DOCTORS NEED SAFE CONFESSIONAL AND CATHARTIC SPACES: What we learned from the research project ‘People Talking: Digital Dialogues for Mutual Recovery’
Doctors losing libido
The newly elected (2017) President of the British Medical Association (BMA), Professor Pali Hungin, describes a crisis amongst doctors resulting from structural factors—particularly chronic under-resourcing. The crisis involves exacerbation ot doctors’ mental health problems—not only in the acute sense such as suicidal ideation, but as a chronic condition of “disillusionment” and “loss of joy” (Hungin 2017), akin to loss of libido. Clare Gerada (2017), former chair of the Royal College ot General Practitioners, describes “a profession in distress.” Medicine is a profession whose urge to create is deeply frustrated, the aesthetic overridden by the instrumental and functional, the functional a burden where the UK has 2.8 doctors per 1,000 people:
fewer doctors per head of population than most other countries in the Organisation for Economic Co-operation and Development (OECD) . . . Out of the 33 countries for which the OECD has provided data, the UK ranks 22nd. The only European countries with fewer doctors per head of population are Poland and Slovenia.
In the UK, one in four people generally will suffer a mental health problem at some stage in their lives, making mental health the largest field ot disability (23% of all ill health) (HMG DH 2011). While doctors have stressful jobs, and this is a structural problem creating vulnerability to mental health issues, they are reluctant to admit to such problems (Manning 2012). This is a cultural problem—doctors are socialised into a faux invincibility. A 2013 review of the literature on the mental health of UK doctors revealed that: “27% . . . show significant stress . . . (doctors) have a 7% lifetime prevalence ot substance misuse . . . (and) a suicide rate that is higher than the general population and significantly higher than other professions” (Howe 2013). Doctors in the UK National Health Service (NHS) may be seen to be in a permanent state of recovery from working within an increasingly dysfunctional system. A 2017
survey revealed a worsening situation from the 2013 review above, where 60% ot doctors admitted to some form of ongoing mental illness (eurekadoc 2017). A 2015 report showed that 48% ot UK junior doctors who had completed their Foundation Programme and prior to Specialist training planned to leave the NHS (many to work abroad), while in 2011 this figure was only 29% (Campbell 2015). This drain of a talented workforce is a symptom of ever- worsening UK work conditions. While the UK Government claims that more funds are being spent on the NHS than ever before, the fact remains that UK healthcare resourcing is amongst the poorest in post-industrial countries, and, as a consequence, health outcomes for the population are relatively poor when compared with near-neighbours such as the Netherlands, Germany or Belgium (Niemietz 2016).
Survey results noted above offer an overview of doctors’ concerns, but nothing ot the fine grain of symptoms of overwork and consequent stress. While the pilot study we draw from below has a very small sample of doctors (n=5), and this involved four consultant psychiatrists and one experienced GP and then is open to bias, the data have face validity when considered as a series of case studies (n=l). These doctors’ stories reveal fascinating fine-grain aspects to the career work circumstances that might lead to debilitating stress and how such stress may be repressed, denied and sublimated. In short, doctors took the opportunity to confess, and to resist conformist professional identities.
The pilot project
We set up a pilot research project to connect the communities ot mental health service users, carers and doctors within a readily accessible digital medium with the aim ot promoting ‘mutual recovery’ (explored below) through storytelling. The medium of digital storytelling is an ‘everyday,’ or ‘available,’ art that requires no particular skill or creative ability in narrative (Alexander
2012). This chapter reports on an important slice through that project, a finding whose contours we could not predict. Given the opportunity, doctors in the study readily admitted to vulnerability and sought safe spaces in which to confess and exercise catharsis or expression of otherwise contained emotions with familial overtones.
Following the medical consultation model, our study was, again, case-based with just 13 participants, five of whom were doctors, five sendee users with mild to moderate mental health symptoms and three carers. From the doctors’ stories, we were able to gauge just how much pressure they are under in the current UK National Health Service (NHS) that can be read as a dysfunctional system. While medicine sets out to heal, it is poor at healing itself (Peterkin and Bleakley 2017), as the story fragments considered in this chapter indicate.
Theoretical underpinning to the pilot project
A story is characterised as having a plot, usually with a crisis or turning point, and real or imaginary characters; after the turning point, unpredictable things may happen (Ricoeur 1984). Stories are produced in a social context, with a teller and an audience, often transmitting normative cultural lore to bind social groups, but also challenging and disrupting social norms through resistance and invention.
Stories are the stuff of clinical encounters (Kleinman 1989; Bleakley 2005). Patients typically tell their stories in fragments where the doctor turns the “chief concern'' (the patient’s own understanding of his or her symptoms) into a medical narrative, a story of the “chief complaint”
or main symptom, shaped as a standard ‘case’ and shared with colleagues (Schleifer and Vannatta
2013). In the medical context, telling stories hopefully leads to a successful diagnosis, treatment plan and cure. But doctors often do not listen closely enough to their patients’ stories, and interrupt the telling too quickly, so that the patient does not articulate the chief complaint. This can lead to a misdiagnosis or poor care through miscommunication. Often, misdiagnoses do not have serious consequences and may be corrected. However, an estimated 15—20% of medical errors arise through misdiagnoses (discovered at post-mortem) (Sanders 2010).
Importantly, other than in informal contexts, doctors rarely have the opportunity to tell their own stories to each other or to the patients they treat; and almost never to their patients’ carers. We identify such ‘story blocking’ as an untreated symptom of medical culture, where the need for doctors to tell their stories has, in recent years, led to an explosion in medical autoethnography (Farrell et al. 2015).
The American oral historian Studs Terkel recalled collecting stories from a single mother on a housing project in his native Chicago. As Terkel recorded her testimony, she was busy cooking food for her children who in turn were creating chaos around the apartment. When he was finished and packing away his recording equipment, the woman’s children came up to Terkel and insisted on hearing their mother on the tape, so he replayed the interview. The mother, initially embarrassed, soon began to listen intently, finally remarking: “Gee, I never knew that’s what I thought.”
Digital Storytelling is a nascent form of first-person storytelling, utilising the readily available and accessible new tools of IT multi-media to craft narratives (placed on a customised website) that can be enhanced by visual images. It is a creative form particularly suited to individuals who have never before ventured into the world of‘creativity’ or the arts, as a “vernacular creativity” (Burgess 2006). The economy of the form, coupled with the intimacy of the potential use of personal photographs, creates an opportunity for anyone who has a story to share to create a lasting artefact in a relatively simple way, utilising accessible computer software. It is a democratising form, allowing access to wider audiences for voices that are often hidden or unheard.
Collaboration and gendered division of labour were the primary forces behind the success of Ice Age hunting and gathering groups, where small, mobile groups must have adopted “congregation” as a core social value (Bagel 2013). In later agricultural societies, planting and harvesting of crops and domestication of animals required highly co-ordinated effort, with collaboration acting as a higher value than individualism. Bagel (2013) describes a “natural history of human cooperation” in terms of the brain being “wired for culture.” Collaborative values are grounded in quality of relationships and intimacy, based on kindness and trust (Sennett 2012). Where free market capitalism and neoliberalism can be seen to have produced rampant individualism and gross inequalities (Stiglitz 2012), so a new wave of commentators has called for social justice based on principles, rituals and politics of local cooperation. Acquiring social capital in the forms of friendship groups, family support, professional support and networking helps to achieve resilience against mental health issues, also reducing stigma (Gele and Harslof2010; Webber et al.
2014). Doctors suffering stress and burnout primarily need mutuality, or accessible and trustworthy support networks (Beterkin and Bleakley 2017).
Comparing today’s doctors with previous generations, Clare Gerada (2017) notes that: “resilience is a process, not a personality' trait.” The context for medical practice has changed radically in a short space of time so that today, “while doctors might work fewer hours, they’ are often unsupported.” Much can be learned about resilience from survivors ot natural disasters, accidents, political conflicts and wars (Joseph 2011). Gonzales (2012) describes how supposed forms of resilience developed in the aftermath of trauma may themselves become additional symptoms and remain untreated, and this is particularly the case for consistent, long-term stress of the kind that doctors may suffer. Further, victims may fail to call for help. After the 9/11 attack on the World Trade Center, the Federal Emergency Management Agency made $155 million dollars available for post-trauma counselling, expecting up to a quarter ot a million to apply. As Gonzales says: “Just 300 people turned up.” Doctors regularly face the traumas of their patients, including mental health issues that may result in domestic violence, self-harm or suicide attempts, and have to soak this up. Such consultations and encounters may re-stimulate doctors’ own unresolved psychological issues, sometimes dormant or unconscious until stirred. With psychiatrists as the exception, doctors do not learn how to deal with such transference effects in clinical encounters as part of their medical education, relying instead on what is often a blunt and unsophisticated resilience. While resilience has been positioned at the centre of the UK Government’s mental health strategy, focused on supportive communities and ready access to services (HMG DH 2011), it is often forgotten that health professionals are themselves vulnerable and, as noted above, may not only need to develop resilience but also to engage with appropriate therapeutic interventions where resilience collapses, fails to develop or was the wrong initial psychological strategy. Mistakenly, resilience has been assumed amongst the medical profession, where junior doctors are tempered in the furnaces of long and demanding hospital shifts. Such naturalistic encounters cannot be assumed to develop effective psychological health strategies, and are often counter-productive.