Denying illness robs you of help

Medical Post
Helping Hand Column, October 4, 2005

Q: I am a medical resident and have been recently diagnosed with a chronic medical illness. I am in shock, as I am young and fit, and expected to be healthy. I had been having some problems lately, but assumed they were temporary and treatable. I did not expect such a serious diagnosis. My life has changed and will forever be complicated. How can I cope with this?

A: I can appreciate how difficult this must be for you, and what a shock it must be. As doctors, we see ourselves as providing care, not requiring it. Like many of our patients, doctors also struggle to cope with chronic illness. While not generally associated with young people, chronic illnesses are actually present in 5% to 10% of youth. Most common are asthma and other chronic respiratory illnesses, musculo-skeletal disorders, heart disease, inflammatory bowel disease and depression.

There is little information about the prevalence of chronic mental or physical illness among physicians. Despite a wide range of disabilities, it is of interest that many continue to practise medicine despite some limitations. The true prevalence among physicians may be underreported as they tend to just accept, adapt and carry on. Some adapt and carry on before accepting their illness.

Doctors share some common personality traits: of being perfectionists, feeling insecure, needing to be in control, having a strong sense of responsibility and delaying gratification. This can affect many stages in the course of an illness—the diagnosis, treatment and ongoing management.

The diagnosis can be delayed, because doctors delay getting help. They do not want to overreact, appear weak or bother a colleague unnecessarily. Also, since it is "just for them," they may put it off and not make it a priority.

Treatment for physician-patients can be a challenge. Often, doctors deny or minimize the problem and its symptoms, and thus do not receive adequate care. When offered treatment, doctors often like to control it themselves, managing and modifying the type of medication or treatment dosage.

Effective ongoing management requires an acceptance of the chronic illness. This is not easy, as it requires grieving for the loss of your own health and assumptions about the future. Plans you may have made or assumed you would be making soon, such as working up North, having a baby or working overseas, may need to be reassessed. There can be understandable fears of becoming disabled and the associated concerns about being unable to be financially independent. Reactions of fear, frustration, anger, sadness and hopelessness are common and normal. There can be additional guilt at having added to the burden of a colleague if your ability to work is limited.

Your initial reaction of shock is entirely normal. People describe a sense of panic, waking up at night in sheer terror and the daily sadness of waking up in the morning to find it has not gone away. This is natural and temporary. The first three months are always the worst. It will be easier with time.

It helps to write out your feelings as you deal with the grief process. Doctors can all too easily intellectualize the situation without dealing with the emotions. Writing is best done on a daily basis, putting aside about 20 minutes each day to reflect. This is long enough to allow your feelings, without being so long as to feel overwhelmed by them. Doing this at night may help you sleep better and feel more rested.

Try the "I will never" list as a strategy to work through the grief and not deny or minimize it. This involves writing a line at the top of a page, such as: "I will never have the healthy future I had expected." Follow this with a list of things you will not have, to define the extent of the loss. This may be the most painful process you ever do, but the most effective one to define the loss and start to grieve it in a healthy manner. Do it in a safe, comfortable place. Allow yourself to cry.

Once you are out of denial, the next step is "anger and protest." Again, use writing to safely and fully express your anger. The Four-Letter Technique encourages you to write out at least four letters to express your anger at your illness and at people around you who can become the displaced focus of your anger. This strategy has you writing uncensored letters, without holding back, to express yourself fully. Be careful not to leave it laying around or send it. Tear up the letter once you finish it; it has served its purpose of validating and expressing your feelings. One letter will not be enough; plan to write four. The first two or three are emotional, angry, ugly. By the time you are at the fourth, you may be calmer and more able to understand and manage your angry feelings.

This will allow you to move on to "acceptance and integration" of this into your life. You will then find ways to accept this and adapt to it. These stages of grieving do not follow a linear process. It is possible to complete one stage and then go back to it at a later date, although usually for a shorter period of time.

It is important to know that coping with this is a difficult process for everyone. Chronic medical illness has been associated with an increased prevalence of depressive symptoms. This may be due to specific biologic effects of the illness, or can be mediated by behavioural mechanisms such as limitations imposed by this illness causing gradual withdrawal from activities. It is not true that "anyone would be depressed in this situation." Be alert to this possibility and reach out to a psychiatrist or psychologist for help. Feeling depressed will greatly increase your burden, and effective treatment of this is available and will ensure an improvement in your daily functioning.

Taking care of you is a top priority. Pace yourself. Do not try to do all that you used to do. Even if you can do it physically, remember that this emotional process is very draining. Ask for help at work. Set more appropriate expectations and limits. Be kind to yourself, pamper yourself. Try yoga or meditation.

Reach out to family and friends. Let them take care of you, and love you. Family relationships and social resources will play a key role in how you manage this emotionally. However, be aware that when you tell each new person, it can bring it all back as if you were reliving it again, and be painful. Expect to be drained each time. Choose with whom to share this; you do not owe everybody this information, so just tell people who you know care about you. Let them help you. Tell more than one person so they can share the impact of this, and there will always be someone available if you need them. You can practise what you will say beforehand, since this may help you open up.

At work, it helps to inform your colleagues about your illness. Know that you did not choose this, and that you do not need to feel guilty or defensive if it causes them inconvenience. It is easier to acknowledge their help and express appreciation. Modify your working hours and workload. Be assertive of any special need you may have, such as a wheelchair or special software. Take regular breaks and holidays.

Be prepared to reassure your patients, and let them know their needs will be met by you for now, and that backup arrangements have been made if needed.

Become educated about your illness. Don't assume that you know all you need to know because you are a doctor. Seek out Web-based educational materials and resources. There may be community or online groups for support.

It is not easy for us as doctors to accept chronic illness or to accept care. Yet this is possible, and doing so can allow us to continue to have active and productive lives.

Mamta Gautam is an Ottawa psychiatrist who specializes in treating physician patients. If you have a question you would like addressed in this column, please contact Dr. Gautam at mgautam@rogers.com. Please include “Helping Hand” in the subject line. All inquiries will be confidential. Your questions will not be replied to, but may be selected to be answered in this column, which is intended to be educational, not therapeutic.