Hugo Jobst, 4th Year Medical Student, University of Glasgow

Published in JHH 19.1 – Integrative Medicine

Emotional depletion and disillusionment seems to be rife among doctors and medical students.

I am nearing the end of medical school and friends of mine who, when in their early days of training carried themselves with a seemingly inextinguishable enthusiasm now, without changing vocation entirely, aim to distance themselves from medicine as much as they can. Some are considering leaving all together.

The weight of a mega-system, where individuals go in and are lost in the process, buries early sentiments that were carrying us into a career in medicine. The flame is blown out by a cold wind and with it we are left in the dark, feeling lost and confused, with a disquieting feeling in the stomach that says, ‘oh no, have I made a six-year long mistake?’. Perhaps the empty exhaustion students feel when they get back from placement may not just be from the hospital work, but from subliminal existential questioning brought on by the dehumanised system they are preparing to enter; can we really see ourselves doing this job and enjoying it? Is this what we signed up for? Are we actually making people healthier and happier?

I see many students actively avoiding the hospital and searching for fulfilment elsewhere in life: reasonable enough responses to sensing that medicine, or at least students’ role in it, is far from enjoyable or fulfilling. But there are problems with these avoidant and distracting ways of coping with the drudgery of medical school. Finding some comfort or enjoyment outside of medical school is not a long-term solution, no compensation for the disillusion and disappointment of having lost touch with whatever called them towards medicine in the first place. Their withdrawing diminishes the system’s potential for positive change. Each person who turns away is one more mind, voice and heart lost from the progress and development of healthcare. For it to improve, we need people with sensitivity and who have recognised problems, have enough confidence to feed their experience back into the system.

Why have these once-passionate individuals become so disempowered and apathetic? Medical education, lacking the progressive culture needed for moving modern healthcare forward, leaves doctors and students to bear an invisible burden: the weight of what we so sorely need to learn, whose absence we dimly sense but can’t describe and speak about. To make sense of how we ended up here, it helps to consider the objective and the subjective factors. Objective factors are the hours doctors work on average and how much they are paid. Young doctors are routinely working 70+ hour weeks, which is a little better than how things were 50 years ago. Unfortunately, the downside of these small improvements in raw hours per week are the fragmentation of work teams and disruptive shift patterns. Does the blame lie with lacklustre institutions that care too little for the wellbeing of their members, or is the industrial trajectory of healthcare itself at fault? Is the pay that they are taking home fair for the work they do? The fact that many foundation doctors are planning to exit the NHS to seek better pay and easier rotas in other countries such as Australia, New Zealand and the USA, may reflect that many don’t think so.

I am told that camaraderie used to be the lifeblood of a hospital, but now you can turn up to a ward round where no one knows anyone’s name, where the consultant treats the foundation doctors like receptionists, and everyone is looking at the clock with their hearts sinking because they are only two hours in to their fourth 12-hour shift of the week.

Subjective factors are important too. Recently a consultant (whose wife was also a senior doctor), was complaining to me about his earnings. He said, ‘If I had a shred of intelligence I’d go to America and earn hundreds of thousands of dollars a year’. His household income must be sickeningly high by most people’s standards (especially those of most of his NHS patients in the city where I work), yet still he grumbled about the hospital coffee, working hours, his taxes and having to pay the receptionist of his private clinic. As he floated from bedside to bedside I observed him delivering life-changing news to patients as though he was telling them the time. One woman was left alone weeping on the other side of the curtain as he clicked off to theatres in his shiny brogues. I asked myself, how big a salary would make a person like him happy? Is this a problem with medicine or with you? No amount of money can make up for philosophical bankruptcy. Is the problem with medicine or with him?

Alongside making the working conditions fairer, subjective factors need to be addressed. If we cannot be ourselves in the workplace, we are much less likely to enjoy being there. A system that encourages individuation – self-discovering and career-long development nurtured by core values – would be a good place to start. We might then be more inclined to create a work environment where values can be realised; surely a pre-requisite for meaningful, fulfilling and sustainable work. Disillusionment and disempowerment are direct consequences of a dehumanised medical system: if we feel we are not making our patients better or that the system is improving, we will get frustrated and consider looking for for fulfilment elsewhere. Maslach named values conflicts and feeling that one was doing a poor job fulfilment as key drivers for burnout.

Burnout is more likely when we feel:
• overloaded
• lack control
• that work is no longer rewarding
• there is a breakdown in the work-community
• unfairly treated
• we are dealing with conflicting values
Maslach & Jackson (1981)

However, at medical school individuality gets lost. We all learn the same material, sit the same exams, and hardly ever have an opportunity to pay attention to our most important assets – our individual sense of purpose and enthusiasm for helping people. It is not surprising that many of my disillusioned friends feel they are only valued for their tuition fees, attendance at the annual exams and their grades in a competitive exam system that pitches medical students against one another.

I refuse to accept that because they feel like they cannot be themselves and enjoy a life of work in medicine, bright young people turn away from the career they had felt committed to. There has to be another way! Our suffering and dissatisfaction has meaning. The huge challenges of our times call for authentic, creative and human-scale responses. But you cannot fix a problem with the same kind of thinking that caused it so I find it hard to believe that the people who got us into this mess are going to lead radical improvement in health and care.

Responding to the topsy-turvy time: the formation of the Humanising Healthcare Forum

The way in which doctors are trained is inextricably linked to the delivery of healthcare. Therefore, shortcomings in medical education are likely to perpetuate and exacerbate current problems in healthcare, whereas good medical education fit for the future would educate a generation to lead a system so obviously in need of effective change and development.

The Humanising Healthcare Forum (HHF) which was set up by a group of medical students at the University of Glasgow to stimulate a culture of progressive change, serves as a platform for people in healthcare to respond to problems and gaps in medical curriculae.

The HHFs central purpose is to create a space and community for doctors to develop personally and professionally in ways that are sustainable, attuned to their own needs, and relevant to the evolving healthcare needs of the communities they intend to serve. We predict that this would make the study and practice of medicine more meaningful for students and staff, more acceptable and effective for patients, and in the long run more likely that medical systems will adapt well to a rapidly changing society.

Its development began as problems in healthcare, such as workforce disillusionment and the growing endemic of lifestyle-related illness, were mapped to gaps in medical school which we believe contribute.

The three main gaps that we believe we can do something about are:

1. the process of learning medical facts is outdated and inefficient
2. medical school doesn’t facilitate the development of empowered individuals or explicitly support values and the faculties for broader deeper thinking
3. medical education is disconnected from the community it is supposed to serve.

We then set up three parallel projects to try and fill these gaps, as detailed below.

The HHF divides a ‘good doctor’ curriculum into two broad domains: 1. Knowledge of medical facts and some techniques 2. Being a caring human being.

Currently, medical education focuses almost entirely on the first, but it does it in an inefficient, outdated way. These inefficiencies pull on students for resources they do not have, thus contributing to junior doctors’ disillusionment and burnout, and preventing creative change for better public health. A learning environment almost completely devoid of meaningful work and space for creative thought turns medical school into a production line and a graveyard for individuality. As a result, the toxic aspects of medical culture go unchallenged by the majority of students who were disempowered along the way.

Being a good doctor (knowledge and humanity)

An ideal system would make acquiring knowledge as efficient and effective as possible to free up time for attuning to the health needs of society, being more engaged and caring, and for thinking more creatively about the future of healthcare.

‘Learning science’, is a flourishing field of cognitive psychology and a vital source of information that could help students learn. However, there is currently no effective bridge connecting learning science with medical schools so that these new learning techniques can be disseminated. Consequently, medical school is riddled with inefficiencies that directly make the first domain of doctoring difficult to do well (learning medical facts), and indirectly detract from the second domain (being a human being).

To fill this gap, the HHF is working with The Learning Scientists, a group of leading researchers in this field to deliver a workshop series called Learn How to Learn. We hope to engage early year students and introduce them to study tools they can quickly use for efficient learning and free them from the burden of exam-motivated knowledge acquisition. The tagline of the workshop series is: Learning strategies you can trust to help you flourish in medical school and free up time to live your life. As I think back to my countless nights of fearful cramming (which I now know to have been largely ineffective) I wish someone had offered me this in my first year of medical school!

Being a good doctor (and a human being)

If the acquisition of medical knowledge can be streamlined, time and attention can be directed towards the other important bit of doctoring, being a human being. This is a tricker gap to fill because a ‘good’ human being cannot be manufactured. Goodness is grown. The point of the HHFs work in this vein is not to introduce moralistic ideals that students should learn, but to encourage individuals to seek out their own core values: the things they really care about. Asking ‘What does good mean? What do you want to do with your work? How do you really think and feel about the future?’ We believe that someone who has truly engaged with these questions will have more chance to make their work sustainable, meaningful and progressive.

There is no absolute way to do this. Individuation is a unique and, by definition, personal process of seeking to live more consciously. Each person’s circumstances will be unique, but the whole of life can be part of the process: all conversation, suffering, celebration, travelling, reading, relationships, work if the individual can more fully engage with their life and begin the search. The prerequisite is an attitude of care, curiosity and openness in the absence of overwhelming oppression from outer forces.

Once at medical school our experiences become more constrained. Our vocabulary is tailored to the medical context, our friends are often fellow medics, we settle into a routine, and, in the latter years, we are in a hospital every day with sick people. Hemmed in by such powerfully polarised experience there is little room for finding oneself. In fact, some who have lost their true self in the dark may feel misrepresented and confused if any light gets through.

To remind readers, medical students in Scotland begin their career at the age of 17, fresh from their parent’s kitchen table and their high school exam hall. Some will be doctors responsible for the care of patients at 22 years old. Students have said to me, ‘This (individuation) isn’t the responsibility of the institution: it’s there to make doctors’. If we had a workforce of motivated and happy individuals, a buoyant healthcare system and a hopeful public health trajectory, I would be more inclined to agree. But we don’t, so in the existing circumstances, our quality of work is bound to suffer unless we have a strong base in who we are and what we care about. Because being doctors, if our work suffers, so to do our patients.

My belief is that the traditional medical school system is a counterproductive environment for the development of individuals and as such is implicated in making and sustaining a toxic health climate with rock bottom morale of the medical workforce. As a first response to this problem, the HHF is creating an environment for stimulating critical thinking and personal development in medical school. We run a fortnightly discussion group about health and care, philosophy, spirituality, sociology and ethics, using everything from poetry to epidemiology to ignite the conversation. It is a student-led, bottom-up approach for facilitating ideas and creative thought. Eventually, we hope to normalise this sort of discussion in medical school.

Being a good doctor (in the community)

The third gap in the medical curriculum is the disconnect between medical students and the community. No one would argue that doctors’ clinical acumen should develop alongside a truthful understanding of the people they will eventually apply it to. Yet medical school remains largely walled off from the community and unresponsive to the societal problems at the root of many modern diseases.

Engaging in the community would sensitise students to these problems and how they affect human beings day-to-day; what people are like and what they face before they present at hospital in extremis. Hopefully, more of us would then be motivated to make things better, or at least not make them worse. At base, a genuine sense of care for ordinary people is essential in medicine; medical education confined to a tutorial room or hospital limits the scope of that care and hampers bigger-picture thinking.

So, to fill this gap, the HHF has made connections with community organisations in Glasgow for our ‘Service Learning’ project. We have created a system for medical students to volunteer in roles ranging from creative writing with people in recovery from addiction to cooking for isolated elderly members of the community. They do this not as trainee doctors, but as fellow human beings.

To tackle the problems now facing all healthcare systems requires a more progressively educated generation of doctors. The HHF is a small, growing team of freethinking students who are looking for ways to fill medical education’s many gaps and blind spots. Our work is not the ultimate solution to these shortcomings, but we are listening and responding as best we can to the heartbeat of our culture. Our platform is here to enable people to make the changes they feel need to be made.

If you are reading this and wondering about an alternative system for a better future, pick up that thread and follow it. It may take you months or years before it leads you somewhere that makes sense, but for the sake of your work and the future of health and medicine, we need you to engage with, not turn away from the problems that we face.

Reach out and get involved: humanisinghealthcare@gmail.com

Reference

Maslach C & Jackson SE (1981) The measurement of experienced burnout. Journal of Occupational Behavior, 2 (2) 99–113.