The inner lives of junior doctors
Junior medics must learn to set aside their own struggles to help others – but there’s a hidden cost, says psychologist Caroline Elton
We like to believe doctors are all-powerful and omniscient. When we visit one, it is naturally concerns about our own health that are uppermost in our minds.
Yet rarely do we stop to consider the psychological toll a doctor’s work takes on them. In my work as a psychologist specialising in helping doctors, I have seen at close quarters just how serious this can be. The emotional and physical strain experienced by those in the medical profession is described in my new book, Also Human: The Inner Lives of Doctors, in which I’ve tried to shine a light on the hidden cost of medicine.
For more than 20 years, I have met doctors dealing with depression, burnout, extreme trauma, exhaustion, anxiety, and a whole host of other problems, which they must somehow set aside while powering through long shifts helping others.
Bella was one example; a real high flier, she attended one of the most academic medical schools in the country, winning prizes in both medicine and surgery. But as her first day of work as a junior doctor approached, she experienced a mounting dread: how would she cope with the demands of the job?
A few weeks in, she was nearing the end of a 13-hour shift in A&E. She and her peers had been clearly told in their induction they must not work more than 13 hours at a time. Some doctors, once they’re 12-anda-half hours in, will busy themselves with paperwork rather than take on any new cases, but Bella wasn’t like that, and took on a new patient just before her shift ended. First she made sure that all the immediate tasks had been completed, but when she went to her supervisor to try to ensure a safe handover, she was given a furious dressing down in front of the whole team and accused of being irresponsible. Despite what she’d been told in her training, Bella was ordered to stay for as long as it took to finish treating the patient, and ended up working a 15-hour shift.
“What really shocked me was that I worked so hard, and followed all the rules, but I still ended up getting shouted at,” she told me later.
Too exhausted to drive home, she went to the lavatories and broke down in tears. When a colleague found her crying there, she was devastated the image of herself as a cool and competent doctor was torn to shreds.
With her confidence destroyed, an insidious depression spiralled rapidly out of control. Again, Bella did as she’d been instructed to do in medical school and asked her supervising consultant for help. His response? “Of course this is how you feel. You’re an F1 [Foundation Year 1 medic]; you’re a girl. You’re going to be upset.” She ended up leaving front-line healthcare and working in pharmaceuticals.
Bella’s case is far from exceptional. Over the years I have seen a number of junior doctors who have become so distressed in their first posts they have had to stop work. Some quit permanently while others – like Kelly – return to the profession.
Within days of starting her first job as a doctor, Kelly thought, “I can’t do this any more.” So extreme was her anxiety, she vomited out of fear every morning before work. A couple of weeks later she went to speak to the senior clinician in charge of training; the clinician was so concerned about Kelly’s state of mind, she mentally ran through a suicide checklist before letting her go home.
“I’m not going back,” Kelly told me in our first session. But she did, eventually, return and is now on her way to completing her training as a psychiatrist.
Each year, at hospitals nationwide, newly qualified junior doctors start work on the first Wednesday in August and, like Bella and Kelly, become overwhelmed by the extent of their responsibilities. On a night-shift, they can be called all over the hospital to deal with patients. If uncertain, they can theoretically ask someone more senior, but these seniors have their own heavy workloads to manage and may not respond as quickly as needed, or at all. Unsupported and overloaded, junior doctors can go for 13 hours without finding time to eat, and sometimes, like Hilary, they face situations they do not feel equipped to handle.
Hilary, a GP who came to see me because she was also thinking of leaving medicine, described her first day as a junior doctor years earlier, in which she was the only medic on the surgical ward that day. Faced with a very sick patient who looked like she was going to die, she had little idea what to do and no one to ask. When a fledgling doctor attached to another ward walked past, she spotted Hilary’s distress and summoned her own mother, a nurse in the same hospital.
Meanwhile Hilary’s bleep had been going off repeatedly, summoning her to the surgical assessment unit (SAU). Once the initial patient had been dispatched for urgent treatment, she dashed down to the SAU and encountered an angry nurse. “There are nine patients waiting. Where have you been?” the nurse demanded. Before Hilary could explain, the nurse gave her a rushed account of each of the nine patients. “Could you possibly help me work out who I should see first?” Hilary asked.
“Figure it out yourself, blue eyes,” came the response. And with that the nurse walked off – probably to get on with her own enormous list of tasks.
Even when the systems function more effectively, and junior doctors aren’t thrown in at the deep end, it remains the case that death, dying and distress are inescapable components of their work. Yet there’s little understanding of what happens when doctors are exposed to such traumas repeatedly.
How do they respond when they hear a patient screaming in pain, or see the ravages of disease on somebody’s body? How do they cope when they need to tell a parent their child has died? A common defence is to shut down emotionally, unable to take on board so much suffering. This is understandable but can rapidly turn into burnout. Yet if they can’t put any form of protective barrier between themselves and the suffering of their patients, very rapidly they can become overwhelmed. Neither response is healthy, but doctors are given precious little help with finding the middle way.
Some specialities, such as surgery, remain hostile to women, and – as in many other professions – there is still not equal pay. Incidents of institutional racism are also more common than we might like to think.
One student encountered a patient who refused to be examined by her because she was black. When she told her supervisor of her distress, the senior medic brushed it off, telling her it was no different to when a patient won’t let a junior doctor examine them because they fear they’re inexperienced.
In another incident, a Muslim doctor was looking at an X-ray of someone with broken bones when a consultant remarked to him, “you people blow people up”.
Perhaps historians looking back at how we treated doctors in 2018 will regard our medical systems with the same horror we do when reading about surgeons in the 19th century refusing to wash their hands between patients. Perhaps society will eventually recognise that, while the demands of a job in medicine are exceptional, doctors, like their patients, are also human.
Some names have been changed As told to Rosa Silverman
Also Human – the Inner lives of Doctors by Caroline Elton is published by Cornerstone (£16.99). To order your copy for £14.99 plus p & p call 0844 871 1514 or visit books.telegraph.co.uk
‘Kelly’s anxiety was so extreme she vomited every day’