“Our son T. is under enormous stress at the
moment. When he visits us he falls asleep or breaks down in tears. He is 26 and
a Senior House Officer in a busy medical ward full of traumas and deaths. We
are extremely concerned. However, he won’t go and speak to anyone about it
saying he cannot be a “sick doctor”. We don’t know what we can say or do to
help him and are deeply worried. Isn’t there anyone looking out for junior
doctors? He’s not just our son he is also a trained professional whose
potential is being wasted.”
Mr & Mrs O.M
Whenever an individual’s potential is eroded
by internal or external factors (or a combination of the two) and is not
redressed by policy change, support or treatment there is always a double loss
- the loss to the individual and to those who care for him. Where the
individual is an adult who performs a needed role in society, like T, that
double loss is underlined by an added sense of waste - both economic and
emotional. It is extremely expensive to train a doctor and it is also
emotionally expensive to be a junior doctor and deal daily with pain and
suffering.
What are we demanding of such young
practitioners? In Dorothy Judd & Aleda Erskine’s excellent book “The
Imaginative Body” Jon Jureidini and Deirdre Moylan ask “How do you speak of
death when the patient wants to live? How do you talk to a 22 year old woman,
pregnant for the first time, who needs immediate treatment which will kill her
child and leave her sterile but without which she will die?”
In some medical schools there is increasing
attention paid to the emotional aspects of medicine in the hope that such work
will alleviate later stress and mental health problems. At St Georges Hospital,
Tooting, for example, there is a “Breaking the Bad News Seminar” which helps
medical students consider the feelings of patients and their families in
working out the most therapeutic way to discuss medical complications, serious
operations or terminal illness.
At the Royal Free Hospital in Hampstead Dr
Margaret Lloyd, Reader in General Practice, has established a pioneering
project to teach psychological skills to medical students. Brett Kahr, Lecturer
in Psychotherapy at Regents College teaches on the course. “The medical
students do appreciate an opportunity to discuss the complex subjects of loss,
pain and death, subjects which evoke terrific anxiety and need to be processed.
It is hoped that this will enhance their ability to deal with challenging
situations and lower their own stress on qualification”.
However, such new initiatives take time. An
important survey conducted by Professor Liam Hudson and Dr Rob Hale on stress
in junior doctors emphasises only too strongly that T is not alone. Indeed,
senior house officers are in the most vulnerable position of all. “Newly
qualified House Officers have a Senior House Officer to look after them and
Registrars have a rotation that provides a structure. In some areas it is
specifically the Senior House Officer who lacks support” comments Dr Hale. He
advises T. “Don’t wait until it is too late and don’t think you are the only
one who feels desperate.”
However,
although many doctors make their individual way to therapy only 300 doctors a
year make their way to the National Counselling Service for Sick Doctors. In
fact, in the Hudson & Hale survey only one junior doctor in 20 knew that
the service existed. There are also local services for doctors in trouble in
Newcastle, Birmingham, Leicester and London’s Tavistock Clinic.
Why is it so hard for T and other young
doctors to go for help at the moment? Some worry that their career prospects
will be dramatically diminished if they show stress to a senior colleague or
tutor. Others refuse to accept that carers need to be cared for too. In taking
on what could be called a caring parental role the overworked Senior House
Officer can sometimes be experiencing both the patient and the junior House
Officer as the desperate needy baby who has to be put first at all costs. The
long hours and the lack of sleep adds to this. When faced with extremes of
human suffering it can also feel selfish to admit to needs oneself. Perhaps for
T, only coming home to his real parents means he is then able to be the
uncomfortable tired and distressed baby who cries and needs sleep and is looked
after.
How could T be helped further? Can his region
offer him support?
Professor Sheila Hollins, a University
appointed teacher for South Thames Region (West) comments that her region has
pioneered a weekly one-hour educational supervision for the psychiatric
rotation. This is an unstructured time that can be used for teaching,
counselling or timetable issues. In her role she meets with SHOs on rotation in
her region without their consultants present. This provides them with a chance
to air any difficulties- with staff or the syllabus. She has found that the
provision of this supervision has alleviated stress. She adds that where students’
needs are not being adequately met the students themselves carry some
responsibility for setting the agenda.
For women, the umbrella group “Women in
medicine” can also give support. It caters for Senior House Officers on GP
training schemes. Dr Rachel Hopkins comments “The GP training schemes provide
relative protection as we have a half day group where we can discuss what is
troubling us and we have course organisers who take a personal interest in our
career development. However we still have the stress of being SHOs in hospital
posts with the lack of proper supervision, restricted access to study leave and
the appallingly difficult working conditions - understaffing and too many
hours.”
Dr Sebastian Kraemer Consultant Child &
Adolescent Psychiatrist agrees. “There is much more to do than previously.
There is much lower morale in the NHS and because they’re not allowed to be on
duty so long - although it is still too long - they’re also not off enough
either - so they cannot get a long rest. I personally think demoralisation is
the most serious for all doctors. The internal market will not work”.
It was in the 1950s that Michael and Enid
Balint led groups for GPs. These groups placed more weight on the emotional
interaction between doctor and patient that underlay the medical consultation.
Are the changes in structure of the health service hindering further progress?
Dr Hale pointed out that such simple facts as the closing of some hospital
canteens at night to be replaced by vending machines takes away the feeling of
support junior doctors used to get when on late shifts. In some large hospitals
many junior doctors do not know who their tutor is. Hopefully the effect of Dr
Hale’s report and the new training initiatives will make an impact.
“The Imaginative Body” ed. Aleda Erskine
& Dorothy Judd, Whurr 1994
Women in Medicine, 21 Wallingford Ave, London
W10 6QA
Dr Rob Hale & Professor Liam Hudson, The Tavistock Clinic, 120 Belsize Lane, London NW3 5BA.