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  So how can we help the next generation of doctors make better choices so that they don’t have to come banging on my door for help?

  I’m not advocating long-term psychotherapy or Rorschach inkblot tests, or even in-depth career counselling. Some doctors need specialist psychological support in the task of specialty choice, but the majority don’t.

  However, all doctors need to approach the task with their eyes wide open. They need to remain curious both about themselves and about the full range of available options. This will only happen if the whole issue of specialty choice is reframed. Starting from the beginning of medical school and continuing throughout training, there must be ongoing discussion about specialty choice in particular, and the emotional demands of medicine in general.

  A student doesn’t enter medical school as a tabula rasa. All students should be taught that things that have happened in their life before medical school (pressure to follow in parental footsteps, family or personal illness, divorce) might have an impact on how they experience different specialties. Both students and qualified doctors should be encouraged to be alert to atypical responses (fainting/crashing cars/unexplained exam failure) – not in order to reach quick, simplistic conclusions but just to start wondering whether these are vital clues to aspects of work that might be overwhelming. They need to think carefully about the patients they enjoy treating – the clinical puzzles they love to solve, as well as those tasks that they find too traumatic. Or perhaps just not very interesting.

  I am advocating this ‘eyes wide open’ approach because of the countless stories of mistaken career choices that doctors have recounted over the last ten years. Yet it’s also an approach that is entirely congruent with contemporary models of occupational psychology. A leading psychologist in the States, Tom Kreishok, argues that, although a conscious, rational approach to career decision making has a role to play, rationality has its limits30. He suggests that if we really want to help people make better career decisions we need to encourage them to think about, and inhabit, the feelings associated with their day-to-day experiences at work.

  If this simple message had been reinforced throughout the years of medical training, Lola, and many other doctors, might have been able to choose more wisely.

  4

  Brief Encounter

  THE INITIAL EMAIL was short and to the point, requesting an appointment as soon as possible. There were no further details bar a name, Peter, and the fact that he would be travelling for a considerable distance to get to me. I responded suggesting some dates, and a time was arranged with minimum delay or fuss.

  On the appointed day, I opened the door to a tall, good-looking man of African heritage whose face seemed creased with worry. Once in my office, he paused before sitting down, as if he was uncertain whether he wanted to stay or go. Eventually we both sat down, and I waited.

  Without prompting, Peter began telling me his story. He had grown up in London although both his parents had been born in West Africa. He’d attended medical school in the north of England but had moved back south to complete his postgraduate training. Now thirty-five years old, he had been working as an obstetrician in London for the past two years. He was eligible to apply for consultant posts, but he was having doubts. Did he really want to be delivering babies for the next thirty years?

  Recently his dilemma had become more pressing as a consultant obstetrician post had come up in the hospital where he was currently working, and everybody there was keen for him to apply. That the application deadline was only two weeks away was the main reason why he wanted to meet with me. He just wasn’t sure whether he wanted the job.

  ‘I’m quite an anxious person,’ he told me, ‘and I struggle with the acuteness of the labour ward.’

  ‘Is this new?’ I asked.

  ‘No – it’s always been like that. I kept on hoping that things would change. But I’ve completed my training and nothing has shifted.

  ‘I’m quite introverted,’ he added, ‘and I don’t really like being in charge of a large team in the labour ward – the anaesthetists, midwives and nurses. I prefer one-on-one. It’s an effort being on call and having to take charge in an emergency. And it will only get worse when I’m a consultant.’

  As an alternative, Peter explained, he was seriously considering changing track and applying to train as a GP. In fact he had applied for GP training on four separate occasions during his obstetrics training. Each time he was accepted and each time he turned the offer down, and continued in obstetrics. Yet he continued in the specialty, despite the fact that he invariably found the labour ward an emotional struggle.

  ‘I want a better work–life balance in future,’ Peter told me. Then there was a pause. ‘I keep my private life quite separate from work – but I don’t want to be overwhelmed by my work so I have no energy for a private life, when I get home.’

  There was another, longer pause.

  ‘There’s also an issue of my sexual orientation. I’m gay. A couple of people at work know, but most don’t. And neither do my family.’

  I thought back to some of the homophobic jibes I had heard over the years: the not so subtle innuendo about a distinguished physician who was a ‘confirmed bachelor’ or the raised eyebrows in the outpatient clinic when a gay patient left the consulting room. And studies that have looked at sexual attitudes within the medical profession paint a disquieting picture. For example, a study published in 2015 by researchers at Stanford University in California found that over a quarter of medical students in the US and Canada who identified themselves as belonging to a minority sexual orientation concealed this at medical school1. So Peter was not alone in feeling the need to remain in the closet. Medicine, it would appear, is not the easiest profession in which to be openly gay.

  Peter continued his tale. Each time he had applied for GP training he’d felt relief at the prospect of removing himself from the demands of the labour ward. But his family and friends thought it would be a waste of all the time he had spent in obstetrics if he changed course. The nearer he got to completing his training the more he wanted to leave, and the more everyone around him argued that he should stay. Now, the need to decide whether or not to apply for the consultant post in his current trust had galvanised his thinking.

  ‘Last week, when I emailed you, I was really unsure, but I spent the weekend thinking things through, and my gut feeling is not to apply. The job has got a heavy clinical load in labour ward with little time for anything else, and I just don’t want it.’

  I had a sense that Peter had made his decision and that he might not actually need any further sessions. ‘It’s fine, if you get home and decide that you don’t want any more sessions with me,’ I told him. ‘Sometimes preparing for a session like the one today can be enough – and people realise they don’t need to delve any deeper into their career.’

  Thanking me for my time, Peter then left with a firm handshake.

  That afternoon, my mind turned back to our meeting: the urgent request to see me, and travelling halfway across the country for the session even though he had already made up his mind not to apply for the job; the large body in the too-small chair, almost as if he had outgrown something that he had been sitting on; applying to train as a GP on four occasions, but never being able to make the switch; continuing for eight years in a specialty which he had never really enjoyed.

  I started to wonder how his sexual orientation might have impacted on his choice of specialty. Two decades ago a young man growing up in his community, where being openly gay probably felt impossible, might well have struggled with the feelings he experienced when he examined some of his male patients. I don’t for a second think that he ever behaved inappropriately – and he might not have been conscious of the source of his discomfort – but perhaps he wanted to minimise contact with male patients. Could he have been drawn to obstetrics, even though he knew that he found the labour ward extremely stressful, because it was the one specialty where he knew all his patients
would be women?

  This is an issue that applies to all doctors, whether straight, gay, or whatever. All doctors have to be sufficiently at ease with the desires that a particular patient may evoke in them, so that they recognise the attraction while resisting the temptation to respond. Equally, it is unhelpful if the recognition of an attraction to a patient results in an overwhelming self-persecutory response.

  Working on the labour ward, you can never escape the risk of a woman experiencing a massive haemorrhage. This is a clinical emergency which can rapidly escalate into a clinical catastrophe – with the added complication that one has to consider the safety of both mother and child. As somebody who hated acute clinical emergencies, Peter would be better suited to the GP consulting room. I wondered whether it had taken Peter a long time to be sufficiently comfortable with his own sexuality, so that the thought of treating male patients no longer felt problematic. And perhaps coming to see me and being able to tell me that he was gay – even though he still kept his sexuality secret from his family and most people at work – was one of the final pieces of the jigsaw? I obviously thought that his sexuality had no bearing on his choice of specialty, and could see no problem at all with him training to be a GP.

  Mulling all of this over, my prediction was that he wouldn’t need to come and see me again.

  And he never did.

  Although I only saw Peter once, he made me curious. How well does medical training equip young people to carry out intimate examinations of another person’s body? After all, some of the students may never have seen the genitals of a person of the opposite sex – let alone touched them.

  My colleague Helena came to mind. She was an older obstetrician coming up to retirement – somebody who held a senior training role in the specialty and had supervised generations of medical students and junior doctors. Helena is also a friendly and open-minded individual, with whom it is easy to discuss sexual and emotional matters. I emailed her, asking how she helps neophyte doctors manage their feelings about carrying out intimate examinations, and how she approaches the possibility with them that an erotic dimension could enter into the process. This was her reply:

  This is an issue which has never come up and has certainly never been discussed in any training forum. This is not to say that it could never be an issue, but we never discuss even the possibility and how to handle it. We perhaps disassociate the clinical aspects of the patient assessment from any emotional process.

  I was astounded by her response. As a psychologist, I don’t examine any body parts. And I don’t touch, beyond an occasional handshake at a first or last meeting. I listen, I talk (and of course I look out for non-verbal signals such as blushing, shifting around in the chair or avoiding my gaze). The verbal currency that forms the basis of my professional exchange is qualitatively different from that of the doctor who is shown and touches parts of the body hidden from everyday view. Yet an essential part of my training as a psychologist was to make me aware of the emotional dynamics embedded in any verbal exchange with a client.

  I am alert to the power of the ‘transference’ that clients bring to any encounter. This is the notion, originating in Freud’s work, that people unconsciously displace on to the therapist feelings or thoughts derived from earlier key relationships in their life2. In other words, a client may respond to me ‘as if’ I were their father, or their mother, or some other key person in their life. This is an everyday occurrence in my work with clients:

  Natalie, a GP trainee, tells me about a recent incident at work. Her surgery was running late and she knew that patients were stacking up in the waiting room. In a rush to get through a particular consultation, she unthinkingly pressed a key on the computer and brought up the notes of the patient who was next in the queue, rather than the patient who was actually sitting in front of her. When it then came to issuing a prescription, she issued it for the wrong patient. Although she realised her mistake before the patient left the room, it had left her with considerable anxiety.

  After Natalie has finished describing the incident, I am left wondering which part of the story to pick up. Should I ask whether there was something about this particular patient that might have distracted her, or perhaps I should hone in on her anxiety? There is a pause as I ponder which avenue it might be most helpful to explore.

  Natalie interrupts my thinking:

  ‘You probably think I’m too stupid to be a doctor. That’s what my dad always said.’

  Natalie experienced my pause ‘as if’ it was laden with something.

  But transference isn’t a one-way street. Responding ‘as if’ one person was somebody else doesn’t just happen to clients. A comparable process happens to the practitioner, and is known in the trade as ‘counter-transference’. Again this is a ubiquitous feature of psychological work:

  Following a session with a desperately unhappy medical student, Frances, I am left with overwhelming feelings of anxiety. In part this is due to her previous history of self-harm, and her isolation, but I find myself entertaining the fantasy (which I obviously don’t voice) that perhaps she should come and live with me for a while, until she feels better able to care for herself. Even though I see many clients in comparable states of distress, and can usually manage my anxiety on my own, I have an urgent need to discuss my concerns with my clinical supervisor. I telephone her as soon as Frances has left and in this discussion I become aware that Frances is the same age as my daughter. There was something about Frances’s vulnerability that momentarily made me feel an intense desire to scoop her up and become her mother – hence the unspoken fantasy of offering her a home. Counter-transference.

  A couple of weeks later I met up with two colleagues who were also involved with supporting Frances. It emerged that they had both been left feeling unusually anxious. But these other colleagues didn’t have daughters of the same age as Frances – so they weren’t wanting to look after her because in some way she reminded them of their daughters. There was also something going on with Frances that made those supporting her hyper-aware of her extreme vulnerability. Later still, Frances told me that she had been abused by her stepfather as a child.

  In other words, my counter-transference to each client is partly a product of my personal history (Frances reminded me of my daughter) but also due to the unique history of the client, (Frances had been abused and unconsciously managed to project feelings of overwhelming anxiety into those who were tasked with providing her support).

  Transference and counter-transference are the warp and weft of psychological work. A key part of our training is learning how to step back and discern patterns in how the client unconsciously responds to you (transference) and how you unconsciously respond to the client (counter-transference). But these processes are not confined to the consulting room. They are ubiquitous phenomena that happen all the time, in our interactions with others.

  Back when I was a secondary school teacher, I can remember pupils putting up their hand and saying ‘Mum’ instead of ‘Ms Elton’. For a second they had unconsciously responded to me as if I was their mother. Typically they were then incredibly embarrassed. And it’s not just children. At work, some of the spats we get into (and our alliances) may have their roots in our relationships with siblings. And how we respond to authority often harks back to our early relationships with our parents. Transference and counter-transference happen between doctors and patients, therapists and clients, teachers and students, priests and parishioners, bosses and junior staff. They are everywhere. What’s different about being a psychologist is that not only are we taught about it, but we are also allowed (and even expected, in some theoretical circles) to talk about it. With the exception of psychiatrists, and GPs, doctors are rarely afforded this luxury.

  Yet even for psychologists there are times when discussions about transference and counter-transference get tricky, and that’s when one starts to stray into the territory of sex. The client may experience you as hyper-critical (as Natalie did), or unint
erested, chaotic, preoccupied – any emotional state, depending upon their own developmental history. So erotic feelings towards the psychologist can definitely be part of the rich mix. And the same is true for the psychologist, where an erotic dimension can enter into the counter-transference.

  My sessions with doctors focus on helping them think in depth about their work. Whilst all sorts of emotions can emerge in the consulting room, typically the discussions don’t become erotically charged. But in my training as a counselling psychologist I have worked with clients who were struggling with different sexual issues. I know what it feels like when you find yourself positioned as the object of desire (or the object of sexualised hatred) within a therapeutic relationship. And if I hark back to an even earlier stage of my career, when I was in my early twenties, I can remember noting a certain A-level student who seemed particularly keen to hang around after lessons and talk to me. There was definitely a sexual frisson in the air; I never transgressed any professional boundary, but there was a small part of me that felt quite flattered.

  *

  Erotic potential is never that far from the surface. Yet the response of my senior obstetrics colleague when I asked how she prepares medical students to carry out intimate examinations suggests that a defensive shield has been placed around the medical profession as a whole. The received wisdom seems to be that sexual stuff infiltrates other professions, but doctors are immune. Despite a vast literature on whether it is better to use manikins, anaesthetised patients or volunteer teaching associates to train students in carrying out gynaecological examinations, there was almost nothing written about helping students manage their sexual feelings. Just like intimate body parts, this topic was hidden from view.