Also Human

by Caroline Elton

  Since leaving medicine he hadn’t experienced any periods of serious mental illness. I was delighted to find him in such good health and able to put his intellectual abilities to good use. A few years after that, I bumped into Bijal at a library where I was doing some research. He took out his phone, and proudly showed me a photo of his son.

  I needed Bijal’s permission before I could tell his story. Recently we had a long catch-up phone call, nearly eight years on from when we first met. I was relieved to hear that he remained in good health, and that he attributed this to being in a less pressurised line of work. He was grateful that he had some balance in his life, and that he was able to spend time with his son. But the topic of leaving medicine was still highly sensitive. ‘I hesitate before telling people at work that once I was a doctor,’ Bijal said. ‘And I don’t keep in touch with school friends who went into medicine.’

  Exiting medicine can leave lingering feelings of sadness. And this remains true even for doctors whose struggles with clinical responsibility made them seriously unwell.

  *

  On the face of it, Owen’s story was completely different. He was almost at the end of his training when he first came to see me, and his career progression hadn’t been complicated by health issues. In fact anyone reading Owen’s CV couldn’t help but be impressed by his achievements: an Oxbridge graduate with a first-class degree; a PhD quickly completed in the middle of his medical school training; a string of publications in respected journals; postgraduate exams all passed at the first attempt. Without a doubt, Owen was on track to complete his training in psychiatry in a couple of years’ time, and secure a consultant post in a prestigious teaching hospital.

  Scratch a little bit below the surface, however, and a different picture emerged. In his initial email requesting some sessions, Owen wrote: ‘I am finding it increasingly difficult to muster up any enjoyment in my work. My clinical days are mostly characterised by worry before the day starts, followed by a sense of relief when it’s over (and then more worry about whether I’ve got everything right).’

  I agreed to meet him.

  What struck me in the first couple of sessions was the wide disparity between the ‘paper’ Owen (all the achievements on his CV with a clear focus on completing his training in psychiatry), and how he appeared in person. Face-to-face, Owen was diffident about his accomplishments, and deeply unsure about his future.

  Owen had in fact experienced doubts about medicine from the beginning of his undergraduate training. Although at school he was equally strong in science and humanities subjects, his parents (who were the first in their respective families to go to university) encouraged him to opt for science as they reasoned that this would lead to greater job security. Having chosen science subjects at A level, as Owen clearly had the academic ability to study medicine, his parents and teachers all encouraged him to apply to medical school. Nobody seemed to have looked beyond his academic strengths to wonder whether he was interested in, or suited to, the practice of medicine.

  Once at university, Owen looked enviously at fellow students in the humanities; they didn’t have to put in the same hours as the medical students and when they talked about what they were studying in the college dining hall, he found himself much more interested in their conversations than in those of his medical peers. During the first couple of years at university his motivation nose-dived, and Owen had to resit his end-of-year examinations. It was only in the third year when he faced examinations that would determine his degree class that he started to put consistent energy into his academic work. And when he did, he was able to graduate with a first-class degree.

  On the back of his degree results, Owen was offered funding to complete a PhD, which he duly accepted. Again he put his head down, and even though he wasn’t particularly interested in the subject, and he encountered terrible difficulties with one of his supervisors, he still managed to get the PhD done and dusted.

  At that point, Owen could have abandoned clinical medicine and headed off on an academic pathway. But he felt compelled to continue – a decision which he described as follows: ‘One decision at aged sixteen, for people with a certain personality type, and a certain background, can take years to repair … Medicine can be very consuming. The hours you work, the constant exams. It’s a bit like a cult.’

  So Owen continued. After his PhD he returned to medical school to complete the three clinical years; next he progressed through foundation followed by four years as a specialty trainee in psychiatry. In all, he spent a staggering fifteen years pursuing a career that he never really enjoyed. And that’s what struck me most forcefully when we met – quite how long he had kept going, despite having doubts from the outset about his career choice.

  In Owen’s initial email, he mentioned that he was considering leaving medicine. A key issue to review when doctors say that they are thinking of quitting is whether such dissatisfaction is new or long-standing. After the first couple of sessions with Owen, I had no doubt whatsoever that thoughts of leaving medicine weren’t a temporary blip on an otherwise committed career pathway.

  Some of Owen’s doubts related to his chosen specialty – psychiatry. He felt that the specialty was moving sideways, and in contrast to other medical disciplines, there had been few impressive developments over the last thirty years. Sometimes he felt that putting a diagnostic label on a patient’s condition and calling it ‘personality disorder’ or ‘major depression’ did more harm than good. The patient would have the diagnosis on their medical file for the rest of their life. And he disliked the sense that treating psychotic patients with anti-psychotic medication sometimes made patients feel that the psychiatrist had robbed them of their individual personality. The medication might dampen down the hallucinations or irrational thoughts, but these changes came at a high personal cost for the patient.

  ‘I feel about my work as I do about flying,’ he told me. ‘There’s little inherent enjoyment, and I’m just glad when the plane lands, or the day is over.’

  In our second session, Owen talked about how he felt when things went wrong at work. The previous year a patient had died by suicide, and although his clinical management hadn’t been called into question, it brought a lot of his doubts about psychiatry to a head.

  ‘It’s not the same as a patient dying from cancer,’ Owen told me. ‘There’s just something awful about a patient killing themselves.’

  I wondered whether it was the tragedy of this suicide that had led to Owen wanting to change career, but he was adamant that this was not the case. I also wondered whether perhaps he was depressed, and I encouraged him to discuss this possibility with his GP. But what was most striking was how engaged Owen became when he started to talk about the pleasure he derived from writing. I learnt that not only was Owen extraordinarily widely read, but he was also a prolific writer of poetry, short stories and essays. In stark contrast to his academic papers and chapters in medical textbooks, it was the creative side of writing that he loved.

  ‘I’m very aware that I couldn’t earn my living as a creative writer,’ Owen said. ‘There’s no money there.’

  Just like Bijal, Owen was stuck.

  In subsequent sessions, we reviewed all sorts of different options. The most obvious way forward (and the pathway that all his senior consultants were suggesting he should follow) was to become an academic. Owen admitted that he would probably feel less anxious if he traded clinical sessions for research responsibilities as he wouldn’t have to worry about the well-being of his patients. But he was fearful that if he went down this route, he might lose the opportunity to leave medicine.

  ‘There’s been a pattern in my life of using three-year blocks as delaying tactics,’ Owen said. ‘First the PhD, then returning to finish my medical degree, and so on. I don’t want to make the same mistake now.’

  When we looked instead at changing specialty, Owen concluded that he had done so many exams over the past fifteen years that he hadn’t the heart to do any mor
e. So that ruled out a specialty shift. Quite by chance, one day I saw a job for a senior editor with a global scientific publisher: I sent the link to Owen, he applied and was duly appointed. But even then, he found it impossible to sever his links with medicine completely. He accepted the new job, but asked the psychiatry training programme to give him the option of returning to clinical medicine in a year’s time, should he decide to do so.

  Not surprisingly, he didn’t return to psychiatry. Two and a half years into his new job he found himself launching a new book series. ‘The job demands a mixture of creativity, being meticulous, and seeing where the issues are,’ Owen said. He marvelled at how quickly he had been promoted and how natural the different tasks felt, in comparison to the sorts of things he had done as a doctor. In passing, Owen told me that he had recently married.

  Working as a doctor had made Bijal unwell, and Owen deeply unhappy. ‘I was like a car that was being driven with its handbrake on,’ was how Owen put it. Being miserable at work eats into one’s confidence, and corrodes one’s self-belief. Conversely, feeling that one is able to put one’s talents to good use at work gives one a sense of identity and purpose which can spill over into how one responds to people outside work. I didn’t find it at all surprising that the radical changes that both Bijal and Owen made at work were paralleled by significant changes in their personal lives. Both of them found new partners as well as new careers.

  *

  When I first set eyes on Deepak, my heart sank. Sitting next to him in the reception area was a middle-aged woman who I assumed was his mother. The only other time a medical client had come to see me with Mum in tow, things hadn’t worked out well. That doctor was being investigated by the GMC for falsifying research results, and his life had been in meltdown. We only met once, for an initial session. He didn’t turn up for the next session, and a few weeks later I got an email from him telling me that he had been admitted as an inpatient to a psychiatric clinic and he would get in contact when he was discharged. He never contacted me again.

  All of this rushed through my mind when I first saw Deepak; unthinkingly I equated turning up to a session with one’s mother as a bad sign. I feared that yet again I would be faced with a client whose career (and life) difficulties were so profound that there was nothing I could do to help. In the event, Deepak’s mother didn’t expect to come to the session; she was simply there to keep her son company in the waiting area.

  ‘I feel that there is no way out of my current situation,’ Deepak told me in our first meeting. ‘I can’t go back to my job, but there’s nothing for me if I look ahead – no light at the end of the tunnel.’

  So what was the problem?

  Seemingly out of the blue, Deepak had recently started to suffer from severe panic attacks. There had been no suggestion that he was particularly anxious during the six years of medical school, the two years of foundation training or the earlier part of his training as a surgeon. This was the first time he had experienced any psychological problems.

  I learnt in the first session that Deepak’s mother was a GP. He had a close relationship with her, and sensibly she had encouraged him to go and discuss his problems with his own GP. Deepak followed this advice and his GP referred him to a psychologist for cognitive behavioural therapy (CBT), prescribed medication, and suggested that he take sick leave for a couple of weeks. It was then that he contacted me and asked for help.

  When a client tells me about an uncharacteristic change in their psychological well-being, inevitably I ask myself ‘Why now?’ So I started to wonder whether currently there was something going on in Deepak’s life that might account for these panic attacks. And as is often the case, there were a number of different possible causes, rather than one clear-cut answer. Deepak came from a particularly close family. His uncle had recently died and all of his relatives (and especially his mother) had been devastated. This bereavement happened at a time when he had to change placement in his surgical training, and his new colleagues were unsympathetic. They couldn’t understand why the death of his uncle was relevant to how he was feeling. Instead, they constantly criticised aspects of his surgical performance, to the extent that it seriously eroded his confidence. Then Deepak’s sleep was affected, which meant that he was going into work feeling exhausted. In turn, this made him feel even less confident that his surgical performance would escape the criticism of his supervising consultants. At this point, the panic attacks started.

  I could see how the family bereavement, hostile colleagues, and sleeplessness could all have contributed to his distress. But a deeper answer to the ‘Why now?’ question only emerged when I stopped asking Deepak about his current circumstances, and instead went right back to the beginning. What had Deepak enjoyed studying at school? When had he decided to apply to medical school? What had drawn him to medicine?

  Deepak told me that he came to the UK from India when he was six years old. From primary school onwards, he had excelled at maths and science and this continued throughout secondary school. He couldn’t exactly remember when he’d decided to train as a doctor, but for somebody who was ambitious, achieved excellent grades, and also came from a medical family, it seemed like an obvious career choice.

  Problems only started when he got to medical school. Throughout secondary school he had striven to be top of the year, but once in medical school he described himself as ‘going through the motions’. He wasn’t interested in what he was learning, and he did just enough work to scrape through the end-of-year exam. Each year he hoped that what he would learn the following year would capture his interest. But it never did.

  Once he started the three clinical years of medical school, things went from bad to worse. Deepak really disliked the way in which medical students can be treated as an impediment on ward rounds and he hated having to ‘scrabble around’, asking senior clinicians for permission to examine their patients. When I asked him if there was a single specialty that he had studied at medical school that had interested him, Deepak couldn’t think of any. Not one.

  Like Owen suddenly switching into gear when faced with his final examinations, Deepak crammed like mad to get through his medical school finals as he was terrified of failure. And he progressed from medical school to being a foundation trainee, in the hope that some aspect of medicine might come along that would inspire him. Plus, he didn’t want to let his family down, or feel that he had failed. So with no feelings of excitement about a future career in medicine, he drifted from medical school into being a junior hospital doctor.

  In contrast to his feelings about his studies, Deepak had thrown himself into sports at medical school. He had no difficulty motivating himself to turn up for rugby practice and he had captained the medical school first team. Deepak told me about his team’s sporting achievements with obvious pride. But his enthusiasm disappeared once he returned to talking about medicine.

  Many of Deepak’s colleagues on the rugby team decided to pursue a career in orthopaedic surgery. He’d noted that people who enjoyed sports often seemed to choose this option, and as no aspects of clinical work excited him, it seemed as good an idea as any. But entry to surgical training is extremely competitive and Deepak became aware that applicants were more likely to succeed if they had already passed Part A of their surgical postgraduate exams. For the first time in many years, Deepak rediscovered his intense ambition, and he decided that not only would he get Part A, but he would complete Part B as well. This is an extraordinary challenge. In fact the guidelines published by the Royal College of Surgeons strongly advise foundation doctors against attempting both exams as they deem it ‘highly unlikely’ that a foundation trainee would have the necessary experience to pass.

  Deepak not only attempted the challenge, he succeeded. And with this exceptional achievement under his belt, unsurprisingly he got through the surgical selection process. But it was at this point that Deepak’s career ran into difficulties; whilst he was delighted by his examination success, he had a growing re
alisation that he wasn’t actually interested in being a surgeon.

  Luckily there were things that Deepak did find really interesting. In our second session Deepak told me that in his spare time he read about finance and investments. Recently he had bought a house and was currently involved in its renovation. He loved finding the best contractors to work on the house, and negotiating deals. In fact he’d enjoyed all the commercial aspects of the project, even when it involved researching his legal rights, and getting compensation from a builder whose work turned out to be substandard.

  And it wasn’t just legal issues linked to the renovation that fired him up. Suddenly he remembered that when he was a foundation trainee he’d challenged the hospital on how they had categorised out-of-hours payments. This was an issue that many other junior doctors had raised in the hospital, but he was the one who managed to get the calculation changed, so that the doctors were paid correctly for their work.

  Then there was the issue of a distant cousin who was refused the right to remain in the UK. The matter was referred to an immigration tribunal, but the cousin couldn’t afford a lawyer. Deepak researched the case and successfully represented his cousin at the tribunal.

  It was law that interested Deepak. Not surgery.

  I began to understand the panic attacks.

  Deepak was bright, energetic, and hugely ambitious. His family were tremendously proud of his medical achievements. Psychologically he was being pulled simultaneously in opposite directions: part of him wanted to finish what he had set out to do, build on the successes he had already achieved in medicine, and continue in what his family regarded as a ‘noble’ profession. The other half of him knew that fundamentally he lacked the passion to pursue a surgical career as his heart lay elsewhere.