Clare Gerada says that there are serious problems with working life in the NHS and that these must be tackled if the NHS is to have a secure future
Just as the historian Tony Judt said that “something is profoundly wrong with the way we live today,” I believe that something is profoundly wrong with the NHS today. The health service’s prevailing culture is one of fear, even though its staff are meant to espouse kindness and compassion. The service is becoming a place where staff feel attacked, unloved, and abandoned by their political and managerial leaders.
A quarter of NHS staff report that they have been bullied in the past year. This is a higher proportion than in any other employment sector and is double the rate from four years ago. Surveys have shown that the main concern of NHS trust finance directors is staff morale, ahead of waiting time targets or patient experience. For doctors and nurses, high rates of mental illness, emigration, whistleblowing, suspensions, referrals to the regulator, and complaints all point to a system in serious trouble.
The causes of this distress are not hard to find. One is the industrialisation of healthcare. The move from a national state funded, state owned, and state managed organisation to a fragmented system of multiple competing providers, outsourced management, and increasingly mixed funding sits uncomfortably with the public sector ethos of many NHS staff. Increased privatisation also causes widespread anxiety.
Steve Iliffe, professor of primary care for older people at University College London, said that changes to the state’s relationship with the health service go to the core of professional self identity. He said that the role of medicine was changing from “a craft concerned with the uniqueness of each encounter with an ill person, to a mass manufacturing industry preoccupied with the throughput of the sick.”
Iona Heath, a former president of the Royal College of General Practitioners, described the commercialisation of general practice as one of the “dark forces at work behind the subversion of professionalism.” In a lecture titled Love’s Labours Lost, she described the changes that had undermined professionalism during her own career. She reflected in particular on the disappearance of “any idea of a ‘gift economy,’ where professionals could be knights but recipients could be queens—once altruism wasn’t recognised, it began to disappear.”
The second major cause of distress is unprecedented change. Over the past 20 years, the NHS has existed in a permanent state of flux. Nurses, doctors, and managers want stability, security, and safety rather than a state of constant transition. For decades, governments across the world have used reorganisation and policies of “destructive innovation” to juggle the clinical and financial priorities of health services. Each attempt to fashion a new order produces a new state of disorder. In 2008 Don Berwick, then president of the Institute for Healthcare Improvement in Cambridge, Massachusetts, commented on this in his review of the NHS. “Each change made sense, but the parade doesn’t make sense,” he said. “It drains energy and confidence from the workforce and middle managers.”
The physician and philosopher Raymond Tallis says that successive “disorganisations” of the NHS have the effect of reducing the influence of the medical profession and doctors’ ability to shape the services they work in. Iliffe goes further; he believes that the process of industrialisation of healthcare means that professionals are changing the “colour of their collar from white to blue.”
Organisations and individuals can and must change, and they must have the social resilience to adapt to external stresses and the disturbance resulting from change. But if that disturbance is big enough, a threshold will be reached where the system undergoes a fundamental shift. In 2012 the NHS was exposed to a reorganisation so large that, in the words of its then chief executive, David Nicholson, it “could be seen from outer space.” The subsequent changes in routines, customs, practices, and ways of working have destabilised the complex ecosystem of the NHS. The result is that the older generation of doctors, nurses, and managers are less able to support their younger colleagues, leaving vulnerable members exposed to developing mental health problems and other symptoms of distress. 
Studies of group therapy can help us understand the destructive forces behind this distress. Like the NHS, group therapy can trace its origins to the aftermath of the second world war, when two therapists, Wilfred Bion and Siegfried Foulkes, developed the idea of treating injured soldiers in groups and sharing their experiences together.
With over 1.5 million employees, the NHS functions not as a single group but as a collection of groups within groups. It is effectively a web of interdependent systems, connected by a matrix formed through historical and cultural links and by the social solidarity and shared experiences built up over several generations.
Groups can have a positive therapeutic effect, but in times of distress they can be destructive and can threaten an organisation’s functioning. Gerhard Wilke, who trained as an anthropologist before becoming a group analyst, argues that our working groups can, depending on their circumstances, either make us safe by becoming a carer substitute or threaten our integrity by making demands that we believe exceed our inner resource. Wilke says that clinicians now feel like “naughty children, and managers as enforcers of utopian visions generated by out of touch politicians.”
Some destructive forces, if not harnessed, can destroy a group’s creative and healing potential and can undermine its foundations and functioning. Another group analyst, Morris Nitsun, coined the term “anti-group” to describe these forces. The concept of the anti-group is used in psychotherapy, and the sources of destructive forces are similarly relevant to the NHS. One force that reinforces the development of the anti-group in the NHS is the failure to create an empathic environment for staff; and the paradox of values—in which staff care for patients but employers do not care for staff—gives rise to profound bitterness. John Ballatt and Penelope Campling, authors of Intelligent Kindness, highlighted some of the difficulties that staff face in the NHS. “It is easy to forget the appalling nature of some of the jobs carried out by NHS staff day in, day out—the damage, the pain, the mess they encounter, the sheer stench of diseased human flesh and its waste products,” they said.
Clinicians have always worked alongside death, distress, and disability. They are used to hard work and long, unsocial hours, and this has not changed in recent years. What has changed is the working environment and the compact agreement between staff and employer. Doctors, especially, have seen the biggest change in their working life. Changes to training mean that the tacit agreement whereby the NHS provides sustenance, refuge, and support, and the doctor in training works as hard as possible for patients, has been fractured. Trainees are now expected to move location—sometimes every three months—with no certainty that accommodation will be found. They have little control over their working hours, space, days off, and job security, and no guarantee of support from superiors when things go wrong.
Another force that helps to create anti-groups in the NHS is, Nitsun says, exposure—which can feel shameful and humiliating. Policies are now being deliberately designed to name and shame. For example, NHS Choices and the Friends and Family Test encourage patients to post anonymous comments about a practice, clinician, or hospital online. The Friends and Family Test was described by Rachel Reeves, principal research fellow in the school of health and social care at Greenwich University, as a “foe to the NHS.” She said that the test used a methodology that was not fit for purpose and led to casual brutality being displayed towards those selected as examples of what is wrong with the NHS. Another policy designed to name and shame NHS staff is the new Care Quality Commission inspection regime. This has already created fear in those who are inspected, as well as in those doing the inspecting. One CQC inspector described taking part in the process as being more like being part of a “lynch mob, not a serious regulator.”
These policies of naming, blaming, and shaming mean that doctors can face humiliation for any alleged transgression, even if what is seen as a transgression is merely being an understandable outlier in performance, or refusing to participate in a process.
The policy is having its predicted effect. Three surgeons who were at the bottom of the league table—though this was in retrospect shown to be a result of coding errors—were named on the front page of a major newspaper, and grainy photos above their names added a hint of criminality to their situation.
The NHS is exposed daily to negative stories in the media. Its staff are accused of being lazy, cruel, and uncaring, and the service is blamed for failing to meet necessary standards. Doctors, nurses, and managers are seen as villains and are berated by journalists, who overlook the fact that the NHS still tops the list of what makes the public feel proud about being British. This barrage of negative stories corrodes trust, saps morale, and creates defensiveness. It also ignores the good work done by most NHS staff and the fact that the NHS delivers, in monetary terms, vastly superior services to many comparable health services.
In his plan to save the NHS David Owen, the former health secretary, said that the NHS was a vocational service and that, in order to continue, it must retain a generosity of purpose, philosophical commitments, and a one to one relationship with patients, who must be central to its purpose.
To do this, politicians have a moral responsibility to support those charged with caring for the most vulnerable people in our society; and they must be tasked with urgently improving the health of the NHS and those forces within it that are contributing to its destruction. If they do not, then we will all be the losers, and NHS staff may leave for pastures new.
Competing interests: I have read and understood the BMJ policy of declaration of interests and declare: I am medical director of the Practitioner Health Programme, a confidential London based health service for doctors and dentists.
- Judt T. Ill fares the land: a treatise on our present discontents. Penguin, 2011:1.
- Briefing note: Issues highlighted by the 2013 NHS staff survey in England.www.nhsstaffsurveys.com/Caches/Files/NHS%20staff%20survey_nationalbriefing_2013_FINAL-1.pdf.
- Fullfact.org. Demoralised and bullied? What the figures show about NHS staff.https://fullfact.org/live/2014/may/demoralised_bullied_nhs_staff-32243.
- Iliffe S. From general practice to primary care: the industralization of family medicine. Oxford University Press, 2008.
- Heath I. Out of hours primary care—a shambles? BMJ 2007;334:341.
- Royal Society of Edinburgh; Heath I. Michael Shea memorial lecture organised in partnership with the International Futures Forum. Love’s labours lost: why society is straitjacketing its professionals and how we might release them. 10 September 2012.
- Berwick D. A transatlantic review of the NHS at 60. BMJ 2008;337:a838.
- Tallis R. Hippocratic oaths: medicine and its discontents. Atlantic, 2005.
- Peters M, Hasan O, Puddester D, Garelick T. Doctor’s health: taking the life cycle approach.BMJ 2013;347:f7086.
- Martin E. Flexible bodies: science and the new culture of health in the US. In: Williams SJ, Gabe J, Calnan M, eds. Health, medicine and society: key theories, future agendas. Routledge, 2000:125-45.
- Practitioner Health Programme. The first five years of the NHS Practitioner Health Programme 2008-2013. http://php.nhs.uk/wp-content/uploads/sites/26/2014/05/Five-Year-Report.pdf.
- Wilke G, Freeman S. How to be a good enough GP: Surviving and thriving in the new primary care organisations. Radcliffe, 2001.
- Nitsun M. The anti-group: destructive forces in the group and their creative potential. Routledge, 1996.
- Ballatt J, Campling P. Intelligent kindness: reforming the culture of health care. Royal College of Psychiatrists, 2011.
- Reeves R. The friends and family test is a foe to the NHS. Health Serv J 7 August 2013.www.hsj.co.uk/comment/the-friends-and-family-test-is-a-foe-to-the-nhs/5061906.article#.U42zytwoLG4.
- Soteriou M. CQCs inspections reducing GPs to tears, LMC warns. GP Online 2 December 2013. www.gponline.com/News/article/1223403/cqc-inspections-reducing-gps-tears-lmc-warns/.
- Calkin S. Exclusive: “exhausted” inspectors raise concerns about unsustainable CQC regime. Health Serv J 3 June 2014. www.hsj.co.uk/5071554.article?WT.tsrc=email&WT.mc_id=Newsletter2#.U429Z9woLG4.
- Chorley M, Davies E. Hospital doctors who refuse to release details of their track record will be named and shamed. Mail Online 13 June 2013. www.dailymail.co.uk/news/article-2340703/Doctors-perform-badly-hide-track-record-public-farcical-league-table-loophole.html.
- Borland S. The surgeons whose patients were up to 30 times likelier to die. NHS to publish death rates of doctors for the first time. Mail Online 28 June 2013.www.dailymail.co.uk/news/article-2350376/The-surgeons-patients-30-times-likelier-die-NHS-publish-death-rates-doctors-time.html.
- Ipsos-MORI. State of the nation 2013. 14 January 2013. www.ipsos-mori.com/researchpublications/researcharchive/3111/State-of-the-Nation-2013.aspx.
- Commonwealth Fund. 2013 Commonwealth Fund international health policy survey. 13 November 2013. www.commonwealthfund.org/publications/surveys/2013/2013-commonwealth-fund-international-health-policy-survey.
- Owen D. My plan to save the NHS—in the nick of time. 28 January 2013.www.theguardian.com/commentisfree/2013/jan/28/my-plan-to-save-nhs-ravages-market.
Clare Gerada medical director Practitioner Health Programme, Riverside Medical Centre, London, UK
Click the following link for the original document
Group of suspended Doctors on the Practitioner
Health Programme this morning about recovery
It was a real honour and privilege to be invited to give a talk to a group of medical Doctors who were currently suspended on the GMC Medical Register this morning (in confidence). I gave a talk for about thirty minutes, and took questions afterwards. I have enormous affection for the medical profession in fact, having obtained a First at Cambridge in 1996, and also produced a seminal paper in dementia published in a leading journal as part of my Ph.D. there. I have had nothing to do with the medical profession for several years now, apart from volunteering part-time for two medical charities in London which I no longer do.
I think patient safety is paramount, and Doctors with addiction problems often do not realise the effect the negative impact of their addiction on their performance. No regulatory authority can do ‘outreach’, otherwise it would be there forever, in the same way that Alcoholics Anonymous or Narcotics Anonymous do not actively go out looking for people with addiction problems. I personally have doubts about the notion of a ‘high functioning addict’, as the addict is virtually oblivious to all the distress and débris caused by their addiction; the impact on others is much worse than on the individual himself, who can lack insight and can be in denial. Insight is something that is best for others to judge.
However, I have now been in recovery for 72 months, with things having come to a head when I was admitted in August 2007 having had an epileptic seizure and asystolic cardiac arrest. Having woken up on the top floor of the Royal Free Hospital in pitch darkness, I had to cope with recovery from alcoholism (I have never been addicted to any other drugs), and newly-acquired physical disability. I in fact could neither walk nor talk. Nonetheless, I am happy as I live with my mum in Primrose Hill, have never had any regular salaried employment since my coma in the summer of 2007, received scholarships to do my MBA and legal training (otherwise my life would have become totally unsustainable financially apart from my disability living allowance which I use for my mobility and living). I am also very proud to have completed my Master of Law with a commendation in January 2011. My greatest achievement of all has been sustaining my recovery, and my talk went very well this morning.
The message I wished to impart that personal health and recovery is much more important than temporary abstinence, ‘getting the certificate’ and carrying on with your career if you have a genuine problem. People in any discipline will often not seek help for addiction, as they worry about their training record. Some will even not enlist with a G.P., in case the GP reports them to a regulatory authority. I discussed how I had a brilliant doctor-patient relationship with my own G.P. and how the support from the Solicitors Regulation Authority (who allowed me unconditionally to do the Legal Practice Course after an extensive due diligence) had been vital, but I also fielded questions on the potential impact of stigma of stigma in the regulatory process as a barrier-to-recovery.
I gave an extensive list of my own ‘support network’, which included my own G.P., psychiatrist, my mum, other family and friends, the Practitioner Health Programme, and ‘After Care’ at my local hospital.
The Practitioner Health Programme, supported by the General Medical Council, describes itself as follows:
The Practitioner Health Programme is a free, confidential service for doctors and dentists living in London who have mental or physical health concerns and/or addiction problems.
Any medical or dental practitioner can use the service, where they have
• A mental health or addiction concern (at any level of severity) and/or
• A physical health concern (where that concern may impact on the practitioner’s performance.)
I was asked which of these had helped me the most, which I thought was a very good question. I said that it was not necessarily the case that a bigger network was necessarily better, but it did need individuals to be open and truthful with you if things began to go wrong. It gave me a chance to outline the fundamental conundrum of recovery; it’s impossible to go into recovery on your own (for many this will mean going to A.A. or other meetings, and discussing recovery with close friends), but likewise the only person who can help you is yourself (no number of expensive ‘rehabs’ will on their own provide you with the ‘cure’.) This is of course a lifelong battle for me, and whilst I am very happy now as things have moved on for me, I hope I may at last help others who need help in a non-professional capacity.
Best wishes, Shibley
Link to original document http://www.sochealth.co.uk/2013/05/10/it-was-honour-to-speak-to-a-group-of-suspended-doctors-on-the-practitioner-health-programme-this-morning-about-recovery/
Authors: Jonathon Tomlinson
Publication date: 02 Jun 2014
Many doctors who become patients have been shocked by their experiences from “the other side.” Jonathon Tomlinson looks at these writings and considers what can be learnt from them
For many years, doctors have written about their experiences as patients in the hope that others might learn something from what they have been through. They are motivated by the often shocking realisation that medical education and clinical practice have prepared them so poorly. They are concerned about the treatment they have received and the way they have treated patients in the past (box 1). They are keen to explain what it is like to be a patient, the particular problems that doctors have in coping with illness, and the health risks associated with their profession.  
Box 1: How we treat patients
Kay McKall, a general practitioner with bipolar disorder, wrote in The BMJ in 2001, “I’ve become sensitive to mistakes that other doctors make when managing me, and I have translated those mistakes into corrections in how I myself manage people with depression.”
Kate Granger, a young doctor with metastatic sarcoma wrote her book, The Other Side, to help health professionals “to be better able to understand exactly what being the patient is really like and how their behaviours, no matter how small, can impact massively on the people they look after.”
For a long time, doctors as patients have been concerned about how poorly doctors give bad news. In 1952 Henry Sigerist wrote, “Medical colleagues were incredibly secretive … I was never told results, only general answers, not the facts and figures I wanted to know. The result of this secrecy was that for a number of years I never again consulted a doctor.”
Things were little better 30 years later, when Campbell Moreland, a 28 year old doctor with testicular cancer, was told that his chest x ray, showing metastases, was normal. “My trust … was irreversibly damaged,” he said. In 2009, Kieran Sweeney found out he had lung cancer by reading his discharge summary at home. In an interview online, he is in tears as he describes his experience. 
These continued efforts and the themes that consistently recur in these narratives suggest that educators are failing to honour their experiences and share their lessons. It is recommended that medical students and trainees are taught about patient experiences and health problems among doctors, and I propose that reflective engagement with the narratives of doctor-patients is an effective way of achieving these aims.
To examine this issue, I read books, professional and lay articles, and blogs written by doctor-patients and others who wrote about doctors’ experience of illness. I have summarised my findings in a blog, given lectures on my findings to medical students and trainee general practitioners (GPs), and have organised reflective discussion sessions on these issues. Four major themes arose—the need to be seen as a person; poor standards of care; loss of professional identity; and shame and stigma. Complaints that doctors fail to see the person in the patient go back many years (box 2). Following their experience as patients, many doctors realise that, despite the frequency of mistakes in healthcare, most mistakes are not noticed by patients (see box 3).
Box 2: Being treated as a person
Complaints that doctors fail to see the person in the patient go back decades and continue to the present day.  The introduction to a book that was published in 1952 containing short essays by doctors with conditions as varied as heart disease and tuberculosis concluded, “The first need … is the recognition … that every disease is psychosomatic, that is, that it effects[sic] both body and soul.” Concerns that the personal aspects of care are neglected have been a consistent feature of doctors’ reports.
One time medical student and now full time patient Anya De Longh teaches medical students about patient experiences. She has described the contrast between being a medical student and being a patient in an outpatient clinic, saying, “In my first rotation, orthopaedics and rheumatology, I lost track within the first week of how many outpatient appointments I sat in on. I didn’t really think anything of them—they are just another 15 minute slot of time filled with learning in a very busy day. As a patient, my perspective couldn’t be more different. I have one appointment with my consultant a year, and spend weeks planning and preparing, then a month recovering emotionally.”
Time spent with patients was considered very important to many doctor-patients. Many doctors would like more time to spend with their patients, but feel that the pressure of work and administrative burdens are barriers to this.
Doctor-patients often wanted to stress that it ought not to be an excuse, as Kate Granger explained, saying, “If being ill has taught me anything about being a doctor it is the importance of seeing a patient as a person and not merely a condition or disease sat in a hospital bed. It is amazing what you learn about people if you just ask. In the past few months I have looked after a world record-breaking knitter, an Olympic cyclist, and a lady who had 11 children. The disease focused clinicians may see these facts as irrelevant, but I think they are central to understanding the person, how their pathology impacts on them, and why they are special to their family.”
Medical students rarely ever fail to introduce themselves to patients, but when they become infected with the culture of working life, they (we) slip into bad habits. Doctors as patients were struck by the lack of common courtesy they experienced. Granger has started a campaign that has rapidly gained massive support from grassroots healthcare workers to NHS England called #hellomynameis to get healthcare professionals to start introducing themselves again. 
Box 3: Mistakes and magic
Most mistakes in healthcare are not noticed by patients. When interviewed about his book about doctor-patients, Albert Klitzman said that they “also became more aware of how many mistakes are made, like the wrong dose of medication. They were astonished by that.”My own experience as a patient and a relative of sick family members has made me acutely aware of how frequently mistakes are made.
Other doctors, including Kate Granger, emphasised their distress when waiting for results, saying, “I am frightened and it feels as though nobody is talking to me. I know my MRI report is available, but again no one has taken the time to discuss this with me so I know this must be bad news. I am laid in a hospital bed sobbing and scared, about at the most vulnerable a patient could be.” Klitzman noted that doctors with HIV got results back to their patients “with added urgency.”
Doctor-patients also became more aware of the limits of care, and those interviewed about end of life care chose less intervention than they recommended for their patients.Doctors with serious illnesses, even Anna Donald, an academic in the field of evidence based medicine, chose to use massage, meditation, and alternative diets. Klitzman was surprised by the “degree to which ‘magic’ and irrationality persisted in the lives of these scientifically trained doctors.”
Why do we need a doctor to tell us what it is like to be a patient?
One strength of doctors’ narratives is that they usually state, and almost always imply, what readers are expected to learn, for example that doctors should introduce themselves, listen to their patients, respect privacy, and remember that their patients are afraid or lonely. Other, more complex medical narratives require quite demanding skills of literary interpretation and criticism, which students and teachers may not have.  
Professional identity is particularly strong in doctors and medical students, and perhaps more than their non-medical peers they assimilate this into their personal identity. Doctors’ illness narratives therefore have a particular power because of the inescapable sense that if it happened to “one of us, it could also happen to me.” For example, when sick doctors complain that their own doctor did not take time to talk to them, they do so with the knowledge that the doctor may be tired and busy and have other sick patients to treat. Doctors, who know by virtue of personal experience what it is like to be a patient, also have a special role as “wounded educators” able to teach from first hand experience.  
Using either doctors’ or patients’ narratives can pre-empt critical reading or alternative interpretations because it is hard to criticise accounts written by someone who is seriously suffering.  This is made additionally difficult if the author is an experienced doctor, when students and trainees may consider themselves to be relatively lacking in experience and expertise.
The experiences of doctors clearly may not be typical of patients who are often poor, very young or old, illiterate, or immigrants. There are also risks that medical students and trainees may give greater credence to their professional elders as the source of medical education, even though patients are beginning to be seen as educators, rather than solely as educational material. 
Loss of identity
It is generally acknowledged that doctors make bad patients. Our professional identity enforces, or reinforces, the divide between us, the healthy doctors, and them, our sick patients.
Albert Klitzman has written about doctor-patients, and has noted that, “Often, only the experience of becoming seriously ill finally compels them to change their thinking, and see themselves and their work more broadly, and from a different vantage point to realize how their prior professional view is just one of several possible perspectives.”
Psychiatrist Rebecca Lawrence has described her experience of psychotic depression. “I thought my training as a psychiatrist would help, but it was quite the opposite,” she wrote. “The experience forced me to cross the border from provider to patient, and taught me how much I did not know. When I read a textbook description of psychotic depression, my diagnosis, I can’t marry it with how I feel. I do feel low, but also agitated and frightened, and simply very ill. I have always felt like two people—the psychiatrist and the psychiatric patient—and it is very difficult when they overlap.”
Chronic illness is associated with loneliness and isolation,  and doctors who are unable to work because of illness feel this acutely if they can no longer associate with their peers. It is not only professional boundaries that separate doctors from patients but also doctors’ perceived attitudes to illness. In a qualitative study of GP attitudes to their own health,one doctor is quoted as saying, “We think we’re superhuman and that we don’t get ill, or if we do, we can cope with it.”
The same study summed up GP attitudes by means of an “informal shadow contract,”which included working through illness, ignoring symptoms of distress, and expecting colleagues to do the same.
Doctors’ belief that they can cope better than their patients is sometimes expressed as a refusal to “give in” to illness. Not giving in is an important part of the way doctors think about and judge themselves and their colleagues and, possibly others who are sick. Susan Sontag, a writer and philosopher who had breast cancer, was particularly perceptive about difficulties accepting illness. “It is not what it is really like to emigrate to the kingdom of the ill and live there, but the punitive or sentimental fantasies concocted about that situation,” she wrote.
Shame and stigma
The divide separating doctors and patients is nowhere stronger than in mental health, and many doctor-patient narratives are about mental illnesses.    Doctors have the same rates of depression, schizophrenia, and bipolar disorder as their patients, but they are much more likely to commit suicide—female doctors are two and a half times more likely to kill themselves than their non-medical counterparts. The Australian Beyond Blue study in 2013 showed that one in five medical students and one in 10 doctors had had suicidal thoughts in the past year, compared with one in 45 people in the wider community.
One description by a psychiatrist with bipolar disorder was typical of many doctor-patients. “I had become a psychiatric patient and am embarrassed to say the stigma made me feel physically sick,” the psychiatrist wrote. “I felt ashamed of being ‘weak’ and hated the idea that personal information and ‘failings’ were going to be kept on an NHS database. As a psychiatrist it is deplorable that I had such negative cognitions about mental illness. I can put some of it down to my depressed thinking at the time, but not all of it. Despite the Royal College of Psychiatrists’ anti-stigma campaign and some eminent psychiatrists and celebrities being candid about their illnesses, stigma is alive and well.”
Feelings of shame and stigma apply not only to mental illnesses but also to a wide range of illnesses, especially when they stop doctors working.   Feelings are imposed internally and externally, as discovered by a GP recovering from breast cancer. “The shocking hostility that some healthcare professionals display towards vulnerable colleagues did not manifest itself until I went back to work.”
Anya de Longh, who was forced to give up her medical studies because of a rare and severe neurological disease, wrote in her blog about her shame when she realised that some of her symptoms might be psychosomatic. She said, “I fear about being so open about the psychological aspects of my illness because the stigma I apply to myself is likely to be applied by others. Writing this and being so open about the conflicting emotions that it entails has made me question my own sanity on more than one occasion.”
Doctor-patients fear being judged and stigmatised and so they tend to suffer in silence and carry on in a profession that prides itself on stoicism and bravado. Sometimes it is a more-straightforward denial that stops doctors seeking care, as explained by Kay McKall,a GP with bipolar disorder. “Don’t assume depressed doctors know that they’re sick. The view is quite different from this side of the sanity divide. Chances are that we think that we are only stressed by work, and are distressed by our perceived inability to cope.”
Teaching and learning
Doctors who have been patients often feel compelled to report back, and what they have been telling us has been remarkably consistent over the years. These powerful accounts include lessons that can help us better understand what patients go through and the difficulties doctors have in coming to terms with their own health problems. But little has been made of this in medical education.
I have presented my findings on three occasions to second, fourth, and final year medical students and GP trainees in the form of a short lecture with quotations from doctor-patients, followed by small group discussions. On each occasion there were some trainees for whom the presentation had particular resonance. For some it was supportive and for others upsetting. I was grateful for the support of the student welfare service at Guy’s and St Thomas’ and the Tower Hamlets vocational training scheme course organisers for their expert facilitation of the small groups.
This work can be used to help doctors develop the reflective skills and personal insight necessary for them to better understand their own predispositions to illness. In addition, it can be an important component of pastoral care, helping students and doctors to learn about how to care for each other and tackle shame and stigma in the profession.
GP Liam Farrell, who wrote about his experience of, and recovery from, opiate addiction made this point powerfully. “When you are faced so starkly with your own vulnerability, it does make you understand patients so much better … we are frail, we are human—bad things can happen to us, just like anybody else. I think we have to be aware of our own mortality and our own frailty as well, and not be ashamed to look for help if we need it, and also to watch out for each other—not in a ‘big brother’ kind of way—but I think we have to look out for each other’s health.”
Competing interests: None declared.
- Pinner M, Miller BF (eds). When doctors are patients . WW Norton and Co, 1952.
- Jones P (ed.) Doctors as patients . Radcliffe Publishing, 2005.
- Klitzman R. When doctors become patients . Oxford University Press, 2007.
- Field R, Haslam D. Do you have your own doctor, doctor? Tackling barriers to health care. Br J Gen Pract 2008;58:462-4.
- Tomlinson J. Doctors as patients: A Better NHS blog.http://abetternhs.wordpress.com/2014/01/27/dr-patients.
- Tomlinson J. Lecture slides online: A Better NHS blog. http://abetternhs.wordpress.com/?attachment_id=4007.
- Columbia University. Program in narrative medicine. Mission statement.www.narrativemedicine.org/mission.html.
- Jurecic A. Illness as narrative . University of Pittsburgh Press, 2013.
- Greenhalgh T. Narrative based medicine in an evidence based world. BMJ 1999;318:323.
- Sinclair S. Making doctors. An institutional apprenticeship . Berg Publishers, 1997.
- Carson A. That’s another story: narrative methods and ethical practice. J Med Ethics 2001;27:198-202.
- Sigerist H. A history of medicine. Primitive and archaic medicine . Oxford University Press, 1951.
- Sigerist H. A history of medicine. Early Greek, Hindu and Persian medicine . Oxford University Press, 1961.
- Wessely A, Gerada C. When doctors need treatment: an anthropological approach to why doctors make bad patients. BMJ Careers 12 Nov 2013,http://careers.bmj.com/careers/advice/view-article.html?id=20015402.
- Benziman G, Kannai R, Ahmad A. The wounded healer as cultural archetype. Comparative Literature and Culture 2012;14:1.
- Batt-Rawden SA, Chisolm MS, Anton B, Flickinger TE. Teaching empathy to medical students: an updated, systematic review. Acad Med 2013;88:1171-7.
- Tomlinson J. Doctors and empathy: A Better NHS blog.http://abetternhs.wordpress.com/2013/12/20/empathy.
- Pattison S, Dickinson D, Parker M, Heller T. Do case studies mislead about the nature of reality? J Med Ethics 1999;25:42-6.
- Higgs R. Do studies of the nature of cases mislead about the nature of reality? A response to Pattison et al. J Med Ethics 1999;25:47-50.
- Lauckner H, Doucet S. Patients as educators: the challenges and benefits of sharing experiences with students. Med Educ 2012;46:992-1000.
- Wykurz G, Kelly D. Developing the role of patients as teachers: literature review. BMJ 2002;325:818.
- McKall K. An insider’s guide to depression. BMJ 2001;323:1011.
- Granger K. The other side . Kindle, 2012.
- Moreland C. Teratoma of the testis. Lancet 1982;320:203-5.
- Sweeney K. A patient’s journey: mesothelioma. BMJ 2009;339:b2862.
- YouTube. Kieran Sweeney interview. 6 Nov 2012. http://youtu.be/3TignNvHNx4.
- Lawrence R. Psychotic depression. BMJ 2012;345;e6994.
- Age UK. Loneliness and isolation. Evidence review for health professionals. Age UK, 2010.
- Thompson W, Cupples M, Sibbert CH, Skan DI, Bradley T. Challenge of culture, conscience and contract to general pracitioners’ care of their own health: qualitative study. BMJ 2001;323:728.
- Sontag S. Illness as metaphor and AIDS and its metaphors . Penguin Books, 1983.
- Lawrence R. A patient’s journey. Psychotic depression. BMJ 2012;345:e6994.
- Polkinghorn C. Doctors go mad too. Royal College of Psychiatristswww.rcpsych.ac.uk/pdf/Doctors%20Go%20Mad%20Too.pdf.
- Shooter M, Jones P. Doctors as patients . Radcliffe Publishing Ltd, 2005.
- Beyond Blue. Beyond Blue launches world-first doctors mental health survey results. 8 Oct 2013. www.beyondblue.org.au/about-us/news/news/2013/10/07/beyondblue-launches-world-first-doctors-mental-health-survey-results.
- Henderson M, Brooks S. Shame! Self stigmatisation as obstacle to sick doctors returning to work. A qualitative study. BMJ Open 2012;2:e001776.
- Kay M, Mitchell G. Doctors as patients: a systematic review of doctors’ health access and the barriers they experience. Br J Gen Pract 2008;58:501-8.
- Garelick A. Doctors’ health: stigma and the professional discomfort in seeking help.Psychiatr Bull 2012;36:81-4.
- Anon. Cancer journey. Bullet proof cardie. Blog. 4 Nov 2013.http://bulletproofcardie.wordpress.com/2013/11/04/cancer-journey.
- De Longh A. Getting my head around functional neurological symptoms. The Patient Patient blog. 19 Jan 2014.http://thepatientpatient2011.blogspot.co.uk/2014/01/getting-my-head-around-functional.html.
- Chapple A, Ziebland S, McPherson A. Stigma, shame and blame experienced by patients with lung cancer; qualitative study. BMJ 2004;328:1470.
- Peabody F. Care of the patient. JAMA 1927;88:877-82.
- Jiwa N. A hungry patient is a grumpy patient. Bull RCS Eng 2014;96:78-9.
- De Longh A. About the patient patient. The Patient Patient blog. 2013.http://thepatientpatient2011.blogspot.co.uk/p/about-patient-patient.html.
- Swinglehust D, Greenhalgh T, Roberts TC. Computer templates in chronic disease management: ethnographic case study in general practice. BMJ Open 2012;2:e001754.
- Granger K. Painting the picture. Dr Kate Granger blog. 4 Aug 2013.http://drkategranger.wordpress.com/2013/08/04/painting-the-picture.
- Granger K. Healthcare staff must properly introduce themselves. BMJ 2013;347.
- NHS England. Campaigning doctor to speak at Health and Care Innovation Expo 2014.www.england.nhs.uk/2014/01/22/kate-granger-expo-2014.
- Parker-Pope T. When doctors become patients. New York Times 8 Feb 2008.http://well.blogs.nytimes.com/2008/02/08/when-doctors-become-patients/?_php=true&_type=blogs&_r=0.
- Murray K. Doctors really do die differently. Zocalo Public Square. 23 Jul 2012.www.zocalopublicsquare.org/2012/07/23/doctors-really-do-die-differently/ideas/nexus.
- Donald A. From the other side. BMJ Blog http://blogs.bmj.com/bmj/category/from-the-other-side.
- Farrell L. The professional path to recovery. Irish Med Times 12 Jul 2013.www.imt.ie/features-opinion/2013/07/the-professional-path-to-recovery.html.
Link to original article - http://careers.bmj.com/careers/advice/view-article.html?id=20017843
The Time to Think programme is a unique initiative with an emphasis on psychological development—identifying not just the structural or organisational but also the psychological barriers to change and improvement and using tried and tested techniques to address these barriers and so improve patient care.
Our team of GPs, group analysts and behaviour therapists are here to help. We have put together a menu of options from mindfulness training to a package of remediation for doctors who find that everyday workplace pressures are preventing them from performing at their best.
Doctors have always risen to the challenge and adapted to meet changed demands and circumstances. But our working life is becoming increasingly difficult. Doctors have little time to stand still, reflect, recharge, and re-engage with why we entered this wonderful profession in the first place.
Who should attend?
The course is specifically tailored to doctors who want new ideas and solutions to more effectively meet the changes and demands they face, revitalise careers and improve clinical practice.
It is a first port of call for those who wish to improve how they respond to pressure, or address specific areas of stress.
Or if doctors just need to refresh their batteries or meet like-minded health professionals and improve practice then this course is for them.
The course will help you meet your requirements for next year’s appraisal, demonstrating an ongoing commitment to improving performance.
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The course is flexible, but as it currently stands it is delivered over 8 weeks, beginning and ending with a whole day Masterclass where practitioners have the opportunity to network, share experiences about working at the deep-end of practice and learn from each other.
Two small groups (8 practitioners) will take place between the Masterclasses.
What is included?
Initial one to one assessment including assessment of resilience, burn-out, insight and mental health
• Individual tutor throughout course (unlimited access)
• Masterclass 1— whole day (small [max 8 people] and large group [max 24 people]) (6 hours)
• Small group 1—half day (small group) (3 hours)
• Small group 2— half day (small group) (3 hours)
• Masterclass 2—whole day (small and large group) (6 hours)
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The first Masterclass is from 1pm to 8pm on the 27th of June, at the IGA in Swiss Cottage, London. Thereafter dates are flexible and depend on the best fit of your small group and group facilitator
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If you would like any further details about the Time to Think programme, please contact us at firstname.lastname@example.org
The former RCGP chairwoman Clare Gerada believes the medical regulator needs to rethink the way it treats doctors with health problems. Tom Moberly reports
The General Medical Council is “traumatising” doctors and may be undermining the safety of patients through its adversarial approach to doctors with health problems, Clare Gerada, former chairwoman of the Royal College of General Practitioners, has said.
Gerada is now NHS England’s chair of primary care transformation for London and medical director of the Practitioner Health Programme (PHP), a confidential London based health service for doctors and dentists. Speaking at a conference held last week to examine the lessons learnt during the first five years of the programme, she argued that there were “serious problems” with the GMC’s treatment of doctors with health problems.
She said that although the GMC’s treatment of such doctors had improved over the past five years, the organisation still had “a long way to go” to improve its processes. “Our clinicians and our patients tell us that being involved with the regulator for mental health problems is either making them sick or, if they were sick to start with, not helping their mental health improve,” she said.
“Whilst the regulator, of course, has to protect patients, it must start to look at what it is doing in supporting doctors,” she said. “It is not good news to have doctors who have mental health issues go through an adversarial process where they have to prove, without any possible doubt, that they are never going to get a mental health problem again.”
She added, “We also have to ask the regulator why its processes take so long and why [it] continues to send letters in a way that causes considerable distress. They have gone a long way. But I think that there is a long way to go.”
Gerada also argued that the NHS’s approach to medical training was putting doctors at increased risk of health problems. She said that change was needed in “the way we train doctors, and the way we then put young doctors into a system with very little support where we expect them to work—not in teams, not in firms, but in shifts.”
“All the doctors in this room will remember bursting into tears when you were very tired. To be sent home and told you have a mental illness doesn’t actually help you very much. What you want is a bit of love. I think we have to do something pretty urgently about looking at why the NHS is making people sick and why we have an increased number of suspensions, mental illness in doctors, and bullying.”
Talking to BMJ Careers after her speech, Gerada argued that the GMC needed to “move on from the catastrophic events of Shipman a decade and a half ago and swing the pendulum back towards a kinder, less adversarial system of regulation.”
She said, “The GMC website says, ‘We are not here to protect the medical profession—our job is to protect patients.’ Of course it’s important to protect patients from rogue doctors. Who can argue against that? But my experience running PHP is that the regulatory system has gone too far and skewed the balance to assuming that doctors are guilty just by virtue of being referred to them [the GMC].”
Gerada said that many doctors who have been referred to the GMC have mental health problems, have made minor transgressions, or have been referred by disgruntled colleagues. “The number of referrals to the GMC has been increasing year on year, yet most are eventually closed with no sanctions or findings made on the doctor,” she said. “During the process a doctor is made to feel tarnished, and for many their personal and professional lives are impaired as the process grinds forward.”
She added, “The current system has created fear and paradoxically may actually harm patients. Doctors aren’t willing to admit when something is going wrong, because the chances of them being suspended or of having to go through a GMC process would be very high.
“Doctors are assumed guilty until proved otherwise, and the process they go through can take years, leaving doctors traumatised and unable to progress their careers or, even worse, unable to work. For doctors with mental health problems the punitive and unpredictable system drives secrets underground.”
Commenting on Gerada’s comments, Niall Dickson, the GMC’s chief executive, said, “Clare Gerada makes some important points, and we know that this is a sensitive issue. I am pleased she recognises the steps we’ve taken to make the investigation process less stressful for doctors, but we know that there is still more to do. We are looking at how we communicate with doctors, and we are looking at a number of measures to see how we can best support doctors going through our fitness to practise procedures.”
Dickson said that some doctors were referred to the GMC because they had serious mental health problems, including severe depression and various forms of addiction, that could affect the care they provided to patients.
“We recognise that these can be very vulnerable individuals and that being part of a fitness to practise investigation is almost always a stressful experience for everyone and especially for the doctor involved,” he said. “Doctors with mental health problems in our procedures all have a supervising doctor in their place of work. They are also regularly examined by two practising psychiatrists. Our aim is to get them back to safe, effective practice whenever that is possible. We also seek wherever possible to agree any restrictions on practice without the need for a panel hearing.”
He added, “Our priority, though, must always be to protect the public while at the same time being fair to the doctor—sometimes that does mean having to take immediate action when we believe patients may be at risk.”
Tom Moberly editor, BMJ Careers
The original article can be found in this link http://careers.bmj.com/careers/advice/view-article.html?id=20017662
The NHS Practitioner Health Programme (PHP) Five Year Report provides an overview of the PHP service and the support it has provided for its practitioner patients over the past five years. It gives an insight into the treatment commissioners are funding for practitioner patients living within their borough, the reasons that practitioner patients require such a service, and it provides details of the financial benefits of this system.
This report shows our reflections on the past 5 years of the PHP, from the day the service first opened its doors to practitioner patients.
This gallery contains 18 photos.
On Wednesday 14/05/2014 The NHS PHP held an event “The NHS Practitioner Health Programme Five Years On – Lessons Learnt and the Future Challenges” at the Regents Park Marriott Hotel, to celebrate and review the first five years of PHP and look forward to the challenges facing practitioner health.
A number of speakers provided presentations on this theme and they can all be found here.
Richard Jones NHS PHP Clinical Director
Dr David Walker Deputy Chief medical Director Department of Health
“Given the benefits to practitioners and their families, patients and employers, I think one can only conclude that a service like PHP is not a nice to have, but an essential to have component of a modern healthcare system”
Professor Terence Stevenson Chairman, Academy of Royal colleges
“PHP is expert work, so not everyone can do it”
Louisa Dallmeyer London Commissioner
“We are spending to save and PHP undoubtedly does this”
The NHS PHP also launched its Five Year Report and this also can be found here
The following are a series of photos of the event.
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Dr Clare Gerada and Richard Jones work for the Practitioner Health Programme (PHP), a specialist service for doctors and dentists in the London area with mental health / addiction problems (www.php.nhs.uk). Here they discuss some of their preliminary findings (specific to surgeons) from a wider project exploring the ill health experiences of specific specialities within medicine.
When compared to the general population and other professional groups, doctors have higher rates of mental illness. In the UK between 10 and 20% of doctors become depressed at some point in their career. This figure is likely to be an under-representation.
Doctors are a difficult group to reach. When they do fall ill, doctors tend not to access their own GP and attempt to access healthcare via a friend, self-referral or self-prescribing. There are times when this approach might help, but when it comes to mental illness or addiction, the perceived shame and stigma can often lead to doctors finding themselves in an even more difficult situation than they really need to be.
For the doctors presenting to a confidential London based practitioner health service (www.php.nhs.uk) surgeons are an under represented group (making up around 6% of doctors seen over the last five years) compared to their numbers on the General Medical Council (GMC) register (around 11%). The groups that are over represented (compared to the numbers on the GMC register) are Emergency Care Doctors, anesthetists and psychiatrists. The under representation of surgeons may be because they have particular personality characteristics that protect them from mental illhealth, or that they find it even harder to approach treatment services than other medical specialists.
The literature does not help us. There is a sparsity of research of the mental health of surgeons compared to other medical practitioners (or indeed the general population). Where it does exist however, it points to high rates of burn out, anxiety and depression. For example, in a survey of almost 8000 US surgeons, burn out, anxiety and depression were reported by between 30 and 50% of the sample, with rates of depression increasing as work load (and in particular night work) increased . This same survey found that surgeons struggle with suicidal thoughts – with as many as one in 16 having experienced such thoughts in the previous year – yet only 26% seeking professional help. Older surgeons were especially likely to have suicidal thoughts. Making a medical error was significantly associated with suicidal ideation . In a survey of 549 members of the Society of Surgical Oncology, 28% of respondents met the criteria for burnout and approximately 30% screened positive for depression with further analysis suggesting that around 10% of respondents would have met the criteria for major depressive disorder at the time of the survey if they had undergone a full psychiatric assessment .
In a UK survey of 1000 surgeons they scored significantly higher than the general population on a range of occupational health factors, especially with respect to anxiety . Other studies find similar high levels of burn out in surgeons working for the NHS .
It is our experience at PHP that surgeons find accessing mental health services even more difficult than other professional groups. Structural factors can act as a significant barrier. For example, long shifts makes it difficult to access a GP and frequent moves associated with a surgical rotation makes it difficult to register with one or have continuity of care with a mental health team.
Stigma (something that is especially prevalent in relation to mental health in doctors) and fear that expressing vulnerability will affect their career chances means that surgeons will rather suffer in silence than admit that they might have problems.
The surgeons that have presented to PHP service often present in crises – following a problem at work (for example acting out in theatre, shouting or swearing at staff) or after a drink-drive offence or following discovery of self prescribing. Many are encouraged to attend by their occupational health department or educational supervisors.
Surgeons may have particular risk factors compared to other medical specialties. Presenteeism – that is staying at work beyond what is safe is especially prevalent in surgeons and PHP has found that many surgeons stay at work well beyond the point where it safe for their (or indeed their patients) health. They often work very long and unpredictable hours; and have the longest post graduate training programmes, meaning that they have made considerable and significant sacrifices to achieve their goals. They deal with life and death on a daily basis. They are required to be up to date with ever changing protocols, technologies and procedures. Their patients and their employers give them little room for error, and in the theatre setting their every move is often witnessed by large numbers of people. One error could quite literally mean the end of their career. A casualty of these risk factors is the high rate of divorce, with an American survey finding that surgeons have the highest rate of divorce in the medical profession – around 30%.
Personality factors may be important; after all to survive long surgical training individuals must have some personality traits that help them through. Again, research is not available but one can assume that some of the personality factors that make individuals good surgeons (obessionality, altruism, perfectionism) may also make them particularly vulnerable when things go wrong. As we mature and develop we learn to modify certain
personal characteristics. This might mean learning to build upon certain skills we have, whilst trying to hide certain other traits. We might like being in control of situations, and having an eye for the finer detail of things, but be
less comfortable working in large teams as this lessens our ability to control our environment. Learning to manage these skills and traits might make us particularly suited to certain specialties where these skills are seen as desirable.
When we feel in control of our environment things go well, but when we feel under pressure we may revert to the more negative traits we had previously learned to manage. A surgeon, who developed meticulous practices
to influence better outcomes, might, under stress become obsessional, to give just one example.
Surgeons that do present to PHP often struggle to identify or acknowledge that they might actually be ill, or when they do, they often seek a quick fix that might not exist. When they present to PHP, surgeons talk at length
of the fear they have of other colleagues finding out, reporting that other surgeons don’t ‘believe’ in mental illness, and fearing that they will be excluded by their peers. This self-stigma is prevalent amongst the medical profession.
The good news is that when doctors do access the right health services, they have good outcomes. This is especially the case for addicted doctors, with around 80% remaining abstinent from alcohol and 90% abstinent from drugs at three years follow up. Patients with addiction problems are treated by detoxification and then we encourage adoption of a 12-steps approach and attendance at the British Doctors and Dentists Group (BDDG). Those
with mental health problems are treated with a mixture of psychological therapies. On all outcomes, doctors who come into treatment improve – be it their health, social functioning, ability to return to work or training and a lessening of involvement with the regulator. Surgeons must not suffer in silence – and we must improve their ability to access timely and confidential help.
1. Campbell DA, Jr, Sonnad SS, Eckhauser FE, Campbell KK, Greenfield LJ. Burnout among
American surgeons. Surgery 2001;130(4):696-705.
2. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons.
Arch Surg 2011;146(1):54-62.
3. Kuerer HM, Eberlein TJ, Pollock RE, et al. Career satisfaction, practice patterns and burnout
among surgical oncologists: report on the quality of life of members of the Society of Surgical
Oncology. Ann Surg Oncol 2007;14(11):3043-53.
4. Green A, Duthre L, Young H, Peters T. Stress in surgeons. British Journal of Surgery
5. Sharma A, Sharp DM, Walker LG, et al. Stress and burnout in colorectal and vascular surgical
consultants working in the UK National Health Service. Psychooncology 2008;17(6):570-6.
It’s taken me over 20 years to appreciate just how little attention is paid in medical education to what it’s like to be a patient.
Often, only the experience of becoming seriously ill finally compels [doctors] to change their thinking, and see themselves and their work more broadly, and from a different vantage point to realize how their prior professional view is just one of several possible perspectives. When Doctors Become Patients
I decided to write this blog after reading The Other Side, by Dr Kate Granger. Kate is a young doctor and a cancer patient dying from a rare and aggressive form of cancer. She wrote The Other Side to help health professionals ‘to be better able to understand exactly what being the patient is really like and how their behaviours, no matter how small can impact massively on the people they look after.’ Her book succeeds in doing this better than anything I have experienced in formal medical education. Doctors’ illness narratives have a particular power in part because there is the inescapable sense that if it happened to ‘one of us, it could also happen to me’. But there is more to it than that. It is easy, particularly for a student or a young doctor to treat one patient’s account of illness as a strictly personal tale, with little generalisability – interesting, but of little obvious educational value. On the other hand, when an experienced doctor, even a relatively young one, writes about their experience as a patient, with an explicitly educational purpose, we pay closer attention to what they have to say.
Kate’s book is one of a growing number of books, articles and blogs written by doctors about their experience of illness, many written with similar intentions, for example, a GP writing about bipolar disorder for the British Medical Journal in 2001,
I’ve become sensitive to mistakes that other doctors make when managing me, and I have translated those mistakes into corrections in how I myself manage people with depression. The point of this article is to share these with you.
One of the first of these educational narratives was published in the Lancet in 1982 with a longer pamphlet version produced for use in medical education at Queen’s University Belfast. Dr Campbell Moreland was diagnosed with testicular cancer at the age of 28 and in common with many doctor-patients wanted to emphasise the importance of communication skills, especially in relation to end of life care, when treatment was no longer curative,
If a doctor’s satisfaction comes from the concept of disease/diagnosis/treatment/cure, then he or she is likely to be disappointed and may travel along the path of narrow-minded, self-centred glory. When this linear process breaks down, as in chronic relapsing illness or terminal illness, the doctor will fail to achieve job satisfaction by his own definition. The patient will expect the doctor to understand his or her situation, but since the doctor cannot, the patient will feel rejected.
He noticed this not only among the doctors who were treating him, but also among his colleagues,
As [the cancer] became more chronic, some lost interest, and … others who met me completely ignored the fact that I was ill despite my appearance … This may have been another manifestation of the denial mechanism- my colleagues denying that I was ill and protecting themselves from a reminder of their own vulnerability to disease. Doctors often forget that they are also human.
This blog accompanies a lecture that I have given to medical students at Guys and St Thomas’ and GP trainees from Tower Hamlets. I will be soon be presenting it to students at Bristol and Imperial Medical Schools. I would like to present it elsewhere and continue to develop it. From the narratives I have read there emerged four themes, which are presented as a discussion here and as quotations from doctor-patients in the slides. A great deal of what follows is also quoted from doctors who are, or were patients.
Loss of identity
Stigma, shame and loneliness
Being seen as a person
The poor standards of care -and medical scepticism
Loss of identity
Illness comes from the night side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick … although we prefer to use only the good passport, sooner or later each of us is obliged, a least for a spell, to identify ourselves as citizens of that other place. Susan Sontag, Illness as Metaphor.
Doctor-patients are reminiscent of our ancient forebears, Shaman and traditional healers. They were a special caste, uniquely able to access both human and spirit worlds and act as intermediaries between them. It took special powers bought about by careful selection, arduous training and demanding rituals, sometimes-involving hallucinogenic drugs to be able to do this.
The Wounded Healer in medicine and theology is one who has special healing powers by virtue of their experience of illness.
In the traditional African Xhosa culture, becoming a healer is a process that involves experiences of illness, physical injury and pain. One of the Xhosa rites of initiation is Thwasa, a state of illness. The person experiencing it will undergo ailment and pain of body and mind and be made to suffer stomach aches, nervousness, and severe ache in the back, as well as possible periods of unconsciousness. During these attacks, this person might also become emotionally withdrawn and be troubled by dreams. Thwasa is crucial for becoming a healer. Illness is regarded in this case as the state through which communication from the person’s ancestors occurs. In Xhosa culture, it is believed that a person is chosen to protect and heal people by becoming an igqira (healer), and his ability to enter a state of Thwasa is both a part of his training and an indication that the ancestors have preferred him. The process of Thwasa demonstrates how close this tradition is to the Western concept of the wounded healer: the interpretation of illness in Xhosa society is based on the rationale that it is from experiencing illness that the person undergoing training will learn how to observe, diagnose and treat other people’s illnesses.
By contrast, in modern medicine, ‘the nature of doctors’ training results in a deep rooted sense of being special and the institutionalisation of [our] professional identity’ which (re)enforces the divide between us, the healthy doctors, and them, the sick patients. But it is not only our good health, but also our refusal to ‘give in’ to sickness that divides us.
A qualitative study of GP attitudes to their own health summarised the views of 27 GPs by means of an ‘informal shadow contract’ which emphasised this attitude,
I undertake to protect my partners from the consequences of my being ill. These include having to cover for me and paying locums. I will protect my partners by working through any illness up to the point where I am unable to walk. If I have to take time off, I will return at the earliest possible opportunity. I expect my partners to do the same and reserve the right to make them feel uncomfortable if they violate this contract.
In order to keep to the contract I will act on the assumption that all my partners are healthy enough to work at all times. This may mean that from time to time it is appropriate to ignore evidence of their physical and mental distress and to disregard threats to their wellbeing. I will also expect my partners not to remind me of my own distress when I am working while sick.
Last Wednesday as I cycled to work, I rode far too fast over the cobbles at the end of the street, barely 100 meters from my surgery. I went flying. My left hand hit the cobbles, hard. It hurt a lot more than I was expecting. I arrived and scrubbed the dirt out of a bleeding hole in my palm and asked our practice nurse to help me put a dressing on it. But most of the pain was coming from the base of my thumb, and I suspected strongly that it was fractured (broken). I had an evening surgery with 15 booked appointments; three of them were patients with severe learning difficulties here for an annual check up. So I took two paracetamol and saw my patients. I finished at 8pm and cycled home – about 25 minutes in the dark. I was too tired to go to hospital and so the following morning I went to A&E and an Xray confirmed a Bennet’s fracture and I left in plaster. I did the same thing when I fractured my scaphoid a few years ago.
A survey of British doctors back in the ’90s found that 87 percent of G.P.’s said they would not call in sick for a severe cold (compared to 32 percent of office workers who were asked the same question). In Norway, a 2001 survey revealed that 80 percent of doctors had reported to work while sick with illnesses for which they would have advised their own patients to stay home. Two-thirds of these illnesses were considered contagious. Why Doctors Don’t Take Sick Days Daniele Ofri, New York Times
Not ‘giving in’ is an important part of the way doctors think about and judge themselves. Many would deny that they judged others in the same way, but doctors who have been patients give us reason to doubt that. The less frequently referenced continuation of Susan Sontag’s quote above is particularly perceptive,
‘[it is] not what it is really like to emigrate to the kingdom of the ill and live there, but the punitive or sentimental fantasies concocted about that situation’.
Despite the biological substrate of clinical depression or the genetic underpinnings of alcoholism, many physicians still believe these disorders are evidence of a lapse of will or moral failure, especially when they appear in other physicians.
Stigma, shame and loneliness.
The divide, and the associated fantasies are nowhere stronger than in mental health. Perhaps unsurprisingly then, the majority of the doctor-patient narratives I found were about mental illness. Doctors have the same rates of depression, schizophrenia and bipolar disorder as their patients but are much more likely than their patients to commit suicide; female doctors are two and a half times more likely than their non-medical counterparts. The Australian Beyond Blue study last year showed that one-in-five medical students and one-in-ten doctors had suicidal thoughts in the past year, compared with one in 45 people in the wider community. Only two weeks before I gave this lecture about doctor-patients to 4th year medical students at Guy’s and St Thomas’ hospital, one of their year had committed suicide.
Many patients experience shame and stigma, and in one study 71% of doctors described themselves as embarrassed when seeing another doctor. Doctors with mental illness appear to be particularly vulnerable, as described by this psychiatrist with psychotic depression,
I had become a psychiatric patient and am embarrassed to say the stigma made me feel physically sick. I felt ashamed of being “weak” and hated the idea that personal information and “failings” were going to be kept on an NHS database. As a psychiatrist it is deplorable that I had such negative cognitions about mental illness. I can put some of it down to my depressed thinking at the time, but not all of it. Despite the Royal College of Psychiatrists anti-stigma campaign and some eminent psychiatrists and celebrities being candid about their illnesses- stigma is alive and well.
Anya de Longh was forced to give up her medical studies because of a rare and severe neurological disease. In her latest blog she writes about the self-stigmatisation and shame that arose when the possibility was raised that some of her neurological symptoms couldn’t be explained by her disease,
I fear about being so open about the psychological aspects of my illness because the stigma I apply to myself is likely to be applied by others. Writing this and being so open about the conflicting emotions that it entails has made me question my own sanity on more than one occasion!
Shame is associated with drug and alcohol abuse, both of which are more prevalent among doctors than their non-medical peers. Shame also causes social withdrawal and isolation and stops us seeking help when we need it, because we are too strong, or not worthy;
We feel shame and we fear being judged and stigmatized so we tend to suffer in silence and carry on in a profession that prides itself on stoicism and bravado Wallace
Shame is feeling that I am not worthy of love, care and attention … Underpinning shame is excruciating vulnerability, the fear of being seen as we really are.
Brené Brown: The power of vulnerability
Sometimes it is a more-straightforward denial that stops us seeking care, as explained by this GP with bipolar-disorder,
Don’t assume depressed doctors know that they’re sick. The view is quite different from this side of the sanity divide. Chances are that we think that we are only stressed by work, and are distressed by our perceived inability to cope. An insiders guide to depression.
Many doctors spend so much time at their work that when they are unable to continue because of sickness, and are cut off from their busy peers, they become lonely and depressed.
The physical effects of illness compound this, as these two young doctors with metastatic cancer explain,
I had unfailing family support and the best treatment available, yet I have experienced the acute sense of isolation and, occasionally, the despair endured by many cancer patients Tertoma of the Trestis. Lancet 1982
Unpredictable, treatment-induced fatigue means I can’t reliably attend social events. I dread small talk. The inevitable “What do you do?” “I’m not working, because I’ve got cancer.” “Oh, you’ll be fine.” “Um, no, actually; I might not be. It’s quite advanced. Miracles happen, though” “Oh.” Person exits right to stiff drink. (The other version of this conversation concerns my now-permanent baldness: “But of course your hair will come back.” “Actually no.” “Oh.” Exit right. Etc.) I don’t blame people for coming to an abrupt halt in the conversation: what are they supposed to say? Before I got ill, I was exactly the same. Who wants to talk about the precarious nature of life and death when you could be networking? Social events aren’t designed to hold these kinds of conversations. Anna Donald
Seeing a patient as a person
One of the most common themes to doctors’ accounts of being patients was the importance of being seen as a person.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability Hippocratic Oath – Modern Version
One time medical student and now full-time patient, Anya De Longh described the contrast between being a medical student and a patient in an outpatient clinic,
In my first rotation, orthopaedics and rheumatology, I lost track within the first week of how many outpatient appointments I sat in on. I didn’t really think anything of them – they are just another 15 minute slot of time filled with learning in a very busy day. As a patient, my perspective couldn’t be more different. I have one appointment with my consultant a year, and spend weeks planning and preparing, then a month recovering emotionally.
Dr Kate Granger, revealed in several passages in The Other Side how shockingly often healthcare staff failed to introduce themselves, such as on this occasion when she was admitted to hospital with an infection due to complications from her chemotherapy,
I am laid on a trolley in the emergency department feeling extremely unwell. My temperature is 39 C and my pulse is 150. It is about 36 hours since I underwent a routine extra-anatomic stent exchange, and I have developed sepsis. A young surgical doctor clerks me in. He does not introduce himself by name, instead plumping for, “I’m one of the doctors” A nurse comes to administer my IV antibiotics. She does not introduce herself at all. Over the 5 day admission I lost count of the number of times I have to ask staff members for their names. It feels awkward and wrong.
In my experience, medical students rarely ever fail to introduce themselves, but once they become infected with the culture of working life, they (we) slip into bad habits.
Kate’s campaign to get us to start introducing ourselves again is called, #hellomynameis. She explains;
If being ill has taught me anything about being a doctor it is the importance of seeing a patient as a person and not merely a condition or disease sat in a hospital bed. It is amazing what you learn about people if you just ask. I have looked after a world record breaking knitter, an Olympic cyclist and a lady who had eleven children in the last few months. The disease focused clinicians may see these facts as irrelevant, but I think they are central to understanding the person, how their pathology impacts on them and why they are special to their family.
When was the last time you stopped and had a conversation with someone on the ward just for the sake of having a conversation? We all blame being too busy on not doing this but are we really? Do we not have 10 minutes to sit down and explore someone’s worries? Having a chat can be therapeutic in itself. I know this. A few months ago when I was struggling with the uncertainty of my prognosis and the effect this was going to have on my career I had a long chat with my Oncologist. There was no examination, no diagnosing, no investigations and no prescribing; just talking. And it helped. It really did. Kate Granger
Continuity of care, the deliberate organisation of patient care so that the same doctors and nurses attend to the patient, was mentioned by several doctors. Having a serious, complicated illness and feeling exhausted doesn’t leave patients in the mood for answering the same questions over and over again. As medical sociologist and anthropologist Arthur Frank writes, “Th[e] structured disruption of continuity of relational care is more than an organisation problem; it is a moral failure of health care, deforming who patients and clinicians can be to and for each other.”
Poor standards of care and medical scepticism.
Lack of courtesy is just one aspect of poor care. Many doctors dread illness because they are acutely aware of modern medicine’s weaknesses and limitations. Albert Klitzman interviewed doctors who were patients for his book, When Doctors Become Patients,
[Doctors as patients] also became aware of how many mistakes are made, like the wrong dose of medication. They were astonished by that.
Kate Granger gives another example,
The following morning I notice that MRI is written next to my name on the ward white board. At first I wonder if this is just an administrative error and it is actually meant to say ultrasound. They wouldn’t have requested an MRI without talking to me first surely. I get claustrophobic sat in the back of a three-door car so the thought of having an MRI is not a pleasant one.
The next thing I know a porter has arrived with a wheelchair to take me for the mysterious MRI. I question if it is a mistake so we read the medical notes. A discussion between my Consultant and the Gynae-Oncology team is clearly documented the previous evening suggesting an urgent MRI abdomen and pelvis in addition to the rest of the management plan. I can see that it is a completely appropriate investigation but I’m absolutely fuming she did not bother to discuss this with me. As I have no other choice I sit myself in the chair and am wheeled off to the scanner. My heart is pounding the whole way. The Other Side
After I gave this presentation to the Guy’s and St Thomas’ medical students, several described how shocked and disappointed they had been at the standards of care they had seen when they had accompanied relatives to hospital. Often it related to junior doctors trying to cover up for their obvious lack of knowledge, giving an evasive answer instead of saying ‘I don’t know’. When I fractured my finger last year I watched a junior orthopedic surgeon attempt to put a wholly inadequate splint on it and even when challenged, he persisted. Among the narratives I have read, communication skills are at least, if not more of a concern than clinical skills, as Campbell Moreland, the young GP with metastatic testicular cancer described,
In March, 1980, I underwent chest tomograms and a creatinine clearance test. I suspected lung secondaries but was not informed. I asked a junior doctor about my X-ray results. He went to the X-ray department, came back, and told me the films were normal. I know this was a blatant lie, as did he. My trust in him was irreversibly damaged. How much better had he said, “I don’t know, but I’ll find out. If it is bad news do you want to discuss it?” Junior doctors are shy of giving a patient bad news because they are afraid both of the patient’s reaction and of their consultant” Tertoma of the Trestis. Lancet 1982
The third day of admission brings me some examples of doctor’s communication skills being the worst I could possibly imagine under the most painful of circumstances. First thing today I have been crying. It is the day of the MDT meeting, I am frightened and it feels as though nobody is talking to me. I know my MRI report is available, but again no-one has taken the time to discuss this with me so I know it must be bad news. I’m laid in a hospital bed sobbing and scared, about at the most vulnerable a patient could be. Kate Granger
Other doctors who had been patients appreciated the anxiety patients suffered whilst waiting for results,
Many ill doctors now came to identify more with their patients (e.g., getting results to patients faster); gay doctors with HIV who treated members of the gay community often encountered this issue with added urgency. Klitzman
Medical knowledge also makes doctors more aware of the limitations of medical care. Of particular note, doctors choose less intensive treatment at the end of life than they recommend for their patients.
Faced with a terminal diagnosis some doctors turn to alternative therapies and become more interested in the spiritual aspects of care. In his academic account of doctors as patients, Albert Klitzman was particularly moved by this,
Their scientific training did not inure these physicians against irrational, nonscientific beliefs and behaviors. The degree to which “magic” and irrationality persisted in the lives of these scientifically trained doctors surprised me. They often perceived medical knowledge as overrated, and magically imbued. Despite this age of ever-increasing scientific knowledge, magic endures.
Dr Anna Donald blogged for the British Medical Journal about her experience as a patient with metastatic breast cancer. She was an exceptional academic in the field of evidence-based medicine, and yet her blogs are full of descriptions of prayer and meditation. She described the value of massage and alternative diets, and became a firm advocate of Emotional Freedom Technique (EFT)
Our professional identity shapes what are often destructive attitudes towards ourselves and our patients, especially when the diagnosis is unclear, the symptoms hard to treat and the prognosis poor.
Protests from patients that doctors are too busy to talk or that we lack sympathy or empathy are often met with defensiveness and excuses, but doctors who have experienced the isolation, fear and despair of serious illness are keen to emphasise the importance of humanity in care.
Our colleagues who have suffered as patients often feel compelled to report back, and what they have been telling us has been remarkably consistent over the years. It is time we paid more attention.
I conclude with a quote from GP, Dr Liam Farrell, who wrote about his experience of, and recovery from addiction,
when you are faced so starkly with your own vulnerability, it does make you understand patients so much better … We are frail, we are human — bad things can happen to us, just like anybody else. I think we have to be aware of our own mortality and our own frailty as well, and not be ashamed to look for help if we need it, and also to watch out for each other – not in a ‘big brother’ kind of way — but I think we have to look out for each other’s health.
The Centre for Psychosocial Research, Occupational and Physician Health at Cardiff University has launched a new survey to understand doctors’ in England’s attitudes to their own mental health.
Doctors are recognised as an ‘at risk’ group for developing mental ill health and there is a growing recognition that this requires closer scrutiny if we are to support doctors effectively in the workplace. At present we have only a rudimentary understanding of doctors’ attitudes to disclosure of their own mental health concerns and their perceived obstacles to disclose to their workplace. Understanding these obstacles is important if services in England are to deliver effective and timely support.
This survey aims to address some of the gaps in our understanding and provide evidence for how such services should be developed and delivered. This anonymous survey is for
all doctors, regardless of whether they have personally experienced mental ill health. If you are a doctor working in England and you wish to share your views, please complete the short online anonymous survey available here:
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Nearly 25% of doctors working in the UK have been found to experience stress at some point in their careers. This conference on ‘Doctors’ Health and Well-being: from medical students, to trainees and senior doctors’ will be suitable for both trainees and trainers. The date of the event is Tuesday 12th November 2013 and the venue is the Royal Society of Medicine building, I Wimpole Street, London W1G0AE.
Doctors’ Health and Well-being: From Medical Students, to trainees and senior doctors
Reducing stress, increasing resilience and improving the mental well-being of doctors
Conference aims include:
• Learn about causes of stress and how to reduce stress in healthcare settings
• Increase your personal resilience and learn more about managing emotions
• Find out more about how to support trainees and doctors in difficulty
• Understand what doctors need from their colleagues when they are ill
The Keynote speaker is Dr Steve Peters who will describe a successful mind management system that he has used to help medical students, and has also used successfully with medal-winning elite athletes in the Olympic Games. Other speakers include leading psychoanalysts from MedNet, an occupational physician, Debbie Cohen and Dr Jane Marshall, a psychiatrist in addictions.
This is a great opportunity to hear these and other experienced speakers, and to learn more about how to improve doctors’ health and well-being.Please go to the RSM website for more information and to make bookings:
Various rates are available for delegates.
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Please message us using our new email address via our contact page
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Practitioner Health Programme
We have been shortlisted for the BMJ Mental Health Team of the Year award 2013: More information here
The PHP Team
Left to right, top to bottom:
Max Henderson, Lynne Simpson, Lucie Thorn, Jane Marshall, James Anderson, Richard Jones, Ruth Deighton, Sheila Jones and Claire Gallagher
Doctors on the GP performers list in Brighton & Hove can now self refer to PHP. Brighton & Hove CCG have entered into a call off arrangement with PHP to enable these practitioner patient’s to self refer to access timely and expert care
The report for the first three years of the NHS Practitioner Health Programme (PHP) report can be found here; PHP Three Year Report.
The report has been prepared by the PHP team with assistance from London Specialised Commissioning Group and we hope, when you read the document, that you will agree that this is an effective service.
The last year has seen PHP move from being a prototype service to a mainstream commissioned service. PHP has contract arrangements for practitioners living in London and is also able accept practitioners on a cost per case basis from all other areas of the UK.
PHP endorsed as a “crucial service” by JMCC, BMA, NCAS, Academy of Medical Royal Colleges and defence organisations
PHP has been endorsed as a “crucial service” by JMCC, BMA, NCAS, Academy of Medical Royal Colleges and defence organisations, further information is contained in this PDF document.