Refilling the tank


How can we gain strength from draining conversations?


Some months ago Mike, a doctor friend and I were discussing how end of life conversations affect us. He had recently had to tell a teenage boy’s parents that their son had a devastating head injury after a car accident and was brain dead. Everyone was was overcome with grief the and he found the conversation extremely draining; the parents were lovely, understanding and cooperative, and he identified with them and shared in their grief. Discussing it afterwards, a senior consultant colleague told him “I only have a certain number of these conversations in my tank and I really feel I am now beyond empty”. 

During our conversation we discussed a few other cases, I told Mike about one where immediately after the conversation I retreated to my office and cried for about 20 minutes before being anywhere near ready to work again. Even now I feel the grief of that mother as if it were yesterday, I’ll never forget her reaction at hearing my words, the disbelief, the pain. 

Is it true there are only a certain number of these conversations in our tank? How can we refill the tank or at least limit their draining effect?
I suppose the easy way is to shut out our own emotions: protect ourselves from other people’s grief, limit empathy, separate our work from our personal lives, not feel their pain. However most of us find that difficult. We went into medicine because we care about other people and we want to help them. We enjoy helping people and shutting this out also shuts out our enjoyment of our job, and the satisfaction we gain from it. We may successfully prevent the tank draining out but we also reduce its size, and this method certainly won’t refill an empty tank. 

So we need to find a way of gaining satisfaction from these difficult encounters. How can we possibly make ourselves feel good from the grief of others? Is it right to gain pleasure from end of life conversations?

Recently I looked after a man who came in severely injured, but still conscious and very much aware of what was going on. We had some very honest conversations with him, his wife and his daughter, and he chose to have care withdrawn in the emergency department, rather than go for an operation with very limited chance of success and a high likelihood of permanent disability. The department was busy but we succeeded in providing a modicum of privacy and he died without pain with his wife and daughter by his side. Reviewing it afterwards I felt we absolutely did the right thing, we provided just the right balance of support and privacy, the quality of communication provided by us (and here I’m referring to the whole team: me, ED consultant, nurse, and surgeon) was outstanding and I think despite working in a busy, small department we provided him with a really good death. Rather than draining me I felt this encounter refilled my tank, and particularly the reflection afterwards provided a sense of satisfaction and achievement – it has made me a better, more resilient doctor.

Breaking bad news well requires skill, time, experience, emotional intelligence and empathy. We cannot forget the tragedy of the people we’re breaking the news to, but we can also gain satisfaction from doing so well. Giving yourself permission for this satisfaction when there is so much grief involved is extremely difficult but will strengthen you and also improve the quality of communication. It’s a real chance to give a life changing gift to these families: better psychological outcomes – particularly in families of organ donors – and a more positive memory of what for most is an indescribable tragedy.

Next time you deliver bad news review your delivery afterwards. Allow yourself to feel you did a good job, and if you just watched someone else do a good job don’t be embarrassed to tell them afterwards. Preserving our psychological strength to carry out these conversations well gives so much to the families in their time of tragedy, and allows us to keep our reserves full. 

 

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7 Comments

  1. Excellent piece. I wrote a while back on why I enjoyed my job http://rolobotrambles.com/what-i-learnt-this-week-am-i-narcissistic-in-my-enjoyment-of-emergency-care-wiltw/. I wasn’t as brave as you have been and fell short of speaking positively about the impact of breaking bad news:

    “Even in the most desperate of tragedies you can avoid breaking bad news badly (I am uncomfortable about saying you can be good at breaking bad news).”

    You are definitely right though. This positive approach will sure keep your tank running..

    Liked by 1 person

  2. Really well said. I remember often feeling guilty as a rape crisis counselor about “a job well done” because how can anything good come of supporting someone through that crisis? But when the victim walks away feeling more in control of her body and her life because of care we have given her, that is our “job well done”.

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  3. Very thoughtful and useful. I cover this somewhat in How To Survive a Career in Medicine (BMJ Books). There’s so much now about the psychological and physiological changes that come about when you talk about difficult or traumatic experiences so doing that is bound to help. I wish ‘time’ could be had easily as you’re right that compassionate care always takes time. Emotional intelligence is always useful in good doctoring. Thanks again for your piece. @bythewall Jenny Firth Cozens

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  4. We are finding out that burnout is a huge factor in a clinicians ability to ‘bounce back’, or not. We found the same phenomena in the airline industry following post-accident counselling. Thanks to all who are writing and educating clinicians on this, but there is a glaring hole in medical school curricula – how to maintain the health of the care giver?

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    • I think med school is too early for this – it needs to start during foundation training after they’ve been properly exposed to the reality but before burnout sets in. I also think regular sessions with high-risk specialties (ICU, EM, oncology, Acute Med for instance) at consultant level establishes it on people’s radar before it’s too late.

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