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  In the event, my reservations couldn’t have been more misplaced. Bernard had chosen his patients with enormous care. He knew the three patients well, and had treated each of them for many months. Barbara was in her forties, and dying of breast cancer; Shirley was twenty years older and had advanced ovarian cancer. The third patient, Edward, was in his seventies and had lung cancer. All three had been told by their doctors that any future treatment would be for symptom management rather than curing the disease. But whilst all three had terminal diagnoses, they were still living at home and attending the hospice as day patients.

  Bernard interviewed them one at a time; an intense dialogue in the centre of the circle. Barbara spoke movingly about her fears of leaving her two sons without a mother. I noticed that many of the medical students in the outer circle had to wipe tears from their eyes. She also talked about insensitive doctors whom she had encountered at different points of her treatment, focusing on a particular cancer specialist who had been unable to understand her distress at the words for advanced metastatic disease printed on the outer packaging of some medication that she took at home. The consultant had said to Barbara, ‘We’ve discussed your prognosis, and you know that the cancer is advanced. Why does it matter that this wording is printed on the box?’

  Barbara described how this box of medication sat on her dressing table next to her favourite photo of her two sons, some earrings that belonged to her grandmother, and perfume given to her by her husband. Bernard understood that knowing and not-knowing could exist side by side. He appreciated that although on one level Barbara could have an intellectual understanding that her cancer was advanced, on another level she was distressed to have this fact thrown in her face every morning, when she sat at her dressing table. For Barbara the wording on the box served no clinical purpose, and instead intruded into the ordinary domestic pleasures of her family life – photos, earrings, perfume.

  Shirley railed against her GP, who had failed to pick up the symptoms of ovarian cancer until the disease had already spread throughout her body. Despite repeated visits to the surgery, first she was reassured that she was suffering from irritable bowel syndrome. Later on, the GP suggested that perhaps she should be referred for counselling, because she seemed so anxious about her health. Turning round to address the medical students, Shirley said, ‘If any of you become GPs, remember me. Don’t fob off a middle-aged woman with a bloated stomach as having IBS. Listen to her and examine her thoroughly.’

  There was a silence in the outer circle.

  The final patient, Edward, had difficulty breathing, and he spoke quietly. The students in the outer circle craned forward to catch what he was saying.

  ‘I smoked all my life, from the age of sixteen. We all did. I suppose you never think it’s going to happen to you.’

  Bernard nodded.

  ‘I’ve had a good life,’ Edward continued. ‘I’ve been married nearly fifty years, three children and five grandchildren. I just want you doctors to do all you can to stop people smoking.’

  Edward paused, with a rueful look on his face, then said, ‘I wish somebody had tried harder to make me stop.’

  In medical school lectures and seminars, I’ve often witnessed surprising levels of messing around; students playing with their mobile phones, passing notes and even surreptitious games of noughts and crosses. The students that morning in the hospice were among the most engaged that I have ever witnessed. I have little doubt that what they learned through observing the conversations in the centre of the goldfish bowl will stay with many of them throughout their working lives. And although my hospice visit took place over a decade earlier, subsequent research from the King’s Fund highlighted how enabling students to hear patients speak about their personal experiences of care can be one of the most effective ways of enhancing their compassion23.

  I had also completely misjudged the impact on the patients of being asked to take part in the session. My fear was that there would be an element of voyeurism, and they would feel like a spectacle in the centre. I couldn’t have been more wrong. What I hadn’t adequately anticipated was the overwhelming desire that some patients have, to give something back to the doctors who treat them.

  Bernard couldn’t offer Barbara, Shirley or Edward a cure. But he could give each of them an opportunity to share their experiences with fledgling doctors who had their whole careers in front of them. In this way, the three of them clearly felt that after their deaths something constructive might come out of their individual suffering. Barbara needed oncologists to understand that patients don’t want to be reminded of their prognosis as they go about their day-to-day business at home. Shirley felt passionately about the frequent misdiagnosis of the early symptoms of ovarian cancer. Edward hoped that more would be done to stop young people from smoking.

  With each of these three patients, there was a change in their faces as their initial anxiety was transformed by the experience of being allowed to tell their stories. In fact there was a palpable sense, during the goldfish bowl session, that allowing these patients an opportunity to take part was tremendously healing.

  *

  I am not so naïve as to assume that all palliative care physicians are as compassionate as Bernard. Over the years, other clients have told me horrible tales of highly dysfunctional doctors working in hospices. Doctors whose kindness has been completely eroded by having to bear witness to death and dying every day.

  But at its best, there is something about the specialty of palliative medicine that can lead to an exceptional form of patient care. Perhaps this is because palliative care physicians can’t resort to a form of clinical omnipotence and hold out the promise of a cure to their patients. And whilst the medical aspects of the specialty – symptom management and pain control – are clearly vital, medicine alone will be insufficient if it isn’t coupled with a capacity for engaging with the patient’s suffering.

  It’s not easy to listen to patients’ stories – to hear about the physical and psychological pain that they have experienced. Bernard didn’t shy away from this task. And his capacity to respond empathically to others wasn’t restricted to his patients but extended to those he encountered as a teacher. For whatever reason, Ellen was not open to Vartika’s distress, whilst Bernard intuitively responded to the initial question raised by the junior doctor, and put his intended talk on one side.

  The truth is that the best palliative care physicians have much to teach doctors in every other specialty.

  3

  Which Doctor

  THE MINUTE LOLA walked on to the ward she wanted to flee. This desire to get out of the hospital was so intense that she was unable to concentrate, or make any decisions, yet she knew that if she made a mistake, it could have hideous consequences. Every aspect of the ward – the people, the noises, the smells – felt unbearable. Three weeks into the job, the urgency with which she tried to escape the hospital resulted in her driving into another car in the staff car park. Three weeks after that, on her drive home, she crashed into a stationary car at a traffic light. Both accidents were her own fault. What was going on?

  Lola was a doctor who had got through medical school and the early years of clinical practice without any difficulty whatsoever. Her life only started to unravel when she began her specialist training as an oncologist, treating cancer patients. After the second car crash she took a couple of days off work, and then, on her return, handed in her notice. ‘I felt like a different person once I had resigned,’ she told me.

  She came to see me a couple of months later when the intense anxiety had subsided, but she was deeply confused about what to do next. Would she cope better if she became a GP and treated patients with a broader range of illnesses or should she abandon medicine entirely? And why hadn’t she been able to cope with the oncology job for more than six weeks?

  Quite early on in our first session, I asked Lola about her parents – what jobs had they done? Lola told me that her mother was a head teacher, and the ‘driv
ing force’ of the family. Her father had been an engineer, a quiet, gentle man, who had died when Lola was ten. Lola’s mother had found it hard to cope; on top of a demanding job she had to take care of four children on her own and she lapsed into depression. Most of Lola’s close relatives lived in Hong Kong, but some cousins who lived in London helped out and eventually her mother was able to take responsibility for her family. The relationship between Lola and her mother, however, remained strained.

  It wasn’t difficult to guess what Lola’s father had died of.

  From the time of her father’s death, Lola had set her heart on becoming a doctor. But the disruption to family life caused by her father’s death took its toll, and she described herself as ‘wild and disengaged’ as a sixth-former, with little interest in her studies. Unsurprisingly, she didn’t get the grades to go to medical school, so instead she studied biochemistry. Moving away from home felt like a liberation, and over the course of the three years she became increasingly focused on her academic work, eventually graduating with a first-class degree. At that point she reapplied to medical school, and was accepted.

  In the first couple of years in the more traditional medical schools, students see only a few patients, but from the third year onwards, they spend more time on the wards. Lola described her experience in some of the different specialties; obstetrics was ‘hanging around waiting for something to happen’ whilst orthopaedics was ‘a bit of a laugh’. And oncology?

  Lola paused. And then she remembered that the first patient she had caught sight of in the oncology ward was a middle-aged Chinese man, bald from chemotherapy – just as she remembered her father had once looked. She had fainted at the foot of his bed. This was five years earlier, and she hadn’t thought it significant at the time. Yet it was the only time that she had ever fainted in her entire medical school training.

  Once Lola had qualified, she struggled with working out what she wanted to do with her career. She spent some time in A & E, then she went to New Zealand for a couple of years to work as a doctor. But she still wasn’t sure. Meanwhile, her siblings were putting increasing pressure on her to return home to the UK, which, in the end, she did.

  Back in the UK, she took a temporary locum post in oncology, which she found extremely distressing. I asked her what in particular she had found difficult, and she told me she had been shocked by how young some of the patients with cervical cancer were, and how poor the prognosis could be.

  ‘The treatment was horrible,’ she said, ‘with all sorts of complications. I hated having to tell women that they wouldn’t be able to have children.’

  Yet despite the fact that she had struggled with her temporary post in oncology, Lola still went ahead and applied for a six-year specialty training programme, at the end of which (had she completed it) she could have been appointed as a consultant oncologist. Throughout the lengthy selection process for the oncology training scheme she was simultaneously applying for jobs outside medicine as a management consultant. Even when she got her oncology place she asked the management consultancy firm that had also offered her a job to keep it on hold for the next six months. From the beginning of her training in oncology, Lola was deeply unsure whether she had made the correct choice.

  Lola had resigned from oncology before she first came to see me. She was aware that her intense distress during the six weeks she spent treating cancer patients was somehow linked to her father’s death. And she described her relief when she made the decision not to continue in the specialty. ‘I felt as if I was continually scratching open a wound,’ was how she put it.

  What was more puzzling was the way in which Lola had ignored all the earlier clues that she might find treating patients with cancer overwhelmingly difficult. She fainted just once in medical school – and that was at the sight of a patient receiving chemotherapy, who reminded her of her father. She’d tried out a locum post in oncology, and found it deeply upsetting. She crashed her car within weeks of starting her oncology training, in her rush to get out of the hospital. And still she continued – until she crashed her car for the second time, and realised that she couldn’t go on.

  Lola didn’t come to see me for bereavement counselling (although I suggested that she might find it beneficial). We didn’t focus on how she might have felt as a child when her father died. I don’t know whether her emotional response as a ten-year-old was characterised by fury at being abandoned or guilt that she could have done more to help her parents, or by any other emotion. But what Lola’s story shows is the overwhelming need that people have to make sense of their world through their work. Even though she eventually concluded that the task was too hard, part of her was powerfully drawn to helping patients who were suffering from the disease that killed her father.

  In our early sessions, Lola toyed with the idea of leaving medicine entirely – in large part because she had been so traumatised by the six weeks she had spent on the oncology wards. But at the end of our sessions she realised that there were many aspects of medical work that she enjoyed, and that it was only being surrounded by patients with cancer that she couldn’t manage. Lola decided to change direction, and successfully applied to train as a GP.

  *

  Tessa told me her mother had died, at the age of forty-one, when Tessa was eleven. She came from a family of four children, and she was the eldest. When we talked about her early family life, Tessa remembered that she had actually wanted to train as a doctor before her mother had become ill. Her grandfather had been a GP, and as a little girl, she had often stayed with her grandparents during the holidays and seen his patients walking up the garden path to the surgery next door to the house. But after her mother’s death, her goal had switched from wanting to follow in her grandfather’s footsteps and be a GP, to treating patients suffering from cancer.

  ‘I put all of myself into my work,’ Tessa said.

  Whilst she won prizes and plaudits, this intense emotional investment in her work took its toll. In her late twenties she was diagnosed with Crohn’s Disease – an autoimmune disorder of the gut. It’s a horrible condition to manage as the symptoms include violent diarrhoea, difficulty absorbing food, severe pain and extreme fatigue. Although genetic predisposition and childhood infections are recognised as causing the condition, emotional stress influences the course that the disease takes.

  For over twenty years Tessa had suffered from a particularly severe form of the disease, characterised by frequent hospital stays and different surgical interventions, interspersed with ever-decreasing periods of remission when she felt well. Tessa had tried reducing her hours and going part-time, but in the end realised that she had become too unwell to continue.

  ‘I’ve had to give up work, in order to live,’ was how she put it.

  Tessa recognised that the intensity of her commitment to her patients made her ill. But why would a doctor continue working, for over a quarter of a century, when it extracted such a high personal cost? It’s difficult to make sense of this without recourse to the psychoanalytic idea that people are driven, often without being aware, to seek ways in the present to deal with unresolved emotions from the past, especially from infancy and childhood.

  John Ballatt and Penelope Campling describe this clearly1:

  The unconscious motivation is often to heal a sick, or dead, family member and the guilt and fear of facing failure can become channelled into a relentless drive to work even harder. Unfortunately the choice of work brings not only the opportunity for reparation and healing but also repeats the experience of failing the incurable, which in turn, further feeds the associated emotional drive to apply oneself to this impossible task.

  And that is exactly what happened to Tessa. She worked at this ‘impossible task’ until her own health failed.

  Yet alongside the intensity of Tessa’s commitment to patients with cancer, and her sorrow at having to take early retirement, was an enormous passion for life. When we discussed how she now wanted to make use of her medical knowledge an
d skills, she realised that she wanted to shift from illness to well-being. As an oncologist she had become interested in mindfulness meditation as a way of helping patients manage distressing and painful symptoms. Now she wanted to train as a mindfulness teacher and offer sessions to healthcare staff, as opposed to working directly with patients. And perhaps most important of all, in the absence of patients, for the first time in her life, she prioritised her own health over the health of others.

  *

  It’s not difficult to see how the death of Lola’s father and Tessa’s mother influenced their specialty decisions. But parents aren’t the only family members whose illness or death impact on a doctor’s career choices. With other doctors, the experience of a sibling has been the critical factor.

  I first became aware of this when observing a consultant give a lecture on asthma to a particularly disengaged group of medical students.

  ‘You might think of asthma as a pretty trivial illness,’ she began. ‘With a few puffs on an inhaler there’s nothing to worry about. But you would be wrong.’

  She paused, to get the attention of the whole group.

  ‘An asthma attack killed my twelve-year-old brother.’

  This was twenty years ago. I’ve never forgotten it, and I suspect that many of those students present remember it as well. And what was this consultant’s specialty? Respiratory medicine. The specialty that treats breathing difficulties. Including asthma.

  I’ve also seen neurology trainees who have grown up with siblings suffering from multiple sclerosis and trainees specialising in the psychiatry of learning disability, who have learning-disabled siblings. The reparative urge isn’t only induced by parental illness. And it isn’t only caused by cancer. Illnesses occurring in any close family member can influence the career decisions that someone makes. Often the response (as with Lola, Tessa and the respiratory medicine consultant) is a desire to treat patients with the same disease that killed a beloved family member. Sometimes, however, as with Kevin, a doctor who switched from engineering to medicine after his sister died of leukaemia, it works a bit differently.