The Inner Life of Physicians and Care of the Seriously Ill
JAMA. 2001;286:3007-3014
Diane E. Meier, MD; Anthony L. Back, MD; R. Sean Morrison, MD
Seriously ill persons are emotionally vulnerable
during the typically protracted course of an illness. Physicians respond to
such patients' needs and emotions with emotions of their own, which may reflect
a need to rescue the patient, a sense of failure and frustration when the
patient's illness progresses, feelings of powerlessness against illness and its
associated losses, grief, fear of becoming ill oneself, or a desire to separate
from and avoid patients to escape these feelings. These emotions can affect both
the quality of medical care and the physician's own sense of well-being, since
unexamined emotions may also lead to physician distress, disengagement,
burnout, and poor judgment. In this article, which is intended for the
practicing, nonpsychiatric clinician, we describe a model for increasing
physician self-awareness, which includes identifying and working with emotions
that may affect patient care. Our approach is based on the standard medical
model of risk factors, signs and symptoms, differential diagnosis, and
intervention. Although it is normal to have feelings arising from the care of
patients, physicians should take an active role in identifying and controlling
those emotions.
JAMA. 2001;286:3007-3014
Persons living with serious chronic illness are
psychologically vulnerable and subject to strong emotions. It is not surprising
that physicians respond to these patients with emotions of their own.1, 2 These emotions are
many and include a need to rescue the patient, a sense of failure and
frustration when the illness progresses, feelings of powerlessness against
illness and its associated losses, grief, fear of becoming ill oneself, and a
desire to separate from and avoid patients to escape these feelings.3-7 Although these
emotions are common in the everyday practice of medicine, they can affect both
the medical care that physicians provide and the well-being of physicians
themselves.8, 9 Here we provide a
rationale for increased physician self-awareness through exploring the
influence of the emotional life of physicians on patient care. We describe a
model for detecting and working with physicians' emotions that may influence
medical care and illustrate it with composite and hypothetical case
descriptions based on our experiences in hospital-based geriatric medicine
(D.E.M. and R.S.M.), oncology (A.L.B.), and palliative medicine (all authors),
as well as experiences recounted to us by colleagues.
Theoretical Rationale and the Importance of
Self-awareness
The need for physician training in the conscious
recognition of their emotions is based on the professional obligation to care
for the sick. The patient-physician relationship is fundamentally asymmetrical.5, 10, 11 In the idealized
professional model, the needs and interests of the patient are intended to be
the sole focus of the relationship and, with the exception of appropriate
recompense and respect for rules and boundaries (showing up for appointments,
paying bills), physicians' feelings are extraneous. If, however, physicians'
inevitable emotions are not acknowledged, there can be unintended consequences.5, 12 Although
psychiatrists have long recognized the importance of transference (patients'
feelings about clinicians) and countertransference (clinicians' feelings about
patients) and have used recognition and naming of these emotions as a
therapeutic modality,12, 13 most nonpsychiatrists
are not trained to use identification of the emotions generated in clinical
encounters as therapeutic information.5, 14, 15 The following case
illustrates the impact of unexamined physician emotion.
Dr R
prided himself on his expertise at treating pediatric leukemia. One of Dr R's
patients, Alex, was 16 years of age and had acute myelogenous leukemia. Alex
was close in age to Dr R's son, and Dr R had become quite fond of him and his
family. After a year of chemotherapy and a failed bone marrow transplant, Alex
died. Dr R had lost several other young patients in recent months, and Alex's
death felt like the last straw. For a few months after Alex's death, Dr R
experienced feelings of helplessness, hopelessness, and uncertainty about the
purpose of his life's work. He found it difficult to go to work, noticed he was
irritable with his family and colleagues, and felt burdened by the needs of his
patients. His confidence in his medical skill and abilities was shaken, and for
the first time in his career, he wondered if he was burned out.
Dr R's story is familiar. A patient's death
following a long illness may be experienced as a personal and professional
failure.5, 16-19 Dr R's inability
to cure Alex, combined with his attachment to this young patient and his
family, resulted in emotions that adversely affected both Dr R and his ability
to care properly for his patients.
Consequences of Unexamined Physician Emotion
on Patient Care
The most visible consequence of unexamined
physician emotions is compromised patient care.8, 9, 11, 20 A small body of
research has examined the consequences of physician emotion on medical care21-23 (BOX 1). Physicians' feelings
of medical ineffectiveness and strong emotion about the meaning of the diagnosis
interfere with their abilities to assess human immunodeficiency virus (HIV)
risk.24 Similarly,
case studies25-28 and data29-31 suggest that
requests for assisted suicide are so disturbing to some physicians that they
disengage from or avoid their patients. Such reactions to expressions of
suffering do little to respond to patients' communications of distress and
implicit requests for help.2, 31-44
Another consequence of unexamined emotion is
that physicians themselves may experience chronic loss of engagement and
satisfaction with work.1, 8, 14, 44-47 Dr R's case
illustrates how this phenomenon can be associated with unexamined and sometimes
overwhelming feelings of conflict between consciously mandated behaviors
(taking care of the patient) and unconscious feelings (the care
and the physicianhas failed).44, 47, 48 The consequences of
unexamined emotions resulting from the care of seriously ill patients can
include physician distress, disengagement, burnout, and poor judgment.1, 45-54
Does improving self-awareness influence care
outcomes, such as better medical decision-making or reduced physician
impairment?55 Although the
available evidence is based largely on reports of experienced educators,14, 45-47, 56, 57 these issues merit
discussion because the impact of unexamined physician emotion on physicians and
patients alike is self-evident, because it is consistent with limited data1, 21, 22, 24, 30, 40, 44, 49, 51, 53, 56, 58, 59 and observations of
case studies,25-28 and because
these issues are not part of routine medical training and are not commonly
discussed among (nonpsychiatrist) physicians.14, 30, 39, 43, 48, 60-70
A Medical Model for Detecting and Working With
Physicians' Personal Emotions
It is both universal and normal for physicians
to have feelings about their patients.5, 14, 67 Acceptance and
awareness of this phenomenon are prerequisite to the self-knowledge and
self-control required in a professional patient-physician relationship.68 Regulating the degree
of emotional engagement between self and patientnot too close and not too distantis one
of the fundamental developmental tasks of physicians.46 Excess attachment and
avoidance or disengagement are forms of abandonment of the physician's primary
mission, caring for the patient.38 One approach to
helping physicians successfully regulate their degree of emotional attachment
is to use the familiar medical model71 of identifying risk
factors that predispose physicians to excess emotional engagement and
disengagement, recognizing the signs and symptoms of emotion adversely
affecting patient care, establishing a differential diagnosis, and engaging in
corrective action.
Risk Factors
Certain clinical situations predispose
physicians to emotions that increase the risk of overengagement or
underengagement in the patient-physician relationship (BOX 2). These situations may
be influenced by internal factors that the physician brings to the encounter, external
factors inherent in the patient or illness, or factors related to the clinical
situation.15
Dr P
had cared for a close family friend for many years. After a years-long bout of
lung cancer, her patient was hospitalized with dyspnea and renal failure. Dr P
called in the best consultants she knew to care for her friend. Several weeks
into the hospitalization, the patient's daughter complained that no oneincluding Dr Pwas coordinating the
patient's care or talking to him about his wishes. Subsequently Dr P called for
a palliative care consultation to manage her friend's symptoms and address the
goals of further medical care. The patient's now extreme dyspnea was controlled
with opioids, and as a result the patient became more alert and comfortable. He
then asked that dialysis be discontinued and that he be allowed to die, saying,
"I just want to go to sleep." Dr P felt incapable of discussing this
request with the patient and withdrew from day-to-day involvement with the
case. Both the patient and his family were disturbed by Dr P's absence and
wondered aloud if the request to stop dialysis had angered her. After
psychiatric consultation, which determined that the patient had decisional
capacity and no evidence of depression, and repeated discussions with the
palliative care team, the patient chose to discontinue dialysis. He died of
progressive respiratory failure several weeks later.
Dr P made sure that physicians addressed each of
her patient's organ systems, but no single professional took responsibility for
his overall care, in Dr P's case because of her close personal relationship
with her patient. The prospect of her patient's death and the fear that her
medical decisions might play a role in it caused Dr P to withdraw emotionally
and professionally. Dr P failed to perceive the ethical and legal difference
between a patient's right to choose to stop life-sustaining treatments vs a
request for a physician-assisted suicide.2, 25, 33-37, 41, 44 Her inability to
address the reasons for her patient's desire to discontinue dialysis, combined
with his rapidly worsening clinical condition, only heightened the patient's
sense that there was little reason to remain aliveeven his long-term friend and physician appeared to have lost
interest in him.
Illness characteristics may also be risk
factors. Chronic illnesses and protracted dying may require a sustained level
of attention over prolonged periods. Physicians can develop a sense of
helplessness and frustration directly related to the patient's increasing dependency
and demands on the physician's time.2, 25, 56, 69 The patient's
unimproving health may lead the physician to feel guilty, insecure, frustrated,
and inadequate. Rather than address these feelings, physicians may withdraw
from patients.
Conflicts with family members or other
physicians42, 43, 72 about the proper
goals of medical care in the setting of a life-threatening illness may also be
risk factors for disengagement.
Mr J is
a 35-year-old man with advanced acquired immunodeficiency syndrome (AIDS) and a
history of multiple hospitalizations for recurrent opportunistic infections and
multiple intubations for respiratory failure. He was admitted to the intensive
care unit (ICU) after being intubated for pneumonia. Several weeks later, the
ICU team recommended that the ventilator be withdrawn and he be allowed to die.
His mother adamantly refused this request and would no longer speak with the
doctors. She began to visit late at night after the ICU attending physician had
gone home. The primary care physician, who had had a close and long-term
relationship with the patient, began to make only brief visits to the ICU and
leave notes stating that care should continue "as per the ICU team."
In chart notes and discussions with colleagues,
the ICU physicians expressed the view that Mr J's continued ventilatory support
was futile, burdensome to the patient and family, and wasteful of scarce
resources. The primary care physician, who also viewed ventilatory support as
futile, had little time to engage in the needed discussions with the patient's
mother and was not optimistic that she would accept his advice. He had never
discussed his patient's wishes for care under these circumstances, an omission
he regretted, since he was confident the patient would not want a prolonged
dying process on the ventilator. Because of the physician's own guilt, fatigue
with the repeated critical illnesses of this patient, workload, and sense of
hopelessness about the patient's outcome, he withdrew from participation in
decision making and communication with the patient's mother and the ICU team.
At the same time, Mr J's family, who had worked closely with this physician and
had lived with the patients' chronic illness, decompensations, and recoveries
for years, struggled to come to terms with his fluctuating medical status and
with their role as family members with the power to discontinue ventilatory
support and, in their view, become the proximate cause of his death. These
tensions led to mutual anger and irritation, and on the family's part, to a
sense of abandonment by the primary physician. In these instances, both family
and professionals may have difficulty adjusting to changing goals of care:
where once all shared the same aim, to save or at least prolong life, now
uncertainty regarding changing goals inhibits communication between physician
and family just when communication is most important.41-43, 70-72
Finally, system-level conflicting obligations or
interests may come between physicians and their ability to work in the best
interests of patients. Managed care is the classic example of physician
conflict of interest wherein physicians' financial self-interest may be at odds
with the interests of the patient.73, 74 More quotidian
examples of such competing obligations abound in many settings, including
academic medicine where pressures to do research and publish conflict with
clinical practice and in private practice where pressures to complete insurance
documentation detract from time that might otherwise be spent caring for
patients.1, 73-75
Dr C is
a successful academic physician. As a result of hospital financial
difficulties, he and his colleagues have been required to substantially
increase their clinical activities. Dr C is becoming frustrated at his
inability to write and conduct research as a result of his patient care responsibilities.
He often fails to return patients' phone calls and refers patients to the
emergency department rather than seeing them himself. He is relieved when
patients cancel their appointments.
Dr C's conflicting work obligations and academic
pressures are compromising his care of patients. If he were more aware of his
feelings of anger and resentment resulting from the conflicting demands on his
time, his behavior and its effect on patient care could be exposed. Awareness
of the impact of his emotions would make it possible for him to cope
differently with the pressures he confronts: for example, he could arrange
referral of his patients to someone who is more clinically focused and redouble
his grant writing to make up the financial difference, or he could adjust his
expectations so that he no longer places his academic productivity above all
other considerations. In any case, his awareness of his emotions and their
impact on patients precedes correcting the situation and ensuring appropriate
medical care.
Becoming aware of clinical situations in which
risk factors are present should help physicians recognize signs and symptoms
indicating emotions that may harm patient care.14, 15, 23, 46
Signs and Symptoms
Signs and symptoms of emotions affecting a
patient's care lead to recognition of the phenomenon and then prompt the search
for a cause and an appropriate response (BOX 3).
Mrs K
was an 88-year-old woman with diabetes, hospitalized for recurrences of
pneumonia and gangrenous foot ulcers. Her hospitalization was complicated by a
protracted delirium and significant physical discomfort and pain. Mrs K's
daughter insisted on continued maximal application of technical life-sustaining
therapies, saying to her doctor, "You're her hero and you'll save her.
Don't give up on her!" The daughter refused to allow adequate analgesia,
fearing it might worsen her mother's delirium and shorten her life. The
physician felt helpless to intervene on behalf of his patient and began to
avoid both her and her daughter. The patient died after a difficult 3-week
hospitalization despite maximal life-sustaining treatments.
The behaviors and emotions listed in BOX 3 and described above
could be recognized if physicians were more aware of the accompanying signs and
symptoms. The sign of emotions influencing patient care in this case was the
physician's avoidance of the patient and her daughter, which signaled his
mounting sense of frustration and helplessness in being asked for something he
was unable to give. If this physician had been able to recognize this avoidance
and its impact, he might have maintained closer involvement in his patient's
care and continued negotiations with Mrs K's daughter for appropriate
analgesics.23, 46, 48, 76
Another sign of unrecognized physician emotion
affecting patient care is anxiety and distress about the patient's problems and
an accompanying desire to avoid engagement with the situation.
Mrs T,
a 55-year-old successful lawyer, had struggled with progressive renal cell
cancer for several years and was increasingly distressed by her progressive
dependency and feelings of isolation. She asked her doctor for advice on ending
her life, saying that she "just [couldn't] take it any more." Her
doctor recalls feeling distressed by her request and her evident despair and
ill equipped to explore the reasons for it with her. Instead, she tried to
encourage her, saying that she didn't believe in helping her patients die and
that now was not the time to give up hope. "You are a fighter and I know
that you want to beat this." She closed the visit by saying, "Hang in
there," and then gave the patient a pat on the back. Mrs T went home and
took an overdose of sleeping pills 1 week later.
This physician's distress about her patient's
desperation and her discomfort with the request for assistance in dying
prevented her from exploring with Mrs T the reasons for her request and may
have left the patient with the belief that she had few options and no place to
safely explore her distress. Her physician later wondered whether hearing her
reasons for wanting to die might have yielded a means of helping her decide to
go on (such as a trial of treatment for depression) or at least allowed the
patient to feel less alone in her despair.31-40, 76 The physician
involved in this case underwent a protracted period of distress and sadness in
the aftermath of her patient's suicide.
Another common sign of unrecognized physician
emotion affecting patient care is the unexamined redoubling of therapeutic
efforts as a patient's health declines and death nears.77
Mr I
was a 52-year-old father of 3 from Kenya and had advanced hepatocellular
carcinoma. Despite disease progression after several rounds of intrahepatic
chemoembolization, he was rehospitalized for a third course of the same
treatment. The oncologist did not promise a cure but told the patient it was
all that he had to offer. He felt uncomfortable telling Mr I that his death was
imminent, and Mr I did not ask. Mr I declined rapidly in the hospital and died.
His family was devastated that they had missed the opportunity to take him home
to Kenya to die because they felt he should have died on his native soil.
This physician's inability to discuss the
patient's prognosis created false hope for both patient and physician, leading
to an isolated hospital death and a family with permanent regret about their
failure to bring Mr I home to die on his native soil.78 Although offers of
heroic or last-ditch experimental therapies can signal the physician's
persistent hope,79 there are costs
associated with these behaviors.71, 77, 80 In Mr I's case, the
physician's failure to inform the patient of his prognosis took from him a
genuine choice about how best to spend his last weeks. Pursuing more
chemoembolization also distracted his physician from offering appropriate
palliative interventions.81
BOX 3 lists some signs and
symptoms of physician emotion that have the potential to affect patient care.
These examples are broken down by feelings (symptoms) and behaviors (signs),
since either can provide self-monitoring information to physicians.
Differential Diagnosis
Once risk factors are identified and emotions
and behaviors are recognized, the next step is to formulate a differential
diagnosis of their possible causes. Such emotions can often be traced to a
variety of causes rather than a single etiology, and the connections are not
always explainable (BOX 2).23, 29, 46, 48, 82 One important
etiology stems from a patient or another physician unconsciously reminding the
physician of an important relationship83, 84 or difficult
experience. Some attempt to understand the sources of the emotion may help the
physician identify effective coping or compensatory mechanisms.
Dr B's
father developed renal failure from toxic aminoglycoside levels associated with
postoperative sepsis. Although Dr B's father recovered, he remains dialysis
dependent. Feelings of anger and regret about the failure to appropriately
monitor his father's gentamicin levels have prevented Dr B from communicating
well with the infectious disease specialist responsible for his father's care.
These feelings have resulted in a failure to communicate appropriately with
this specialist about several mutual patients in the hospital. When Dr B
recognized the effect of his feelings on the care of his patients, he was able
to carry on an appropriate professional relationship with the consultant on
behalf of their mutual patients.
In this case, Dr B's feelings about his
colleague's medical error leading to his father's renal failure interfered with
a professional relationship and compromised medical care. Other common root
causes of physician feelings interfering with patient care include unachievable
physician expectations for perfection in the care of patients; exhaustion,
burnout, depression, and other personal problems; responses to strong emotions
expressed by patients or families; and difficulty tolerating the uncertainty
and ambiguity that characterize the practice of medicine.1
Ms B is
a 27-year-old woman with HIV and was admitted to the hospital after candidal
esophagitis was diagnosed. After 5 days in the hospital, she lapsed into a coma
of unknown cause. After several weeks of extensive inpatient evaluation and increasing
levels of life support, the patient's condition stabilized, although the
etiology of her continued coma remained unclear. The patient's mother was
repeatedly counseled as to the gravity of her daughter's illness, and the
physicians caring for Ms B began to recommend that life support be
discontinued, a recommendation that was consistently rejected by her mother.
Chart notes described the mother as angry, highly unrealistic, and in denial.
However, after a diagnosis of Wernicke encephalopathy, Ms B gradually recovered
cognitive and motor function and was transferred to a rehabilitation center.
Several of the physicians caring for Ms B
expressed anger in their written chart notes toward the patient's mother for
what they perceived as her unrealistic hope for her daughter's recovery. The
loss of hope and sense of frustration and helplessness felt by these physicians
(as well as by the patient's mother) as they worked to care for this patient
led to decreasing tolerance for the uncertainty44, 72, 85 and ambiguity of
goals associated with this case. When the physicians' predictions of a hopeless
outcome proved incorrect, this family's sense of trust in the medical
profession, already compromised, was irrevocably harmed. Looking back on the
case after Ms B left the hospital, several physicians remarked that their anger
seemed to reflect the rage of the patient's mother. The fact that the same
emotions expressed by patients and families may be felt and reflected by the
professionals caring for them is a critical observation. Distressing feelings of
sadness, anger, and helplessness in physicians may simply have their source in
or mirror the understandable reactions of seriously ill patients and their
families.5, 7, 10-12, 23, 46-49 Recognizing the
source of the emotion as originating within the patient or family may help the
physician to remain professionally committed and involved, despite the painful
nature of the encounter.
Multiple sources and etiologies may contribute
to the presence of physician emotions affecting both patient care and physician
well-being. A partial list of such causes is given in BOX 2. Although etiology is
often complex and multifactorial, awareness of common risk factors and
contributors, their manifestations in feelings and behaviors, and their impact
should help physicians engage in the routine process of reflection,
self-monitoring, and coping necessary for the responsible practice of medicine.
Approaches to Addressing Physician Emotions
We have presented examples of common clinical
situations in which we identify a relationship between unexamined physician
emotion and adverse effects on patient care. We have argued that such emotions
are normal and inevitable and have a significant influence on the practice of
medicine. Physician emotions need not be treated as a disorder but do need to
be acknowledged and understood so that the consequences of unrecognized
physician emotion can be prevented. To help physicians use a professional
process of reflection, self-monitoring, and coping, we offer the following steps.
1.
Name
the feeling. Recognizing and naming
the feeling is the first and most important step in controlling the effect of
the physician's emotions on the patient's care. Although much of what occurs
between physician and patient involves unconscious processes, the act of
separating enough from the feeling to be able to name it may lead to
restoration of conscious control over, and rational choices about, how best to
care for the patient,86, 87 even if the root
causes of the emotion remain unknown.88
2.
Accept
the normalcy of the feeling. The
discomfort or guilt associated with strong emotions can inhibit regaining
control over their influence on patient care. Such feelings are usually normalit is the resulting
behaviors that may be maladaptive. Accepting the feeling allows the
professional to make a conscious and therefore genuine choice about how to
proceed in the relationship with the patient.5, 11, 14, 46 This step allows
physicians to think about the sources of the feeling, connect behaviors toward
the patient with these feelings, and make conscious the therapeutic
implications, either good or bad, of these behaviors.
3.
Reflect
on the emotion and its possible consequences. Considering possible connections between emotions and behaviors
is a conscious effort. It allows physicians to step back from the situation's
immediacy and gain perspective needed to decide how to best take care of the
patient.89 This
reflection process may include conscious anticipation of alternative outcomes
for the patient as a result of different kinds of professional behavior.
4.
Consult
a trusted colleague. Because strong feelings
are inevitable in health professionals caring for extremely ill patients, a
routine and structured mechanism for their identification has been recommended
by a number of medical educators.1, 14, 46, 62, 63, 67, 68, 90 Physicians in some
training programs and many hospices schedule regular meetings for reflection
and feedback about emotions occasioned by the care of patients.14, 46, 63, 67, 68, 90-93 For most
physicians, however, finding a trusted colleague with whom to discuss feelings
and their consequences can be useful. Talking through a difficult situation can
enable physicians to confront their own emotions and still provide excellent
medical care. This process can reduce isolation and help build the network of
support that is necessary for complex and demanding clinical work.
This process was successfully used by Dr B,
whose father's iatrogenic renal failure interfered with his professional
relationship with the responsible infectious disease specialist. The sequence
of events was initiated by a patient who had repeatedly asked Dr B to telephone
the specialist about his antiretroviral therapy. The patient's irritation with
Dr B's delay in accomplishing this small task allowed Dr B to become conscious
of his reluctance to make the call. Dr B realized that he was avoiding the
infectious disease specialist and compromising the care of his patient because
of anger about his father's bad outcome. He discussed his behavior with a colleague,
which allowed him to resume appropriate professional communication with the
specialist.
COMMENT
Physicians work daily with patients and families
struggling through devastating illness and loss. That such work has an
emotional impact on health professionals is indisputable. Because feelings
influence behavior and decisions, it is necessary for physicians to learn to
identify and assess their feelings consciously. Taking a descriptive case-based
approach to this syndrome of unexamined physician feelings influencing patient
care, we propose a step-wise method for preventing and adjusting adverse
physician behaviors: recognizing high-risk clinical situations and risk
factors, monitoring signs and symptoms, developing a differential diagnosis,
and determining a practical means of responding to these emotions (Figure 1).
Our approach has limitations. Although the
medical model places awareness of physician emotions into a format familiar to
physicians, we do not intend to imply that emotions arising in practice are
problems that need treatment to be fixed. Rather, we wish to emphasize the
importance of a nonjudgmental approach to detecting and examining emotions
while maintaining that physician behaviors resulting from these feelings should
be assessed critically. Our model does not attempt to provide guidance as to when
physicians should seek professional counseling, although it is likely that
unexamined and unaddressed physician emotions arising in the course of care of
the seriously ill are contributors to the high rates of burnout, depression,
and substance abuse reported in the medical profession.1, 18-20, 29, 30, 45, 47-55, 74, 82, 94, 95
The foundation of our argument is that physician
feelings are normal and inevitable and that these feelings influence behavior.
The corollary of this observation is that it is a medical professional
obligation to take responsibility for self-monitoring feelings to protect our
patients (and ourselves) from the consequences of unexamined impulses. The key
to successful self-monitoring is recognizing and symbolizing the feelings in words,
accepting them, and reflecting on their potential consequences in a safe and
confidential professional setting, such as during a conversation with a trusted
colleague. This approach can enrich the experience of clinical practice and
strengthen the profession's commitment to care for patients.
Author/Article Information
Author Affiliations: Hertzberg
Palliative Care Institute, Department of Geriatrics and Adult Development,
Mount Sinai School of Medicine, New York, NY (Drs Meier and Morrison); and the
VA Puget Sound Health Care System, Department of Medicine, Department of
Medical History and Ethics, University of Washington School of Medicine,
Seattle (Dr Back).
Corresponding Author and Reprints:
Diane E. Meier, MD, Box 1070, Mount Sinai School of Medicine, New York, NY
10029 (e-mail: [log in to unmask]).
Funding/Support: Drs Meier, Back, and Morrison are faculty scholars of the Project
on Death in America, New York, NY. Dr Meier is recipient of an Academic Career
Leadership Award (K07 AG00903) from the National Institute on Aging. Dr
Morrison is the recipient of a Mentored Clinical Scientist Development Award
(K08 AG00833) from the National Institute on Aging and is a Paul Beeson
Physician Faculty Scholar in Aging Research.
|
Box
1. Potential Impact of Unexamined Physician Feelings on Patient Care and
Physician Well-being Impact on Patient Care Poor-quality patient care Impact on Physicians Professional loneliness |
|
Box
2. Risk Factors for Physician Feelings That Can Influence Patient Care Physician Factors Physician identification with the patient:
similar appearance, profession, age, character Situational Factors Long-standing and close patient-physician
relationship Patient Factors Patient or family is angry or depressed |
|
Box
3. Physician Feelings Influencing Patient Care: Warning Signs and Symptoms Signs (Behaviors) Avoiding the patient Symptoms (Emotions) Anger at the patient or family |
The Patient-Physician Relationship Section
Editor: Richard M. Glass, MD, Deputy Editor.
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