Clare Gerada argues that doctors too often ignore their own needs and that systems to support them need to change to cope with the problems they face
Doctors are their own worst enemies. Each one of us is vulnerable to personal distress, burnout, or difficulty in functioning at work. Yet we normalise our struggles and remain silent about our own needs, sacrificing them for our patients. In doing so we are perpetuating the myth of Chiron, the wounded healer of classical mythology (see box). Just as Chiron failed in the end to live with his pain, we cannot live with excruciating pain forever.
Sadly, increasing numbers of doctors are losing their vocational spirit or their enthusiasm for caring or healing or are choosing to die through suicide. Doctors need to stay compassionate, attuned, and focused when dealing with often unsustainable workloads and when trying to treat many patients with problems that cannot be easily solved by the medical interventions available to the health service.
The combination of repeated reorganisation, marketisation, and increasing austerity has left those working in the health service feeling battered and bruised. High rates of bullying, whistleblowing, early retirement, staff turnover, emigration, and sickness illustrate the pain that is being felt by NHS staff.
At the same time, the media portrayal of many types of doctor, oscillating between hero and villain, does not sit easily with a profession whose main calling is to serve its patients and communities. For doctors, the burden of regulation and inspection and the threat of being referred to the General Medical Council (GMC) are a constant presence, adding to the culture of fear, blame, and shame with which many doctors live.
Unless supportive systems and structures are in place, the burden of caring can have a serious impact on doctors. For example, the Practitioner Health Programme, a confidential service for doctors and dentists with mental health or addiction problems, has seen numbers of patients in the service soar in recent years, from an initial 150 a year in 2008 to a peak of 600 patients in 2015, with many of the new referrals being under the age of 30. Other services targeted at doctors, such as the London based service Mednet, have reported similar surges in referrals.
The government is aware of the problems that all healthcare staff face, and the special problems faced by doctors, but there are still uncertainties as to how these problems should be tackled. One suggestion has been that doctors should be given training to build up their resilience.
Terence Stephenson, chairman of the GMC, told a House of Commons health committee hearing earlier this year that doctors should expect to face a GMC investigation during their career. He suggested that doctors should build up resilience to deal with the challenges of their work in the same way as that expected of soldiers. However, resilience training might add to, rather than reduce, the pressure on doctors and would add to the burden of mandatory training facing doctors.
Resilience and mindfulness training is not the solution to a problem that is structural, not individual, in nature. Doctors are already some of the most resilient individuals in society. They are chosen for attributes that point to high work ethic, survival under pressure, ability to deal with complexity, and staying power. Given the competitiveness of medical school entry, embryonic medical students begin their journey from their early teens.
Doctors endure a long training and then work long hours, without sleep. They have to break bad news and then get on with it. They have to endure frequent changes of job, location, team, system, and role. They have to rapidly adapt, taking on new roles, sometimes with only minimal induction.
Being resilient means being able to bend under pressure and recover quickly, and necessitates being flexible, strong, and tough. These are the attributes of most doctors, across all generations.
When doctors suffer it is not enough to assume that the answer is more training, this time in resilience. What is required instead is to examine the causes of the distress at individual and structural level and to tackle factors that perpetuate this distress.
This might mean recalibrating inspection regimes to deal with staff wellbeing and the gap between what staff are expected to espouse to their patients and what they themselves experience from their workplace. It might mean changes in rosters so that they build in, rather than exclude, continuity among staff teams. It might mean introducing safe spaces to relax, reflect, and recharge. It might mean a review of the regulatory process that conforms to the principle of “innocent until proven guilty.” And it might mean confidential services for those whose problems cannot be healed by time alone and who require more expert services.
The origin of the wounded healer
In Greek mythology the demigod Chiron was wounded by Hercules with a poisoned arrow. The wound never healed and caused him immense pain. As a demigod, Chiron was immortal and he chose to transform his suffering into help for others. Eventually, Chiron was able to die by exchanging his life for that of Prometheus and through death he became free from pain.
Chiron was a kind and gentle man. He was also a teacher, and he used his gift to reduce suffering in others. The myth of Chiron is the basis of the modern concept of the wounded healer.
Suffering is part of the human experience and everyone carries with them psychological, emotional, physical, and even spiritual traumas from the past. For many aspiring doctors, as well as other health professionals, the nature of their wound might influence their choice to enter a caring and healing profession and also their choice of specialty.
This choice provides the theatre for playing out the wounded, unresolved part of their past. For example, a doctor with an addicted parent might become an addiction specialist; another might become a paediatrician after the death of a sibling or a psychiatrist after past abuse from a childhood caregiver.
These unconscious motives can be a driving force for compassion and commitment. But they may also be a portent for future problems if not understood and kept in check. In addition, a pattern might be established in which the doctor risks becoming overinvolved with patients, transgressing professional boundaries or developing burnout, anxiety, or depression.
Competing interests: I have read and understood BMJ’s policy on declaration of interests and declare the following interests: I am a partner of the Hurley Group, an organisation that runs a number of practices and GP walk-in centres across London. I am medical director of the Practitioner Health Programme. The Practitioner Health Programme conference on 15 September 2015 is entitled “The wounded healer—helping each other to care in the modern health service” (see https://www.eventbrite.co.uk/e/the-wounded-healer-helping-each-other-to-care-in-the-modern-health-service-tickets-17227798810) and will look at some of the issues discussed in this article.
- Matthews-King A. revealed: The rising tide of GP burnout as NHS cuts support. Pulse Today 2015, 11 Jun. www.pulsetoday.co.uk/your-practice/battling-burnout/revealed-the-rising-tide-of-gp-burnout-as-nhs-cuts-support/20010133.article#.VXnMhdyECgc.
- General Medical Council. Doctors who commit suicide while under GMC fitness to practise investigation. 14 Dec 2014. www.gmc-uk.org/Internal_review_into_suicide_in_FTP_processes.pdf_59088696.pdf.
- Williams H, Lees C, Boyd M. 2014 Civitas. The General Medical Council: fit to practise? www.civitas.org.uk/pdf/GMCFittoPractise.pdf.
- Support for Doctors. MedNet—interview with Dr Antony Garelick. www.support4doctors.org/detail.php/44/mednet-interview-with-dr-antony-garelick?category_id=16.
- Lind S. Doctors need resilience training like soldiers in Afghanistan, GMC head says. Pulse Today 2015, 6 Jan.. www.pulsetoday.co.uk/your-practice/regulation/doctors-need-resilience-training-like-soldiers-in-afghanistan-gmc-head-says/20008855.article#.VXnLmdyECgd.
Clare Gerada medical director, Practitioner Health Programme
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