Growing Doctors

Where is the Life we have lost in living?
Where is the wisdom we have lost in knowledge?
Where is the knowledge we have lost in information?

From Choruses - The Rock – T.S. Eliot

We are about to once again try and ‘fix the NHS’. I applaud the desire to make it better but feel the approach is likely to once more mirror the conventional symptom approach of just ‘writing a prescription’ and ‘swallowing the pills’. Whilst this has its place we also need to really look at the underlying relational issues at play and the endemic low vitality in the system. I speak not just as a holistic doctor but also as someone who over the last couple of decades has been coaching other doctors and health care workers, mainly from a GP setting. This, and time working at Southampton medical school, leading first on holism and then on personal professional development for the medical students. These experiences have left me with some clear ideas about both the dysfunction in the system and the developmental needs of doctors and other careers ‘in the system’.

There are a number of areas of the inner work of doctors and health care workers that contribute to the negative and at times toxic working environment that is too often part of the conventional working environment. These include a sense we are failing to address the basic lifestyle and psychological needs to enable a patient to ‘re-cover’ and that get in the way of enabling a healing contract creating a healthy environment. I have many observations about these and how they might be addressed through a shift in the healing ‘contract’ we set up with patients and the importance of providing long term support and supervision for all healthcare workers. Somehow the deep negative feelings and fear that is, in my experience, endemic in all parts of the NHS needs to be better recognised and addressed. If you are interested in this do read on.

Medicine is too often presented as exclusively a science dependent on knowledge, skill and evidence. Whilst these are important they need to be balanced with emotion, creativity and personal experience. The science and art need to balance each other, especially when working with complex cases. In some studies over 80% of patients presenting with common physical symptoms have no clear organic cause (Kroenke and Mangelsdorff 1989). Used wisely, a doctor’s emotional and creative developmental edge empowers and enables a patient to embark and continue their healing journey. Without this ability not only do patients suffer but the organisations that support doctors also suffer. Some of the behaviour that I have felt most uncomfortable about as a medical student and trainee were ones that generated strong negative feelings but that I was unable to articulate at the time. Experiences such as consultants belittling patients, nurses, junior doctors and students, set up a strong aversion to medical hierarchies and concern about the impact on me and others involved. These consultants (and others that behave this way) of course are likely to have experienced a high level of distress themselves to behave that way. These experiences have consequences including those who are more sensitive and noticing these things avoiding leadership positions and the systems in which care is given often failing to support those working in them. ‘Wilful blindness’ (Hefferman 2011) explores how behaviours that are offensive even negligent can continue in a group or profession. Harming not just patients but also those working in these systems.

It is by attending to the development and support needs of learners that they can be equipped to navigate in a sustainable and compassionate way not just through their training but in a lifetime of emotionally challenging and changing practice. It is by reflecting on and reviewing their own training that trainers glimpse their own important developmental milestones and gain insight into how to build the support networks and emotional capacity to allow practitioners to recognise the developmental challenges they face and explore the creative solutions available to them. Emotions and strong feelings are often the first sign that a behaviour is inappropriate but they also give important additional sources of information to doctors in relation to patient care and their work environment (Van den Bruel et al. 2012) (Goleman 1988) (Gibbs 1988). 

As a clinician I increasingly find my feeling response to patients and organisations offers a reliable and helpful insight into situations that are otherwise confused (Heath 1999). However emotional intelligence (EI) is rarely an explicit part of a doctor’s training and different individuals have variable aptitude and capacity for developing EI in relation to self-awareness, self-management, social awareness, and relationship management which are all core aspects of working professionally. When emotional awareness is used constructively to inform and meet either your own or others needs it often leads to more creative outcomes and solutions. In many endeavours the link between emotional awareness and creativity is well described (Ivcevic, Brackettand Mayer 2007) and I have written elsewhere on the importance of creativity for personal vitality. I now feel it is possible to think of teams and organisations in terms of their creativity and vitality. Those with low creativity and vitality often failing to adapt and adjust to the challenges and changes that all teams and organisations face.

There has been a tendency in medical training to think that EI can be trained by learning behavioural competencies, and that individuals can be educated, trained and assessed in them. My experience is that this behavioural approach leads many to think they are emotionally competent by mimicking the behaviour they see modelled to them. When taught without developing the underlying feeling or developing their creative capacity learners lack the ability to apply or trust their emotional reactions. Indeed this can lead to the detuning of learners emotional awareness during their training. Perhaps explaining the reduction in empathy most medical students and trainees experience in training (Neumann 2011).

“One of the mysteries of illness is that no one can be healed by anyone whose emptiness is greater than their own." Mark Nepo 2007

Table 1. Aspects of a doctor’s ‘inner’ professional persona

Of course as the levels of knowledge and technical competence required by doctors increases, it becomes increasingly challenging to find time to prioritise ‘personal development’ and the inner journey.

Time taken to sharpen your blade during harvest is time well spent

A developmental journey often implies a shift in an individual’s personal emotional nature, whilst acquiring new knowledge or skills is seen as adding to an existing body of knowledge. In our current doctor training paradigm development can be seen as a process of transformation as the learner sheds one skin that reflects their old developmental shell to allow a new skin to grow (Cranton 1994). Like an insect or snake growing into a new skin the transition phases are often difficult and the learner needs a high level of support from, and trust in, those responsible for overseeing or supervising their development. Sometimes the change is so significant it might be considered more a metamorphosis.

One of the key times for developmental learning is at times of difficulty or challenge. At these times the learner meets the limitation of their existing developmental body and has the opportunity, in the right training environment, to grow past these limitations. If this is not possible they may instead hide or fail to attend to the impact on them of working outside their emotional or creative competencies. In my work as a supervisor I suspect this is impactful on many learners and doctors resilience, ability and desire to keep working. On the other hand working with learners who are engaged with the developmental process is an exquisite and rewarding art, guiding learners through natural but transformative processes that can inform and enthuse their work. The relationship between learner and trainer is central to this work and is often articulated through a role model, mentor, coach or supervisory relationship. While opportunities for these relationships already exist for many learners, and there are pathways for training the trainers, there is too often a lack of real acknowledgment of the importance of this development and an assumption that it is only necessary during formal training rather than as part of lifelong practice (Owen and Shohet 2011).

Resistance to change

At a national meeting discussing a doctor who had been found guilty of child abuse in their general practice, I reminisced about boundaries and consent in relation to my training. At the time I was a medical student it was common practice when assisting at surgical procedures to practice intimate examinations on patients under anaesthetic without explicit consent. I find myself horrified not just by the thought of being party to this but equally staggered by my disempowerment to challenge this. I wonder what we require of learners now that they will be equally horrified by as they near the end of their career. Does it have to be this way, does medicine truly only move forward one retirement at a time?

If it is accepted that the development axis is important when learning to be a doctor, and that it is under represented or resourced in the learning journey, then we need to explore why. Personally learners can be uncertain about the transformational aspects of professional development. It can be hard to contract and agree to a process of change in which you are uncertain how you will be changed. If learners are recruited based on their experience and expertise in navigating the theoretical axis it is perhaps unsurprising they are daunted, unpractised or reluctant to immerse themselves in developmental learning. At a clinical level, despite the General Medical Council (GMC) giving clear leadership on the importance of professionalism (GMC 2009) many learners are kept so busy acquiring theoretical knowledge and practical skills that development becomes a distraction to learners and trainers. Learners are consumed by the need to pass the mostly theoretical and practical summative assessments, perhaps considering it unwise to share challenges or difficulties in case they are perceived as weaknesses. Trainers sometimes appear to indicate that they preferred how it was in ‘the good old days’ or that ‘if it was good enough for me it should be good enough for you’ or even ‘if you can’t cope with this you’ll never cope as a real doctor’. Organisations may also orientate curricula away from areas that provoke uncertainty or anxiety (Menzies-Lyth 1960) as a sort of defensive reaction to the unmet needs of learners and trainers. Over time this creates an organisational culture where relationships become secondary to the idea of care as a product, and the emotional needs and creative expression of individuals must be contained, leading to organisational features described in table 3.

Table 2, Features of organisations resistant to developmental opportunities: (Fotaki and Hyde 2014)

When the developmental needs of learners are championed it brings fresh insights to challenge out-dated assumptions and harmful behaviours not just impacting on personal and clinical relationships but also at the organisational level. When learners feel fully situated in the organisations that host and represent them they understandably engage differently from when they feel unrepresented or at odds with the organisational norms they can become cynical and distressed (Dyrbye et al 2006) as this inturn can impact on patient care (West and Shanafelt 2007)

Physicians are themselves therapeutic instruments that require maintenance and renewal to remain effective (West and Shanafelt 2007)

Looking to the future I find myself wondering whether as computers and technological advances continue to improve the theoretical and practical capacity of machines in medicine. Then the emotional and creative aspects of medicine may find re-newed recognition and currency. In this place the NHS and those working in it could feel more supported and positive. Perhaps allowing them to embark on a journey of recovery for the health service itself, who knows perhaps this will include some of the ancient, traditional, culturally diverse and natural treatments that are available but to too many invisible.

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Fotaki M and Hyde P. (2014). organizational blind spots: Splitting blame and idealization in the National Health Service. Available: http://hum.sagepub.com/content/68/3/441. Last accessed 17th January 2016.

General Medical Council. (2009). Tomorrow’s Doctors Outcomes and standards for undergraduate medical education. Available: http://www.gmc-uk.org/Tomorrow_s_Doctors_1214.pdf_48905759.pdf. Last accessed 17th January 2016.

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West C and Shanafelt T. (2007). The Influence of Personal and Environmental Factors on Professionalism in Medical Education:  Med Educ. 7 (29)