Danielle Ofri, What Doctors Feel: How Emotions Affect the Practice of Medicine, Beacon Press, 2014    

Robert Arnold, MD
Department of Medicine
University of Pittsburgh
Pittsburgh, PA, USA

It is interview season for our residency. So I spend a good deal of time reading applications—and if you read one of them, it is like you’ve read them all. They have each trained at a well-recognized institution in biology or neuroscience, done some research, and have volunteered for worthy causes. Their personal statements talks about how they like internal medicine because of its diagnostic dilemmas, and most want to go into technologically sophisticated subspecialties because they are interested in science and/or they want to help people.

The view of medicine espoused in these applications is of a scientist in a white coat seeing patients and, a bit like Sherlock Holmes, figuring out “what is wrong” and making it better. After office hours, they would go into their university lab (they all want to stay in the university) and make scientific discoveries.

This view of doctoring is quite different from my normal outpatient office. There are few diagnostic dilemmas—after practicing medicine for twenty years, most things fall into a few routine categories. What makes medicine interesting and complex are patients’ stories and our relationships. Complicated patients are complicated less because of medical science and more because of their personalities and social situations. Rather than being a scientist, I am often a frustrated social worker/psychologist/friend/counselor.

At the heart of these encounters are emotions. The degree to which I can help patients often depends on the degree to which I bond with them and develop a relationship. More important than my scientific knowledge is my emotional intelligence. Often, when I am having a bad day, it is because my emotions (frustration, anger, sadness) distract me from what the patient is really saying.

In this interesting and very readable book, Danielle Ofri focuses on doctors’ emotions and their central role in doctoring. This is a book that every person who is thinking of going into medicine should read. It describes what it is like to be a doctor and the challenges and joy of the practice of medicine. In particular, she describes physicians as human beings whose ‘humanness’ determines and limits a good deal of their therapeutic effectiveness.

The book is structured around different topics ranging from the socialization of physicians, to death and dying, shame, malpractice, and errors. The topics represent common clinical situations that will resonate with most doctors. What they have in common is that they evoke strong, typically negative emotions. Interestingly, as Ofri admits, the emotions that she focuses on are more negative than positive.

I am not sure why she made this choice and hope it does not scare off medical student applicants. There are many positive emotions involved in doctoring. What is interesting is they may require a broader, more flexible view of doctoring. By that I mean that if being a doctor is focused on curing people or getting the right answer, medicine will often be frustrating, as Ofri discusses in her chapter on shame and mistakes. On the other hand, if being a doctor means serving as an advocate, counselor, or guide, then the practice of medicine is associated with much joy. To the degree to which you are interested in people’s stories, in guiding them through difficult life events, in working to integrate health into their life (rather than making it the only value in their life), the day-to-day practice of medicine is full of small treasures (like the trash talk I hear from Patriots fans or the stories about my patient’s struggle with her teenager). Ofri gives a hint of what that is like as she interweaves the story of Julia, an undocumented immigrant who needs a heart transplant after developing heart failure, between the other chapters.

In each chapter, Ofri discusses both her experience and that of one or two other clinicians. In addition, she does a good job reviewing the literature on each topic, making the book appropriate for an academic environment. Her description of her emotions is refreshing among physician-authors in that she does not white-wash her reactions. She admits her flaws and talks about how her emotions may interfere with her doctoring. In addition, while she shows a good deal of insight into her own behavior, I particularly like her willingness to admit, even when she is in touch with her emotions, she has trouble, in the moment, controlling them. The writing is conversational and she comes across as a wise friend rather than an academic who has all the answers. Her chapters on shame and medical education particularly resonated for me and cover topics that are often ignored.

This book would be an excellent companion to a bioethics textbook. Ethics textbooks often provide analytical descriptions of the problem, while this book focuses on how physicians, in the messiness of real life, confront issues such as errors and end-of-life dilemmas. It would lead to a good discussion of how bioethics can be operationalized in the real world. The book would also be appropriate for a course on professionalism or medical sociology.

My criticism of the book is that I wanted more. Sadly, Ofri does not talk about two topics that also are important for building a more emotionally resilient physician. First, how physicians view their role as physicians (what are sometimes called identity issues) shape their emotional reactions to patient care. If you go into medicine thinking that you are going to be a scientist and help people, you may get discouraged when chronically ill patients are admitted, and readmitted, for the same problem. It may be frustrating to be a primary care physician whose days are filled with social issues and problems of adherence, depression, hypertension, and diabetes rather than complex diagnostic dilemmas. If you view medicine as “saving lives and helping people,” you may end up disliking geriatrics and caring for patients who are terminally ill. (In fact, the data show that that is one reason that people go into subspecialties rather than primary care and particularly steer away from geriatrics.) I would have liked a longer discussion about how our societal norms regarding the role of physicians impact our emotional reactions.

In addition, I think she missed an opportunity to talk about how individuals can build emotional resiliency. To a certain degree, she seems to suggest that our emotions control us, and that while we can build an external environment that may help us to be more emotionally resilient, she says very little about the emerging literature on meditation and mindfulness and their impact on emotional resiliency. Some doctors deal with the topics that Ofri discusses with equanimity while others respond with burnout and leaving the profession. A chapter talking about how she—as a person—coped with the emotional stress of doctoring and what the literature says about emotional resiliency would be helpful.

Finally, this is a book that is more descriptive than normative. The degree to which emotion should influence our ethical decisions, and the role of emotions in making ethical decisions is not discussed.

Still it is not a bad thing to leave the reader wanting more. This book fills a unique niche, and I hope it gets the readership it deserves. There are no other books that focus on physicians’ emotions and how they influence the day-to-day care of patients. I hope that patients read it to better understand what it is like to be a doctor. Pre-medical and medical students should read it so that they have a better idea of what they are getting into. It is the most honest and clear picture of doctoring that I have read.

Robert Arnold, MD
Department of Medicine
University of Pittsburgh
Pittsburgh, PA, USA

                             Fri, 06 Mar 2015 16:09:56 +0000