On Caring, Part 2: A missing part of the Curriculum in Medical Education
As someone trained in science, I thought how I cared for patients was related to how much knowledge and expertise I could cram into my brain. In school, we were never praised for developing strong relationships with patients, but for how much medical minutiae we knew. It is no wonder that I graduated thinking good psychiatry meant seeing as many patients as I could, with the emphasis on diagnosis and medication treatment. The result was equating efficient care for good care, ignoring how they are at times incompatible. The very nature of doing anything patient-centred and individualized is that it will be inefficient and take time. The analogy I use is the difference between a one-of-a-kind designer dress and an off-the-rack pair of jeans from a department store. This seems so obvious to me now, but I never got the impression that taking your time in medicine was a good thing, ever. And it became an impossible tension. I began thinking I was a bad psychiatrist and resenting patients for taking "too much" of my time. Adding salt to the wound was seeing my colleagues being rewarded, not for the kind of care they gave, but which supervisor they impressed and had inside jokes with. All of this, coupled with my own experience of how little medications alone actually worked in many of my patients made me seriously question everything I was taught about what it actually meant to care for mental health patients.
The real world of psychiatry, fortunately and unfortunately is so much more complicated than that. Fortunately because in psychiatry, the only way to get an accurate diagnosis, is to develop a strong and trusting relationship with the patient and many psychiatric diagnoses are most accurate when made over a period of time. I have also found that the caring part of the job is what is most sustaining and meaningful to me. It can make or break the success of treatment. Unfortunately, I had to run myself into the ground first to find this out. What I mean is that for the first 5-7 years of my career, I valued the quality of my work as "the system" does, in numbers. Building the therapeutic relationship was part of the treatment that was never valued, taught, modelled or addressed in any of my medical school and residency training. This meant I had no idea how to manage my caring and the toll it would have on me, particularly in the more difficult, resistant patients. It is mind-boggling that I did not know or think that caring for these patients would affect me in any way. As a doctor, I believed it should not. My job was to care, it only went one way. This oversight in my training seems so unacceptable and bonkers to me now.
What is it to care? I think the answer lies in what we already know in the research on how therapeutic relationships work. There are common traits in effective therapeutic relationships that include mutual respect, trust and being genuine with one another. It is the feeling of being understood and seen in a relationship. In training, we actually rarely talked about this in any clinically useful way. What I understood was that any threats to the therapeutic alliance was my problem, my fault. When patients were dismissive, disrespectful or hostile, I internalized that I was solely responsible for this and that I was not good enough. I just had to keep working harder for these patients to benefit.
What real life has taught me however is that for care to be good and effective, the care MUST GO BOTH WAYS. As I care for the patient, for me to continue providing genuine sustainable care, I too must feel cared for by the patient.
Let me be clear, when I say "cared for", I do not mean I expect patients to buy me chocolates and ask about my day. Reciprocal caring is not about sharing the same facts about ourselves with one another. What "caring for the physician" means is that the patient is considerate of the physician. For me, this means showing up for appointments on time and following through with treatment recommendations. This means being receptive to my input and being honest and respectful in interactions. Again, let me be clear, a physician is not entitled to this care from patients like patients are entitled to a kind of care and professionalism from physicians. I do not expect this from my patients and I do not take being poorly treated personally...anymore. But what this does mean, is that I will no longer rely on patients solely to judge the quality of the care I provide. In patients who are unable or not wanting to care for the physician, I accept that for factors beyond my control, the care I provide and the health outcomes for the patient, will be less good. I hope the care is good enough, I know I will always do my best, but one-sided caring will always be less good than when it is two-sided.
In other words, I use how a patient cares for me as a predictor of outcome and a gauge to help me manage my own expectations and emotional resources. No longer will I pour more of myself into patients who are most resistant. No longer will I define the value of my care based on my most difficult, least respectful patients.