The Care They Can Feel
How chronic stress erodes physician presence, and how to restore it.
It was Day 7, my last day on service at the hospital. I was finishing rounds the way I always do at the end of a stretch, making sure every patient knew what came next.
One of my last visits that morning was with a patient I’d come to know well over the week. I went over the plan for the day, then let him know that another physician would be taking over his care tomorrow. I expected a nod, maybe a small smile. That’s what most patients give me.
Instead, his eyes filled with tears.
My stomach dropped. Had I said something wrong? Was he in pain? I asked, “What’s wrong?”
He looked at me and said, “I just feel like you really care about me, and I’m not sure the next doctor will feel the same.”
I have heard some version of these words from patients many times, in the hospital and in clinic, and I am surprised every single time. Of course I care. Most doctors do. We didn’t sacrifice over a decade of our lives to this work because we didn’t. I’m surprised because he didn’t know, or maybe couldn’t see, how much his other doctors care about him too.
The reality is that what my patients are responding to isn’t only the high-quality, evidence-based care we continue to provide. I believe it’s the experience of feeling truly seen and heard by another person, a kind of presence we rarely get these days, even from friends and family in our busy lives. It’s also a presence I’ve learned I can only offer when I’m grounded and regulated.
There were years when I couldn’t give this to my patients. It wasn’t that I didn’t care. I had so much to do that my mind was always racing ahead to the next item on my list. I rushed from room to room, already thinking about the next chart before I’d finished the conversation in front of me. I could hear what my patients were saying, but I wasn’t truly listening.
What changed wasn’t how much I cared. It was my ability to be present. I had to retrain my nervous system to move out of a constant sympathetic, survival mode and back to calm.
What Survival Mode Looks Like in Medicine
Stress itself is normal, and in the right dose it’s actually good for us. It sharpens our focus and helps us get things done. The healthy pattern is moving into stress and then back out of it. The trouble starts when the pressure is constant. Chronic stress, and repeated exposure to vicarious trauma, can change how our nervous system responds. The body begins to treat a heightened, sympathetic state as the new normal. Over time, it adapts, often through one or more of four survival responses: fight, flight, freeze, and fawn.
In medicine, these responses could show up as:
- Fight might look like snapping at an MA or colleague over something minor, or feeling angry when an outcome isn’t the one we wanted and couldn’t control.
- Flight could look like constant busyness, telling ourselves we’ll rest after one more task. In medicine, this is often rewarded, which makes it harder to acknowledge and adjust.
- Freeze might look like brain fog or feeling numb, where we know we should care but maybe just don’t feel anything.
- Fawn could look like saying yes when we really want to say no and taking responsibility for everyone else’s emotions. I see this often in physician colleagues who work within hierarchical organizations.
None of these are character flaws. They are the nervous system’s best attempt to protect us, each one a response to an increasingly demanding environment. With so much going on, it’s no wonder we find it hard to be present. We can end up physically in the room yet emotionally disconnected from the patient sitting right in front of us.
Why Patients Can Tell
Here is what I wish I had understood earlier in my career: our internal state doesn’t stay contained within us. We may think we’re in control, or that we’re putting on a convincing performance. But humans are wired to pick up on each other’s emotional cues. It’s called coregulation. A calm, grounded person can help steady someone who is distressed. The reverse is also true. When we’re rushed, depleted, and anxious, our patients can feel it, even when we say all the right words.
When I’m regulated, I can slow down enough to notice the fear behind a patient’s question, sit in silence while someone gathers the courage to say something hard, and listen for what isn’t being said out loud. That presence isn’t a character trait I either have or don’t have. It’s a capacity I can offer when I have the mental and emotional bandwidth, and one that I want to protect.
Small Practices That Make a Real Difference
Regulating your nervous system doesn’t require an hour of meditation every day or a week’s vacation away. Some of the most helpful practices take less than a minute, something you can do at home, or even in the midst of your busy day.
- The pause. Before I walk into a patient’s room, I stop to check myself. Sometimes, I take a slow breath and try to let go of the last encounter so I can arrive fully in the next one. You can do the same before walking into your home after work or right before joining a meeting.
- Box breathing. Breathe in for a count of four, hold for four, breathe out for four, and hold for four. Repeat a few times. Slow, deep breathing stimulates the vagus nerve, which activates the parasympathetic nervous system and helps shift your body back toward calm.
- 5-4-3-2-1 grounding. When your mind starts spiraling into anxiety, you can stop by shifting your attention to the present moment using this somatosensory technique. Name five things you can see, four you can touch, three you can hear, two you can smell, and one you can taste.
- Connection. A brief check-in with a colleague, calling a friend who truly listens, or a hug from someone you love can lower cortisol and steady your nervous system.
Coming Back to the Room
When my patient told me he felt like I really cared about him, he was describing something that can’t be faked or rushed. It comes from being present enough to meet another person where they are. Over the years, I’ve learned that this presence depends on whether I’m grounded and regulated enough to offer it.
Yes, we “do” all the things to help a patient. We adjust their blood pressure meds, call the home health agency to make sure their antibiotics get delivered, and talk with their family to make sure they understand how to provide care at home. But “doing” those things doesn’t always translate to the care and presence we bring into the room.
We assume that if we do enough, it shows that we care. After all, acts of services is a love language. But patients sense whether we’re actually there. If we want them to feel how much their doctors care about them, we have to learn how to bring ourselves back to the present moment, even with multiple things piled up on our to-do list.
And isn’t that the real goal, in medicine and in life? Not to finish everything as fast as we can, because the to-do list will always be there and it never ends. It is to be fully present experiencing life with the person in front of us. I had this patient for seven days, and what he took with him wasn’t the plan of care. It was the connection with someone present who was right there in the room with him.
References
- McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med. 1998;338(3):171-179. doi:10.1056/NEJM199801153380307.
- Van der Kolk B. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Viking; 2014.
- Walker P. Complex PTSD: From Surviving to Thriving. Azure Coyote; 2013.
- Porges SW. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation. W. W. Norton; 2011.
