I’m not alone. A systematic review of longitudinal studies by Neumann showed that over the course of medical school and residency, empathy for patients and families goes down. There are many reasons for this. Stress is on the rise. Another factor is the apparent need for speed. These days, we seem to be in a perpetual hurry. In interactions with colleagues, we’re in such a hurry we finish each other’s sentences and tell one another to get to the bottom line.
Our encounters with patients in the clinic are now doled out in packets of five and ten minutes. Interruption is a pervasive communication style with doctors. In a well-known study by Beckman and Frankel, patients were allowed to complete their opening statement expressing their agenda in its entirety in only 23% of physician interviews. The average time to interruption was 18 seconds. In a more recent study of primary care residents, patients were allowed to speak for only 12 seconds on average before they were interrupted.
The work is getting more challenging. For good and valid reasons, there are never-ending efforts to close gaps and shortcomings in healthcare. But these add to an ever-increasing list of must-dos and don’ts. Let’s not forget that fatigue and sleep deprivation are also present frequently.
Health professionals are exposed to human pain and suffering on a daily basis. They witness men and women who are grievously harmed in motor vehicle collisions and shootings. They see preschoolers and teens with meningitis and sepsis.
In time, they lose count of the number of patients to whom they have to deliver bad news and of the families to whom they must deliver the worst news. For them, it will be the single worst conversation of their lives. For health professionals, it may be the fiftieth or hundredth.
Then, there are the inevitable mistakes in the course of one’s career. It is human to do so. However, an unknown percentage of physicians carry a burden of shame that makes them prone to depression following each error. Especially those that cause serious injuries. Guilt makes you feel bad about what you did. Shame reaffirms a pre-existing belief that you are bad. Psychologists have written much about shame. Almost none of it can be found in the medical literature. I believe it’s no accident.
Brené Brown, a research professor in The Graduate College of Social Work at the University of Houston, has written professionally and personally about shame. She has said it needs three things to grow: secrecy, silence, and judgment.
On a personal and at a culture-wide level, health professionals are reluctant to talk about their mistakes and shortcomings. Burdened by depression or burnout, many physicians choose to remain silent and suffer because of it.
Health professionals are judgmental about themselves and about one another. They question the competence of a colleague who uses a diagnostic term that is outdated. A consultant berates a referring physician for not knowing why he or she requires the consultation.
“If you have a choice between being right and being kind, choose kind.”, said Wayne Dyer, an American self-help author, and motivational speaker.
In medical culture, doctors value being correct far above being kind.
In a powerful commentary published in 2017 in the journal Medical Humanities, Lyons and Dolezal argued that shame is “underacknowledged, under-researched and under-theorised in the contexts of health and medicine.” They described the maladaptive behaviours of health professionals to deal with shame, including what they referred to as “acute shame avoidance behaviour.” By that, the authors meant denying accusations of unkindness, rationalising bad behaviour, and blaming others.
All of this has much to do with empathy. If cognitive empathy is the ability to imagine what it’s like to be someone else, and you’re feeling shame, I can’t imagine the pain one would feel imagining what it’s like to be the patient or the family member of the patient who was harmed.
The good news is that there’s a way out of the shame spiral.
“Courage starts with showing up and letting ourselves be seen,” said Brené Brown. “Because true belonging only happens when we present our authentic, imperfect selves to the world, our sense of belonging can never be greater than our level of self-acceptance.” And that was my fix.
Instead of running away and hiding from my mistakes, I had nothing to lose trying to acknowledge them. That meant meeting with the family that accused me of being unkind. It was not an easy session. The husband arrived with all of his adult children and their spouses. As each spoke, their testimony gave me a vivid picture of a vibrant and accomplished woman, a loving partner and a devoted mother and grandmother. A picture that was hard to see when I first met her. In part because she could not speak, in part because I was unable or unwilling to see it.
Their words touched me so much that I found myself crying, as did they.
That was the first time I apologised to a family and discovered kindness and generosity in them. Something I have found with patients and families over and over again. But the lesson that family gave me, more than any other, told me that deep down inside, I was still hardwired to be kind. As are you.
Here are a few bits of advice on how to be a kind physician in the exhausting and sometimes unkind world of medicine. Fight back against the need for speed. Slow down every chance you get. Be mindful. Breathe. Meditate. Venture outside the hospital and look at nature. Spend time with a beloved pet.
For those who are prone to shame, those mindful moments can be scary. As you breathe, unpleasant thoughts and memories will enter your consciousness. If you latch onto them, they stay. But if you see them as ugly floats in a garish parade, they simply pass by. If you’ve made an error, and you’re prone to shame, tell someone you trust about it. Give the thing you’re ashamed of some air, and watch it shrink.
If you want to be nurturing, the first person you have to remember to nurture is you. If you want to take care of others, first, take care of yourself.
And, if you want to remember how to be kind to others, the first person you need to be kind to is you.
Follow Brian on Twitter: @NightshiftMD