Review by Elsie Ohem
What do doctors need to establish empathetic behaviors? Acknowledgement and understanding of their own emotions. Dr. Danielle Ofri, in her book What Doctors Feel: How Emotions Affect the Practice of Medicine, offers readers her personal insight into her emotional—and often times complicated—world as a doctor who deals with the difficulties of stressful work environments, traumatic third year intern experiences, and emotionally intense patient/doctor relationships. Dr. Ofri’s exploration of why doctors are the way they are offers both doctors and patients an interesting insight into her opinion of the medical profession.
Let’s begin with a simple definition, one that should help those who wish to broadly understand what What Doctors Feel is about. A simple online reference would tell you that the word affect means to “have an effect on; make a difference to” and to “touch the feelings of (someone); move emotionally.” In this sense, the subtitle of Dr. Ofri’s book “How Emotions Affect the Practice of Medicine” means that Dr. Ofri aims to discuss how emotions impact doctors’s feelings towards the medical profession, as well as the actions towards patient care when practicing medicine. Dr. Ofri quotes her working definition of empathy from Sir William Osler: “It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”
The book’s structure as a personal narrative allows Dr. Ofri to offer readers a dramatic account of medical training that an average readership otherwise would not learn on their own. Her book is constructed to include her personal accounts of third year medical training as well as a handful of her personal interviews and patient experiences that she has had to emotionally deal with. One example of an occurring patient experience is “Julia.” Dr. Ofri uses Julia, a noted Guatemalan immigrant (soon an American citizen), to outline her struggles with emotionally tolling personal care. Julia’s story is told in seven parts, each written with moving dialogue and prose in mind. Essentially, Julia’s story integrates into the book as an intercession between the chapters that focus on “fear, shame, grief, and being overwhelmed.”
Dr. Ofri introduces readers to a dramatic scenario all third year medical training students endure—the reality of intense, at times chaotic, on-the-job medical training. Medical students must learn to adjust from an academic life to an overwhelming learning environment by modeling the actions and behaviors of their attendees. Dr. Ofri also points out that medical students must be aware of the responsibilities established by the third year hospital learning environment, “The medical student observes that even the most thoughtful and humanistic intern operates under the brutal calculus that every minute spent on nonessentials simply prolongs the work.” As such, completing what is termed the “scut list” is of highest priority, since completing these lists is essentially completing the backbone of basic patient care—that is, the care a doctor is able to manage within the chaos of the medical territory, “[I]n the end, most residents are simply too busy to incorporate yet another thing, no matter how beneficial, into their day, or maybe it’s just too difficult for doctors to practice medicine and chew gum at the same time.”
It is in understanding the role attendees play under the “brutal calculus” that is the third year of medical training that Dr. Ofri recognizes as essentially determining the root of empathetic absence. According to Dr. Ofri, the third year of medical training sharply defines a reality that most medical students are not equipped to handle. The fear of not fitting into an unfamiliar environment, the stress of not being able to uphold one’s weight outside of the strict academic setting, the lack of familiarity with differing cultures, the opposing (often hypocritical) attendee’s disrespect of patients, and/or the overall potential for patient/doctor hostilities all make up an emotionally turbulent medical learning environment that puts stress and fear at the highest point on the Richter scale. Dr. Ofri’s comparison of this environment to that of the battlefield and triage centers is one that illustrates the misplaced, out of orbit feeling novice medical students feel upon facing their future employment. Ultimately, for this scenario, Dr. Ofri posits that a change of some sort needs to start with a change in how attendees model respectful behavior.
“Old school habits” learned from Dr. Ofri’s medical training days are one suggestion she proposes for gaining back lost empathetic skills—skills that are especially useful when modeling respectful behavior. Simple manners, respect, and understanding are but a few habits that Dr. Ofri learned as being useful when maintaining empathy. These old school habits stem from doctors that were raised in a different time and/or different cultural background—as Dr. Ofri notes, doctors that are predominately white with the lack of multicultural ethnic integration. According to Dr. Ofri, this type of “old school” doctor actually benefits from not being ethnically aware of differing cultures—this helps doctors to become patient enough to learn about the different cultures and different ethnicities of their patients that they would have otherwise not have been exposed to, “They trained in an era in which their entire medical-school class looked exactly like them, with no diversity awareness, affirmative action, or cultural competence. Yet they were the most culturally aware people I’ve ever seen […] [because] these older physicians exhibited [what is] termed clinical curiosity. They strove to understand their patients in order to elucidate the underlying medical conditions.”
What is interesting, however, is the debate on whether the lack of emerging doctor’s empathetic skills are due to a student’s lack of hospital exposure in the first and second years of medical training. Dr. Ofri does note that medical students, fresh from the academically structured womb, experience a type of trauma when encountering the realities of their profession in the third year of academic training—a trauma that inhibits the growth of empathetic skills. This begs the question whether or not the traumatic hospital culture should be reviewed and changed. What I believe Dr. Ofri intended to do in this book is to provide readers her personal experience of her struggles with a problem that is deeper than she can handle alone. This problem is ideological in nature and requires a cultural shift in medical education and an overall modification of medical values in patient care in order to cure non-empathetic individuals.
Dr. Ofri never loses touch on what her main audience expects to read—that is, she makes an effort to get across to audiences the need to understand how emotions affect doctors. In an attempt to balance between lay and professional audiences, Dr. Ofri often uses hospital jargon as a way to emphasize an extreme, often overwhelming, confusion that new interns may feel when setting foot in a hospital for the first time. This jargon is directed to those who are unfamiliar with medical terms and aims to create an unsettling “oh wow, that is confusing” feeling. Of course, when reading this medical jargon, professional audiences would quietly smile to their books, knowingly understanding/relating their own initial fears and agitations to the portrait Dr. Ofri has expertly constructed. This, as well as using cliche’s that make medical dramas so popular with an average audience, is what Dr. Ofri does well. She craftily constructs what would otherwise be a difficult medical situation (for those who don’t enjoy medical technicalities) into an understandable and, oftentimes, relatable human experience.
Throughout the book, Dr. Ofri does a great job in identifying the emotions that doctors have to deal with on a daily basis; she does less work, however, in identifying possible, factually tangible solutions to these problems that can propel real policy change. In discussing the emotion of fear, Dr. Ofri notes that doctors need to find a way to control it:
There is no easy answer about how to proceed onward in daily medical life with that ongoing churn of anxiety and fear, and certainly no research to guide us. Each doctor has to come to terms with it and negotiate an individual emotional armistice. We need to keep it nestled in a recess contained enough to permit us to function. But if we wall it off too hermetically, we will lose a fundamental layer in the polyphonic texture of being a doctor. This fear and anxiety, in a modest amount, maintains the reverential and vigilant stratum required in caring for other human beings. We physicians need to tuck it away but also keep it alive (93).
Dr. Ofri defines the emotion of disillusionment as “a pervasive state of being, calling up complex emotions triggered by feeling that medicine wasn’t what you thought it was, that your dials of being a doctor have come into conflict with reality, and that reality is flattening those ideals to the mat.” Dr. Ofri shows that doctors often feel disillusioned because of stress or because of the impending failure stemming from modern medicine. She also shows that doctors feel disillusioned because of extreme job expectations that may inhibit the doctor’s ability to balance their time:
The fundamental issue is that our medical system places doctors in impossible situations and thinks nothing of it. It is somehow a given in medicine that doctors are expected to be in two places at once or to do two different things at the same time. This basic premise accounts for much of how the system surveys, without much consideration for the effects on the doctors or their patients (161).
A possible model that Dr. Ofri provides doctors, when dealing with the emotion of disillusionment, is finding an intellectually stimulating outlet to address the shock of exiting (and transitioning to) an academically strict environment to a divergent and traumatic learning atmosphere. For Dr. Ofri, the intellectually stimulating agent was learning the cello and regaining her need to learn knowledge. Another solution is finding solutions that are practical (no pun intended). Dr. Ofri gives an example of a simple time change for a routine schedule for medical students, “[The medical students] were required to attend a conference that finished at 1:00 in one place and also be hard at work at 1:00 in another place that was a quarter of a mile and two elevators away from the first place. […] So the program director changed clinic to begin at 1:15 for the residents. […] Magically, everyone now seems to be punctual.” Another solution Dr. Ofri suggests is to provide doctors with more personal time and wellness programs to improve a physician’s quality of life.
Being “judged,” or scrutinized, is what Dr. Ofri describes as an overwhelming emotional toll that is uncomfortable and “awful”—a toll which inhibits trust and brings up feelings of betrayal among doctor/patient relationships. When writing about shame, Dr. Ofri is acutely mindful of its potential for particular impediments, often declaring shame as “the major impediment to the full disclosure policies that are increasingly demanded.” When investigating why doctors feel risk when admitting to shameful behaviors or decisions, Dr. Ofri implies that a “culture of perfection in medicine” creates a bifurcated result of a doctor’s sense of purpose, “either you are an excellent doctor or you are a failure”—as such, doctors need to “come forward with their errors and near-misses” so that solutions may find problems.
Ultimately, Dr. Ofri doesn’t provide readers with a theory or with an advanced medical solution for incorporating emotions into the practice of medicine. Mostly, her book is about reminding patients and doctors that emotions are real and are an unavoidable truth in any work environment, including a hospital. As such, What Doctors Feel can be viewed through a lens of potential action. Dr. Ofri identifies and justifies emotions felt by doctors while at the same time softly proposing needed behavioral change for medical trainers as well as an overall change to control an overwhelming and solution-worthy medical environment.
Although Dr. Ofri does discuss somewhat the ramifications that non-empathetic doctors have on patient care, readers should take note of Dr. Ofri’s tone and style of her personal narrative throughout the book. While her personal narrative does make her book somewhat accessible to a larger audience, it has the potential to detract from the reality of which she is documenting. In other words, too much of a personal narrative has made her book read as a piece of fiction, bordering on the very dramatic hospital scenes she so first noted as overly exaggerated. There are some passages that can be read as unbelievable—especially if they were written with such dramatic detail 20 years after the initial account (it would be at this point for Dr. Ofri to mention if she has a photographic memory, in which her detailed accounts would be more plausible). This stands to reason that Dr. Ofri’s book appeals more as a piece of melodramatic fiction rather than a serious, impetuous call-to-action for change.
Dr. Ofri risks much when writing a personal narrative on a topic that should be addressed with less bias—which could jeopardize her credibility as a professional doctor and researcher. However, readers should be aware that this book is not necessarily a piece of non-fiction. As such, there should be a strong awareness of the trust Dr. Ofri is asking of her audience. That is to say, a personal narrative requires readers to trust an author’s word at face value. There are many complications to this form of documentation, many, which I am sure, Dr. Ofri has balanced with when writing her works. For the most part, What Doctor’s Feel is an interesting read on one doctor’s opinion of emotion and the medical workplace. More accounts, however, of doctors’ personal thoughts on the role emotions play in affecting the practice of medicine are needed to add to the larger discourse of emotions in the medical field.
Danielle Ofri, MD, PhD is an essayist, editor, and practicing internist in New York City. She is an attending physician at Bellevue Hospital and Associate Professor of Medicine at New York University School of Medicine. She is a regular contributor to the New York Times health section. You can find her online at http://danielleofri.com