On Professional Dissociation
Required learning, no class.
“All of my patients die.”
As a medical student, I remember chuckling a little to myself at the funny, slightly morbid sign on the door to a mentor’s back office. Now, about 9 years later, I can at once feel the relief and tension in those 5 words.
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It was a usual morning in the clinic. I clicked through results and faxes between appointments. Brief messages were typed up, making recommendations to patients for our next steps.
Click.
Click.
Click.
The next fax read “Discharge Notice” at the top. Usually, my patients will call or let me know if they’re going to the hospital, so I was a little surprised. Occasionally something minor happens on the weekend, and they don’t call, so I assumed it was one of those more trivial situations. I read on to see who the patient was and what had prompted the visit.
Chief complaint: suicide attempt
Condition: deceased
My heart stood still while my brain shifted into high gear.
What happened? Had I missed something? Should I have been more proactive?
I read the rest of the hospital note.
Then I read it again.
And again.
I heard someone at the door: the next patient had arrived.
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“So you kinda dissociated at that point?”
I felt a little embarrassed and a little relieved to hear that was the expected response. Physicians are professionals. However, professionalism is largely learned through observation of modeling and the hidden curriculum. Many professional behaviors, therefore, tend to be largely unconscious.
In some ways, this is a good and necessary way to learn: professionalism takes up little space in the perpetually overstuffed formal medical school and residency curricula.
However, this method of learning has the unique flaw of keeping its students from a conscious knowledge of its teachings. Without this knowledge, physicians may act as professionals, but are we missing something without a conscious knowledge of why we are compelled to act a certain way?
In the memory above, I had felt disappointed in myself for being able to disassociate so quickly after learning of my patient’s death. I initially thought, “Am I so uncaring I didn’t cry or feel more emotionally upset?”
However, as medical students and resident physicians, we are unconsciously trained over and over again to have this expected professional response. I recall many times during ICU shifts when we would perform CPR and then maintain our composure as we told the family the news. Sometimes there was a pause for a minute or two if the patient did die, but then everyone quickly picked up their work and moved on.
The first time I witnessed this professionalism performance as a student, I was horrified how quickly everyone moved on. Over the years, I’ve learned this as a common response from students or those outside of healthcare who witness such an event. It appears almost uncaring. One minute: everything is chaotic, someone is dying. Then next minute: people are chatting about what to order for lunch. However, this is professionalism in action: there are other patients to care for, and it would be a disservice to them to not clear our minds and shift our focus to their needs.
This professional dissociation may even be said to occur on a smaller level in everyday clinical practice. As physicians, we often set aside our own worries (and sometimes even our own needs - perhaps a topic for another blog) every day when we sit across from patients.
Experiencing and being made aware of this more dramatic professional dissociation again in another context - this time as the family physician with a slightly more intimate knowledge of the patient - gave me a better appreciation for the hidden curriculum of professionalism. I am grateful my mind and body knew what to do before I was aware it was happening. The rest of the day, I cared for patients as if it were any other day. A professional dissociation example for the books. It worked well.
Where we often miss the mark in subconsciously teaching this professional dissociation is how to re-associate with our own feelings and lives when the work is over. When we take off the metaphorical white coat and become a little more human. We are not God - what a relief! But the tension is this: all of our patients will die eventually - not [hopefully] because of us, but despite our best efforts. And while we must sometimes dissociate, we need to return to ourselves - our bodies, our minds, and our spirits - to do our most meaningful, professional work as physicians in the long run.
And that will be the topic of my next blog.
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Thank you for Learning Medicine - a lifelong endeavor - with me.