“Five years since qualification, I have learned that if I truly felt the sadness and enormity of the things that passed through my hands, I would drown. It needs to be ok to talk about that.” – So writes Dr Aoife Abbey, an intensive care medicine trainee, courageously sharing her feelings in a blog for the British Medical Association (BMA). She tells a shocking story about her patient who died suddenly at induction of anaesthesia.
In a heartfelt plea she adds, “People will tell you that empathy is the key to being a good doctor. That the ability to really see not just a patient, but a person and their narrative is the key to compassionate care. They’re not wrong of course, but what we don’t seem to want to tell each other is how to turn that tap off.”
On the same day, an anesthesiologist from Canada posted on the Hearts in Healthcare website that healthcare needs, “Physicians brave enough to be human, authentic and real.”
How do we reconcile these views? Is ‘turning the tap off‘ being human, authentic and real? As an anaesthetist who has written extensively and campaigned all around the world for more compassionate healthcare, I felt the need to respond to my colleagues. How can we survive the challenges of medicine and still be fully human?
The first time I truly grieved for one of my patients was when I’d been a doctor for twenty-five years. Actually I grieved for 31 patients. These were all the patients I could remember, that had died during my care. I sat at the top of a waterfall in a very beautiful forest, and threw 31 flower petals into the stream, one by one, commemorating each patient. I cried alone in the forest and allowed myself to feel loss and grief.
I think it’s sad that it took me a quarter of a century to acknowledge that as a doctor I felt pain, loss and grief. But then I’m an anaesthetist, a super-hero. In all my years of practice, I have rarely if ever seen any of my senior medical colleagues openly admit to feelings of vulnerability, sadness or grief. When we witness death and tragedy, we so often carry on working as if nothing has happened to affect us.
More recently, I was part of a tragedy as confronting as the story told by Dr Abbey. As the anaesthetist on call for the maternity unit I witnessed a young mother collapse unconscious minutes after she walked into the hospital. We rushed her to the operating theatre and a premature infant was delivered by Caesarean, stillborn. We managed to resuscitate the baby but at the end of the surgery, the mother had fixed dilated pupils and CT scan showed a catastrophic intra-cerebral bleed.
After many hours frantically trying to save the life of mother and baby, I then had the heartbreaking job of conveying to the husband and family the news of their terrible loss.
As if the tragedies we witness in our clinical care are not burdens enough, at the same time we were also suffering the tyrannies of corporate restructuring, cost-savings and cut-backs. In times past I would have travelled home at the end of the day feeling only despair. Sometimes we have to endure too much.
On this occasion I chose self-compassion and dared to examine my feelings. I admitted to myself that I felt profoundly shocked and upset with the events of that day. I rang the Chairman of the Department and explained that I was not in a good state to be looking after patients. I asked for sick leave and took two weeks off work. This was an unprecedented action but he supported my request.
In the operating rooms the doctors, nurses, midwives and others gathered together to share our burden. The hospital chaplain joined us for prayers in the room where the mother had died. The OR staff made a collection of food and clothes to give to the bereaved family. I gave my personal cell number to family members and we stayed in touch via text messages. Two weeks later I was able to attend a memorial service with the family, in the hospital chapel. We shared hugs and tears. I returned to work with my equanimity restored.
The day of tragedy had its joys also. I earlier had the extraordinary privilege of caring for a mother during an elective Caesarean, knowing that my technical skills, compassion, and personal presence helped to create a safe and joyous experience for the new parents. And even in the face of this day’s tragedy and loss, open-hearted compassion sustained me as much as it did the victims.
I have the advantage of years of life experience to buffer tragedies like this. It’s harder for our young trainees and I can understand the desire to ‘turn off the tap‘ of empathy and compassion. My belief is that this turning away ultimately does us harm and make us more vulnerable, not less.
Rather than emotional detachment, it’s healthier to relate to all of our patients with open-hearted compassion but to let go of our attachment to the outcomes. As the years go by I’ve learned than many factors other than my personal efforts determine the outcomes for my patients. With experience we discover there is mystery and awe in medicine, many things we can’t explain. Letting go of attachment to the outcomes is not relinquishing professional responsibility, it’s knowing with more wisdom and humility the limits of our efforts.
So in the face of tragedy we can offer our compassion and have the experience that deep caring and connection helps to heal our own heart too. Every act of compassion is equally compassion for the giver as well as the receiver. We can walk away from tragedy saddened by not diminished. But to sustain compassion we first have to take care of ourselves and that includes looking after our emotional and psychological wellbeing. We owe that to our patients.
What we need is a medical system that acknowledges the emotional burden suffered by doctors and provides the time and collegial support for these painful experiences to be absorbed and integrated. That process includes grieving for our patients, not pretending that we have no emotions.
Brene Brown, who write and speaks with such inspiring wisdom about vulnerability, empathy and compassion talks in this brief video about necessary boundaries. To her great surprise, and contrary to her previous belief, her research showed that the most deeply compassionate people she met were the most rigid in setting boundaries. By that, she doesn’t mean that we should set ourselves apart from our patients – though proper professional boundaries are important – she’s referring to people who are absolutely clear about what is and what is not acceptable. I think that’s a failing of the medical profession. In our professional culture and conditions of employment, we’ve not set any boundaries about reasonable and humane expectations regarding the emotional burden of being a doctor. In most other professionals, there would be a mandatory stand-down period after traumatic events and organised forms of personal and professional support.
Perhaps Dr Abbey can tell us, after her tragic event, was she given a period of leave? Did she have compassionate support and counselling from her senior colleagues? Were they even competent to offer that kind of support or do they still pretend that emotional trauma doesn’t affect them?
If we’re going to address this issue, then we need ‘physicians brave enough to be human, authentic and real.’ Why not simply decide that mandatory leave and emotional support after major trauma is departmental policy? If all the anaesthetists, or surgeons, or physicians together decide that the wellbeing of their colleagues is important then management can be presented with an ultimatum: Make this part of our employment contract, or we withdraw services. That’s called ‘setting boundaries’. The end result would probably be greater resilience and less sick leave overall – a win-win for both professionals and employers.
As doctors, we give our heart and soul to our work. We hope and pray to have leaders who share our values of love and compassion. But in the end we realise that each one of us has to be the leader. Heart and soul comes from within. Compassion shines its light into the darkest corners. Nobody can take that away.