Dr. Jon Hunter is a full Professor in the Department of Psychiatry at the University of Toronto, where he leads the Division of Consultation-Liaison Psychiatry. He is also the Head of Psychosocial Services in the Marvelle Koffler Breast Centre at Mount Sinai Hospital, Toronto. Dr. Hunter’s clinical work focuses on the psychiatric care of cancer patients emphasizing psychotherapeutic interventions. His research includes psychological management of chemotherapy side-effects, group psychotherapy in women at high risk for breast cancer, and the impact of early life experiences on illness adaptation. (Modified from the University of Toronto Dept. of Psychiatry)
Rina Huo: Could you tell us about your journey in medicine so far?
Jon Hunter: I have always found the idea of primary care and general expertise very appealing. After entering medical school, I had the good fortune to do my clerkship at the Wellesley Hospital, a hospital similar to how St. Joseph’s Hospital is today. I had a very active experience there, and learned a lot of medicine quickly, especially about the inner city population. I graduated from there with a very strong interest in oncology, so I started a residency in internal medicine at the Toronto General Hospital. However, I quickly realized that I was not as interested in administering chemotherapy or calculating body surface area, as I was drawn to understanding the patient experience, and wanting to support patients as they went through illness. In those days that was the sole purview of psychiatry, so I transferred over.
In my 2nd year of psychiatry residency, I began working in consultation liaison psychiatry, seeing medically and surgically ill patients in the hospital from the perspective of psychiatry. I came back in 4th year to do a focused year-long rotation, and subsequently stayed for a fellowship focused on psychotherapy. This was the best kind of medicine for me to do.
RH: Why were you interested in oncology, and why have you continued working with this patient population?
JH: A very fundamental aspect of medicine is patient experience. As physicians, we not only have to address the disease, but we have to understand what is important to a patient and respond to that. Significant diseases, such as cancer create a context where appreciating the impact of relationship variables on care becomes increasingly significant. In the oncology unit, I feel privileged to have a chance to understand how illness and treatment affects the patient and their family on many levels. Every day I can have the experience of making a difference in someone’s experience of care and support – in the context of a scary, difficult time for them- this remains rewarding work.
RH: Have these experiences of dealing with significant diseases changed you?
JH: For sure, I hope our experiences with patients do change us. For one example, from the many focus groups and conversations with cancer patients, one fundamental idea that recurs is the preciousness of time, the importance of not deferring life to an uncertain future. Patients consistently emphasize living life consciously to the fullest. But, this is by no means an easy task. There is always something proximal competing for our attention, such as a deadline, an appointment – a task of some sort. Listening to patients, though, I try and not take time for granted. Spending unstructured time with people important in my life matters deeply, and shouldn’t be postponed.
RH: Medicine is a demanding career. How do you maintain a work-life balance?
JH: Personally, I never take work home. I think that everyone should figure out their own strategies on how to sustain work in a rewarding way. For me, it means having that boundary between work and home, but some people may find integrating family with work helpful. The point is not to adopt a particular strategy, but to reflect on how you work, and whether or not you are continuing to feel productive and engaged, both in medicine and outside of it. It is hard to practice any medicine for decades if you don’t have strategies to sustain it.
RH: Can you tell us more about your work and how it relates to patients?
JH: As a consultation-liaison psychiatrist, I try to find ways of helping patients with their suffering, both in the context of their lives longitudinally, and in the here-and-now. My colleague Bob Maunder and I have been using Attachment Theory to help us, and others, appreciate patient experience. The basic premise of attachment theory is that stress response gets calibrated by early developmental relationship experience. For example, being brought up within a secure attachment relationship results in a well-modulated and flexible stress response; whereas insecure developmental years can program our stress response less adaptively. Therefore, as a consequence of their developmental experience people may feel relatively OK in hospital, or feel scared and isolated and distrust others to take care of them. So hospitalization and illness are attachment stresses, which means they stimulate attachment behaviours. Understanding how people act during hospitalizations through this lens helps us to ally with them, so our team can collaborate with them on how to optimize their hospital experience.
The implications of this go beyond just troubleshooting one encounter, however. As a result of developmental experience – (including physical and sexual abuse and other hardships now called ‘ACE’s’, for ‘adverse childhood experiences’) – some people experience more stress and act less adaptively, and this is amplified by hospitalization. This is not a small proportion of people either – 40% of people report having at least 1 ACE. If this is the case, how can we expect everyone to benefit from the same type of communication or frequency of contact within medical and surgical care? By taking a little bit more time to tailor care to patient’s specific needs; physicians can meet patients where they are at, and make sure that the consequences of their developmental history does not compromise their current treatment. Despite the common use of the phrase “standard care”, Bob and I would argue that there is no single model of care that is best for every patient. Of course there are common ‘values’ of care that are universal – things like informed consent, patient autonomy, etc., but people vary in their capacity to benefit from or even tolerate our standard communications. We would improve our patient satisfaction scores, and, importantly, likely also adherence to our treatment recommendations, if we took a bit of time up front to figure out how stressed our patient is, and what their preferred communication style is. Because the patient is the one with the illness threat, it is up to the doctor to be reflective, and work to understand how things can be improved.
RH: Where do the humanities come into your work?
JH: The humanities can help any of us appreciate patient experience better. Reading subjective accounts of illnesses, or watching movies of what it is like to be defined as mentally ill for instance, can help any physician broaden their appreciation of what sick patients go through – both good and bad. Doctor’s accounts of their experiences are also helpful – Bob and I have collaborated on several accounts like this. Our latest effort is a serialized report on the psychotherapy of a man with Crohn’s disease who also had severe early adversity. It describes how difficult it is for him to manage his severe illness because of the distrust created by his early abuse (see: https://medium.com/@boiby/the-damage-i-am-part-1-dc0b06a5d9b3). Even simple short observations can help us as doctors organize our experience of patients. The attached (very!) short story did that for me:
Miniatures – Dr. Jon Hunter
I heard on the CBC the other day that Ernest Hemingway wrote the world’s shortest story:
“For sale: baby shoes, never worn.”
Being a psychotherapist, I hear many people speak of their experiences. Sometimes people utter a phrase that seems to contain all of the crucial elements of their life or struggles. Like Hemingway’s story these phrases encapsulate massive experience and feeling in a deceptively tiny package of words.
A selection from the consulting room:
“Living in my family is like living in a collapsed tent.”
“Six years later, her glasses are still on the bedside table.”
A woman, with a beautifully wrought crab brooch hanging on her jersey in the place where her breast used to be: “I’ll tell you what I want for Christmas- I want my health for Christmas.”
“I just remember being airborne, knocking him down and the freedom I felt pummeling him. It never occurred to me that Freddy would be teased about being defended by his sister.”
“No one knows how to talk to me, but it’s not like my cancer metastasized to my personality.”
“I see knowledge about me as power that can be used against me”
“That man has cried more for that car in the last 2 weeks, than he ever has about my cancer.”
Man awaiting scan results to determine if his cancer has returned: “I am Schrödinger’s cancer cat, I am alive and dead.”
“My husband and I are like two animals scrambling over each other to get out of a hole”
“In my dream my mother tied my leg to hers and she planned to jump off the boat, so why wouldn’t I jump first?
“I feel like a turtle without its shell.”
“She’s the glue that holds this family apart.”
“I just want someone to hold me in mind”
“You know I still set him a place at the table…..yesterday, as I lit the candle I realized it was the anniversary of his cremation.”
“I didn’t know how to tie my shoelaces. If I tied knots I couldn’t get my shoes off and on at gym class, and the teacher scolded me in front of everyone. My brothers and sisters wouldn’t help, so I had to ask Mum. But if I woke her she hit me. At least that was in private.
So I had to go upstairs, every day, and wake her. I remember climbing those stairs, looking down at each individual step. Even now, if I have to tie a lace or rope in public, I break into a sweat.”
These moments are like miniatures, those paintings that – although tiny in size – hit hard. They may make you peer closer, maybe smile, maybe frown, maybe they clang somehow on your sensibilities. But the intricate detail crammed into that little space stays with you, and somehow the smallness of it conveys more feeling than a larger canvas would.
In the brevity is a distillation of the essence of a life.