Also Human

by Caroline Elton

  5 Patients who regularly go to their GP with vague, undiagnosed medical symptoms tend to have insecure attachment styles: Taylor, R. E., et al., ‘Insecure attachment and frequent attendance in primary care: a longitudinal cohort study of medically unexplained symptom presentations in ten UK general practices,’ Psychol Med 42:4 (2012), pp. 855–64.

  6 The following researchers found that terminally ill cancer patients, with a secure attachment style, had a greater capacity to form a close working alliance with their physician: Vincenzo, C., et al., ‘Reciprocal empathy and working alliance in terminal oncological illness: The Crucial Role of Patients Attachment Style,’ J Psychosoc Oncol 32:5 (2014), pp. 517–34.

  7 Gwen Adshead’s description in: Adshead, G., ‘Becoming a caregiver: attachment theory and poorly performing doctors,’ Med Educ 44:2 (2010), pp. 125–31.

  8 George Vaillant’s mechanisms of defense in: Vaillant, G., Adaptation to Life (Cambridge: Harvard University Press, 1977).

  9 Psychiatrist and social anthropologist, Simon Sinclair’s Making Doctors: Sinclair, S., Making Doctors: An institutional apprenticeship (Oxford: Berg Publishers, 1997).

  10 Danielle Ofri described the experience of a paediatric trainee in: Ofri, D., What Doctors Feel (Boston: Beacon Press, 2013).

  11 A recent systematic review concluded a consistent decline in empathy as training progressed: Neumann, M., et al., ‘Empathy decline and its reasons: A systematic review of studies with medical students and residents,’ Acad Med 86:8 (2011), pp. 996–1009.

  12 William Osler’s essay Aequanimitas in: Osler, W., Aequanimitas (New York: Norton, 1963).

  13 Renee Fox and psychiatrist Harold Leif’s ‘detached concern’ in: Fox, R., and Leif, H., ‘Training for “Detached Concern” in Medical Students,’ in Harold, I., Leif, V., et al., eds., The Psychological basis of Medical Practice (New York: Harper and Row, 1963).

  14 The statement produced by the Society for General Internal Medicine on empathy: Markais, K., et al., ‘Teaching empathy: It can be done,’ Working paper presented at the Annual Meeting of the Society of General Internal Medicine in San Francisco, April 29 – May 1, (1999).

  15 Psychiatrist Jodi Halpern’s research on detachment and a doctor’s effectiveness in: Halpern, J., ‘Clinical Empathy in Medical Care,’ in Decety, J., ed., Empathy: from bench to bedside (Massachusetts Institute of Technology: MIT Press, 2014).

  16 A study of over 7,000 physicians found that those with great empathic concern for their patients were more satisfied with their work: Gleichgerrcht, E., and Decety, J., ‘Empathy in clinical practice: How individual dispositions, gender, and experience moderate empathic concern, burnout and emotional distress in physicians,’ PLoS ONE 8:4 (2013), 10.1371/journal.pone.0061526.

  17 Michael Crichton’s description of human dissection in: Crichton, M., Travels (New York: Vintage Books, 2014).

  18 Kenneth Schwartz wrote about his experience of being a patient for the Boston Globe Magazine in: Schwartz, B. K., ‘A patient’s story,’ Boston Globe (July 16th, 1995) available online at: https://www.bostonglobe.com/magazine.

  19 The Schwartz Center Rounds are described in: Penson, T. R., et al., ‘Connection: Schwartz Center Rounds at Massachusetts General Hospital cancer centre,’ Oncologist 15:7 (2010), pp. 760–764.

  20 Information on the adoption of Schwartz Center Rounds is available online at www.theschwartzcenter.org.

  21 The BMJ argued, ‘we do not know what proportion of staff … may need to attend (Schwartz) Rounds’ in: Robert, G., et al., ‘Exploring the adoption of Schwartz Center Rounds as an organisational innovation to improve staff well-being in England, 2009 – 2014,’ BMJ Open 7 (2017), 10.1136/bmjopen-2016–014326.

  22 Staff comments on using Schwartz Centre Rounds in this 2017 study: Farr, M., and Barker, R., ‘Can staff be supported to deliver compassionate care through implementing Schwartz Rounds in community and mental health services?’ Qual Health Res 27:11 (2017), pp. 1652–1663.

  23 Research from the King’s Fund highlighted that enabling students to hear patients personal experience of care is effective in enhancing compassion: Firth-Cozens, J., and Cornwell, J., ‘The Point of Care: Enabling compassionate care in acute hospital settings’ (2009), available online at https://www.kingsfund.org.uk/publications/articles/enabling-compassionate-care-acute-hospital-settings.

  Which Doctor

  1 John Ballatt and Penelope Campling described how the unconscious motivation to heal can become channelled into a relentless drive to work, in their book: Ballatt, J., and Campling, P., Intelligent Kindness: Reforming the culture of healthcare (London: Royal College of Psychiatrists, 2011).

  2 In 2014 the World Psychiatric Association (WPA) study found evidence between personal experience of mental illness and choosing to specialize in psychiatry: Farooq, K., et al., ‘Why medical students choose psychiatry – a 20 country cross-sectional survey,’ BMC Med Educ 14:12 (2014), 10.1186/1472–6920-14–12.

  3 Dr Mike Shooter’s description of his own struggles with depression in: Shooter, M., ‘Depression,’ BMJ 326 (2003), pp. 1324–5.

  4 The notion that a doctor’s capacity stems from their own suffering has ancient roots, for example, Plato’s Republic. Quoted in Jackson, W. S., ‘Presidential Address: The Wounded Healer,’ Bull Hist Med 75: 1 (2001), pp. 1–36.

  5 In contemporary psychotherapeutic practice, the idea of the ‘wounded healer’ is closely associated with the writings of Carl Jung: Jung, C., The practice of psychotherapy: Essays on the psychology of the transference of other subjects ([trans. RFC Hull] NJ: Princeton University Press, 1966).

  6 The link between personal experience of mental illness and wanting to help others who have similar conditions applies to psychologists and psychotherapists: Ivey, G., and Partington, T., ‘Psychological woundedness and its evaluation in applications for clinical psychological training,’ Clin Psychol Psychother 21: 2 (2014), pp. 166–77.

  7 In the UK doctors have the choice of sixty-six specialties. Further information is available online at: https://www.gmc-uk.org/education/approved_curricula_systems.asp.

  8 Information on the thirty-seven specialties on offer in the US is available online at: http://www.abms.org/.

  9 Information on the eighty-five specialties on offer in Australia is available online at: http://www.medicalboard.gov.au/.

  10 The following 2013 survey of over 7,000 doctors in the States found that between a third and a quarter were not happy with the specialties that they had chosen: Liselott, N. D., et al., ‘Physician satisfaction and burnout at different career stages,’ Mayo Clinic Proceedings 88:12 (2013), pp. 1358–1367.

  11 Nearly 20% of oncology and surgical trainees in the States would not choose their specialty again: Shanafelt, D. T., et al., ‘Oncology fellows’ career plans, expectations and well-being: Do fellows know what they are getting into?’ J Clin Oncol 32:27 (2014), pp. 2991–7; Tchantchaleishvili, V., et al., ‘Current integrated cardiothoracic surgery residents: a thoracic surgery association survey,’ Ann Thorac Surg 99:3 (2015), pp. 1040–7.

  12 In a UK study, 34% of obstetric trainees regretted their specialty choice: Thangaratinam, S., et al., ‘Specialist training in obstetrics and gynaecology: a survey on work-life balance and stress among trainees in UK,’ J Obstet Gynaecol 26:4 (2006), pp. 302–4.

  13 In the States this study found that over 94% of anaesthetists were satisfied that they had chosen the right career: Augustin, I. D., et al., ‘Recruitment of house staff into anesthesiology: a longitudinal evaluation of factors for selecting a career in anesthesiology and an individual training program,’ J Clin Anesth 26:2 (2014), pp. 91–105.

  14 Dissatisfaction is contagious: Liselott, N. D., et al., ‘Physician satisfaction and burnout at different career stages,’ Mayo Clinic Proceedings 88:12 (2013), pp. 1358–1367.

  15 Harvard researchers compared the personalities of medical and surgical trainees using the Rorschach inkblot test: Stanley, H., et al., ‘The surgical personality: A comparison of medi
cal and surgical residents with the Rorschach,’ Cardiovasc Dis 2:2 (1975), pp. 117–128.

  16 This review, in a leading psychological journal, concluded that the Rorschach method is reliable: Kivisalu, T. M., et al., ‘An investigation of interrater for the Rorschach Performance System (R-PAS) in a nonpatient U.S. sample,’ J Pers Assess (2016), pp. 1–9.

  17 There are studies that have used standardized personality questionnaires that agree with the Harvard findings, for example: Warschkow, R., et al., ‘A comparative cross-sectional study of personality traits in internists and surgeons,’ Surgery 148:5 (2010), pp. 901–7.

  18 Some studies have found that surgeons are more extravert than doctors in other specialties, for example: MacNeily, E. A., et al., ‘The surgical personality: comparisons between urologists, non-urologists and non-surgeons,’ Can Urol Assoc J 5:3 (2011), pp. 182–85.

  19 Some studies have also found that surgeons are less warm and considerate compared to doctors in other specialties, for example: Bexelius, T. S., et al., ‘Association between personality traits and future choice of specialization among Swedish doctors: a cross-sectional study,’ Postgrad Med J 92 (2016), pp. 441–446.

  20 A selection of studies on role models: Ravindra, P., and Fitzgerald, E. J., ‘Defining surgical role models and their influence on career choice,’ World Journal of Surgery 35: 4 (2011), pp. 704–9; Murinson, B. B., et al., ‘Formative experiences of emerging physicians: gauging the impact of events that occur during medical school,’ Acad Med 85:8 (2010), pp. 1331–7; Stahn, B., and Harendza, S., ‘Role models play the greatest role – a qualitative study on reasons for choosing postgraduate training at a university hospital,’ GMS Z Med Ausbild 31:4 (2014), Doc45.

  21 The Medical Education paper ‘Trying on Possible Selves’: Burack, J. H., et al., ‘A study of medical students’ specialty-choice pathways: trying on possible selves,’ Acad Med 72:6 (1997), pp. 534–41.

  22 A selection of studies have found that medical students and junior doctors tend to choose specialties that they have enjoyed in medical school and the early years of clinical practice: Maisonneuve, J. J., et al., ‘Career choices for geriatric medicine: national surveys of graduates of 1974–2009 all UK medical schools,’ Age Aging 43:4 (2014), pp. 535–541; Smith, F., et al., ‘Factors influencing junior doctors’ choices of future specialty: trends over time and demographics based on results from UK national surveys,’ J R Soc Med 108:10 (2015), pp. 396–405.

  23 Findings from researchers in Oxford, on specialty choice and work-life balance: Smith, F., et al., ‘Factors influencing junior doctors’ choices of future specialty: trends over time and demographics based on results from UK national surveys,’ J R Soc Med 108:10 (2015), pp. 396–405.

  24 In the States, the director of Medical Education observed that ‘millennials seem to be more inclined to trade some of their income for more control of their hours’ in: Glicksman, E., ‘Wanting it all: a new generation of doctors’ places higher value on work-life balance,’ AAMC Reporter (2013) available online at: https://www.aamc.org/newsroom/reporter/336402/work-life.html.

  25 Studies in Australia and Canada have also found that doctors place a higher value on work-life balance than previous generations: Tolhurst, H. M., and Stewart, A. M., ‘Balancing work, family and other lifestyle aspects: a qualitative study of Australian medical students’ attitudes,’ Med J Aust 181:7 (2004), pp. 361–4; Results from the 2010 National Physician Survey in Canada available online at: http://nationalphysiciansurvey.ca/wp-content/uploads/2012/05/NPS2010-Students-Binder.pdf.

  26 A 2015 study of over 15,000 doctors found that student debt had influenced specialty choice: Smith, F., et al., ‘Factors influencing junior doctors’ choices of future specialty: trends over time and demographics based on results from UK national surveys,’ J R Soc Med 108:10 (2015), pp. 396–40.

  27 In the US, the median indebtedness at graduation for medical students was $170,000: Rohlfing, J., et al., ‘Medical student debt and major life choices other than specialty,’ Med Educ Online 19 (2014), 10.3402/meo.v19.25603.

  28 Students with higher debt were more likely to choose a specialty with a higher average annual income, as found by: Rohlfing, J., et al., ‘Medical student debt and major life choices other than specialty,’ Med Educ Online 19 (2014), 10.3402/meo.v19.25603.

  29 Increasing financial debt has been found to correlate with students’ reports of depression, for example: Mader, M. E., et al., ‘The temporal decline of idealism in two cohorts of medical students at one institution,’ BMC Med Educ 14:58 (2014), 10.1186/1472–6920-14–58.

  30 In the following article, psychologist Tom Kreishok argues that rationality has its limits: Krieshok, S. T., et al., ‘Career decision making: The limits of rationality and the abundance of non-conscious processes,’ J Vocat Behav 75 (2009), pp. 275–290.

  Brief Encounter

  1 A study published in 2015 found that over a quarter of medical students in the US and Canada who identified themselves as belonging to a minority sexual orientation concealed this in medical school: Mansh, M., et al., ‘Sexual and gender minority identity disclosure during undergraduate medical education: “In the Closet” in medical school,’ Acad Med 90:5 (2015), pp. 634–44.

  2 Freud’s notion of transference in: Freud, S., Introductory lectures on psychoanalysis, se., XV – XVI (1916–1917 [1915–1917]).

  3 In 1997, Kapsalis wrote of the precarious relationship between pelvic exams and sex acts in a detailed study of how doctors are taught gynaecology: Kapsalis, T., Public privates: Performing gynaecology from both ends of the speculum (Durham and London: Duke University Press, 1997).

  4 As an example, Kapsalis quoted a male physician in: Kapsalis, T., Public privates: Performing gynaecology from both ends of the speculum (Durham and London: Duke University Press, 1997).

  5 A major review of the teaching of pelvic examinations concluded that the ‘psychological impact’ on the learner was not well explored in the literature: Jha, V., et al., ‘Patient involvement in teaching and assessing intimate examination skills: a systematic review’, Med Educ 44:4 (2010), pp. 347–57.

  6 Since the late 1970s, the issue of consent around the intimate examination of anaesthetised female patients has been widely debated: Ralph, W., et al., ‘Professional patients: An improved method of teaching breast and pelvic examination,’ J Reprod Med 19:3 (1977), pp.163–6; Holzman, G. B., et al., ‘Initial pelvic examination instructions: The effectiveness of three contemporary approaches,’ Am J Obstet Gynecol 129:2 (1977), pp. 124–9; Robertson, N., ‘Panel faults, breast, pelvic test methods,’ New York Times (1969).

  7 Recent patient surveys indicate that attitudes of the general public have moved on, with women expecting to be asked before medical students practise intimate examinations on them: Wainberg, S., ‘Teaching pelvic examinations under anaesthesia: what do women think?’ J Obstet Gynaecol Can 32:1 (2010), pp. 49–53.

  8 A survey published in 2011 found that students still find themselves in situations where they are asked to conduct intimate examinations without asking the patients: Rees, C., and Monrouxe, R., ‘Medical students learning intimate examinations without valid consent: a multicentre study,’ Med Educ 45 (2011), pp. 261–72.

  9 ‘This article is dangerous’, a counter-argument from: Kaushik, N., ‘Please don’t touch me there: the ethics of intimate examinations. What examination is not intimate?’ BMJ 326:1326 (2003), 10.1136/bmj.326.7402.1326-b. In response to: Coldicott, Y., et al., ‘The ethics of intimate examinations – teaching tomorrow’s doctors,’ BMJ 326:7380 (2003), pp.97–101, an article from the BMJ about the need to gain informed consent.

  10 In 2009, the article titled ‘The other side of the speculum’ caused fury online: Thoma, B., ‘The other side of the speculum,’ Can Fam Physician 55:11 (2009) p. 1112; Pimlott, N., et al., ‘Uncomfortable reflections,’ Can Fam Physician 56:3 (2010), pp. 221–222.

  11 In response to the ‘The other side of the speculum’: Andres, E. D., ‘The other side of the spectru
m,’ Can Fam Physician 56:3 (2010) p. 221.

  12 American psychiatrist Julius Buchwald wrote of students’ first pelvic examination in: Buchwald, J., ‘The first pelvic examination: Helping students cope with their emotional reactions,’ J Med Educ 54:9 (1979) pp. 725–8.

  13 The following 2014 Australian study found students used jokes when uncomfortable sexual feelings were discussed: Dabson, M. A., et al., ‘Medical students’ experiences learning intimate physical examination skills: a qualitative study,’ BMC Med Educ 14:39 (2014), 10.1186/1472–6920-14–39.

  14 Freud, in his Jokes and Their Relation to the Unconscious was first to explore how jokes bear the traces of repressed desire: Freud, S., Jokes and Their Relation to the Unconscious (Harmondsworth: Penguin [Original work published in 1905]).

  15 Balint groups were started in London in the 1950s: Balint, M., and Balint, E., The doctor his patient and the illness, 2nd ed., (London: Pitman Medical, 1968).

  16 As one participant explained: ‘you leave the group relieved …’ in: Steinlieb, J. L; Scott, P; Lichtenstein, A., Nease, D. E and Freedy, J. R., ‘Balint Group Process: Optimizing the Doctor-Patient Relationship,’ in O’Reilly-Landry, M., ed., A psychodynamic understanding of Modern Medicine: Placing the person at the center of Care (London: Radcliffe Publishing, 2012).

  17 The GMC guidelines on: ‘Maintaining a professional relationship between you and your patient,’ GMC online (2013) available online at: https://www.gmc-uk.org/guidance/ethical_guidance.

  18 The Medical Council of New Zealand’s guidance on professional boundaries: ‘Sexual boundaries in the doctor-patient relationship: A resource for doctors,’ available online at: https://www.mcnz.org.

  19 The GMC failed to incorporate the findings of a national research project on sexual boundary violations in healthcare: Halter, M., et al., ‘Sexual Boundary Violations by Health Professionals – an overview of the published empirical literature,’ CHRE (2007); CHRE: ‘Clear sexual boundaries between healthcare professionals and patients: responsibilities of healthcare professionals,’ CHRE (2008) both are available online via: https://www.professionalstandards.org.uk.