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- Carter, III, Albert Howard
Summary:This important and much needed book describes the psychological difficulties of doctors in training and in practice and the woeful lack of support to them from teachers, colleagues, and institutions. When there are over 50 percent of doctors suffering burnout (or depression, even suicide), shouldn't we see and ameliorate this "significant public health crisis" (p. 263)?
Carolyn Elton is a vocational psychologist who has spent the last 20 years working with doctors in England and the U.S. She has worked with over 600 doctors in a wide variety of specialties.
Introduction: “Medicine in the Mirror”
Elton starts with a real-life email from a desperate medical student. She cites examples of med. students who commit suicide, studies of depressed doctors, and surveys that show impacts on medical care for all of us when it is given by doctors suffering from poor morale.
Ch. 1, "Wednesday's Child" discusses young doctors suddenly thrown into clinical practice; many are unready for the stress, and many training programs do not support them sufficiently.
Ch. 2, "Finding the Middle." Many senior doctors are inhospitable to young doctors, especially those trained in other countries, for example India. There’s hope for sharing and support in Schwartz Rounds, where staff (clinical and nonclinical) meet and discuss issues.
Ch. 3, "Which Doctor." We learn that many troubled doctors have chosen the wrong specialty for them, often because of a specific illness in their families. They should have more time to chose or, even, to change specialties.
Ch. 4, "Brief Encounter." Psychological concepts of transference and counter-transference are helpful in understanding sexual issues (examining patients' sex organs, homosexuality, sexism, inappropriate humor, attraction to a patient, even past sexual abuse). Many of these are common but so taboo that they are ordinarily—and unfortunately—not discussed in training.
Ch. 5, “Role Reversal.” The book’s title “also human” is front and center here, because doctors become sick, injured, or otherwise compromised so that they must have medical assistance. Regrettably, other doctors often dismiss such problems or even blame the doctor for causing them or not overcoming them. Further, doctors often try to avoid a sick role. Psychological dilemmas and physical disabilities are often stigmatized.
Ch. 6, “Leaky Pipes.” Women doctors are often ill-treated, especially in surgery, where “surgical culture embodies masculinity” (p. 152). Women wishing to have children and family life in general are seen as slackers. Women doctors often “leak out” from hospital work to part-time community-based roles.
Ch. 7, “Risky Business.” Once again, we read that there is bias against Asian, black, disabled, or female doctors. Specific examples and studies from social science make this dramatically clear. This unfortunate dynamic makes careers in medicine for such doctors “psychologically risky” (p. 192).
Ch. 8, “No Exit.” For many reasons it is hard to quit medical school, later training, or work in medicine, even when this is the best choice. Doctors often feel pain, even guilt when patients die, and they have little support.
Ch. 9, “Natural Selection.” Reviewing many problems already discussed, Elton summarizes: “sometimes the dream of training as a doctor turns out to be a nightmare in reality” (p. 229). There’s bias in selection of students, reliance on tests with limited accuracy, insensitivity to the whole person, and inappropriate retention of students who should not become doctors. The Darwinian chapter title is ironic; much of the medical world as structured today is not natural.
Epilogue, “There’s No Such Thing as a Doctor.” This arresting subtitle brings us back to the personhood of doctors, who have psychological needs right along with the rest of us. Regrettably, “doctors’ psychological needs are denied, ignored, not thought about. Unmet” (p. 258). Sexism and racism are common. Lister’s reforms took a long time but are now pervasive and standard; can we similarly expand better care for doctors? “Improving the emotional well-being of the medical workforce requires interventions that tackle three interconnected levels—the individual, the organization, and the culture of medicine as a whole” (p. 265).