Tuesday, February 21, 2017

Doctors ‘Need Their Space!’

Doctors ‘Need Their Space!’

The day to day work of physicians must sometimes seem like climbing a mountain.  Starting every morning, seeing a full schedule of a couple of dozen patients coming in at 15 minute intervals with a wide range of ailments, symptoms and complaints that may or may not be easily diagnosed, and hoping that you can figure out most, if not all of the diagnostic puzzles seems like a tall order.  Many of these patients are filled with anxiety when they come to their appointments, and they often release it all in the presence of their physician.  The physician tries to relieve the patient’s anxiety while taking on her own uncertainty in the hopes that the patient’s relief is lasting.  And, at the ‘end’ of the day, this physician makes sure her charting is completed, answers phone messages, calls in prescription refills - or not, and is left with many thoughts form the day’s work - thoughts about the patients whose questions could not be answered easily or the serious diagnoses she had to reveal or the patients who struggled with lifestyle habits they couldn’t easily change, or even the patients who ‘push their buttons’ and to whom they develop an allergy.  

Maybe it’s not every day, but I can imagine at the end of most physicians’ days (even sometimes in the middle of the day) having the feeling of needing some space to get away, to let down, to unwind, to process the emotional rollercoaster they’ve been on, to somehow leave the heaviness of that day, to talk to another physician to find out if it is only them.  In short, the goal is to get out of all their patients’ lives and to enter their own life, and to do so without the feeling of just ignoring or even betraying everything I just listened to.  I also could imagine that physician considering how much easier it might be if I just didn’t listen so intently; but that’s not why I got into this work.  I also know that some physicians leave this emotional residue of their work using some sufficiently engrossing distraction or an anesthetic such as alcohol.  It takes strong medicine to mentally separate from unsolved or unresolved patient dilemmas.

“It’s me, not you!” 

Whether they think about it this way or not, physicians have a relationship with their patient panel.  And like in any relationship, there comes a time when we ‘need our space,’ meaning “I need to get away from it.”   I thought of the Seinfeld show and George Constanza’s line when breaking up with his current girl friend: “It’s me, not you!”  It was his effort to get some space without having to explain why or to not blame his girl friend and probably not to own up to his own feelings.  It is a common impulse to blame the other.  For the physician, one might think how difficult it was to see all these challenging patients.  It seems amusing to imagine a physician saying to her practice: “It’s me, not you!”  For George, that was just a ruse; it seems he was wanting to break up, but not have a conversation with his girl friend about why.  He did not believe it was him.  It was his escape.  However, in reality, it’s always me, not you.  It’s helpful in the long run if we are willing to acknowledge our own role and be willing to look there.  When we present a case to our Balint group, it’s about what did I miss? or what am I not realizing? or why is it so difficult for me to listen to this patient? 

Clearly, membership in a Balint group does not answer all of the burdensome feelings that physicians carry.  Even meeting once a week (which most Balint groups do not do) would not be enough.  However, Balint groups - even those that meet only every fortnight - do provide a regular, structured, emotionally safe Holding Space in which the physician can totally let their feelings out, get support for whatever struggle they share, be reminded of the reason they are doing this work, and even begin to understand why some patients get under their skin.  Having a group of any kind - Balint, support, etc. - allows physicians to share any of their emotions with the group, and in doing so, physicians can dissipate some of their own anxieties about the uncertainties of this work.  This is the essence of the supportive nature of any safe group.  It is what allows physicians to enjoy their own life fully, and to return to their work with more compassion to listen and more empathy to give.

Unfortunately, there is no medical school or residency course titled Holding Space 101 or the advanced version, Holding Space 2.0!  If there were, the description might suggest that because of the importance and intensity of their work, physicians may find that from time to time they need to get away either by themselves or with like minded colleagues to sort through or process the emotional nature of this work and the impact it has on them.  This is best done in a place and time where they would have no outside pressures, and they can feel free to explore all their feelings about the people they treat, the struggles they encounter and the limits of what physicians can accomplish.  OR, it can just be a time to let go of tension, re-center or work out frustration through exercise.  It can take the form of meditation, journaling, a walk in nature, or yes, even a Balint group.

I recall years ago when I had a full time psychotherapy practice and my two children were in elementary school, enrolling all four of us in an early evening yoga class on my longest day in my office.  I ended the day by driving to the class, knowing my family would meet me there.  I never minded the exceedingly long day, just knowing it would end with a yoga class with my family.  It was relaxing, energizing and centering all at the same time.  I confess that I did not intentionally think of this time as a holding space or a re-centering time.  However, I have had similar experiences planning other Holding Space activities at strategic times in my week.  

The advantage of Balint groups is that the group and this Holding Space is already there.  It is an established ritual.  I don’t need to do anything except show up.  I feel connected to and accepted by the group.  The leaders are trusted and in charge.  They will respond to the needs of the group and gently shift us into our task.  Their presence helps me be present.  There is a ceremonial beginning: “Who has a case?”  Merely entering the group space helps me let down defenses, there is no need to explain anything, the professional mask relaxes - I have entered a sacred space.  Whether or not I chose to share a patient story, I will engage with the group at an emotional level as we explore the human reactions we all have to these stories.  It is a reminder of the healing nature of the work we do, and I leave this group thankful for so much - not the least of which is my appreciation of this Holding Space.  I have given to the group by my presence and sometimes by my story, and in turn, I have received support, validation and membership in a community of healers.

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