Clare Gerada: Doctors and their defences
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l871 (Published 04 March 2019) Cite this as: BMJ 2019;364:l871All rapid responses
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Clare Gerada is correct in her assessment of the need for doctors to develop healthy psychological defence mechanisms, these being one component of resilience. However, this requirement should be seen both in a societal context, and in company with other workers with the same requirement:
a) Society expects, and indeed encourages, today the open disclosure of emotional distress. Some professional work can only continue effectively if this distress is contained: hence a conflict with current mores.
b) Other workers are exposed to (sometimes enormous) stress with unpleasant, tragic and emotional demands: the Ambulance Service, Armed Forces, Fire Service, Police, undertakers, and clergy, to name a few. Most of these work in small, cohesive teams (often as part of larger organisations with a clear purpose and focus), and develop emotional resilience through their shared experience of adversity, and crucially, mutual colleague support, formal or informal.
All personnel have a level of personal resilience which can be increased, both through training, and mutual support: the resilience 'vessel' can be increased in size, but not infinitely, and all individuals will reach their own individual limit. What is particularly dangerous is a lack of recognition or insight when this limit approaches.
The very high academic requirements required to read medicine favour high-achieving perfectionists. Perfectionism is a trait that can continue through medical school, but becomes a burden in the messy world of the qualified doctor: it can be a very uncomfortable (but vital) transition to high quality pragmatist!
Growth of psychological resilience can occur with both overt and subtle experiences. ( A lot of resilience training in other work areas is not billed, or even recognised as such, but is highly effective.) In medical training the 'affective' and 'scientific' learning acquired from morbid anatomy dissection have been recognised, (eg: by Warner and Rizzolo: Anatomical instruction and training for professionalism from the 19th to the 21st centuries. https://doi.org/10.1002/ca.20290). The affective learning of this and other medical school experiences are not widely appreciated or analysed. Cadaver dissection and many other challenging experiences, (in and out of normal working hours), have often been diluted, or have ceased altogether in some undergraduate medical courses, with the result that the step to Foundation Year is an even greater challenge. At a very basic level, I have had to advise FY doctors who have not appreciated the need to remain nourished and hydrated when on night duty! Medical Schools should have a duty to fully prepare students for their future role, not just ensure they achieve an degree.
The closure of many hospital messes, moves to shift working, the reduction in Clinical Firm cohesion and the tendency for juniors now to be commuters, rather than Residents, all have the effect of reducing the opportunities for effective mutual peer support.
Prevention is better than cure: Medical Schools and Trusts, in addition to postgraduate medical educators, need to recognise their responsibility in 'training in' the subtleties of psychological defence mechanisms.
Competing interests: No competing interests
I was in Nairobi in November giving a series of talks to Strathmore University medical staff about mental health and burnout - the College where Theresa May did the famous dance. There is one psychologist for 6500 students - not counting staff - so I think if she wasn't burnt out to a cinder she should have been. Defence mechanisms were discussed and empathy, friendship, peer support, humour and altruism or doing things for a higher purpose eg helping those in need.
The students have much the same type of issues as any third level group. Smart phone addiction and screen times are as widespread there as anywhere and contribute to isolation, loss of friends and mental health issues. I used "The Big Five" animal tag as a reminder of the five pillars of mental health that we all should have and are fundamental somatic defence mechanisms - the animals are Lion, Leopard, Buffalo, Elephant and Rhinoceros. The five pillars are - a good night's sleep, and adequate nutritious diet, exercise appropriate to our stage of life, someone to talk to and be friends with, and an occupation or job of good fit. These are also defence mechanisms any stressed doctor can incorporate into their lifestyle to enhance those defences Clare Gerada mentions in her article. Some jobs are toxic, some are stressful, some are routine and all need to be studied to see how to improve motivation, fulfilment, satisfaction, collegiality, and seeing how to bring the joy back into medicine. Jobs can overwhelm and incapacitate staff especially conscientious staff.
Doctors and nurses and their staff need to assess their job spec and see if they have a job description, a clear outline of what their responsibilities are and are not, and an avenue of consultation to iron out discrepancies in their real world from what it says on their paper job description (if they have one). A toxic work situation - bullying, very unsuitable material conditions, excessive demand and protracted hours, absence of support or acknowledgement, etc - is a health and safety issue and staff need to exit or be protected. Many medical jobs are toxic and the morbidity and mortality related to them speaks volumes. The ultimate defence mechanism in a toxic environment is to exit it and find alternative work.
Competing interests: No competing interests
Re: Clare Gerada: Doctors and their defences
I was delighted to see Claire Gerada's article "Doctors and their Defences" in the BMJ last week. I came across it whilst preparing to talk to University of Bristol medical students as part of the student-led, month long "Let's Talk" campaign, that focusses on medical students' own mental health and wellbeing. I spoke to the students about some of the emotional challenges presented by Medicine, and covered the merits and pitfalls of various defence mechanisms that doctors use. As I finalised my slides for the talk, I wondered how the ideas I wanted to share would be received; would they seem too far-fetched or left field? It was therefore reassuring to see this very topic explored in a high profile medical journal. I absolutely agree with Dr Gerada's assertion that one of the ways we need to support our doctors is by creating time and space for them to reflect on the psychological and emotional impact of the challenges that they face. As it happened, I needn't have worried, the students were open, thoughtful and engaged and I was impressed to see so many turn up, on a rainy Friday evening, to think about their own mental health and wellbeing.
Competing interests: No competing interests