Also Human

by Caroline Elton

  *

  ‘They have no skin,’ Dr H said. ‘They are completely lacking a skin.’ Then he paused, to allow the seminar audience to reflect on his words.

  Dr H was a consultant psychiatrist who specialised in treating medical students and junior doctors and I first heard him speak at a medical education conference. In referring to these ‘skinless’ medical patients he was speaking metaphorically – describing those individuals who had to change profession because medical practice caused them excruciating pain. But as soon as he used the term, a roll call of medical students and junior doctors came to mind. I thought about a student who couldn’t bear human dissection because she saw the body in the anatomy lab as a person rather than a cadaver. Then I remembered a junior doctor who had to run out of the paediatric ward when confronted with the sight of children experiencing severe pain and another who hated treating elderly patients because all he could think of was that soon they would be dead. Coming face to face with human suffering is difficult without a protective layer – which was the point Dr H was emphasising in his seminar.

  But ‘skinlessness’ doesn’t only make it difficult for these individuals to interact with patients; often many other aspects of their life are unbearably painful, including having to consider or discuss a career change. So these medical students and doctors can be extremely difficult to help; they turn up late for sessions, or they cancel at the last minute, often using bizarre excuses. They promise to contact particular people to explore different career options but in the end never get round to doing any of the agreed tasks between sessions. All of this can be extremely frustrating when one is trying to help these doctors move on from medicine.

  If somebody was grieving the death of a partner, one wouldn’t respond by sending them a link to a dating site. Yet as a practitioner working with these clients it’s so easy to fall into the trap of becoming busy and practical – pointing out all the other great careers that they could pursue in future – rather than attending adequately to the distress that the need to leave medicine can cause.

  It’s difficult to stay with the sense of quite how painful life can be without a skin.

  *

  Nobody is writing about how distressing it can be when a doctor wants to (or has to) leave the profession; apart from a small-scale study of fourteen doctors published by the BMA over a decade ago, nothing has been written on the subject15. And that study, ground-breaking as it was, didn’t look at the psychological complexities in any detail.

  There’s not a single study in a medical journal that describes how doctors can be pulled in two directions simultaneously: wanting to remove themselves from the burden of clinical responsibility yet not wanting to feel disappointed in themselves, or be a disappointment to their families. And there are no accounts of how it can take years to move on from medicine, or how senior clinicians encourage trainees to continue for just that bit longer, rather than discussing whether it might be better for them to switch career.

  A lone voice on this issue is that of the novelist, the late Michael Crichton. In his essay ‘Quitting Medicine’ he described how in his last year at Harvard Medical School he developed numbness and tingling in his arms and legs which were diagnosed by a neurologist as possibly being a symptom of multiple sclerosis16. Following the diagnosis Crichton consulted a psychiatrist, who suggested instead that the symptoms could be hysterical and indicative of underlying psychological distress rather than due to a neurological disorder such as multiple sclerosis. At the time Crichton rejected the psychiatrist’s interpretation. A decade later (when he had experienced no further neurological symptoms) he had this to say:

  Almost ten years passed before I could look back and wonder whether the decision to leave medicine was so difficult, so traumatic, that I needed the added boost of a serious illness – or at least a possible illness. Because the immediate effect of the terrifying diagnosis was bracing: I was forced to ask myself what I wanted to do with the rest of my life, how I wanted to spend it.

  And it was clear to me that if in fact I had only a few years of unencumbered activity, then I wanted to spend those years writing and not doing medicine, or any of the things that colleagues, friends, parents and society in general expected me to do. The illness helped me to stand on my own, to make a difficult transition.

  *

  Crichton eventually came to understand how difficult quitting medicine can be. But when training senior clinicians I’ve seen how rational debate tends to fly out the window when the topic of students leaving the profession gets discussed – particularly if the student is academically able. Shortly after working with Bella, the doctor who left ten weeks into her first foundation year, a senior colleague from her medical school contacted me. Would I be willing to see another final year student who didn’t feel able to cope with the impending transition to work?

  ‘I’m happy to see this student,’ I told my colleague. ‘But I’ve seen so many other unhappy students from your institution that I’d like to come and run a session for senior faculty on early intervention. It doesn’t help the students or the NHS if people drop out within weeks of starting their first job.’

  My suggestion wasn’t well received. Well, not at first. Six months later, however, my colleague got back to me. Could I possibly run a session on how to support those students who didn’t think they would cope with medicine, and were thinking of not starting their foundation jobs?

  Twelve people came to the training afternoon, all of them senior faculty within the medical school. One of the attendees, a professor of medicine, took great exception to what I was saying.

  ‘It’s always better for somebody to finish their medical degree than to change track,’ he challenged.

  I told the professor about all the people I’d seen from his institution who had taken many extra years to get their degree and then been unable to work as a doctor. He wouldn’t shift his views. I was wrong.

  Another attendee, also a professor, but not medically qualified, entered the fray.

  ‘I’ve had an extraordinary career as a research biochemist,’ she said. ‘But I know that I wouldn’t have survived medical training.’

  The Professor of Medicine remained unconvinced. At the coffee break halfway through the training session he left.

  *

  Ironically, it is an ex-nun, rather than a doctor, who has written most persuasively on the topic of changing roles. Helen Rose Fuchs Ebaugh left her life as a Catholic nun in order to become a wife, mother and eventually Professor of Sociology. Using her own experience as a springboard, in her study Becoming an Ex: The Process of Role Exit, she interviewed people who had experienced significant role changes in their life17. They included women who had been widowed, mothers who had lost custody of their children, people who had changed sex. And doctors who had left the profession. Ebaugh concluded that:

  Disengagement from old roles is a complex process that involves shifts in reference groups, friendship networks, relationships with former group members, and most important, shifts in a person’s own sense of self-identity.

  [Exiters] can feel in mid-air, ungrounded, nowhere. The future is unknown and they no longer belong to the past.

  This is an almost poetic description of some of the doctors I have encountered. I have a profound sense of satisfaction that I have helped some doctors to feel less tied to the past, and better able to construct a future. But I am only too aware that there have been others who I was unable to help and whose careers remained suspended in mid-air.

  9

  Natural Selection

  I WAS ONCE at an event for medical school applicants organised by the British Medical Journal. It kicked off with a talk by Ben, a round-faced paediatric surgeon with an endearing smile. If one of my children had ever needed surgery, he was just the sort of doctor I would have wanted them to have; calm, reassuring, kind and obviously highly competent. Almost without exception, Ben held everybody spellbound. He showed them photos taken during operations, a
nd explained that recently he’d saved the life of a seven-year-old boy who had been propelled through a car windscreen at eighty miles an hour. The little boy’s insides consisted of ‘a puddle of blood’, Ben told us, and he put up a slide to prove the point. Four weeks after extensive surgery, the child had left hospital and returned home, with no residual injuries.

  About 70% of the audience were young women, nearly all of whom were looking up at Ben with barely concealed adoration. Their male counterparts looked similarly smitten. Everybody wanted to be like him. Everybody wanted to be him. He embodied all they hoped to achieve in their working lives. But the more Ben captivated the audience, the gloomier I became. I was the next speaker.

  Ben finished his talk to rapturous applause, but as soon as I explained who I was, and what I was going to talk about, the buzz in the room evaporated. That I was the same age as their parents, and a psychologist, made me far less interesting to the audience than Ben. But more than that, it was my central message that they didn’t want to hear. If you are attending a seminar on applying to medical school, the last thing in the world you want to sit through is a lecture from a psychologist telling you about all the unhappy doctors she has seen in recent years.

  I framed the talk with a simple analogy: just as patients don’t tend to go to the doctor when they are well, doctors don’t tend to seek out a psychologist who specialises in career difficulties when they are loving their work. When I was planning the talk, a line from a Yeats poem kept buzzing through my head. ‘Tread softly because you tread on my dreams.’ The audience was on the cusp of adulthood, grappling with what they wanted to do with their lives; I was desperate not to tread on dreams.

  But how can you softly convey the message that sometimes the dream of training as a doctor turns out to be a nightmare in reality?

  There was muted applause at the end of my talk and I quickly exited stage left. On my way out, a tall middle-aged woman stopped me.

  ‘I wish that had been filmed, so I could show it to the girls at my school.’

  She explained that she headed up the sixth form in one of the most academic girls’ boarding schools in the country. When pupils were aiming for medicine, they (or their parents) never gave any thought to the issues I had raised. I thanked her, and left – glad that at least one person had found it useful.

  A couple of weeks later somebody who had been in the audience emailed me:

  Dear Caroline,

  I attended the BMJ seminar last month where you did a talk on things to consider before applying for medicine. I am in my last year of school and hoping to study medicine at university. My query is with regard to my health situation. I am currently receiving treatment for anorexia, which I have had since I was 12. Although I am an outpatient, I was wondering whether I would actually be allowed to study medicine. Is there a policy regarding people who have illnesses or disorders that might impact on my application?

  I would be incredibly grateful if you could respond to my query. Thanks, Kesia

  I thought of the many doctors with eating disorders whom I had encountered, and how in at least some cases promising futures had turned sour. If Kesia was still struggling with anorexia after six years of treatment, would she get through the selection process? On paper at least, the selection panel leaves health considerations to the occupational health team. But anorexia (as opposed to bulimia) is a condition that’s hard to hide, so how might her appearance impact on how she was viewed by the panel? Would she be seen as a suitable candidate? If she succeeded at interview, would she pass the occupational health assessment? And if she got through that – how might her career pan out in the longer term? So many questions.

  I was unsure how to respond.

  *

  So who were some of the doctors that Kesia heard me talk about in the BMJ seminar?

  I started by describing some doctors I’ve encountered who were nearly, but not quite bright enough to succeed in medicine. Some of these doctors took multiple attempts to get into medical school, and then, once they had been admitted, regularly failed the end-of-year examinations, and had to repeat them during the summer holidays. Typically these doctors had to study much harder than their peers just to keep up, and they had no spare time for social or extracurricular activities. Most medical schools limit how many times a student can fail an examination before they are kicked off the course – but there is also an appeals process which allows students who lose their place on the course to appeal the decision. And that’s not all. If the medical school dismisses the appeal there is a national body (the Office of the Independent Adjudicator) that they can take their case to – and often they do.

  Students who find themselves in a cycle of repeated examination failure often appeal on the grounds that their performance was affected by depression or anxiety – and this may well be true. But sometimes I wonder whether the depression or anxiety was the cause of the examination failure – or a response to the fact that they knew that despite working as hard as they could, they still couldn’t make the grade. I’ve encountered doctors who have taken over ten years to complete a five-year course. Some of these have qualified in the end – whereas others have spent over a decade failing to get their medical degree.

  Sadly, for those students who have struggled in medical school, gaining their degree doesn’t mark the end of their difficulties; they then encounter an even bigger hurdle – passing their postgraduate specialty exams. When you’re working eleven hours a day as a junior doctor (or sometimes more, as we have seen), it’s hard to squeeze in time to study for exams on top of your job. There just aren’t enough hours in the day. And if you’ve only got through your exams in medical school by studying sixteen hours a day, things can fall apart once you start working as a doctor. This was the point I emphasised in my BMJ seminar.

  Kesia also heard me talk about a different group of medical students – those who struggled with the emotional rather than the academic demands of medical training. Some of these students are academic high-flyers who experienced no difficulty at all gaining a place at medical school. Furthermore, in the more traditional medical school courses where the first couple of years are lecture and lab based with minimal patient contact, these students might also make good progress. But as soon as these students leave the lecture halls and are exposed to suffering and distressed patients – their careers can unravel. In other words, when some vulnerable students start to understand the enormous responsibility inherent in medical work, they can feel overwhelmed. Often these students will then have time out, due to depression and anxiety, or they will have to repeat years because they were too unwell to sit their end-of-year examinations. And this too can drag on for years and years.

  Part of the problem is that until very recently, when the GMC started to track doctors from the beginning of medical school onwards, there has been a disconnect between medical school and postgraduate training. The medical schools kept track of their alumni for one year after they left, but they had no systematic way of knowing what happened after that. But I knew – at least for the doctors who came to see me. I always took a detailed educational and career history and before too long I came to see how doctors who struggled to get their postgraduate exams had often had medical school careers that were equally bumpy.

  *

  Competition for medical school places is fierce. For example, at the University of Oxford in 2015,1 only 11% of applicants were accepted, notwithstanding the fact that the overwhelming number of these applicants would have achieved excellent secondary school exam grades. Other courses are equally competitive at Oxford; that year applicants to study History of Art had the same chance of being accepted as those applying for Medicine. But there the similarity between the two courses ends. If Oxford gives a place to a History of Art student who turns out to have poor aesthetic judgement, who, beyond the applicant, suffers? But if a medical student struggles to learn the core content of the course, future patients may be placed at risk. ‘Selection for Medical
School implies selection for the medical profession’ is how the Medical School Council puts it.2 The stakes for medical school selection are high.

  In the UK, four-year graduate-entry programmes comprise 10% of admissions.3 For the remaining 90%, gaining a medical degree takes five or six years, depending upon whether or not a student adds on an intercalated degree. For these students, gaining a medical qualification takes at least five years; often six, if the student adds on an intercalated degree. When you look at the stats, what is striking is the low attrition rate:4 two studies have recently reported rates of 6% and 5.7% respectively. Similarly, in the US, the Association of American Medical Colleges (AAMC) reported in 2010 that approximately 3% of students failed to complete medical school.5

  On the face of it, it might seem that the process of selection for medical school in both the UK and US is remarkably successful. The overwhelming majority of students accepted end up graduating.6 But an alternative explanation is that, from medical school onwards, the medical training system has a profound reluctance, where necessary, to remove those who are not suited to the practice of medicine. This is known in the trade as the ‘failure to fail’ problem. So what’s the evidence for this claim?

  In part the evidence is anecdotal, based on the many doctors I have seen over the years who have got through medical school and perhaps even the foundation programme, but didn’t have what it takes to progress their medical careers any further. But in addition to this personal experience there is empirical evidence of a significant gap between the numbers of students experiencing difficulties at medical school and the number who end up failing. For example, Janet Yates, a researcher at Nottingham Medical School in the UK, analysed the progress of five consecutive intakes at the school.7 Yates reported that 12.8% of students at the medical school experienced considerable difficulties: failing a number of examinations, having to repeat a year, serious attitudinal problems noted in their undergraduate records, and suffering from a depressive illness. Just under a third of these struggling students (4% of the total sample) left medical school before graduating. But that leaves 8.8% of the total sample remaining in the system and potentially continuing to struggle, even if they eventually get their medical degree.