As a resident in the ICU, I’ve spent 160 hours over the last two weeks treating pneumonia, respiratory failure, alcohol withdrawal, and dozens of other diagnoses. I have spent less than precious few of these hours in reflection, discussion with families, or thinking hard about the underlying reasons my patients are admitted to the hospital. Oddly enough, in healthcare, the more emotionally charged the work, the less time and attention is given to responding to emotions and thinking affectively. Is this because highly technological fields require less emotional competency – or that emotions have no role in treatment? To frame the issue more broadly, what is the role of emotions in clinical decision making?
There are two ways of conceptualizing the role of clinician emotions in healthcare:
(1) Emotions -> Increased moral capacities of clinicians -> Increased patient engagement and attention to emotional dimension to care -> Better patient outcomes
(2) Emotions -> Decrease in rationality in clinical decision making -> Worse patient outcomes
Western biomedicine views emotions through the second framework, as an unwanted appendage that gets in the way of academic thinking. Jerome Groopman, a prominent physician writer, has said as much in numerous works on clinician decision making. Certain specialties such as psychiatry and family medicine focus more on emotions than others — and devote curricular time for clinicians to reflect on how their emotional state impacts patient care, and vice versa. These initiatives capture both a pragmatic and theoretical point – that emotions are useful and grounded in how we think as humans. In the words of Sidney Callahan, “following Darwin’s lead, psychological theorists now see human emotions, like human cognitive capacities, to have been selected through evolution to ensure the survival of individuals and the group. Emotions are energizing and adaptive, and serve communicating, bonding, and motivating functions.”1
Responding to and cultivating emotions takes time – which is the most precious commodity in healthcare. One fear may be that such time may be better spent processing more clinical data, of which there is an increasing volume. For instance — on an admission of a patient with sepsis to the ICU, a physician may well electronically look over hundreds of data points through past charts, labs and imaging studies. What role, if any, is there for an assessment of one’s emotional reaction to this case? Using the cognitive model of a mind as a processor of data, could one’s emotions to the case be seen and discussed as an additional “data point” to shed light on treatment? I would argue yes.
Here are a few examples:
1. A 28 year-old female with PTSD and drug-abuse history presents with an intentional overdose. The prominent emotional reaction from the overnight nurse and resident is profound sadness, followed by anger at the patient’s repeated drug-seeking behavior, followed by disgust at her insistence to leave against medical advice.
2. A 60 year-old female with morbid obesity presents with difficulty breathing and needing invasive therapy to help her breathe – she is bedridden, on home oxygen, has multiple skin infections, and refuses to have a large IV placed to help manage her fluids and give her antibiotics. The understated reaction of the team is again, sadness, evident in the gaze of each physician laying eyes on her. The next salient emotion is again, anger, although in this case anger at the patient herself for refusing treatment that could be life-saving.
3. A 70 year-old Haitian female presents with sepsis and end-organ failure, on a ventilator, with nearly no chance of meaningful recovery. After a family meeting, the family continues to hope for “a miracle” and wants everything to be done for the patient. Again, the salient emotion in this case is at first, sadness and dejection at medicine’s unfruitful attempts to help her. On rounds, the team discusses the allocation of healthcare resources and the moral/ethical/legal status of offering invasive measures such as feeding tubes, tracheostomies, and dialysis when they are not medically necessary.
In each case, the team is briefly emotionally engaged, only to channel this anger/disgust into working tirelessly on the medical problems of other patients. Moreover, the salient emotion points back to a structural problem underlying the patient’s diagnosis: poverty leading to substance abuse, failed preventive healthcare leading to morbid obesity, and misaligned incentives that normalize costly technological interventions promulgated as standard of care.
There are few forums in hospitals to discuss these structural issues. At Boston Medical Center, I have been a part of creating Social Medicine Grand Rounds to begin dialogue around these issues. Addressing the social dimensions of health is not a new concept, nor is cultivating emotional reflection of clinicians. I think the link between clinician’s emotions and their reference to structural issues has yet to be fully explored. To put it simply, we all have capacity for moral outrage.
As clinicians, we learn through practice to be problem-solvers: to integrate large amounts of data, diagnose, and then build a treatment plan. In a similar way, to cultivate emotional attunement to patients and the structural determinants of health takes practice. In practicing, the fear is that we will be overwhelmed by the enormity of societal problems, and have less time to treat patients. The case of the elderly woman on a ventilator offers the perfect example to the contrary – only in discussing society’s reliance on technology do we realize that we are the front-line to assess what is medically and ethically needed. Addressing social determinants of health in fast-paced, technological settings is as simple as asking two questions: What does this case bring up for you? What could be the underlying structural problems leading to this hospital admission? If model (1) is correct, this will in time lead to greater moral capacity and better care.
1. Callahan, Sidney. The Role of Emotion in Ethical Decision-making The HastingsCenter Report, Vol. 18, No. 3 (Jun. – Jul., 1988), pp. 9
Picture courtesy of: http://www.stateofformation.org/wp-content/uploads/2012/07/brain.jpg