Balancing medicine with a lifeBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7172.2 (Published 05 December 1998) Cite this as: BMJ 1998;317:S2-7172
Has the difficult and demanding training of British junior doctors created a generation of wounded healers? Sian Falder wants to change medical culture
In 1987 Glin Bennet asked: “Why are so many doctors unhappy, despite their interesting work for which they are well rewarded; and why are their patients unhappy about the care they receive?”(1) These questions are still relevant today. The high rate of suicide and drug and alcohol misuse among doctors testifies to their continuing unhappiness.(2) Stress counselling services are well used and welcome, but they have become our societyõs instinctive panacea to personal problems. It is reassuring to know that there is a friendly ear to listen to our problems, but we would do better to address not only why we have these problems but what we can do to prevent them.
Eleven years on, Bennet's own answer needs revisiting. His thesis was that the wounded doctor is a better healer. He believed that doctors fail to recognise their vulnerabilities and appreciate themselves as ordinary human beings; instead, they devote their entire lives to the pursuit of medical goals and self advancement, to the detriment of patient care. By the time they reach the middle aged “plateau” and realise the lack of meaning in their lives, they are too emotionally immature to seek help. He argued that the “wound” is the doctor's eventual acknowledgment of his or her inadequacies and that accepting and dealing with these inadequacies leads not only to a happier life but also to being a better doctor.
But why do these bright, broadly gifted individuals who enter medical school fail to mature as “ordinary human beings”? Perhaps the answer lies in the authorõs later statement that “most doctors have relatively simple lives in these early years, so it is possible, if they want, to give all their waking hours to the work in hand.”(3) It is not so much possible as inevitable; wanting has little to do with it. To deny any responsibilities or interests outside a full time job is to subscribe to an old fashioned myth. Evidently “lifestyle” is important to young British doctors. Of a cohort of 554 medical graduates in 1995, 58% felt that they deserved a decent family life and leisure time, and a further 29% believed that the organisation of medical practice must allow doctors to balance their career with their family and other interests.(4)
I believe that both the symptomatic troubles of junior doctors and their later disillusionment stem from the same source - the conflict between a career in medicine and a life outside it.
Who can we blame?
The fault lies both with the entrenched structure of the medical profession and our own response to it. Bennet is right that doctors are flawed individuals, like any other human beings, and they occasionally lose sight of this fact. Sometimes doctors do get caught up with a feeling of their own self importance and would do well to acknowledge this.
But it is easy to blame the individual. Medical schools are swamped by academically gifted students, each expected to have “a wide range of interests demonstrating an outlook on life which is broad rather than narrow.”(5) Why do these multi-talented individuals fail to fulfil their potential for personal as well as professional development?
One reason for this is the narrow mindedness resulting from concentration on medical issues. “Junior doctors' hours” is a phrase so familiar that we no longer give any thought to what it means - even nurses who subsequently train in medicine are shocked by their work hours as junior doctors.(6) There will always be occasions when working long hours is inevitable. It is not simply the excessive periods of continuous duty which inhibit a fulfilling life outside medicine, but the additional hidden hours of work - the time that doctors must devote to revising for exams, carrying out research and audit, preparing presentations, and updating their medical knowledge - that takes up most of their little “free time.”
What can we do about it?
Bennet believed that the most effective changes will come about through development in the attitudes of doctors, but it is not as simple as this. If doctors are to recognise themselves as ordinary human beings, they need a public climate which sees them as such and a profession which allows them to be such.
The public and the media glorify doctors and imply that they have a vocation rather than a job, and that trainees implicitly agree to long hours and self sacrifice when they become doctors. Medics themselves view it differently: of recent medical graduates, only 1% felt that medicine was a vocation.(4) Work is still a necessity for most people, but fewer now regard it as a central, self defining force. Gray reminds us that employment is only a job and that we should pursue happiness by increasing physical activity and social life and making wider opportunities for ourselves.(7) Here lies the key to change.
From medical school onwards, we need to balance our lives better. Mature students, who see their medical training in a broader context, do better and have a lower drop-out rate than their younger counterparts.(6) Why donõt we encourage medical students to broaden their perspective by incorporating an additional non-medical module, such as photography or a foreign language, into their training?
Common sense dictates that companies which enable staff to balance work and other aspects of personal life effectively are the ones best able to attract talented and skilled employees.(8) The NHS does not have a problem attracting workers, as shown by the number of applicants to medical schools, but, although there is not a great efflux from the profession, members increasingly seem to want time off.
A fifth of respondents in the aforementioned cohort study had spent time not working in Britain. The most common reason for leaving Britain was the “need for a break.” Sixty per cent of this cohort indicated that they planned to work overseas temporarily, mainly because they wanted to travel and broaden their horizons. These desires may come from the well publicised pressures facing junior doctors and the long hours of medical training.(4) Well planned career breaks allowing time for other interests, with entry back into the profession, would alleviate dissatisfaction and improve morale and performance, and are accepted practice in organisations such as the police force and the civil service. General practice seems more progressive in this respect, with some general practitioners taking a six month sabbatical every five years,(9) although certain hospital trusts allow employees to take formal career breaks to work abroad and return to their former position.(10)
From the cohort study, in addition to those who worked overseas or simply travelled, a further 25 doctors took time out. The most popular reasons were for undertaking further study or research (not necessarily medical), just needing a break, domestic commitments, or pursuing other interests such as renovating a house or sailing. Although substantial breaks from clinical medicine to pursue medical research generally receive the stamp of approval, breaks for other reasons are often harder to justify. But in terms of training, quality is better than quantity, and a refreshed doctor learns more in a short time than a tired one over a longer time. The benefits, both to the individual and the profession, are well documented by those who have used time out to good advantage.(10–12) Surely such schemes should become more widespread.
It is no longer acceptable for flexible employees or those who have taken time out to be considered as lower status professionals who are not committed to their work. Such archaic attitudes stem from the too narrow perspective of people in positions of influence and are to the detriment of the profession. They lead to the loss of potentially some of its best contributors and leaders.
Finding a balance
Medicine is a challenging career which does demand commitment from its practitioners, and reaching the top, as in anything else, requires a degree of self sacrifice. No one is arguing for easy lives, just reasonable ones. This battle for a balance between medicine and a life is not a new one. What is new is that it is no longer the province of women, who have traditionally had to try juggling their career with having a family, but also affects men. Younger women are now less likely to make career changes for the sake of their family, whereas young male doctors are twice as likely as their older male colleagues to do so.(13)
The health service has been in existence for 50 years, but its medical career structure has failed to keep pace with the changing face and demands of its workforce. Change is overdue, and this is the age of the portfolio career.(14) We are a self regulating profession. We can do something about it.