When I started my first full-time faculty position, one of my biggest worries was how I would manage working with the interdisciplinary team. I’d spent the last few months working as a locum at my most recent site of training, where I’d had years to develop rapport with consultants, nurses, allied health, and other staff. While that experience left me feeling confident in my abilities on the clinical side of medicine, my new position felt like stepping into someone else’s white coat. Not only was I inheriting a roster of patients from several other physicians, but I was inheriting a team of health care workers, including nurses, a pharmacist, a dietitian, schedulers, a nurse practitioner, and two physician assistants.
“Don’t worry,” I was told. “The team is highly experienced.” An understatement, to say the least. The collective expertise of the team included prior work in hospice settings and patient advocacy, dedicated postgraduate oncology training, dedicated postgraduate academic training, time in the Peace Corps, time in the police force, and even medical school training. Some team members had decades of health care experience more than I had. Daunting, to say the least.
By the time I first met my new clinical team, I had worked myself into a properly terrified state. Would they resent working with me? See me as a fraud? Terror morphed into heavy impression management, and I put my best foot forward to try to be as “serious” an oncologist as I could. I timed my bathroom breaks, used the most professional language I could muster in emails and messages, and aimed to keep displays of emotion (ranging from laughter to tears) under wraps while on hospital property. I dressed in dark-colored suits and refrained from asking for help or advice lest I appear weak.
But, then, several shifts happened.
My academic work centers around societally relevant sociologic concepts playing out in the microcosm of medical environments. In particular, my PhD work focuses on impression management. A concept from the early 1960s, impression management describes the theatrical performance that humans engage in in front of others in order to elicit some sort of outcome or response in the audience (in this case, that I was a serious, competent oncologist worthy of respect). Impression management, however, comes with cost, including required effort which can leave the practitioner feeling exhausted and unable to focus on other tasks.
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And exhausted I was. By the end of the day, all of the tears and laughter and stressors were fighting to be released, and the nights before clinic days were plagued with nightmares and cold sweats. Our GI medical oncology clinic is stressful at baseline, with the high morbidity and mortality seen in devastating illnesses like metastatic pancreatic cancer. Compound that with heavy impression management and suppressed emotion, and you have the consummate burnout recipe.
As time (and my knowledge journey) progressed, I began to wonder whether the heavy impression management I was engaging in was truly the best option. Simultaneously, I began to get to know my team, not in their roles, but as people. I learned about new births, family illnesses, pets, sports team rivalries, weekend marathons, Mellow Mushroom pizza, true crime documentaries, birthday trips turned into surprise engagement parties, and more. I opened up, too, about fears and struggles, about challenging patient cases, about stories from my training days. As I would with friends or family, I began to keep mental notes, asking follow-up questions about stories from the week prior, leaning more into curiosity and caring, and less into impression management.
Vulnerability which was rewarded multifold.
Existing literature about impression management teaches us that congruence (non-manipulated impressions in line with our “true” selves) can help us relate to others and decrease the strain that managed impressions require. While some form of impression management is necessary in any type of patient-facing health care role, the question arose whether it was necessary to the degree I was engaging in.
And, as I started to relax, I found the answer was a resounding “no.” I started to wear more color and the fun jewelry I had collected during my training. I began to play lo-fi beats and videos of aquariums and fireplaces on the spare monitor in the team room. I began to brainstorm with the team, asking them for help to use our combined expertise for the good of patient care. I began normalizing voicing difficulties and frustrations and grieving for patients lost.
As time went by, the team reciprocated. Laughter and tears replaced clinical silence between patients and at the end of the day. Cheerful knick-knacks appeared on desks. The team bought me a stuffed cat, Lil Bub, in the image of the guest star in a frequented fireplace video. He has now been dubbed “Dr. Bub” and serves as a clinic cozy on stressful days. But benefits extended into the clinical side: Ideas flowed more easily, suboptimal steps were caught more quickly, and patient care became more seamless and timelier.
I was still exhausted at the end of the day, but it was a different kind of exhaustion, one born from compassion and cognitive work than a heavily managed impression. While the tenets of impression management teach us that there can be clear benefits to considering the impact of our actions on others, impression management, like all tools, needs to be used responsibly and carefully. Heavy impression management that is overly self- and fear-focused runs the risk of depleting resources without reciprocal benefit. Perhaps my first flawed judgment was deciding that seriousness and absence of emotion equated to competence, especially in an emotionally charged field like oncology. I now know that vulnerability, while more daunting to embrace initially, can also have its role, without compromising perceived competence. The therapeutic balance between impression management and congruence can require trial and error, but, over time, the benefits can reach both sides of the patient-professional relationship.
Beatrice Preti is an oncologist.
