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Physicians' Feelings About Themselves and Their Patients To the Editor: In their discussion of the inner life of physicians, Dr Meier and colleagues [1] propose a medical model to address emotionally sensitive issues that most physicians keep secret. The medical model that I use to understand such issues is that of post traumatic stress disorder (PTSD), which is defined as a set of typical symptoms that develop after a person sees, is involved in, or hears of an "extreme traumatic stressor." [2] Although PTSD has been described as a consequence of rape, war, bombings, or other obvious overt traumas, [3] it is usually not considered a result of medical training. I believe that most physicians have PTSD and that the resulting feeling that physicians ignore most is toxic shame. Shame has been defined as the failure to live up to one's own expectations.[4] I define shame as the healthy sense that one is limited and toxic shame as the belief that one is defective.[5] Toxic shame has its roots in PTSD. During their training, physicians experience both physical (80- to 100-hour work weeks) and emotional (shaming by professors and supervising house staff) abuse. Once in practice, patient care "retriggers" the toxic fear, loneliness, pain, anger, and shame physicians experienced in training. I believe these extreme feelings are related to PTSD. Although these feelings may be "normal," they certainly are not healthy if left untreated. Physicians survive PTSD through isolating in work, hiding their feelings, and deceiving others and themselves. Isolation then promotes accepted mood-altering codependent behaviors of excessive attempts to please others, intellectualization, workaholism, secret keeping, and perfectionism. Less acceptable but tolerated behaviors include passive-aggressive failure to perform needed duties (eg, finishing their medical records) or shaming of paraprofessional personnel (eg, condescending anger toward nursing staff). Only when end-stage behaviors occur (such as crossing romantic boundaries with patients or overt drug addiction) do colleagues and others intervene. I believe the solution requires that medical schools, psychiatrists, and hospital administrators embrace the medical model of PTSD in evaluating and intervening in physician mental health problems. Unless taught these tenets, physicians cannot fully assess their feelings or confront and support others in their own struggles. Unless educated about these potential problems, hospital administrators and medical schools will not see their role in perpetrating or enabling the maladaptive behaviors and learn how to confront them effectively. James S. Kennedy, MD, CCS Department of Medicine Vanderbilt University Nashville, Tenn To the Editor: In emphasizing physicians' reactions to the care of seriously ill patients, Dr Meier and colleagues [1] may have overlooked their reactions to conditions that may not be life-threatening but nonetheless significantly affect the quality of those patients' lives. Spinal cord injuries are perhaps the most obvious of these conditions. It is important for physicians to recognize that caring for patients with any condition with the potential for even partially limiting activities important to the individual may provide reminders of the physician's own vulnerability. This can put the physician at risk for feelings that, unless recognized, could impair patient care. Simon Auster, MD, JD Departments of Family Medicine and Psychiatry F. Edward Hébert School of Medicine Uniformed Services University of the Health Sciences Bethesda, MD USA To the Editor: Dr Meier and colleagues [1] describe a model for assisting physicians to maximize their patients' and their own well-being. Their approach identifies risk factors, signs and symptoms, differential diagnosis, and intervention strategies for physicians to use as a guide toward identifying and addressing emotional distress. Yet application of these standard medical principles to emotional dynamics does not allow for deeper exploration of emotion. The medicalization of emotion in this context may, for some, create yet another wall for physicians to stand behind when emotions threaten to overwhelm them. In other words, use of a medical approach may actually strengthen the barriers this model seeks to alleviate. Aside from the limitation of its medical basis (which Meier et al recognize), the model does not appear to be comprehensive enough to allow physicians to achieve substantial self-knowledge of emotions and self-awareness of behaviors applicable to various situations. Although Meier et al suggest that self-monitoring be a routine skill, what seems to be called for is a broader acceptance in medicine of the humanness of physicians. Recognition of what it really means to be a physician, the sense of power or powerlessness, of connection and disconnection is both an attitude and a skill that may be imparted to physicians over the course of their medical education and practice through some deviance from strict medical model standards. Pervasive and routine emphasis on self-knowledge, self-awareness, and compassion can complement medical protocols. Mechanisms such as support seminars and grand rounds may help create a supportive environment wherein the open discussion of emotions is not preempted by a rebound to the familiar and comfortable, yet emotionally unchallenging, technicalities of patient care. The inner life of individual physicians should, to some extent, be brought into the outer life of physicians as a collective. Dena Schulman-Green, PhD Center for Excellence in Chronic Illness Care Yale University New Haven, Conn USA In Reply: These letters reflect a range of concerns about the impact of the inner emotional lives of physicians on the care of their patients. Dr Kennedy likens the sequelae of the trauma of medical education to PTSD. Dr Auster argues that phenomena similar to those described among physicians caring for persons with life-threatening illness also affect physicians' care for patients with chronic degenerative disorders or disabilities. Dr Schulman-Green believes that medical educational and community norms should change to integrate the recognition of the role that unexamined feelings can have on both physician and patient. Judging by these letters, our article seems to have stimulated dialogue on the responsibility of the profession to acknowledge that physicians are people too, with feelings that may affect care of patients. If the self-evidence of this observation is accepted by medical educators, some of the suggestions offered by these writers may find their way into the curriculum both for physicians in training as well as those already in practice. Diane E. Meier, MD Mount Sinai School of Medicine New York, NY Anthony L. Back, MD University of Washington School of Medicine Seattle R. Sean Morrison, MD Mount Sinai School of Medicine New York, 2002 American Medical Association. All rights reserved. http://jama.ama-assn.org/issues/v287n9/ffull/jlt0306-3.html janet paterson: an akinetic rigid subtype, albeit perky, parky pd: 54/41/37 cd: 54/44/43 tel: 613 256 8340 email: [log in to unmask] smail: 375 Country Street, Almonte, Ontario, Canada, K0A 1A0 a new voice: http://www.geocities.com/janet313/ ---------------------------------------------------------------------- To sign-off Parkinsn send a message to: mailto:[log in to unmask] In the body of the message put: signoff parkinsn