Also Human
Page 32
3 Paediatrician and psychoanalyst Donald Winnicott in: Winncott, D., ‘Further thoughts on babies as persons,’ in Hardenberg, J., ed., The child and the outside world: Studies in developing relationships (London: Tavistock Publications Ltd, 1957 [original work published 1949]).
4 In a classic paper, Winnicott lists eighteen reasons why a mother may, at times, experience hateful feelings towards her baby: Winnicott, D., ‘Hate in the Counter-Transference,’ Int J Psychoanal 30 (1949), pp. 69–74.
5 One hundred and fifty years ago, the surgeon Joseph Lister published his findings on using antiseptics: Jackson, M., The History of Medicine: A Beginner’s Guide (London: Oneworld, 2014).
6 ‘Resilience is always contextual’ state the authors of a recent article in the BMJ: Balme, E., et al., ‘Doctors need to be supported, not trained in resilience,’ BMJ Careers (2015) available online at: http://careers.bmj.com/careers/advice/Doctors_need_to_be_supported,_not_trained_in_resilience.
BRIEF GLOSSARY OF UK MEDICAL TERMS
BMA British Medical Association – the doctors’ professional union
BMJ British Medical Journal
EPM Educational Performance Measure (used in Foundation Application)
F1 Foundation Year 1. 1st year of clinical practice after leaving medical school. Doctors are provisionally registered with the GMC at this point in their career
F2 Foundation Year 2. 2nd year of clinical practice after leaving medical school. Doctors are fully registered with the GMC at this point.
GMC General Medical Council. National organization responsible for the licensing of doctors
IMG International Medical Graduate
MSC Medical Schools Council
SJT Situational Judgement Test – a multiple-choice assessment of professional judgements
Trust Grade Doctor delivering a clinical service, but not on a career progression ladder
UKFPO United Kingdom Foundation Programme Office. The organization responsible for the management of the two-year foundation programme across the UK.
TRAINING CHART
Simplified Map of Medical Training in the UK
FURTHER READING
Balint, Enid; Courtenay, Michael; Elder, Andrew; Hull, Sally and Julian, Paul. The Doctor, the Patient and the Group. London: Routledge, 1993
Ballatt, John & Campling, Penny. Intelligent Kindness. London: RCPsych Publications, 2011
Carel, Havi. Illness. London: Routledge, 2014
Cassell, Eric J. The nature of Suffering and the Goals of Medicine. Oxford: Oxford University Press, 1991
Cassell, Joan. The Woman in the Surgeon’s Body. Cambridge, Mass: Harvard University Press, 1998
Charon, Rita. Narrative Medicine. Oxford: Oxford University Press, 2008
Gawande, Atul. Complications. London: Profile Books, 2002
Gawande, Atul. Being Mortal. London: Profile Books, 2015
Groopman, Jerome. How Doctors Think. Boston: Houghton Mifflin, 2008
Kalanithi, Paul. When Breath becomes Air. London: Bodley Head, 2016
Katz, Jay. The silent World of Doctor and Patient. Baltimore, MD: The Johns Hopkins University Press, 2002
Kleinman, Arthur. The illness narratives. New York: Basic Books, 1988
Main, Tom. The Ailment and Other Psychoanalytic Essays. London: Free Association Books, 1998
Marsh, Henry. Do No Harm. London: Weidenfeld & Nicholson, 2014
Maunder, Robert & Hunter, Jonathan. Love, Fear and Health. Toronto: University of Toronto Press, 2015
Montross, Christine. Falling into the Fire. London: Oneworld, 2014
Neighbor, Roger. The Inner Physician. London: Royal College of Physicians, 2016
Ofri, Danielle. What Doctors Feel. Boston: Beacon Press, 2013
Pringle, Rosemary. Sex and Medicine. Cambridge: Cambridge University Press, 2011
Ross, Howard J. Everyday Bias. Lanham, MD: Rowman & Littlefield, 2014
Sinclair, Simon. Making Doctors. Oxford: Berg, 1997
Sontag, Susan. Illness as Metaphor. London, Penguin Classics, 2002
Straker, Norman (Ed). Facing Cancer and the Fear of Death. Lanham, MD: Jason Aronson, 2013
Subotsky, Fiona; Bewley, Susan & Crowe, Michael. (Eds). Abuse of the doctor-patient relationship. London: RCPsych Publications, 2010
Tweedy, Damon. Black Man in a White Coat. New York: Picador, 2015
Vaillant, George E. Adaptation to Life. Cambridge, Mass: Harvard University Press, 1995
Watermeyer, Brian. Towards a Contextual Psychology of Disabilism. London: Routlege, 2013
ACKNOWLEDGEMENTS
The generosity with which the doctors in this book have allowed me to share their stories is astounding; my largest debt of gratitude goes to them. To protect their anonymity, I cannot acknowledge them by name, and even though each has given me permission to tell their story, I have also gone to great lengths to protect their identity. However I want each and every one of them to know how deeply grateful I am. I also want to acknowledge how many of these doctors were motivated to share their stories through altruism; in their emails back to me, after I had sent them what I had written, a number expressed satisfaction that their story might be used to benefit future generations of doctors. The following example is typical: ‘Given my experience I am so grateful that mine and other trainee doctors’ experiences are being highlighted and I really hope this will effect much needed changes in the system.’ I hope so too.
I couldn’t give a precise figure for the number of doctors I have supported in the two different roles described in this book – but it is definitely over six hundred. Whilst I have only told the stories of a small fraction of this total, all the other encounters, both consciously and unconsciously, have informed my understanding of the psychological demands of medical work. And although I owe a special debt of gratitude to those doctors who agreed to be included in the book, I also want to acknowledge how much I learnt in my first job, when I was tasked with observing doctors at work, and also in my second one, when doctors came to talk to me about the difficulties that they were experiencing in their medical careers.
Thankfully in both of these roles, I didn’t work alone. I am inordinately grateful to Danë Goodsman who gave me my first job in medical education and from whom I learnt so much. It was Danë who came up with the radical idea that if you want to improve the quality of medical teaching it is far more effective to send trained faculty to observe doctors at work, than to extract these doctors from their hospital duties, plonk them in a classroom and subject them to lectures on ‘top tips’ of teaching. In this role, I also benefitted from the wisdom of Joan Reid, Pam Shaw and, until her untimely death, Kath Green. The ten years that I spent observing doctors at work laid the foundation for everything that came later.
In 2008 I jumped ship and moved to London Deanery, to set up the Careers Unit; many of the stories in this book are of doctors who sought support from that service. I am particularly grateful to Andrew Long, who was the senior clinician working alongside me to set up the Careers Unit and who has always been a great source of practical advice. My two administrators – Nicola Greaves and later Franco Henwood also played an important part; those who know me well would attest to the fact that administration has never been my forte. Philippa Shallard, former Manager of the North West Thames Foundation School based at Imperial College helped me with the chapter on transition from medical school. Camilla Kingdom and Suni Perera have also both been exceptionally generous with their support, encouraging me, answering my annoying questions and checking the clinical content of stories. Suni Perera, in addition, gave me the opportunity to co-facilitate two Balint groups – I found this work fascinating, have written a bit about it in the book and hope to do more of it, now that the book is finished. I would also like to mention the important role that my colleague Kath Sullivan played, particularly in the early stages of writing this book.
Beyond my immediate colleagues at the deanery, I have benefitted from the expertise of Clare Ger
ada and her team at the Practitioner Health Programme, as well as Julia Bland from DocHealth. I would also like to thank two colleagues from UCL Medical School: Anne Griffin who helped me with the section on dissection and Kath Woolf who read the chapter on racism in medicine; the latter rightly questioned my use of the term ‘non-white’. ‘Would you like to be referred to as non-male?’ she asked.
In 2011 I was awarded a travelling fellowship by the Association for the Study of Medical Education, and went to work with psychologist Nicole Borges, a leading medical education researcher in the US. Nicole and I collaborated on an academic book chapter, and also co-facilitated a workshop at a conference organized by AAMC – the Association of American Medical Colleges. In addition to support from Nicole, contacts at AAMC such as George Richard and Sarah Conrad have been exceptionally generous with their time, and have helped me enormously with research into medical training in the US. Sarah Conrad also identified medical schools in the US with innovative approaches to widening diversity; in turn conversations with Marlene Ballejos and Robert Sapien at the School of Medicine, University of New Mexico and also with Jocelyn Mitchell-Williams at Cooper Medical School, Rowan University gave me inspiring examples of what medical schools can achieve, when there is a commitment to change from the top.
That old adage ‘if you want something done, ask a busy person’ has consistently been confirmed whilst writing this book. Many practitioners have been exceptionally generous in sharing their time and expertise; often it is those in the most senior positions, who responded first. In the UK I would like to acknowledge wonderful conversations with Susan Bewley, Aneez Esmail, Michael Farquhar and Jyoti Shah. I also approached Domhnall Macauley based in Northern Ireland, after I read his blog post entitled ‘A young doctor’s death’. In the course of that conversation I realized how angry I felt about the loss of life through suicide, in the early years of medical training. Domhnall encouraged me to hold onto the anger, rather than adopt a more neutral, academic tenor – a suggestion which I found particularly liberating.
But I didn’t only benefit from contacts close to home – clinicians and researchers from across the globe were extraordinarily helpful. In the US, Howard Ross, an expert on implicit bias had a lengthy conversation with me and then pointed me in the direction of Pamela Abner, a diversity specialist at Mount Sinai Health System in New York City. Johanna Shapiro, a psychologist researching empathy was generous with her time, and helped me write the chapter on trauma and the erosion of empathy. Brian Watermeyer, a psychologist based at the University of Cape Town wrote an astonishing book on disability; a subsequent conversation with him helped with the ‘Role Reversal’ chapter.
In addition to learning from senior practitioners, a number of junior doctors have also read and commented on different chapters. In the UK I am particularly grateful for the input of Senem Sahin, Jemma Saville and Meenakshi Verma, whilst in the US, Anna Kuan-Celarier was wonderfully patient at answering my email queries. Rebecka Fleetwood-Smith, a psychology PhD student who will surely go far, helped with literature searches, and also was fantastically efficient in compiling the final version of the ‘Notes’.
As a psychologist, I’ve depended on regular monthly supervision from an experienced colleague. I would like to acknowledge how much I’ve learnt over the years from Rob Nathan, who supervised my work with many of the doctors described in this book. More recently I have enormously enjoyed being supervised by Mary Burd who combines a deep psychodynamic understanding with considerable experience of supporting junior doctors. I also want to mention how much I learnt from Pam Howard and Lawrence Suss; the two best teachers I have ever had, and without whose input, I would not have been able to write about anyone’s inner life.
In addition to my professional work in medical education, the experience of being a patient has also informed my understanding of what it takes to be a good doctor. GPs don’t always get a good press but the doctors at Keats Group Practice are excellent and I am particularly grateful to Drs Lucia Grun and Eunice Laleye for their sensitive way in which they have looked after my physical and mental health over the past twenty-five years. Growing up with an autistic sibling posed its own set of challenges, and the input of Professor Sir Michael Rutter and his colleagues at the Maudsley Hospital, again over very many years, made a huge difference to all of our family. More recently I have benefited from Howard Cooper’s exceptional skills as a psychotherapist. The capacity to understand somebody else’s inner life – crucial for writing a book of this kind – critically depends upon the capacity to appreciate one’s own; his sustained support, in so many ways, helped me complete this book.
Many friends also played a part. Claire Elliott and Sarah Thurlbeck, answered many medical questions; when I felt that I couldn’t bother colleagues any more, these two dear friends stepped into the breech. Suzanne Franks played a crucial role right at the beginning, and without her support, I would have abandoned the project. Alison Donaldson was also incredibly helpful in the early stages of writing. Nat Janz has a rare combination of psychological and publishing expertise, and many writing blocks were dissolved on walks across the heath. Sometimes we had the good fortune to be joined by Katy Steward, who brought a nuanced understanding of organisational issues in healthcare to the discussion. Both Nat and Mark Ellingham also helped with decisions about the cover. When writing the epilogue the experience of Ruth and Noam Tamir came to mind and I would like to acknowledge my gratitude to both of them for allowing me to share their family’s experience of live donor liver transplantation.
This book would never have happened without a chance conversation with the literary agent, Patrick Walsh. ‘Why don’t you write a book?’ Patrick asked me as we were both leaving BMA House, following the Annual BMA Book Awards. ‘Actually I’ve started on a proposal,’ I replied as we headed off in different directions. I thought no more about this until a couple of days later when Patrick emailed and asked me to send him what I had written. I am particularly grateful for the way in which Patrick pushed me to improve the initial proposal; with the benefit of his expertise, it was sharpened up beyond recognition. Then, to my great delight, Tom Avery at William Heinemann bought the book. I couldn’t have asked for a better editor as Tom combines kindness and positivity with exceptional editorial skills. The difference between the first and final drafts of this book is remarkable and almost entirely down to Tom’s insightful editorial input. Kate McQuaid, the Publicity Director at William Heinemann has been fantastic to work with, and I would also like to acknowledge the patience of the design team who had to produce numerous different cover options before we ended up with one that everyone was happy with.
And finally, my family – Michael, Jonathan, Miriam and Andrew Franklin. Some family members were early adopters of the idea that I might write this book, whilst others took far longer to come on board. Irrespective of their initial response, in the end everyone helped, be it through the provision of 24/7 technical support, late-night conversations around the kitchen table on how the racial context is different in the UK and the US, sourcing obscure references, offering perceptive feedback on title options, encouraging me when it all felt too difficult and sharing their editorial expertise. Even my two grandchildren (who were both born during the course of writing the book) played a part. Admittedly neither of them had much to say about the inner lives of doctors, but grandchildren proved to be the perfect antidote to the loneliness of writing. And entirely serendipitously, with one born in the UK and the other in the US, their arrivals gave me a more personal sense of how the culture of medicine differs between the two countries. I am inordinately grateful for the love and support that each family member has given me – this book is for them.
This ebook is copyright material and must not be copied, reproduced, transferred, distributed, leased, licensed or publicly performed or used in any way except as specifically permitted in writing by the publishers, as allowed under the terms and conditions under which it was purchased or as strictly
permitted by applicable copyright law. Any unauthorized distribution or use of this text may be a direct infringement of the author’s and publisher’s rights and those responsible may be liable in law accordingly.
Epub ISBN: 9781473537620
Version 1.0
1 3 5 7 9 10 8 6 4 2
Copyright © Caroline Elton 2018
Cover photography © Getty Image
Caroline Elton has asserted her right to be identified as the author of this Work in accordance with the Copyright, Designs and Patents Act 1988.
First published by William Heinemann in 2018
William Heinemann
20 Vauxhall Bridge Road
London SW1V 2SA
www.penguin.co.uk
William Heinemann is part of the Penguin Random House group of companies whose addresses can be found at global.penguinrandomhouse.com.
A CIP catalogue record for this book is available from the British Library.
ISBN 9781785150906 (Hardback)
ISBN 9781785150913 (Trade Paperback)
Introduction: Medicine in the Mirror
fn1 In this book I focus on the inner lives of doctors. This is not because the other professionals working in healthcare don’t matter; they do. They are essential. Instead, the reason is that in both of the roles I have held over the past twenty years, I was solely responsible for supporting doctors and had minimal contact with staff from other professions. I don’t want to presume that I have much understanding of the challenges that other professional groups face which is why I have remained silent on the matter.
1. Wednesday’s Child
fn1 Triple A stands for abdominal aortic aneurysm – a swelling in the abdominal aorta, the main blood vessel that leads away from the heart, down through the abdomen, to the rest of the body. If the aneurysm bursts it causes huge internal bleeding and is usually fatal. A burst triple A is a clinical emergency.