The drama of being a doctor.

O ne comparatively unusual and perhaps uncomfortable way of thinking about the practice of medicine is that the consultation with a patient is a kind of theatre. The doctor and the patient have their roles, actually encapsulated by the medical sociologist’s Talcott Parson’s conceptualisation of the ‘‘sick role’’—which the patient plays. What part the doctor adopts has oddly received less attention from medical sociology, partly perhaps because the profession is resistant to the notion that sometimes the consultation entails playacting. Talcott Parsons idea of the sick role in the 1950s was the first theoretical concept that explicitly concerned medical sociology. In contrast with the biomedical model, which pictures illness as a mechanical malfunction or a microbiological invasion, Parsons described the sick role as a temporary, medically sanctioned form of deviant behaviour. Parsons used ideas from Freud’s psychoanalytic theories to shed light on the social and psychological forces involved in episodes of sickness. The Freudian concepts of transference and counter-transference led Parsons to see the doctor/patient relationship as analogous to that of the parent and child. The idea that a sick person has conflicting drives both to recover from the illness and to continue to enjoy the ‘‘secondary gains’’ of attention and exemption from normal duties also stems from a Freudian model of the structure of the personality. Since Parson’s work other issues like ‘‘breaking bad news’’ have received much similar attention in the academic medical literature, but the basic notion that often doctors are indeed enacting lines from a script—they are playing a part that entails them not actually being true to what they are really feeling from moment to moment in a consultation— is something that is rarely openly acknowledged, far less discussed. Doctors often have to appear sympathetic or caring or involved when they could be far from feeling these things. While doctors admit this privately in consultations with psychiatrists (like myself), this is an emotion issue that otherwise they dare not speak its name within the profession. Could it be that playacting is in itself not a bad way of proceeding, but the key issue is how we engage with this vital part of what we do when we interact with patients. If we were always totally authentic when with patients, the strain of this might be incompatible with a viable career, plus it’s not something patients themselves might desire either. But there is a basic tension between the values of truth and science as imparted in medical training, and the notion of the consultation as basically an act of theatre that requires dramatic skills from the doctor, as the lead player. This model however lends itself to the useful idea that physicians need to learn certain emotional control and manipulation techniques with which actors would be familiar, to best cope with the psychological demands of patients. One way of thinking about medicine, and particularly the stress of working in this career, is that doctors conduct two basic interactions in their daily jobs— they interact with ‘‘things’’ like technology such as an MRI scanner, and they interact with people. There is accumulating psychological evidence that much of the stress of medical work arises from interactions with people rather than things. It has long been said that postindustrial societies have a workforce that is moving relentlessly through a key transition—from manufacturing to service oriented work. This basically means that we are increasingly doing jobs where we don’t deal so much with ‘‘things’’, like components on an assembly line, but more with other people. But what hasn’t been realised fully is that having to constantly deal with people rather than ‘‘things’’, often brings a unique constellation of stresses, which the modern workplace or workforce doesn’t seem at all prepared for. Much of medical training for example, at one level seems to be focused on how to deal with ‘‘things’’ like a liver or a liver function test result, rather than how to cope with people, like patients and colleagues. This lack of training on how to deal with people could mean doctors are ill equipped when it comes to this vital part of their jobs, and this explains much of their subsequent stress. Note also that doctors are often dealing with people precisely at one of the most difficult times in their lives and so are at their most complex in terms of the psychological handling they require. For example, some recent psychological research has established that a large part of the stress of working in the rapidly expanding sector of call centres is the strain of having to be remorselessly cheerful to callers. The so called ‘‘have a nice day’’ syndrome is about the ‘‘emotional labour’’ we have to do on a daily basis to keep ourselves appearing fairly reasonable to all around us, no matter how ragged we are really feeling, plus to smilingly absorb the difficulties of dealing with problematic customers, when you really want to wring their necks. Psychologists are now increasingly recognising that this ‘‘emotional labour’’ may in fact be more mentally taxing than the more physical toil required of us in the past. Psychologists use the term surface level emotional labour to capture the basic fact that a large part of dealing with people at work is basically ‘‘faking it’’ or pretending to emotions we basically don’t actually feel, like feigning interest, sympathy, or understanding. But now new research by occupational psychologists Celeste Brotheridge and Alicia Grandey at the University of Pennsylvania in the USA has found that the more your job requires you to fake emotions, the more likely you are to become emotionally detached from those around you at work, also more detached from your own emotional state (you may not realise how depressed and upset you truly are) and the greater therefore your future job dissatisfaction. It seems that the two key emotional labour tasks required of doctors, are to hide negative emotions, plus to display positive feelings even when these are not residing within one. Psychologists believe that constantly hiding the deep 276 PERSONAL VIEW