This case was highly unusual and is a rare example of when the MMI method demonstrates that somebody may struggle to cope with medicine. It would be difficult to devise an effective MMI task that directly assessed emotional resilience (although a few medical schools have tried). Other medical schools have advocated using a screening questionnaire. However, I suspect that applicants who are desperate to gain a place will answer these questions by thinking about what the assessment panel is looking for, rather than giving answers that actually reflect how they typically respond in stressful situations.43
It’s not that emotional resilience cannot be measured. Organisations that assess whether staff will cope with extremely demanding assignments (working in the field during the Ebola crisis, for example) have developed sophisticated questionnaires. The breadth of issues these cover is astonishing: childhood traumas; past and current relationships with family; current support from friends; relationship with one’s partner (or lack of relationship); previous episodes of depression; sleep difficulties; current and past ability to look after oneself appropriately, etc.44
If medical schools’ admission panels asked these sorts of questions, I suspect they would be able to identify some (but not all) of those who go on to struggle. But it wouldn’t be ethical to probe in this way, and this approach risks breaching the protection that individuals with mental health problems are entitled to under the law. Also when answering these questions, applicants would be prone to biasing their answers, just as they would with a questionnaire that asked directly about their emotional resilience. It’s not the way forward.
But could these sorts of questions be asked after the selection process, in order to identify students who were likely to require additional emotional support? If the students knew that their responses would not be shared with the medical school faculty teaching them, they might be more likely to give honest answers. And then, if the students had been fully supported but still were unable to manage, faculty might find it easier to terminate a student’s training. In other words, the ‘failure to fail’ tendency might be held in check.
*
Another email in my inbox. But this time it’s from a colleague who has a senior training role in their particular specialty.
Had a really difficult day of annual reviews today. There just seem to be so many trainees with problems and I saw someone who is utterly failing … Four years after leaving medical school, her supervisors said that she is barely functioning at medical student level. Anyway – I asked her about her undergraduate education. It won’t surprise you to hear that she spent 12 years as a medical student because of repeated episodes of depression and anxiety … I find that utterly unbelievable and completely depressing. How is such a thing possible? They have totally failed this trainee and the general public … And all that it means is that she has invested several more years in a career that is going nowhere.
Medical schools need to acknowledge that the selection process doesn’t (because it probably can’t) provide a robust screening for emotional resilience. This means that, inevitably, there will be students in their institution who turn out not to be suited to the profession of medicine. I don’t blame the institutions for selecting students who don’t have what it takes to be a doctor because selection is, at best, an inexact science. But there is an urgent need to manage these students more effectively, once they start to struggle at medical school. Nobody should be allowed to train for a job for twelve years (and pay for that training) when there was no realistic prospect of success.
*
I decided to discuss my response to Kesia with my supervisor, Margaret. She’s a clinical psychologist and psychotherapist and her perspective on my work is invaluable. I described how I had explained to Kesia that there is a legal framework in place that means she could not be discriminated against for health (including mental health reasons). In my email I had also told Kesia that the key issue was whether the illness would impact on her ability to get through the course and, following graduation, to work as a doctor. But this issue would be dealt with by occupational health, separately from the interview itself.
‘Did you say anything else in your email?’ Margaret asked.
I told Margaret about the different suggestions I had made to Kesia: that she should discuss her career intentions with the psychologists/psychiatrists treating her who were best placed to review whether now was a good time for her to apply; that she should try to get some relevant voluntary experience working with people who are sick, or frail or distressed, and ask herself how she found this sort of work; that she might want to give herself more time to get her anorexia under control and apply for medicine as a postgraduate; and that there were also careers in healthcare other than medicine that she might want to consider.
‘And did you hear back?’ Margaret asked.
‘Yes, almost immediately. Kesia thanked me for taking the time to reply and said that she was considering other options, but her heart was still set on medicine.’
After this discussion with Margaret, I went back home and reread my email exchange with Kesia. I was struck by the fact that Kesia’s email posed one question (Will the fact that I am still being treated for anorexia mean that I won’t be allowed to study medicine?) whilst most of my email was actually devoted to answering something different. Kesia never explicitly asked for my opinion on whether she would be suited to medical training, given her long-standing anorexia. But that is the question I devoted most space to in my response.
Is it significant that Kesia didn’t ask? Perhaps she was discussing her suitability for medical training with the clinical team treating her for anorexia. As I indicated in my email, they would be much better placed to have a view on this issue than I could ever be. But some of the doctors with eating disorders whom I have supported have been unable to face up to the impact of their illness on their capacity for medical work. And I’ll never forget how one medical student with anorexia, who spent twelve years trying (but ultimately failing) to qualify, gave me an abridged career history in our first meeting. It was only after the session, when I matched her date of birth to her description of what had happened to her in medical school, that I realised that there was a gap of six years in her story. A gap that she couldn’t bear to admit to me – even though she had come to see me in order to rebuild her career.
I contacted Kesia to ask if I could include her email in the chapter. Almost immediately she emailed me back, giving me permission, and updating me on what had happened:
I did eventually apply to study medicine and have a place for next year. I was meant to be starting this October but unfortunately became unwell so had to defer the place. I am not ready to go anyway so I am concentrating on getting myself well enough to go next year.
For the time being, Kesia was on the receiving end of medical care, rather than training to be a doctor.
EPILOGUE
There’s No Such Thing as a Doctor
IF IT WASN’T for advances in medical science, my mother would have died when I was born. She was one of the first people in the UK to be successfully treated for a blood disorder – aplastic anaemia – which she developed towards the end of her pregnancy. As it was, her survival was far from guaranteed, during the first few weeks of my life. A quarter of a century later, my father developed myeloma – a cancer of the bone marrow. Although eventually he died from the disease, chemotherapy extended his life for over seven years.
The advances in medical science during the twentieth century, and continuing into the twenty-first, are extraordinary. Much of it we now take for granted; the vaccinations for diphtheria, tetanus and whooping cough – once childhood killers – that my grandchildren received when they were eight weeks old were only developed in the 1920s. The polio vaccine came later, in the 1950s. Ultrasound scans of the foetus were available when I had my children, but nowadays it is possible to perform surgical procedures on the foetus in utero.
Last year, a close friend in his early sixti
es with Primary Sclerosing Cholangitis – a relatively rare chronic liver disease – had a transplant1. The donor was his 23-year-old son, who gifted his father 61% of his liver. Without the operation, this friend would have died of liver failure. The son has made a full recovery and my friend is doing well, although he will have to take immunosuppressant medication for life, to stop his own immune system rejecting his son’s liver.
When I watch the video of the liver transplant operation (filmed with permission from my friend, as part of a series that the Guardian ran on the NHS), I am in awe. I remember talking to his wife on the day both her son and her husband were in hospital awaiting surgery. Her bravery was astonishing – I would have been in pieces. And the brief glimpses of the operation shown in the video increase my admiration for the surgical team a thousand-fold.
I am not a medical Luddite – somebody who turns their back on or scorns the achievements of 21st-century medicine. But there’s an astonishing gap between, on the one hand, advances in medical practice and, on the other, our understanding of the psychological demands of medical work. It’s almost as if the psyche has been surgically excised from our conception of what it means to be a doctor. In fact this psychic excision underpins all the stories in this book.
We’ve seen how doctors can have the intellectual ability to pass their medical school examinations but lack the psychological resilience to manage the emotional demands of medical work. We’ve also seen how the transition from medical student to junior hospital doctor represents a quantum shift in responsibility. And innovations such as the reduction in working hours that have been put in place to enhance junior doctors’ well-being can have unforeseen psychological consequences when they erode the continuity of the clinical team.
We regularly require doctors to carry out extraordinarily distressing tasks with inadequate attention given to their psychological well-being. Then we blame doctors when their psychological defences kick in, and they respond to patients or relatives with a lack of empathy. Not only do we underestimate the emotional demands of clinical practice, but we also fail to recognise that some of the people who are attracted to the profession in the first place may be drawn to it out of a desire to manage their own psychological vulnerabilities. Clinicians’ understanding of specialty choice is often woefully simplistic, with inadequate attention given to the psychological complexity embedded in the decision to treat a particular patient group.
Doctors can become ill or disabled, as can members of their family or close friends; inevitably, thoughts and feelings linked to the personal experience of illness will be evoked when doctors treat their patients. Medical work can involve sharing deeply private information as well as the exposure of intimate parts of the body. Doctors are not immune to developing sexual feelings for their patients but the training system denies that this could ever happen. The forces of sexism and racism that infect other professions are also found within medicine but the psychological impact of discrimination may be particularly devastating for doctors, given the enormous responsibility we require them to shoulder.
Even leaving the profession can be psychologically fraught. When doctors feel that they have been pushed to the edge, they frequently find themselves paralysed between equal, but opposing, forces. On the one hand, there is an enormous desire to leave medicine in order to escape from the psychological pressures of the work. On the other, there is terror that they might feel a failure, that they have let other people down, or that they may later wish they had stayed put. ‘I’m just as scared that I may regret it if I stop,’ was what Leo wrote in his email.
*
Taken together, doctors’ psychological needs are denied, ignored, not thought about. Unmet. A systemic ‘psycholectomy’ has been performed on the profession as a whole. But its impact is felt most acutely in the doctor–patient relationship.
What is especially curious is that the psychological needs of one half of the dyad – the patient – are well recognised. So medical students and junior doctors are thoroughly versed in the mantra of ‘patient-centred care’2. They are taught and are tested on their communication skills and exhorted to show empathy to patients and family members. But if you dig a bit deeper, it soon becomes apparent that patient-centred care only tells half of the story. This becomes clearer if one makes a simple analogy with physics.
At secondary school I was taught the first law of thermodynamics. This law states that the energy within a system cannot be created or destroyed; it can only be transformed from one form to another. It strikes me that this basic law of physics has a psychic parallel. Perhaps it should be known as the first law of human dynamics? And just as the physical law demonstrates that the energy in a system cannot change but can only be transferred, the psychic law reminds us that a person’s ability to carry out emotional work – to care for somebody else in distress – critically depends upon the quality of care that that person has themself received. It’s almost as if the potential for giving care to others rests on a form of ‘caring capital’ that a person has accrued in the past. And currently. If a person feels uncared for, emotionally depleted, they will struggle (in some way or other) to carry the emotional burden of another person’s suffering. They will struggle to care.
When it comes to the care of infants this basic principle is well understood. Mothers (and fathers) who are emotionally or physically depleted may struggle to provide effective and responsive care for their babies. And the emotional resources that a parent brings to bear – their caring capital – is influenced both by that parent’s own experience of being parented in the past, as well as by their current networks of emotional support. None of this is controversial.
None of it is new, either. In the 1950s paediatrician and psychoanalyst Donald Winnicott wrote ‘there is no such thing as a baby … a baby cannot exist alone, but is essentially part of a relationship’3. I don’t imagine that Winnicott would have been a proponent of ‘infant-centred care’. He understood that the relationship between parent and child was all important.
Winnicott also recognised that the feelings that parents have for their children aren’t always nice. In a classic paper, he lists eighteen reasons why a mother may, at times, experience hateful feelings towards her baby. These include4:
He is ruthless, treats her as scum, an unpaid servant, a slave
His excited love is cupboard love, so that having got what he wants, he throws her away like orange peel
He is suspicious, refuses her good food, and makes her doubt herself, but eats well with his aunt
After an awful morning with him she goes out, and he smiles at a stranger, who says ‘Isn’t he sweet!’
Winnicott was playfully provocative in the way he framed these reasons – but at the same time he was highlighting a truth known to every parent. The palette of parental feelings doesn’t only contain warm and sunny colours – it also spans murky, darker, hues. Of course, Winnicott wasn’t advocating that parents should act out these feelings of hate; he was simply drawing attention to the inevitability of their existence. They are normal.
These two basic principles (the critical importance of the relationship between infant and parent, and the inevitability of hate alongside feelings of love towards one’s baby) would be hard to dispute. But what is widely accepted in the context of mothers and babies is frequently overlooked when thinking about doctors and patients. Again this is extraordinary, because Winnicott explicitly made the parallel in the original paper when talking about the relationship between psychoanalysts and their patients.
Winnicott died in 1971. But if he were alive today, I wonder what reasons he would intuitively cite for doctors sometimes resenting, or even hating, their patients. Perhaps his list would include:
Fear of making a significant mistake
Time pressures; too many patients to see in too short a time
Uncertainty about the diagnosis, or treatment plan
Professional impotence when the patient’s illness can’t be cured
Patients’ unrealistic expectations about what modern medicine can achieve
Patients challenging your professional knowledge
Fear of being the subject of a complaint or a legal claim
Exhaustion caused by working through the night
Hunger and thirst through working a whole shift without a break
Being on the receiving end of derogatory comments from patients
Disgust at physical decay or deformity
Fear of contagion
Contempt at injuries caused by the patient’s own behaviour
Having to work in a part of the country where one is separated from family and friends
Missing out on a special family celebration because one has to work
And above all else, the reason why patients have always had, and will always have, the potential to evoke difficult feelings in the doctor is that inevitably they remind doctors that they, and those they love, are mortal.
*
Every item on the list is something that doctors have talked to me about over the years. The list isn’t exhaustive but it illustrates the enormous psychological complexity of medical work. Of course, doctors are not the only ones who encounter these sorts of pressures. And other healthcare colleagues (for example nurses or midwives) have to put up with additional sources of stress such as low pay, or lack of recognition of their professional contribution. I’ve never forgotten old-style ward rounds where a busy nurse had to trundle behind the consultant for half the morning, yet was never once asked for her opinion on any of the patients under her care.
But it’s the doctor who is responsible for diagnosing the illness, deciding on the best form of treatment, prescribing drugs, analysing progress and reviewing whether the treatment needs to be altered. Admittedly there are some senior nurses who, in certain contexts, take on some of these responsibilities. But from the fateful first Wednesday in August, junior doctors can be on call, running between different wards, tasked with making decisions which, if they get wrong, can have terrible consequences. Some doctors who come to see me cannot bear the nature of this responsibility. They agonise over the fact that a mistaken clinical decision could cost a life.
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