Also Human Page 14

  In contrast, Orla’s supervisors understood that working with newborn babies so soon after losing three pregnancies could pose an intolerable emotional burden. In this case, it was Orla who struggled to allow herself to assume the role of patient. She was gentle and kind, and I am sure that she was a highly empathic paediatrician. When supporting parents after one of her paediatric patients died, I imagine she was well aware of the pain that these parents suffered. But when faced with her own losses, it was hard for her to ask for help.

  *

  Sadly Sarah and Orla are far from unique. I have seen many doctors whose careers have been derailed by health issues. Sometimes their problems were compounded by their own difficulties in accepting that they were unwell. At other times, enormous distress has been caused by the intransigence of their supervising consultants – all of whom were doctors – in making any allowances for the fact that they were ill.

  One doctor, Amy, whom I only saw a couple of times, had left medicine a few years earlier, and was attempting to return to clinical training. Amy had been diagnosed with insulin-dependent diabetes shortly before her medical school finals. Although she passed all her examinations, once she started working as a junior hospital doctor, the stress of the job, combined with working nights and irregular mealtimes, meant that she couldn’t keep her diabetes well controlled. As a doctor Amy knew only too well the longer-term implications of poor diabetic control (blindness, heart disease, kidney failure, amongst other conditions), and she became terrified that by continuing to work she was jeopardising her future well-being. So she left her job as a doctor.

  For a few years Amy worked in a research lab without any responsibility for patients. During this period she got used to managing her illness, and eventually was able to achieve reasonable diabetic control. She then successfully applied for a post that allowed her to complete her foundation training, and at the point when she came to see me she was about to apply for a place on a GP training scheme.

  What prompted Amy’s request for a meeting was that one of her supervisors had advised her to lie on her application form. Instead of giving the true reason for her time away from clinical practice – that she had been struggling to get her diabetes under control – the supervisor suggested she should come up with some other story. Perhaps she could say that family members had been ill. Amy was particularly upset by her supervisor’s comment that, if she talked about her diabetes, she would never get a place on a GP training scheme.

  My view was that Amy had been given lousy advice. Leaving aside the fact that there is legislation in place to protect an applicant from discrimination on the grounds of health, there were two major flaws in her supervisor’s suggestion. First, if, for whatever reason, the lie had been discovered, Amy’s application would have been thrown out. She might even have been reported to the GMC. Honesty is a core professional value in medicine – and indeed in all other professions. Advising somebody to lie is encouraging them to commit professional suicide.

  Second, chronic illnesses including diabetes are increasingly managed by GPs, rather than by hospital doctors. Patients with chronic illnesses also have to manage complex treatment regimens at home, and problems with non-adherence are rife. It’s not always easy to take medications according to a strict timetable, or stick to diet and exercise recommendations. Amy had personal experience of making changes in her life in order to accommodate the demands of a lifelong illness. Rather than hiding her diagnosis on her application form, she could turn it round to her advantage and talk about what she had learnt, and how she would use her experience to support patients when they struggled with different chronic conditions. Amy didn’t lie on her application form or at interview. And she was successfully appointed to a GP training scheme.

  *

  Being accepted as a doctor with diabetes is one thing, but many of the doctors in Klitzman’s study talked about the stigma attached to psychiatric symptoms. For example, Jessica, the paediatrician with cancer, became depressed during her treatment. When this happened, she felt blamed by her colleagues: ‘Cancer’s not your fault. You can’t help it. But doctors view mental illness as your own fault. I felt it in conversations about other people: a lessening of respect for the person who had it.’

  Another doctor in Klitzman’s study, Ernie, had been diagnosed with Huntington’s Disease – an incurable genetic condition with increasingly severe neurological and psychiatric symptoms. He had this to say: ‘I have not faced any discrimination from Huntington’s Disease. But the hospital was not nice about the depression: they actually were going to fire me!’

  Not surprisingly, given these sorts of responses, doctors in Klitzman’s study who experienced psychiatric symptoms talked about the difficulty of admitting (to themselves, and to others) that they had become mentally unwell.

  Over the years I have spoken to doctors diagnosed with a number of illnesses, including cancer, MS, epilepsy, narcolepsy, rheumatoid arthritis, diabetes, Crohn’s Disease, lupus, schizophrenia, bipolar disorder, and depression. Whilst many have struggled to progress their medical careers, given the difficulty of being both a doctor and a patient, doctors diagnosed with psychiatric conditions have undoubtedly had the hardest time of all.

  As one psychiatrist told me, following his admission to a psychiatric ward:

  The other patients were always moaning about the psychiatrists who treated them. I didn’t want any of them to know what my job was. But the psychiatrists treating me saw me as a patient rather than a colleague – I didn’t belong with them either.

  After a pause, he continued: ‘On the ward I couldn’t be either a patient or a psychiatrist. And there was no way that I could be both.’

  *

  How can we best understand the impossibility of being allowed to be both a doctor and a patient at the same time?

  The most compelling answer is that the doctor–patient split serves an important psychological function. On a daily basis, doctors encounter distress, disease and death. Doctors are mortal, as are the people they love. So any of the difficult things they see in their patients could happen in future to them, their families or their friends. (Indeed, as we have seen in previous chapters, some of these tragedies may already have happened in their lives, which might be one of the reasons why they were drawn to medicine in the first place.) Positioning themselves as ‘other’ than their patients happens unconsciously, and assists doctors in going about their work without being psychologically overwhelmed by anxiety.

  The notion that people can respond to extreme anxiety by resorting unconsciously to these sorts of defensive strategies might sound far-fetched. But how else can we explain the fact that the doctors who had themselves experienced fertility difficulties were the least sympathetic to Sarah’s plight? The simple explanation is that Sarah’s infertility reminded them that they too had once been treated for the same condition. This reminder was far from welcome as it made them feel vulnerable – so they reacted with particular hostility as they tried to distance themselves from Sarah’s experience.

  It’s also important to acknowledge that the fantasy of being categorically different from one’s patients is often institutionally reinforced from the very beginning of medical training. The author Michael Crichton isn’t the only doctor who has commented on the place that human dissection plays in this respect2: ‘An important part of the dissection laboratory is that it requires students to break taboos surrounding the desecration of human remains … such an act has the effect of setting the medical student apart from others,’ concluded two researchers3.

  Writing about his experience as a medical student, psychiatrist and psychoanalyst Norman Straker had this to say4:

  I remember my first day of medical school as a young medical student with horror. We were casually introduced to our cadavers without any preparation or discussion. My first cut into the cadaver was the first of many traumatic experiences in medical school that changed me. I was being prepared psychologically to be an objective docto
r … I now believe that this frightening experience with no preparation began the unconscious psychological defensive split between the patient and me. Cadavers, our first patients, were made very distinct from us, the healthy ‘immortal medical students.’ Our defense against death, ‘our specialness,’ was being established.

  Norman Straker was describing what happened forty years ago. I doubt whether this institutional neglect of the potential emotional impact of dissection would happen nowadays. As an example, Sabine Hildebrant, a researcher based at Harvard Medical School, has outlined a range of different strategies that need to be incorporated into the anatomy curriculum, in order to prepare students for dissection5. Her suggestions include identifying those students who might find the experience particularly stressful, pre-course meetings, team reflection in the lab with faculty feedback, and a memorial service organised by students for faculty, students and donor families. Other medical schools – particularly some of the newer ones – have entirely abandoned the use of human dissection as a way of teaching anatomy6. Times have moved on.

  But despite all these changes, in those schools that use dissection, the cadaver is still routinely referred to as the ‘first patient’7. And whilst on the one hand it could be argued that this reminds students of the need to treat the cadaver with respect, on the other hand, as Norman Straker suggests, it also reinforces the idea that doctors and patients are categorically different.

  *

  I was once invited to sit in on an interview preparation workshop that a consultant organised for foundation trainees in his hospital. It was a ‘twilight’ session – held at the end of the working day after doctors on the day shift had handed over to their night-shift colleagues. I remember the doctors coming into the teaching room in the hospital education centre in successive waves – they couldn’t leave the different wards around the hospital until somebody had come to relieve them. And I also remember being touched by their delight at finding that tea and biscuits had been provided at the back of the room. Tiny examples of being cared for or nourished by the training system are often in short supply for junior doctors.

  Although these foundation doctors would have had times in the week when they were brought together for training, most of the week they would have been separated, spread thinly across the different hospital wards. They were eager to catch up with each other’s news, and before the session started there were noisy and animated conversations going on within the group. And a lot of laughter.

  The furniture in the room made it clear that there was going to be a mock-interview. At the front was a table with two chairs facing each other – one for the interviewer, and one for the interviewee. Behind the interview table were rows of seats, arranged in such a way that the doctors could sit and observe.

  ‘Let’s get started,’ said the consultant. ‘Who is brave enough to go first?’

  ‘I will,’ answered one of the trainees.

  I’d noticed this woman as she came in, cracking jokes with her colleagues. But it wasn’t only her animated manner that had caught my eye – she was over a foot shorter than most of her colleagues. She suffered from dwarfism.

  With some difficulty this trainee manoeuvred herself into the hot seat and the consultant kicked off with his first question.

  ‘What makes you stand out as a doctor?’ he asked.

  The colour drained from the trainee’s cheeks, and for a brief moment I thought she was going to cry. All eyes in the room were on this young woman and collectively we witnessed how the animation present a few minutes earlier, when she was laughing with her colleagues, seeped out of her body. As if temporarily frozen, she was unable to speak. A couple of seconds later, with obvious difficulty she regained her composure and started to answer the question.

  It was painful to see this lively young woman rendered temporarily speechless in front of her colleagues. And why had the consultant been so clumsy with his choice of words? At the time I thought the consultant must have been unusually insensitive – somebody who spoke without first thinking about possible associations of the words he chose to use. But over the next few years when doctors with different physical and sensory disabilities came to see me, I learnt that such insensitivity was not uncommon.

  Just like the consultant’s in the mock-interview course, the comments were often thoughtless rather than deliberately cruel. So, for example, I’ve never forgotten one hearing-impaired doctor, Ian, who repeatedly had to ask his consultant on a ward round not to hold the patient’s notes in a way that obscured her mouth. Day after day the consultant made it impossible for Ian to lip-read what she was saying. After yet another interminable ward round when he was left unclear what clinical tasks he needed to get on with, Ian reminded his consultant about his reliance on lip-reading.

  ‘The trouble is, Ian, you’re such an able doctor. We all forget that you lip-read,’ said the consultant. ‘Why don’t you wear a badge saying “I’m Deaf”?’

  Ian remained silent. Yet this insensitive comment, alongside the lack of provision of basic equipment such as a device to enable him to use the telephone on the ward, eroded his motivation to the point that he was considering leaving medicine. Luckily his next placement was completely different, and Ian was able to rediscover his enjoyment of clinical practice.

  Other doctors with a range of physical and sensory impairments also told me about hospitals’ failure to provide vital equipment. And this equipment that didn’t materialise despite being requested wasn’t multimillion-dollar kit – it was specialist chairs, or information printed in larger type. The sorts of accommodation that medical schools and hospital trusts were legally obliged to provide in order to be compliant with equality legislation. Doctors like Ian knew that they could have sought legal redress, but frequently they didn’t want to be seen as difficult or demanding, so they just put up with inadequate (and illegal) levels of support.

  Sadly, alongside thoughtless comments and lack of necessary equipment, there were also examples of downright hostility. ‘I don’t know why you were ever allowed to come and work here,’ was the greeting that one doctor with a physical disability received on her first day of a new job. Another was told within days of starting that ‘this is never going to work out’. Faced with this type of response from her consultant, the trainee found herself unable to carry out straightforward procedures such as taking blood, which she had performed without any difficulty in her previous, far more supportive placement.

  Little wonder then that some doctors tried to hide their disabilities, fearful of the impact these might have on their careers. I remember, in particular, a doctor with a progressive congenital visual impairment who hadn’t told anybody at work about his slowly deteriorating eyesight. I managed to persuade him that even if he lost his sight entirely, there would still be jobs for him in health policy or health promotion, or in the pharmaceutical industry. But if it was discovered that he had been seeing patients without having an occupational health assessment of his vision, he risked a referral to the GMC, and possibly being struck off for a lack of professionalism. With that black mark against his name, establishing his career in a non-patient-facing role might prove far harder. Luckily he listened to me, and he agreed to go and see occupational health. His eyesight was judged to be good enough for clinical work, although provision was made to check it regularly in future. However, I’ve never forgotten the message he left on my answerphone, as he sat in the occupational health waiting room:

  ‘Caroline, I’m frightened.’

  *

  Julie Madorsky, a physical medicine and rehabilitation specialist in California, was once teaching a group of medical students about the work opportunities for people with physical disabilities8. A gowned patient was wheeled in, and it was explained that the patient had cerebral palsy (a neurological condition caused by problems in the parts of the brain responsible for controlling muscles) together with a speech impediment and severe ataxia (loss of full control of bodily movements). After Madorsky had
taken the patient’s history and carried out a physical examination, the patient was wheeled out and the medical students were asked to appraise his capacity for learning or employment. The collective opinion of the students was that the patient was severely disabled and could do a menial part-time job perhaps, but nothing more. The patient got dressed, returned to the classroom and was re-introduced as Dr Thomas Strax, Assistant Medical Director at a rehabilitation hospital in Pennsylvania. That was his position in real life.

  If you had asked the medical students before the session about their views on employing patients with disabilities, I suspect that most of them would have talked about the importance of equality of opportunity. But faced with a patient with a significant physical impairment, they jumped to stereotypical assumptions about his intellectual and occupational potential.

  I doubt that the medical students in that classroom ever forgot that session. I also imagine that Julie Madorsky was driven to carry out what some people might think of as an act of deception because of the intransigence of attitudes towards the disabled within the medical profession. She wrote: ‘a constant refrain is that physicians, however educated and beneficent, are a steadfast impediment to bringing the disabled into medicine’.

  Just like the doctor with dwarfism on the interview course, reports on the experience of doctors with physical and sensory disabilities are replete with examples of casual insensitivity. For example studies have detailed thoughtlessness in relation to anticipating problems with access – such as when a senior academic physician who was due to be honoured at an award ceremony found herself stranded in her wheelchair, at the bottom of a flight of steps into the hall9. Then, as if her dignity hadn’t already been compromised enough by having to be carried up the steps, she couldn’t risk having any refreshments during the award ceremony because there was no wheelchair-accessible toilet.