GROUSE ARE NOT the only creatures at risk in August. It is the time when fledgeling doctors traditionally leave their medical-school nests to try their wings in the real world. The public, unlike the grouse on the 12th, are now aware of the danger but, as with the grouse, their fate may be determined by factors beyond their control. Not all of this week’s BMJ makes good reading for those about to be admitted to hospital.
Among the book reviews in the journal is a description by Tessa Richards, the BMJ’s assistant editor, of Doctors as Patients (edited by Dr Petre Jones, a GP). Psychiatric disease, especially the depressive illnesses, dominates accounts of the ills of doctors. It seems that the doctor forcing a smile as he or she greets the next patient in the ward or out patients may in reality be feeling suicidal.
The high incidence of psychiatric troubles, especially depressive diseases, among doctors has been observed frequently over the past 30 years. When it has been investigated, research has shown that in many cases there is a history of depression in the doctor’s family. In other cases doctors claim that their early family life had unusually dysfunctional elements — often, apparently, a cold and distant father and ferocious sibling rivalry.
Clinical experience teaches that many high-achieving, but depressed or disturbed, patients seek succour by attributing their ills to the way in which their parents and other family members related to them.
Detached observers involved in other research have shown that 40 per cent of medical students, when starting their career, have a depressive streak in their temperament. This compares with about 20 per cent of students in other faculties.
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Research from University College London, published last year, indicated that the situation was better after qualification. One in five of the hospital doctors assessed had symptoms of such severe depression and anxiety that they warranted psychiatric care, should it have been sought. Using the same criteria, 14 per cent of the British population would have been similarly classified.
The editor of Doctors as Patients has, in the words of the BMJ review, collected “bleak self-portraits that are harrowing; not merely for the description of the inexorable slide down to suicidal despair but for the repeated mention of failure, isolation, shame, self-blame and dread of disclosure”.
Many severely depressed patients, whatever their occupation, express similar feelings. Even so, these should be assessed in relation to the doctor’s role and personality. Many doctors are by nature obsessively conscientious and possibly co-dependent (needing to be needed before they can feel fulfilled). Their life may become unrewarding, even meaningless, if they don’t feel wanted and valued by colleagues and patients, yet the doctor may not have a personality that will attract these emotions. It is not a coincidence that the only younger women with a suicide record as bad as men’s are those who become doctors. The life of a young doctor could have been designed to uncover latent instabilities and depressive feelings in anyone with a potentially vulnerable personality.
Dr Jones blames the NHS. Others have blamed the university selection system, with its emphasis on A-level results coupled with an interview technique, often learnt and practised, that displays a fawning homage to well-rehearsed politically correct opinions, and a history of extramural activities planned to show an apparently caring nature.
In the real life of a general-practice surgery, the brilliant academic, or even the Mother Teresa manqué, may struggle to find intellectual satisfaction or to retain an abiding interest in the humdrum happenings of ordinary families. Once they are disillusioned, any feelings of isolation may easily “slide down to suicidal despair” at an increasing pace.
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The problem in the hospital service to which Dame Carol Black, president of the Royal College of Physicians, Professor Roy Pounder, Dr Hugh Mather and Alice Murray have drawn attention in the BMJ is the still-unresolved one of sleep-deprived junior doctors.
Doctors now work in shifts. This may appal my generation but is an inevitable consequence of changing social patterns and the expectations of junior doctors, their wives, partners and families. But the change to a shift system has revealed the difficulties of running intermittent night shifts with junior doctors, who, unlike factory workers who may have done night shifts for years, find it difficult to make up sleep during the day.
In America junior doctors work shorter shifts, yet research suggests that they still make 36 per cent more serious medical errors when working at night than they do during the day. When their night hours were cut, the number of mistakes that could be attributed to tiredness was halved. The importance of catnaps has been shown in aviation: after a 40-minute nap, performance increased by 34 per cent and alertness by 54 per cent.
These risks of tiredness are not borne only by patients. The traffic-accident rate experienced by US hospital doctors increases by 9 per cent when they are working night shifts. The accident rate for doctors actually commuting to and from the hospital is increased by 16 per cent.
Dame Carol and her colleagues have made various recommendations in the BMJ on how rearrangement of the shift system could lessen fatigue and presumably medical error.
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They have also listed various measures that encourage daytime sleep once at home, such as heavy curtains, eye masks, phones that light up rather than ring, and earplugs. If patients are to have the best chance of making a good recovery, whatever the time of year, they need alert doctors — and never more so than when the doctor is new to the job.