On Caring

In the next two posts, I will be writing about what it means to care, as a physician, as a psychiatrist, as a person. I apologize in advance if the posts have some repetition and are not polished. I am still figuring this out, and I want these posts to reflect that.

Part 1: Caring for Physicians

Physicians are taught to genuinely, emotionally care for our patients, that this is the job and what gives our job meaning. For example, the vision of the Ottawa Hospital where I work is, "To provide each patient with the world-class care, exceptional service and compassion we would want for our loved ones".
Sounds nice doesn't it? I've always liked it, the idealism of it. But over time, I have taken issue with this vision because it grates against the reality of patient care, which is that the quality of the care I provide and the impact it has, is directly proportionate to the caring and compassion that is reciprocated by the patient. Why? Because that is what good, sustainable care is: a two-way street.

When we, physicians are told to care, this does not simply mean providing a treatment, but suggests a greater investment of ourselves; to pour our emotional resources into our patients also, because isn't that what we do for our loved ones?

But in patients who do not value or appreciate this emotional side of caring, the patient is effectively telling us that he does not care about us. It happens a lot, at least in psychiatry it does. And that is ok. I can still offer evidence-based treatment and provide education. Lots of services like surgery, blood transfusions and dialysis can continue even if the physician does not emotionally care for the patient. But to be blunt, only a sucker with poor boundaries and no self-esteem would continue to pour emotional caring into a relationship where the other party could not care less. This applies to personal relationships and the physician-patient relationship is no different. I know this kind of relationship very well as a psychiatrist. I am often in the trenches in these dysfunctional relationships as I attempt to help manage the many negative impacts of this imbalance in the patients I see.

I think it is very important that I clarify what it is for a patient to care for her physician within the professional boundaries of the patient-physician relationship, as it differs from personal relationships.

In personal relationships, examples of caring may be asking about a person's wellbeing, buying gifts for and spending personal, recreational time with a person. Emotional caring can also be physical affection, or volunteering to help with a task. What I will emphasize, is that in healthy caring personal relationships, both the one providing the care/the gift/the affection is receiving and feeling cared for too.

Here are some ways patients show they care about their physician (and what we, physicians should take note of and appreciate):

1) Showing up to their appointments and if they can't, calling in advance to cancel and reschedule.
2) Following through the best they can on treatment recommendations.
3) Being respectful, cooperative and engaged during appointments.
4) Recognizing and respecting the limits of what their physician can and can not do.
5) Showing or expressing gratitude

Since recognizing the toll of caring and what good caring entails, I have changed how I practice. I try to emotionally care for everyone, but I now understand the limitations my caring has as a treatment, and how valuable it is as a resource. Therefore, I only dole it out to patients I have assessed as being able to benefit. Let me be clear, emotional caring is not the equivalent to providing ethical, evidence-based treatment. Physicians are obliged to provide the latter. No patient is entitled to the former.

I also have started to see how a patient cares for his physician as a determinant of health. Like high blood pressure as a risk factor for heart health, I see and assess caring the same way. When a patient can not care for and be considerate of me and my time, this tells me that the prognosis will not be as good, and there is nothing I can do about this. It has relieved me of a responsibility and sense of control that used to weigh very heavily on me. At that time, I was not yet ready to accept the powerlessness I felt in these patient encounters.

I used to think caring for a patient was my duty, and that it would change a patient's outcome, even when the patient did not want the outcome to change. Over time, I have learned that if a patient does not care about me and what I have to say, my emotional caring is useless, and the burden/pain of this on me, too great. To waste such a valuable, effortful, priceless resource of mine is something I can no longer afford, and what's more, it does not make clinical sense.