Also Human

Introduction

Medicine in the Mirror

As the airplane wheels touched down on the tarmac I instinctively reached for my cell phone, like many others around me. The flight from London to Washington, DC, was only eight hours, so there wasn’t much to work through. And there was nothing that a breezy “out of office” message wouldn’t hold at bay for the next eight days. Nothing of concern—until I reached the last email:

I froze. This was not an email to ignore. But how could I provide “sane input” when I was on the wrong side of the Atlantic? In the taxi to my son’s house, I phoned a colleague in order to pass the baton to her—but I only got her voice mail. There was no option but to answer Leo’s email myself.

Everybody goes to the doctor from time to time. For some, visits are a frequent occurrence, while for others they are mercifully rare. But however often we seek medical advice or need treatment, most of us, quite naturally, tend to be preoccupied with our own concerns and make all sorts of assumptions about the doctor who is listening to us, taking our medical history, or cutting into us during an operation. If we think of them at all.

We take it on trust that the doctor is up to the task and doesn’t feel tired or overwhelmed. We rarely consider whether the doctor, like Leo, is terrified of accidentally hurting us. We simply assume that if they are relatively junior, there will be a senior clinician somewhere nearby to answer their questions and ensure that they’re doing their job correctly. We tend not to worry whether they are bright enough for the job—after all, they will have trained for years and will have passed countless exams to get through medical school and beyond. And when parts of our body are being examined, we don’t want to entertain the possibility that doctors may find some patients attractive. We don’t wonder if the doctor likes patients at all, finds them disgusting, or resents the responsibility inherent in patient care. Instead we imagine that doctors enjoy their work and find it satisfying to treat patients like us.

For many of us, much of what we know about the medical profession comes from watching television. But neither the medical soap operas nor the fly-on-the-wall documentaries paint an accurate picture. We don’t see junior doctors feeling so overwhelmed by work that they run away in fear. Neither, for ethical reasons, would we be shown doctors telling parents that their baby has died. Yet that’s just one of the many traumatic tasks that might be on a doctor’s to-do list alongside calming down a delusional patient or deciding whether to call a halt on a failing resuscitation attempt. And television, compelling though it may be, is restricted to sights and sounds; it can’t convey the smell of decaying flesh, or as one doctor described it to me, “the feel of burnt, crispy, human skin.”

Much of what we require doctors to do is shielded in secrecy. “We cannot speak of these things to people outside medicine, because it is too traumatic, too graphic, too much,” wrote one doctor recently in the New York Times. But the writer then flagged up the difficulty of gaining solace through talking to colleagues, as medical culture regards these difficult tasks as “just the job we do, hardly worth commenting on.” A conspiracy of silence.

This book breaks the silence. Over the past twenty years, working as a vocational psychologist in two unusual roles, I have seen and heard things that are hidden from patients.

I found the first of these roles by chance; while idly flicking through the jobs section of the newspaper, I spotted a vacancy on a project that aimed to make hospital consultants (attending physicians) more effective teachers. Rather than removing doctors from their clinical duties and sending them en masse to the education department for training, faculty from the education department went into hospitals to shadow the clinicians as they taught their students and junior doctors. Ward rounds, operations, or outpatient clinics could continue as normal as clinicians were observed as they went about their everyday duties. What’s more, the educational feedback was more precise: tailored to the specific context in which each particular clinician worked.

I applied for the role, and ended up working on the project for the next decade. During this time I shadowed hundreds of consultants; I watched as babies were born, patients were given terminal diagnoses or took their last breaths. My job was to help these consultants become more effective teachers in the different settings across the hospital; in the process I witnessed many extraordinary things.

Alongside this hospital-based role, I also had a more typical job for an occupational psychologist: working as a career counselor, helping people sort out the difficulties that they were experiencing in the workplace. For many years my two jobs were separate: some days I observed doctors while on others I counseled people in all occupations other than medicine. Then in 2006 my two jobs merged. Postgraduate training of doctors in the UK was completely overhauled, junior doctors had to make specialty choice decisions at an earlier point in their careers, and the National Health Service (NHS) woke up and realized that there was a need to establish career support services for doctors.^*

In 2008 I was employed by the NHS to set up and run the Careers Unit—a service for all trainee doctors in the seventy-plus hospitals across London. Although I hadn’t embarked on the observation work to prepare me for this new role, serendipitously the ten years I’d spent shadowing clinicians turned out to be invaluable. I had seen, for example, anesthesiologists and gastroenterologists and cardiac surgeons in action, so I had a more nuanced understanding of the pleasures and challenges of each specialty than I could ever have acquired from a book.

But the doctors who came banging on my door at the Careers Unit didn’t only want to talk about choosing the right specialty. Other themes recurred again and again: coping with the transition from medical school, questioning whether they were suited to the practice of medicine, the impact of exposure to patient suffering, the seeming impossibility of reconciling family and professional demands, the emotional complexity of leaving or abandoning a medical career. These are some of the issues that I explore in this book.

As a psychologist, I saw how medical training often fails to acknowledge that doctors are people too, with their own thoughts, feelings, fantasies, and desires. Their training moves them around the country and separates them from family and friends. They become ill, or get divorced, or fail to find a partner. Some struggle to progress their careers after taking time out to care for their children or elderly parents; others struggle with passing specialty exams. The sexism or racism found in other professional spheres hasn’t been surgically excised from medical work. Some doctors feel that they have ended up in the wrong specialty. All of this takes a toll.

All of this needs to be told.

It might be tempting to think that the doctors I encountered were atypical. But this would be false. In August 2016 a final-year student at a New York medical school climbed out of her window and jumped to her death. The dean of the university wrote an impassioned opinion piece in the New England Journal of Medicine. Referring to research from the Mayo Clinic, he described a “national epidemic of burnout, depression, and suicide” among medical students. And he went on to say that the “root causes” of this epidemic stemmed from

A few months before the New York medical student committed suicide, Rose Polge, a junior doctor in the UK, walked into the sea and drowned. This tragedy received widespread newspaper coverage, at least in part because it occurred when junior doctors had taken the unprecedented step of going on strike—the first in forty years—in protest against the imposition of a new working contract.

“Long hours, work related anxiety, and despair at her future in medicine were definite contributors to this awful and final decision,” wrote Rose’s parents on the web page of a charity set up to raise money in her memory.

Except it isn’t final. The following year another junior doctor disappeared. As with Rose, her car was found abandoned by the sea. What happened next is not known.

Rose’s parents were not alone in pointing the finger at the working conditions doctors face in the UK. A 2016 study published in The Lancet concluded that general practitioners’ (GPs) clinical workload was reaching “saturation point.” Similarly, the quarterly monitoring report from the King’s Fund published at the beginning of 2017 noted sustained increases in patient demand, particularly from elderly patients with complex health needs, rising delays in transferring patients out of the hospital into social care, and severe financial pressures leading to cuts in staffing. These findings were echoed in a survey of nearly five hundred junior doctors conducted by the Royal College of Physicians, which reported that

But ultimately it’s not just doctors who are suffering. It’s all of us. The Royal College of Physicians’ survey found that nearly half the doctors felt that poor morale had a serious, or extremely serious, impact on patient safety. Similarly, the 2016 General Medical Council (GMC) survey of junior doctors reported that one in five emergency medicine trainees were concerned about the impact of their workload on patient safety. And another study carried out by researchers at Harvard Medical School reported that pediatric trainees suffering from depression made six times more medication errors than their nondepressed colleagues. These researchers also found that the rate of depression among these trainees was twice that expected in the general population. Despite these high rates of mental distress, nearly half of the depressed trainees seemed unaware that they were unwell, and only a small number were receiving treatment.

It’s extremely rare for a psychologist to gain such intimate exposure to the day-to-day reality of medical work. In many ways I have been granted an insider’s vantage point on the profession. Yet crucially, in both of my roles, I was working as an outsider, as a psychologist rather than as a medic. I haven’t been socialized into the world of medicine through a long and arduous training process, so things that medical colleagues might take for granted, I have questioned. My training has also given me a psychological lens to interpret what I have seen or been told; I’m often interested in the unconscious reasons that lie beneath some of the decisions doctors make.

But the significance of being a psychologist rather than a doctor goes further. I suspect it’s a bit easier for doctors to admit to me that they are struggling at work than to have the same conversation with another doctor. When their jobs are making them unhappy, doctors often imagine that they are the only ones who feel as they do, and they are wary of voicing their concerns to the senior clinicians who supervise them. And stigma—particularly around mental health issues—is still a very real problem in the medical profession.

There are, of course, a number of books written by exceptional physicians that provide readers with an extraordinary glimpse into the world of medicine. I have read many of them, and they have enormously enriched my understanding of the profession. But this book is different; it’s not describing the personal experience of one doctor, but instead draws on observations and conversations with hundreds of doctors over a twenty-year period. And while other books involve doctors writing about their patients, in this book the mirror is reversed: doctors like Leo come to see me, a psychologist, and I am writing about them.

So what did happen to Leo?

With the tragic cases of students and junior doctors who had committed suicide in mind, I responded to Leo’s email with considerable care. I wanted to acknowledge his obvious distress yet at the same time convey hope. I told him about other medical students and junior doctors I had encountered in the past who had expressed similar feelings. I also told him that some of them had gone on to have successful careers within medicine, while others had decided to build their careers outside the profession. But above all else, I emphasized that he shouldn’t attempt to soldier on without help. His first priority was to go and see his GP and tell her how he was feeling. In addition, he might find it helpful to seek support from the university counseling service, as well as pastoral staff within the medical school. And I flagged up the twenty-four-hour crisis line operated by the British Medical Association.

I explained that I was out of the country but would respond to any emails he sent me, and would be happy to talk on my return to the UK the following week. A couple of days later Leo wrote back. He’d already made contact with his GP and his personal tutor, and he had found it helpful to know that I had supported other doctors who felt as he did. He also wanted to arrange a time to talk when I was back in the UK.

The following week, we talked on the phone for over an hour. Leo told me that he was feeling better than when he had first emailed me; he had contacted the BMA helpline, and in addition, his GP and personal tutor had been helpful. When I asked about the impending exams Leo was clear that he was well enough to take his finals and he’d done enough studying to pass. It wasn’t the exams per se that he was worried about, more what came next. When we then discussed how he felt about starting work, Leo was adamant that he wanted to give it a try, even if he decided a few months down the line that clinical medicine wasn’t right for him.

After his exams Leo was due to go away on holiday for a month with his girlfriend. On his return he would be moving to a new town with her, to start his first job as a doctor. We left it that Leo would get in contact with me if he wanted to think about which specialty might work best for him, or if he wanted to consider leaving medicine entirely. But a couple of weeks before finals wasn’t the right time to discuss either of these issues.

A month into his first job I received another email—very different from the first.

It’s probably a bit too early to tell how Leo’s medical career will pan out in the longer term. But later on in the book we’ll meet doctors who walked out within days of starting their first job; the fact that Leo is enjoying work is certainly encouraging.

I’m still shocked, however, by how frequently medical students and junior doctors find themselves at the “edge.” Aren’t there better ways of training our future doctors? Ways that mean they don’t need to phone twenty-four-hour helplines, or send desperate emails to unknown psychologists, in the hope that someone out there will listen. And couldn’t we manage the transition from medical student to junior doctor better?

That’s the place where these stories begin.

* In this book I focus on the inner lives of doctors. This is not because the other professionals working in health care don’t matter; they do. They are essential. Instead, the reason is that in both of the roles I have held over the past twenty years, I was solely responsible for supporting doctors and had minimal contact with staff from other professions. I don’t want to presume that I have much understanding of the challenges that other professional groups face, which is why I have remained silent on the matter.