EP. 54: SUPPORTING THE MENTAL WELLNESS OF PHYSICIANS

Mar 22

WITH CAROLINE ELTON, PHD

An occupational psychologist and author who counsels physicians discusses how modern medical training contributes to burnout and how we can better support clinicians’ mental health.

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Episode Summary

For all the deeply rewarding moments medicine offers, it is also a profession often intensely challenging on both systemic and personal levels. Our guest in this episode is Caroline Elton, PhD, an occupational psychologist who has devoted her career to counseling doctors and medical trainees in the National Health Service and various medical schools in the UK. She is the author of Also Human: The Inner Lives of Doctors, which discusses the physical, mental, and emotional toll of medical training and practice. Among other issues, she writes about how doctors deal with guilt and shame, gender and racial discrimination in health care training, the erosion of the clinician-patient relationship in modern medicine, and how clinicians can build emotional resilience. Over the course of our conversation, Dr. Elton shares what led her to this work, exposes the many shortcomings in how doctors are trained today, and explores how we can create a more humane path forward.

Caroline Elton is an occupational psychologist who has spent the last twenty years training and supporting doctors. She received her PhD from University College London's School of Medicine and set up and led the Careers Unit supporting doctors in over seventy hospitals across London.
In this episode, you will hear about:
• What led Dr. Elton to her unique work in counseling physicians - 2:04
• Reflections on both the compassion and the callousness Dr. Elton witnessed as she observed physicians (her patients) in their working environments - 10:01
• A review of medical training in the UK versus the US - 15:16
• A discussion of Also Human: The Inner Lives of Doctors and the concept of moral injury - 19:51
• The kinds of patients Dr. Elton sees in her present work - 25:00
• How institutional cultures can come to valorize toxic, brutal expectations placed on physicians - 27:03
• How Dr. Elton’s managed her first patient, a doctor who was planning on quitting medicine just weeks after beginning her postgraduate training - 32:49
• A discussion of how sexism and other forms of bigotry factors into burnout - 38:20
• Why the screening process for selecting future doctors should be improved - 43:37
• How a trainee can prepare themselves for the psychological demands of a medical career - 48:00
• Advice to administrators and executives of how best to serve the psychological demands of their medical workforce - 50:34
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor/patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives; those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] For all the deeply rewarding moments medicine offers, it is also a career that is often intensely challenging on both systemic and personal levels. Our guest in this episode is Caroline Elton, an occupational psychologist who has devoted her career to counseling doctors and medical trainees in the National Health Service and various medical schools in the UK. She is the author of Also Human: The Inner Lives of Doctors, which discusses the physical, mental and emotional toll of medical training and practice. Among other issues, she writes about how doctors deal with guilt and shame, gender and racial discrimination in health care training, and how doctors can build emotional resilience. Over the course of our conversation, Elton shares what led her to this work, exposes the many shortcomings in how doctors are trained today, and explores how we can create a more humane path forward. Dr. Elton, thank you so much for joining us and welcome to the show.
Caroline Elton: [00:02:02] Thank you. It's a pleasure.
Henry Bair: [00:02:04] You are unlike many of our guests, in that even though you are not a clinician, you have an intimate perspective on many of the issues we often discuss on this program, such as moral injury and burnout. Can you tell us what first led you to a career in psychology and how you came to focus specifically on helping doctors who are struggling with their work?
Caroline Elton: [00:02:25] In terms of how I first got interested in psychology, I think this was something that interested me really from a very young age. I was interested in what was going on in my mind, what was going on in the minds of those around me, what made people tick. And I think that at least in part, that was due to the experience of growing up with a brother who was nine years older than me, who was profoundly autistic. And interestingly, in the literature, there's evidence that those who grow up in a household with an autistic sibling are more likely to go into the helping professions: teaching, psychology, medicine. So in terms of my draw towards psychology, I think that the experience of growing up with my brother was a very big thing. As to how I came to support doctors, You know, I certainly didn't finish either my first degree or even my second degree, thinking I know what I'm going to do. I'm going to go off and help the medical workforce. So for me, I could identify kind of three big random events that led to me ending up in what I'm doing. The first is when I was doing my PhD in psychology in the Department of Academic Psychiatry in one of the big London teaching hospitals, University College, London, I hit a bit of an impasse. I was actually researching something very different from what I do now.
Caroline Elton: [00:03:52] It was a health psychology PhD and I realized I'd made a miscalculation as to how long it was going to take me to get a sample and and that I needed to approach other hospitals in order to get an adequate sample and all of that. I'd had to go through the Ethics Committee process again. So essentially I was in a bit of a hiatus and an opportunity came to work as an education advisor. Briefly, I had been a secondary school teacher before becoming a psychologist, and I took this opportunity to work as an education adviser whilst I sorted out my PhD impasse. It was supposed to be for six months but actually did it for a couple of years and then went back to my PhD, finished my PhD. So that was random event number one, which really only became relevant with random event number two. I had finished my PhD and I was looking for postdoc positions. This was 25 years ago and a job caught my attention that I hadn't thought of going into this line of work, which was in medical education. And the focus of the job was to improve the quality of teaching that hospital doctors gave to their medical students, to their residents or trainees, as we call them. And it was an incredible job in that it turned the usual model on its head because typically, at least in the UK, hospital, attendings, hospital consultants, as we call them, what we do is that you'll scoop them up and you'll send them off to a lecture or workshop or whatever on on kind of pedagogical theory, pedagogical practice.
Caroline Elton: [00:05:37] And this innovative project turned that it flipped it over and said, Why are we doing this? Why are we taking the attendings from their work? Let's send an educationist or a psychologist to the attendings. That way the attendings didn't need to cancel their clinical work to come to a lecture on education. But also and more importantly, the conversations that we had were really detailed and specific to the actual reality of teaching in a clinical setting for that particular clinician. Because if you're a forensic psychiatrist or you're a pathologist or you're a surgeon, you're training challenges are likely to be very different. So I saw that job and it looked interesting and you needed to be a teacher. Tick I'd done that for a few years. You needed to be an education adviser. You needed to have had experience of training other teachers, which I only randomly had because of the interim job whilst doing my PhD. And you needed a PhD, which I'd just finished. So I applied and I got it. And that was my initial introduction to medical education and it was a phenomenal introduction, a phenomenal one, because for a non clinician, I just, you know, I got scrubbed up and went into theater and watched how that surgeon was teaching their trainee.
Caroline Elton: [00:07:03] I sat in on a supervision session with a psychiatrist, with their junior doctor talking about the suicide of a recent patient and the senior psychiatrist kind of coaching the junior through that. And I'm watching and then later coaching the senior psychiatrist. I went everywhere and anywhere, and it was just incredibly interesting at times, very challenging. And the most extraordinary introduction to the practice of medicine that a non clinician could ever really get. Because I had changed from a teacher to a psychologist, I got interested in the whole process of thinking about one's career from a psychological point of view. And I did a when I finished my PhD, I did a vocational psychology, occupational psychology, we call it both terms are used training. And in my early years working in medical education, I got involved in occupational psychology and career coaching and I was coaching everybody other than doctors, and I was doing this educational observation work and I had two parallel unjoined-up streams. And then the third random event, the structure of postgraduate medical training changed in the UK and doctors had to choose their specialty much earlier on after leaving medical school. It's still later than in the US, but in the UK.
Caroline Elton: [00:08:31] Prior to these changes, doctors could drift between different specialties for as long as they wanted until they chose what they wanted to do. And in the early start, around 2000, 2002, this all changed. And they said, No, no, they've got to choose. We've got to streamline this. And suddenly the NHS was saying, Oh, well, doctors are going to need career counseling. And when I saw these positions, I suddenly thought, I'm probably the only person in the country who has experience in career counseling and medical education. So that was how I got into the work. Through all these different layers. I finally ended up setting up a support service in one region and did that for a number of years. And then I got the opportunity to set up a pan-london service across the sort of 90 hospitals in the in the UK. And the thought had been think that people coming to this service would be very unproblematic, they would be kind of a couple of years after leaving medical school and trying to decide if they wanted to go into family medicine or pediatrics. That was No One. Like we never saw that. We never ever. And their reasons for that as we know about stigma, the difficulty, the reluctance to seek help, actually the people who came banging on my door were in a really, really difficult position very often.
Tyler Johnson: [00:10:01] You know, I have thought a lot about the fact that one of the things that is so difficult and also distinctive about being in medicine is that the entire world of medical training is this. Private world that is set apart from almost everywhere and everyone else, right? Like when I try to explain to my family members what the difference is between an intern and a resident and a fellow and an attending and how rounds work and what like all of those things. It's just totally opaque to them, right? They have no idea. And I think a little bit of that has started to fall away over the last few years with television shows like Grey's Anatomy and Scrubs. So so there is starting to be a little bit of transparency, but it's still a pretty walled garden. So I guess I'm just wondering, and certainly when you were shadowing around these different people and trying to give them educative training as part of them, you know, teaching doctors and training, I mean, at that point there would have been almost no transparency. So I'm just curious, as you're going around and watching this process that you've never directly taken part in and you're this kind of, you know, stranger in a foreign land, what most struck you like what what most jumped out at you about this culture that you were seeing up close and personal, even though you didn't really have your own direct part in it?
Caroline Elton: [00:11:26] I mean, it's a really difficult question, but so many things struck me. You know, sometimes I was bowled over by the the compassion, the care, the quality of the care that an individual could show to their patients or family members or to those who they were teaching. And sometimes. I was struck by the complete opposite, the sort of inhumanity that I witnessed. I mean, I can give you an example. I was once doing an observation, did a lot of anesthesiologists anesthetists, as we call them, in the UK for various reasons. We, the head of anesthetic training in the region, decided because remember in the in the UK we have one employer, the National Health Service. So things are decided on a regional basis. The head of anesthetic training decided that all the consultants, all the attendings who taught residents would go through this program. So we saw a huge numbers of anesthetists. And once I was in theater, really sweet anesthetists and they were performing, I think it was a hysterectomy on an older woman who was morbidly obese. And the surgeon there was a screen up from the waist down. And I was with the anesthetist and the and the resident at the head of the patient. And the anesthetist started a whole long spiel on the challenges of anesthetizing, morbidly obese patients and all the different problems that could occur higher morbidity, higher mortality, the whole the whole kind of doing this whole long spiel.
Caroline Elton: [00:13:19] And then blow me down. I had assumed the patient was under a general blow. Me. Down he goes and taps the patient at a certain point saying, Mrs. Smith, Mrs. Smith, how are you doing? And it was actually an epidural. And she was awake, although sedated, so. I end up having a conversation with the consultant afterwards saying. Is this the time for that conversation? Well, I've reviewed all the all the risks with Mrs. Smith. She knows all about them. You know, she's signing, saying, yes, I'm sure you've reviewed them in a preoperative meeting. But was that the time and place for this particular bit of teaching for that particular resident when the patient is awake having having a hysterectomy? So I would see those sorts of things and try to unpick them with the surgeon, with the anesthetist. And equally I would see other things sometimes when the the doctor was completely unaware what a superb piece of teaching or a superb piece of patient care that it was that they had just delivered.
Henry Bair: [00:14:37] You know, hearing that story, I can't help but think that there's this concerned notion amongst medical training, even in the US, that over the course of this long and arduous process. Are we suppressing or reducing the ability of clinicians, trainees to empathize, to see their patients as humans? You know, so.
Caroline Elton: [00:14:59] And I think we we know certainly that training that does happen. We know that that, you know, there's a there's and there's a large literature on that. Is it inevitable? No, I don't believe it's inevitable.
Henry Bair: [00:15:16] Well, as an aside to to the rest of the conversation, because we do want to talk more about your your work helping medical trainees, I think it's helpful here perhaps for you to share with us a little bit briefly what medical training is like in the UK. I mean, we do have a fair bit of listeners from the UK, but also a lot of listeners who are not. So you know, in the US, high school graduates who are interested in medicine do have to do four years of their undergraduate training and then at least four years of the postgraduate training. And they may elect to do a PhD, which may add another 4 to 6 years to that process. And then after that they apply into residency. So right after completing medical school, you decide which branch of medicine you want to work in for essentially the rest of your life, right? And then you do residency, which may last between three years to seven years or even longer in some cases. And then after that, if you want to subspecialize, you can elect to do a fellowship, which may also be between one and I'm not sure actually how long the longest fellowships are. So that is the process by which doctors choose. So essentially clinicians choose their specialty before they've actually practiced independently as as a clinician. Right. So what is it like in the UK?
Caroline Elton: [00:16:36] So first off, about 90% of of people go straight from high school into a medical undergraduate medical degree. So that's a significant difference. About 10% have the American model where they first of all do a bachelor's degree in whatever and then go into med school. So that's one big difference. Med school is 5 or 6 years for the 90% who have gone straight from high school. And it's four years like the the US for the 10% who have already done a first degree. Another difference is that although since about 2002 or 3, people have to choose their specialty earlier, they can still they do not choose it on leaving med school. They have to all do a two year intern program which is called the Foundation Program. F1 Foundation. F1, F2 Foundation. Year two. Increasingly, they opt for F3 another year before, so there's great reluctance actually to choosing their specialty. It's possible in the UK in a way that I think is much harder in the US for people to work part time. So any residents who if they've got young families or whatever, they can work part time. There are advantages of that. There are disadvantages of that. The disadvantages is that training can go on forever. Literally forever, you know? See, trainees who've had two, three, four children and they you have a year of statutory maternity leave.
Caroline Elton: [00:18:13] I know this will be very, very different in the US. You have a year, six months of which you're paid full time, six months, you're paid less, but your job is kept open and then you can go back and work. You can't work less than 50%, but you can work anywhere between 50% and 100%. That's the good news. The bad news is if you think about the length of training and you're doing it with maternity leave breaks and 50% times it can go on forever, and that is a real, real issue. And also, specialty training takes longer in the UK than the US. And I puzzled about this when I was writing about the book and my daughter in law. My son lives in America. My daughter in law, who's American's best friend, is a was a medical student and is now a resident. And she was my source of all things about American training. And I said to her once, Anna, how come specialty training takes so much longer? And she said, Well, how many hours do you work in the UK as a as a junior doctor? And we work fewer hours. So, you know, it comes out in the wash in different ways.
Henry Bair: [00:19:16] How much fewer?
Caroline Elton: [00:19:17] On average, 48 hours a week?
Henry Bair: [00:19:21] Wow.
Tyler Johnson: [00:19:23] That's, uh. That. That that's. That's not, like. Not like what it is here.
Caroline Elton: [00:19:29] I mean, obviously the NHS is under terrible, terrible pressure, so that's the theory. That is the theory. Of course it's often more. But, but, but it is still routinely and substantially less than the US. Great, you might think. But then training just takes all that longer. So swings and roundabouts, as we say in the UK.
Tyler Johnson: [00:19:51] So let me ask a question. As our listeners may know you are the author of a book called Also Human: The Inner Lives of Doctors. One of the things that strikes me first about your book is that the title is phrased almost as if it's a rejoinder, right? It's like you're responding to those who would suggest that doctors aren't, or a culture that thinks that we're not or we're not supposed to also be human. So can you just talk a little bit about the impetus for the title?
Caroline Elton: [00:20:24] Well, the book was sold under a very different title, which was The Doctor With No Skin and Other Stories. And I do I do to talk about, I think, the doctor with no skin briefly, that was a remark that a junior doctor said that had been made to her by a treating psychiatrist, saying it is as if you have no skin. The title, I think it was very much a response to something, people saying, well, the doctor is only human. And I didn't want to call it only human, because what I wanted to emphasize was the shared human experience between the doctor and the patient. But it's interesting that you pick up about the title, Tyler, because I have done so many talks where I have been introduced as the author of Almost Human. So many, and this is by clinicians.
Tyler Johnson: [00:21:22] I don't want to invite Freud into the room, but we could invite Freud in and talk about it?
Caroline Elton: [00:21:27] Well, it's happened really on a very many times and I think that's because of the way in which people that people can find the practice. Those medics can find the practice of medicine dehumanizing, dehumanizing of the patient. And then if we're talking about moral injury, dehumanizing of themselves.
Tyler Johnson: [00:21:52] Now, I want to pause you for one second. Just because moral injury, I feel like, is one of those terms that, first of all, everybody thinks everybody knows it, but some people don't know it at all and some people who think they know it actually know they quote unquote, know it, but they actually understand it to mean something that it actually doesn't mean. So can we pause before you keep going? What does moral injury mean?
Caroline Elton: [00:22:13] Right. I probably should have had a kind of looked, looked up, a kind of precise definition which did for burnout. My understanding of moral injury is when in the course of your work you are being asked to carry out tasks or the manner in which you are being asked to carry out tasks contradicts some deeply held principles you have as to how you should be working as a doctor. And that's what causes moral injury. And I think increasingly it's being understood as being sort of intimately linked with contributing to burnout.
Tyler Johnson: [00:22:52] Yeah. So if I if I can just interject for one second. So I think a good example just to illustrate this for young trainees, especially if you know that you have 30 hours of work that you're being asked to do in 16 hours, then pretty much by definition you're being subjected to moral injury because your options are either you just don't do some of the work, but with the expectation that it's been done or you do you quote unquote do all of the work, but you do a sort of half baked job of all of it, which, you know, is not as good as you wish that it were, but you're not really left with any other option. Right. And so sort of no matter how you maneuver, no matter what you do, you're in a position where you just can't your hands are tied. You can't you just can't do all of it and do it the right way. And so that might seem like, well, okay, yeah, that, you know, everybody has that problem. I'm just going to get through it. But the problem is that there's always that little part of you in the back of you that's thinking, Well, no, but you should be doing a better job. Well, should you really be attesting to having done this very complete med school level physical exam when the truth is that you put your stethoscope on them for 14 seconds and that was the extent of it. And yet you're asked to document so much more, right? Like, it just it's this sort of death by a thousand paper cuts. Right? Because you just it's this one thing that you kind of compromise here and you compromise there and you compromise here and covers there. And then at the end of the day, you end up feeling as if you're coming up fundamentally, morally short because of all of these compromises that you've made, which compound over time.
Caroline Elton: [00:24:24] And within a culture that sort of denies or tries to minimize that those pressures exist. That isn't having those conversations about the fact that nobody can to deliver the standard of care that you actually train to do the the depth of the med school exams that you would train to do initially. In the title. It wasn't so much that I thought that doctors were inhuman. It was more that I wanted to stress the shared humanity of the doctor and the patient.
Henry Bair: [00:24:59] So getting getting back to the work that you do. Earlier you described how you went into this career thinking that you'd mostly be helping young trainees debate. Should I go into general medicine or should I go into pediatrics? But instead you get a very different kind of individual who's knocking your door asking for your help. So what are those individuals like? What are they going through? Who do you help?
Caroline Elton: [00:25:27] So I should. I should just just for the sake of sort of transparency and clarity. Currently, I am not working for the NHS. I'm working for a medical school and I actually left a salaried position in the NHS when I wrote started to write my book, although I did a lot of freelance work for the part of the NHS where I'd previously been a salaried employee and I also have a private career coaching practice, which again, I am not seeing anybody at the moment because I have this other job at a medical school and also I'm writing another book, but who do I help? Everybody and anybody who is feeling that their working life is not right, who is aware, is aware that they are unhappy, and at least at the point that they contact me, thinks that the cause of their unhappiness is linked to work. So, yeah, it's not the happy person who is trying to choose which branch of medicine to go under because those people probably don't seek help and if they do, they're going to seek help from senior clinicians around them or whatever they're going to from there. And that's rightly so. That's I have no problem, no problems with them. So people who come to talk to me or people who are often very, very, very unhappy and who attribute it to their work.
Tyler Johnson: [00:27:03] When I was in my internal medicine residency at Stanford. The residency program got a grant to bring this consulting firm into the residency program to consult on how they could help our residents to feel more well. And what was really striking to me is that when they came in, this company consultancy was known for trying really hard to understand the culture of the organizations that they were asked to help so that then they could make recommendations that would fit within the culture rather than trying to overhaul the culture that was kind of their their calling card. And so the first day that they came to sort of make a presentation to us and to let us know that they were going to be embedding themselves in the residency program for a few days a month to understand our culture. They showed us this video of a similar consultant project that they had done at another very famous institution, and the first half of the video was them demonstrating all the work they had done to get to know the culture at this other place. And then the second half talked about the interventions that they had come up with at the end. But what was so striking to me is that in the first half of this video, the first half of the video was basically a series of interviews that they did with leaders and residents at this other program to try to understand the culture there. And I will never forget two of the comments. One was from a trainee and one was from a leader. The trainee said, you know, the thing that I really like about the residency program at such and such a place is that like pretty much every day we have interns and residents who are just in the stairwells, sitting on the stairs, crying to themselves because they're so tired and they're so sad. But usually someone will hear them crying and go and try to help. And I really appreciate that. And then there was a comment from one of the directors of this residency program who looks right into the camera and says, look, this is the residency program at such and such a place. Everybody knows that it's drinking from a fire hose. And if you can't cope, don't come here. And these were the things that were recorded as. Supposed to be representative of what a great culture this program had, right? Which I just remember being so struck by this because it felt like watching a video about Stockholm syndrome or something, right? I mean, it was like.
Caroline Elton: [00:29:37] Well, it was a video on Stockholm syndrome. Indeed, it was that they had imbibed that culture to the point that that nobody was saying, you know, it's like the Emperor's new clothes. You need a little boy on the corner to say the emperor has no clothes. This is this is not how a functioning culture should be.
Tyler Johnson: [00:30:00] Right. And I know this is sort of an impossibly deep and historical question, but I guess a sort of a strange question to start with is why do you think it's like that? Like, why would we have come to valorize that sort of grinding difficulty as if it were a good thing?
Caroline Elton: [00:30:20] Well, I think there are all sorts of ways we can think about that. I think there are various kind of writers thinkers on on the topic of physician well-being who particularly impressed me. And one of them is Tait Shanafelt, who I know is now at Stanford and is I imagine, you know, may well know Tyler. And he wrote a paper in 2019 that was published in Academic medicine. And I think that if you if you were a martian who was visiting Earth or you were a bird flying over different sites of clinical work and trying to understand why that person was on the stairwell crying, he talks about the fact that we have aging population, which we do in in the developed world. We have a huge growth in the complexity, in the range of medical knowledge and medical treatments. And so the volume and complexity of medical work, if we compare in my grandfather was a doctor and he qualified in about 1916. So sort of, you know, over a hundred years ago, he would have had completely different work, completely different treatments available to him. So the volume and complexity of what doctors can offer has increased beyond recognition. Let's say, over the last 50, 60 years in the developed world that has led to spiraling costs. Whether you have a national health system as we do, whether you have an insurance based system in the US and whichever healthcare system. Therefore, increasing concerns about value for money costs rising too much. So that's led to a whole kind of documentation performance management system superimposed onto the onto the health care. And what that has done is that that has fundamentally eroded the nature of the doctor patient relationship. That that is the core of why we see these Absolutely An epidemic of of burnout. Now don't I think that that. Yeah, I mean, it's a very it's very scant. But I think that those are some of the pressures that have have contributed to the extraordinary levels of burnout that we see.
Henry Bair: [00:32:49] In your book, you delve into many of the issues we've discussed. You write about the difficulty that comes from choosing a specialty and having to stick with that specialty for the remainder of your career and what happens when one becomes disillusioned with that choice. You write about long working hours as well as racism and sexism in the health care workforce. And to illustrate these points, you use stories of the patients, you counsel patients who are, in this case themselves, doctors. Can you share one of these stories to help us understand some of the most salient issues in medical training today?
Caroline Elton: [00:33:25] I often think about and I do write about them as kind of client 001. The first person who came banging on my door when I sort of put the sign up. She was a doctor. She was about six weeks out of leaving med school. And the hospital where she was working, she was doing her first year of her foundation program. I happen to know the senior clinician in charge of foundation doctors in that hospital, and she had walked into residents have got a teaching center. She'd walk into that area of the hospital, broken down in floods of tears, and an administrator who had previously been a nurse clocked that. This girl was very unwell and called the person in charge of the foundation program. This woman was a very experienced clinician and she told me she mentally did a suicide check before she sent this this woman home. And she immediately went off sick. And when she came to see me, she was six weeks into leaving medicine. As she was six weeks into working as a doctor and she was never going to be a doctor. I mean, she was never, ever, ever going to be a doctor. She she was leaving and she just knew that she could never work as a doctor. And one of the things that became apparent that I learned from this from this I call her Kelly in the book was you can't make a major decision like to walk out from medicine after six weeks when you are acutely depressed, you can't do it. It's like building a house on jelly.
Caroline Elton: [00:35:04] So some of the work that I do is kind of thinking, is this the right time for making the decision or do we really have to kind of prioritize your mental health and get you into a better mental space before you can make the decision? And we have various psychotherapy services, but she didn't want to go down that route. She did later on, actually. But at that point, she didn't. She had a time out and slowly started to kind of reconsider what was going on. So some of the things that I learned from this particular individual, at one point I took her to the person who was not in charge in her hospital, but in charge of the whole region of foundation trainees who turned to her and said, Kelly, if you leave, it'll be a complete waste of taxpayers money, not a helpful intervention. She was already feeling incredibly guilty. So I learned about, you know, the lack of compassion sometimes that more senior doctors can show to somebody who's who's struggling. But also in the course of our sessions, one of the things that is really important is to take a really good history. And I found out that actually each time there had been a transition in her life, Kelly had had a wobble. And that was really helpful for me and helpful for her to see this as another manifestation of an older pattern. But each time she had wobbled, she had stabilized afterwards. Eventually, she decided to give it another go.
Caroline Elton: [00:36:41] And she is now a fully qualified child and adolescent psychiatrist who remains in contact with me 14 years later. And what I learned. What are some of the issues, some of the issues that I've said about the hostility? If you if you become vulnerable and you mention that the hostility with which you some people will treat you, the fact that there are kind of rhymes and reasons, psychological reasons in her own history, but that that if somebody is going through a very bad patch at work, it usually kind of makes sense when you start to unpick it. And the fact that different specialties have very different psychological demands and also that a kind of ongoing, although not a very frequent, but at key junctions, she sought me out and we've had a few a session or two and then she's gone off on her way. So I think another thing I've seen is that how beneficial a kind of longitudinal relationship of support can be, but that having somebody who knows you, who knows what you've been through, who you can go back to, and just kind of top up with a with a with a bit of support. And I think I've also seen how and I think that their clinical parallels here, you absolutely have to keep an open mind. I didn't know whether she would be able to make it as a doctor. I could see that there was a possibility that if she walked out after six weeks, she might regret whether she had given it an adequate chance.
Tyler Johnson: [00:38:20] So I serve as a mentor for medical students in the medical school here. And one problem that I have had brought to me multiple times is by women who are considering going into orthopedic surgery in particular, which if you look at the numbers of orthopedic surgeons in the United States, the overwhelming majority of orthopedic surgeons are men. It's a very ghetto in the UK for women and and many Women report that it continues in many institutions to be a very hostile environment. And so the thing that has been brought to me multiple times is people who come in and say, in effect, you know, I, I had this rotation, I did this experience, and I really loved orthopedic surgery. I think it would be a really great fit for me. I really want to do this. And yet as a woman, I'm really worried because if I know that it's a very hostile field in general and yet I'm going to try to go into it, then I feel like in addition to the rigors of the training, which is difficult, no matter who you are, I'm going to be taking on this additional burden of the difficulty of being a woman and having to, you know, fight my way through harassment and discrimination and people ignoring me and whatever else. And so the reason I bring that up is as a microcosm of a larger question, which is this I think that so many health care workers and health care workers in training find just getting through to the end of the day to be such a demanding prospect that the idea of trying to. Really effectively do battle with elements of the health care world that need to change, whether that's racial discrimination or gender discrimination or discrimination based on sexuality or whatever. The thing is, it's just like, well, how you know, I can't possibly also take that burden on top of just learning how to be a surgeon or an internist or whatever. And so I guess that I'm just wondering if you were counseling people who are facing some version of that on the ground as they're trying to make their way through medical school or residency or whatever, how would you help them to think about those dual burdens?
Caroline Elton: [00:40:43] I mean, it's it's a really tough one. It's a really tough one. I suppose I would want to look at with them how they had encountered previous challenges, what sources of support had proven useful in the past, and how that might manifest itself, what the implications of that would be, whether that would be enough were they to take on this additional sort of dual burden of training, which is hard enough, and then being an environment which really wouldn't be supportive. I would also want to get a sense of the extent to which somebody had quite a strong sense of their own, who they were and what was right, or if that was more fragile and they were therefore going to be really battered by the potentially hostile negative stuff that would come their way. I would want to think about their collegiality because in those situations, if they can make good links with others, I think that can be a huge source of support. I would want them to choose their residency wisely because yes, collectively certain, you know, certain specialties have fewer proportions of women. The lifestyle, the expectations may be less friendly to those with a family. So I would want them to think about how they could find out if they were choosing some more favorable places to apply to.
Caroline Elton: [00:42:21] And I would also want to explore, you know, for example, I know I don't and I don't know how this works in the US, but in the UK, hand surgery is a subspecialty of trauma and orthopedics hand surgery is much more feminized and often a very different environment. Less, less. There is a merge. Obviously somebody can smash the hand in the middle of the night and they're going to be called out, but less sort of emergency acute. So to also I would want to understand what was it about this specialty and is it only that specialty or are there some other ones where it might be a slightly more nurturing environment? And I would also, you know, I would raise the question which I can do because I don't have jobs up my sleeve. So I'm not a you know, this isn't discriminatory. I would want to ask them about family plans and I would want to think about, you know, how how might that fit in? Have you talked to women who had children during residency afterwards in that specialty? So those are the sorts of conversations that I would have. I would want them to be realistic. It's not my job to kill people's dreams, but I do want people to be realistic.
Henry Bair: [00:43:37] Yeah. Actually, to that point, you know, one of the things that stood out to me as I read the stories in your book was the frequency with which the story of an individual you're you're counseling ends up actually leaving the career of medicine entirely and doing something else. And I think maybe part of that or perhaps a lot of that has to do with the way that we select for future doctors and train future doctors. If we're up to you, you know, given your experience in medical education, given your experience, counseling, many people who have gone through the training, the selection process and the training process and not come out where they want to be, how would you fix it? How would we how do we choose future doctors?
Caroline Elton: [00:44:27] I mean, obviously, a lot of the reasons why people are leaving are. To do with the extraordinary pressures which COVID have. You know, it's amazing. We've talked for over an hour and we're only now just bringing talking about COVID. But the pressures aren't new. Covid didn't bring the pressures. Covid ratcheted them up and COVID put a spotlight on the pressures that that healthcare organizations were operating on beforehand. A lot of the problems of people leaving would be fixed if the the working pressures were reduced. But for those who probably should never have gone into medicine, one of the things I touch on in in the book is that I don't think we really screen out those who are going to find the practice of medicine too psychologically demanding. I think the methods of selection are pretty effective in identifying those who are likely to have the cognitive ability to get through their degree. It's not 100%. It can never know. Selection method is 100%, but basically it's pretty good at finding out whether people have got the smarts to get through. They can make some mistakes, blah, blah, blah. But but what I think that they are not good at doing because it's very difficult to do, is to find those who may find the day to day practice of medicine too emotionally overwhelming and think the problem is not that we're not very good at doing that, but that the systems think that they've done it when they haven't. So there's a notion in psychology, particularly in occupational psychology, called the psychological contract, which is the idea that an employer and an employee there's the formal written contract, but there's also an implied contract about how an organization will treat you as an employee and how you as an employee will will behave.
Caroline Elton: [00:46:30] And I think that that in terms of the psychological, we say and I here have heard this say, you know, the first day a dean of a new medical class intake say things like, you know, it's great that you've got through to medicine. It's a medicine is a very broad church. There's something for everybody, blah, blah, blah. And nobody is raising the conversation, saying that perhaps for some of you in a very unproblematic way, some of you might decide that this isn't the right course and that's fine. And we'll help you think about it. And neither do they say we may decide with some of you that it's not the right course and we'll try to help you remediate. And if it doesn't work, we'll also help you. But that none of that goes on. So there's a kind of fuzzy area. There's assumption in the whole cohort that everybody's going to be right for being a doctor, that the selection methods have been so accurate that everybody in this pool is suited to this profession. And I think there needs to be greater humility that the overwhelming majority are. But there's going to be a minority who are not. And that's not a problem because there are plenty of other things you can do. And that was one of the reasons why I've just gone since last year to be spending a bit of time working in a medical school because it's very interesting, having spent 20 years working with already qualified doctors to go back to the beginning.
Henry Bair: [00:47:59] On the flip side of that, for those who are cut out for this, it doesn't mean that they won't also need support from time to time. So how would you counsel a trainee or a clinician on being more prepared for the emotional toll of their work?
Caroline Elton: [00:48:12] I think that this is something that needs to and I think in medical some medical schools it probably does. But to start right from the beginning, I've never heard a medical school where they've had conversations with people about their own illness, history, their family illness history, and how that may impact on on on how they feel about their training, about their work going forward. But in answer, I'm sort of rambling on a bit. Henry But in answer to your question, I think we need to see in terms of building somebody's preparedness. It's not a resilience course. Just a few, six weeks before they they graduate. Mindfulness is great, but it's not a panacea. It's getting people to think about themselves, to think about the challenges, to think about their responses, and becoming self-aware and aware of the sources of support that have to be there and creating a culture where accessing that support is unproblematic. I think those would be the three, the kind of and I would see that as a project that begins at the beginning of medical school and continues to the point of retirement about kind of thing, being aware of yourself, having a knowledge of where else you can go to support and working in a culture where accessing that support is just seen to be unproblematic. And I think we're probably a long way away from that on all three fronts. But I have to say in the UK we do have two mental health services for doctors, one of which is free and funded, one of which is subsidized by the British Medical Association. So it's low cost but not free. They are entirely confidential. They are self-referral and they're relatively recent in the last 15 years. And that's a game changer. And I know when I get people writing to me from the US that there's nothing like that in the in. There's some physician support, usually with addicted physicians or physicians in pretty tricky situations. So I think that is something that is absolutely essential.
Henry Bair: [00:50:34] So let's say a residency program director or the hospital executive who is surprisingly passionate about truly caring for the well-being of their workforce. If they came to you and asked you from an institutional perspective how they can better support their clinicians, what else can they do in addition to having a counseling program?
Caroline Elton: [00:50:56] I think they would need to be and it would link to kind of what Tyler was saying about the consultants that were brought in. They they would need to find out, you know, what the the starting point was, what is the experience of those residents? I would want I would I would I would want to know, is it is it overwork? Is it that they're working too long hours? Is it they don't feel that they're getting the training. So I think a kind of general answer to that and this again links to I know Schoenfeld's work on on the kind of chief wellness Officer role is that what one needs what one needs is that one needs a senior person who has the time, the budget and is using the now available metrics to really get a handle of what is happening and do something, do something about it. But it has to be, I think that that individual resilience is obviously key, but that if we're looking at burnout or if we're looking at moral injury, we're actually talking about systemic issues fundamentally within which individual resilience is a part. It's not irrelevant, but essentially we're looking about systemic issues. And so when I'm asked to speak on resilience, I always emphasize that.
Henry Bair: [00:52:16] Well, there is still a lot we could potentially talk about, but we've already had so much of your time. Thank you for graciously sharing your stories and insights with us and for your continued work in making this profession a better, healthier one for clinicians and the patients they care for.
Caroline Elton: [00:52:33] It's been a pleasure. Hope I haven't rabbited on too long.
Henry Bair: [00:52:38] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.thedoctorsArt.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:52:56] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:53:10] I'm Henry Bair.
Tyler Johnson: [00:53:11] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.