It's tough smiling at your patients when that is the opposite of how you feel inside but medicine has a lot to do with acting as Raj Persaud explains

Doctors and medical students typically conduct two basic interactions in their daily jobs ­ they contend with 'things' like technology (such as MRI Scanners), and they interact with people. There is accumulating evidence that much of the stress of medical work comes from interactions with people rather than things.¹

People versus things

Post-industrial societies have workforces which are moving from manufacturing to service oriented work. This basically means that we increasingly have jobs where we deal with people rather than things (such as components on an assembly line).

Having to constantly deal with people rather than 'things', often brings unique stresses, which the modern workplace or workforce doesn't seem prepared for. For example, much of medical training appears 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, such as 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. This explains much of their subsequent stress (especially as doctors are often dealing with people who are going through one of the most difficult times).

Have a nice day syndrome

Some recent research has established that a large part of the stress of working in call centres is the strain of having to be constantly cheerful to callers.² 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 everyone around us, no matter how ragged we are really feeling.

Psychologists are now increasingly recognising that this 'emotional labour' may be more mentally taxing than the 'physical labour' we did in the past.

Faking it

Psychologists use the term 'surface level emotional labour' to capture the fact that a large part of dealing with people at work is basically 'faking it' or displaying emotions we don't actually feel, like feigning interest, sympathy or understanding.³

But now new research by occupational psychologists In the United States 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. You are also more likely to be detached from your own emotional state (you may not realise how depressed and upset you really are) and so are more likely to be dissatisfied with your job in the future.³

Tasks

Two key tasks required of doctors and medical students are:

• To hide negative emotions
• To display positive emotions even when you feel the opposite

Psychologists believe that constantly hiding the deep dislike you feel for colleagues and difficult patients is stressful enough but if combined with forcing false positive emotions pushes you nearer to 'Burnout'.⁴

Burnout

Jobs that are particularly prone to burnout are those where you have to be relentlessly positive, so the caring professions like medicine, nursing, social work and teaching, (where there is a large amount of personal interaction that requires deep personal attention and concern) require a huge amount of emotional labour.⁵

Burnout is the state of mind you achieve as a result of stressful work: you feel emotionally exhausted, and usually appear detached from others making it difficult to genuinely care for them. As a result of this you feel that you are not effective at work therefore, diminishing satisfaction derived from personal accomplishment⁶ making it much more likely that you will leave.⁵

Acting lessons

However the latest research on the link between burnout and emotional labour by that the key issue isn't the acting you have to do at work, but it's the way you try to act that predicts whether you are going to suffer from burnout or not. In some jobs it is the high emotional labour that actually predicts a greater sense of personal accomplishment.³ So the key seems to be whether at work you are performing emotional labour requiring 'superficial' acting or 'deep' acting.

Superficial acting

Superficial acting is where you just pretend to be pleased to see someone while deep down you can't stand them.

Deep acting

Deep acting is where you try to change your basic attitudes towards the people you interact with by positively altering your thoughts and deeper feelings you have about them. So for example if you are in child care work and some of the children you are looking after annoy you, you make a conscious effort to remain positive and not snap at them because deep down you believe that this is a better emotional state to be in than showing how irritated you are.

The key finding of this research was that those who engage in 'deep' acting seem to find jobs which demand high levels of emotional labour more personally rewarding.³

You learn the skill of 'deep acting' by using the same techniques as Hollywood actors who seriously research a part. For example, if an actor is to play the role of a cop, he or she will go and hang out with real cops, adopt a role model and immerse themselves in that world.

Learning from receptionists

So you need to find a role model or hang out with those who model the kind of behaviour you are trying to adopt. It could be there are people at the reception desk who are relentlessly good natured no matter how awkward the patient ­ what drives them? How do they see the world?

Back story

Another key technique that actors use to develop compassion for the character they have to play (no matter how distasteful they may be) is to create a back story which helps to generate sympathy and compassion. For example, they may see an exasperating patient as someone who is having a very bad day or who could be dealing with terrible problems in their personal life. This back story helps the actor develop the right attitude to the part they have to play.

Changing deeper attitudes

So the answer seems to be that if it's the people at work who you feel are driving you crazy, you need to find a way to change your deeper attitudes to begin to enjoy your work.

Raj Persaud Gresham professor for public understanding of psychiatry and consultant psychiatrist Maudsley Hospital, London and author of Staying sane: how to make your mind work for you


studentBMJ 2004;12:309-348 September ISSN 0966-6494

1. Hochschild, A. R. (1979). Emotion work, feeling rules, and social structure. American Journal of Sociology, 85(3), 551-575.
2. Pugliesi, K. (1999). The consequences of emotional labor: Effects on work stress, job satisfaction, and well-being. Motivation and Emotion, 23(2), 125-154.
3. Brotheridge, C., & Grandey, A. (2002). Emotional labor and burnout: Comparing two perspectives on "people work". Journal of Vocational Behavior, 60, 17-39.
4. Gross, J., & Levenson, R. (1997). Hiding feelings: The acute effects of inhibiting negative and positive emotions. Journal of Abnormal Psychology, 106(1), 95-103.
5. Maslach, C., & Schaufeli, W. B. (1993). Historical and conceptual development of burnout. In W. B. Schaufeli, C. Maslach, & T. Marek (Eds.), Professional burnout: Recent developments in theory and research (pp. 1-16). Washington, DC: Taylor & Francis
6. Jackson, S. E., Turner, J. A., & Brief, A. P. (1987). Correlates of burnout among public service lawyers. Journal of Occupational Behavior, 8, 339-349.

People in real life, rather than in the movies, tend to be suspicious of somebody who is constantly in 'smiley' mood. It comes across as inauthentic or false. What people in relationships with practitioners, or indeed students, need, to is to have a genuine transaction - otherwise both parties are tending to hide their real experience. Feelings and thoughts - hardly likely to lead to much understandding - or a working degree of empathy.

In Raj Persaud's field this 'acting'is the last thing practitioners should be encouraging when so much relies on the actual relationship between individuals and pratitioners. It is indeed rather patronsing to propose that a false self needs to be adopted. Almost everybody including people with mental health problems,experiences and recognises the whole range of emotions, likes and dislikes, rational or not towards others. They will not take to all those they consult but have very little choice in the matter, less so than practitioners in fact. In most cases attention to treating people with common courtesy will be sufficient. If there is great antipathy it is actually quite unethical to carry on a relationship when this is the component so stressed in the the field of psychiatry as vital to a beneficial outcome.

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