The Invisible Graveyard Of Every Physician’s Career: Why Every Doctor Needs A “Badness” Plan


By Maryna Mammoliti, MD

As physicians, we all know what “badness” is in medicine. “Badness” is a word many physicians use to convey a painful, complicated, tragic, or adverse clinical experience. Badness is usually some bad, particularly emotional “bad.”

Due to medical training most physicians struggle to describe their emotions or even allow themselves to acknowledge emotions, especially around distressing patient cases. The word “badness” frequently conveys to others how awful the event was, typically for everyone involved – the patient, the doctor, the trainees, and the patient’s family. Badness can describe various events, including complex medical cases, medical or systemic errors, patient deaths, unanticipated clinical complications, patient complaints and lawsuits, hospital responses to a patient’s difficulty, etc.

Badness builds the invisible graveyard of every physician’s career – a graveyard physicians visit in their heads frequently. The graveyard is usually full of trauma cases, cancer diagnoses, patients we couldn’t resuscitate, stillbirths, obstetrical losses, the kids we couldn’t help, the patients we lost to suicide, the violence, the crying mothers in the ER. Many physicians visit this graveyard night after night, even 20 to 50 years later, with unresolved emotions over the badness. Some physicians turn to substance use, develop PTSD, quit medicine, or other unhealthy ways of dealing with this unresolved emotional badness. Unfortunately, medical training does not give us the tools to process this predictable and real badness of medicine.

What is a badness plan? A badness plan is your personal plan for managing your emotional distress triggered by a badness event. In psychiatry, we work with patients on their crisis plans – or what concrete steps they feel they need to take when they feel distressed to help with distress – such as calling friends or therapists, coming to the ER, or calling 911, depending on the severity of their distress to manage a distressing episode.

As physicians, we all need our own badness plans or concrete steps we may need when in emotional distress after a badness event happens. We need to prepare this plan in advance and not scramble during an active event – just like preparing your winter car kit before leaving the house and not when driving through a snowstorm.

Step 1. Radical acceptance, or accepting that pain and disappointment are part of human existence, is a concept from dialectical behavioral therapy created by psychologist Marsha Linehan. Radical acceptance does not mean agreement or acceptance that it is okay for bad events to happen or helplessness. On the contrary, Radical acceptance is accepting that life is full of pain and disappointment and how we choose to cope with it. Radical acceptance accepts reality instead of wishful and magical thinking or blame. Radical acceptance is a mindset of “I acknowledge there is pain and disappointment in life, and what do I choose to do about it” – moving towards problem-solving and options. Radical acceptance in medicine is accepting that every physician and medical learner will encounter some “badness” in their clinical practice. Badness is a predictable and real part of medicine as people come to us while sick, due to disease processes, or seeking disease prevention.

People don’t come to see a physician because life is great, and their body is great. People come to doctors to rule out disease, treat disease, prevent disease, and deal with the consequences of accidents or interpersonal violence and the “badness” of humanity towards each other. Being human, every doctor has a limitation in their skill, knowledge, ability, or even understanding of the condition today vs. ten years from now with more advanced knowledge. We have to radically accept that we can be doing our best as a doctor, and unfortunately, some patients will die, complications will happen, and patients will file complaints and lawsuits. We can only focus on what we can control, practicing the safest and best medicine we can reasonably deliver within our systemic abilities. We are not magicians; we are human. We do not have a magic wand; we only have our human abilities.

Step 2. Accept that you can have an emotional experience from badness.

Step 3. What do you need to manage the emotional impact and meet your needs when badness happens? Let’s break that down into bio-psychosocial categories with some suggestions below:

Biological: Do you have distress tolerance skills to manage your body’s symptoms of distressing emotions? Do you need time and space to cry? Do you need someone with you in your space, so you are not alone yet quiet? Do you need a break away from people? Do you need sleep? Do you want a hug from a trusted soothing person? Do you need a cold shower? Do you need to go for a run? Do you need to hug your dog/cat, etc.?

Psychological: Do you need to speak with a therapist? Do you need to call a crisis line? Do you need to see a psychiatrist? Do you need confidential peer support?

Social: Do you need some time off? Do you have a trusted medical peer who can validate you if you need to review the case development? Do you need to let your spouse/family know that you need some space due to a work event instead of irritability or shutdown? Do you need to call your malpractice lawyer?

Ideally, we all can sit down and create such badness plans to help us manage and process the emotional cost of badness in medicine. Badness will happen no matter how much we try and do our best. Let’s take charge of what we can control and prepare to manage our emotional experience of badness when it happens. Walking by the lake and hearing the waves is a huge part of my badness plan. What do you need to manage the real and predictable emotional pain of medical badness and make that graveyard visits less painful?

Maryna Mammoliti is a psychiatrist.


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