"On Healing" March 2008

Posted on Mon, March 31, 2008
Building doctors' emotional link to patients
By Dan Gottlieb

In a recent column I described my experience dealing with a severe illness in a health care system that was often devoid of the compassion I needed but rarely received. Many of the doctors were probably very kind and caring people who had the compassion stripped away - first by unreasonably demanding training and then by great stress on the job.

An article this month in the journal Academic Medicine described how medical students generally enter school with a great deal of emotional empathy - indeed, it's a big part of why they signed up. But the researchers found that empathy has diminished dramatically by the end of the third year.

Dr. Marsha Snyder knows that all too well. She began her career as a nurse. Throughout her training, she was taught to care for the emotional needs of patients. She said nursing students were encouraged to share their own emotions with faculty and colleagues as well.

She excelled as a nurse, so she decided to go to medical school. There, she said, the training was purely cognitive - not one word was spoken about the patient's emotional experience or spirituality. When she got the courage to ask about either the doctor's or the patient's emotional needs, she was laughed at or belittled. And when she began her residency - in psychiatry - she felt completely isolated, she said. "Neither the patient nor I had any emotional support."

That was more than 20 years ago. Today there is a movement to try to humanize medical training.

At Jefferson Medical College, Dr. Birgit Rakel teaches students about care of the soul, nurturing one's wholeness and the difference between healing and curing. All the courses are taught in small groups, and an attending physician leads what can be intensely personal discussions about loss, grief, vulnerability, and the healing power of silent listening.

A unique kind of patient conference called Schwartz rounds - Kenneth B. Schwartz, a cancer patient in Massachusetts, made it a mission to strengthen the emotional bonds between doctors and patients - is used at 139 sites around the country, including several local teaching hospitals. Unlike typical rounds, in Schwartz rounds everyone who worked on the case talks not about the patient but about their own emotional experience. It is a rare opportunity for caregivers to have an open dialogue about the emotions that go with being a caregiver.

At the University of Pennsylvania, where Snyder went to medical school, there is a required 18-month course called "Doctoring." Each beginning medical student is assigned to have at least one home visit and monthly contact with a family living with a chronic illness. Their only purpose is to try to understand what it's like to live with illness. And yet, says Dr. Paul Lankton, who directs the course, "in the process, they get to know the patient as a person and not just a container for a disease." The most important lesson, he says, is that disease occurs not just in bodies, but in lives.

Several hospitals around the region also offer a program called "narrative professionalism." In small groups, medical residents write about an episode in which they struggled with deeply emotional or moral dilemmas. Sharing it with the group, they come to understand that colleagues struggle with the same insecurities they have. And because they have 10 minutes to reflect on their experience, some of the essays poignantly capture the humanity of the doctor-patient relationship.

Finally, St. Luke's Hospital in Bethlehem, Pa., is developing the Center for Physician Success and Well-Being. The plan is to provide practicing physicians with emotional support services, education and even psychotherapy when needed, and to run workshops on resilience and healing for both doctors and patients.

Its director is Dr. Marsha Snyder.

Posted on Mon, March 17, 2008
Midlife depression: Not unusual or incurable
By Dan Gottlieb

Marge was 48 years old when she came to my office last year complaining of depression. She said her marriage was "comfortable, but without passion." Her teenage children were doing well, but she was worried about paying tuition when the time came. Her work life had been stable for 15 years. And then she woke up one day and realized that, at her age, many of her professional dreams would never come true. And she would probably be spending the rest of her life in her merely "comfortable" marriage.

I've treated many people like Marge over the years: men and women in middle age who realize they are unhappy with their lives yet fear it is too late to change. This is also a time when many marriages end because one spouse leaves to find the kind of love felt to be missing.

Research published this month in the journal Social Science & Medicine found that the probability of depression rises around middle age, peaking around age 44. After studying data from 500,000 Americans and Western Europeans, the researchers discovered that psychological well-being is at its lowest during the middle of the life cycle regardless of gender or location.

It has been like this for many years but now things seem to have gotten worse. The U.S. Centers for Disease Control and Prevention just reported that the suicide rate among 45- to 54-year-olds increased nearly 20 percent from 1999 to 2004.

Midlife has always been difficult. Often it's the first time we feel the effects of aging and mortality. Our children need us less, forcing a shift in focus back to ourselves - and often we are unhappy with what we find.

And pressures on middle-age people have increased consistently over the last several years. Many in that generation are now caring for children and parents at the same time. Insecurities seem to have grown, pushing us to work harder, worry more, and sleep less and socialize less. As a matter of fact, other studies have shown that Americans have significantly fewer close friends and support systems than they did a generation ago. All of this increases one's risk for depression.

So what can be done?

Plenty. A history of depression in your family places you at increased risk in midlife. If you are feeling depressed, and see changes in your sleep, appetite or social activities, get treatment quickly. Often a loved one will notice these changes before you will. A combination of psychotherapy and medication works well with depression, and the prognosis is better if it's caught early.

Sometimes, however, sadness or irritability in middle age is a signal that you are living an unfulfilled life, and a thoughtful review might be helpful. The great pain of midlife isn't feeling mortality for the first time - it's feeling death without having experienced a fulfilling life.

So a review may include mourning the loss of your dreams (some of them, anyway) and your youth. It can also be an exploration of what it is that you hold most precious, and what changes you can make to create a life that brings you more meaning, joy and love.

Marge did well with depression medication and psychotherapy. As part of her treatment, she reached out to people she felt close to, and they spent more time together. She and her husband not only got into counseling, they also made a commitment to go out on a date at least once a week. And she volunteered at her local Boys and Girls Club, which gave her great pleasure.

Most pieces of her life didn't change. She still had the same job, still worried about tuition and, the last time I saw her, was still in a marriage that was "comfortable, but without passion." But she was happier.

Tips on How to Avoid It

There are no guaranteed ways to prevent depression, but family therapist Dan Gottlieb advises the following to minimize the risk.

Get support: Close friends and support systems, always important, are more so during periods when people are isolated, self-focused, and at risk of depression.

Mind your body: What's good for the body - healthy eating, aerobic exercise, a good night's sleep - is good for the mind.

Have fun: You can learn this from toddlers and small children. Be sure to experience pleasure frequently.

Live a meaningful life: Spend time talking with your family about what's most important to all of you, and what being alive really means. Make sure you are living in support of your deepest values rather than in fear of your greatest anxieties.

Posted on Mon, March 3, 2008
A patient yearns for a caring touch
By Dan Gottlieb

I took a couple of months off because of some health problems.

It all began last summer, when my normally slow heart rate suddenly dropped to dangerous levels. A pacemaker was implanted the next day, but within hours I was experiencing wild fluctuations in blood pressure, and extreme fatigue. The doctors thought it was temporary. It wasn't.

Several months of consultations and evaluations left me feeling pretty isolated as I navigated a complex and often impersonal health-care system. Two doctors said my body was beginning to wear out. Neither one looked at me when he said it.

Sometimes care is as important as cure. In the operating room getting my pacemaker, I felt very alone and frightened. I needed care - so I asked if someone would make eye contact with me, perhaps smile and touch my face. Everyone was too busy to stop, and they couldn't take their masks off anyway.

The vast majority of doctors are caring, dedicated people who are working way too hard to meet unreasonable demands and expectations. They feel stress about their schedules, responsibilities and liabilities. And many of them feel stress when they don't have answers, or when they have to deliver bad news. I'm sure that the doctors who didn't look at me cared very much; they just didn't know what to do with what probably were very uncomfortable emotions of helplessness while delivering painful information.

Most medical training teaches doctors to be strong, independent, and to hide their vulnerability - essentially, to keep their masks on. Plus, most doctors today are pretty isolated in their work, with little time to talk to colleagues about medicine, let alone difficult emotions. The good news is that there are many new programs around the country that teach medical residents compassion for themselves and others.

Despite my reputation for compassion, in the midst of my fear and isolation the only thing I really cared about was whether someone was going to care about me. I needed someone to touch my hand or put an arm around me and ask - not tell me - what I was experiencing. I needed to be with more than a technically skilled doctor; I needed a caring, compassionate and feeling human being.

There were exceptions, of course. One of my doctors was so troubled by the lack of answers - the medical literature for 61-year-old quadriplegics is limited - that he called colleagues and searched journals to find any mention of my symptoms. And there was the integrative medicine specialist. When I told her what was happening, she closed her eyes and took a deep breath, as if to try to truly understand my experience. In that moment, I felt for the first time that someone understood what I was going through. Hippocrates would have been proud.

Throughout the medical system, doctor and patient typically share physical space while adopting predictable roles (knowledgeable doctor and compliant patient); points of discussion are usually confined to symptoms and treatments. Both may be feeling isolated, both may care very much about what's happening in that room, but neither one speaks about it. Maybe both wear masks.

I never did get a diagnosis, but my symptoms are substantially diminished. So while I feel much better, I may well be dealing with this again in the future. If I do, I hope I have technically skilled doctors who will be able to ask me what it's like, and then take their emotional masks off while they listen. It will be good for both of us.

New book and TV special. My column's return to this page coincides with two events, both titled Learning From the Heart: Lessons on Living, Loving, and Listening. Both the book and the broadcast examine what makes us human: How is it, for example, that children who readily experience awe grow into adults who go through life so fast they often don't even notice the world around them? And what can we ultimately do to find the kind of security and happiness most of us long for?

The 90-minute special will air tonight at 9 on WHYY TV12. It will be rebroadcast on March 15 at 5:30 p.m.

The book was released today and is available at area bookstores or via my Web site (www.drdangottlieb.com). I will be doing readings at the Free Library of Philadelphia, 1901 Vine St. (noon on Wednesday), and at the Barnes & Noble bookstores at 1311 Nixon Dr., Moorestown (2 p.m. March 15), and 301 Main St., Exton (2 p.m. March 16).

Emotional Side of Surgery

Therapist Dan Gottlieb offers these suggestions for improving your emotional state in the operating room:

For patients

Be aware: Acknowledge how you feel. You don't need to pretend you are "strong" when you don't feel that way.

Communicate: If you feel frightened or vulnerable, it is important to let the doctor know. Anxiety could interfere with your ability to understand what is being said.

Request: If you are anxious as details are discussed, ask the doctor to slow down. Feel free to request a few moments to collect your thoughts; additional questions or concerns may appear.

Connect: If you are afraid, ask your doctor if he or she understands how frightened you are.

For doctors

Breathe: Before entering the room, take a minute to catch your breath. Allow your body and mind to make a transition between patients.

Think: Be aware of how you feel about seeing the next patient, what you might need to say and what assumptions you might be making.

Listen: Please don't simply reassure. It only takes a few seconds to try to understand what the other person might be experiencing.

Connect: Allow yourself to feel what the person said, and then respond. If the patient says that he or she is frightened, make eye contact and touch a hand or a shoulder. It means a lot.

Our Partners and Sponsors