On Powering Through

How physicians' disconnection to their physical and emotional needs impacts them...and you!

Author’s Note: I have been trying to squeeze writing this article into the margins of working all weekend. I jettisoned editing, hyperlinks, and the very optimistic idea of a painting in lieu of sleeping. Look at me listening to my body’s needs

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You’ve been struggling with a health problem for months. You finally decide that you don’t want to put up with it anymore. You wait on hold for eons and get an appointment scheduled with your doctor. You clear your schedule for that day, still several weeks away. Finally, the day of the appointment arrives. You meet with the doctor and he or she goes through the motions and ends the encounter with some polite way of saying “It’s all in your head” or “It’s not a big deal”. You leave the appointment feeling worse than when you got there because nothing changed, you wasted a lot of time and money, and you’re just angry at this person for being an asshole. 

Have you heard that one before? I’m guessing if you’ve gone to the doctor, particularly if you are a woman, that you have. Until recently, I thought that the general public knew that doctors were terrible at ensuring their own physical and emotional needs were met and that it has a profound impact on the care they are able to provide. I had a couple of conversations recently that helped me realize that was not common knowledge, that people assume that as experts on the human body, that doctors would understand the importance of nutrition, hydration, and rest, and act accordingly in order to feel and be their best. That is not an accurate assumption, so I thought reflecting more deeply on this might be useful to myself and to you. 

At the risk of being a doctor apologist, it’s not entirely our fault. Some of it is definitely a system that is focused on seeing patients quickly, “moving the meat”. I have discussed that frequently including here and here. There are also the emotional and spiritual wounds of medical education and medical practice that lead to doctors feeling victimized by the system.

Shame plays a prominent role in medical education and, in my opinion, results in stunting of our emotional development. When the range of emotions that it is acceptable to have is narrowed, in a setting where you are exposed to the full range of human experience, it not only narrows our experience and emotional well-being, but narrows the range of emotions we can be present for in others. In exploring shame in medical education, Sandy Miles notes:

One of the subliminal messages communicated to trainees by established doctors is the need to suppress emotions to be competent, delivering necessary but occasionally painful or unpleasant treatment to patients. Elton highlights the distinction between this practical, conscious and temporary deferment of emotion and the more pernicious defensive strategy of repression where ‘difficult emotions are pushed out of the conscious mind entirely’

In addition: 

Doctors feel that they need to perform faultlessly despite creaking systems of care. This becomes their internal benchmark against which they measure themselves. This perfectionism and fear of being exposed is a fertile breeding ground for shame. It has not yet been accepted in medical hierarchies that ‘errors are evidence of system flaws not character flaws’

In addition, trainees are often thrown into the deep end. After medical school, trainees have enough knowledge that they probably know what to do if the diagnosis is common or everything is going according to plan, but if the workload is high and they need to prioritize they have not received any training on how to do that. Similarly, trainees are often penalized (anything from an eye-roll to berated) for asking a senior resident or attending for help for problems “they should be able to handle”, but also chastised for not asking for help if something bad happens. You take high-achieving people who have often never failed significantly and put them in a situation where they just can’t win. Then we are surprised they don’t have to tools to cope.

Me, out for a beer with a friend, back in my baby doctor days. They were difficult and formative times.

Providing a safer training environment for learners is easier said than done though, because many of the changes we make have unintended consequences. For example, work hours restrictions were first started in the US in 2003, and expanded in 2011. These restrictions capped hours at 80 hours per week, no longer than 30 hours straight. In 2011, first year residents were no longer allowed to work more than 16 hours straight. Getting more rest would seem to be a no-brainer, and better rested doctors do perform better, but sometimes those restrictions mean someone else getting called in to cover a shift on short notice or that you don’t feel like as much of a team. Similarly, improved supervision by attending doctors would help residents feel less overwhelmed by the difficult decisions they are still learning how to make, but burned out supervising doctors aren’t great educators and may leave the field prematurely. 

Using shame as a tool in medical education is not without consequence. Miles also summarizes research by Hojat, et al, saying  “Feelings of shame can cause trainees to emotionally and physically withdraw from patients. There is a well-documented reduction in empathy among medical students from the start of the patient-facing, clinical part of their training.” This definitely resonates with my own experience. In my opinion, I am a worse person for having undergone medical training, (perhaps those that have known me since before 2004 might care to comment on that). I am more cynical and judgmental. I have a growth mindset in most other areas of my life, but a fixed mindset when it comes to my medical practice. Medical training and particularly the more recent focus on checking boxes of specific requirements in graduate medical education emphasizes that there is only one way to be a competent doctor and definitely does not celebrate individuality. One of my medical school classmates was routinely evaluated negatively because of her clothing. It was important to her not to contribute to waste within the fashion industry, so she bought her clothing from Goodwill and thrift stores. It definitely looked different than the J. Crew and Banana Republic of her peers, but she was not wearing sweatpants to the hospital. In my opinion, it reflected the biases of her teachers more than her professionalism. Even now, as an established physician, 15 years into my career, I still feel apprehensive about going “off doctor script” in a lot of situations. Usually, this means getting more into emotional, lifestyle, or herbalism topics. The emotional and lifestyle-based discussions really should be standard of care, but it still feels counter-cultural. In I Know Why the Caged Bird Sings, Maya Angelou said that love is knowing the song their heart sings and humming it back to them on the days they forget how it goes (hat tip to

Nadia Bolz-Weber

for reminding me of this). In medicine, we definitely do not show our love for each other in this way. Can you imagine if there were a network of doctors who saw each other’s unique gifts and called each other back to those gifts on hard days. How would our lives as physicians be different? How would our lives as patients be different?   

Lastly, my unpopular opinion is that you do not go into medicine if you are an emotionally healthy person. Yes, we are called to be healers. Yes, we want to help people, but there are many easier and more effective ways to help people if that is what you want to do. There are definitely easier and more effective ways to make money if that is what you want to do. On the other hand, if you want a secure job that is both high status and virtuous. Medicine is where it is at. Because of that, it tends to attract people who feel the need to prove their worth to someone. Then, you take these people who have low self-worth to begin with and tell them that their needs don’t matter. It becomes a vicious cycle, in which you subjugate your needs for the good of the patient, but soon the line becomes blurred on when it is best to put the patient first and when it is best to put oneself first. Over time, the disconnection from one’s own body and emotions reaches a point that you don’t even know what your needs are. You become so used to overriding signals from your body that you don’t even notice you are doing it. 

This is not to say that doctors are bad people or selfish people (though I would say there is a normal distribution of these traits compared to the population). Doctors are wounded people just like everyone else. Like the general population, we often have little self-awareness of those wounds and emotional blind spots, and more than the general population we are discouraged from exploring those areas. The impact of these blind spots, however, is high, as we feel it is weak or unprofessional to share our struggles. Then we find ourselves feeling “deep distress, leaving the profession prematurely” or contemplating or committing suicide.  Beyond ourselves, our willingness or inability to listen can have life-threatening or life-altering implications. When our emotions are out of whack we have a unique power to humiliate people, both learners and patients.  

When you take a person who has low self-worth to begin with and tell them their needs aren’t important, they are inclined to believe you. When you tell a doctor their needs don’t matter compared to the patient’s needs they are all too eager to listen because it feeds their desire to always feel needed. When you have spent years telling them that they are not good enough and people will die because they are not good enough, it makes it very difficult to turn that off. Eventually, after years of feeling that your body’s signals that you were hungry, tired, or needed to go to the bathroom were unimportant, you don’t really notice the impact that has on your mood, your focus, or your resilience because it becomes the standard operating conditions. 

Similarly, you are expected to power through when you are sick. As fellow ER doctor

Bess Stillman

noted, when she tried to get scheduling accommodations because of a vocal cord condition, “In medicine, scheduling accommodations for something as ridiculous as your own health and wellbeing are balked at…If you’re looking for empathy, or, at the least, looking to not be resented for being a human being in a human body, I suggest a field other than medicine.” It was not a joke when people said, “If we are not rounding on you, you should be rounding with us.” Meaning, if you are not sick enough to be in the hospital you should be working. Doctors make the worst patients, in part, because they want to have control in a situation where they have no control, but also because they feel shame when someone has to cover for them, and are trained with the expectation that they are always good to go. 

We never learned strategies that seem essential to care for our bodies over the course of a long and taxing career. Learning how to manage changing from day shifts to night shifts and back during training or how to strategize fitting needed breaks into our days or how to cover for each other to get those breaks are essential for physical wellbeing and career longevity. Sleep Medicine specialist, Michael Farquhar, took the findings of some recent Nobel Prize winners and applied it to medical training. At his hospital, there is now mandatory training on how to best manage sleep on night shifts. He is also creating a program called HALT (Hungry, Angry, Late, Tired) to change the culture across his organization to understand that breaks are absolutely necessary to effectively manage a workforce. The program is set up so that staff get a 15-20 minute break every 5 hours. There are some days I get this, but many that it seems inconceivable. When I worked at a larger trauma center it seemed entirely unimaginable, though it doesn’t have to. Larger hospitals are certainly busier than my small hospital. On the other hand, there are many, many doctors who work there so it seems possible to strategize ways to provide breaks on all but the highest acuity shifts. 

If we can not even treat our physical needs with respect, you can imagine that we don’t even acknowledge that emotional needs exist. For me, it became impossible to even hear my body’s signals that I was scared, angry, sad, or ashamed. I honestly had no idea. When I started this spiritual and emotional journey a couple years ago, the idea that I had emotional needs, that those needs might be different from what other people needed, and that just because no one else needed it didn’t mean that I needed it any less was a totally revolutionary concept. First, I had to tune into the physical sensations I felt when experiencing a particular emotion and develop the pattern recognition. “Oh, the tight feeling in my chest and throat, I am afraid.” “A heavy feeling in my face and chest, I am sad.” I feel like I am getting better at this, but I am still far from good at it. I still don’t feel like I have a great handle on what my emotional needs are or how to ask for them, but I’m making progress. I realized I like a lot more attention than my introverted parents or spouse, and more importantly, that that’s OK, I am not a bad person for liking attention, so I have been trying to put myself in situations where I can have more of it. 

All of this powering through and overriding our bodies’ signals means we are absolutely merciless when it comes to self-discipline, and especially merciless with ourselves when we lack self-discipline. That is definitely another way that our inattention to our own needs impacts patient care. We have pathologic levels of self-discipline and can’t understand why you are unwilling or unable to do the same. We have ignored our needs for so long we often don’t recognize the needs of others. Since patients are often coming to us with some fairly significant needs, this often leads to misunderstandings or miscommunication. 

There are times when you absolutely need to be able to shift into another state of being and perform even if you are hungry, tired, or overwhelmed, and you need to have practiced and be ready to do that. However, those times are the exception, not the rule. Most of the times that I am ignoring my body’s needs it is not because of one or several critically ill patients, but instead because of many patients who are not critically ill who are waiting to be seen. Nearly all of those patients could wait an additional 15 minutes for me to eat and use the restroom, but it is not part of our culture. In high school, I worked in restaurants and often felt a similar sense of urgency on a busy shift, even though I could in no way make the argument that it was a life and death situation. The similarities in these senses of urgency make me think that it is more cultural than necessary in most situations. 

I have been reading Anatomy of a Calling by

Lissa Rankin, MD

, which feels strangely like reading my own memoir. In it, she writes about when she realized how much of her story about herself in medicine was about her as a victim. I still find myself stuck in the rut of that story most of the time, as evidenced by this article and much of my writing, but I am starting to see the choices I had and have. I am starting to see, as a solo doctor in the ER, in many ways, I have the opportunity to create my own culture rather than let myself be absorbed into the larger medical culture. I am trying not to minimize the suffering and struggle of medical training and practice by denying my victimhood. On the other hand, I am trying not to wallow in that suffering without seeing where I had the choice to do something different, but continued to tell myself that I was trapped and did not have a choice. I hope your doctor will join me. 

• Has your doctor’s emotional blindspots or disconnection from their body impacted your medical care? 

• How have you reclaimed a connection to your body or emotions in your life? 

• Do you know anyone who strikes this balance between their body’s needs and the work they need to do well?