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Doctors shouldn’t reveal so much

BMJ 2018; 361 doi: (Published 11 June 2018) Cite this as: BMJ 2018;361:k2495

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The fig leaf- a sign of shame, not modesty

“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. (last accessed 17th June 2018)
3. Leap E. What Physicians call burnout others call PTSD. (last accessed 17th June 2018)
4. Medscape Physician Lifestyle report 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.
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 and the Those We Carry website (twitter: @thosewecarry)

17 June 2018
Olusegun O Olusanya
Clinical Fellow in Intensive Care Medicine
Nitin Arora, Mahesh Ramanan, Jennifer Leckie, Dave Christie, Alina Sato, John McGarva, Jason Hui Wai Cheung, Andrew Tagg
St Bartholomew's Hospital
West Smithfield, London EC1A 7BE