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  Kevin didn’t want to train in haematology, the specialty that treats patients with leukaemia. Instead from the moment he started medical school, he only ever considered one specialty – obstetrics. When he came to see me he had completed medical school and had spent five years training in obstetrics. However, his career progression had ground to a halt because he couldn’t pass his last specialty examination. This exam failure was puzzling because he consistently received excellent feedback from his supervisors for his clinical work and he had also completed a PhD in a leading academic research centre. Neither his clinical nor academic ability were in doubt. But he couldn’t pass this one last exam.

  What emerged from our sessions was that he had been drawn to obstetrics because he thought it would allow him to be surrounded by new life, rather than death. But of course if a doctor has chosen obstetrics for this reason, it is a doomed enterprise. Babies can be stillborn, or die shortly after birth. And very occasionally, mothers can die too. Whilst death and dying will be less of your daily diet at work if you are an obstetrician as opposed to an oncologist, you can’t escape death entirely.

  As we talked, it became clear that Kevin didn’t really want to bear the responsibility of being a consultant obstetrician. He’d seen the drama that could ensue in obstetric emergencies, and he didn’t want to be the person heading up the whole team. Yet this was the role he would be destined for, if he passed his final specialty examination. Kevin told me that he dreaded being held responsible for the death of a mother or a baby. Perhaps for him this responsibility felt unbearable because he knew, from his own family, what the death of a young person could feel like. I tentatively suggested to Kevin that perhaps his repeated examination failure was an unconscious solution to the problem of having to assume an intolerable burden of responsibility. As long as he kept on failing the exam, he could never become a consultant.

  At the end of our sessions, Kevin reached the point where he felt able to leave clinical practice. Whilst previously he had attributed his repeated examination failure to stupidity or laziness, he came to see that perhaps it had served an important psychological function. He also decided that he would be happier working outside the hospital environment. Eventually he accepted a job with a pharmaceutical company, and he contacted me a few months later to tell me how much he was enjoying it. Although he missed seeing patients, his career change had brought him considerable psychological relief.

  *

  Every new service will have a first request for help – Client 001. Kelly was my first client in the service I set up in the autumn of 2008.

  Just one month into her first job as an F1 doctor, Kelly walked into the office at the hospital education centre and announced that she wanted to quit. Her distress was so intense that the senior doctor in charge of foundation trainees did an assessment of suicide risk before she let Kelly leave her office and go home. A couple of days later, following an appointment with occupational health, Kelly went on an extended period of sick leave. It was also recommended that she should access support from the Careers Unit. Although she didn’t know it, she became my Client 001.

  In our first session Kelly was adamant that she would never return to medicine. Working as a doctor had made her physically sick – she vomited before she went into the hospital each day. Instead she wanted a non-medical job which involved working with children. A few weeks later she was able to see that perhaps she hadn’t given clinical medicine much of a chance. After all, she had studied for five years to train as a doctor, and had then abandoned the career after working for less than five weeks. Although she was terrified at the prospect of going back to the hospital, maybe she would regret it if she jumped ship at this stage. Would she always ask herself whether medicine could have worked out?

  A month or so after she had first walked out of her job, she remembered that at medical school she had enjoyed her placement with the community paediatrics team. What had fascinated her in particular was seeing how the paediatrician tried to understand the psychological causes of a child’s behavioural problems. Perhaps she could work as a community paediatrician?

  I didn’t discount this idea when Kelly suggested it. In fact, I encouraged her to find out more about what the job entailed. But I also knew that you can’t train as a community paediatrician without spending a number of years as an acute hospital-based paediatrician, including treating newborn babies. Given that she was terrified of carrying out technical procedures on adults (inserting a cannula, taking a blood sample), I wondered how she would manage to carry out the same tasks on tiny premature babies.

  ‘What about child and adolescent psychiatry?’ I asked.

  Kelly had learnt nothing about this specialty in medical school. She agreed that it was worth exploring further, so I put her in touch with a consultant.

  At our next session, Kelly told me she felt completely torn. Having spent some time in a child and adolescent psychiatry clinic, she agreed that she might enjoy the work. But this realisation was unwelcome. If she wanted to train in this specialty she would have to return to working as a foundation doctor – a prospect she found simply terrifying.

  In our sessions it became increasingly clear that Kelly had a particular sensitivity to transitions. The move from primary to secondary school, from secondary school to sixth form college, from college to medical school and, most of all, from medical school to her first job, had all been problematic. This is not uncommon. And those individuals who have suffered repeated disappointments in life, or who have regularly had their confidence undermined, are more likely to experience difficulties at points of transition. Which is exactly what happened to Kelly.

  Kelly found it helpful to see how her acute distress when she started her first job was a repetition of a long-standing pattern. With each of the earlier transitions she initially felt overwhelmed, but after a period of time she settled in and adjusted to her new school, college or university course. The fact that her first job had been in a town where she knew nobody had definitely contributed to her distress. Second time round, with some reluctance, she applied through the ‘special circumstances’ route, citing her depression and anxiety. This allowed her to return to the hospital where she had completed her undergraduate training, and live amongst friends in a town where she had strong links.

  The consultant in charge of the foundation trainees at this hospital was a particularly sensitive doctor whom I knew well. I was confident that Kelly was in good hands. But even with all the support in place, Kelly’s anxiety remained problematic. When we spoke during the first two foundation placements, she wasn’t sure if she would be able to get through the whole year.

  A month into her third placement Kelly emailed me:

  Thought I would just drop you a quick email to let you know how things are.

  I have just started my psychiatry placement and am loving it so far. For the first time in medicine I feel I am finally enjoying something and I just wanted to thank you again for helping me to see that there is an area of medicine that I enjoy. Without your help I would have given up and never seen this.

  End of story? Not exactly.

  Perhaps predictably, Kelly suffered another mini-crisis when she moved into the second year of the foundation programme. She became acutely anxious about whether she was capable of fulfilling the additional responsibilities that doctors take on in the second year. She weathered that storm, but once she started applying for specialty training in psychiatry she worried whether she might end up having to move again. Either she stayed put, or changed her career – she wouldn’t countenance a move. In the event, her application was successful and she started training as a psychiatrist, still based in the same town.

  I contacted Kelly recently and asked permission to tell her story. She is married now and has two young children. Kelly told me that she is pleased that she stuck with her training, as she realises she has the potential to work as a consultant. But she also recognises that staying with it has come at a huge personal
cost. The periods of intense anxiety linked to each job shift are shorter – but they haven’t gone away.

  When Kelly returns to work after her maternity leave she will be working part-time. This is something she wanted to do years before, but when she asked prior to having children, her request for part-time work on health grounds was denied. She wasn’t regarded as sufficiently unwell.

  ‘Why do you have to be at crisis point before there is any flexibility in the system?’ she asked.

  I didn’t have a good answer. But I saw the irony in her question: doctors tell their patients that prevention is better than cure, yet a preventative ethos is frequently absent in medical training.

  *

  Kelly is not alone; personal experience of mental illness is known to be one of the reasons why a doctor might opt for a career in psychiatry. For example, a 2014 World Psychiatric Association (WPA) study across twenty-two countries found strong empirical evidence of the link between personal (and family) experience of mental illness and choosing to specialise in psychiatry2. Of course it’s not the only reason, and it doesn’t apply in some blanket way to every psychiatrist. But if you compare a group of psychiatrists to a group of doctors who have chosen another specialty there is likely to be a higher incidence of personal or family mental health problems in the former group.

  Dr Mike Shooter, former President of the Royal College of Psychiatrists, has talked openly about his own struggles with depression3. In a remarkably candid interview, he described how his personal experience of mental illness – knowing what it feels like from the inside – has helped him care for his patients. Sometimes he tells patients how being depressed felt for him. He will then ask the patients if this was how they, too, experienced the illness. And in this way, a dialogue is opened up. His openness about his own periods of depression brings him closer to the patients and allows him to learn something valuable about them. Shooter is also aware that, when treating patients for an illness that one has suffered from oneself, there is always the danger of blurring one’s own experience with that of the patient. But on balance, he feels that it has given him a particular understanding of the suffering endured by patients with a mental illness.

  The notion that a doctor’s capacity for healing stems from their own suffering – the so-called ‘wounded healer’ – has ancient roots4. As an example, Plato’s Republic, written in around 380 BC, contains the following verse:

  The most skilful physicians are those who, from their youth upwards, have combined with the knowledge of their art the greatest experience of disease … and should have had all manner of diseases in their own person.

  In contemporary psychotherapeutic practice this idea of the ‘wounded healer’ is closely associated with the writings of Carl Jung who suggested that through the experience of personal suffering5, the healer can acquire a deep wisdom which they can then use for the benefit of their patients. But Jung was also aware that there was always the potential that such healers could over-identify with patients, feeling their pain too deeply, reawakening wounds of their own.

  Over the years I have seen many trainees whose personal experience of mental illness has attracted them to psychiatry – and whose commitment and empathy have been enhanced in the ways that Shooter has described. Sadly, as we’ll see in a later chapter, I have also encountered doctors whose progression through psychiatry training has been derailed by severe and recurrent episodes of mental illness. It doesn’t always work out for the best.

  *

  It’s not only with psychiatrists that there is a clear link between personal experience of mental illness and wanting to help others who suffer from similar conditions6. This link applies to psychologists and psychotherapists as well. And it applies to me.

  My older brother is autistic. As a child I can remember times when he was extremely agitated and distressed. When I was six, my mother suffered from a serious episode of depression following the death of her beloved sister from cancer. As a teenager at boarding school, I became so unwell with depression that I had to come home for half a term while I received outpatient psychiatric treatment. And as an adult I have experienced further episodes of depression following a traumatic bereavement and also after the birth of two of my children.

  I am in no doubt that my personal and family experiences of psychological distress played a part in my decision to train as a psychologist. If one has never witnessed psychological problems close-up, or experienced them oneself, it is harder (although not impossible) to become interested in what goes on in other people’s minds. These personal or family experiences teach you – often from a young age – that minds matter. But it’s not always easy to talk openly about the ways in which one’s own mental health difficulties have affected one’s career. Amongst doctors, there’s tremendous stigma attached to any admission of psychological problems (which makes Mike Shooter’s openness all the more extraordinary). Given that studies have repeatedly demonstrated that medical students and junior doctors see psychiatry as being unlike all the other specialties, it’s almost as if the stigma spreads beyond the individual to infect the profession of psychiatry as a whole.

  *

  Lola, Tessa, Kevin and Kelly. Four individuals whose career stories show how the threads of family life ripple through the decisions that people make about their work. But these few stories don’t convey the sheer number of specialty choices facing each doctor. Of course young people qualifying in other professions such as law or accountancy face choices – but not on the same scale as doctors. So how many specialties are there?

  It’s a simple question that doesn’t have an equally simple answer.

  The division of medical knowledge and tasks into specialties and sub-specialties doesn’t map on to a physical reality. In chemistry, for example, an element is defined on the basis of its atomic structure, so a carbon atom remains a carbon atom wherever one is in the world and occupies the same place in the Periodic Table of Elements. In terms of medical specialties, however, different countries carve up the medical universe in many different ways. So in the UK doctors have to choose between sixty-six specialties7, which in turn branch out further into thirty-two sub-specialties. In the USA there are thirty-seven specialties8, which then branch out into eighty-six sub-specialties whilst in Australia there are eighty-five specialties with no further sub-specialisation9. Yet one thing that unites all of these countries is that in the second decade of the twenty-first century, doctors have to navigate their way through an enormous array of options. And some doctors make choices that they later come to regret.

  A consistent finding in studies is that a significant minority of doctors feel they have chosen the wrong specialty. For example, a 2013 survey of over 7,000 doctors in the States reported that between a third and a quarter were not happy with the specialties that they had chosen10. Specialty dissatisfaction was particularly acute amongst mid-career doctors. Other studies have looked within particular specialties, and similar patterns emerge; nearly 20% of oncology and surgical trainees in the States wouldn’t choose their specialty again11. A whopping 34% of obstetric trainees, in an admittedly small study in the UK, regretted their specialty choice12. An exception to the rule was anaesthetists, where a recent American study found that over 94% were satisfied that they had chosen the right career. Unfortunately such high satisfaction bucks the general trend13.

  It is clear that many doctors are disappointed with their specialty decisions. This doesn’t only represent a widespread degree of personal dissatisfaction in the medical profession; it also has ramifications for patients. Not surprisingly, when doctors are dissatisfied at work, they tend to have more dissatisfied patients. And the patients of more dissatisfied doctors are less likely to stick to the treatment plans that they have been prescribed. Dissatisfaction is contagious14.

  So what do we know about the process of specialty decision making? And how can we use this knowledge to help doctors make better decisions?

  There’s no shortage of studies
that have asked doctors why they chose their particular specialty. From the 1950s onwards, thousands of papers in medical journals have looked at every conceivable specialty, including reports from far-flung corners of the globe. Some researchers have suggested that specialty choice boils down to personality and there’s a micro-industry of studies that have examined whether surgeons are a particular breed with a distinct ‘surgical’ personality. As an example, over forty years ago a group of Harvard researchers compared the personalities of medical and surgical trainees using the Rorschach inkblot test15. With this method subjects are presented with pictures of inkblots; the number of responses and the nature of each response are recorded and later analysed. Rorschach is a controversial method, and one can imagine that the subjects (all young Harvard doctors) might have been somewhat sceptical at having their personalities assessed in this way16.

  The aim of the study was to explore whether the surgeons were more ‘aggressive, rigid, insensitive, impersonal, hostile, extroverted, explosive and possibly more energetic and ambitious’. And the conclusion?

  The common stereotype of the cold, aloof, and aggressive surgeon was not confirmed.

  It might be tempting to dismiss this conclusion on the basis that the Rorschach test is nothing more than pseudoscience. However, there is a resurgence of interest in Rorschach and a recent review in a leading psychological journal concluded that the method is reliable. Also, there are other studies using standardised personality questionnaires that agree with the Harvard findings17. Yet again, there are studies that disagree, which have concluded that surgeons are indeed more extravert than doctors in other specialties18, as well as being less warm and considerate to others19. In terms of there being a distinct surgical personality the jury is still out. But after half a century of research there is little compelling evidence of a simple link between personality and the decision to opt for a particular specialty.