Ten days after the shocking Grenfell Tower fire the BMJ of 24th June 2017 responded by dedicating seven of its pages to the events. Some readers may have been surprised by the political tone of comments and opinions expressed. What particularly caught my eye, however, was the short column by Helgi Johannsson on page 506. Dr Johannsson is a consultant anaesthetist and clinical director who described his involvement in a third major incident in just ten weeks.
“I am much more emotionally affected now than I was on the day. Some would say we must remain emotionally detached and equate that with professionalism, but I am human.” He goes on. “I feel I am a better doctor for giving myself permission to stop, reflect on what has happened, and to grieve.“
Dr Johannsson’s comments differ from the detached approach taken by many doctors across the globe. Detachment has been promoted as the norm for generations. Advocates advise separation to ensure optimal technical performance and as a self-protection mechanism. This sounds straightforward but does could it be an overly simplistic approach? Is it good practice or just behaviour which persists because of prevalent culture and the way things have always been?
Who benefits from detachment?
The suggestion is that a doctor who is detached will deliver better patient care. Put simply, emotionally disconnection aids a steady mind and a steady hand. Some argue emotional distance as a self-preservation technique. Blocking out the harsh realities of human suffering protects the doctor psychological harm. Others are willing to admit that emotional distance may not have been a conscious choice. They have just gradually de-sensitised. The physical parallel is the natural process of skin thickening in response to persistent irritation.
Let’s pause for a moment though to contemplate the mental well-being of doctors. Our UK media regularly praises the levels of resilience demonstrated. This is especially true when reporting on the response to major incidents. Such ability to cope is impressive – at least in the short term. But what about the long term?
The effects of over-dependence on ‘experiential avoidance’ as a coping mechanism are well known. They range from poor work-performance through to mental health issues. The high incidence of mental health problems and even suicide for doctors is also well established. It also worth bearing in mind that we are always more open with and believe people that we trust. We place trust in those we believe understand our personal situation which is dependent on a level of connection. This has particular relevance for interactions with patients and colleagues.
So its worth asking: at what point does ‘professional control’ with a stiff upper lip become an issue? Can it reach the level of professional neglect? The end points are failure to properly connect with patients, colleagues and to protect oneself long term. But if that’s where it ends, where do the issues start?
Examples of connection
I’ve had the pleasure in recent months of doctors sharing some truly powerful moments of connection during our Advanced Communication Skills courses. For example:
- One doctor bravely shared the moment that their eyes welled-up and overflowed when breaking bad news to her patient’s parents. The case had echoes of the clinician’s personal family experience. Both parents later personally thanked the doctor, recognising they were being supported through difficult choices by someone who really cared.
- A young trainee described the sequence of tragic events her team had faced. She went on to describe how in the following days her Consultant worked with team members to consider their thoughts and feelings. The young doctor eloquently explained the positive consequences of the permission to be open.
- Another delegate raised their personal upset at a lapse in team communication which had potential for dire consequences. Ever since, similar scenarios had become a source of significant anxiety. In response, a senior doctor shared a similar experience – one where the outcome was a patient fatality. He shared what he had learned about himself, how he coped and why he was a better doctor as a result. Their discussions continued throughout the course break-times.
Control versus dissociation
There is a fundamental difference between emotional control and dissociation. Understanding that difference is essential for quality interaction with both patients and colleagues. Genuine interaction requires appropriate human connection. Positive human connection depends on empathy. Empathy requires the application of emotional intelligence. Such application of emotional intelligence in difficult circumstances involves the development of personal resilience. But its not enough to simply tell someone “be resilient!” The development of true, long-term resilience is achieved via a set of skills which must be learned. For doctors this learning ideally goes hand in hand with the development of both patient and team communication skills.
- Where do you stand on the ’emotional detachment’ versus ‘permission to grieve’ scale?
- What are the pros and the cons of that approach?
Read the follow up blog posted on 12th December 2017: A prescription for being a better doctor which offers some thoughts on practical steps related to this issue.
Stephen McGuire – Head of Development
