Also Human Read online

  Often the proceedings drag on for an exceedingly long time. It’s not unusual for it to take nearly a year from the point a doctor is charged, to the case being heard in a criminal court. That’s long enough. Then a subsequent Fitness to Practise tribunal during which conditions may get imposed on a doctor’s registration, and any subsequent appeal can drag on for two years or more. Technically, if a doctor has conditions imposed (as opposed to suspension or erasure from the medical register) they can work as a doctor, as long as the conditions are met. In practice these doctors can find themselves in occupational limbo.

  As a woman (and the mother of a daughter), I can imagine how horrible it would be if one thought that the doctor who was examining one’s body was deriving sexual pleasure from the experience. It’s stressful enough to let a stranger touch one’s body in places that one otherwise reserves for a lover (or lets nobody touch). So I am not in any way condoning the behaviour of a doctor who attempts to obtain sexual gratification from their patients. I would also want to feel certain that the GMC had placed conditions of sufficient stringency on a doctor’s practice so that future patients would never be left feeling violated, following a medical examination.

  But I can also imagine some young doctors – particularly if they are sexually inexperienced – being tasked with carrying out an examination of a woman’s body. Nobody is around – it’s just the doctor and the patient in a cubicle. It felt different when these doctors had to examine a woman as a medical student. Back then there were a number of people watching over them, assessing what they were doing. Here it was just the doctor and the patient. Perhaps at this point there is an almost imperceptible change in the doctor’s breathing or his hand seems to linger longer or stray further than the patient expects.

  The patient has some sense that the doctor is not as detached as he should be and that something isn’t quite right. Understandably, the patient feels that the trust she placed in the doctor has been abused. They would probably deem it necessary to lodge a formal complaint – and they would be right. Yet at the same time, I can’t help but feel sadness about some of these young doctors.

  On some level, they might well be aware that there is a problem. They note the frisson of excitement when they walk into a cubicle and find that the patient is a young woman – particularly if she is good-looking. And these doctors may be aware that the excitement increases when a clinical reason requires an internal examination. They know that they shouldn’t be having these feelings. But they have no idea what to do about them.

  At no stage in their training has anybody ever discussed the possibility that they might find aspects of examining a patient’s body sexually exciting. The whole topic is taboo. They have read the GMC guidelines and know that doctors are not allowed to have relationships with patients, and that doctors mustn’t use their privileged access to patients’ bodies for their own sexual ends. But despite the explicit recommendation in the CHRE review that trainees should be taught that there is nothing unusual or abnormal about developing sexualised feelings towards patients and that it is acting on these feelings that is problematic – the GMC guidelines fail to mention that this could ever happen. Thus doctors in this position think that they alone have these feelings. They have no idea where to turn for help.

  So they continue examining patients, keeping their shameful secrets to themselves until there is a complaint. And then the career they have dedicated themselves to for well over a decade comes crashing down. Any savings that they have get used up during the three-year period that it takes to complete the GMC proceedings. In theory the GMC conditions allow them to continue working but the harsh reality is that often it proves impossible to find a clinical setting where the conditions can be met.

  When doctors with these sorts of conditions come to see me, I try to encourage them to explore options beyond medicine. But typically they counter this suggestion, pointing out that they have been acquitted of a crime and the GMC has kept them on the medical register, so why should they give up their dream of returning to medicine? But sometimes months have turned into years, and despite endless meetings, and sporadic hopes that a given hospital would offer them a job, each possible lead evaporates.

  *

  If the possibility of a doctor being aroused by a patient has never been discussed during one’s training, how can young doctors seek out a trusted older colleague and talk about any sexual feelings that they may experience when carrying out intimate examinations? And as long as the taboo surrounding this issue remains in place, doctors will be denied opportunities to talk about their feelings and – crucially – to put strategies in place so that their sexual desires aren’t enacted when they are alone in the consulting room with a female patient.

  There’s also the impact of the regulatory process itself. Every medical system needs a way of holding doctors accountable, in order to protect the well-being of patients. This issue is not new. Four hundred years before the birth of Christ, Hippocrates recognised that doctors had privileged access to patients’ bodies, leading to the danger that this can be exploited for sexual ends. But when we look at our 21st-century solution to the problem, it’s hard to conclude that we have got it quite right.

  Following a spate of suicides of doctors who were subject to GMC investigations, an internal review was commissioned which published its findings in late 201420. Amongst the report’s many recommendations were the need to reduce the length of time it takes to complete an investigation and the importance of assisting – in a compassionate way – doctors who are being investigated. The following year the GMC commissioned a specialist service to provide confidential emotional support to any doctor involved in a Fitness to Practise case. These developments would have helped some of the doctors I’ve encountered.

  Maybe the arcane details of specialty training regulations in the UK are particularly hard to navigate. But I suspect that doctors in other countries face comparable challenges once they have been reported to the regulator. Across the English-speaking world, only the GMC has published data on the psychological impact of being the subject of a Fitness to Practise investigation. As a national body, the GMC is in a stronger position to undertake this sort of research than the regulatory organisations in the USA and Canada, where disciplining doctors takes place at the state rather than the national level. Little is known about what happens to doctors in these countries who end up falling foul of the regulator. But I don’t imagine that their stories have happy endings.

  5

  Role Reversal

  SARAH HAD PLANNED to conceive her first child in December so that it would be born the following September. She had read that children with birthdays at the beginning of the school year tended to do better academically and she wanted to ensure that she gave her child the best start in life. But four years later, with no baby in sight despite a range of different fertility treatments, Sarah didn’t care what month she conceived; she just wanted a baby.

  In our sessions together it became clear that her inability to conceive was overshadowing everything else. She described herself as somebody who liked order and control in her life and planned everything meticulously. Whether it was revising for postgraduate exams or preparing for her wedding, Sarah needed to know that she had left nothing to chance. Sadly, she had to learn that even with the best fertility treatment on offer, her baby project could still fail. And she didn’t have the option of immersing herself in her work as a distraction from the pain of infertility. Babies were her work, as Sarah was an obstetrician.

  Every hour of her working day Sarah was surrounded by women who were either expecting babies or were in the process of giving birth to them. The only exception was the infertility clinic where she had to talk to patients about the different treatment options, all of which had failed to work for her. When her infertility patients became pregnant she longed to be the patient rather than doctor. When they failed to get pregnant it not only reminded her of her own childlessness, but also made her feel us
eless. A doctor who couldn’t protect her patients from the pain she was feeling herself.

  When Sarah first came to see me she felt trapped. She was in her sixth year of specialty training as an obstetrician, had long since passed all her postgraduate exams, and in a couple of years’ time would be eligible to apply for a permanent post as a consultant. Yet the prospect of delivering other women’s babies for the rest of her life, if she herself couldn’t have one, filled her with dread.

  One might have imagined that as Sarah’s colleagues were all obstetricians who had treated infertile patients they would have been kind and sympathetic to her predicament. But they weren’t. The prevailing response from her supervisor seemed to be that she should ‘pull herself together, and concentrate on her patients’. What made this even more galling was that she knew from colleagues that this particular consultant had needed IVF treatment to become pregnant.

  A similar thing happened in Sarah’s annual review meeting. The whole procedure left her feeling bitterly disappointed by the training system; nobody on the panel accepted that her struggle to conceive should have had any impact on how she was feeling about her career. Instead they implied that she was lazy, or unmotivated, or making a fuss about a minor matter. She later found out that two senior consultants on the panel had also been through IVF, yet neither had come to her defence.

  I couldn’t give Sarah what she most wanted in life. But by the end of our sessions, two things became clearer for her. First, she came to understand that the pain she experienced at work wasn’t a sign of weakness. It would be extremely cruel to walk somebody who was starving through a supermarket stocked full of food without letting them eat. In the same way, to expect a young woman who was trying to come to terms with her own infertility to be surrounded by pregnant women and babies and just be able to ‘pull herself together and get on with her work’ was both heartless and unrealistic.

  The second thing we were able to do in the sessions was to come up with a Plan B – an escape route – should Sarah feel at some time in the future that she needed to change career. The small number of consultants who were able to give credence to her distress had suggested that the obvious thing was for her to retrain as a GP. But Sarah instinctively felt that the GP route was the wrong option, and I agreed.

  Prior to her difficulty getting pregnant, Sarah had loved the drama of the delivery suite, where you are always working alongside lots of other colleagues. Being on her own in a GP surgery held no appeal. She had also enjoyed the fact that pregnancy was a time-limited condition with a definite end. In contrast, with specialties that she had encountered earlier in her career, she had found it depressing to treat lots of patients with chronic illnesses, often with poor prognoses. If she trained as a GP, her surgery would be full of patients with long-term conditions which had no quick cure.

  Through our discussions Sarah decided that, should she need to switch in future, emergency medicine would be a better Plan B. This option would give her lots of colleagues and lots of drama, and – perhaps most important of all – with a four-hour limit on being treated: patients in A and E either become the responsibility of clinical colleagues in other hospital departments, or they are discharged back to the care of their GP, who is responsible for providing lifelong care.

  That doctors, or their family members, should be inflicted with the same conditions as their patients isn’t surprising. But what was surprising in Sarah’s case was the way her supervisors made her feel that she was at fault for experiencing distress. Somehow, as a doctor, she was expected to be able to rise above any upset. Other doctors respond to this expectation by feeling that there is something wrong with them if they can’t push their feelings to one side and just get on with their work. This was what happened to a paediatrician called Orla who came to see me shortly before she was due to start a neonatal placement.

  Orla had recently experienced, for the third time, a late pregnancy loss, and she was dreading the prospect of caring for newborn infants. She hadn’t countenanced the possibility that her rotation could be altered, or that she could request some time out of training to recover from her recurrent miscarriages. Luckily the clinician in charge of paediatric training was extremely sympathetic, and Orla’s neonatal rotation was changed. But when I first suggested it to her, Orla felt that such a switch would only be granted in much more severe situations; she had no sense that most women would find caring for neonates challenging if they had recently lost three pregnancies.

  *

  At least Orla knew why the prospect of working with neonates felt unbearable. I’ve also encountered doctors who have repressed any conscious connection between events in their personal lives and their feelings about work – which was what happened to Jack.

  In our first session, Jack told me he wanted to leave medicine. We talked through his career history; when he had first thought about medicine, his experience at medical school and how things had panned out once he started working as a doctor. Nothing he told me cast any light on his current dissatisfaction at work. Puzzled, I asked him about his current placement. Were his supervisors supportive? How were his colleagues? This line of enquiry also led nowhere, as he liked all of his current team.

  ‘Tell me a bit about your family,’ I said. ‘Is there anything going on at home that might be having an impact on your work?’

  Jack let out an audible sigh, paused, and looked down at the floor.

  ‘My mum was diagnosed with breast cancer three months ago. She’s responding well to the treatment, but it’s hard to find time to visit her as much as I would like.’

  Jack was rotating through different medical specialties, and currently was working with cancer patients. Extraordinary as it sounds, he hadn’t made the conscious link between his mother’s illness and his growing unhappiness at work. Once we started to talk about it, he realised that when patients responded poorly to treatment, he felt extremely anxious. Perhaps that was how his mother’s cancer would progress in future. And irrespective of their prognoses, he resented spending time with other people’s mothers rather than his own. When Jack gave voice to his fears about his mother’s illness and seeing how being surrounded by patients with cancer constantly reminded him of her, his urge to flee medicine felt much less acute.

  *

  The challenge that doctors face when they themselves become ill isn’t just that their patients remind them of their own health concerns, which makes it hard for them to take refuge in their work. Far bigger than this issue of reminders is that of incompatible roles. Like the binary alternatives zero and one, the culture within medicine often positions patient and doctor as mutually exclusive categories. You can be one, or the other – but never both together.

  Psychiatrist Robert Klitzman had a sister who died in the attack on the World Trade Center on September 11, 2001. A few months later he became seriously depressed – although he resisted the diagnosis initially. Through this personal experience he became interested in how doctors respond when they face a significant illness, and once he had recovered and returned to clinical practice he set about researching this topic. The extreme difficulty of being both a doctor and a patient is one of the major themes that emerged.

  For example, Jessica, a paediatrician in his study, who was being treated for cancer, described how her oncologist talked to her as if she were a colleague rather than a patient:

  Because I was a doctor, he would talk to me about his other patients. ‘I have a patient just like you. She looks like you: same age, and has the same exact tumour. She’s in the hospital.’ So of course I say, ‘How’s she doing?’ He says, ‘She’s dying.’

  Of course it’s not inappropriate for colleagues to discuss the similarity between two cases – this happens all the time. But even though Jessica was a colleague, it was insensitive in the extreme to draw her attention to this other patient. One can’t imagine that the doctor would have made this comparison to a patient who wasn’t also a colleague. Jessica, and many of the other d
octors in Klitzman’s study, encountered less than optimal care because their treating physicians approached them as if they were colleagues rather than patients.

  But Klitzman’s analysis makes it clear that the root cause is more complex than that of insensitive physicians. Many of the doctors in Klitzman’s study described how difficult they found it to relinquish the role of doctor and assume that of a patient. So, for example, Dan, an oncologist with metastatic lung cancer, described how:

  The hospital staff have seen me over the years and know who I am. It’s very strange to sit there in a hospital gown … When I go for my scans, I bring along a pair of [theatre] scrubs, and change into scrubs, rather than into one of their sets of patient pyjamas which, because of my girth, don’t fit me.

  Dan may have rationalised this decision as relating to his size. But by choosing clothes that doctors wear at work (theatre scrubs) rather than more neutral attire (a tracksuit, for example), he was simultaneously reminding people of his professional status. Non-medical patients don’t have access to theatre scrubs.

  So doctors, when ill, often struggle to be seen as patients, in the same way that doctors treating other doctors might respond to them as colleagues rather than sick patients. Both parties contribute to the difficulty of inhabiting a space where somebody could be both a doctor and a patient at the same time1.

  Sarah, the obstetrician who couldn’t conceive, was viewed by her colleagues as a doctor rather than a patient. I cannot imagine that other patients these colleagues were treating in their infertility clinics would have been told that they should just pull themselves together and stop worrying about whether or not they would conceive. But Sarah was a doctor and therefore, in their eyes, shouldn’t be vulnerable to the distress experienced by non-medical patients.