Wednesday, March 18, 2009

Do We Care?

A reader wrote in the following:

At least with pediatric psychiatry, the shrinks really don't know how bad it is or how much stress is on the family or the other kids caring for violent, manic, agitated kids at home.

Actually, when I initially read the comment, I thought it said the kiddy shrinks don't really "care how bad it is".... as I've re-read it, I realize it's a more accurate portrayal: "the Shrinks don't know how bad it is..." Oh, if it's okay, I'm going to springboard off the "don't care how bad it is"'s likely quite true that the docs don't know how bad it is.

It is a regular sentiment, however, that people feel their docs "don't care." I'm always perplexed by that because caring is an internal emotion, how do you know if someone cares? You could ask-- hey do you care that I'm miserable? Oh, of course, the answer will be yes. Maybe a doc cares but doesn't quite know what to do, and feels internally squirmy at the inability to fix a patient's suffering. Maybe the patient has a low-key personality style and doesn't adequately convey that they are suffering. One can say they are tormented, but if they say it wedged in between a discussion of NCAA pics while they are knitting, sometimes the tenor of the suffering is attenuated. And one can scream and rant and rave about their suffering, but if they've screamed and ranted and raved about the poor service in a restaurant, well, there's that whole crying sheep issue that makes it hard to filter.

It's not that docs don't care, it's that there is some professional distance. And if the kiddy shrink has lived through the same exact nightmare, he may or may not state this out load. There's an unpredictable element of trade-off in the perception the patient's family might have: 1) I'm so glad you know exactly what I've been through and it's comforting to have this kind of empathy 2) Your experiences color your ability to see clearly all the possible options and you're too caught up in your own kid's issues to fully appreciate my kid's issues, or 3) You've screwed up your kid, why do I want you near my kid? I've used the kid example because our reader provided it, but it could just as easily be a case of pneumonia-- yours got better in 3 days so you can't appreciate that I'm still sick 2 months later.

Some of what comes off as "caring" isn't really about caring at all, it's about the doctor's external display of concern. Some peeps are pretty reserved--they can be distraught, eaten up inside, thinking about a patient's problem, going home and reading about, calling friends for ideas, and still not convey this to the patient-- they can look uncaring and cavalier. Another doc can jump up and down and seem very concerned, but not actually change anything or do anything.

In medical school, I had a brief period where I got eaten up by other people's problems. The summer after my first year, I did a rotation in a psychiatric unit with some more advanced medical students-- it was a very psychoanalytically-oriented staff and we constantly being asked to process what had happened on the units, how we felt about things, and for weeks it seemed we were being asked how we felt about leaving. There was a suicide in the hospital, there was a long-term (meaning years) patient there who was being treated for borderline personality disorder, and she kept lighting fires. The drama was non-stop, the emotions were intense. By the end of the summer, I wasn't sure I should be a psychiatrist, not because I didn't like it, but because I was emotionally over-involved. It got better.

Medicine as a whole, requires some distance. You want your doctor to care enough to hear your pain, to address it, to explore a variety of treatment options, but you don't really need, or perhaps even want, your doctor to feel your pain. And my guess is that our reader is correct that the doctors don't really know how bad it can be.

Note to Retriever: May I use your entire comment as a free-standing Guest Post?? It was a good synopsis of some of the policy problems behind the mental health system.