Thursday, December 7, 2006

The Mask

Dr Dork is not a psychiatrist.

However, one skill he recalls well from his time as a psychiatry registrar is that of the mask. The façade.

This is a necessary thing, at times, in all of medicine. Particularly psychiatry.

A fundamental ethos of medical practice is the necessity to maintain an emotional distance from ones patients. The principal reason is to enable objective judgements to be made, without emotional bias. This protects patients.

Doctors in Oz are discouraged from treating family or close friends, for example. Our emotional attachments result in us usually either undertreating or overtreating. Both of which can be harmful.

Primum non nocere, after all.

A doctor allowing their emotional reaction to a patient to compromise their decision making is perhaps an example of countertransference. A good doctor provides the optimal care to each and every patient, be they saint or sociopath.

But doctors are subject to emotional reactions just like everyone else. Some of us get very desensitised, unfortunately, as a protective defence.

The key, at least to Dr Dorks mind, is not allowing our emotional reactions to affect our decision making. And, obviously, to not express our emotional reactions. Whatever they may be.

To maintain the facade. Protecting the doctor, perhaps, but principally protecting the patient.

Yet we still feel. We feel the lonely, lingering, untimely death that we cannot prevent. We flinch internally at the barrage of expletives. We seethe inside at the dozen old fracture lines on the malnourished childs Xray. Our pulse skips a beat at your drunken threat to our family.

We all learn to wear a mask.

Sometimes it’s hard to take it off.


Deb S. said...

What a thoughtful, well-written post.

I don't think I could do what you do every day. I have worked as a journalist on some disturbing stories. I also covered the health beat. One doesn't survive as a physician, psychiatrist or a journalist without putting on the mask.

Your post reminds me of an experience I had several years ago. I was hospitalized after a brutal attack. I'm told that I was not a pretty sight.

I remember vividly how my wonderful doctor appeared calm as he and a colleague examined me. My doctor then decided to wrap some of the wounds himself. Apparently, he overdid it because the nurse who came in afterward wondered why my right side - the side my doctor worked on - was "buried" in so much gauze!

Yes, my doctor wore the mask, but it slipped a little. :-)

Again, I really enjoyed reading this post.

Health Psych said...

An excellent post and, from a patient viewpoint, a reminder that perhaps the doctor isn't always as unempathic as he/she might appear to be - although there's always some exceptions...ho hum.

Flea said...


I don't wear the mask nearly enough. As a result I've been accused of talking to my patients like a real person instead of a doctor. I hope this isn't causing me to make decisions that harm the patient. I don't believe it is.

When patients say stuff that makes me angry I tell them so. Sometimes, if it's appropriate to do so, I discharge them from my practice.



word verification = wwlyrmm, or stuff you do on the spur of the mmommmenttyrllmm

Dr Dork said...

Trade secret - nurses are far better at dressing wounds than docs.
Yes, for some there is a mask below the mask. Below the mask.
Hi Flea,
I think you're just mean.

Seriously, we all let slip the mask, I'm sure, at times. Especially to aid positive reinforcement I notice in myself.


Godwhacker said...

Many fields try to achieve this type of dispassionate separation. Journalism has a similar code, although I wonder how possible this is for us, as we are all human. Great post.

Rob said...

Dr D.

I don't know how you can survive without the mask. In general we are good at keeping some distance, but it does hit you at times (like when I had a patient commit suicide).

I think it is important to know that you do bring it home with you to some extent, but also essential that you leave a lot at the office. My job is to do my best, nothing more.

Nice to meet you.


Mama Mia said...

Yes, that mask is on most of the time at work. It rarely slips in the presence of the patient, and only sometimes in the presence of the colleagues. It should probably slip a little more.

Dr Dork said...

It is oft an unattainable ideal.
We all let it slip at times of course. I recally an elderly patient with a type of myoclonic epilepsy who *broke wind* repeatedly. Constantly. More than I would have thought humanly possible. I was biting my cheeks to stop from laughing. With limited success. My registrar had to leave the room. Puerile, I know.
Hi Rob,
Ditto. Had that same occurrence, sadly, more than once during my shrink days. You spend months questioning yourself.


scalpel said...

Blogrolled! I like your style, consider me a new fan.

That last sentence was great, btw. I'm a fan of the last sentence thought-provoker, myself. That one hit home.

Pieces of Mind said...

We patients wear masks too.

I'm glad to see you back, BTW - I missed you. :)

Dr Dork said...

Hi Scalpel
Thank you kind sir! I don't consciously plan out such...but you've certainly got me thinking.
I think being a frustrated/aspiring poet for many years lends itself to this style, maybe ?
Hi P of M
We all wear masks, of different types, at different times, do we not ?


The billmaker said...

Your blog has come highly recommended. I stopped by to give it a once over. My opinion about facades. I hate them. Be blunt. Brutally Blunt and don't sugar coat my medical problem. Don't pretend to care, if you don't. Give me the bad news, but have a plan of action in place. Kid with me when I'm nervous because I KNOW you're nervous too. Show me your true face and I'll show mine.
We're both human.
And that was my opinion....

Dr Dork said...

Hi Billmaker,
If only we could be so blunt, at times! I read recently of an anaesthetist successfully sued for 'causing postnatal depression' for advising, perhaps rather bluntly, a pregnant woman to stop smoking. I think he said something along the lines of 'if you quit, you could be here for her wedding, as well as her birth'.
The mask I refer to is about protecting patients and optimising care, not about deception.


shrink-to-be said...

Hey, Dr. D

Real nice. I often struggle with the mask, but I think it also has to lot to do with the kind of insight your patient has. It does no harm to let the mask slip where your patient is pretty much on the same plane as you are. However, there are places where you can't do without the mask..people with pain, drug abusers, borderlines, families of the dead. I guess you live and learn.

You got yourself another fan.

Kim said...

Hi Dr. D!

I'm wondering if you just didn't point out a big difference between nursing and medicine.

We nurses need to wear a mask, on occasion, but it seems that doctors must wear theirs more closely.

I'm wondering if it is easier for nurses to express empathy (and to sometimes tell-it-like-it-is) than it is for a doctor.

I don't often feel like I wear a mask...

Dr Dork said...

Hi Shrink-to-be,
Thanks for the kind words! Yes, the mask is at times essential, at times not so much. You need it a whole lot more when dealing with a frankly psychotic patient than when suturing a finger.
Hi K,
I think it depends a lot on the area in which you practice as well. I would say psych nurses would often have good masks, for example.


7/10 split said...

I knew you wouldn't let me speak. Just the usual.

Dr Dork said...


Please explain - gone over my head, it seems!


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