Doctors’ wellbeing: learning from the past can help improve the futureBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4101 (Published 01 October 2018) Cite this as: BMJ 2018;363:k4101
- Agnes Arnold-Forster, postdoctoral research fellow, Wellcome Trust investigator award
Follow Agnes Arnold-Forster on Twitter @agnesjuliet
Recently, there has been much focus on doctors’ emotional health and the threat of burnout. There are campaigns to excise bullying from certain specialties, as well as research into wellbeing, institutional policy initiatives, and think pieces, all of which attest to this seemingly new concern.
Much of the conversation, however, is historically inaccurate and is coloured either by nostalgia for a fictitious past or is preoccupied with piecemeal initiatives that take little account of the structural, political, and historical context of the NHS.
In my current research, I conduct oral history interviews with practising and recently retired surgeons. I ask them to narrate their lives and we explore the emotions of their personal and professional experiences. When asked about the emotional cost of care and their working conditions, almost all hark back to an era before the introduction of the EU Working Time Directive. They reflect on the compassionate connections they could form with their patients when they were able to maintain continuity of care and talk about long working hours that were made bearable by the emotional support provided by the “firm.”
Histories of surgery and hospital care in the 1960s, 70s, and 80s reveal a different picture, however. They paint one of a hierarchical, male dominated, and exhausting system that relied on nepotism and bravado. They tell stories of male consultants who depended on their wives to perform the domestic labour and childcare that allowed them to work uninterrupted. These histories also reveal a recurring pattern of initiatives that attempted to improve the emotional resources available to doctors.
Many recent schemes set up to improve the workplace cultures of the NHS position themselves as innovative and unprecedented, but history shows that this is not the case.
From the foundation of the NHS to the late 1970s, articles published in The BMJ repeatedly called for the preservation of social spaces in the hospital dedicated to doctors, the protection of surgeons’ lunch hours, and the provision of psychoanalytical and therapeutic support for staff.
None of this is to say, however, that those concerned about the emotional health of medical practitioners today have nothing to learn from the past. Indeed, the current conversation about the conditions of the NHS workforce is often trapped between opposing positions: an ill informed and nostalgic preoccupation with how much better it once was, and a focus on the individual as solely responsible for their “emotional wellbeing.”
This second position involves an unhealthy obsession with resilience and places responsibility for being resilient with the individual doctor rather than seeking institutional change. It offers piecemeal solutions to stress, burnout, and overwork, such as lunchtime yoga classes and mindfulness apps, but fails to acknowledge the structural and resourcing shortfalls that necessitate long working hours and inadequate formalised support networks.
These initiatives implore employees to sleep better, do more exercise, and take up soothing hobbies. In other words, it demands NHS workers to have a good “work-life balance,” without offering them the luxuries of time and the control over their rotas that this transformed lifestyle requires. Thus, it only adds to the weight of responsibility borne by frontline workers.
Instead, we need a third way. We need to work out what we did right, do away with programmes and policies that only place demands on individual doctors, and think about how we might adapt systems that have been successful in the past to a 21st century world and workforce.
Historical research has a place in policy debates about doctors’ mental and emotional health. It serves to inoculate discourse and decision making against nostalgia and helps us to ground programmes and innovations in their historical and structural contexts. On its 70th birthday, the NHS deserves policies that protect the emotional health of its workforce and safeguard its future without harking back to a fictitious golden age of healthcare past.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following: my research is funded by the Wellcome Trust as part of the Surgery and Emotion Investigator Award.