When you're the patient

The medical profession's "doctors don't get sick" philosophy can make for an isolating experience when physicians fall ill.

Gail Garfinkel Weiss

In July 2005, more than a year after he underwent two surgeries for bladder cancer, Tacoma, WA, based family physician Richard E. Waltman wrote a second article for Medical Economics about the experience. He described the BCG treatments, the feelings of helplessness and terror that come with being seriously ill, the comfort he took in the support of family, and his disappointment that some of the colleagues with whom he had worked closely for years didn't, as he put it, "rise to the occasion."
He anticipated that his physician colleagues "would step forward with support and concern," but with a few notable exceptions, that didn't happen. "Some ask in passing how I'm feeling, and a few have commented about the Medical Economics article," he wrote, "but most have remained silent. This made me sad, then angry, then puzzled. When I finally asked some colleagues why they didn't say anything about my illness, the answers were instructive. 'I didn't think you wanted to talk about it,' said one. 'I didn't know what to say,' said another. And perhaps most interesting of all: 'You're one of us, not one of them. They get sick. We don't.' "
How pervasive is the "doctors don't get sick" attitude among physicians? Very, say physician wellness authorities—and it explains why many physicians refuse to seek medical care, choose not to tell colleagues when they're ill, and steer clear of sick colleagues lest the bad karma affect them, too.
The temptation to turn away
"It's human nature to hold misfortune at a distance, and doctors particularly fantasize that the serious things we diagnose in patients couldn't possibly happen to us. It's a coping mechanism when we deal with tragedies on a daily basis," says Elizabeth A. Pector, an FP in Naperville, IL, who has written about physician burnout and other psychosocial issues.
"When one of our own is diagnosed with something serious, it's too close for comfort and we feel vulnerable," she continues. "We also feel helpless, which in-control docs hate. Distancing helps us deal with these emotions. We don't ask, 'How are you doing? How is your family coping?' Unfortunately, this leaves our stricken colleague feeling like a pariah."
Of course, there are exceptions. M.P. Ravindra Nathan, a cardiologist in Brooksville, FL, has nothing but praise for the cohorts who helped him weather a series of health crises that included a kidney transplant and a heart attack. His practice partner and the other cardiologists at the hospital not only kept his practice afloat, he says, "They were very attentive and made sure that I got excellent care." And when Eugene Ogrod, an internist in Sacramento, was hospitalized with epiglottitis, his office partners visited and asked about his recovery, and he describes his physician friends as "inquiring and supportive."
It's also true that some physicians who are ill downplay the severity of the infirmity. They may fear being scorned for having violated the tacit "we don't get sick" oath, or they worry that referrals will diminish.
Too often, though, critically ill physicians, in the words of Ronald L. Hofeldt, a psychiatrist in Salem, OR, are treated almost as if they've disappeared. He recounts a situation in which a member of a multispecialty group wasn't visited by any of his associates when he was hospitalized for treatment of a serious illness. Hofeldt attributes this behavior to physicians' "higher-than-usual level of anxiety regarding illness and dying," and to the fact that "when one of our own becomes ill it frays the boundary between our professional self and our personal self. Because we don't know what to do or say, our reaction is often one of avoidance. Unfortunately, we don't provide the same level of compassion to our colleagues that we do to our patients."
San Francisco psychiatrist Michael Menaster agrees that many physicians "have a sense of omnipotence and immortality," in part because they're high achievers and in part to maintain a confident veneer in a profession that exists to conquer illness and, in the minds of some, death itself. Waltman's colleagues, Menaster says, "may have been uncomfortable with his manifest mortality."
Indeed, in "When Doctors Get Sick," their 1998 article in Annals of Internal Medicine, physicians Howard M. Spiro and Harvey N. Mandell mention "the unconscious pact with the Creator that many physicians have made: We will take care of the sick and You will guarantee us good health." Transplant surgeon Pauline W. Chen, who includes that quote in her recently published Final Exam: A Surgeon's Reflections on Mortality (Alfred A. Knopf, 2007), notes that in denying their own mortality doctors have been able to render incredible patient care in areas rife with bubonic plague and yellow fever, and more recently AIDS and SARS before the natures of those illnesses were understood. An effective way to maintain that steely resolve, Chen says, is for physicians to shield themselves from evidence that doctors are as vulnerable to disease as everyone else.
Training—or, rather, lack of training in this area—plays a role, too. As Ron Hofeldt points out, "We learn about compassion and humanism, but during our professional lives we leave the tender loving care to nurses. Our mentoring process and culture of medicine hasn't taught us how to address each other when we become ill." At the same time, he continues, in physician/physician relationships, "When one person falls ill, we don't know where the boundary is. We have no problem asking patients about their symptoms and progress, but if we're talking to a physician friend such questions might seem intrusive, so we may ask nothing at all."
What to say and what not to say
Internist Alan Roberts, who was diagnosed with prostate cancer in 1999, has written about his experience and participated in symposia for physicians with the disease. His colleagues have been supportive, he says, but he acknowledges that most people view cancer as a daunting illness—especially physicians, who know firsthand of its destructive power.
Complicating matters, says Elizabeth Pector, is physicians' access to their own pathology reports, and a likelihood that the doctor has seen worst-case scenarios involving people with the same illness. "When our colleagues are nowhere to be found, there's no one to whom we can confide our deepest professional and personal fears," she says. "We desperately need someone to listen; someone who is not afraid to call and say, 'I'm so sorry to hear about your illness. How are you doing? Really, how are you doing?' "
Pector offers some advice for physicians on how to reach out to seriously ill colleagues:
Keep in touch. Ask them to have coffee or lunch with you, and be willing to listen to their story, repeatedly if necessary. Continue to invite them to social outings; they may still want to be in the loop.
Offer specific means of help. Rather than saying, "Call if you need anything," ask, "Can I take your hospital call for the next month?" or "Can I arrange a rotation in our department to cover your office patients until you're better?"
Convey concern without trite platitudes. "I'm sorry," or "I have no idea how you feel, but I want you to know I care," are always appreciated. Similarly, it's better to say, "I don't know what to say," than to say nothing at all.
Don't invoke the divinity's role in illness, or characterize the illness as an opportunity for professional growth. Avoid "God doesn't give you what you can't bear," "God has his reasons," and "Enduring this will make you a more compassionate doctor; you'll know how patients feel." Let your colleague find his or her own spiritual or personal meaning in misfortune.
Don't minimize the situation or tell your colleague to "look on the bright side." Phrases that start with "At least" aren't helpful. Try substituting "I'm so glad that." For example, "I'm very sorry to hear about your cancer, but I'm glad to hear it didn't metastasize" sounds much better than, "At least it didn't spread."
If time or distance or your personal inclinations preclude a face-to-face encounter with a sick colleague, send a handwritten note or a supportive e-mail message, Waltman advises.
There are, of course, seriously ill physicians who prefer to maintain a stoic, business-as-usual veneer after receiving dire medical news. Waltman knows of physicians who didn't tell co-workers, or even family, that they had been diagnosed with a dangerous illness. "We can't be expected to read our ill colleague's mind," says Pector, "but we can be expected to reach out and offer practical, tangible help as well as friendship."
After lending an ear, however, be sure to maintain confidentiality, just as you would with patients. Not because there will be legal repercussions—if the physician isn't your patient, there probably won't be—but because no one wants information about their medical problems circulated on the rumor mill.
Crossing the us/them barrier
In writing the articles about his illness, Waltman says he wanted to break the code of silence that prevents physicians from acknowledging that they're ill, and that encourages colleagues to look away—as if the sick person has committed an etiquette lapse and the polite thing is to pretend not to notice. In part, he thinks that the code of silence is a "generational thing" and a "guy thing" that may dissipate as more women enter the medical profession and the World War II and baby boom cohorts yield to the less stoic and more emotionally open Generation X and Y doctors.
Meanwhile, physicians need to do a better job of heeding the advice they give to patients. "We're quick to tell patients to take a few days off from work when they have the flu, and we'd never suggest to them that a critical illness is a sign of weakness," Waltman says. "But we come to work with bronchitis and back pain so severe that we can hardly stand up, and often maintain a 'don't ask, don't tell' philosophy regarding our own and our colleagues' illnesses, largely because we don't want to acknowledge that we're mortal.
"In my case, no one was unkind, and call coverage was never a problem, but even now, two years after my cancer diagnosis, my colleagues still prefer not to talk about it. Well, not only can we talk about it, we should. In addition to being there for our patients, we need to be there for each other."