“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.