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1.
Quill TE, Williamson PR. Healthy approaches to physician stress.  Arch Intern Med.1990;150:1857-1861.Google Scholar
2.
Muskin PR. The request to die: role for a psychodynamic perspective on physician-assisted suicide.  JAMA.1998;279:323-328.Google Scholar
3.
Quill TE. Partnerships in patient care: a contractual approach.  Ann Intern Med.1983;98:228-234.Google Scholar
4.
Butler RN. Psychiatry and the elderly: an overview.  Am J Psychiatry.1975;132:893-900.Google Scholar
5.
Farber NJ, Novack DH, O'Brien MK. Love, boundaries, and the patient-physician relationship.  Arch Intern Med.1997;157:2291-2294.Google Scholar
6.
Caine E, Conwell Y. Self-determined death, the physician and medical priorities: is there time to talk?  JAMA.1993;270:875-876.Google Scholar
7.
Pellegrino ED. Compassion needs reason too.  JAMA.1993;270:874-875.Google Scholar
8.
Zinn WM. Doctors have feelings too.  JAMA.1988;259:3296-3298.Google Scholar
9.
Friedman E. The perils of detachment.  Healthc Forum J.1990;33:9-10.Google Scholar
10.
Blackshaw SL, Miller JB. Boundaries in clinical psychiatry.  Am J Psychiatry.1994;151:293.Google Scholar
11.
Gabbard GO, Nadelson C. Professional boundaries in the physician-patient relationship.  JAMA.1995;273:1445-1449.Google Scholar
12.
Clarke P. Exploration of countertransference toward the dying.  Am J Orthopsychiatry.1981;51:71-77.Google Scholar
13.
Pick I. Working through in the countertransference.  Int J Psychoanal.1985;66:157-166.Google Scholar
14.
Novack DH, Epstein RM, Paulsen EH. Toward creating physician healers: fostering medical students' self-awareness, personal growth, and well-being.  Acad Med.1999;74:516-520.Google Scholar
15.
Marshall AA, Smith RC. Physicians' emotional reaction to patients: recognizing and managing countertransference.  Am J Gastroenterol.1995;90:4-8.Google Scholar
16.
Quill TE. Recognizing and adjusting to barriers in doctor-patient communication.  Ann Intern Med.1989;111:51-57.Google Scholar
17.
Casarett D, Kutner JS, Abrahm J. Life after death: a practical approach to grief and bereavement.  Ann Intern Med.2001;134:208-215.Google Scholar
18.
Whippen DA, Canellos GP. Burnout syndrome in the practice of oncology: results of a random survey of 1000 oncologists.  J Clin Oncol.1991;9:1916-1920.Google Scholar
19.
Gundersen L. Physician burnout.  Ann Intern Med.2001;135:145-148.Google Scholar
20.
McCue JD. The effects of stress on physicians and their medical practice.  N Engl J Med.1982;306:458-463.Google Scholar
21.
Gartrell N, Herman J, Olarte S, Feldstein M, Localio R. Psychiatrist-patient sexual contact: results of a national survey, I: prevalence.  Am J Psychiatry.1986;143:1126-1131.Google Scholar
22.
Gartrell N, Milliken N, Goodson III WH, Thiemann S, Lo B. Physician-patient sexual contact: prevalence and problems.  West J Med.1992;157:139-143.Google Scholar
23.
Smith RC, Zimny GH. Physicians' emotional reactions to patients.  Psychosomatics.1988;29:392-397.Google Scholar
24.
Epstein RM, Morse DS, Frankel RM, Frarey L, Anderson K, Beckman HB. Awkward moments in patient-physician communication about HIV risk.  Ann Intern Med.1998;128:435-442.Google Scholar
25.
Meier D, Myers H, Muskin P. When, if ever, should we expedite death? In: Zeman A, Emanuel L, eds. Ethical Dilemmas in Neurology. London, England: WB Saunders Co; 2000:180-192.
26.
 It's over, Debbie.  JAMA.1988;259:272.Google Scholar
27.
Quill TE. Death with dignity: a case of individualized decision-making.  N Engl J Med.1991;324:691-694.Google Scholar
28.
Modestin J. Countertransference reactions contributing to completed suicide.  Br J Med Psychol.1987;60:379-385.Google Scholar
29.
Vaillant GE, Sobowale NC, McArthur C. Some psychological vulnerabilities of physicians.  N Engl J Med.1972;287:372-375.Google Scholar
30.
Smith JW, Denny WF, Witzke D. Emotional impairment in internal medicine housestaff.  JAMA.1986;255:1155-1158.Google Scholar
31.
Hendin H, Lipschitz A, Maltsberger J, Haas AP, Wynecoop S. Therapists' reactions to patients' suicides.  Am J Psychiatry.2000;157:2022-2027.Google Scholar
32.
Hendin H. Psychotherapy and suicide.  Am J Psychother.1981;35:469-480.Google Scholar
33.
Block SD, Billings JA. Patient requests for euthanasia and assisted suicide in terminal illness: the role of the psychiatrist.  Psychosomatics.1995;36:445-457.Google Scholar
34.
Block SD, Billings JA. Patient requests to hasten death: evaluation and management in terminal care.  Arch Intern Med.1994;154:2039-2047.Google Scholar
35.
Miles SH. Physicians and their patients' suicides.  JAMA.1994;271:1786-1788.Google Scholar
36.
Miles S. Physician-assisted suicide and the profession's gyrocompass.  Hastings Cent Rep.1995;25:17-19.Google Scholar
37.
Quill TE, Cassel CK, Meier DE. Care of the hopelessly ill: proposed clinical criteria for physician-assisted suicide.  N Engl J Med.1992;327:1380-1384.Google Scholar
38.
Quill TE, Cassel CK. Nonabandonment: a central obligation for physicians.  Ann Intern Med.1995;122:368-374.Google Scholar
39.
Von Gunten CF, Ferris FD, Emanuel LL. Ensuring competency in end-of-life care: communication and relational skills.  JAMA.2000;284:3051-3057.Google Scholar
40.
Portenoy RK, Coyle N, Kash KM.  et al.  Determinants of the willingness to endorse assisted suicide: a survey of physicians, nurses, and social workers.  Psychosomatics.1997;38:277-287.Google Scholar
41.
Prendergast TJ, Luce JM. Increasing incidence of withholding and withdrawal of life support from the critically ill.  Am J Respir Crit Care Med.1997;155:15-20.Google Scholar
42.
Prendergast TJ. Resolving conflicts surrounding end-of-life care.  New Horiz.1997;5:62-71.Google Scholar
43.
Block S. Helping the clinician cope with death in the ICU. In: Curtis J, Rubenfeld G, eds. Managing Death in the ICU: The Transition From Cure to Comfort. New York, NY: Oxford University Press; 2001:183-192.
44.
Solomon MZ, O'Donnell L, Jennings B.  et al.  Decisions near the end of life: professional views on life-sustaining treatments.  Am J Public Health.1993;83:14-23.Google Scholar
45.
Yamey G, Wilkes M. Promoting well-being among doctors.  BMJ.2001;322:252-253.Google Scholar
46.
Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician: personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient.  JAMA.1997;278:502-509.Google Scholar
47.
Martin A. Stress in residency: a challenge to personal growth.  J Gen Intern Med.1986;1:252-257.Google Scholar
48.
Martin CA, Julian RA. Causes of stress and burnout in physicians caring for the chronically and terminally ill.  Hosp J.1987;3:121-146.Google Scholar
49.
Gordon G, Hubbell F, Wyle F, Charter R. Stress during internship: a prospective study of mood states.  J Gen Intern Med.1986;1:228-231.Google Scholar
50.
Martin MJ. Psychiatric problems of physicians and their families.  Mayo Clin Proc.1981;56:35-44.Google Scholar
51.
Brewster JM. Prevalence of alcohol and other drug problems among physicians.  JAMA.1986;255:1913-1920.Google Scholar
52.
Rucinski J, Cybulska E. Mentally-ill doctors.  Br J Hosp Med.1985;33:90-94.Google Scholar
53.
McAuliffe WE, Rohman M, Santangelo S. Psychoactive drug use among practicing physicians and medical students.  N Engl J Med.1986;315:805-810.Google Scholar
54.
Billings CV. Declare war on burnout! 12 tips for professional self care.  Am Nurse.1992;24:2.Google Scholar
55.
Strasburger L, Jorgenson L, Sutherland P. The prevention of psychotherapist sexual misconduct: avoiding the slippery slope.  Am J Psychother.1992;46:544-545.Google Scholar
56.
McCue J, Sachs C. A stress management workshop improves residents' coping skills.  Arch Intern Med.1991;151:2273-2277.Google Scholar
57.
Schon D. Educating the Reflective PractitionerSan Francisco, Calif: Jossey-Bass; 1987.
58.
Beckman H, Frankel R, Kihm J, Kulesz G, Geheb M. Measurement and improvement of humanistic skills in first-year trainees.  J Gen Intern Med.1990;5:42-45.Google Scholar
59.
Weiner EL, Swain GR, Wolf B, Gottlieb M. A qualitative study of physicians' own wellness-promotion practices.  West J Med.2001;174:19-23.Google Scholar
60.
Weisman AD. The Realization of DeathNew York, NY: Jason Aronson; 1974.
61.
Block S. Using problem-based learning to enhance the psychosocial competence of medical students.  Acad Psychiatry.1996;20:65-75.Google Scholar
62.
Billings JA, Block S. Palliative care in undergraduate medical education: status report and future directions.  JAMA.1997;278:733-738.Google Scholar
63.
Block S, Billings JA. Nurturing humanism through teaching palliative care.  Acad Med.1998;73:763-765.Google Scholar
64.
Meier DE, Morrison RS, Cassel CK. Improving palliative care.  Ann Intern Med.1997;127:225-230.Google Scholar
65.
Benoliel JQ. Health care providers and dying patients: critical issues in terminal care.  Omega (Westport).1987-88;18:341-363.Google Scholar
66.
Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Toronto, Ontario: University of Toronto Press; 1992.
67.
Novack D, Kaplan C. Personal awareness and professional growth: a proposed curriculum.  Med Encounter.1997;13:2-8.Google Scholar
68.
Gorlin R, Zucker HD. Physicians' reactions to patients: a key to teaching humanistic medicine.  N Engl J Med.1983;308:1059-1063.Google Scholar
69.
Billings JA. On being a reluctant physician—strains and rewards in caring for the dying at home. In: Andrews BJ, ed. Outpatient Management of Advanced Cancer: Symptom Control, Support, and Hospice-in-the-Home. Philadelphia, Pa: Lippincott & Co; 1985:309-318.
70.
Gorlin R, Strain J, Rhodes R. Cultural collisions at the bedside: social expectations and value triage in medical practice.  Camb Q Healthc Ethics.2001;10:7-15.Google Scholar
71.
Goold SD, Williams B, Arnold RM. Conflicts regarding decisions to limit treatment: a differential diagnosis.  JAMA.2000;283:909-914.Google Scholar
72.
Breen CM, Abernethy AP, Abbott KH, Tulsky JA. Conflict associated with decisions to limit life-sustaining treatment in intensive care units.  J Gen Intern Med.2001;16:283-289.Google Scholar
73.
Freeborn D. Satisfaction, commitment, and psychological well-being among HMO physicians.  Permanente J.2000;2:22-30.Google Scholar
74.
Snibbe J, Radcliffe T, Weisberger C, Richards M, Kelly J. Burnout among primary care physicians and mental health professionals in a managed health care setting.  Psychol Rep.1989;65:775-780.Google Scholar
75.
Charon R. Medicine, the novel, and the passage of time.  Ann Intern Med.2000;132:63-68.Google Scholar
76.
Maltsberger JT, Buie DH. Countertransference hate in treatment of suicidal patients.  Arch Gen Psychiatry.1974;30:625-633.Google Scholar
77.
The AM, Hak T, Koeter G, van der Wal G. Collusion in doctor-patient communication about imminent death: an ethnographic study.  BMJ.2000;321:1376-1381.Google Scholar
78.
Jecker NS. Medical futility and care of dying patients.  West J Med.1995;163:287-291.Google Scholar
79.
Dozor RB, Addison RB. Toward a good death: an interpretive investigation of family practice residents' practices with dying patients.  Fam Med.1992;24:538-543.Google Scholar
80.
Faber-Langendoen K. A multi-institutional study of care given to patients dying in hospitals: ethical and practice implications.  Arch Intern Med.1996;156:2130-2136.Google Scholar
81.
Max MB. Improving outcomes of analgesic treatment: is education enough?  Ann Intern Med.1990;113:885-889.Google Scholar
82.
McCue J. The distress of internship: causes and prevention.  N Engl J Med.1985;312:449-452.Google Scholar
83.
Crouch M. Working with one's own family: another path for professional development.  Fam Med.1986;18:93-98.Google Scholar
84.
Mengel M. Physician ineffectiveness due to family-of-origin issues.  Fam Syst Med.1987;5:176-190.Google Scholar
85.
Manian FA. Physicians vs physicians.  Arch Intern Med.2001;161:801-802.Google Scholar
86.
Charon R. Narrative medicine: form, function, and ethics.  Ann Intern Med.2001;134:83-87.Google Scholar
87.
Hurwitz B. Narrative and the practice of medicine.  Lancet.2000;356:2086-2089.Google Scholar
88.
Bradshaw S, Burton P. Naming: a measure of relationships in a ward milieu.  Bull Menninger Clin.1976;40:665-670.Google Scholar
89.
Epstein RM. Mindful practice.  JAMA.1999;282:833-839.Google Scholar
90.
Rabow MW, McPhee SJ. Doctoring to heal: fostering well-being among physicians through personal reflection.  West J Med.2001;174:66-69.Google Scholar
91.
Liossi C, Hatira P, Mystakidou K. The use of the genogram in palliative care.  Palliat Med.1997;11:455-461.Google Scholar
92.
Balint M. The Doctor, His Patient, and the IllnessNew York, NY: International University Press Inc; 1972.
93.
Howells K, Field D. Fear of death and dying among medical students.  Soc Sci Med.1982;16:1421-1424.Google Scholar
94.
Lubitz RM, Nguyen DD. Medical student abuse during third-year clerkships.  JAMA.1996;275:414-416.Google Scholar
95.
Ramirez A, Graham J, Richard M.  et al.  Burnout and psychiatric disorder among cancer clinicians.  Br J Cancer.1995;71:1263-1269.Google Scholar
The Patient-Physician Relationship
December 19, 2001

The Inner Life of Physicians and Care of the Seriously Ill

Author Affiliations

Author Affiliations: Hertzberg Palliative Care Institute, Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY (Drs Meier and Morrison); and the VA Puget Sound Health Care System, Department of Medicine, Department of Medical History and Ethics, University of Washington School of Medicine, Seattle (Dr Back).

 

The Patient-Physician Relationship Section Editor: Richard M. Glass, MD, Deputy Editor.

JAMA. 2001;286(23):3007-3014. doi:10.1001/jama.286.23.3007
Abstract

Seriously ill persons are emotionally vulnerable during the typically protracted course of an illness. Physicians respond to such patients' needs and emotions with emotions of their own, which may reflect a need to rescue the patient, a sense of failure and frustration when the patient's illness progresses, feelings of powerlessness against illness and its associated losses, grief, fear of becoming ill oneself, or a desire to separate from and avoid patients to escape these feelings. These emotions can affect both the quality of medical care and the physician's own sense of well-being, since unexamined emotions may also lead to physician distress, disengagement, burnout, and poor judgment. In this article, which is intended for the practicing, nonpsychiatric clinician, we describe a model for increasing physician self-awareness, which includes identifying and working with emotions that may affect patient care. Our approach is based on the standard medical model of risk factors, signs and symptoms, differential diagnosis, and intervention. Although it is normal to have feelings arising from the care of patients, physicians should take an active role in identifying and controlling those emotions.

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