Death on the Screen

bryce canyon shingles

The next case opened and I began to scroll through CT images of the young woman’s head. It was around 11pm on a Saturday night, and the perfunctory history provided was “overdose, AMS (altered mental status).” As soon as the images of her brain popped up on the monitors, it became clear she had diffuse cerebral edema—swelling of the brain—a condition with an extremely poor prognosis. She would either die or survive with severe brain damage.

I called the doctors in the emergency department to let them know, dictated my findings, and moved on to the next case. The CT scanners at our hospitals run all night long.

Hello darkness my old friend

This week I am on the overnight shift—9pm-6am, seven days in a row—one of three such weeks I will work this year. Emergency departments never close, patients need imaging studies, and radiologists need to interpret those studies 24/7/365. At least one radiologist from my practice is always working.

I sit alone in an office in the basement of our hospital, parked in front of the monitors all night long. I have enough snacks to supply a child’s birthday party (eating helps me stay awake, unfortunately). The solitude and quiet puts me in a reflective mood during the slower hours of the night.

Imaging studies in the form of CTs, MRIs, x-rays, and ultrasounds are obtained throughout the night, one after another. Thankfully, most are normal. Some reveal treatable abnormalities—pneumonia, broken bones—and others uncover previously unknown cancers. An imaging study will occasionally reveal a life-threatening condition. On a handful of occasions, I have been contacted by transplant surgeons to evaluate the liver, heart, or lungs in a brain-dead patient; they wanted to know if the organs looked healthy enough to harvest for transplant in another patient.

It can get heavy sometimes.

Death and disease are omnipresent in my work, yet it surprises me how rarely I stop to consider the people affected by it. How did I get this way? Is something wrong with me?

Time to make the donuts

All doctors have seen a patient die at some point in their careers. Many of us interact with seriously ill patients on a daily basis. How does frequent exposure to death and serious illness affect a doctor’s psyche? For many doctors, death becomes routine, like the Dunkin’ Donuts guy heading to work early each morning.

On the psychologically unhealthy end of the spectrum, patient suffering can engender indifference in some doctors. The infamous book The House of God recounts fictionalized versions of several such doctors. They bemoan the arrival of the sickest, most complicated elderly patients to the emergency department, and refer to them as GOMERs—an acronym for Get Out of My Emergency Room. Not too politically correct, but the truth can sometimes be like that.

Indifferent doctors exist in real life too. I have met some of them. Sensitivity to and empathy for patient suffering are not strong suits for all of us; surgeons—perhaps a little unfairly—stereotypically lack these traits. Indifference is far from the rule for most doctors, but it’s also far from a rare exception.

Mind games

brain MRI

It shouldn’t be too surprising that routine interactions with sick and dying patients become, well, routine. Imagine the psychological impact if doctors were emotionally invested fully in each and every patient; it would be devastating when they become ill and die. As a coping mechanism, doctors normalize these typically devastating social circumstances.

When I have a dinner with doctor friends, it is not uncommon for gross or upsetting topics to arise in dinner conversation. None of us miss a beat or a bite. Is it psychologically healthy for doctors to be so comfortable with death and dying?

My guess: probably not.

The barrage of death-related thoughts encountered by doctors reminds me of the debate surrounding violence in movies and video games.* Recurrent exposure to emotionally-charged, negative stimuli inevitably takes its toll. Too much exposure to violence on the screen increases violent behavior in children, and results in structural changes in the brain. Is it difficult to believe that regular exposure to death might cause lasting effects in the minds of physicians?

The real world ain’t like Grey’s Anatomy. Doctors aren’t that good looking, and don’t have the empathy of Ghandi. In my opinion, it is a rare doctor indeed who possess enough emotional currency to dole it out to all of her patients without adverse effects on her own psychological health.

*Is it a debate? Research seems to overwhelmingly point to their negative psychological effects on children.

A radiologist’s perspective

How do radiologists—sitting in their dark rooms, rarely interacting with patients directly—emotionally process sick and dying patients when we are only exposed to images of those patients on a computer screen?

As a specialty, radiologists do not exactly have a reputation for high emotional intelligence. I’ll be the first to admit that I don’t stray far from the radiologist stereotype of social awkwardness. I also don’t win the award for World’s Most Empathetic Doctor. In medical school, we practiced our responses to emotional or difficult patients via mock interactions with actors. It was my worst grade in medical school.

Before all the radiologists get up in arms, I concede that many radiologists are social butterflies and quite “normal” in their patient interactions. And despite my occasional social difficulties, my wife would tell you that I’m not half bad at a dinner party myself.

Most radiologists don’t get the chance to see patients; we are parked in front of a computer monitor for 95% of the day. Death and illness continually assault our eyes and minds, but in the form of an image of the patient rather than the flesh-and-blood, human patient. The full reality of a dying patient is often limited to our discussions with their doctors, or to our imaginations.

Death on the screen

How does death and suffering on a screen affect one’s psyche? I can only speak from my own experience.

The occasional case showing devastating illness or injury in a child can stop me in my tracks, especially since I had children of my own. I empathize strongly with those parents.

Any young person whose prognosis is very poor—like the example at the start of this post—is obviously sad, but I find that I can quickly and easily move on to the next case. I suppose my training takes over in some sense; aspects of reading a CT or MRI have become reflexive after years of experience, and I can start the next case on autopilot until my analytic mind boots up.

Is it psychologically healthy to operate like this? I don’t know. Do I feel emotionally drained after a busy shift with many sick patients? Not really. Does that mean I’m OK? I hope so.

I don’t feel too sluggish.

My approach

In my practice, I strive to a maintain a balanced perspective on these issues by utilizing a few techniques.

  • Some degree of emotional detachment is necessary. If I were to imagine each severely ill patient as one of my family members, emotional burnout would soon follow. While I don’t suppress feelings of empathy, I do frequently adopt a “business as usual” attitude while reading studies. It’s a difficult balance to strike.
  • My lack of direct exposure to patients can lead to an emotional disconnect from their suffering. This may sound silly, but I sometimes conjure a mental image of a patient from their demographic information; an elderly female or 20-something male, for example. It’s not really them, but it helps to humanizes them for me.
  • Taking a slight detour through the emergency department when I arrive reminds me that those CTs and MRIs come from the people I walked past earlier that day. Simple yet effective.

Physicians, how do you deal with these types of issues in your practice? What psychological challenges do other professions encounter? What is your approach to these encounters? 


6 Replies to “Death on the Screen”

  1. I use nearly identical strategies. When I was a resident, one of my staff specifically stated that radiologists should imagine a picture of the patient with every study. I adopted the practice immediately. I do lots of procedures and I interact with patients and family multiple times a day. That helps me maintain a high level of empathy. Also, family members have spent time in hospitals. I have seen how the words and phrases we use in radiology reports get debated and discussed by them as they try to make some sense of their experience. I avoid jargon and ambiguity when unnecessary. What we say almost always matters to someone.

    1. Good point about making our reports clear and unambiguous. As one of my attendings in residency used to say, the official plant of the radiologist is the hedge; we often forget how a small hedge like “cannot completely exclude cancer” can inflict significant psychological trauma on the patient reading his or her report.

      Thanks for stopping by!

  2. Great article — I appreciate the insight from someone on the other side of the phone. Well, I do actually walk down to radiology from the ER to speak to them in person when necessary (when I have the time). Despite your comment on my site that we have opposite approaches, I think they are closer than you think. You have to move even more rapidly between patients than I do, and being able to quickly focus on each new patient and their story must be extremely challenging. I like that you and some of your colleagues are making an effort to visualize them in some way. Even when we’re seeing them in person it’s easy to be a cynic or force yourself to be detached. I don’t think being detached is healthy nor do I think it’s necessary, but nor can you fully absorb the pain of every patient.

    1. It’ definitely a balance, and a much different experience in the clean and quiet office of the radiologist compared to the blood-and-guts bustle of the ED or OR. I don’t know that I could handle the direct exposure to patient care that most doctors do on a daily basis.

      For any doctor that has worked for a good number of years, it is a challenge to remind oneself that this is not a humdrum, everyday experience for the patient. Their interaction with you is often one of the worst days of their lives.

      I greatly enjoyed your great article as well. Thanks for the insights!

  3. I had one of those cases recently. Massive edema in a younger person. It’s sobering at times to reflect upon how we dance with our own mortality every day. As I start to see patients my own age face devastating and fatal conditions it forces me to realize that this could be me on the other side of the monitor. As a physician we have to detach to some degree. Maintaining empathy while not letting the emotions overrun you is perhaps the greatest skill we learn in medical school and residency.

    1. I’m approaching 40 and can no longer realistically refer to myself as “young.” It’s sobering indeed.

      I recently heard a discussion about the distinction between “emotional” empathy and “cognitive” empathy in regard to physician-patient interaction. Most patients, it was argued, would prefer a doctor with true empathy for their situation and suffering, but not one who is blubbering on their shoulder after presenting a dire diagnosis. As you say, control of your emotions can be learned (as we did in training). Whether or not you have true empathy underneath the controlled exterior, however, is not teachable.

      Thanks for reading, THP!
      Dr. C

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