A Doctor's Guide to Being Human

When I was a senior at Stanford, my ambitions for my final year of college were terminally derailed by a geological event called the Loma Prieta earthquake.  The temblor caused so much damage in my residence that everyone had to be relocated to other dorms. I was the resident assistant (RA) for my house, meaning I was the problem-solver and support person for the rest of the students who lived there. This was a paid position and was something of an honor, and I took it seriously. Within minutes of the earthquake I was back at the house to account for the whereabouts of all the residents. I lost my wallet during the chaos and had to walk around for two weeks with nothing but some loose change in a paper bag. As the days went by and the damage to the building was being evaluated, all of us suffered from various symptoms of post-traumatic stress. I remember diving under the nearest table whenever an aftershock struck. I didn't sleep well. I had no appetite. It was hard for me to concentrate. I looked like something out of an Edward Gorey illustration.

An RA's meeting was called to discuss the plan to relocate the displaced students. I showed up at this meeting, pale-faced and stressed-out, and in a room filled with almost a hundred resident assistants I listened to the advice of one of the resident faculty advisors (RF):

"Whatever you're feeling, whatever is going on inside you--don't let it show," she said.  "You have to be there for your students and if they're having a problem, your feelings come second.  You have to put your needs on hold for them."

Years later, when I was a family practice intern, I was introduced to a different strategy for coping with personal stress and emotion. Our program ran Balint groups, in which residents were encouraged to discuss difficult interactions they'd had with patients, staff, or collegues. In return, you were supposed to receive support and feedback about how you might handle such situations in the future. Our mediators were not terribly skilled at leading this groups and soon they disintegrated into generalized complaining and impromptu nap sessions. We didn't talk about how we felt about patients who died, or attendings who blew up, or spouses who were frustrated about the hours we were putting in--except when we were with each other. Peer-to-peer, we processed a lot of emotions, but in a structured setting, at an imposed time, we were as tight-lipped as a bunch of mob lieutenants. 

These two approaches to dealing with emotional turmoil or conflict in a professional setting are equally flawed. The stiff-upper-lip approach I learned at Stanford is just plain wrong. Perhaps you can put aside your grief, stress or exhaustion once, but you can't keep doing it over and over again. I know this from experience, because I took that wretched RF's advice to heart. For weeks I put my students' needs first and made sure they were all okay, made jokes with them, kept a lighthearted facade. We were all relocated, and the academic year went on, but I was a wreck. I had to drop a bunch of classes and this meant I couldn't complete a double-major. I saw a counselor, but really the most helpful cure was passage of time, and getting as far away from Stanford as I could. I don't have very fond memories of the place because of the earthquake and its aftermath, including the terrible, damaging advice from the RF. In a just world, a person should be strung up by the toes, dragged into the town square, and tarred and feathered for giving advice like that--no matter how well-intentioned it might be.

The Balint group seems encouraging at first. It makes professionals protect time and is meant to create a safe haven to share emotional responses to difficult situations. The problem at my residency was that some of the people leading the Balint groups were the faculty members with whom we'd had difficult interactions. The safety of the group was breached, and so we only trotted out half-hearted stories, and shared the really raw stuff for personal discussions. And really, it was hard to let your guard down, to reveal your feelings, when all you wanted to do was survive the day, or make it through the week. If you're a few hours from going home and perhaps lucky enough to have dinner plans with friends, why would you want to dredge up a fight you had with your boyfriend eight days ago? People want to feel good, and they will indulge in some harmless self-deception in order to achieve emotional equanimity, and I don't think we should hold this against them.

I am a big fan of Rachel Naomi Remen's work. She used to give a talk to the incoming third-year students on the eve of their first clinical rotations. I went to this talk every year for three years, it was so inspiring. I encourage all students who read this blog to follow Rachel's work, and perhaps invest in some of her recordings, because these talks got me through medical school. Rachel talks a lot about the role of the wounded healer, and this has formed the basis of my approach to emotional upheaval. 

When I first heard about my partner's melanoma diagnosis, I experienced the rocking, unstable, fearful jolt I haven't felt since Loma Prieta. I worried about the stupid little things you worry about when something bad is happening in your home: whether to tell people, how to deal with their responses, how to explain to your employers, what kind of food you need to stock at home, how much money is in the bank. Most of all I worried how I need to seem to the world. I'm just returning to work after a mini-retirement, and I really need to be working but I don't want to put up a falsely cheerful facade if I'm not feeling cheerful. I never want to follow that dumbass advice I got at Stanford ever again. 

Then I remembered some advice I got from a friend who went through a very symptomatic menopause. "You know what? There's nothing shameful about having a hot flash," she said. "At first I thought I'd have to run and hide in the bathroom whenever one came on at the office, but then I said, oh screw it. Now if I'm talking to a patient and a hot flash comes on, I just keep talking. So what if I'm beet-red and drenched in sweat?"

So I've decided to follow a similar strategy. If I'm at work and have a moment of profound panic or fear, I'm just going to let it happen. So what if I have to sit down and tremble for a few minutes? The earth will keep turning. Or if I get tearful because I'm worried about the worst, then I'll let the tears come. And if, in the next moment, I am lucky enough to have one of those life-affirming moments which are the silver lining in this difficult profession--well then, I'll just laugh out loud. I've warned my co-workers:  "Don't worry if I seem crazy, because maybe I am right now. But it's good crazy, it's honest crazy, and I think I'm going to be okay."

Instead of suppressing emotional turmoil, or recounting it on demand, I think the best way to resolve the ups and downs of life is to let them move through you, to give each moment its place, and let it move on when it is done. At least that's what is working for me so far, along with watching Project Runway reruns and planning to redecorate my house, which are other manifestations of restless emotion, but I'll save the details for a later post.

Comments

[ddx:dx]

I agree that the Balint experience can be such. About 3 years ago I somehow came to read dr. Balint's book. "The Doctor, His Patient and the Illness". Yes, sexist. But it was 1950's.
Anyway, Balint groups are supposed to allow for reflection and growth of the practicioner. Indeed, to illuminate the nature of the perceived conflict. And aid in the frustrating treatment problems. It really was a good read.
But they never really get pulled off well, Balint groups. Along these lines I actually took Balint Group Leader training. Only to find there really is very little interest in busy, stressed practitioners. Too busy killing alligators to drain the swamp.
Best wishes on your continued humanity.

[Kim]

I've had someone impose the "just pretend everything's OK" coping method on me -- really more of a "work extra hard and extra long and avoid actually addressing what happened even a little" method -- and it was so, so not OK.

[Dr. Val]

I think you've got the right approach. Don't worry about being human - you may be even more beloved for it. :) Hugs to you!

[T.]

If you only knew how timely this post is for me! Thank you for your writing...it's a healing art as much as your doctoring.

[dragonfly]

Hope that your partner is doing well now. Suppression never works for me personally...otherwise the old ticking time bomb effect kicks in...

[Vijay]

Look well into thyself; there is a source of strength which will always spring up if thou wilt always look there. - Marcus Aurelius Antoninus