Deeper Engagement with Both Thous and Its

The plague of pleasant, numb neutrality

A couple months ago, I was sitting in divination. I had just made the decision to take a leave of absence from work. I was still in a panic about the proximate cause of my taking the leave and about what comes next. The message I received was to “Leave in a good way”. I interpreted that to mean that I was to be up front about my plans (not sneak out the back door and be honest that I’m not sure if I’m coming back). Also, to open myself up to feedback, particularly to be present and receive the positive feedback people wanted to give me. 

As I walked out of work Friday night, everyone in there gave me a big hug. I wouldn’t say staff in ERs are known for their warm hugs, so this meant something to me. There was a very sweet card and a potluck. I felt like I would be missed in a way that I hadn’t previously. I’m not sure if it wasn’t said or I wasn’t listening, but either way, it landed differently this time. 

When I reflect on these last few days at work, I have been thinking about feedback and how we receive it, emotion and how we show it, and I-it versus I-thou relationships in healthcare. 

These last couple months, as I have slowed down to receive the feedback that patients and staff offer me, I noticed a few things. The first, the nature of the feedback you are given changes quite a bit with that slowing down. A simple “thank you” when your hand is on the doorknob and you body is already pointed out the door becomes “you’re a wonderful doctor” when you let go of the door handle, turn back around and make eye contact. I also receive it differently, with a different level of meaning when I take that pause. This may be one of the saddest things about the time pressures in medicine, it robs us of a potent source of rejuvenation when we don’t say or hear how we’ve helped. 

Original artwork by my 4 year old daughter

I have also shared why my career has felt like such a struggle over the past few years. Many of my work friends reflected back that a big part of why they liked working with me and why I was a good doctor was because I put a lot more of myself and my emotion into my work, so it made sense that the level of support I would need would be greater too. Though I have been working on understanding that my needs are different from those of other people for the last few years, this was still an eye opener to me. It also makes me really concerned for the future of medicine, because the people who care the most need the most support, and we’re not getting it. We are expected to get by on the same level of support as people who do not emotionally engage with their patient’s at all. It’s not fair and it’s going to lead to a downward spiral of apathy, leaving only the least compassionate doctors in the field. 

Receiving this feedback has been meaningful. As I have noted before (here and here), it is often difficult to know your impact, so I appreciate knowing more directly. That said, I wonder if my relationship to my work would be different if people consistently expressed appreciation for my work or my way with people (when they truly felt that way). I suspect it might. Perhaps I should be a totally internally motivated and validated person who could be satisfied by my own definition of meaningful work and my own definition of proficiency. However, when your work is helping and healing people, I think your personal level of self-satisfaction is only a small part of the definition of success. 

I have come to believe that both giving and receiving feedback graciously is a real skill most of us don’t have. Many people are aware of how difficult it is to give and receive negative feedback because we know being told we’re not good enough hurts. However, I think we underestimate the difficulty of giving and receiving positive feedback. I always think of this video from Amy Schumer that only slightly exaggerates how women often receive compliments. Many praise givers hesitate because they assume the receiver already knows or is too busy or important to care. Many of the receivers either don’t pause to let this praise land or do, then the voices of shame within them immediately start finding ulterior motives from the praise-giver. I shared some poetry I wrote with a coach I work with. He gave me some really positive feedback on it. Initially, I blushed and let it sink in, but minutes later, a voice inside me was saying, “He just said that because you pay him.” Perhaps it is easier to not receive that glowing feedback than wrangle the shame gremlin (mine’s named Susan) who is trying to undermine it. 

I suspect this is similar to positive and negative emotions throughout much of our lives. I was listening to an episode of We Can Do Hard Things. A listener called in and shared an experience where she was sobbing in the grocery store because her child had just left for college. They noted that we are aware that sadness, rage, and panic attacks would earn you some strange looks at the grocery store, but also noted that buoyant joy, singing, hopping, or shouting with glee in the grocery store would earn at least as many strange looks. 

I cannot keep from singing with the music at the grocery store. I try to keep the volume down, but I can’t stop. I often feel like I am violating some code of pleasant, numb neutrality. This pleasant, numb neutrality forms a very narrow band of desirable civic and public behavior and leaves many of us feeling like too much or not enough. I can’t speak with certainty to whether this band of acceptable behavior has increased or decreased in size over time, but I suspect it has shrunk and is shrinking. Currently, singing and dancing in public is only allowable if you are “good", without regard for whether you enjoy it, have something you need to express, or want to celebrate. Trying to fit into this narrow band of emotions and behaviors leads to a lot of the  loneliness and isolation we are dealing with now. You can’t get into the real struggles and successes of your life without risking some kind of messy emotional expression, and we have lost the skills of being present for the emotional expressions of others. 

The intertwining of interpersonal relationships and emotional expression has been on my mind a great deal over this last week of work. I realized that both my relationships with colleagues and patients often swings between I-thou and I-it relationships in interesting and complicated ways. Today, I want to focus on relationships with patients. In general, I think patient’s approach me with an I-it relationship in mind. They have a problem. They think my expertise will help them solve it. There are other healing relationships that may be more I-thou, but that is not what the current healthcare system is designed for. 

This week though, I felt my relationships to patients transform to I-thou several times. Though I do not know, I suspect it was a two-way transformation. How often have your words ruined someone’s life? How do you carry those words when you know something they don’t yet know? How do you carry that person before, during, and after you ruin their life? What do you owe someone when you ruin someone’s life through no fault of your own? What do you mean in someone’s story when you are the messenger who delivers the word of irrevocable change? 

I told two people they had metastatic cancer during one shift earlier this week. The next day, I told someone her milestone birthday celebration would need to be postponed in lieu of an ICU stay for a brain bleed. To me, these moments of delivering a life-altering diagnosis, telling someone their loved one has died or is dying, is one of those moments that naturally transforms a relationship from I-it to I-thou, to seeing our shared humanity. In that moment, I no longer see the person as a patient that I need to get admitted or discharged as quickly as possible, but as a person who has had their whole life turned upside down. I relate to times I have had my whole life turned upside down, though I confess most of those times seem like small potatoes compared to the news I deliver.

For the patient, the doctor delivering the news becomes part of the story, for better or worse. My mom found out she had a non-cancerous tumor in her brain because of an MRI performed after a seizure. The seizure messed with her memory and the only thing she remembers from the time of the seizure until she woke up after surgery 3 or 4 days later was the doctor saying, “We found a something, but if you have to find a something this is the one you want.” We deliver upheaval in one to two sentences, then try to build the outer frame of the puzzle they will have to fill in in the days, weeks, months to come. Before I deliver this news, I work really hard to have as much of the plan in place as possible, or a clear way to explain how we will get that plan before they leave the hospital. I try to get as much of everything else in order so I am not interrupted. I try to get myself ready to absorb any number of emotions. Sometimes, there is rage, like the patient who had been trying to get her doctor’s attention that something was horribly wrong for six months, only to be told by me that she now had metastatic cancer. When I tried to arrange for emergent follow-up because she, understandably, wanted to deal with this after months of not dealing with it, the specialist told me this was “an emotional emergency” as if that made it not a “real emergency”, as if they could not be bothered to muster up some human decency for someone’s emotions. On the other hand, the emotional reactions to this news continues to surprise me. I once told a patient he had pancreatic cancer, which may be the type of cancer I would least want to have. He knew exactly what he was in for having cared for a loved one with it as well. However, during that visit, he focused on complimenting the way I delivered that news. This week, I was surprised at the lack of reaction to the news I delivered. I am pretty sure I was clear about the severity of the situation, but I was not met with tears or anger, simply pleasant, numb neutrality. If we cannot react with the fullest of our feelings when our lives have been torn asunder, when can we?