Over the span of my career and in my own experience as a patient, on the receiving end of medicine, it has become more apparent to me that when our patients seek medical help they are asking not only for our clinical expertise but for our care and compassion. Illness makes you vulnerable and more open to love and care. What then happens if our reactions to our patients are lacking in compassion, if indeed we are judgemental, dismissive, frustrated or even angry? Do the patients get the standard of care that all patients deserve? Do they feel cared for or even cared about? Does the negative energy we react with do them any harm?
A disturbing story
When I was a houseman, many moons ago, I observed something that even 40 years ago disturbed me. My consultant was a mild mannered, well respected physician. At that time, when we were on call, patients who had overdosed were admitted under the medical team rather than the psychiatric team. FD was a long-haired young man in his early twenties who was regularly admitted after trying to take his life. His stomach was pumped, and then he was left to sleep it off. On the morning round our consultant used to get very annoyed by this recurrent self-inflicted harm, acting as though he felt it was an affront to his role as a medical specialist that he had to waste his time on this individual. One day I came in to find that he had got so annoyed that he had ordered the patient’s hair shaved off while he was unconscious. I doubt whether the consultant ever explored why he felt such a strong sense of negativity towards this patient. I do know his complete lack of compassion could only have made life worse for that young man, confirming his belief that he was not at all lovable. Even by a doctor whose job it was to be compassionate.
It is normal to have a human response to the many and varied human conditions that we face in our medical days. Sometimes this is a true response filled with love and compassion, but it is when we feel less than this and we have an emotional reaction that we need to take time to reflect on why we feel that way and whether this reaction directly affects the patient in front of us and the level of care we can give. What is our responsibility here? Is this burnout; are we over-tired; or are we influenced by the ideals and beliefs we carried into medicine, and which perhaps we have never addressed, which are now being triggered by the patient before us.
All of us carry our own beliefs into our medical career and unless we are willing to explore them, they can influence our ability to be caring and may affect our judgement. As students and young doctors, we may believe we are training to rescue the sick, to save humanity! We are challenged as soon as we start to work in the clinical environment, and all our ideals and beliefs are brought to the fore, revealed to us to deal with, or react to.
How our reactions may affect our patients
For our patients, observing clinicians reacting to them in a way which comes from a place of judgement, racism, disgust or disbelief may affect the patient’s willingness to access care when they need it, and indeed to trust doctors and western medicine at all. It is important also for us to remember that the way we feel about a patient is often how they experience others in the community judging them. It may be the very way they have come to see themselves – that they are perhaps dirty, hopeless, unlovable, a waste of time, ugly and will never amount to anything – judgements they may have been receiving since childhood.
How will our negative reactions then affect them – we who profess to be caring and compassionate professionals?
One of my patients with chronic anorexia died two weeks after the hospital manager asked me to discharge her and never admit her again. While she had met with some love and understanding in hospital, she had also suffered deeply because she could hear the night staff discussing how her admission was a waste of bedspace and worse.
Can we train ourselves to react differently?
This is not to say we should tolerate threats to our own safety, accept inappropriate behaviour or allow patients to self-harm or harm others. Clinicians working at the coal face have been facing increasing violence in emergency departments and their safety and that of all staff and patients is of paramount importance.(1) We should, however, take time to reflect on our own reactions, to explore their roots.
Do we feel negative about certain groups of patients and not others?
I felt negatively towards abusive alcoholics and substance abusers who came to emergency. They were often aggressive, dirty and truth be told I was wary of them and sometimes frightened. Later through my general practice I worked with patients attending an in-patient drug and alcohol rehab unit and met these same people in recovery. Then I could hear their, often harrowing, stories and see who they were without drugs and alcohol – actually something joyful to witness.
Clinicians’ reactions to those with Anorexia
In more recent years I spent some time working with patients suffering from anorexia, work I found very interesting and rewarding, balanced as it is on the interface between the physical and the psychological. Health carers’ emotional responses to patients with anorexia are well documented both in scientific papers,(2,3) but also in the blog sites patients contribute to.(4)
When I tried to admit patients, who were often clinically severely compromised, onto the medical ward for refeeding, I often met with the most negative reactions from both clinicians and nursing staff. There seemed to be no recognition that their behaviour was not that of a petulant teenager but the consequence of a severe psychological illness; no recognition that this disorder has the highest mortality of any psychiatric illness in young people; or that the physiological changes of starvation are life threatening and result in cognitive changes which perpetuate dieting behaviours. I was very grateful to those clinicians who were willing to admit these fragile young women, but rather mystified by those who refused. I had to ask myself if I too reacted to other groups of patients in negative ways and whether I treated certain patients with less compassion than others.
What is it in us, the so-called-caring profession, that makes us have sometimes visceral reactions to patients even though intellectually we know that their behaviour is not necessarily their own choice but rather a part of their illness? Anorexia is described as an ego-syntonic disorder.(5) The disorder itself is seen by the patient as beneficial to them resulting in the fact that treatment, which involves weight gain, is directly acting against what they feel is good for them, in fact aligning with their greatest fear. So they reject and fight against our care.
We find it difficult when our care and advice are rejected
We find it difficult when our advice and care are not valued and acted upon, and sometimes we do not really understand why this is the case. I was told the story of a rural woman who, close to term, was transferred by plane to the regional hospital. She discharged herself and went home and was judged to be very recalcitrant. It was only when this had happened three times did the staff find out that she did not feel safe leaving her children with her partner, who was a loving man but became violent under the influence of alcohol.
Can we look to compassion for an answer?
Could it be that our negative reactions are based on the fact that we see ourselves as care givers, but our offer of care is being refused, threatening our own sense of ourselves. Is it possible for us to learn to be non-judgemental, indeed to learn to have equal compassion for all, whoever they are, whatever their illness, however they behave and whether or not they take the care and advice we offer?
For myself, I found that in the acceptance that we are all equal, that underneath the overcoat my patients present to the world lies a heart equal in beauty to mine and any other; that they were not their disease or their behaviour, but a person just like me whose life had taken a different road.
One of the joys of medicine is that we are forever students not only of ever expanding medical knowledge, not only in the deepening of our knowing of human nature and behaviour, but of learning ever more about ourselves as we meet and treat as doctors, as we go through the stages of life and our medical careers and when we ourselves become patients.
It would perhaps be wise of us to learn to deal with our own reactions so that we are more able to offer the care that we ourselves would like to receive, when our time comes.
1. Imlach Gunasekara, F How do intoxicated patients impact staff in the emergency department: an exploratory study…The New Zealand Medical Journal 10th June 2011, Volume 124 Number 1335
2. Currin L Primary care physicians’ knowledge of and attitudes toward the eating disorders: do they affect clinical actions? Int J Eat Disord. 2009 Jul;42(5):453-8. doi: 10.1002/eat.20636