Have you ever asked your GP if they are ok? I know what you're thinking: that’s not how it works. But after reading Also Human, Caroline Elton’s damning study of the medical profession in the UK, perhaps we all should.
Elton is an occupational psychologist who has worked with medics for more than 20 years. For the first 10 years of her career she was employed by the NHS to observe hospital consultants in action, and to help them become more effective teachers.
The following decade she ran an NHS careers advisory service for trainee doctors across London. Elton has been helping them to honestly assess whether medicine is the right choice and, if so, which specialty they should pursue. In the company of an impartial advisor, her clients feel they can speak openly about their experiences without fear of being judged.
Over the years she has compiled a compelling body of research with lots of disturbing case studies. They portray a system that fails to clearly identify and nurture a capacity for emotional resilience, care for medical students as human beings or alleviate pressure at different stages of their career.
That pressure could be internal – feeling desperate not to disappoint one’s parents, or striving to save patients who have the same conditions that lost loved ones succumbed to. Or it could be external. We read about several students who have experienced discrimination on multiple fronts, from gender and race to disability and mental health.
Either way, it is hard to fathom the lack of compassion and empathy for medical students, particularly when you consider how arduous their path to professional qualification can be. To become a GP, it takes 10 years at least from their first day at medical school. If you want to become a paediatric cardiologist, it’s 12 years full-time on top of your five-year medical degree.
According to a recent survey of junior doctors by the Royal College of Physicians, 70% worked on a rota that was permanently understaffed [a rota brings flexibility but also unpredictability to their working week]. Then 80% felt their work put them under excessive stress and a quarter felt it had a serious impact on their mental health. And we’ve all wept at the chronic lack of funding. In this blog, Elton writes that “Of the G7 nations only Italy spends less of their GDP on health than the UK; the NHS is stretched to breaking point.”
Whether someone is suited to this high-pressure profession is a valid question but a separate issue i will come on to shortly. Doctors are being squeezed more and more from day one, and having to pay the price for others’ poor management. Here are a few testimonies from the comments section of a Guardian article about Elton’s book.
I find it ridiculous how junior doctors at F1 stage in the UK are thrown in at the deep end with little of no on-the-job support or shadowing. Their counterparts in New Zealand follow a trainee intern model, where supervisors mentor them over a number of years. Who do think is more likely to stay in the profession? Comparing 2017-18 with 2010-11, there has been a 169% increase in the number of doctors citing work-life balance as their reason for quitting (the numbers are higher for nurses).
We should also mention the double-penalty system or “inverse care law”, where potentially more vulnerable final-year students are sent further away from home to be junior doctors in places with a lower quality of training and less pastoral care, thus increasing their chances of running into difficulties.
You will come across lots of troubling cases in the book:
1) Hilary being left to firefight on a ward by herself on day one as a doctor. The surgical consultant is on a course and the registrar is on annual leave. After being summoned to the surgical assessment unit (SAU), she asks the nurse to help her assess the patient board and determine the highest priority cases. Her response? “Figure it out yourself, blue eyes.”
2) Neil is in his second foundation year and considering specialising in lab-based pathology. He has been battling the anxiety that put him off work 18 months earlier and would like some help with interview preparation. He is late for two appointments with Elton, the first by 15 minutes and the second by 25. “I wonder if your lateness is your way of communicating to me that you don’t want to go to the pathology interview this week?” Elton asks. An immediate look of relief spreads on his face.
3) Senior staff doubting junior doctor Rahma (“an incredibly bright but young shy woman”) and misconstruing her quiet manner as a lack of enthusiasm. In other words, their reading of the situation confirmed their initial stereotype. She retreats further into her shell, which provides additional confirmation to the consultant that Rahma isn’t committed to the profession. As John Dovidio, a professor in the Department of Psychology at Yale, wrote: “The hardest attitude to change is the one you don’t know you have.”
4) Junior doctor Bella had battled depression and left for post for while. She was brilliant academically but had scored lower than expected on her Situational Judgment Test (SJT), which is effectively a dress rehearsal for hospital life. Bella had also struggled to write up her laboratory project and required more support from her supervisor. About a month into her job on A&E she had reached the maximum 13-hour shift on a particular night and was preparing to hand over to her senior. He lashed out in front of the whole team and accused her of being irresponsible. Before long, she was sobbing in the toilets. Depression set in. She went to her consultant for help, as she had been instructed to do in medical school. His response? “Of course this is how you feel. You’re an F1. You’re a girl. You’re going to be upset.” Ten months in, she became very sick and had to be signed off work. She never practiced again.
The section about assessing someone’s suitability for a career in medicine is particularly fascinating. Elton explains that no student enters medical school as a “tabula rasa”. Many pupils with an interest in science and a will to save lives are encouraged to study medicine. But the interrogation must go further, weighing up different factors such as the patients they would enjoy treating, the clinical puzzles they would love to solve and the tasks they would find too traumatic.
Elton quotes leading psychologist Tom Kreishok who argues that although a conscious rational approach to career decision-making has a role to play, rationality has its limits. He suggests that if we really want to help people make better career decisions, we need to encourage them to think about, and inhabit, the feelings associated with their day-to-day experiences at work.
There are other careers out there – medicine-related fields such as biomedical research, which might better complement the aptitude and temperament of certain individuals. Not everyone is cut out to be a doctor, and they wouldn’t be the first to make the wrong decision at 17. A big part of Elton’s job is to help undergraduates and junior doctors to find their place in the professional world and we learn about many successful transfers in the book.
This topic has been on my mind for the past few months. My late brother was an exceptional GP – devoted, compassionate, studious, hugely respected (the go-to doctor for a second opinion). He was one of those people who had the vocation from his teens – and Indian parents’ pressure to go with it – but Hemal had to deal with several wobbles on the academic front. There were the A-level retakes, having to repeat a year at university, dealing with disappointment after failing to achieve his dream of becoming an orthopaedic surgeon…
He combined the responsibility of a practice partnership with out-of-hours shifts, regularly working on minimal sleep to earn enough to build his dream home, get married in style and finally ease up a little. Apparently he was very good at switching off but the question still remains: how much is too much? And who’s there to safeguard the welfare of the practitioner, and the patient in turn?
He lived in Scotland and was fully absorbed in his job so our time to together was very limited. When we did speak, he seemed more interested in talking about other things like rugby. I respected his ambition and persistence, of course, but perhaps I should have inquired more about the day to day. Only after he passed did my father and I really appreciate the tremendous impact he had on so many patients and colleagues – from Dundee to Sydney. Reading this book has been my way of making a connection, but I miss the dialogue.
We lost him in February after he suffered a subarachnoid haemorrhage in the middle of the night. It was congenital but the condition may have been exacerbated by high blood pressure resulting from prolonged stress. Part of that was self-inflicted – he pushed himself extremely hard – but I do wonder whether there was enough support at critical times throughout his career.
We don’t realise quickly enough but our bodies and minds suffer wear and tear over time. That's why I welcome the self-care movement as a riposte to burnout culture. It was miraculous that Hemal was able to function at such a high level despite the sustained intensity of his workload over a number of years. You get on with it and everything is ok … until one day it isn’t.
One of the hardest things to do as a doctor is to strike that balance between being empathic in order to relate to a patient’s experience, and suppressing negative emotions when dealing with certain illnesses in order to be of best use to a patient. Caring about others vs caring for oneself.
Although the development and management of junior doctors are key talking points throughout Also Human, this dilemma is of equal importance in the book. And you can't help but want to figure it out. Solve the puzzle.
Elton writes with a curiosity and fascination that is infectious. And she’s very readable, definitely a few notches up from a thesis or research paper without forsaking the rigour. If you are interested in psychology and want to get a more acute understanding of the challenges facing young doctors in the UK, then have a read.