Also Human

  CONTENTS

  About the Book

  About the Author

  Title Page

  Dedication

  Epigraph

  Author’s Note

  Introduction: Medicine in the Mirror

  1. Wednesday’s Child

  2. Finding the Middle

  3. Which Doctor

  4. Brief Encounter

  5. Role Reversal

  6. Leaky Pipes

  7. Risky Business

  8. No Exit

  9. Natural Selection

  Epilogue: There’s No Such Thing as a Doctor

  Notes

  Brief Glossary of UK Medical Terms

  Training Chart

  Further Reading

  Acknowledgements

  Copyright

  ABOUT THE BOOK

  Doctors are the people we turn to when we fall ill. They are the people we trust with our lives, and with the lives of those we love. Yet who can doctors turn to at moments of stress, or when their own working lives break down?

  What does it take to confront death, disease, distress and suffering every day? To work in a healthcare system that is stretched to breaking point? To carry the awesome responsibility of making decisions that can irrevocably change someone’s life – or possibly end it? And how do doctors cope with their own questions and fears, when they are expected to have all the answers?

  Caroline Elton is a psychologist who specialises in helping doctors. For over twenty years she has listened as doctors have unburdened themselves of the pressures of their jobs: the obstetrician whose own fertility treatment failed; the trainee oncologist who found herself unable to treat patients suffering from the disease that killed her father; the brilliant neurosurgeon struggling to progress her career in an environment that was hostile to women. Drawing on extraordinary case studies and decades of work supporting clinicians, Also Human presents a provocative, perceptive and deeply humane examination of the modern medical profession.

  ABOUT THE AUTHOR

  Dr Caroline Elton completed her undergraduate degree at the University of Oxford, was awarded a postgraduate fellowship to the University of Pennsylvania, and completed her PhD in the Department of Academic Psychiatry, UCL Medical School. She is a chartered psychologist and has held a number of positions working with doctors. Her first role involved shadowing senior clinicians on ward rounds, in outpatient clinics and in operating theatres, as part of an initiative to challenge outdated models of medical education. Later she was appointed as Head of the Careers Unit, responsible for supporting trainee doctors across the whole of London. She has also worked as Head of the Extended Medical Degree Programme – the largest ‘widening participation’ medical degree course in the UK. Caroline has written extensively about doctors, the problems they face and how best to support them, and is a regular speaker at conferences in the UK and abroad.

  For my family

  Mary W is a psychologist who lives in Michigan … More than a decade ago, when I was trying to decide whether to go to medical school to become a psychiatrist, I called her to talk about her practice … Mary shares my love for northern Michigan and its lakes. Without thinking, she reached for that shared territory for a metaphor.

  ‘The patients we work with have fallen through the ice in the middle of a frozen lake … My job – your job should you take this path – is to go out to them, to be with them on the thin ice, and to work with them to get them out of the frigid water.… But you must know that if you go out to them on the thin ice, there’s a real danger that you’ll fall in too. So if you go into this work, you’ve got to be anchored to the shore. You can reach out one hand to the person in the water,’ she cautioned, ‘but your other hand needs to have a firm grip on the people and things that connect you to the shore. If you don’t, you lose your patients, and you lose yourself.’

  Falling into the Fire: A Psychiatrist’s Encounters with the Mind in Crisis, Christine Montross

  AUTHOR’S NOTE

  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.

  INTRODUCTION

  Medicine in the Mirror

  AS THE AEROPLANE wheels touched down on the tarmac I instinctively reached for my mobile 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:

  Dear Caroline

  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.

  Leo

  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 answerphone. 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, whilst 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 to 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 or not 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 a
n 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’.

  A lot of what doctors 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 last twenty years, working as an occupational 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 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 hospital 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 careers counsellor, 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 whilst on others I counselled 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 NHS woke up and realised that there was a need to establish careers support services for doctors.fn1

  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 the capital. Although I hadn’t embarked on the observation work to prepare me for this new role, serendipitously the ten years I spent shadowing clinicians turned out to be invaluable. I had seen, for example, anaesthetists or gastroenterologists or 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 can get ill, or 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 Medicine1. Referring to research from the Mayo Clinic2, he described ‘a national epidemic of burnout, depression and suicide amongst 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 memory3.

  Except it isn’t final. The following year another junior doctor disappeared4. 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 GPs’ clinical workload was reaching ‘saturation point’5. Similarly, the quarterly monitoring report from the King’s Fund published at the beginning of 2017 noted sustained increases in patient demand6, particularly from elderly patients with complex health needs, rising delays in transferring patients out of hospital into social care and severe financial pressures leading to cuts in staffing. These findings were echoed in a survey of nearly 500 junior doctors conducted by the Royal College of Physicians which reported that7:

  70% worked on a rota that was permanently under-staffed. 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 a half of doctors felt that poor morale had a serious, or extremely serious, impact on patient safety. Similarly the 2016 General Medical Council survey of junior doctors8 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 paediatric trainees who were suffering from depression made six times more medication errors than their non-depressed colleagues9. These researchers also found that the rate of depression amongst these trainees was twice that expected in the general population. Despite these high rates of mental distress, nearly hal
f 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 socialised 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, which 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 whilst 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.