Coping With Bad News

For physicians who treat sick children, professional “masks,” such as white coats and detached demeanors, can be both a help and a hindrance.

Nancy Hutton, right, holds a mask at an AfterWards meeting at Johns Hopkins. (Olga Khazan / The Atlantic)

Nancy Hutton, a professor at the medical school of Johns Hopkins University, has one of the hardest jobs in medicine: She specializes in pediatric hospice and palliative care. She sees the sickest children—the ones with severe neurological problems that cause profound developmental delays, or with cancers slowly ravaging their bodies, or severe organ failures.

The worst, though, is when she doesn’t know exactly what’s wrong with a child. “That's even harder,” she said. “When you can't give something a name.”

Sometimes her job is to keep her patients comfortable: helping them keep food down without vomiting or easing their physical pain.

But other times, the child is dying. In those cases, it falls on Hutton to counsel the family.

She has years of experience, but the weight of it all can be too much even for her. She finds herself occasionally straining to put on a composed, proactive face when talking to families on the worst day of their lives.

“When a child is dying ... when that makes me feel very sad, or when I can't adequately do anything to make the situation better,” she said,  “I need to be ... calm and not running away, not engaging in my own emotional response in that situation.”

A few weeks ago, Hutton joined several other physicians, residents, and others in a sunny conference room in Johns Hopkins’s pediatric wing. Led by the pediatrics and internal medicine resident Ben Oldfield and the University of Maryland English professor Lauren Small, the group was there to discuss the various masks doctors wear. These masks are both metaphorical—in that doctors must maintain game faces even when things look grim—and literal, in the sense that physicians, in part to inspire confidence in their abilities, clothe themselves in decidedly non-civilian garb like white coats, scrubs, and actual surgical masks.

Small and Oldfied started hosting these meetings, called “AfterWards,” about a year and a half ago. Each month, they send out a blast email to everyone in Hopkins’s pediatrics department. Whoever shows up spends an hour discussing some topic in literature or culture and then doing a short writing exercise. The writings aren’t read or shared; the exercise is meant to be more therapy than art.

“Having a focused discussion on ... bearing witness to suffering can undo the stopcock on that emotional charge,” Oldfield said. “The other goal is that being a good storyteller will help you advocate for your patients.”

The day I joined the group, Small kicked things off by showing the room this picture of a Yupik healer—with his elaborate mask and large hands—from 1890s Alaska:

                            Johns Hopkins

“The use of masks in healing rituals is part of the culture of shamanism,” she explained. “The premise is that a person who is ill has lost a part of his or her soul. A shaman enters into a trance, and he will travel to the spiritual world, where he will struggle to retrieve a part of the ailing person's soul, and return it to him or her. The restoration of the soul is what results in the healing.”

While she spoke, the group passed around three different masks that Small had collected in her travels. Hutton held one of them—a white mask with rabbit ears—up to her face.

“The mask is revealing his connection to the spiritual world,” Small continued. “It's the source of his healing power. The question we're going to ask today is if any of you in this room are modern-day shamans.”

Next, Oldfield clicked to a new slide featuring John Singer Sargent's 1905 portrait of the four founding physicians of Hopkins: William Welch, William Osler, William Halsted, and Howard Kelly.

John Singer Sargent / Johns Hopkins

“Back then, being a physician was not as academic as it is today,” Oldfield said. “Going to medical school was just a matter of paying for individual lectures.”

At the time, the only entrance requirement of the College of Physicians and Surgeons in New York, which Welch attended, was that the applicant be able to read and write. And so, just a few decades after germ theory had gained acceptance, the four doctors cloaked themselves in black robes and projected competence the best they could.

“What are the accoutrements of healing power that you all put on?” Small asked.

“Scrubs,” ventured Ivor Berkowitz, the clinical director of the pediatric intensive care unit. “It defines you as a medical person. No one else wears scrubs.”

Donald Small, Lauren’s husband and the director of Hopkins’ division of pediatric oncology, said he’s read all the studies that say doctors can transmit germs through their white coats and ties. Still, when meeting patients’ families for the first time, “I wear a tie and a long white coat with a stethoscope in it. I hope that the families then have confidence in me somehow,” he said. “They're going to put their children in my hands.”

Janet Serwint, the vice chair of pediatric education, wore a black shirt and a stethoscope that had a small, yellow rubber duck dangling from it. “I never wear a white coat, and I never have, and people respect me, and they know I'm a physician,” she said.

Small asked the handful of medical residents in the room how it felt to be newly minted doctors. Medical residents across the country started their jobs in July.

Justin Berk, a first-year resident in pediatrics and internal medicine, said the attire itself is not a big change. Unlike most hospitals, first-year Hopkins interns continue wearing the short white coats that are typically only for medical students—a nod to their trainee status. They get their long coats the following year. (To add to the confusion, med-peds interns like Berk switch between long coats while working in pediatrics and short coats in medicine.)

“But there’s a change in demeanor when I walk into a room now,” Berk said. “Like, ‘I'm Doctor Berk, here we go!’  Sometimes when I talk to moms, I bring a stethoscope, even if I have no intention to use it. It's an identifier.”

Olga Khazan / The Atlantic

The participants were told to grab paper and pens and to spend a few minutes writing about a situation in which they had trouble maintaining their physician’s mask. Serwint wrote about a time her team needed to tell a family that their 6-month-old had a brain tumor. The child had just had the scan. Serwint and her intern steeled themselves to deliver the news.

All Serwint remembers hearing were the heart-wrenching sobs of the mother. “The father remaining stoic and comforting,” she said. “A short time later, the father made a call, and I heard the same sobs in private coming from the father.”

“My mask cracked, as did the intern’s. We had tears in our eyes. Later we cried together, the intern and I did.”

Hutton told the group that she, like many doctors these days, feels very rushed—usually just as she’s finishing up another grueling workday, she must run to pick up her husband, think about dinner, remember to feed the cat.

“Things are always moving, so I don't allow myself to finish the experience,” she said. “The mask stays on and I go to bed with the mask and I wake up with the mask. Pretty soon there are 12 masks and my head hurts and I don't know why. I need to start taking some of these off and setting them aside.”

A few people suggested that it might not be the worst thing for doctors to share in their patients’ pain more forthrightly. They all feel pressured to see more and more patients, to do more and more paperwork. Maybe the one thing they can let slide is their facade?

“The families really do appreciate it when you show some emotion,” Don Small said. “It gives comfort to the family to see that you really care about that child also.”

Soon, they wrapped up, promising to meet again in a month. A few people hung back to say hello to friends from other departments and to polish off the sugar cookies. Hutton, in her long white coat, was out the door and on to her next conundrum.