"Hearts Will Never Be Practical Until They Can Be Made Unbreakable"

A recent study suggested that elderly hospitalized patients treated by female physicians had lower mortality and readmissions compared to patients treated by male physicians. But why would that be? In my "short" career as a physician, I frequently hear patient statements that female physicians are more attentive, spend more time with patients and are more empathetic. It may just be that patients look at female physicians as a "mom" figure. In a study where women and men watched videos that induced eight types of emotions, men had more intense emotional experiences but women had higher emotional expressivity, particularly for negative emotions. So, it may be that this emotional expressivity is the difference.

Undoubtedly, emotions in both women and men play a role in not only our day-to-day personal and social activities but also in the therapies we provide our patients. For instance, a decision we are sometimes faced with in the world of advanced HF and transplant is the young patient with poor adherence to recommended therapies, who needs a heart transplant, re-transplant, or mechanical support. All the objective evidence screams that this young patient should be declined, but oftentimes we make decisions based on emotions. Who wants to see a young patient die regardless of what they do after-hours? Right?

These emotions are common in women and men. I see the emotional decisions and reactions during many of our transplant selection meetings. Even though everyone sitting in the room and on the committee knows the decision is risky, and the patient is a marginal candidate, we sometimes go against the "evidence" and make decisions based on feelings. Whether these decisions are correct for the patient, care team or health care system is not always clear and sometimes outright wrong. The feeling of "letting" someone die versus committing them to a new heart or device they are not necessarily a stellar candidate for is hard to reconcile.

What we do not learn in medical school, residency and fellowship is how to process these emotions. Many of us remember how it felt when the first patient we took care of died, and each time a patient dies thereafter we question ourselves and wonder if there was something more we could have done. We wonder if we made a mistake and if so, could that have been avoided, and we perseverate on the death, some longer than others; but no one really teaches us how to process these emotions. Sometimes we develop a stronger connection with certain patients and those deaths are memories forever ingrained in our minds. In morbidity and mortality conferences we discuss the case and the systems errors that could have been avoided, but we do not talk about how the deaths made us feel. Each one of us finds a way to process these deaths so they do not crush us each time they happen.

As advanced HF and transplant cardiologists, we respond to patients in cardiogenic shock who potentially need emergent mechanical support or extracorporeal membrane oxygenation. In my mind as I am running to that code, all I can think of is, "Okay, so I am going to make a decision about whether this person is going to live or die." We all know that life and death is something in the hands of someone/something (depending on your beliefs or lack thereof) bigger than us. However, as an early career physician, it is sometimes difficult to not look at it that way. We once had a young patient that was dying and not a candidate for re-transplantation as decided by the transplant committee. The patient died, and I was invited to a debriefing session led by our social worker. It was attended by many members of the patient's care team, and it was the first time in my entire career that someone asked me how a patient death made me feel. It felt like crap. Of course it did. But it felt good to talk about it with people who understood and felt the exact same way I did.

Our hearts are not unbreakable, but I do not think they are not practical like Tin Man suggested. I think it is impossible to not allow emotions to be a part of our decision making. Sometimes we break the rules because we cannot find it within us not to try, not to pull all strings, not to try everything possible because we hate it when patients die. Maybe women are affected by these deaths more than our male physician counterparts; however, from my experience, men are not fully immune to being affected and they bring emotions to the table in selection meetings, just like we women do. Until our hearts are made unbreakable like Tin Man would like, we need to learn how to process these emotions to not only provide superb care but more importantly for us physicians to stay sane. Evidence suggests in multiple studies that a physician's emotional intelligence – a person's awareness of and ability to respond to emotions in themselves and other people – influences her/his ability to deliver safe and compassionate care. More to come on this in my next article.

This article was authored by Nasrien E. Ibrahim, MD, FACC, an advanced heart failure (HF) and transplant cardiologist and clinical researcher at Massachusetts General Hospital and Harvard Medical School in Boston, MA.