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© 2003 American Society for Clinical Oncology
Full-Impact Medicine
InterCommunity Cancer Center, Rome, GA To the Editor: The Art of Oncology article "The Narrow Path"1 poignantly depicted a major omission from the process of medical education—lessons in how to take care of ourselves and our patients through traumatic events. The specific features of the "narrow path" of being present for our patients while attending to our needs will probably look different with respect to each individual doctor and patient, but the basic tenets are consistent. 1. Being there. The editorial description of a young mother’s loss of an unborn child in the face of a new catastrophic illness brought out several salient points. There is always a place for the technical part of medicine—the first "C" in caring must stand for competency. Competency must also extend to addressing the entire range of what is going on in any situation—the physical, mental, emotional, and spiritual needs of both the physician and patient are important in every moment. The dominance of any one component of treatment at any one specific point of intervention does not categorically remove the other aspects from consideration. There are time-effective ways of being technical while respecting all of the other sides of the individual.2 One method that has been used successfully to help medical students cope with education-related anxiety is the use of mindfulness meditation techniques.3 These can easily be integrated into our everyday practice, such that even the use of a deep cleansing breath can help us to focus on the specific needs of the present moment.4 Being truly with our patients to face the impact of any situation will not provide us with all of the answers, but rather will help us to look closer at the current problems as an ally of the patient. The common fears of transference, overidentification, and resultant burnout are red flags that we have bought into the concept that we are supposed to know how to fix everything—instead of learning to be open to the possibilities for growth that each moment provides. 2. The physician as an example. Our patients look to us for guidance in all matters that are health related. Increasingly, these matters include the uncomfortable stuff of managing emotional, mental, and spiritual crises, in whatever manner necessary. One could argue that the increased usage of complementary and alternative medicine, with all of its attendant risks and benefits, points glaringly at the need for guidance in addressing the whole person.5,6 One could also argue that physicians should be the ultimate directors of any kind of integrative health care—guiding patients through the bewildering list of options. In order to be effective guides, we must be natives to the territory of effective self-care. We must walk the talk. We must learn to take care for our entire person, such that when an emotionally traumatic situation occurs, we are not left with the need to "go to the bathroom and vomit"—a coping technique used by one of the practitioners mentioned in the editorial. Instead, we can be present and begin to address the needs of the situation effectively. Physicians who practice what they preach are more effective in helping patients to make appropriate lifestyle and health changes.7 We can reason also that these same qualities will help us to effectively manage our individual needs while maximizing the doctor-patient interaction during traumatic events. 3. Sharing is an addition. Since we are not generally trained to be mindful, present in the moment, or to take care of ourselves, it is not surprising that many assume that sharing in emotionally charged events can be draining and promote burnout. This faulty assumption leads to the problem of physicians feeling isolated both from colleagues and patients. This isolation is rationalized as an attempt to keep a detached, professional demeanor despite the circumstances. Sharing in any event—whether it has positive or negative overtones—can only potentially increase our range of available opportunities for intervention. Understanding the needs of a situation, we can make appropriate referrals and serve as an effective guide. Effectiveness enhances our self-esteem and automatically removes one of the main tenets of "sharing is loss"—isolation. We don’t need to do it all ourselves, alone in a bubble. We can reach out for help to our fellow practitioners in other specialities, thus providing our patients another beneficial example. Medical education is transforming into a process that educates the physicians of tomorrow in the methods of self-care, mindfulness, and integration of all useful modalities. As practicing physicians, we need to examine ways that help us to walk the narrow path of self- and other care. Appropriate academic attention to this matter will reveal that this path may not be so narrow after all.
Originally published in Journal of Clinical Oncology, Vol 19, No 17 (September 1), 2001: pp 3793–3794.
1. Steensma DP: The narrow path. J Clin Oncol 19:2102–2105, 2001
2. Fogarty LA, Curbow BA, Wingard JR, et al: Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol 17:371–379, 1999 3. Shapiro SL, Schwartz GE, Bonner G: Effects of mindfulness based stress reduction on medical and premedical students. J Behav Med 21:581–599, 1998[CrossRef][Medline]
4. Epstein RM: Mindful practice. JAMA 282:833–839, 1999
5. Palitiel O, Avitzour M, Peretz T, et al: Determinants of the use of complimentary therapies by patients with cancer. J Clin Oncol 19:2439–2448, 2001
6. Ernst E: Intangible risks of complimentary and alternative medicine. J Clin Oncol 19:2365–2366, 2001 (letter)
7. Frank E, Breyan J, Elon L: Physician disclosure of healthy personal behaviors improves credibility and ability to motivate. Arch Fam Med 9:287–290, 2000
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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