Intended for healthcare professionals

Feature Essay

Doctors can’t care for patients if the system doesn’t care for them—an essay by Caroline Elton

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l968 (Published 06 March 2019) Cite this as: BMJ 2019;364:l968
  1. Caroline Elton, freelance psychologist
  1. London, UK
  1. drcarolineelton{at}gmail.com

Improving doctors’ wellbeing requires a radical rethink, writes Caroline Elton, including a multifaceted approach, investment, and support from leaders. It should be taken as seriously at system level as, say, infection control

A GP, six years after completing her postgraduate training, comes to see me, an occupational psychologist, to discuss whether she should continue working as a doctor. She recounts an horrendous first day as a trainee doctor: desperately unwell patients and the rest of the team off sick, on annual leave, or away on courses.

I ask her if she thinks this day had any impact on her current feelings about her profession. She says that she can’t see a link, but the next day she emails: “I was thinking about your question. On reflection, it was just the beginning of a huge number of experiences that brought me to my current belief on working within NHS medicine. It just doesn’t care. It chews people up, spits them out, and then gets another well meaning chump to replace them. Sorry if that sounds harsh, and I do have some sadness in writing it, but I also think it is true.”

This sort of response is far from atypical. A 2017 survey by researchers at Manchester University found that of more than 900 GPs in England a third reported a “considerable or high likelihood” that they would quit direct patient care within five years.1 This is the highest level since the first national GP Worklife Survey in 2005.

Newspapers brim with reports of cancelled elective surgeries, failures to meet targets for emergency or cancer care, and doctors of all specialties voting with their feet.

That the NHS needs additional funds has political consensus, but parties disagree about how much and from where it should come. Without long term investment to meet the costs of caring for an ageing population, it’s hard to have faith in the future of the NHS.

Money isn’t all that is needed, however. Concerns about the wellbeing of doctors have been raised regularly for at least 30 years.2 During this time, though, the NHS has had periods of better and worse funding.

The poor wellbeing of staff isn’t a problem exclusive to the UK. “Physician burnout” is a global phenomenon; worldwide, we need to think more carefully about the human cost to doctors of providing patient care.

Person centred care

The current mantra in the NHS is that care should be “person centred.” This term was coined in 1969 by the UK psychoanalyst Enid Balint to mean an approach that understood the patient as “a unique human being.” She contrasted it to illness oriented care, which aimed “to find a localisable fault, diagnose it as an illness, and then treat it.”3

Since then, for the past half century, the debate about what patient centred care should look like has continued. Over time, terminology has symbolically shifted from “patient centred” to “person centred,” because, for example, “we use the word ‘person’ in order to emphasise a holistic approach to care, that takes into account the whole person—not a narrow focus on their condition or symptoms.”4

Balint understood something fundamental about people and caring relationships. Shortly before her death in 1994, she and colleagues wrote:5 “At the centre of medicine there is always a human relationship between a patient and a doctor. This is the unchanging core of medical work, despite whatever technical advances are made.”

A quarter of a century after Balint wrote these words, I worry that the core of medical work has shifted; I am no longer confident that the human relationship remains central to the practice of medicine. A poignant example of this shift comes from the description by the late GP and academic Kieran Sweeney about the treatment he received following a diagnosis of mesothelioma: “In the care I have received, the transactions have been timely and technically impeccable. But the relational aspects of care lacked strong leadership and at key moments were characterised by a hesitation to be brave.”6

Sweeney also described how alone he felt with his diagnosis and how he looked to the professionals caring for him to “be with him” in his suffering. With the pressures of delivering ever more technically complex clinical services to ever more patients, it is easy to see how helping patients not to feel alone in their illness can get overlooked.

This is certainly what some of the doctors who I see lament when they describe finding themselves too busy or too exhausted to treat patients in the way they had envisaged they would when they entered the profession.

From person centred to relationship centred care

Person centred care isn’t the end of the story. In 1993—the same year that Balint wrote about the centrality of the human relationship between people and their doctor—a high profile taskforce was assembled in the US.

Its aim was to investigate how to train healthcare professionals to care more effectively for an ageing and culturally and economically diverse population, in which chronic diseases were ever more significant.

In its subsequent report, the Pew-Fetzer Task Force proposed a different model—relationship centred care—which aimed to capture “the importance of the interaction among people as the foundation of any therapeutic or healing activity.”7

In this new model, it wasn’t only the doctor-patient relationship that was seen to be important, but also doctors’ relationships with their patients’ communities and with other healthcare practitioners.

The original description of relationship centred care acknowledges that practitioners need to look after their own health if they are to be able to care for others; this seems like a step in the right direction. It says almost nothing, however, about the responsibility of the institutions in which doctors train and work to take care of their students or staff.

What models of patient centred, and even to some extent relationship centred, care seem to have overlooked is that good patient care is predicated on good care of the carer. This idea is not new, and nobody has expressed it better than the intern Chuck, in the US psychiatrist Samuel Shem’s classic novel The House of God: “How can we care for patients if nobody cares for us?”8

From mother care to other care

We might learn something about the nature of caring relationships in general by considering the original locus of care in all of our lives—maternal care. I’m not suggesting that medical care should be modelled on maternal care, or that doctors could or should feel for their patients as they do their children. That would be absurd. However, unpicking the psychology of maternal care can illuminate aspects of caring relationships that tend to get overlooked in medical culture.

Feelings of resentment

Firstly, the feelings that mothers have for their infants aren’t always akin to the warm and sweet “motherhood and apple pie” ideal. Nobody has captured this better than the paediatrician and psychoanalyst Donald Winnicott, who playfully and provocatively listed many reasons why mothers may, at times, have hateful feelings about their infants:9

  • “He [the baby] is ruthless, treats her as scum, an unpaid servant, a slave.”

  • “His excited love is cupboard love, so that having got what he wants, he throws her away like orange peel.”

  • “He is suspicious, refuses her good food, and makes her doubt herself, but eats well with his aunt.”

Winnicott explicitly linked the inevitability of mothers sometimes having hateful feelings for their infants to psychoanalysts having similar feelings for their patients. Yet this fundamental insight hasn’t permeated the practice of medicine.

Doctors who I see often feel ashamed to recount feelings of resentment, terror, hatred, disdain, or disgust. The literature on either patient centred or relationship centred care rarely confronts the full gamut of emotions that caring for somebody else in profound distress can entail.

How we care for others

Secondly, our early psychological attachments to our mothers (or primary care givers) have long term effects on our social relationships in adulthood. In particular, how we were cared for when we were dependent infants influences how we care for others when they are vulnerable, and also how we seek care when we are feeling distressed.

Intergenerational work has found that a new mother’s security of attachment to her own mother affects the chance of her becoming depressed after the birth of a child.10 While there isn’t comparable research on how doctors’ security of attachment to their mothers impacts on their capacity to care for their patients, a study of ambulance workers found that, after a critical incident, those who were more securely attached were less distressed, recovered more quickly, and were more likely to seek emotional support from those around them.11

Emotional weight

Thirdly, the emotional weight of bearing responsibility for a new infant’s life—the exhaustion, fear of something going wrong, and isolation (if you are poorly supported)—all take a psychological toll on a new mother. Postnatal distress is common: the World Health Organization suggests that 13% of women experience a mental disorder, principally depression.12 Although prior psychological difficulties increase the risk of maternal postnatal depression, her network of support, from partner, family, and friends, is also critical.

Again and again, I hear junior doctors describe a medical correlate of this maternal dynamic—exhaustion, the burden of responsibility, the ever growing fear of making a mistake, the isolation, and the lack of support from other colleagues. A conversation I had recently with a distressed trainee on a surgical placement is all too typical: “I’m run ragged, and I can’t look after the patients in the way that I want. On more than one occasion I’ve been shouted at by my seniors. I’m all by myself in this giant hospital covering the postsurgical ward while my seniors are in theatre. I feel so alone.”

From individual to organisation

Too often measures to improve wellbeing concentrate on the individual doctor and leave it at that. So the literature is full of studies on the impact of stress management or mindfulness programmes on the wellbeing of clinicians, and this is the case even though research has consistently highlighted the organisational origins of physician burnout.13

Although we mustn’t look at everything decades ago through rose tinted glasses, we must, however, recognise subtle erosion of many informal structures that used to help junior doctors get support from peers and more senior colleagues. The list is far from exhaustive, but these include:

  • ● Larger medical school intakes, so that even when a doctor has a colleague from the same medical school they may never have met before

  • ● Foundation doctors moving all over the country rather than training in a hospital that they knew from their undergraduate studies

  • ● Rotations lasting four rather than six months in the first two years of practice, meaning less time to build confidence in each rotation

  • ● Doctors living off-site in their first year of practice, and the removal of the doctors’ mess

  • ● Replacing the old style “firm” with a shift system, making it harder for junior doctors to feel part of a coherent team.

In addition, we need to factor in the impact of high profile cases, such as that of Hadize Bawa-Garba, that have created a climate of fear among junior doctors.

From the infective to the affective

So what’s the answer? Here’s a revolutionary idea: might contemporary approaches to infection control provide clues as to how best to support medical staff? Infection control efforts permeate every level of healthcare—individual doctors, the team, the organisation, the region, and the country as a whole.

But there isn’t a similar focus on protecting doctors from the transmission of psychological distress from patients, their relatives, or their peers to the doctor. In fact, the inevitable psychological burden that caring for patients places on healthcare providers is given woefully little attention.

There’s no single simple solution to improving the emotional wellbeing of staff. We know the same is true for infection control, which isn’t restricted to putting up posters around the hospital saying “remember to wash your hands” and leaving it at that.

In the first for a medical centre in the US, Stanford Medicine recently appointed oncologist Tait Shanafelt as its first “chief wellness officer.” In his previous role at the Mayo Clinic, Shanafelt showed that by working across the whole organisation physician burnout could be substantially reduced.

He identified seven key drivers of burnout: workload; efficiency; flexibility or control of work; culture and values; work-life integration; community at work; and meaning in work. Then he introduced strategies that reduced the impact of each of these drivers on the individual, the team, and the organisation as a whole. It can be done. But it needs leadership from the top and an investment of time and resources.13

A report last year from a group of institutions including the US Harvard TH Chan School of Public Health and the Harvard Global Health Institute concluded that “physician burnout is a public health crisis.”14

As well as improvements in mental health services for physicians—which is already happening in the UK with services such as the Practitioner Health Programme and Dochealth—the report also called for the appointment of chief wellness officers on the main board of each healthcare institution, responsible for staff wellbeing across the organisation. Such roles may sound alien to British ears, but comparable appointments to the boards of NHS trusts would be an excellent first step.

Biography

Caroline Elton is an occupational psychologist who lives and works in London. She was formerly a consultant education adviser with Kent, Surrey, and Sussex Deanery and head of the careers unit at London Deanery. The paperback edition of her book Also Human: The Inner Lives of Doctors was published in February 2019. www.carolineelton.com

Footnotes

  • Client consent obtained.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: I am an occupational psychologist in private practice and the author of Also Human: The Inner Lives of Doctors

References