How to be an Authentic Doctor #6: Be A Little Thick-Skinned


This job is tough in many ways.  It challenges you emotionally, physically, mentally and even spiritually. We also see bad things happen on a regular basis.  Over the years I have diagnosed terminal illnesses in patients who I have really liked and knew as friends.  And then I saw them die.  There is risk of being too human, however, and breaking down with every bad outcome is not a good option either.  You can become emotionally paralyzed and you can’t recover to see the next patient.  In summary, expose your emotions too much and you don’t survive in this profession.   So we become hardened and we thicken our skin.  We all do it but unfortunately this “skill” bleeds over into our home life as well.

I am no stranger to being thick-skinned.  There is a story in my house that typifies how even disgusting things just don’t bother me anymore.   Years ago my dog, who was getting quite old, had a bad case of diarrhea.  Instead of barking or scratching to alert us, he chose to just let it go and laid in it.  I thought I was going to get a little extra sleep that morning until I heard the gagging and the “oh my god!” from my wife.  That is when I knew I had to get up and play the good husband.  And it wasn’t pretty. When I went downstairs, I just did what I had to do.  I was able to go into the room, clean it all up and wash the stool covered back end of the dog.  I did it unemotionally and without complaint.

My wife was totally amazed.  “How could you just go in there and clean that stuff up? You didn’t even gag?  Actually, it looked like it didn’t even bother you” she said.

The truth is it didn’t.  I told her that as a physician, we deal with these “unpleasantries” all the time.  You just put your head down and ignore the olfactory or visual stimuli and get the job done.  No, I didn’t enjoy the smell.  But to tell you the truth, I am so thick-skinned to this stuff that I bet for $5 I could eat a ham sandwich while cleaning another bout of canine stool incontinence or cutting open an abscess or sewing back a severely severed arm or whatever.

Don’t get me wrong, I am not sure if this quality is a good thing or not for doctors.  It really doesn’t matter because it is what it is.  We can’t change it.  It starts right from medical school. In fact, I remember in my anatomy class there was this sweet girl who was very bothered by the cadavers.  The school had done all the right stuff to slowly introduce the new students to their “bodies”.  There were prayer sessions for those so inclined.  There were even warm-up periods so that people could acclimate to the cadaver.  Still, people were squeamish and this one young woman especially.  I didn’t pay attention too much to her because I had enough work to do trying to do well in the class.   I had forgotten about this student totally until halfway through the semester when I saw her whistling as she walked by with a sawed-off leg over her shoulder like a slab of meat.  I thought to myself “haven’t we got a little sassy?”

Thickening of our skin may be a survival instinct for us doctors but it does have its repercussions.  I believe that if it is not offset or counter-balanced by something else then we become withered and smoked like those crusty doctors who walk around like drones and never smile anymore   These are the ones who die early or worse, live long and miserable lives.

So there you have another example of the duality of medicine.  On one hand we have to be sensitive so we can be human to patients yet on the other hand we need to be detached and thick- skinned so we can survive in this career.  It’s a constant balancing act that never gets easy.  The key is to know when and how to be sensitive and when and how to be detached or thick- skinned.  I am not sure I am that great at it but I do think about it. I can cut open an abscess with smelly, cheesy discharge from someone’s pannus and stay detached.  I see a woman who needs something for the grief from losing her husband and I ignore checking quality indicator boxes to please others and instead open myself up more to the patient and just sit and talk to her.   More examples of the “art of medicine”.   So don’t anyone tell you that being thick-skinned is bad or good.  It is what it is.



Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  5 comments for “How to be an Authentic Doctor #6: Be A Little Thick-Skinned

  1. Ray
    March 26, 2014 at 6:56 pm

    Nice piece Dougy! I think all of us in the trenches understand the need to remain objective or sometimes detached to be effective. We do not want to lose our humanity. We want to be efficient. The job demands this. It takes a toll, whether we acknowledge this or bury it. anything in life is the key. Physician health and well being are an afterthought. Too many good doctors have been consumed by the practice of medicine. Physician heal thyself. Take more time off, spend less, spend time with people you love. No one else can do it.

  2. Pat
    March 26, 2014 at 12:48 am

    Great points all about the need for compartmentalizing the sadness one feels for a truly sick or injured patient, or his family member. To that I regretfully add, one must also wall off the contempt one feels for whiners, malingerers, and drug seekers; as well as constantly struggle to feel concern for the majority of patients who would turn on a dime and become plaintiffs if the opportunity arose.

  3. Jay Cooperman
    March 25, 2014 at 8:13 pm

    Very well said Doug. In this I don’t think we’re any different from other human beings placed in a situation that challenges us not to respond instinctively. Instead of running away, we’re expected to run towards trouble, much the same as a soldier, firefighter or police officer. Of course, to function in the caring part of the job , we have to compartmentalize our emotional responses. It is definitely a balancing act. Thank you for your personal examples and insights.

  4. Sir Lance-a-lot
    March 25, 2014 at 5:59 am

    Well said, Doug.

    With regard to “trouble at home,” I would add, in addition to the need to handle the disgusting stuff, there’s also the empathy issue.

    I spend all day pretending, with more or less effectiveness to be genuinely concerned about someone’s cut, scrape, cough, sore throat, tummy ache, hard life, amputation, or whatever. When I get home after twelve hours of this, if my wife, who, I believe, has a few more minor problems per day than average, tells me that she’s thrown up, or had a cough, or hurt her hand, I really can’t muster much more than an “I’m sorry” and, after a quick look, “That’ll get better in a few days.”

    She’d like me to be kind and empathetic, but, honestly, after over 20 years in the biz, it’s just not there. I can pretend to care reasonably well for about ten minutes, but that’s my absolute best, and after that, it just runs out. I don’t want to seem or to feel, or to be, callous or uncaring, but it’s like, aside from a crackly tape recording, that part is just not there.

    It takes its toll, not just on us, but on our families.

    • Doug Farrago
      March 25, 2014 at 6:11 am

      Great point

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