The way you make me feel

Short White Coat is a blog about learning to be a doctor. Posts appear here as part of White Coat Notes. Ishani Ganguli is a third-year Harvard medical student. E-mail her at shortwhitecoat@gmail.com.

Countertransference, like many of the terms I've encountered on my psychiatry rotation at McLean Hospital, carries a pleasant Freudian musk and quickly lends itself to semi-ironic use in casual conversation. It refers to the emotions that a patient stirs up in a psychotherapist (whereas transference involves the patient's feelings). When we read a classic paper on countertransference in a recent teaching session, it was more than just an intellectual exercise.

Countertransference can be a hurdle to appropriate care and, when fully recognized, a diagnostic tool. For example, in the suicidal patients who unconsciously lessen their burden of self-hatred by provoking their doctors to hate them, the doctors' resulting avoidance can mean the difference between life and death. And the therapist's feelings of frustration, anger, and guilt when working with borderline personality patients have been all but written into the definition of the disorder.

Such topics seem right at home on the brick and foliage-defined, strangely idyllic liberal arts campus that is McLean. When we (the medical students) are not tending to mental status exams, medication adjustments, and MRIs on the locked unit, we're sitting outside on the lawn, drawing almost literary themes out of our patients' experiences.

Our emotional reaction to patients has become a motif not only in psychiatry (in which therapist and therapy may be one and the same), but throughout this new brand of medical education that emphasizes professionalism.

As trainees, overcome with the charge to Heal and incompletely schooled on medicine's limitations, we are particularly prone to feeling personally inadequate and translating this discomfort to less attentive care. And so, in our yearlong patient-doctor course (which,
incidentally, we often call group therapy), we discuss how frustrations toward a so-called difficult patient or relating to a patient of similar age and background can color our care in subtle ways.

This degree of shared introspection has become a fixture in the field of psychiatry and increasingly in our medical curricula, but I've observed that honest discussions about our reactions to patients fall by the wayside in the daily bustle of the hospital. Though too much introspection can be tedious and self-defeating, as I've experienced during marathon reflection sessions in medical school, the occasional psychoanalysis-inspired chat would go a long way in any field of medicine.

Freud himself was his own psychotherapist, but even his PCP might have benefited from a little self-reflection.