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Physicians routinely face stressful situations. These include dealing with difficult patient interactions, balancing personal and professional joys and responsibilities, coping with medical mistakes, overcoming concerns about professional competence, and processing grief.1,2,3 Physicians-in-training have additional challenges that complicate these routine stresses. During medical school and residency, many trainees confront these issues for the first time, during a period in their lives when they may have recently moved away from supportive family and friends and in the context of a daunting work schedule and intense evaluative process. For physicians of all levels of experience, inadequate coping with such stresses may lead to job dissatisfaction, burnout, isolation, and maladaptive behaviors, including substance abuse and even suicide.4,5
Fostering deeper personal awareness may help physicians to deal with these challenges, improve professional effectiveness, and increase personal satisfaction.6 Several methods have been proposed for enhancing personal awareness: personal awareness groups, physician groups that focus on the patient-physician relationship (such as Balint Groups), individual therapy, role playing, keeping a journal, and exploring literature and art.7,8
We developed a discussion group, called Doctoring to Heal (DTH), that has been held monthly since 1996 in the Division of General Internal Medicine (DGIM) at the University of California, San Francisco, Medical Center. Each DTH session is based on the sharing of clinical narratives and personal stories exploring meaning and emotion in the practice of medicine, with the intention of improving physician well-being. The format of DTH, described below, can be adapted easily to other clinical settings.
Doctoring to Heal is a monthly discussion group, held in the evening “after work” for 2 hours. The topic for each discussion group is announced in advance to all DGIM interns, residents, and faculty. Topics are meant to address existential and spiritual themes in the work of a physician (box 1). Participation is voluntary, but physicians are encouraged to attend. The average group size is about 12 but has ranged from 6 to 37, depending on the topic. The “ideal” group size seems to be 1 that allows each participant to feel comfortable and to have time to speak if he or she wishes. The general format of a session involves sharing a meal, privately reflecting on a personally meaningful clinical experience, sharing these experiences, discussing themes that emerge in a facilitated open forum, and a closing reading.
After dinner, delivered by a local restaurant, all participants introduce themselves, and the DTH ground rules are briefly reviewed by 1 of the 2 facilitators and discussed as necessary (box 2). Resident participants are encouraged to serve as 1 of the facilitators for sessions on a topic particularly compelling to them. Facilitators function to recognize themes and make them explicit, to keep time, and to ensure that the ground rules are followed.9
Physician and nonphysician guests from outside the DGIM with an interest in a particular topic are sometimes invited to participate in or cofacilitate the sessions.
After the meal and introductions, each participant is asked to spend 10 to 15 minutes writing a personal narrative related to the evening's topic. Facilitators introduce the exercise with a simple request, such as “Please write about an instance of anger in your work—for example, a time when you became angry in a patient encounter, a patient became angry at you, or you witnessed another physician's or patient's anger.” For some topics, to stimulate a balanced discussion, half of the group is asked to write about a topic, and the other half is asked to write about its converse. For instance, in the session on compassion, half the group is asked to “describe a time when you acted with compassion,” and the other half of the group is asked to “describe a time when you were unable to act with compassion.”
Participants are encouraged to “keep the pen to the paper” and write freely, avoiding self-censorship or worrying about spelling, grammar, or composition style. Individual participants write in a variety of formats: full narratives, stream-of-consciousness memories or images, lists of words or thoughts, and even short poems (box 3).
After writing, participants are invited to read their story to the group. Participants read in whatever order they choose. During and after each reading, the other physicians are asked to remain silent, simply listening and refraining from any comment. Many participants report that this opportunity to be wholeheartedly and fully listened to is 1 of the greatest strengths of the DTH format. For some particularly sensitive topics (such as Mistakes), if the group wishes, instead of each reading his or her own story, all the papers are mixed together in a stack, shuffled and handed out randomly, and thus read aloud anonymously.
When all who wish to read have had a chance to do so, the rest of the session is spent in open discussion of issues brought up from the writing or the sharing of stories. The discussion is facilitated but unstructured, with the group's participants pursuing topics of their choosing. Often, the discussion focuses on the commonalities or differences in people's experiences, underlying themes related to training, the challenges and joys of caring for patients, issues of personal maturation and development, or concerns regarding personal and professional relationships.
The session is closed with the reading of a short story or poem, often 1 written by a physician, that highlights the evening's theme. These pieces are selected by 1 of the facilitators from classic works of literature such as Tolstoy's The Death of Ivan Illich or William Carlos Williams's The Doctor Stories or from medical journal sections such as “Lessons From the Practice” from the Western Journal of Medicine or “A Piece of My Mind” from the Journal of the American Medical Association.10,11,12,13 Occasionally, participants will bring a reading of special significance to them in their clinical or personal life.
Some DTH sessions follow slightly different formats, substituting another experiential activity for the writing exercise. For example, during some sessions (such as Healing and Connection With Patients), participants create artwork using various media: painting, drawing, collage, tile-making, and quilt panel-making. These sessions are facilitated by an artist with extensive experience using artwork to help patients explore and express their experiences of illness and healing. No artistic experience or talent is required of the participants. The products of these sessions can be kept by the creators or displayed in the clinic, resident's room, or conference rooms. During the session on Touch, participants form pairs and are led by a physical or message therapist through a series of touching exercises to explore the role of intention and issues of safety in the practice of touch.
Session topics usually do not repeat, with 1 exception. At the end of each academic year, DTH hosts a special session that serves as a memorial service for the patients who have died during the year. This session has involved various memorial rituals, including assembling at the San Francisco AIDS Memorial Grove and allowing each participant to share a poem about an individual patient, creating a series of ceramic tiles for permanent display in the clinic that have been decorated with images of a decreased patient, and participating in a traditional Buddhist mourning ritual led by a local Buddhist priest. Participants are welcomed to the DTH memorial service regardless of their affiliation with the DGIM. Following the memorial service, participants gather to share a meal at a local restaurant.
More than 70% of DGIM members have attended at least 1 DTH discussion group and have reported feeling comfortable with the format.14 Both resident and faculty participants report a number of powerful, positive experiences in the DTH sessions. These sessions, like personal awareness groups, allow participants the opportunity to “practice being who we are” and to share a noncognitive experience of “group mind.”9 Participants say that they have experienced 4 benefits.
First, they cite DTH as strengthening their personal and professional identity. One participant explained, “I learned that if we listen—really listen to others—we grow from their experience. That patients can be our teachers. That true satisfaction in internal medicine comes from a relationship with the patient cultivated over time.”
Second, they report an increased sense of connectedness with colleagues. One physician commented, “I learned that I am not alone.” Another learned “how to share extremely powerful experiences with my colleagues.”
Third, participants take home specific practice techniques after hearing the stories of others. According to 1 participant, DTH sessions were effective because they provided “specific ideas that I took with me to improve my awareness of the healing moment and my actual practice of healing.” Another said, “DTH has affected the way in which I examine my patients... and the way that I pronounce them dead after they die.”
Finally, DTH is reported as being an effective tool for some physicians to maintain balance and promote well-being. One participant discovered that “I desperately need this form of processing while I'm doctoring.”
There appear to be benefits to attending DTH even for those uninterested, unwilling, or unable to share directly their own stories with the group. One participant chose to attend DTH monthly for nearly 2 years but elected to remain silent during almost all of the sessions.
The personal reflection at the core of DTH appears to provide benefits to experienced clinicians as well as to physicians-in-training. One faculty participant wondered, “Perhaps we need a separate DTH for faculty?” When other faculty members responded affirmatively, we organized a faculty-only DTH-like group and began to meet monthly at the medical center.
Doctoring to Heal serves an important function for many residents and faculty, highlighting and supporting the existential and spiritual aspects of doctoring that are often ignored or even discouraged in other parts of our work. The program has served as a touchstone within the DGIM. It has provided a vocabulary for talking about issues of meaning and a place physicians can rely on to value personal experiences and explorations. Mistakes, insecurities, and fears are tolerated; forgiveness, growth, and understanding are encouraged. Knowing that a DTH session attended by just the 2 facilitators would be of deep value to us personally, each month we have been heartened to be joined by a community of colleagues who also are committed to healing our patients, our workplace, and ourselves.
Modeled on DTH, similar sessions are now being conducted in several different settings across the United States, including groups in other academic divisions, in county hospitals, and in health maintenance organization practices.15 Ultimately, what is most important about discussion groups like DTH may be their combination of intense personal exploration and the universality of the issues explored. A participant in DTH said that what is discovered is “the universality of concerns and experiences among physicians, the deep fear of looking at our fears, and the sacredness of connection with patients.”
Selected resources for physician well-being and personal reflection
Competing interests: None declared
Authors: Michael W Rabow is a general internist with special interests in behavioral medicine, physician training, and care for patients at the end of life. Stephen J McPhee is a general internist interested in preventive medicine research and end-of-life care. They began Doctoring to Heal as a New Year's resolution in 1996.