“Holding on to anger is like grasping a hot coal with the intent of throwing it at someone else; you are the one getting burned.”
“I came to realize that if people could make me angry they could control me. Why should I give someone else such power over my life?”
Ben Carson, M.D.
“Depression is rage spread thin.”
“Depression is the inability to construct a future.”
The other night I got an email with a survey from the AMA. I don’t recall ever getting one from them before. Not that I have been all that involved with the politics of healthcare; I joined the AMA when I was a senior resident, a newcomer to American medicine, and bought life and disability insurance through them.
In all the years of change and upheaval in American medicine, I have never been asked my opinion on what I need in order to do my job well or how I feel about my chosen profession. Until now, that is. And now, they skipped over any questions they might have had about what I need; they went straight to the more ultimate questions:
The AMA wanted to know if I’m burned out or depressed and if I hate my EMR. They also wanted to know if I am contemplating changing practice location, dropping out of medicine, retiring or committing suicide.
And I had somehow gotten the impression that the AMA was one of the drivers of change for the last thirty years. But maybe I was misinformed.
Clearly, the questionnaire indicates that the medical establishment is quite worried about its constituency.
In “Bitter Medicine” I wrote about how outside forces have distorted the traditional doctor-patient relationship. I also wrote about how doctors need to see their patients as suffering kinfolk and doctoring as having a higher purpose.
The four years that have passed since that piece have been years of increasing physician dehumanization through “Meaningful Use” and other bureaucratic mandates. I have seen more signs of anger and bitterness in doctors and there has been a great deal written about physician depression and suicide.
But what is this anger really, what is the nature of this depression, what are their consequences, and is there a way out?
In psychodynamic theory, Abraham postulated in 1911 that depression can be self-directed anger in people with narcissistic vulnerability. Freud linked depression to anger at oneself after a perceived or actual loss of a person one felt ambivalent toward.
Brenner, while I was in medical school, saw depression as resulting from symbolic castration or more or less actual disempowerment. Aggression towards the person who causes the feelings becomes self-directed instead out of fear of the other person.
Physicians, or rather, people who choose to become physicians, often think of themselves as more dedicated and perhaps even smarter than other people. We carry the world on our shoulders and sometimes feel we are different from other people. These are essentially what psychologists describe as narcissistic personality traits. I believe many of us are vulnerable to and apt to react with strong emotions to real or perceived rejection or loss of power, such as what has happened in our profession in the last 30 years.
The reality of today’s patient encounter is that some of the preciously short time we have allotted is spent fulfilling the requirements of the healthcare system that may or may not directly benefit each patient. That leaves little time for diagnosis and treatment, and even less for relief of suffering. And, of course, if we are trapped in our own suffering, we cannot help relieve that of our patient.
Physician anger and depression may, ironically, be as great an obstacle to good patient care as the Government mandates, insurance company obstacles and Health Information Technology shortcomings we doctors are so upset with.
Venting our frustration with the system is a waste of our patients’ appointment time. At most, we may need to briefly explain what can and cannot be done in the minutes we have together. And harboring feelings of depression or helplessness distracts us from the necessary engagement with each patient.
There may be ways for physicians to effect change of the system, but the place for that is not the exam room. There is also the possibility of opting out of the system. But for all of us who choose to stay, every patient encounter with a fellow human being deserves our full attention and genuine compassion.
Thinkers from all different religions and schools of thought have all said the same thing: We have a choice whether to cultivate our anger or not. Most tell us we can’t suppress it, because it has a way of expressing itself in other ways, even as illness.
Physician anger or depression that stems from powerlessness, like all anger, has an antidote. Borrowing from Buddhist thought, the antidote is love and the path is mindfulness.
Thich Nhat Hanh writes:
“When we embrace anger and take good care of
our anger, we obtain relief. We can look deeply into
it and gain many insights. One of the first insights
may be that the seed of anger in us has grown too
big, and is the main cause of our misery.”
“In a time of anger or despair, even if we feel
overwhelmed, our love is still there. Our capacity to
communicate, to forgive, to be compassionate is
still there. You have to believe this. We are more
than our anger, we are more than our suffering.
We must recognize that we do have within
us the capacity to love, to understand,
to be compassionate, always.”
He also says something that points out Westerners’, including Western doctors’, emphasis on formal education compared with cultivating our well-being. Hearing about divorce rates and alienation of other family relationships among physicians, these words should make us stop and think. Not that we should have forgone our education, but why do we think our life, well-being, and our relationships don’t also require effort and time?
“Getting a university degree may take you six or even eight years, and that is quite a long period of time. You may believe that this degree is important for your happiness. It might be, but perhaps there are other elements that are more important to your well-being, and to your happiness. You can work on improving the relationship between you and your father, your mother, or your partner. Do you have time for this? …You are willing to put aside six years for a diploma; do you have the wisdom to use just as much time to work out a relationship? To deal with your anger?”
Our anger demands attention, but not encouragement. Like Buddha’s hot coal, it hurts the one who carries it. When we are angry, like many of us are with the system, we need to examine our anger. Are we angry more or less because we can’t have our way? Are we angry because we think health care politics need to change? In the first case, our anger is only hurting us; in the second, it needs to be turned into political action.
We need to stop banging our heads against the wall. Yes, our tools aren’t as good as we would like, those who pay us don’t know enough about what we do, and the Government is fixated on form without function.
But did Hippocrates have top-notch equipment, did Albert Schweitzer have all the resources he needed, and did Michelangelo always have the right paints and brushes? Sure, we could all do better if only….but we’re just wasting our breath, using up valuable time and watering the seeds of anger and depression if we harbor such thoughts in the exam room or at home. We can take them to the political arena, but we must not let them poison our patient care, our home life or our souls.