August 4th, 2024
WHAT’S HEART GOT TO DO WITH IT? a book review, Jim Vogele
WHAT DOCTORS FEEL, How Emotions Affect the Practice of Medicine, by Danielle Ofri, MD (Pub: Beacon Press) (2013) ISBN 978-0-8070-7332-2
INTRODUCTION
Dr. Danielle Ofri’s 2013 book, WHAT DOCTORS FEEL, grapples with a serious issue, which I will paraphrase as: How do a physician’s emotions, and, concomitantly, emotional well-being, affect patient care and the physicians themselves? Ofri discusses the issue in a fashion that is honest, confessional, and analytic:
“The experiences of medical training and the hospital world have been extensively documented in books, television, and film. Some of this has been probing and incisive, and some has been entertaining nonsense. Much has been written about what doctors do and how they frame their thoughts. But the emotional side of medicine – the parts that are less rational, less amenable to systematic intervention – has not been examined as thoroughly, yet it may be at least as important.”
Ofri’s book gives an explicit nod to Jerome Groopman’s HOW DOCTORS THINK, a 2007 book which I shall review in due course. Thus, while I cannot yet comment on Groopman’s book, I can say now that I’m pleased that WHAT DOCTORS FEEL, a thought-provoking, enjoyable read, was also in my stack of books to read.
THE BOOK
A major focus of WHAT DOCTORS FEEL is empathy:
“Specifically for medicine, empathy is about recognizing and appreciating a patient’s suffering. The oath of Maimonides, which many graduating classes recite upon receiving their medical degrees, sums it up succinctly: ‘May I never see in the patient anything but a fellow creature in pain.’ Empathy requires being attuned to the patient’s perspective and understanding how the illness is woven into this particular person’s life. Last – and this is where doctors often stumble – empathy requires being able to communicate all of this to the patient.”
Dr. Ofri begins her story — appropriately — with medical training, including recounting some of her own experiences with empathy and the lack of empathy. It turns out that medical training may have an interesting and negative impact on one’s capacity for empathy. Empathy decreases during medical education? Don’t shoot the messenger, this is just a book review! As Ofri explains:
“Smack square in this debate over whether empathy is innate or learned is the consistent and depressing observation that medical students seem to lose prodigious amounts of empathy as they progress along the medical training route. Something in our medical training system serves to stamp out whatever empathy students bring with them on day one.”
I certainly understand that Ofri’s book, with its focus on humanistic perspectives will not be everyone’s proverbial cup. When you are in the middle of a hectic day – seeing patients, charting those visits, supervising APPs, keeping up with developments in your area of practice, all while being mindful of goings-on at home, whether (in no particular order here) home is centered upon a spouse and children, a partner, aging parents, or your dog or cat eager for attention – musing upon empathy may seem like a luxury. But Ofri makes a strong case for empathy as a foundational imperative and not a luxury when it comes to patient care.
Overall, there is much to appreciate about Ofri’s book, including the scope of its citations. I would offer these intriguing examples from the Notes:
- “Is There A Hardening Of The Heart During Medical School?” B.W.Newton et al, Academic Medicine 83 (2008): 244-49.
- “Let Me See if I Have This Right . . .’ Words that Build Empathy” J. Coulehan et al., Annals of Internal Medicine, 135 (2001): 221-27.
- “Effects Of Chewing Gum on the Stress and Work of University Students” A.P.Smith and M. Woods, Appetite 58 (2012), 1037-40.
- “On Apology,” Aaron Lazare (New York: Oxford University Press, 2004)
- “Music Lessons: What Musicians Can Teach Doctors (And Other Health Professionals)” F.Davidoff, Annals of Internal Medicine, (2011): 426-29.
- “Malpractice Suits: Their Effect On Doctors, Patients, And Families,” S.C. Charles, Journal of the Medical Association of Georgia, 76 (1987): 171-72.
- “Practitioner Empathy And The Duration Of The Common Cold,” D.P. Rakel et al, Family Medicine, (2009): 494-501.
- “When Computers Come Between Doctors And Patients,” Danielle Ofri, Well blog, New York Times.com, September 8, 2011, http://well.blogs.nytimes.com/.
I will note here that I can anecdotally relate to (I almost said “empathize with”) the title of the “Practitioner Empathy And The Duration Of The Common Cold” article. When I was growing up, our family doctor was a genteel older gentleman whom I saw many times during my childhood. Each time I saw him he repeated the same pattern: White-coated and bespectacled, he would walk into the exam room while peering at the contents of a file folder, which presumably held charts or medical records from prior visits (or perhaps just my name). Then he would look up and say, “Oh, hi, how are you doing?” There was always a welcoming flash of recognition, when he would say, “Oh, hi,” which communicated something along the lines of, ‘Hello again, I know you.’ That friendly acknowledgement had the effect of putting a young child at ease each time I visited the doctor’s office; it made me feel that the doctor recognized me, was somewhat pleased to see me, and that everything was going to be alright. Perhaps there was a placebo effect to this friendly greeting. In any event, Dr. Ofri’s book suggests that the doctor’s friendly greeting might have contributed to the fact that, without fail, I always got better after seeing the doctor.
WORK – LIFE BALANCE
Another topic Ofri addresses is physician burn-out. Burn-out is something that can occur in any line of work, of course, but in the field of medicine it has been studied, which makes sense given the importance of the decisions doctors are called upon to make on a routine basis. Ofri observes that:
“Most doctors who are burned out, though, do not shift careers. They stay in medicine because it is the only thing they know. . . . Peer support from colleagues or working with a psychologist or psychiatrist can help a doctor reconnect with what was important in medicine in the first place. Other doctors need to make changes in their work lives – switch practice settings, cut back on hours – or in their personal lives. Focusing more on family, scraping together a little time for clarinet or basketball or finally attacking Ulysses can strengthen the girders for them to face the challenges at work.”
I confess that I occasionally wonder about some of these studies, such as the Rand Corporation study Ofri cites, noting it is a “seminal study,” which “followed twenty thousand patients and their doctors for two years. These were patients with ordinary chronic illnesses – diabetes, hypertension, heart disease, and depression – not acutely ill patients in the hospital. Patients and doctors alike were extensively interviewed. One of the most intriguing findings of the study was that patients were much more likely to take their prescribed medications when they were cared for by doctors who were satisfied with their jobs and lives. This is one of the first studies that directly linked doctors’ inner feelings (as opposed to their concrete actions) with improved medical outcomes in patients.”
That is a fascinating conclusion and one that I’ll have to follow up on. Why would this be, that happier practitioners lead patients to comply more consistently with their treatment plans? See “Physicians’ Characteristics Influence Patients’ Adherence To Medical Treatment: Results From Medical Outcomes Study,” M.R.DiMatteo et al, Health Psychology 12 (1993): 93-102.
I cannot say that I’ve ever heard anyone indicate that they weren’t taking their medication because their physician seems unhappy . . . but I’ll have to take a look at that article itself to convince myself this is true; I don’t doubt that it is true – and it has the ring of verisimilitude to it — but I just don’t quite understand why. In any event, the chapter of WHAT DOCTORS FEEL that is devoted to the demands made upon healthcare practitioners is entitled, “Drowning.” That certainly tells you something. More specifically, however, while the book is a decade old now in 2024, the situation Ofri describes no doubt continues to hold true: “The polls do, however, confirm that disillusionment and frustration are nearly universal among doctors, at least to some degree. Even if doctors aren’t exiting in droves, the fact that so many think of leaving is dire. . . . Overall, about one in six general internists had left medicine by midcareer (for any reason), compared with one in twenty-five specialists.” This is concerning, indeed, and not just for physicians but for all of us!
THE MALPRACTICE SPECTRE
In the concluding chapter of her book, Ofri addresses one of the least favorite of topics for a physician – medical malpractice claims and the lawyers who come with them. I completely understand that having one’s professional competence challenged is among the worst experiences that a conscientious professional can have (which is true for lawyers just as it is for physicians). I buried that last phrase in parenthesis, but I probably shouldn’t have . . . as legal malpractice claims hurt lawyers deeply. I haven’t had one and I’ll be keeping my fingers crossed for the next couple decades for even having uttered those words. But Ofri notes, at least two-thirds of physicians will be sued and that rises to 99% if you practice in cardio, neurosurgery, or obstetrics.
On the topic of malpractice actions, and thus of course malpractice insurance, that is a topic which is relevant to the California physician contracts I review, just as it is relevant to Montana, Washington, and Oregon physician contracts. Regardless of whether you practice in California, Oregon, Montana, or Washington, your physician contract will address malpractice insurance obligations. Along with your physician contract review attorney, you will want to pay particular attention to the medical malpractice insurance provisions of your employment contract.
Recently, I have received a surprising number of queries from physicians concerning tail insurance coverage in their contracts; in almost all of these matters the physician did not engage in a formal physician contract review process prior to executing the contracts (as I’ve said elsewhere, the time to have a physician contract review is before you sign the contract). In most of these contracts where obligations concerning tail insurance are unclear, the language (and conditions precedent to) determining who is responsible for tail insurance turns out to be vague, ambiguous, or even simply not addressed. This type of ambiguity is a primary reason why it is recommended that it may be important to engage a physician employment contract review attorney, or in any event a qualified contract review service, to evaluate your contract and identify areas where the contract might be improved, and/or to identify points of clarification that should be sent to the prospective employer prior to signing. Whether by reading posts on this website, or from your colleagues or your personal experience with other physician employment agreements, you likely know that all physician contracts are not created equally. Likewise, some organizations/employers are open to editorial suggestions and others are not.
One quibble I might offer here in this review concerns Dr. Ofri’s suggestion that lawyers and plumbers generally do not work extra hours for their clients simply “because it’s the right thing to do.” In Ofri’s words, “It’s hard to imagine a lawyer or plumber providing eight extra hours of work each week for clients just because it’s the right thing to do. And of course, it is impossible to imagine lawyers or plumbers not billing – heavily! – for it. But that is the expectation of medicine.”
I cannot speak for plumbers, nor for all lawyers, but I can say that this lawyer and many lawyers I know routinely work (countless) extra hours beyond the minimum of what is required – weekly and over the course of a career – for their clients “because it’s the right thing to do” regardless of whether the lawyers are paid for the extra time. And, not to be facetious, but not charging for this additional time is called ‘writing time off.’ Lawyers do this all the time; at least among good lawyers you will find that they do spend a lot of extra, non-compensable time for their clients, running down legal issues that may or may not materialize, investigating and researching background facts concerning a potential matter, and so forth. This does not diminish the point Ofri is making about doctors routinely going above and beyond for their patients, because doctors certainly do this and we can all be thankful that they do.
But doctors are not alone in rolling the Sisyphean rock up the hill, endlessly.
CONCLUSION
Dr. Ofri states that she had long avoided reading THE HOUSE OF GOD by Samuel Shem, in part because she “knew it was derogatory, sexist, dated, and downright offensive.” Indeed, Ofri was asked to contribute to the 25th anniversary of the “now-classic book” but, not having read it, she couldn’t do so.
When she then read the book, she found it to be, frankly, hilarious. Having read it, she found the book to be everything she’d expected or feared it would be, but she also found it to be exceedingly funny in many respects. Nonetheless, she observes that, “parts of the book [that] drove to the heart of difficult issues through humor.” Thus, I sense that Samuel Shem’s book – despite its flaws or context as a bit of a historical document – should probably be added to my growing list of books to read.
Finally, speaking of heart, and the heart of the matter, Dr. Ofri’s book consistently begins and ends with just that: heart, in the metaphorical sense as opposed to cardiology per se. Heart in the sense in which physicians and all of us feel. Denying the heart in the matter as well as the heart of the matter, would be silly and counterproductive to a happy life and a healthy medical care system. The heart is often the guide dog we need, leading us forward to fulfillment and our best performance in the workplace. For an example of what this means, see the story in WHAT DOCTORS FEEL concerning Mr. Easton, and, finally, Mrs. Easton. It is a difficult story to read about – let alone to imagine oneself immersed in the situation – and thus one can imagine how difficult it was for the healthcare practitioners involved, doing their jobs while being humans with hearts all the while.
Reading WHAT DOCTORS FEEL convinces me that the buck indeed stops here, with the heart.
