The Doctor Who Cried: A Qualitative Study About the Doctor’s Vulnerability

Malterud and Hollnagel provide valuable material for study, both by exploring physician vulnerability in an open-ended, qualitative fashion, and also by distinguishing spontaneous disclosure of emotion from considered sharing of experience.

It is useful to explore this material further using an analysis of suffering and compassion created by Warren Reich.(1) Reich's framework is grounded in the etymology of compassion, literally, "to suffer with." He reminds us that there can be no compassion without vulnerability. If I am not willing to experience my patient's suffering, and therefore become vulnerable to suffering myself, I can never offer my patient true compassion.

Reich suggests that compassion can be viewed as having three phases. Silent compassion accepts the fact that the sufferer is usually, at first, simply overwhelmed by the immensity of the suffering and of the loss that caused it; words at this stage are insufficient and bothersome. The compassionate physician must demonstrate a willingness simply to be with the suffering patient. The silent act of handing a weeping patient a Kleenex is perhaps the most common manifestation of this phase of compassion in our everyday office practice.

Expressive compassion follows later when the sufferer herself is ready to speak about the suffering and to try to explain and to place a meaning upon it. The patient here needs a sensitive interlocutor who will respond in an encouraging way to the patient's search for meaning--for a story to place the suffering in the larger context of one's life and of the cosmos. (2) The patient does not need a physician who will rush in with a handy, prefabricated statement designed to dismiss or minimize the suffering--"it can't be as bad as all that" or "just think of those who have it worse than you."

The first two phases, silent compassion and expressive compassion, make up the usual, desired clinical intervention. Reich insists that another phase must follow later--new identity in compassion. We cannot be truly open to experience the patient's suffering and yet remain unchanged by the experience. This is what "vulnerability" ultimately entails. The physicians in Malterud and Hollnagel's study were, in effect, processing this final phase of compassion in their joint discussions. The primary application of Reich's phase analysis to the Malterud- Hollnagel distinction is to point out the reason why considered sharing of experience is somewhat more perilous than spontaneous disclosure of emotion.

Spontaneous disclosure of the physician's emotion may occur readily during silent compassion, and forms an especially meaningful part of silent compassion. Spontaneous displays of real emotion can create a tremendously powerful impression in the patient that the physician has truly opened herself to the patient's experience and that something of the immensity of that experience has been shared between them. As the interview data suggest, patients almost always respond very positively to such disclosure.

By contrast, considered sharing of experience forms a part of expressive compassion and is open to the danger of imposing a physician- generated meaning. The physician's sense of what counts as a similar or analogous experience of his own might be at odds with the meaning that the patient is in the process of constructing. The physician who tells the patient, "You know, the same thing happened to me when . . ." might generate the response, "Yes, that's exactly how I felt myself." But it is possible that the response will instead be, "No, it wasn't like that for me at all, you really don't understand." Lucy Candib, in the earlier paper cited by Malterud and Hollnagel (3), offers an excellent discussion of how appropriately to share past experiences with carefully selected patients, without inappropriately imposing the physician's own agenda.

Family physicians naturally desire to offer a compassionate presence to our patients. Malterud and Hollnagel's work, supplementing Candib's earlier writing, continues to deepen our understanding of how to approach this task.

1. Reich WT. Speaking of suffering: a moral account of compassion. Soundings 1989; 72:83-108.

2. Brody H. Stories of Sickness, 2nd ed. New York: Oxford University Press, 2003.

3. Candib LM. What doctors tell about themselves to patients: implications for intimacy and reciprocity in the relationship. Fam Med 1987; 19:23-30.

Competing interests:   None declared