Also Human

by Caroline Elton

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  Other women make different choices; they decide to slog it out through their hospital training in order to qualify in their chosen specialty – even if their training extends well over a decade. But then, like Sally, they can encounter different problems.

  Sally came to see me when she was close to finishing her training in cardiology. Except that she wasn’t really close; as she was training part-time, she was still two to three years away from completion. Her training had dragged on and on. First of all, she had taken a few years after leaving medical school, rotating through different specialties before she finally decided on cardiology. Then she had four children – the last of whom was born prematurely, and needed to be hospitalised for the first month of his life. Following each pregnancy she had taken a year’s maternity leave. In addition, as competition for cardiology consultant posts is intense, she had been advised to complete a PhD on top of her clinical training. Sally was struggling to motivate herself to write up her thesis, and began the first session by telling me that she felt her career had hit a brick wall.

  When I asked Sally about her parents’ careers she told me that her father had been a physician and her mother had given up her career on starting a family. She remembered that, as a child, she’d always thought her father’s work sounded tremendously exciting, and from an early age she decided she wanted to train as a doctor. But Sally also talked about how pleased she had been each day when she came home from school to find her mother waiting for her, with home-made biscuits and cake. It was almost as if Sally was being pulled in opposite directions – wanting to be the clever, academic doctor (like her father) as well as a devoted mother who was there at the end of each day for her children. Not an easy tension to reconcile.

  What shocked me most, however, about Sally’s story was the totally inadequate preparation for her returning to treat acutely unwell patients. When Sally came to see me, it was six years since she had been responsible for treating patients whose life was in the balance. This period away from acute practice stacked up because of the four maternity leaves and a number of years in a research lab. When she raised her concerns with her clinical supervisor – what did he suggest? A one-day refresher course?

  So Sally had to kick and scream, and demand a more appropriate schedule for her return to work. She didn’t do this to make trouble, or to ask for special concessions. Instead, she refused to go back on to the on-call register as soon as she started her new job, because she knew she wasn’t safe. She wanted to have a supervised refresher period. This request was entirely in accordance with the GMC guidance that as a doctor you have to ‘recognise and work within the limits of your competence’. But her senior colleagues were none too pleased and gave her a negative report in her training record, for the first time ever.

  Over the years I have encountered a number of doctors like Sally who, for one reason or another, have spent considerable periods of time away from acutely sick patients. And frequently (although not invariably) the provision made for their induction back into acute medicine is woefully inadequate. The training system as a whole hasn’t yet adapted to the reality of repeated maternity leaves coupled with returning to part-time clinical work interspersed with periods doing research. There’s a fundamental mismatch between the educational needs of the doctor and the return-to-practice support provided by the hospitals.

  On the face of it, things seem might seem easier for female hospital doctors who don’t have partners or children: they are certainly more likely to work full-time. But sometimes these doctors feel that they have paid too high a price to complete their training in a hospital specialty. I also wonder whether this problem isn’t particularly acute with international medical graduates (IMGs). It can take IMGs a number of years before they obtain a place on a training scheme and in the intervening period, they often take short-term six-month posts all over the country. It’s difficult to build up a solid social network if you move around like this, yet these are the years when people are most likely to be meeting a future partner. Even when these doctors finally get a training place on top of their busy medical job there will be exams to pass (sometimes in a second language) as well as building up skills in research, clinical audit and teaching. Some of these additional tasks may be less familiar to doctors who trained outside the UK so again they can be particularly time-consuming for IMGs. ‘I was entirely focused on completing my training and getting a job as a consultant,’ was what one doctor said to me. And this focus can have a detrimental impact on a doctor’s life outside work.

  In my sessions with doctors I often ask them about things that they have done at work which they are particularly proud of. The answers to this question never cease to amaze me; arranging a wedding for a terminally ill young man in a hospice; setting up a falls service for older patients that won a national award; improving the transition from paediatric to adult services for adolescent patients with sickle cell anaemia. But when I alter the question and ask doctors for things they have done outside of work which have made them proud, quite frequently they remain silent. Sometimes the sense of regret can be palpable. Little wonder then that a respondent in another study of female doctors concluded that ‘medicine is one big career of loss’.

  *

  ‘Ladies would make bad doctors, at the best,’ Elizabeth Garrett Anderson was told, when she wanted to attend the anatomy lectures at Aberdeen Medical School back in 186324. I wonder what the writer of that letter would make of the findings of a study published in February 2017 in the Journal of the American Medical Association. The study conducted by a group of researchers at Harvard School of Public Health analysed thirty-day mortality and readmission rates of over a million patients aged sixty-five years and older, hospitalised with a medical condition between 2011 and 2014. And what did they find? That patients treated by female physicians had lower thirty-day mortality rates, and lower readmission rates. These differences persisted across eight common medical conditions and were not found to be dependent upon the patients’ severity of illness. In a nutshell, sick older patients did better if the doctor who admitted them to hospital was a woman25.

  An editorial about the study, in the same issue of the journal, suggested that the improved outcomes for patients treated by female physicians may be because women are more likely to stick to clinical guidelines, or because they communicate more effectively with patients and tend to have longer consultations than their male colleagues. At this point the precise mechanism causing the difference in clinical outcome remains unclear. But it would be hard to disagree with the conclusion reached by Professor Jane Dacre, a former president of the Royal College of Physicians of London, that medicine is ‘richer’ for diversity in its workforce26.

  The old arguments against doctors working part-time don’t stack up either. Not only is there evidence that doctors who work less than full-time are less stressed and more satisfied at work, but in future it seems likely that the proportion of male doctors choosing this option will increase. As a group of researchers from Oxford University concluded in a 2016 paper, medicine needs to establish legitimate career paths that enable doctors of both sexes to train and work part-time27.

  Another senior female clinician, Professor Fiona Karet Frankl based in Cambridge, wrote recently about her dismay on learning that a female medical student had been advised by a senior male surgeon not to choose a career in surgery – ‘Surely you will want to have a family?’ the surgeon asked28. Subsequently, Karet Frankl heard almost identical stories from colleagues in several other medical schools.

  ‘When I started medical school in 1980, 52% of my class was female but some 35 years later, only 13% of my professorial cohort is,’ Karet Frankl wrote. Then she went on to say, ‘we speak of a “leaky” pipeline, but further discussion often focuses on the water rather than the pipe’.

  In my discussions with female doctors, I’ve seen how they ‘leak out’ of the hospital medicine pipeline into part-time community-based roles. Or they lea
k out of medicine entirely. There’s no getting round the fact that the first decade of a medical career coincides with the time when a woman is most likely to be getting married and wanting to start a family. Part-time work is more readily accessible in the UK, which eases the pressure a bit, but it extends training, sometimes for years and years on end.

  My friend’s daughter, Sophie, who started an obstetrics and gynaecology residency in the US in 2016, was offered the option to freeze her eggs, by some of the residency training programmes to which she applied. But isn’t there something perverse about an obstetrics and gynaecology programme enticing residents with the offer of egg freezing when the gynaecologists and obstetricians working on the programme know that the rate of conception with frozen eggs is lower than making babies the old-fashioned way?

  And can’t we find better ways to allow brilliant doctors like Bridget to continue working in the profession? Ways that would allow her to feel that she fitted into the surgical team and had something of value to contribute.

  7

  Risky Business

  I ONCE WENT to see the dean of one of the London medical schools. The purpose of the meeting was to review whether his medical school could be doing more to help prepare students for the specialty choice decisions they would have to make a year or so after graduation. In the course of the discussion the dean told me that his institution had too many Asian girls who weren’t actually interested in becoming doctors, but were only interested in marriage.

  I have little doubt that if Professor only-interested-in-marriage met a client of mine called Rahma he would find confirmation of his views about female, Asian medical students. Rahma, who grew up in London, was the only child of older parents. She had been brought up to be respectful of her elders and quietly mannered with people she didn’t know well. All of her friends at school and at her sixth form college came from similar backgrounds within the UK Pakistani community.

  From the beginning of medical school, Rahma realised that she was different from many of the students she encountered and she told me that she felt much less confident than many of her peers. She hadn’t travelled the world in her gap year – indeed she had never contemplated doing so because her family couldn’t afford that sort of luxury. And she didn’t share the extracurricular accomplishments of many of her privately educated fellow students, be these in music, sport, debating, or whatever. Fencing, rowing, or playing the harp weren’t on offer to students in the school and sixth form college she had attended.

  ‘Being self-assured goes a long way in medicine,’ Rahma told me. And it’s true. Unlike, say, a degree in history or economics, which will consist largely of lectures, seminars and private study, at medical school students’ knowledge and skills are constantly exposed to senior clinicians and to patients, as part of their clinical training. On a ward round, when Rahma was with a group of students at the bedside of a patient, she wouldn’t be the first to answer the consultant’s questions. Neither did she rush to ask the consultant any questions that she had; she was wary of senior medics, and hesitant to initiate conversation. But when consultants like Professor only-interested-in-marriage encountered students like Rahma, they didn’t see an incredibly bright but shy young woman, who needed encouragement. What they saw was somebody who wasn’t interested in becoming a doctor. In other words, their reading of the situation confirmed their initial stereotype.

  So what happens next?

  Teaching is a reciprocal activity. The consultant clocks the shy Asian girl who doesn’t volunteer questions or answers, and directs his next instruction (listen to the patient’s heart and tell me what you hear) to somebody else. Actually Rahma was confident that she knew the different heart sounds and would have liked to be asked. Disappointed that she wasn’t given the opportunity, she retreats further into her shell, which provides additional confirmation to the consultant that students like Rahma aren’t committed to the profession.

  ‘I was too shy and hesitant to get noticed,’ Rahma told me. ‘Maybe my interest in medicine didn’t show.’ Throughout her six years at medical school there were hundreds of daily encounters where she was misread; encounters which meant that opportunities for building up her confidence or furthering her learning were missed. Rahma had a particular interest in dermatology and chose one of her optional modules in this specialty. But she couldn’t convey her passion to the module supervisor; he didn’t respond to her emails, and she missed out on the opportunity to get some research experience that would have greatly enhanced her CV later on in her career.

  ‘What am I not doing, that I’m not getting the opportunity to take part in research?’ Rahma asked herself. Rather than blaming her supervisors, she began to believe that she must be lacking in some way, which led to yet more erosion of confidence. And on it went to the point that although she passed her medical school finals with no difficulty whatsoever, she was completely overwhelmed when she started her first job as a junior hospital doctor. Which is when she first came to see me.

  ‘Siblings never have the same parents,’ a psychologist colleague once remarked. What she meant by this puzzling statement is that, with the exception of twins, each additional sibling will arrive when the parents are at a different stage in their marriage, or career, or family life. For example, an older child might have been born at a time of marital stability whilst a later child arrives when the marriage is in difficulty. And each child will have their own personality and physical appearance, reminding parents of other relatives – perhaps a brother whom the father looked up to, or a sister with whom he always competed. This then sets up a pattern of interaction, gathering momentum as it plays out over time. When one looks in detail at how parents respond to their different children, the notion that siblings don’t share the same parents starts to make sense.

  It’s the same with education. Students from different ethnicities – even if they grew up in the UK, and sit in the same lecture theatre at medical school – don’t have the same day-to-day educational experiences. Professor only-interested-in-marriage wasn’t alone in his views about Asian students and there is good evidence that negative stereotypes are common. In a paper published in the British Medical Journal in 2008 psychologist Kath Woolf described numerous examples of negative stereotypes of Asian students perpetuated by both students and clinical teachers1:

  ‘Some of these sweet little Asian girlies are very hard to get through to. I’m quite a physically biggish sort of chap, maybe that’s another factor. I’m older, obviously that’s a factor. I’m male. I’m … they don’t communicate terribly well.’ (Teacher, male consultant, white)

  ‘They came over in the sixties when Idi Amin kicked them out, they’re very keen on their children achieving excellent attributes. So their children bloody well have to work, there’s a work ethic at home, um, and they get three A grades at A level so the authorities let them in because they think three As at A level’s a good thing, which I think is bonkers.’ (Teacher, male consultant, white)

  ‘There’s a stigma of sort of ethnic families wanting their children to do best and then there’s the whole doctor, lawyer, you know, get the upper, upper rank jobs or whatever they’re called and so I suppose if they’re thinking “oh bollocks, I’ve got to choose between three jobs, I’ll choose the doctor then.”’ (Student, male, white)

  If clinical teachers and students openly express these views to a bright-eyed and bushy-tailed research psychologist who has come to interview them, what do they say when the researcher isn’t there? Little wonder then that the paper concluded:

  Teachers of clinical medical students, and the students themselves, have strong perceptions about ‘typical’ Asian students, and there is a systematic mismatch between these perceptions and the (equally strong) perception of what makes a ‘good’ clinical student. These findings are consistent with the hypothesis that negative stereotypes of Asian medical students exist.

  A recent incident at Cardiff Medical School provides further evidence of the wid
espread nature of negative stereotyping amongst medical students. In 2016 a complaint was made by a group of black students at the medical school following the performance of a student revue. Events of this type happen in many medical schools, and provide an opportunity for students to make fun of teaching staff under the guise of raising money for a suitable charity. At Cardiff, one of the lecturers who was lampooned was black. And how was he portrayed? By a white student with a blacked-up face, wearing an over-sized dildo. The stereotype of the over-sexualised black man played out for all to enjoy.

  When a group of BME (black and minority ethnic) students complained, they were told by those who participated in the revue that there had been a warning at the beginning of the show about the nature of the content, and they should have left, if they felt sensitive about race. (I wouldn’t want to be treated by these particular revue participants when they grow up and become doctors.)

  Following the complaint and the subsequent investigation by the medical school, the student body as a whole became irreparably divided. The complainants reported that they were ostracised, and as a consequence some of them decided to continue their medical training elsewhere. Another group of fifth year medical students started a Facebook petition to let the dean know that there was nothing wrong in the revue, and that they stood in solidarity with their colleagues who had taken part. And some of the students involved in the revue never understood why the content had been criticised in the first place.

  In the end an independent review panel had to be drafted in, headed up by Dinesh Bhugra, Professor of Mental Health and Diversity at the Institute of Psychiatry in London2. Not surprisingly, in their report the independent panel made recommendations that went far beyond overseeing the content of the student revue: complaints procedures; support for staff; training in diversity and equality; the medical school curriculum and mentoring were some of the issues raised. Because incidents like this are never merely about a small group of students.