential for my understanding of this otherwise horrific experience. And importantly, the very existence of dedicated time for reflection, even for those who did not avail it, showed solidarity in support of emotional response. Some residency programs have taken a similar approach to addressing grief on the wards by instituting "Death Rounds," or "Wellness Rounds," where training physicians meet every so often to discuss their experiences with dying patients, the guilt and sadness that often linger, and strategies they use to cope.

Third and fourth year medical students, who are supremely impressionable, would derive additional benefit from direct mentorship on the wards as clinical events unfold in real-time. Yes, rounds must go on regardless of a patient's death or a physician's feelings. But taking a moment to pause for reflection can provide closure and meaning in an otherwise emotionally sterile setting. Grief and guilt are deeply unsettling, and they are often experienced in isolation. Particularly in young trainees, guidance from more experienced physicians should be deliberate and routine.

Clinical medicine is one of few professions where emotional investment can tremendously enhance the quality of one's work. As I transition to doctor-hood soon, I know that it will be challenging to stay emotionally engaged in the care of all of my patients without burning out or becoming apathetic. However, this is a battle that I believe is worth fighting. I'd like to be part of a generation of physicians that takes the time to step back from our pagers and paperwork to reflect on why we do what we do. The effects of "turning off" emotionally are profound, and the impact is far greater than the scope of the individual physician. Empathy is critical for the health of our patients, as well as our relationships with them. It forges trust and fosters mutual respect. Above all, emotional engagement -- in medicine, politics, education and beyond -- drives us to create change, inspires us to make our world a better place, and connects us to the very reason why we set out on our paths.

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