I finally figured out what’s wrong with all the portrayals of doctors on TV. They show emotion.

They have to, of course; they’re actors, for one thing. And basically, the drama would be a lot less gut-wrenching if the doctor didn’t act heartbroken when delivering bad news.

Real doctors don’t do that. We learn to hide emotion, from everyone – our colleagues as well as our patients. For example:

- Fear. This one is especially important to hide, perhaps because it’s such a constant companion. After all, fear is what makes us good: you have to be scared of how easily something bad could happen, in order to work hard at preventing it. You have to have seen vent-associated pneumonia, and fear its return, to really care about preventive measures or early diagnosis.

But it has to be private. After all, they say surgeons are like sharks: they attack at the smell of blood. Fear of not knowing the right answers only draws more pressure.

As for fear of the outcome for a patient, that has to be hidden, because such things only get stronger by being shared. If everyone in the trauma bay getting ready for a bad level I admitted their fear, we wouldn’t be able to function. Some of the seniors lately have been demonstrating that to me. The trauma pager has been going off again and again, one trauma after another, and now a really bad one. The patient was intubated en route, which is not good, and the confused early reports suggest that there’s something seriously wrong. The nurses and techs run around, laying the room out, assembling the monitor wires, getting the ventilator set up beside the bed, laying out the needles for starting ivs and drawing blood. They’re efficient, but the atmosphere is hectic. Then the senior physician in charge walks in. It could be the ER attending, or a chief surgery resident. They walk slowly (when there’s time), and move deliberately; no wasted steps. Calmly, loudly enough to be heard, they start arranging: who will stand where, who’s responsible for which part of the resuscitation, who’s in charge of the airway, who’s standing by to place a central line, where the thoracotomy kit is if it should be needed. Their calmness settles everybody down, and keeps the room from exploding into chaos when the patient actually arrives. (The worse a trauma is, the quieter the room is. When things are really bad, no one chatters, for fear of drowning out important information.)

Fear also has to be suppressed when talking to patients or families. They ask for the truth, but they don’t really want to know what we know. Even when things are unquestionably bad, the news has to be broken gently, maybe over the course of a couple conversations – because they need to be able to keep functioning. And if the worst-case scenario is only a shadow in my head, there’s no need to torment the patient and family by discussing what will most likely never happen. If I look excessively worried, that scares people so badly that they can’t think; the other children still need to be fed and put to bed.

- Sorrow. I learned this probably in August or September of intern year, and keep relearning it: if you cry about every patient, there’s no time or energy for actually working. Really, I’m hurting my patient if I allow more than a minute or two to consider how awful their predicament is, and how tragic it must be for their family and friends. I need to be thinking about can be done to make him better.  Crying wastes time; meditating on the nature of evil wastes time.

- Of course anger has to be hidden as well (another emotion that TV doctors are frequently good at). Anger, like fear, wastes time and clouds judgment.

Above all, emotion is unprofessional. We’re supposed to be cool, calm, rational – in charge. And that means not showing our colleagues or our patients what we really feel. Drama is for the soap operas, not for professionals.

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