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  As I sat in the office wondering how Ellen and Vartika were getting on, my mind turned back to another paediatric ward round that I had observed years previously. Raj, the consultant on that occasion, couldn’t have been more different to Ellen. He was warm, gentle and kind. I remembered how a little boy of about two or three wriggled off his mother’s lap and ran away when Raj walked into his bay on the ward. The boy’s parents had been mortified and shouted to him, but Raj had simply followed the boy to the centre of the ward where there was a large pile of toys. By crouching down next to where the boy was playing, Raj got his stethoscope out and carried out the examination while the boy was absorbed by the toys.

  Later that afternoon on the same ward round, Raj was summoned to an emergency in A & E. The helicopter service had been called to an eleven-year-old boy who had been hit by a car; the boy wasn’t expected to survive. Raj’s registrar wanted him to come down to A & E, to talk to the boy’s parents. I waited a very long time that afternoon, increasingly anxious about getting back to my own children because the observation was taking much longer than anticipated. At the same time I was acutely aware how trivial my own childcare concerns were, in comparison to the devastating information that Raj had to convey to the dead boy’s parents.

  Just when I had decided that I would leave Raj a note and head off home, he returned, looking exhausted. I had imagined that the last thing he would have wanted to do was to get my feedback for his ward round teaching – but I was wrong. Perhaps as a way of de-intensifying the emotional load of the day, he wanted to shift his attention from telling parents about the death of their child, to the more benign task of listening to my feedback. I had no doubt that he had been as compassionate with the bereaved parents as was humanly possible and the strain in his face showed that the encounter had taken its toll.

  As with Raj, I waited a long time for Ellen to return to the ward. But unlike Raj, she didn’t want to receive my feedback on the ward round and suggested that perhaps we could talk on the phone at a later date. I wasn’t willing to comply with this request as I felt it was my responsibility to point out her failure to respond to Vartika’s desperate requests for assistance.

  There are different models of how best to give critical feedback, but none of them suggest that you should go straight for the kill. Yet that’s precisely what I did with Ellen. I didn’t attempt to re-establish rapport, or get her sense of what had worked well in the pre-ward round meeting. Instead I gave her copies of my observation notes and pointed out that I had noticed Vartika’s distress from the moment she first said she didn’t feel able to certify the baby’s death. My anger at Vartika’s abandonment spilled over into how I approached giving Ellen feedback. It was a poor piece of pedagogy on my part and I wasted a valuable opportunity to model a more supportive stance. Although the stakes were much lower, I failed to meet Ellen’s needs in much the same way that she failed to attend to Vartika.

  Ellen did allow me to come back and do the subsequent observations but our relationship never quite recovered. Despite frequent reminders, it took her nine months to agree on a date for the next session. The spectre of the dead baby, the unsupported trust grade doctor and the angry psychologist never quite went away.

  *

  What is it that makes some doctors empathic, and acutely attuned to the emotional needs of those around them, whilst others remain oblivious to other people’s distress? Why did Ellen fail to support Vartika, whilst Raj treated everyone around him with kindness? Why did I continue the pattern of insensitivity, and compromise the support that I offered Ellen?

  If I start with myself, it was my anger that got in the way, perhaps tinged with an element of shame. My role was to observe how Ellen trained her team, not to intervene in the day-to-day running of the ward round. But when we abandoned Vartika, I could have asked Ellen for a quick word, in private. I had noticed Vartika’s distress but failed to assume a more active role in getting her the help she needed.

  What about Ellen? Perhaps she had been on call the previous night, and was short of sleep. Or perhaps she had young children at home who had kept her up at night. It’s harder to be empathic when one is exhausted; that’s why reducing the working hours of junior doctors has been shown to enhance their capacity for empathy.

  But it’s not only exhaustion that influences our adult capacity for empathy. Despite the fact that adults typically remember little that happened to them prior to the age of three, our experiences in infancy have a pervasive impact on our psychological functioning throughout life. In particular, the quality and consistency of our early relationships with a primary carer (who doesn’t have to be our mother) shapes how we tend to respond when we feel threatened by separation or loss.

  These ideas are not new. In the aftermath of the Second World War, the paediatrician and psychoanalyst John Bowlby studied children who had been orphaned, and noticed the damaging impact that parental loss had on their subsequent psychological development1. Bowlby then became interested in how psychological bonds (which he termed ‘attachments’) develop between infants and carers, why these bonds develop, and what happens when the normal process of attachment is disrupted. Drawing on research from animal behaviour, Bowlby recognised the evolutionary advantage of an infant being able to signal distress to their carer when they feel under threat, thus drawing the carer into closer proximity.

  Later, Bowlby’s student, Dr Mary Ainsworth, conducted a series of observational experiments (known as the ‘Strange Situation’), in order to assess differences in how infants of one to two years of age were attached to their parents2. These experiments took place in a playroom which was new to the infant, and full of toys. Throughout the experiment the infant was observed through a one-way mirror. A set series of events took place, with the parent leaving the room and coming back a few minutes later. Sometimes a stranger was present in the room, and sometimes not. The events were designed to be stressful enough to trigger an attachment response on behalf of the infant.

  The observers behind the mirror looked closely at how the infant responded to the stranger, to the departure of the mother, and then to their later reunion with the mother. Through studying hundreds of infants in this experimental situation, Ainsworth concluded that there were three different ways in which infants can be ‘attached’ to their mothers. Infants who were ‘securely’ attached to their mothers readily explored their new surroundings when their mother was present, showed anxiety in the stranger’s presence, were distressed by their mother’s brief absence, rapidly sought contact and were quickly reassured once the mother returned. About 60% of infants fell into this group.

  The remaining 40% of infants were classified as ‘insecurely’ attached and exhibited one of two different patterns of behaviour in the experimental situation. Infants whose insecure attachment was classified as ‘avoidant’ appeared less upset at separation, might not seek contact with the mother on her return and might not prefer the mother to the stranger. In contrast, infants whose insecure attachment was classified as ‘resistant’ showed limited play initially, became highly distressed by the separation and did not easily settle once the mother reappeared. A subsequent group of researchers identified a third group of insecurely attached infants with ‘disorganised’ attachment3. This was characterised by first seeking contact from the mother on her return, but then, once they were close to the mother, becoming extremely fearful. In addition these researchers also developed a way of assessing adults’ attachment – the so-called Adult Attachment Interview (AAI)4. This semi-structured interview consists of twenty questions and takes about one hour to administer. During the interview, participants are asked to describe early childhood experiences with primary attachment figures and evaluate the impact of these experiences on their development.

  On the face of it, how infants respond to their mothers (or primary caregiver, if the person regularly looking after the infant doesn’t happen to be the mother) might seem to have little to do with doctors. But studies have
shown the enduring impact of our early attachment relationships on aspects of our adult life that have a direct bearing on the medical profession. Thinking first about being on the receiving end of medical care, the nature of the patient’s early attachment experience influences how they respond to illness. For example, a 2012 study found that patients who go regularly to their GP with vague medical symptoms, which never get diagnosed, tend to have insecure attachment styles5. The authors of this study concluded that these patients’ high consultation rates could be thought of as a form of care-seeking behaviour, linked to their insecure attachment. Similarly, another study of terminally ill cancer patients found that those with a secure attachment style had a greater capacity to form a close working alliance with their physicians6.

  What is perhaps more surprising is that one’s early attachment experience not only influences how we respond when we are the recipients of care, but is also implicated in our capacity to give care to others. Gwen Adshead, a forensic psychiatrist, beautifully describes how this works:7

  Early attachment experience becomes represented cognitively in the brain as an ‘internal working model’, a complex schema of images, beliefs and attitudes towards attachment relationships … the ‘caregiver icon’ which is engaged psychologically when the individual is either in need of care or has to provide it.

  So how we were cared for when we were dependent infants influences our capacity to care for others, when they too are vulnerable.

  *

  A sick or dying baby is probably the most powerful example of a human being in need of care. From a psychological point of view, a dead baby represents a catastrophic failure of care. There’s no escaping the fact that managing one’s emotional response to this situation is a demanding psychological task. On the morning that I observed the ward round, Ellen and the two other trainees didn’t want to think about the dead baby, or the parents – and instead chose to dump their duties on the least powerful doctor in the room.

  And it’s not only the tragedy of a baby’s death that imposes a psychological burden on healthcare staff. Caring for babies in the early stages of life, particularly if they have been born very prematurely, can also be an acute psychological stress for some doctors. Of course on a practical level, the physical tasks associated with medical care (taking blood samples, putting in a cannula) are much trickier when the patient is tiny. But when trainees have talked to me about their intense fear of the neonatal ward it probably has as much to do with their personal response to extreme vulnerability, as with any problems linked to tricky practical procedures. This was made clear to me when a medical student called Laura came to see me. Laura had a long history of anorexia and staff at the medical school were gravely concerned whether she was well enough to start working as a foundation doctor. Laura had opted to spend her elective period in her final year at medical school working on the paediatric wards. I didn’t think it coincidental that whilst she could cope with older children in the paediatric ward, some of whom were suffering greatly, it was the neonates that she found most disturbing. The tiny, scrawny premature babies presented an image of extreme vulnerability that in some way mirrored her own physical and psychological state. I have never forgotten Laura’s intense feelings about neonates and the way in which it dramatically illustrates how the needs of the patient can reverberate within the psyche of the doctor.

  We also need to remember that we require young (and sometimes vulnerable) doctors to carry out appallingly difficult things – like certifying the sudden and unexpected death of a baby. I asked a consultant paediatrician colleague exactly what this entailed:

  Only a doctor can certify death, so this task cannot be delegated to a nurse. The doctor would probably not be alone. The parents would be given the option of attending, and if they chose to, they would probably be accompanied by a senior nurse to support them. The police have to be informed of a sudden death of a child, and they might be in attendance as well, if any aspect of the case made them concerned that a non-accidental injury had taken place.

  First the doctor would check that there were no signs of life. Then they would have to remove the baby’s clothes and examine their whole body, carefully documenting any findings. If there was any resuscitation equipment, they would note it, but leave it in place. In order to establish the cause of death, the doctor would take swabs from different parts of the body, blood and urine samples, and perhaps cerebrospinal fluid.

  If the parents requested it, a forelock of hair might be cut, for the parents to keep. Or foot and hand impressions might be taken, or a photo. Then the baby’s body would be wrapped up.

  Next the doctor would speak to the coroner, to discuss their findings, and a designated person within the hospital would also need to be informed. A ‘Rapid Review’ meeting would be convened within a couple of days, with the parents, consultant, police and social workers all present.

  My paediatrician colleague was appalled that this task had been delegated to a trust grade doctor who had only recently arrived in the country. Apart from anything else, the whole issue of non-accidental injury might be thought of completely differently in the UK than in India. This colleague also said that her registrars don’t learn from a protocol in a file, but instead go on a full-day training course before they would be asked to certify the death of a baby. And even after they have been taught what needs to be done, you can never escape the emotional impact of the task. As the consultant, she would want to have a quiet word with a trainee afterwards, so the trainee feels supported throughout.

  Death, dying, distress and disease are inescapable components of a doctor’s work. It’s hard to see how it could be otherwise. Excruciatingly difficult tasks cannot be surgically removed from the daily ‘to do’ list of healthcare staff. What can shift, however, is our understanding of the psychological demands that carrying out this work entails.

  So how do doctors (or anybody else, for that matter) respond when they hear a patient screaming in pain, or they see the ravages of disease or trauma on somebody’s body. How do they manage when they need to tell a parent that their child has died? What resources can the doctor draw on in these situations?

  Just as the body has a whole system of defence against infection (the immune system) which kicks into action when a pathogen is detected – so too does it have a way of protecting itself from emotional disintegration in the face of overwhelming psychological stress. In the immune system, the component parts such as the B cells, and the antibodies they produce, have an actual physical presence in the body – they can be analysed and measured in the blood. But the psychological defence system doesn’t reside in a particular part of the human anatomy. Instead, as the psychiatrist and psychoanalyst George Vaillant puts it, mechanisms of defence are ‘metaphors … not pieces of clockwork’8. Crucially, Vaillant goes on to stress that defence mechanisms ‘are normal responses to abnormal circumstances’.

  Take avoidance – a really common defence mechanism. For whatever reason, it seems that Ellen’s automatic response was to avoid having to certify the death of the baby, or having to help somebody else from the team do so. I wanted to avoid confronting Ellen with how she had treated Vartika. Laura wanted to avoid having anything to do with neonates. Often this happens automatically, and beyond our conscious awareness.

  *

  When I train hospital consultants in how best to support their trainees, I frequently ask them how they know if one of their junior team members is struggling. Without hesitation they reel off a list of warning signs such as frequent absence due to sickness, arriving late, leaving early, or failure to respond to their bleep. These answers are all correct, and have been well documented in the literature. What the consultants often don’t see is that each of these behaviours represents an avoidant response on the part of the junior doctor. If you stay at home or you shorten the working day, you will reduce your personal exposure to experiences at work that you are finding aversive. If you fear that you will be asked to carry out clinical t
asks that are beyond your level of competence, you are not going to rush to answer your bleep. These responses may be deeply unhelpful for the patient or for the other members of your team, but from a psychological point of view they make perfect sense.

  Another defensive strategy is intellectualisation – concentrating on the dry, factual, intellectual bits of a situation while ignoring the possibility that it could have any impact on one’s feelings. Vartika was told that everything she needed to know would be included on the pro-forma but this advice entirely missed the point. A list of instructions is ideal for putting together a piece of self-assembly furniture or guiding one through a new recipe, but it doesn’t begin to address the emotional complexities of certifying the death of a baby.

  The late Simon Sinclair, a psychiatrist and social anthropologist, in his observational study of medical training gives another powerful example of the ever-present pull towards intellectualisation9. Sinclair describes how a mature student, following an embryology lecture in which slides of human foetuses at different stages of development were shown, commented ‘I could only see them [the slides] each as personal tragedies for someone’. But as Sinclair goes on to point out, this student would have to reconceptualise what these slides represented, and use them to learn the stages of organ development, in order to pass his end-of-year examination.

  And then there are the twin defensive strategies of suppression and repression. The former represents a conscious decision to delay paying attention to one’s feelings in order to cope with the present reality. Doctors have to suppress their emotions all the time, when they deliver a painful or unpleasant treatment to a patient. In this situation they must focus on the provision of safe care, and may have to suppress their desire to stop inflicting pain on the patient.

  Repression, in contrast to suppression, is the defensive strategy in which difficult emotions are pushed out of the conscious mind entirely. This happens in medicine, when doctors become so emotionally overloaded by different aspects of their work that they stop feeling anything at all. Physician Danielle Ofri describes a paediatric trainee at the end of her training programme10, who received no support in managing the emotional consequences of treating dying children or mourning parents. Faced with a four-year-old boy in intensive care, who had suffered catastrophic brain damage after falling into a lake, the trainee told Ofri, ‘I felt absolutely nothing for that boy and his family during the entire two weeks I cared for him … I was almost finished with residency, almost out of this mess where I was always dealing with dead or near-dead children. I was determined that this was not going to bring me down.’