Use code DAD23 for 20% off + Free shipping on $45+ Shop Now!
The Inner Lives of Doctors
Formats and Prices
- Hardcover $30.00
- ebook $17.99 $22.99 CAD
This item is a preorder. Your payment method will be charged immediately, and the product is expected to ship on or around June 12, 2018. This date is subject to change due to shipping delays beyond our control.
Also available from:
From ER and M*A*S*H to Grey’s Anatomy and House, the medical drama endures for good reason: we’re fascinated by the people we must trust when we are most vulnerable. In Also Human, vocational psychologist Caroline Elton introduces us to some of the distressed physicians who have come to her for help: doctors who face psychological challenges that threaten to destroy their careers and lives, including an obstetrician grappling with his own homosexuality, a high-achieving junior doctor who walks out of her first job within weeks of starting, and an oncology resident who faints when confronted with cancer patients. Entering a doctor’s office can be terrifying, sometimes for the doctor most of all. By examining the inner lives of these professionals, Also Human offers readers insight into, and empathy for, the very real struggles of those who hold power over life and death.
A note on client confidentiality, which I have taken very seriously. I have changed names and all identifying particulars so as to preserve my clients’ anonymity. Before using any personal information in the book (even under the guise of anonymity), I showed each client the draft, invited comment, and sought their permission: all were willing to share their experience. Most were willing to do so on the basis that it is this book’s aim to help doctors facing career struggles and highlight the extraordinarily difficult pressures that many doctors face.
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 have questioned from day one whether medical school was right for me, and since then things have only gotten worse: I have got more depressed and felt more hopeless as I have gone through—persisting always with the hope that things might get better (and everyone around me encouraging me to do so). But I just can’t cope with the pressure and stress of hospitals, and the thought of starting work as a doctor fills me with dread.
I am now a month away from finals and very distressed about what to do. I keep trying to tell myself that I just need to pass my finals then can always stop and do something else with my medical degree. But I have no real clue about what I would do instead—and am just as scared that I may regret it if I stop…
I am just not sure I will survive working as a doctor, and I’m worried I would get so stressed, anxious and depressed that I would end up either hurting someone else by accident or more likely drive myself to the edge. I am sorry if this comes across quite melodramatic. I really have reached crisis point though and am in desperate need for some sane input.
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 culture of performance and achievement that for most of our students begins in middle school and relentlessly intensifies for the remainder of their adult lives. Every time students achieve what looks to the rest of us like a successful milestone—getting into a great college, the medical school of their choice, a residency into a competitive clinical specialty—it is to some of them the opening of another door to a haunted house, behind which lie demons, suffocating uncertainty, and unimaginable challenges.
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
70% worked on a rota, or rotation, that was permanently understaffed. At least four times per month doctors completed a full day or night shift without having time to eat.
18% had to carry out clinical tasks for which they had not been adequately trained.
80% felt their work sometimes or often caused them excessive stress.
25% felt their work had a serious impact on their mental health.
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.
I am happy to tell you that things got a lot better after speaking with you. I managed to pass finals and had a very relaxing holiday and have now moved in with my girlfriend. I’m working at the university hospital which is going much better than expected, and I have actually enjoyed the acute side of medicine. Anyway, I am taking things slow and steady and making sure I prioritise my own health and happiness first, and I’m trying to keep myself as balanced as I can.
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.
I always ask clients about their first job as a doctor. I don’t specifically ask about the first day of that first job—but sometimes, as with Hilary, that’s the story I am told.
Hilary, a qualified GP, came to see me because she was thinking about leaving medicine.
“I’ve reached the end of the road with general practice,” she explained in our initial phone conversation. “The only thing that I like about it is that it provides a regular income.”
Like many other GP clients, Hilary told me how she felt that contemporary general practice pulls doctors in opposing directions. On the one hand, she lived in fear of incorrectly reassuring a patient that a particular symptom didn’t warrant a referral to a specialist for further investigation. On the other hand, she dreaded being singled out by her clinical managers as having an inappropriately high referral rate to specialist services. Damned if you do and damned if you don’t, with no wriggle room in between.
It was five years since she had first qualified as a GP, but even before she finished her GP training, she had started to doubt whether it was the right career for her.
“I’m not a natural doctor,” she said. “I constantly feel like a square peg in a round hole.”
But leaving wasn’t easy either. Neither of her parents had been to university, and her mother’s father had worked as a gardener for the local doctor.
“My mother is so proud of me and everything that I’ve achieved,” Hilary explained. “She really doesn’t want me to change career.”
I asked Hilary to tell me about her first job as a doctor, and she described how her heart sank when she saw from her rota that she’d been placed on the on-call team on her first day. What this meant was that in addition to her responsibilities on the surgical ward to which she had been attached, she also had to assess new patients as they were admitted to the hospital for surgery. It’s a bit like trying to be in two places at once; nobody wants to be on call on Day 1.
On her first morning as she walked onto the surgical ward she was immediately informed by the senior nurse that, following surgery, one of the patients was extremely sick and urgently needed to be seen by a doctor. Naïvely, Hilary asked which other doctors were available.
“Mr. Baker, the surgical consultant, is on a [training] course, Mr. Shah, the registrar [or senior trainee], is on annual leave, and Dr. Glover is off, having worked a bunch of nights. It’s just you,” said the nurse.
Hurriedly, the nurse led Hilary to the patient’s bedside. The first thing that Hilary clocked was the patient’s strange gray pallor. With extreme difficulty the patient opened her eyes and whispered, “Doctor, am I going to die?” Then, a second later, a barely audible request: “Doctor, please call my family.”
Hilary didn’t have a clue whether the patient was at death’s door, or whether she should urgently summon the family. More importantly, she also didn’t know whether there were medical interventions she should be making to save the patient’s life. Moving away from the patient’s bedside to confer with the nurse, Hilary asked for help.
“You’re going to have to get used to this,” said the nurse. “Mr. Baker never turns down an opportunity to operate—he’ll operate on anybody. With some of the patients on this ward it might have been better if they had escaped the knife. They’re often even sicker when they come out of [the operating] theater.”
A junior nursing assistant called the senior nurse away. Left on her own and unsure what to do next, Hilary decided to review the patient’s notes. There were no clues there either. With mounting anxiety, she wondered whether she should call the registrar from another team, or ask the senior nurse to return to the bedside. Nothing that she had learned in medical school had prepared her for this situation.
By chance, Fiona, a fledgling doctor attached to another ward, walked down the corridor and out of the corner of her eye caught sight of a panic-stricken Hilary. Realizing that all was not well with her colleague, Fiona slipped away from her own clinical team and walked onto Hilary’s ward.
“Are you OK?” asked Fiona.
“Not really,” Hilary replied. “I’m the only doctor on this ward, all the others are away today, and there’s a really sick patient who looks like she is going to die.”
She led Fiona to the patient’s bedside; neither of them spoke as they peered down at the sickly looking patient, who had fallen asleep.
“I’ll call my mum,” Fiona whispered.
For a second, Hilary thought that Fiona was joking. Even though she would love to magic her own mum onto the ward, she couldn’t see how the appearance of Fiona’s mum was going to improve the situation.
“Mum’s a nurse on the Rapid Response Team,” Fiona explained. “She’ll know what to do, and I am sure she will come if I ask.”
So that’s what they did. Fiona’s mum was summoned and five minutes later appeared. She took one look at the patient, realized she was desperately unwell, and called the consultant anesthesiologist. A couple of minutes later the anesthesiologist appeared, agreed with his nursing colleague’s opinion, and less than ten minutes after that, the patient was transferred to the High Dependency Unit, for urgent medical treatment.
The patient survived. And Hilary’s first day continued.
All the time that Hilary had been trying to sort out the desperately ill patient, her pager had been going off, summoning her to the Surgical Assessment Unit. As soon as the patient was transferred, she dashed down to the SAU and encountered an extremely angry nurse.
“There are nine patients waiting. Where have you been?”
Before Hilary had the opportunity to explain that she had been dealing with an emergency on the ward, the nurse gave a rushed account of each of the nine patients whose names were on the whiteboard by the nursing station. Hilary absorbed almost nothing of this informational deluge.
“Is there another doctor here?” she asked, finding it hard to believe that she had been expected to fly solo on the SAU as well as on the ward.
“Triple A emergency admission.* Everyone’s in theater,” was the unwelcome response.
By this stage in the day, the nine names on the whiteboard were swimming in front of Hilary’s eyes. And having already dealt with a clinical emergency (albeit by calling Fiona’s mum), she was desperate to know if any of the names were higher priority than the others.
“Could you possibly help me work out who I should see first?” asked Hilary.
“Figure it out yourself, blue eyes,” was the nurse’s response. And with that, she walked off—probably to get on with her own enormous list of tasks.
- "With a compassionate eye for detail and a deep understanding of just how the systems we train and practice in as doctors can fail us as human beings, Caroline Elton offers a crucial and timely reminder that doctors arealso human."—Atul Gawande, author of Being Mortal
- "Written with perceptive sympathy for the wounded healer, it is necessary reading for both doctors and patients."—Hilary Mantel, Man Booker Prize-winning author of Wolf Hall and Bring Up the Bodies
- "Elton...passionately advocates for paying greater attention to the unique emotional needs of physicians."—Health Affairs
- "This important and much needed book describes the psychological difficulties of doctors in training and in practice and the woeful lack of support to them from teachers, colleagues, and institutions."—LitMed
- "Elton is particularly good on the subtle matters of gender and ethnic discrimination that punish doctors who are different from the white, male mainstream.... A useful adjunct to books from within medicine by the likes of Richard Selzer [and] Atul Gawande."—Kirkus
- "Elton, a vocational psychologist, spent the last 20 years observing, counseling, and helping very real, vulnerable, and wholly human people in the medical field.... Written in a welcoming style, this practical and helpful look at best medical practices will benefit patients, practitioners, and everyone else involved in health care."—Booklist
- "At a time when burnout and depression among doctors have reached epidemic proportions, Caroline Elton masterfully dissects the issues to explain how we arrived at this point. Ultimately, we must remember that doctors are Also Human and we need a comprehensive approach to uplift the emotional well-being of the medical workforce."—Eric Topol, Executive Vice-President of Scripps Research Institute and author of The Patient Will See You Now
- "At the heart of this book is the problem of how emotional resilience can be identified in prospective doctors and strengthened in practicing doctors. We are fallible human beings, not omniscient gods."—Henry Marsh, Sunday Times (UK)
- "A vivid, compelling account of how wounded healers may struggle to find healing. Elton has helped hundreds of doctors through crises in their personal and professional lives, and her stories read as an urgent manifesto to reform the caring professions--that they might begin to care for their own. With reference from the psychological literature, as well as her own extensive clinical experience, she examines why some doctors are overwhelmed by the pressures of medicine, while others may even thrive under them."—Gavin Francis, physician and author of Adventures in Human Being and Shapeshifters
- "Fascinating and troubling. Read it and weep."—Susie Orbach, author of Fat Is a Feminist Issue
- "Haunting, beautiful, and urgent."—Johann Hari, author of Chasing the Scream and Lost Connections
- "For patients and doctors alike, this book is required reading."—Daily Mail (UK)
- "[Elton's] description of the psychological forces underlying the ways doctors act--avoidance coping, intellectualization, suppression, repression--is fascinating."—Literary Review (UK)
- On Sale
- Jun 12, 2018
- Page Count
- 336 pages
- Basic Books