The Case for Emotions
In his book Communication
Skills that Heal, one physician
helps
others communicate in a therapeutic way. In this chapter,
“But There’s No Room for Emotions Inside This White Coat,”
Dr. Bub encourages physicians to welcome their feelings
others communicate in a therapeutic way. In this chapter,
“But There’s No Room for Emotions Inside This White Coat,”
Dr. Bub encourages physicians to welcome their feelings
Emotions are challenging. These little
beasts tend to show up at the most inconvenient time. We
physicians pride ourselves on our scientific objectivity, and
when these rascals emerge from their hiding place we are taught
they need to be collared, examined, and then locked up so they
won’t interfere.
A journal article, “The inner life of physicians and care of the
seriously ill,” opens up
a Pandora’s Box as it unbuttons that sterile veneer of
objectivity, the white coat, and displays a host of emotions
that may adversely affect both quality of care and physician
well-being. The authors point out that physicians react to
seriously ill patients with a variety of emotions which, if
unexamined, can lead to “physician distress,
disengagement, burnout, and poor judgment.” The
conclusion is reached that “...physicians should take an
active role in identifying and controlling those
emotions.”
At first glance this
conclusion sounds so reasonable that the introject it expresses
may easily be overlooked. After all, something needs to be done
with emotions—one need only think of medical students
who, left unchecked, may spill their emotions uncontrollably.
For example:
= Anxiety. In the
article “Don’t discuss it: Reconciling illness,
dying, and death in a medical school anatomy laboratory,”
the author describes her study of communications in a medical
school anatomy dissection laboratory. She writes:
“Particular
attention is given to the history and maintenance of the
medical faculty’s tacit prohibition against discussion of
their own and their students’ attitudes and anxieties
about illness, dying and death.”
She also makes note of what
she describes as “a conspiracy of silence between
professors and students and between students and their fellow
students.” Even today, when there tends to be a more
enlightened approach of openness, students still often hide
their discomfort behind cynicism and humor.
= Compassion and grief.
In a 55-word narrative this student writes about her
crisis—her fork in the road. “Do I remain
compassionate and suffer? Or do I become desensitized and tough
in which case I will have lost my humanity.”
The Student’s
Dilemma: “In the hospital’s predawn
stillness, she confided fears about surgery to me, the medical
student. I tried to reassure her. They operated. Finding
extensive metastases, they closed immediately. That evening,
aching for her, I cried. ‘Don’t worry,’
another student reassured me. ‘It gets easier.’
‘I hope not. If it does, I’ll have lost my
humanity.’”
= Excitement. David
loved clinical medicine and was uninhibited in the way he
shared his excitement. His voice would carry across the open
wards, ‘Wowwww, did you guys feel this liver!’ or
‘Guys, you gotta come and see this!’ Patients would
turn ashen and I would cringe. Eventually, he learnt to be more
tactful and controlled. Still, once in a while he would express
himself with a low whistle. Fortunately David went on to become
a psychiatrist.
Infants and children
can be delightful (and embarrassingly honest) when they express
their emotions spontaneously and openly. Then they learn to
modulate their expressions in ways that are socially
acceptable. Young adults who choose to become medical students
are confronted by situations they have never before
encountered, and one of their developmental tasks is to develop
appropriate coping strategies to handle their emotions.
= The
faculty in the anatomy laboratory role-modeled silence as an
appropriate way of dealing with emotions.
= The
distressed medical student used reassurance as a response to
her patient’s fear, and in turn received reassurance from
her fellow student when she was distressed. Here reassurance
was used to modulate or control emotions of
another—unsuccessfully as it turns out.
= David
learned to filter and modify his exuberant expressions of
excitement.
In none of these situations were emotions
welcomed, listened to, accepted without judgement, validated,
and supported. Instead they were suppressed or aborted with
reassurance. In each case control was the method of choice in
dealing with emotions.
For medical students,
so much knowledge must be acquired in four short years that it
is far more expedient to create an environment where the
experience and expression of emotions is simply discouraged
than it is to incorporate programs that facilitate personal
reflection and incorporation of emotions. Where such programs
do exist, they are frequently inadequate.
One student wrote in A Parting Gift, “We masked our
emotions and curbed our imaginations in favor of scientific
interest. It was a sink-or-swim introduction to shutting off
our feelings.”
There are many reasons why
masking and suppressing emotions presents a problem.
= Many
students have a history of serious trauma prior to entering
medical school. They inevitably encounter situations that
retrigger their traumas and result in behavior that is not
necessarily in the best interest of themselves and their
patients. Processing their own emotions may be helpful in
raising their awareness of issues and situations related to
traumas that are troublesome to them.
= It
takes energy to control emotions. Far from protecting against
burnout (another myth), application of control over part of
oneself as a coping tool is more likely to stimulate it. The
use of control sets up a conflict between intellect and
emotion, the one suppressing the other wishing to assert
itself. This struggle drains energy, suppresses vitality, and
is self destructive.
= Emotional
health is greatest when knowledge (intellect) and feeling
(emotion) are cultivated and integrated rather than separated.
Many people spend years in psychotherapy trying to accomplish
this. The culture of medicine encourages the opposite. When
intellect and emotion support each other, rather than control
each other, the result is emotional health, harmony, and
personal empowerment.
= Control
of emotions cannot be totally selective. Suppression of
‘negative emotions’ is likely to cause suppression
of joy and compassion as well. A full range of emotions is
needed for healthy relationship and function.
= Far
from being an inconvenience, emotions are essential for
empathy, compassion, communication, and healing. When the
practitioner listens to his or her emotions as valuable (albeit
sometimes painful) messengers, they fade into the background.
When they are ignored or suppressed they call out even louder,
may inadvertently and unconsciously emerge, and then endanger
the physician-patient and other relationships.
= Many
physicians already control their emotions by burying
‘them’ under work or medicating them with alcohol,
drugs, workouts at the gym, and even stress reduction
techniques. In a profession where medical mistakes trigger a
great deal of anxiety, fear, guilt, and shame; where a high
level of stress is the norm for other reasons as well; it is
tempting to speculate that this control, stoicism, and silence
are factors that result in a physician suicide rate that is
significantly higher than that of the general population.
= The
more comfortable a physician is with her own emotions, the more
she is able to tolerate and even welcome the emotions of
others. In the movies of the 1950s, when the heroine hears bad
news and is shocked, the hero typically rushes to pour her a
shot of whiskey. “Here, drink this, it will help,”
he says. Medical practice is much like this, with physicians
being trained to rush for tranquilizers and antidepressants in
order to suppress the fears and tears of patients.
= When
emotions are suppressed, then they need to be replaced by
something. An authentic smile becomes a forced smile. Genuine
empathy may be replaced by empathy that is acted or even worse
by distance and stilted affect. Professionalism requires that
conscious expression of empathy be part of the routine, yet
when totally acted out, an expression of emotion can be
exaggerated or inappropriate.
Jerry had a total knee replacement and in the
immediate post-operative period suffered excruciating pain. His
orthopaedic surgeon, however, would radiate complete cheer and
well-being as he ‘waltzed’ into the room. ‘If
I talked about my pain or asked a question, he would instantly
lose his broad smile and take a step back as if he wanted to
escape from the room,’ Jerry reported.
= When
emotions are suppressed, the subtle ones that lurk in the
shadows of the loudest are also never given the opportunity to
see the light of day. All are uniformly suppressed, and tend to
seep out as laments, cynicism, anger, irritability.
= Ironically,
the suppression of emotions may be counterproductive. There is
always the risk that pent-up emotions may burst out, like a dam
break. This may occur at highly inappropriate moments and may
well interfere with professionalism.
Despite this, the
article “The inner life of physicians and care of the
seriously ill”
perpetuates the myth that feelings are best examined and
controlled.
In the following
example, the resident’s underlying problem was one of too
much control, not too little. Times are slowly changing in
medical schools with the introduction of creative programs such
as narrative medicine, medical humanities, etc. Still, it comes
too late for some, and those pesky critters that emotions are
eventually find a way of escaping from their cage...
The patient was a
sorry sight. Overweight, gray unkempt hair, disheveled shabby
clothes, she sat with shoulders slumped. Leaning over her was
the handsome, well-groomed resident, his red necktie neatly
knotted and pale blue shirt crisply starched. I could not hear
him through the one-way glass, but could see him aggressively
wagging a finger at her.
‘What’s
up, you seem angry,’ I commented when he emerged from the
examination room.
‘She
hasn’t lost weight, she smokes, her blood glucose is high
and she’s dirty. She’s a pig and she’s
wasting my time.’
Startled by his angry
outburst and somewhat appalled by his attitude, I suggested we
meet later to review this incident. Later, rather than telling
him to control his temper, I thought I would try to learn more
about him.
‘What made you
decide to do medicine as a profession,’ I asked.
‘It was my
parents’ idea. I always wanted to be a professional
basketball player; I was good at it too.’
‘You had to set
aside your dreams to fulfill theirs?’ I responded.
‘Yes, exactly,
and I hated doing it. Every day was a struggle for me. It
doesn’t get easier and now I don’t even have time
for an occasional game.’
‘How did you
manage to succeed when you hated it so much?’ I asked.
‘Through
determination, discipline, and hard work. I don’t dwell
on it, though. Anybody can do anything if they try hard
enough.’
Even a poor fat,
elderly woman with diabetes, I thought.
Ted had learned his
lesson well. He used control to suppress the anger that was
eating away at him. No doubt he had other emotions, perhaps
guilt at feeling so angry, shame at failure, frustration,
sadness, etc. He needed a safe supportive environment (i.e.,
therapist’s office) for venting and processing his
feelings. Instead, he focused on being a good physician, and
his emotions built up and were projected safely onto hapless
patients.
It is conceivable that
later on in his career, Ted may well become a
‘disruptive’ physician. A less-disciplined
individual or one with an addictive personality might well end
up abusing drugs or alcohol as well.
Contrary to the prevailing
introject that personal well-being and patient care are best
served by students and physicians examining and controlling
their emotions, authentic communication requires access to a
full range of emotions. An alternative approach is to set aside
times for introspection; to welcome emotions rather than to
distance from them; to approach emotions with curiosity rather
than judgment; to integrate them as an aspect of oneself rather
than to isolate and attempt to control them. g
Barry Bub, MD is the author of Communication Skills that Heal, (Radcliffe Medical Press, 2005). He has had a
successful family practice, taught counseling skills, and
studied chaplaincy. He now teaches novel concepts that promote
authentic communication in medicine and confidentially mentors
physicians undergoing litigation and professional stress.
The comments in Remarks are solely those
of the author and may or may not be shared by UO or its
advertisers.
