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Clare Gerada: Doctors and their defences

BMJ 2019; 364 doi: (Published 04 March 2019) Cite this as: BMJ 2019;364:l871

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Re: Clare Gerada: Doctors and their defences

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. 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

13 March 2019
Vernon H Needham
Retired GP & Case Manager, Wessex Professional Support Unit
Professional Support Unit, HEE Wessex
Andover, Hampshire