Monday, October 11, 2010

HEAL THYSELF


According to a recent article in the NY Times (http://www.nytimes.com/2010/10/07/health/views/07chen.html?pagewanted=1&_r=1), physicians have higher rates of suicide than the general population. Male doctors suffer a rate forty percent higher, and female doctors an alarming one hundred thirty percent higher. Since freshman medical students exhibit mental health profiles similar to their peers, it must be something within medical training and practice that damages physicians. The fact that practitioners themselves are in such poor emotional shape is a profound indictment of our healthcare system.

There’s no shortage of causative theories for these suicide rates. Do they result from the isolation medical students endure, or perhaps the intense competition in which they’re immersed? Numerous studies are now addressing these features. Strangely, though, no one has asked me.

I suspect the key lies in gender differences. You’ve probably noticed that women generally express emotions more easily than men do. Being female, they don’t need to exemplify male strength and cool, so they can allow themselves to be vulnerable, and to be cooperative with one another.

Physicianship has historically been male turf. My medical school class (1967) comprised sixty-four men and four women. Now, I understand, the majority of medical students are women, but it’s been a hard climb.

I remember one of my few female professors, a dignified, illustrious medical scholar, who began a lecture with a dirty joke. We laughed politely, as it wasn’t funny. Obviously not used to this humor, she’d picked something like what we giggled at in third grade. As she told it, she was red-faced embarrassed. Thinking about it years later, I realized she’d attempted to put us at ease by enacting a ritual that said, “You can listen to me; I’m one of the boys.”

I wasn’t conscious enough in those days to have pursued the subject, but now I wonder how my female classmates accommodated and responded to the  subtle but endemic sexual harassment and condescension directed toward them. I witnessed one strategy in my senior year, when a female gynecology resident stood up in rounds and asked why she wasn’t permitted to perform a culdoscopy on every patient. (A culdoscopy is an invasive procedure that involves inserting a high-tech periscope through the upper vaginal wall into the abdominal cavity.) Today such a suggestion would be considered close to criminal, but then the chief of gynecology was merely curious. He asked her why she wanted to do that. She replied, “This is a teaching hospital, isn’t it?” She was one of the boys, alright, in spades.

What does it mean for any of us, male or female, to act the mythologic male? Who knows, after all, what a “real” man is like aside from the cultural images we absorb? In Berkeley, decades ago, a psychotherapist named Chris Elms (thanks, Chris!) posted flyers all over town for his men’s groups. The bore a photo of young boys at the beach around the turn of the century, posing for the camera in their woolen swimsuits. Every one of them was flexing his biceps. Elms’ caption read, “Tired of holding that pose?”

Here’s the pose: strong; invulnerable, in fact, imperturbable; confident; able to handle any situation without help. Indeed, this model runs deep and wide. It describes almost every hero, from films to comic books. Medically, it’s Doctor Christian to Doctor House, and every fictitious physician between. It’s the implicit character model of medical training and practice.

I could list hundreds of facets of medical training that exemplify this myth, but that would be a book, and I’m only writing a blog entry here. In sum, though, a bright and altruistic freshman medical student is taught, slowly and thoroughly, to ignore suffering. Don’t believe for a moment that doctors, who for a living wade in suffering every hour of their career, don’t hurt as a result.

But obviously, you can’t practice medicine if you’re continually crying. Act like a man, for God's sake. Practically, though, you need to do something with the suffering you’ve absorbed, and there are only two routes available: express it or repress it. Repression, like denial, is an effective defense but must eventually fail. A member of a cancer support group put it perfectly when she said, “Buried suffering is always buried alive.”

All healthcare practitioners, not just physicians, need a self-care tool that’s currently in short supply, the ability to express their own suffering and still practice. This isn’t an easy challenge, since it requires deep self-reflection and usually intimidating adjustments. When the old masters like Sir William Osler wrote about the sacredness of the medical profession, they weren’t just addressing the magic that ought to occur inside the examining room. They included the deep, almost mystical, preparations doctors must make in themselves.

6 comments:

  1. Thank you so much for linking your eloquent blog to your NYTimes comment regarding when a nurse disagrees with a doctor...
    Your blog reminds me of my darkest days of nursing school, when I did, momentarily, become truly suicidal, and tried to kill myself, consuming a bottle of Wellbutrin....A vicious cycle of hopelessness subsumed me until I was too pathetic to make friends, nor did I want to make friends, nor could my counselors possibly understand my utter disgust with the whole system, which was fundamentally a hierarchical one...in such a system, I viewed even kindness as mere condescension, and I could see it did not mitigate my fundamental worthlessness, because I was too incompetent to understand this confusing stew of medical jargon and haunting acronyms and abbreviations that meant totally different things on different units...
    Thank goodness, over time, I have found my equilibrium, which, above all, comes from a profound understanding that as life and death cuts through us all, _existence_ is NOT a hierarchy, though we may attempt to set up and navigate hierarchical circles.

    I loved the nurse who pulled you aside and warned you you might get to where you were going. More often, I say nothing...but I am no longer under any illusion that any doctor is any wiser than me about how equally and swiftly death will one day cut us both.
    More often, I feel sorry for the doctors because I do see how the patients put on a brave face for them, and the patients don't deeply confide in them... and I see how callous attitudes just prevent them from seeing the ultimate truth of our vulnerability, from which we can run, but not hide...

    I go through ebbs and flows of despair and optimism regarding the communication between doctors and nurses on our unit...some attendings (both men and women) deeply and genuinely reach out to nurses...others do so rotely on rounds, because "it is policy." Others clearly have never cared, and never will. The patients suffer, the nurses suffer, and the doctor suffers in that case.

    But above all, I now view the reservoir of suffering I experienced in nursing school as the "baptism by fire" with which to deeply and genuinely connect with my patients and their terrified, overwhelmed, utterly subsumed family members...

    That, and reading Chekhov, gives me the courage to keep trying...

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  2. Thanks for your kind words. I'm sorry for the suffering you underwent, but it seems like you turned it into something useful. The practitioner who's suffered--the "wounded healer"--is someone primed for compassion.

    Into my twenties and thirties, I hadn't experienced significant suffering, so my patients' pains weren't much more to me than an abstraction. Only after I'd felt real pain did the light come on, and I realized that medicine's goal isn't simply to diagnose and treat disease, but to offer comfort, always.

    I may have written in the blog somewhere that over the years, a half-dozen MDs with cancer have been in my support groups. Every single one of them reported that until they got sick, they had no idea what patients experience. And that's tragic. You shouldn't have to get a life-threatening disease to come to that conclusion.

    Reading Chekhov ought to be mandatory, but I hope you also strive continually to develop relationships, especially at work, that support you.

    Best wishes,
    Jeff

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  3. I have tried to read as much of your blog as possible, and will soon finish it...delightful, and full of humor...I truly thought I had just made up the term "testosterone poisoning" as a comforting term to explain way out of bounds behavior by men I could in no way comprehend...yes, so much of our jargon, and supposed medical studies, are just ways for people to console themselves, and to be convinced of what they wish was true...

    Alas, the "Well Blog" has far more commentary than yours does, reflecting the worldwide audience of millions the Times pools from, but I wish there was as much discussion on your posts, just like the diverse and impassioned commentary on "When the Nurse Disagrees with the Doctor"....

    Blogs such as these are a marvelous tableau, because I do indeed consider every doctor and every nurse anywhere in the world to be my "colleagues"...and it is fascinating to see which chords are universal, and where regional differences emerge, both in geography and within fields of medicine...and it provides a type of comaraderie that is unique to to the forum...(for example, I would _never_ tell anyone I work with about my suicide attempt, because even your closest friend can accidentally say something that escapes into the merciless grape vine...and writing, in general, allows people the time and space to say and reflect on more profound thoughts than ordinarily occur in conversation....)

    Relationships at my workplace are fraught with the tensions you see reflected on the Well Blog, "When the nurse disagrees..." reader comments...compounded now by the fact that, insanely, our neonatal intensive care unit is spread across miles of private patient rooms, so that though a nurse may have 2 or 3 babies, she is connected to each one only by her phone, which rings to the monitors they are connected to, each in immense private rooms...talk about human touch being all but gone...the docs no longer even come to the bedside unless we insist...I frequently express my concerns over the phone, as they put the orders for whatever intervention we think is appropriate into the computer as we speak...the residents are all so much younger than myself and most nurses, and for the most part are all too easily persuaded into doing almost anything the nurse wants to do...When they ask me questions about how to calculate their TPN, I have to inform them I have zero training in that as a nurse, and I hope they get appropriate help from Pharmacy or a nutritionist or someone! But when you get inappropriate questions from the docs, you realize how on a wing and prayer this whole operation sometimes seems....

    Anyway, those of us who were together in our overcrowded unit tend to not only still be friends, but be closer because we have to make such an effort to stay connected on our new unit. But forging new friendships is infinitely harder when there aren't 2 or 3 nurses together in a room, and you can just chime in conversation...thus our new (for almost 2 years now) set-up reinforces the sensation of cliques...compound that with the "old nurses eat their young" phenomenon...I still try absolutely to be extra kind to the new nurses... and I still feel infinitely grateful that some of the most intimidating "Nurse Ratchet" types on our unit when I was young and new turned out to actually become at least warm and accepting of me, and one has surprised me in actually turning to confide in me...
    Overall, though, we have gone in a distressing direction...ironic for being a "world-class" highly ranked and esteemed hospital, blah blah blah...really, just sad, especially when we went to computer charting...So I will finish your blog to at least remember there are still some people who realize that the appearance of things is a confusing deception, and we have to keep looking for our hearts wherever we go, wherever we interact...

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  4. Dear DreamsAmelia,

    Reading your comments is making my day.

    What you say feels important, insightful, poignant, and certainly worth its own blog.

    I hope if you're not already in some sort of, well, say, a nurses' support group, that you start one. The rehumanization of healthcare can happen only when those who have the vision commune.

    - Jeff Kane

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  5. I stumbled across this blog after reading several comments on the above-mentioned NY Times article. I am beginning nursing school in January after teaching secondary art for five years in the Chicago Public Schools. I struggled every day, and was usually successful, at keeping a positive attitude in a sea of dysfunction and negativity.
    I am very moved when reading such inspirational and honest words as I prepare to make this transition. I am driven to move out of my comfort zone in various ways as I navigate daily living, but this blog and its contents are a beacon in a somewhat overwhelming sea of information here in the binary code.
    Thanks!

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  6. Dear Anonymous,

    Thanks for your positive words. As you enter nursing school, may I offer you a piece of advice? Please, please, connect ASAP with your fellow students in order to maintain emotional support for one another through your training. Nurses are healthcare's prime caregivers, and as we say in this biz, "Caregivers need caregivers."

    May you thrive,
    Jeff Kane

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