Treating the Physician: An Exploration of Iatrogenic Suffering

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You might say that I’m part of a new breed of physician. When I applied to UBC medical school in 2005, my application was weighted in two parts: 50% of my evaluation score came from my GPA, work and volunteer experience, research, personal letter and references, and the other 50% was based on a 25 minute interview.

Thirty or forty years ago, GPA, research/publication credentials, and high profile references almost exclusively determined entrance into medical school. I personally benefited greatly from this shift; I nearly came below the cut-off to interview based on my paper application alone, and it was only because the interview is so heavily weighted that I was accepted. This is no small change, and I think the implication for what this means for the future of (Western) medicine is worth exploring.

What’s at the heart of this shift towards a focus on the interview (and the accompanying implied importance of communication and interpersonal skills)? What kind of new physician is the medical system attempting to create? What’s the crisis we’re responding to?

I’ve recently been introduced to a term that I think can be helpful for framing this inquiry: iatrogenic suffering.

The word ‘iatrogenic’ derives from iatro, meaning healer or physician, and genic, which means producing. photo2So iatrogenic suffering is suffering caused by the action (or inaction) of the physician towards the patient.

This term was coined by Dr. David Kuhl, a family physician who worked as a palliative care (care of the terminally ill and dying) specialist for more than 10 years, and subsequently obtained his PhD. Dr. Kuhl now works at the Centre for Practitioner Renewal in Vancouver, which seeks to support and sustain health care providers in the work place.

Dr. Kuhl developed this concept during his work as a Soros Faculty Scholar with the Project on Death in America, which involved an exploration of spiritual and psychological issues at the end of life. Through his long and in depth interviews with individuals living with terminal illnesses, he identified several core themes of importance.

One of his key discoveries was that the way physicians communicate with their patients has a profound effect on them, one not to be underestimated. He gives one harrowing example:

"Marjorie, a woman in her late 70s had a different experience. After months of being reassured that the mass in her groin was benign, her doctor gave her another message from the doorway of her room, as she was waking from the general anesthetic. “Oh, by the way, we were wrong; it is cancer. I have madeimages-1 an appointment for you to see the oncologist in a few days.” No interaction, no touch, no discussion, no hope. For Marjorie, “The way the doctor talked to me caused me more pain than the disease itself.”

We can all feel ourselves cringe at this woman’s story. She’s experiencing one of the most vulnerable moments of her life, and is given a remarkably cold, dispassionate and I would say inhuman response. What has happened in our medical system and the training of our “healers” that makes this even possible? What is the responsibility of the physician in this case? How should we respond?

In one sense, I think what we’re witnessing is the loss of interiority on the part of the physician, and a lack of inter-subjective communication in the clinical encounter.

What I mean by interiority is the inner experience of the physician: her emotions, mental state, energetic level… perhaps her reactions to the patient, relationship with death and illness, or her expectations of herself. With this in mind, what does it mean to expect our physicians to be “clinical?” There’s an implied level of detachment, ostensibly in the name of creating distance and clear decision-making (wouldn’t want to let our feelings cloud our judgment). And certainly this is important to some degree – if I’m sobbing uncontrollably while giving my patient his cancer diagnosis, I’m certainly not doing him any favors.

But I also feel that this focus on the removal of our “selves” (our interiority) is a bit of a cop out and potentially really harmful. In the name of remaining “clinical,” we spare ourselves the hard work of recognizing our own fears, judgments, resistances, etc., taking responsibility for them, and finding a way to still serve our patients from that place of awareness. I feel that the detachment we’re encouraged to develop as physicians has gone too far, and at its worst can lead to the kind of disastrous iatrogenic suffering that Marjorie experienced in the example above.

To frame this in explicitly integral terms, what I’m describing is a massive deficit of the upper left Quadrants3quadrant, or the interior of the individual. Conventional (or biomedical) medicine operates from a rational (or modern) stage of development and it’s praxis is profoundly dominated by the upper right quadrant (exterior of the individual). Examples of this abound, and one of my favorites is our approach to depression.

Depression understood through a conventional medical lens is caused by an imbalance or disregulation of three neurotransmitters, dopamine, norepinephrine, and serotonin: the monoamine hypothesis. These chemicals can be seen, touched, measured and represent the upper right quadrant view of depression. We are less willing to consider the aspect of depression that resides in the interior (or inner experience, psyche, mind – UL quadrant)) of the individual. An integrally informed approach would recognize that the neurotransmitters mentioned (real, and very important) represent the exterior correlates of the total human experience of depression, which also includes that oh-so important innervan_gogh_depression experience (the one you’re having right now reading this).

This over-bearance of the upper right quadrant permeates all aspects of medicine, from how we understand health and illness, our approach to treatment (the default treatment for depression, SSRI’s and other pharmaceuticals, act on the neurotransmitters mentioned above), and the culture and expected behaviours of physicians (and other conventional health care practitioners of course). What was going on in the mind/heart of Marjorie’s doctor that prevented her from communicating more compassionately? Perhaps she has difficulty facing illness and death, perhaps Marjorie reminded her of the pain of losing her own mother to cancer, or perhaps she has simply never been expected to develop her own emotional/spiritual fluency.

A re-invigoration of interiority on the part of the physician begins to create room for what I am calling an inter-subjective clinical encounter. In this vision, there’s the recognition that both the patient and the physician are having a very real, very messy, very real-time inner experience. And that can create lots of friction, disconnect and most importantly, suffering and dissatisfaction on the part of the patient… particularly when it’s unconscious. And conversely, a physician who is conscious of her interiority and holding the encounter with space and caring presence begins to create the conditions for real healing and positive change.

It’s important to remember the profound privilege that it is to be a physician. In my very short career, I’ve already had opportunities to be with people in incredibly vulnerable and tenuous moments in their lives; from the 56 year old mother of three just receiving her diagnosis of metastatic carcinoid bowel cancer, to the woman I met the other day, towards the end of her reproductive years, reckoning with the loss of her third pregnancy. In these moments, their profound openness and tender vulnerability is utterly complete, and so very unlike any other human interaction I’ve ever had. It’s scary, to be honest, and on one level I can understand why many physicians shrink away from the responsibility of trying to hold that experience for people, why they choose to hide behind the clinical.

In his foreword to the anthology Consciousness and Healing, Ken Wilber describes the difference between conventional, integrative and integral medicine like this: conventional medicine treats the illness, imagesintegrative medicine treats the whole person, and integral medicine incorporates all of this and also treats the physician.

Physicians need to develop the capacity to be in touch with their own interiority and remain compassionately available to their patients, especially in their most challenging moments. This requires a major shift in how we select those we allow to be physicians in our society, which is a process already in motion. We also need to provide opportunities for current physicians to develop their emotional/spiritual capacities, which inspiring people like Dr. Michael Krasner are undertaking.

The reality is that medicine is alarmingly steeped in a rational-materialist worldview, and the individuals who choose to step outside of that face the recoil of it’s gravitational pull. So it will take time, and coming together in places like Beams to create a new culture. I’m excited though, to put my energy behind this process already deeply underway. I think there are very real opportunities to change the ways we are doing things as a medical community, and to take responsibility for our communication with our patients. By developing our own consciousness and interiority, we can take each clinical encounter as an opportunity to reduce iatrogenic suffering, and perhaps foster healing instead.

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12 comments

  • Comment Link Paul Duke Tuesday, 08 February 2011 15:45 posted by Paul Duke

    Wow. Amazing insights Sarah. I'm extremely impressed by your thoughts. Your thoughts are very courageous and resonant.
    The line that really stood out for me was "I feel that the detachment we're encouraged to feel as Physicians has gone too far." In your revealing this take, you touch on a key issue for our times. Detachment, in all its forms, even its pop-cultural forms, has gone too far. Detachment has become an epidemic posture people of all walks ad professions have adopted, and in my opinion, adopted as a means of avoiding their true responsibility as human beings-to take responsibility, for their lives, and in sharing this responsibility,
    the lives of others.
    In the case of Medical work, it appears to me that adopting a detached posture or attitude toward treatment is merely a way for the Physician to avoid responsibility, engagement and of doing the hard work of accepting the great responsibility of actually working to heal someone, rather than simply taking the attitude of an assembly-line supervisor.
    Your courage and integrity in proposing new models and attitudes serves as a great example to your profession.

  • Comment Link Sarah Olson Tuesday, 08 February 2011 17:15 posted by Sarah Olson

    Thanks so much for your comment Paul.

    I agree with you that this detachment I describe goes beyond the profession of medicine and into the culture at large... all (or at least most) of us reading and writing here live with mind-boggling priviledge and with that comes the responsibility you are talking about.

    I deeply feel that this is true for physicians. We just have way too much capacity for doing harm with the way we show up/communicate/be with our patients.

    There is another perspective I wanted to add here though, one that wasn't as present in my original article. I am currently on an obstetrics rotation (a surgical specialty that deals with high-risk pregnancy) and the other day was witness to a rather large and alarming hemorrhage following delivery. In these moments of real emegency, the physician needs to rely on those capacities for clear thinking and decision-making... actual lives are at stake. Here, detachment is critical.

    The perspective I shared comes from a future family doctor, and family medicine is a heck of a lot more about relationship than it is about emergency.

    So there is huge diversity in what the practice of medicine looks like in our time, and we need diversity in our physicians. I still stand strongly by my position in the article though, and feel that even those who most of the time rely on detachment and clarity (surgeons, intensive care physicians, emergnecy room docs), need to develop their emotional/spiritual capacities, because there are still plenty of moments when they will be breaking bad news, giving test results, and encountering their patients in deeply vulnerable moments..

  • Comment Link Vanessa Fisher Wednesday, 09 February 2011 16:47 posted by Vanessa Fisher

    Great article Sarah. Really appreciate your astute insights on this complex topic. I also really like these distinctions you are pulling out in your comments about the different needs of different of doctors (and also likely the diverse needs of the same doctor moment-to-moment depending on the situation).

    I have no doubt you are going to make a very significant contribution to your field and I look forward to reading more of your work.

  • Comment Link TJ Dawe Wednesday, 09 February 2011 20:07 posted by TJ Dawe

    The importance of the level-headed rational approach is a valuable thing to bring up, and fits in with the Integral precept that each stage is necessary and contributes something vital.

    Even though it sounds like the medical profession has been dominated by Rational Stage thinking for quite a while (after all, it's much easier to teach about causes and cures we can measure with numbers (and by extension, it's satisfying to live in a world dominated by those logical, cooperative laws), and feelings are so messy and hard to catch in bottles), the rational approach gave us sanitary practice, valuable research and, as you said, the ability to stay cool in an emergency and do what needs to be done, with precision and with all of their scientific knowledge at their fingertips.

    The Integral physician would have that Rational stage approach ready at hand when they need it, and also know when a kind word or the incorporation of a patient's psychological state would result in healing.

  • Comment Link Andrew Baxter Thursday, 10 February 2011 18:56 posted by Andrew Baxter

    Reading your piece Sarah - and by the way, any reluctance that you might hold about sharing this perspective with your colleagues should be banished immediately! - I was reminded of a character I was introduced to by that oft-referred to friend of Beams, Mr Robert Harrison.

    Dr. Abraham Verghese, now a Stanford University professor with a focus on training his students in actually having a 'bedside manner' - and you can find his interview with Mr Harrison archived on Entitled Opinions - made it his practice to meet his patients first prior to any diagnosis. He would actually sit and listen, get to know the people he would be entering into a mutual relationship with in the first meeting, and only on the second appointment would he begin his diagnosis.

    I think what most intrigued me about him, and now your piece, is the understanding that any doctor-patient relationship is actually a two-way relationship and reciprocal.

    Wow!

    Anyways, can't do him justice myself, but I thought he might be somebody that if you hadn't already become acquainted with, would be of some interest for you.

  • Comment Link chloe Thursday, 10 February 2011 20:15 posted by chloe

    Fantastic article Sarah.
    I just wish you could be my doctor now...
    ; )

  • Comment Link Trevor Malkinson Thursday, 10 February 2011 20:37 posted by Trevor Malkinson

    The Entitled Opinions piece Andrew mentions (which is very good) is linked here. It's show #97:

    http://itunes.apple.com/us/podcast/entitled-opinions-about-life/id81415836

    I would also recommend the show called 'The History of Psychiatry' with Dr. Stewart Agras, founder of Behavioral Therapy. Both he and Harrison speak to, and criticize, the medicalization of all mental illness, which Sarah's speaks to in her example of depression. It's show #110.

  • Comment Link Jasmine Leslie Friday, 11 February 2011 03:58 posted by Jasmine Leslie

    Wonderful reading Sarah!! I am really glad that Trevor posted this on FB. I couldn't agree with you more, and I am also very thanksgiving clarified the times when we do need to detach. I had a moment once after a failed resuscitation of a sudden MI in the community. I found myself hovering between a complete emotional-breakdown watching his wife greive on his now lifeless body and being strong and present for her like I needed to be. I had to detach and it was hard to do. Often I tell myself to stay strong now and allow myself to also cry and greive in private. Someone who I respect dearly once told me to always have empathy, but not always sympathy. That makes sense to me as I go along. Not always possible, however!

  • Comment Link Lynda Pickrell Friday, 11 February 2011 05:01 posted by Lynda Pickrell

    Sarah, how lucky the 'community' is that you have chosen to be a doctor and have the capacity for empathy that will be a healing factor in itself.

    Glad to have the opportunity to read your thoughts and ideas and thanks Trevor for posting this.

  • Comment Link Peter Simmons Friday, 11 February 2011 05:46 posted by Peter Simmons

    Very well written article Sarah. On the flip side, there is also too much "attachment" to learned theory and a reluctance to accept that there are alternative treatments that may provide some benefit to the patient. A little humility would help restore the bed side manner. You cannot know it all. The human body is a very complicated organism.
    As one who went through radiation treatment for malignant tumours followed by surgery for a recurrence, I went through conventional treatment protocols and had the range of Dr opinions. However, I also used complementary medicine to mitigate the side effects of the treatments, and healed a lot faster than the Drs were expecting. More openness to what I learned and experienced may help the Drs treat other patients. Listen to the patients - we may have more first hand experience of the disease and treatment than the Dr and can offer a lot of good advice. When the student is ready the teacher will appear.

  • Comment Link Sarah Olson Friday, 11 February 2011 21:24 posted by Sarah Olson

    Thanks all for your comments and contributions.

    @TJ and Vanessa; I agree it is critical to draw out the strengths of the rational approach to medicine.. in addition to the context of emergency that I brought in earlier, if you have a broken leg or a resectable tumour, you definitely want someone helping you who was trained in a scientific "logical" fashion. (no homeopathy here, thank you very much!)

    And Vanessa your point is well taken that actually I am asking a lot of physicians here... the capacity to move fluidly between the rational/capable, and the emotional/intuitive on a moment to moment, as needed basis. And I am okay with that. Again, the responsibility is just too great.

    @ Andrew and Trevor; yes no doubt Harrison has something to add here (where doesn't he?). Will check out those links and get back to you.

    @Jasmine; so glad to see you here, thanks for commenting. I hope this is the beginning of an exploration here on Beams and invite you to continue to share your valuable experiences and insights!

    @Peter; so great to hear from your perspective. You brought up some key challenges that I think medicine of the future (integral medicine, or whatever you want to call it) will need to address.. namely (humble) open-minded collaboration between professionals.. a recognition that different discplines (conventional, complementary, traditional, etc) offer valuable perspectives and should be given voice. Of course we need to include rigorous research and evidence-based approaches to disease, but the complexity of what research gets done (and funded by whom!) has not escaped my attention... nor has the way that our deeply held beliefs and worldviews prevent us from really grasping the impact of research that is being done (for example.. the placebo effect is real, and some studies show that how we think/feel about our treatment affects it's success... what the *&%* does that mean for the way we understand/approach health and illness?!?) I hope to devote another article (or several) to what you are getting at here.

  • Comment Link Joanne Squires Saturday, 12 February 2011 18:23 posted by Joanne Squires

    one thought from an historical viewpoint is that in the past,( long ago) most Doctors were men, and came to their profession with the cultural baggage that they carried ie: not touchy feely. When women started to enter med school, they came with their cultural norms also, more feeling and empathy. When they entered the med schools, they were trained by men and had to adapt to the male norm or they did not progress. As women became greater in numbers and thus became the teachers this started to change for both male and female doctors.
    It is a wondeful progression.

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