Doctors also have to cope with the sheer unpredictability and uncertainty of medical work. In medicine a given condition can present itself in a completely different way in two patients and whilst one may respond to a particular course of treatment, the other may not. This unpredictability weighs heavily on some doctors and is a frequent reason why so many of the doctors in this book have struggled.
*
One hundred and fifty years ago, the surgeon Joseph Lister published his findings on using antiseptics to reduce the risk of post-operative infections5. Lister advocated the use of carbolic acid to disinfect the surgeon’s hands, the instruments, the wound and even the air around the patient. When these simple measures were used, patient survival rates following amputation improved from 55% to 85%. But even with these extraordinary results, Lister’s antiseptic methods were not immediately taken up by his colleagues; they found them complicated and time-consuming and tried to argue that the results were actually due to other changes such as improved ventilation in hospitals.
That was 1867. Today infection control informs every layer of medical practice: the GP washing their hands in their surgery after examining a patient; barrier nursing an immunosuppressed patient; isolating whole wards to control an outbreak of a hospital-acquired infection; and even national plans to manage the outbreak of a pandemic. In addition, many of the achievements of modern medicine are predicated on the capacity to control the spread of infection, and to treat it effectively when it occurs. Operations such as live-donor liver transplants wouldn’t be possible if the risk of post-operative infection couldn’t be minimised in both donor and host.
Just imagine, for a second, if the emotional well-being of the medical workforce (and the healthcare workforce more generally) was accorded the same priority as the control of infection. Parity between the infective, and the affective, in other words. In Lister’s time, 45% of patients died of infection post-amputation. Today some reports suggest that over 50% of doctors experience burnout. Given this level of burnout (and of depression, and suicide) it would be hard to argue that we don’t have a significant public health crisis on our hands. Is the comparison really so absurd?
The comparison also flags up that there’s no one-off, simple solution. Infection control in a hospital isn’t restricted to putting up a poster saying ‘now wash your hands’ in the toilets. Of course not. Yet I walked into the education centre of a London teaching hospital and saw a noticeboard covered in brick-patterned paper, at the top of which was the title ‘resilience wall’. Staff members were encouraged to stick Post-it notes with upbeat comments (‘I’ll practise my breathing if I become stressed’; ‘I’ll go outside to get fresh air at lunchtime’). All good stuff, but the resilience wall is about as likely to have a serious impact on doctors’ well-being as the brick-patterned paper is to bear the structural load of the building.
The problem with attempts to build doctors’ resilience (and there have been many) is that they lay the blame at the foot of the individual. This approach is flawed, as the authors of a recent paper in the BMJ pointed out:
Resilience is always contextual. It is a complex and dynamic interplay between an individual, the individual’s environment and sociocultural factors. Any intervention to promote resilience must deal with organisational as well as individual and team issues6.
And that’s what we’ve seen in this book. At the level of the individual, it’s clear that some of the people who are selected into medicine are never going to be able to make it as doctors, that some doctors choose particular specialties out of an unconscious attempt to resolve their own personal conflicts, and that events going on in a doctor’s private life can impact on how they feel about their work. These individual factors then interact with organisational ones – the systemic ‘failure to fail’; the inverse-care law, in which those in greatest need of support end up receiving the least; the pressures of years of underfunding; the appalling lack of thought given to significant career transitions; the corrosive forces of sexism and racism, to name but a few. And the culture of medicine as a whole, with its reluctance to adopt an evidence-based approach to medical education and its tendency to disavow any signs of vulnerability on the part of the doctor and to lay blame at the foot of the individual is the glue loosely holding the system together.
Is it a wonder that there are cracks?
One thing is abundantly clear, and that is that there are no simple answers. Improving the emotional well-being of the medical workforce requires interventions that tackle all three interconnected levels – the individual, the organisation, and the culture of medicine as a whole.
It would be easy to despair, given the scale of the problem. But as we’ve seen in this book, across the world there are tiny flickers of hope. Michael Farquhar’s sleep campaign needs to spread from London across the UK, and then to the rest of the world. It is a rare example of doctors using their clinical knowledge to benefit not only their patients – but also other clinicians. Many countries could learn from New Zealand and introduce a trainee intern year to manage the transition to clinical practice. Canada and the US are more enlightened than the UK when it comes to opening up medical training to those with physical disabilities, and the growth of the Schwartz Round movement across North America and the UK is encouraging. There are medical schools in the US that exemplify just what can be achieved when a commitment to diversity is tackled across an institution as a whole, while trainee doctors in the US would benefit from services like the Professional Support Unit where I worked in London.
Perhaps in 150 years’ time, the attention given to doctors’ emotional well-being will match that given currently to infection control. Perhaps historians looking back at how we treated doctors in 2018 will regard our medical systems with the same horror that we experience when we read about surgeons in Lister’s day refusing to wash their hands between patients. Perhaps in 150 years’ time, society will recognise that, whilst the demands of the job are exceptional, the person inhabiting the role of the doctor is, just like their patients, also human.
Perhaps.
NOTES
Introduction: Medicine in the Mirror
1 The Dean of the University wrote an impassioned opinion piece in the New England Journal of Medicine: Muller. D., ‘Kathryn,’ N Engl J Med 376 (2017), pp. 1101–1103.
2 The research the dean referred to is from the Mayo Clinic: Dyrbye, L. N., et al., ‘Burnout and suicidal ideation among U.S. medical students,’ Ann Intern Med 149 (2008), pp. 334–41.
3 The web page set up in Rose Polge’s memory is available at: https://www.justgiving.com/teams/rosepolge.
4 The following year another junior doctor disappeared, and Dr Shaba Nabi wrote this article for Pulse Today, 31st March 2017: http://www.pulsetoday.co.uk/views/blogs/we-must-be-forced-to-care-for-ourselves/20034150.blog.
5 The 2016 study published in The Lancet concluded that GPs’ clinical workload was reaching ‘saturation point’: Hobbs, R., et al., ‘Clinical workload in UK primary care: A retrospective analysis of 100 million consultations in England, 2007–14,’ The Lancet 387:4 (2016), pp. 2270–2272.
6 The quarterly monitoring report from The King’s Fund is available online at: http://qmr.kingsfund.org.uk/2017/22/overview.
7 The survey of nearly 500 junior doctors conducted by the Royal College of Physicians reported that nearly 70% of doctors worked on a rota that was permanently under-staffed: Royal College of Physicians., ‘Being a junior doctor: Experiences from the frontline of the NHS,’ RCP policy: workforce & Mission: Health (2016) available online at: https://www.rcplondon.ac.uk/guidelines-policy/being-junior-doctor.
8 The 2016 GMC survey of junior doctors: GMC., ‘National training survey 2016,’ GMC (2016) available online at: https://www.gmc-uk.org/National_training_survey_2016___key_findings_68462938.pdf.
9 The following study carried out by researchers at Harvard Medical School reported that trainees who were suffering from depression made six times more medical errors t
han their non-depressed colleagues: Fahrenkopf, M. A., et al., ‘Rates of medication errors among depressed and burnt out residents: prospective cohort study,’ BMJ 336: 488 (2006), 10.1136/bmj.39469.763218.BE.
Wednesday’s Child
1 The 2014 GMC conclusions on the August transition: Monrouxe, L. et al., ‘UK Medical graduates preparedness for practice: Final report to the GMC,’ GMC (2014) available online at: https://www.gmcuk.org/How_Prepared_are_UK_Medical_Graduates_for_Practice_SUBMITTED_Revised_140614.pdf_58034815.pdf
2 The Situational Judgement Test; example scenario taken from SJT Answers & Rationale available online at: http://www.foundationprogramme.nhs.uk/pages/fp-afp/applicant-guidance/SJT/EPM.
3 Foundation Programme 2016 facts and statistics are available online at: http://www.foundationprogramme.nhs.uk/pages/resource-bank.
4 GP Julian Tudor-Hart’s famously termed the ‘inverse care’ law in: Tudor-Hart, J., ‘The inverse care law,’ The Lancet 297: 7696 (1971), pp. 405–12.
5 For the 2016 data on Foundation Programme allocations see the 2016 UKFPO Annual Report available online at: http://www.foundationprogramme.nhs.uk/news/story/annual-report-2016.
6 Information from the National Resident Matching Program available online at: http://www.nrmp.org/press-release-results-of-2016-nrmp-main-residency-match-largest-on-record-as-match-continues-to-grow/.
7 Information on the algorithm that gained its two inventors a Nobel Prize in Economics is available online at: https://www.nobelprize.org/nobel_prizes/economic-sciences/laureates/2012/popular-economicsciences2012.pdf.
8 ‘April is the cruellest month’ wrote Eliot in: ‘The Waste Land’, T. S. Eliot in The Complete Poems and Plays of T.S. Eliot (London: Faber and Faber, 1969).
9 ‘Why July matters’: Petrilli, M. C., et al., ‘Why July matters,’ Acad Med 91:7 (2016), pp. 910–912.
10 In 2009 a group of researchers at Imperial College London published this retrospective study: Jen, H. M., et al., ‘Early in-hospitality mortality following trainee doctors’ first day at work,’ PLoS ONE 4:9 (2009), 10.1371/journal.pone.0007103.
11 In 2011, this research reported that 90% of physicians felt that the August transition had a negative impact on patient care: Vaughan, L., et al., ‘August is always a nightmare: Results of the Royal College of Physicians Edinburgh and Society of acute medicine August transition survey,’ Clin Med 11:4 (2011), pp. 322–6.
12 In 2014 the GMC found that the quality of induction was highly variable: Monrouxe, L., et al., ‘UK Medical graduates preparedness for practice: Final report to the GMC,’ GMC (2014) available online at: https://www.gmc-uk.org/How_Prepared_are_UK_Medical_Graduates_for_Practice_SUBMITTED_Revised_140614.pdf_58034815.pdf.
13 Rose Polge’s tragic suicide happened at the height of the junior doctors’ strike: Clarke, R., ‘Suicides among junior doctors in the NHS,’ BMJ 357 (2017), 10.1136/bmj.j2527.
14 Psychologist Jenny Firth-Cozens’ study of stress and depression in junior doctors: Firth, J., ‘Levels and source of stress in medical students,’ Br Med J (Clin Res Ed) 292 (1986), pp. 1177–80.
15 In 1987, Firth-Cozens reported the results of a longitudinal study of first year junior doctors: Firth-Cozens, J., ‘Emotional distress in junior house officers,’ Br Med J (Clin Res Ed) 295 (1987), pp. 533–6.
16 Twenty years after starting the first research project, Firth-Cozens lamented that not enough had been done to support doctors’ wellbeing and stress: Firth-Cozens, J., ‘Doctors, their wellbeing, and their stress,’ BMJ 326: 670 (2003), pp.670–671.
17 In 2015, this opinion piece was written following the suicide of two first year residents: Goldman, L. M., et al., ‘Depression and suicide among physician trainees: Recommendations for a national response,’ JAMA Psychiatry 72:5 (2015), pp. 411–412.
18 A major international review of fifty-four studies in the Journal of the American Medical Association: Mata, A. D., et al., ‘Prevalence of depression and depressive symptoms among resident physicians: A systematic review,’ JAMA 314:22 (2015), pp. 2373–2383.
19 In an editorial accompanying the international review, the authors concluded that personal and professional dysfunction and suicide rate could be construed as a depression endemic among residents: Schwenk, L. T., ‘Resident depression. The tip of a graduate medical education iceberg,’ JAMA 314:22 (2015), pp.2357–8.
20 This BMJ article, published in 1994, suggested that the New Zealand training model might have ‘much to offer’ the UK system: Allen, M. I. P., and Colls, M. B., ‘Improving the preregistration experience: The New Zealand approach,’ BMJ 308:6925 (1994), pp. 398–400.
21 The following survey from the New Zealand Medical Journal reported that at the end of the trainee intern year 92% of students felt prepared to be a doctor: Tweed, J. M., et al., ‘How the trainee intern (TI) year can ease the transition from undergraduate education to postgraduate practice,’ N Z Med J 123:1318 (2010), pp. 81–91.
22 Importantly, another study in New Zealand found that first year doctors’ scored in the normal range for measures such as depression: Henning, A. M., et al., ‘Junior doctors in their first year: mental health, quality of life, burnout and heart rate variability,’ Perspect Med Educ 3:2 (2014), pp. 136–43.
23 A 2014 BMJ review found that limiting doctors’ working hours reduced road traffic accidents caused by exhausted doctors: Rodriguez-Jarneo, C. M., et al., ‘European working time directive and doctors’ health: a systematic review of the available epidemiological evidence,’ BMJ Open 4 (2014), 10.1136/bmjopen-2014–004916.
24 Reducing working hours does not reduce fatigue as one trainee commented in: Morrow, G., et al., ‘Have restricted working hours reduced junior doctors’ experience of fatigue?’ A focus group and telephone interview study. BMJ Open 4 (2014), 10.1136/bmjopen-2013–004222.
25 Michael Farquhar’s piece in the BMJ ‘We must recognise the health effects associated with shift working,’ available online at http://blogs.bmj.com/bmj/2017/10/06/michael-farquhar-we-must-recognise-the-health-effects-associated-with-shift-working/.
26 Details about the HALT campaign can be found online at: http://www.kingshealthpartners.org/latest/1028-staff-encouraged-to-take-regular-breaks.
27 The GMC annual trainee survey found that more than 50% of doctors in training worked beyond their rostered hours: ‘National training survey 2016: Key findings,’ GMC (2016) available online at: https://www.gmc-uk.org/National_training_survey_2016___key_findings_68462938.pdf.
28 The British government review, commissioned by the Secretary of State for Health, reviewed the impact of the European Time Directive on the quality of training: Temple, J., ‘Time for training: A review of the impact of the European Time Directive on the quality of training,’ (2010) available online at: https://www.hee.nhs.uk/sites/default/files/documents/Time%20for%20training%20report_0.pdf.
29 There is some evidence that more recent groups of trainees welcome restrictions on working hours: Morrow, G., et al., ‘The impact of the Working Time regulations on medical education and training: Literature Review, a report for the General Medical Council,’ Centre for Medical Education Research, Durham University (2012).
30 Female trainees have been found to be more positive about working hour restrictions than their male counterparts: Maybury, C., ‘The European Working Time Directive: a decade on,’ The Lancet 384:9954 (2014), pp. 1562–1563.
31 Psychiatrist Gwen Adshead’s article in Medical Education: Adshead, G., ‘Becoming a caregiver: attachment theory and poorly performing doctors,’ Med Edu 44:2 (2010) pp. 125–31.
32 The Libby Zion case in: Patel, N., ‘Learning lessons: The Libby Zion case revisited’, Journal of the American College of Cardiology 64:25 (2014), pp. 2802–4.
33 Resident duty hours across the globe in: Temple, J., ‘Resident duty hours around the globe: where are we now?’ BMC Med Educ 14 (Suppl 1): S8 (2014).
34 A systematic review of 135 studies on the impact of duty hour restrictions: Ahmed, N., et al., ‘A systematic revi
ew of the effects of resident duty hour restrictions in surgery,’ Ann Surg 259:6 (2014), pp. 1041–53.
Finding the Middle
1 Paediatrician and psychoanalyst John Bowlby studied the psychological bonds that develop between infants and carers: Bowlby, J., ‘Separation Anxiety,’ International Journal of Psycho-Analysis 41 (1959); Bowlby, J., Attachment and Loss, Vol.1: Attachment (London: Hogarth Press and Institute of Psycho-Analysis, 1969); Bowlby, J., Attachment and Loss, Vol.2: Separation: Anxiety and Anger (London: Hogarth Press and Institute of Psycho-Analysis, 1973); Bowlby, J., Attachment and Loss, Vol.3: Loss: Sadness and Depression (London: Hogarth and Press and Institute of Psycho-Analysis, 1980).
2 Bowlby’s student, Dr Mary Ainsworth, conducted a series of observational experiments to assess differences in how infants were attached to their parents, see: Farnfield, S., and Holmes, P., eds., The Routledge Handbook of Attachment: Assessment (London and New York: Routledge, 2014).
3 The identification of ‘disorganized’ attachment: Main, M., and Solomon, J., ‘Discovery of an insecure – disorganized / disoriented attachment pattern,’ in Brazelton, B., and Yogman, W. M., eds., Affective Development in Infancy (New Jersey: Ablex, 1986).
4 The Adult Attachment Interview: Hesse, E., ‘The Adult Attachment Interview: Protocol, method of analysis and empirical studies,’ in Cassidy, J., and Shaver, P. R., eds., Handbook of Attachment: Theory, research and clinical applications, 2nd ed., (New York: McGraw Hill, 2008).
Also Human Page 28