Clinician Shame: Making Peace With the Unfixable

Recently, I received an email from a neurologist with whom I share a complicated patient. He is a middle-aged man with a portfolio of ailments that are uncommon enough together that to name them might be considered a breach of confidentiality. I will forego the details and say that these are diseases that will likely end his life in the next few years, but not before a course of considerable disability. Needless to say, he is depressed as well, but also grieving (not only his lost healthy self, but also grieving some of the choices he has made in life and paths not taken), two conditions that, despite their similar appearance, grow from different rootstocks.

To make matters more complicated, his other conditions are prone to be exacerbated by many psychiatric medications. As a result, I have been treating him with the medications I can use and primarily working with him in psychotherapy to address his grief.

So, I was troubled to receive this email from my colleague that expressed concern that as his life-threatening conditions advance and become less responsive to treatment, his depression and hopelessness are, not surprisingly, worsening as well. I shared her concern for the patient, but I was bothered by her intimation that the reason for his depression was a failure of medication. and at her insistence that he see a psychiatrist (as I am a psychiatric NP). The implication was that his worsening condition was a reflection of my lack of competence.

In my first blog posting on this topic, I wrote about how shame, that corrosive feeling of “not being good enough,” is a silent cancer that contributes mightily to our epidemic of clinician suffering and depression, this suffering expressed most distressingly by the 750 suicides that occur each year among nurses, physicians, and psychotherapists. I wrote about how we sow the seeds of shame through training programs that pit us against one another, and then highlight our mistakes through humiliation when mistakes are inevitably made. I wrote about how we perpetuate this feeling of being not good enough through slights and microaggressions that we unconsciously inflict upon our peers and colleagues.

The email from my neurologist colleague was exactly the kind of slight I was talking about. I am a good enough psychotherapist that I could see through the surface layer of her communication to her anxiety that shone through from underneath. Here is a patient who is rapidly falling apart, sadly hurtling towards the inevitable, which is that one of these incurable conditions is going to kill him at a much younger age than anyone would want. What doctor wouldn’t feel helpless against such a foe? But why do we project this feeling of helplessness onto our colleagues? I suspect psychiatry is more prone to this kind of critique than other professions because the ailments we treat are more indolent, subjective, and chronic than, say, the bailiwick of an oncologist. Can you imagine saying to an oncologist who lost a patient to cancer, “Do you think if you had tried harder, they would still be alive?” Of course not, because cancer is seen as a formidable foe that too often claims its victims, and oncologists are given the benefit of the doubt that mental health professionals are not always afforded.

Sometimes, the problems we treat are not fixable; they are chronic. In a recent clinic meeting, one of my psychiatrist colleagues mentioned she had been there for 25 years and still had a handful of her original patients in her care. Someone quipped, “Still haven’t fixed them, eh?” Those of us who have been doing this for a while, know all too well, that sometimes the greatest gift we can give to our patients is to sit with them in their pain. The word “patient,” after all derives from the Latin patior – to suffer, to wait. Of course, this should not be mistaken to mean that we don’t continue to try to find effective treatments. The great dialectic of our profession is to both continue to find solutions and to not abandon our patients when their conditions overpower our treatments.

And when we are interfacing with our colleagues about these challenging patients, what if we assumed that our colleagues were doing the best they could, and what if we didn’t quietly undermine one another with subtle (and not so subtle) critiques of their competence?

In my first blog on this topic, I wrote that no one is surprised when Superman can fly. That’s expected. They’re only surprised, even disappointed, when Superman can’t fly. I suspect most of us have come to expect ourselves to be supermen and superwomen, and when we can’t cure someone as we have come to expect, we are most disappointed with ourselves. But what if we realized the gift that it is to sit with someone who is suffering incurably and to not leave them? That sometimes, our compassionate presence is not just a consolation prize, but rather, is the best intervention we can provide.

Andrew Penn was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. Currently, he serves as an Assistant Clinical Professor at the University of California-San Francisco School of Nursing. Mr. Penn is a psychiatric nurse practitioner with Kaiser Permanente in Redwood City, CA, where he provides psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. He is a former board member of the American Psychiatric Nurses Association, California Chapter, and has presented nationally on improving medication adherence, emerging drugs of abuse, treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice. 

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.