I remember my dread and shame when I realized I was struggling as a clinician. I should know better. I should be doing better. After all, I had additional training and sufficient expertise and was considered proficient by external measures. I was working hard, I wasn’t in a personally vulnerable time, and I enjoyed my patients and community. Regardless, bad outcomes felt very near. I worried I was missing something.
What if my care was negligent or harmful? I cycled back to how I should know better and should be doing better.
Is this a slippery slope? Is this the slippery slope?
I couldn’t say for sure, but it felt muddy, dark, and cold.
Looking back, I can better understand the cumulative stress and impact of practicing medicine. Patient care is complex and challenging; it’s not a matter of if, but more a question of when (and how we manage) the experience of feeling lost and alone. However, at the time, it surprised me to feel so overwhelmed. My training and collegial environment explicitly promoted self-reflection and/or personal therapy, regular supervision, and acceptance of our limits. How did I end up feeling in over my head?
Thankfully, my duty to help my patients sufficiently outweighed my fear of scrutiny and I sought help. Wouldn’t it be better to learn of my transgressions before bad outcomes occurred? Maybe clinical courses can be corrected even if I can’t be redeemed (though I hoped both were possible).
I approached a colleague and asked him to review my clinical care in a similar manner to how he conducted expert opinion reviews for the college. I held my breath and wondered if he could hear my palpitations. I remember my relief when he smiled and offered to meet regularly to review our tough cases together. He kindly said, “We don’t learn about this stuff in residency, do we?” His “we” provided immense and immediate relief and invited me back to the fold of belonging.
I am so grateful for his generosity, wisdom, humour and both clinical and personal anecdotes. Meeting with colleagues and having a regular opportunity for discussion has since become an important part of my work, akin to lifestyle practices to support longevity, quality of life and disease prevention.
I used to believe if I had done things differently I wouldn’t have felt so lost and its corollary belief that when I have enough experience, I’ll know what to do and I won’t become overwhelmed. I have since learned these dilemmas will continue to happen because of the nature of the work. I have also developed a better appreciation for the role of bearing witness, not solely in the context of patient care, but also for physician health and illness-prevention.
We can all agree there is therapeutic value in bearing witness. It quietly and reliably provides presence, acceptance and the space to repair and grow. It is an action over time. No matter our field of practice, clinical medicine involves being with one another. We bear witness to our patients’ pain, vulnerabilities, resolve and clinical course. In Abraham Verghese’s wonderful book Cutting for Stone, a preceptor provides an apt riddle to learners: Quick, what is the emergency treatment we administer by ear? Answer: words of comfort. Throughout the book, the art of medicine and the value of compassion and presence are emphasized.
As physicians, we bear witness to the impact of psychological and physical trauma on individual patients, their families and within populations and broader systems. In the process, we will naturally have emotional responses and activations of our own attachment systems, which are hard-wired for nurturing relationships and carry concomitant fears of abandonment. My own relational chords were struck when I approached my colleague years ago and asked for supervision: I sought being seen and reassured; I feared being exposed and reproached.
Diana Fosha, founder of Accelerated Experiential Psychodynamic Psychotherapy, speaks to the necessity of “undoing aloneness” in therapeutic encounters. Similarly, Christine Forner, expert in trauma and dissociation, states that nurturing relationships are needed to resolve trauma and facilitate “securefulness.” As clinicians, we are faced with trauma regularly and often feel alone. We also need to feel the presence of an accepting other to undo our aloneness and to experience securefulness.
Having a supportive network and community for providers is not a new concept, but it can be challenging to implement. It is always easier to fall back on a safety net rather than try to create one when in crisis. There may be additional challenges for physicians who have trained abroad and may not have established networks, who work in rural communities, who are in solo practice, and who identify with marginalized populations. Regular supervision provided an anchor and helped me find my bearings when I was struggling with clinical stress. Establishing accessible, regular meetings with colleagues, personal supports and developing interests outside of medicine are ways to bring awareness and presence to oneself. Bringing awareness and understanding to our emotional responses (i.e., bearing witness to ourselves) can also motivate additional meaningful actions, including patient advocacy, seeking more education, contributing time or money to charitable organizations and being more present in one’s personal life and relationships.
Conversely, if physicians are unable to manage the toll of what they witness, there is risk of burnout, moral distress, adverse relational impact and physical and emotional health conditions. The capacity to check in and take care of our emotional responses may be the fine line that distinguishes bearing witness from vicarious trauma.
I continue to encounter clinical scenarios in which I feel stuck and alone. When I hear myself asking “how did I get here?” it’s a signal to share more in supervision, connect more with personal supports and look after myself. Because there’s no shame in being here. No matter our experience or expertise, we will inevitably encounter clinical dilemmas and personal and professional fears – and we will feel alone. It’s not a question of having vulnerabilities but of catching sight of them and finding ways to undo our aloneness and build securefulness.
Accepting our humanity, reaching out for support and being a support to others are necessary features to facilitate a cohesive community of health care providers. During times of increased suffering, polarization and global crises, it may be even more important to try to support one another.
Banner image credit: Sasin Tipchai, pixabay.com
