Doctors shouldn’t reveal so muchBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2495 (Published 11 June 2018) Cite this as: BMJ 2018;361:k2495
All rapid responses
This article was categorised under 'Provocations' and I'd say that based on the response, it has justified that label.
I welcome the public demand for the 'extreme' candour Mr Sokol describes. There is now, it seems, a market for the sort of confessional which the author is against. We're seeing an increasing number of books (This Is Going To Hurt by Adam Kay ), documentaries (BBC One's Celebrities On The NHS Frontline) and even blog posts and social media meme pages detailing the sticky end of medicine. Good. Should the naked truth be ugly let us not cover it up for fear of embarrassment.
I would hope by now that Mr Sokol is aware that medical professionals are human beings. A greater public perception of this might lead towards greater empathy towards doctors struggling with the increasing demands placed on them, as he acknowledges. It is fitting that the article cites sources from sixty and two hundred years ago ; the paternalistic attitude this belies is equally dated. We would not withhold poor prognostic information from a patient who asks for results; we should not deceive the public by keeping calm and carrying on when clearly there are systemic problems within the NHS. The patient-centred medicine sword cuts both ways; if we are to (rightfully) recognise our foibles when prescribing and administering treatment then I welcome a wider recognition that healthcare staff are human beings. If we are not to dispense with it and doctors are to remain aloof on their pedestals, then as one holding GMC registration, I would caution the any spokesperson who does not to remain silent on the matter for fear of being a hypocrite. If the position of 'doctor' is to remain sacrosanct, then I can expect anyone who doesn't work in that environment not to have sufficient understanding of what it is like.
These public airings of grievances, as well as giving patients a more realistic glimpse of the NHS, also warn future professionals of what to expect. Resilience is a popular word in medical school lectures at the moment. Working in current conditions isn't always the dream job - I say this not to discourage anyone, but ensure that there is an accurate perception of the lifestyle prospective medical students are signing up for. I'm not convinced that anybody is truly aware of what being a doctor means when they apply to read medicine. If we keep these experiences behind closed doors, we risk giving future professionals false expectations of what it means to work in the most human career. Should any of these ill-informed future doctors struggle at work, they may not reach out if they feel as though they are the only one who has trouble coping.
In my own experience, I dislike any lofty capital 'P' Professionalism ideas which dehumanise the interactions I have with patients. The environment I am in often calls for empathy and understanding for relatives having the worst day of their lives or patients coming to the end of theirs. I do introduce myself as George if I feel that Dr Huntington is putting up too much of a barrier. It is unkind to hold people in these extremes at arm's length. In practising medicine, we are exposed to some truly awful situations. It is hardly surprising that these may affect someone and change their perspectives. If this leads to better public understanding of these crises then it isn't wrong to disseminate that information .
Finally, I do not feel that the comparison with airline pilots is apt. A pilot announcing his struggles with insomnia over the tannoy is a gross abuse of trust. But if lack of sleep across all employees of an airline company has the potential to harm passengers, we have a duty to discuss it . This affects change by creating the sadly necessary political climate to encourage a review. To do otherwise sweeps the problem under the rug. As doctors, we have experience of managing patients with mental health. I know of no clinician who, upon reviewing a patient with a low mood who is struggling at work, discourages them from discussing their problems. While doing so at work directly is an infraction of trust, if the public are not aware that there are concerns because nobody breaks ranks, it is as though the problem does not exist as there is no impetus to act.
1. Sokol D. Doctors shouldn't reveal their vulnerabilities. BMJ 2018;361:k2495
2. Kay A. This Is Going To Hurt. Picador. 2018
3. Huntington G. CPR rarely works – why do people have so much faith in it? The Guardian. 2018. Available online here: https://www.theguardian.com/healthcare-network/views-from-the-nhs-frontl...
4. Rimmer, A. Urgent action is needed to manage doctors’ fatigue, says BMA. (2018) BMJ 2018;360:k127
Competing interests: I have written publicly about difficult situations at work. Example included in the sources.
“Of course, doctors are human and hence flawed, but many people expect them to have a mental toughness and calm demeanour that set them apart from most other groups. This image doubtless contributes to their high status and patients’ trust”.
The need for a degree of resilience or mental toughness has been emphasized throughout medical history- not least through the famous Aequanimitas, by William Osler (one of Mr Sokol’s favourite pieces of writing1). It is a message that has been repeated from from the moment a student thinks of applying to medical school, throughout their training, throughout their postgraduate years, and one that is eventually repeated back to others.
Those who have been most convinced of this need for a supranormal level of mental toughness are none other than the clinicians themselves. The end result of this is an overwhelming culture of fear and bullying. Clinicians who display even a shred of humanity are told to “man up”. Traumatic events come and go, and attempting to speak to colleagues, supervisors, and even support services are met with eye rolls, sighs, and fliers for “resilience courses”. Antidepressants, alcohol and illicit drugs are used and abused in silence and shame 2. “Burnout”- our general term for what is almost certainly a secondary traumatic stress reaction3 – is a widespread problem4.
“The trend for public outpourings of emotion by doctors sits uneasily with this image and may lower doctors in the estimations of the public...this candour may have advantages, such as making doctors more “human” and gathering public support for certain causes, but those advantages may well be outweighed by the damage inflicted on the profession’s image, which some think has lost the lustre it enjoyed just a few years ago”
There are a number of suppositions in this statement:
1. The outpouring of emotions by doctors is unpalatable to the public
2. This damages the doctor’s image
3. This damages the profession’s image
4. This has contributed to the loss of lustre the profession has
We would like to argue the opposite. In this era of information sharing, it is the reverse that has happened- the closedness of doctors is unpalatable to the public. It is that closedness which has damaged the profession’s image, and has resulted in the loss of lustre to the profession. The recent case of Bawa-Garba illustrates this well, where an apparent lack of remorse was picked up on by the Adcock family5.
“…they should keep their fig leaf in place when in the public eye…”
In the Bible, Adam and Eve sewed themselves fig leaf aprons out of shame at their own nakedness6. The resolution of this shame was the death of their descendant, naked, on a cross, reconciling all children of Adam and Eve with the creator once more7. In the same vein, doctors baring their souls allows the reconciliation of patient and clinician, creating a new and different relationship of mutual support.
1.Sokol D. Aequanimitas. BMJ 2007;335:1049
2. Beyond Blue National Mental Health Survey of Doctors and Medical Students. https://www.beyondblue.org.au/docs/default-source/research-project-files... (last accessed 17th June 2018)
3. Leap E. What Physicians call burnout others call PTSD. https://www.kevinmd.com/blog/2015/11/what-physicians-call-burnout-others... (last accessed 17th June 2018)
4. Medscape Physician Lifestyle report 2018. https://www.medscape.com/sites/public/lifestyle/2018 (Last accessed 17th June 2018)
5. What about my son? Mother's fury as doctor who let boy die goes free after pleading she has to care for her own disabled child. http://www.dailymail.co.uk/news/article-3359630/Doctor-nurse-guilty-mans...
6. The Bible, Genesis 3:7
7. The Bible. Romans 5: 14-21
Competing interests: The authors have administrative roles on the Tea and Empathy group https://www.facebook.com/groups/1215686978446877/ and the Those We Carry website (twitter: @thosewecarry)
Sadly, the rush for Sokol to produce a column a week does sometimes lead him to produce ill prepared drivel. To attack medics who share their feelings on the grounds that, somehow, this devalues the 'profession' and lowers the 'esteem' patients may have in their doctors, reflects someone who does not realise what really happens in the world. The closed off , non emotional medic was the cause of many patients being disillusioned with medicine and has been part of the problems with many of the medical scandals we have become accustomed to with failures being covered up in case patients feel less in awe. Sokol's conception of 'profession' has also led to rising toll of mental health issues drug problem and even suicides amongst those unable to express how they feel or else, knowing if they did, Sokol and his ilk would request them to pull themselves together. Stick to the ethics, David.
Competing interests: No competing interests
As a member of the online prescribed dependent and harmed community and an active campaigner for recognition of the devastating effects of prescribed drugs of dependence, I would have to disagree with Daniel Sokol. Patients have battled long and hard to have their concerns about these drugs taken seriously in the consulting room and for many it has been to no avail. This has resulted in immense pain and suffering, physical, emotional and psychological. Consequently, a large online community of patients has been formed and patients have become far more expert in the subject of benzodiazepine and antidepressant withdrawal than most prescribing doctors simply because they have been forced to do their own research on this subject. We have indeed created a parallel universe because the medical profession has failed us so terribly and mutual understanding is extremely difficult to achieve.
The BMA has taken our concerns seriously (1) and now Public Health England is conducting a review (2). The Scottish Government is also planning a parallel review after pressure from campaigners and a petition which achieved an unprecedented number of submissions.(3) We have met resistance from RCPsych and largely silence from the RCGP. Patients have tried extremely hard to engage via Twitter with these bodies and their representatives but it has been largely fruitless. This has been completely counter-productive, fuelling greater despair and only making campaigners more determined to intensify their demands. Indeed, what we now seek is a public inquiry into the issues of drug dependence, particularly benzodiazepines and antidepressants. Meantime a formal complaint to RCPsych remains unresolved several months after it was first lodged.(4) This has caused further pain and distress to patients.
In Scotland only one GP and one psychiatrist has spoken publicly in support of the Scottish petition and thereby the wider patient community, Dr Des Spence, GP (4) and Dr Peter Gordon, psychiatrist who regularly blogs on our behalf. Both have been very honest about the issues at play here. Dr Gordon was recently interviewed by a member of the patient community, James Moore. (5) We also have the support of Dr Terry Lynch, GP in Ireland and of course Dr David Healy, psychiatrist and international expert on SSRIs in Wales. Each of these doctors has sent supporting statements to the Scottish Public Petitions Committee. (3) Dr Healy and campaigners appeared together on a Talk Radio Europe show only recently. (6)
We have the utmost respect for these doctors for their openness, honesty and integrity whilst we only have contempt for those who have tried to silence our voices and who remain silent themselves. Dr Peter Gordon has talked about his own experiences and difficulties with an SSRI antidepressant. We think he is extremely brave to have done so. I am sure there are many more who could do the same. The ongoing battle between patients and the medical establishment around antidepressants has come about entirely because doctors have been less than honest with patients about the possible benefits and risks of these drugs. Perhaps this is to maintain the illusion that they can provide an effective remedy or may simply be a desire to help. Or they have simply been misled by the marketing tactics of the pharmaceutical industry.
The ongoing battle for recognition of patient suffering, the silence of most doctors and the lack of communication from the medical establishment have been the biggest obstacles to a successful resolution. It is time for greater openness, not less. The respect for doctors is on the wane because patients have so much more access to information than in the past and know how very fallible doctors indeed are. We have no desire to see them as somehow separate and superior to the rest of us, we do however expect them to be competent at the job they do. Working conditions are crucial as are training and education. If GPs do not have enough time to discuss the adverse effects of the drugs they prescribe, then there can be no informed consent and it seems lack of time, inadequate guidelines and insufficient education and training in prescribed drug dependence and withdrawal are crucial factors here. I hope many doctors will continue to speak out, patients will appreciate it.
Competing interests: No competing interests
I would like to thank you for using the female pronoun for the barrister and pilot. It may not have been deliberate, but it is rare to see this done and it does not go unnoticed.
On the substance, I must agree with the previous comment. Although we maintain an appropriate professional boundary in work, there is lots that would make the medical profession both more tolerable to its members and more human to our patients which would be no bad thing. I would be in favour of relaxing the dress codes, for example. Men , who have the luxury of being assumed to be a doctor without the title, often use their first names with patients. I think that's a good move away from the paternalistic model, although it clearly has limitations.
I wonder also, if you have confused discussion of difficult medical questions, or indeed ethical questions - which may well be best kept in the medical press - and the absolutely political issues of staffing, stress, burnout, and working conditions. If those discussions are not had openly then we cannot hope to achieve change. We should not stifle the reality of working in an NHS system under immense financial and political pressure. In these cases, it is not our professionalism we call into doubt, but the resources of our environment.
A factor I would like to raise here is patient confidentiality, and the recent Share a Story in One Tweet demonstrated how easily that can be messed up.
Competing interests: No competing interests
Sokol's article reminded me of the tale the Emperor's New Clothes,<1> in which many observers stay quiet due to fear of being ridiculed and punished, until one naive, or brave, individual states the obvious problem. But the main difference between the tale and Sokol's articles is Sokol apparently glorifies individuals who stay quiet, and criticises the ones who state the elephant in the room.
I do not see candour from physicians as rants. Rather, this candour raises concerns about healthcare which many medical and non-medical readers relate, debate, and suggest solutions. The BMJ column No Holds Barred by McCartney is a good example. Sokol mentions that venting in journals and books is acceptable and desirable, and appears to have a double standard between print and social media. Ironically, he later quoted the GMC for advising the same standard on all mass media.
Regardless, information presented in these print media are often accessible to the public through social media like Twitter. Almost anyone can follow the BMJ Latest Twitter account, unless you live in a communist country. Would it be considered "crossing the professional boundary" for posting links to and excerpts from journal articles on Twitter? If yes, then many professionals, including Sokol, would be guilty. A medical ethicist ranting about physicians in a journal would also be guilty.
The BMJ Twitter page explicitly states it is meant to lead debate on health and improve patient outcomes. As per the GMC Good Medical Practice, physicians must promote and encourage a culture that allows all staff to raise concerns openly and safely.<2> Then, does following the GMC guidance to speaking out mean damaging the "profession’s image"?
If physicians were prohibited to speak out, would they become invulnerable then? It would just be hiding the truth. Does the #MeToo Movement on social media make women look vulnerable? Rather, it shows courage against injustice, and encourages others not to suffer in silence. The opposition could argue these matters should be discussed in an even more private manner, inaccessible to the public. If these matters were settled this easily, I am sure the number of people speaking out would be considerably less.
I prefer individuals who are honest rather than faking their confidence. I'd rather have a boxer who admits to his trainer about his lack of confidence, so his team can modify his training to help him put up a good fight. I appreciate a barrister who honestly tells me my slim chance of winning a court case, so that we can work on an alternative settlement. I want a pilot raising concerns about anxiety due to workload, but not silently putting passengers at risk. Similarly, as a patient, I'd rather have an honest physician who tells me the overstretched NHS situation and my expected wait time, than a liar who gives me false hope.
1. Sokol D. Doctors shouldn’t reveal so much. BMJ. 2018;361:k2495.
2. Respond to risks to safety. London, UK: General Medical Council; 2013 Mar 23; cited [Jun 13, 2018]. Available from: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/goo....
Competing interests: I have been paid for working as a physician, but not writing this letter.
Thanks for your articulate response.
Have doctors not maintained this façade for a very long time, without being led to desperation? Is it really a cause of their current distress?
To bridge the doctor-patient divide, should doctors ditch their shirt and tie in favour of casual clothes, like the majority of their patients? Should patients call you “David”, like friends and family, rather than the more distant and reverential “Dr Berger”?
Should doctors openly express their revulsion at doing a PR examination, or their irritation at a patient who fails to take their medication?
Is maintaining some sort of façade not part of professionalism?
Just some thoughts.
Competing interests: I am the author of the article
I would argue that the need to maintain a facade is what drives so many doctors to desperation and makes them feel like impostors. Yet here you are arguing for more of it and in so doing demonstrating a viewpoint of doctors which is quite outdated. Patients are not so dim that they cannot understand that their doctors are human and that perhaps such a novel notion may even be an advantage because it means their doctors can empathise with them far better than some remote Victorian martinet, festooned with a top hat, a fob watch and a monocle.
We are human, patients are human; we do a tough job, patients often have tough lives. Let's just try to recognise our mutual humanity and use it to all our benefit instead of putting on a show all the time. Life's too short and our job is too important to waste time on silly theatricals and superficial pretence.
Competing interests: No competing interests