Book Review: Doctors as Patients

There are inevitably many comparisons and contrasts between this book and Doctors as Patients. Written by doctors for doctors, it is more specific than the title suggests as it is about doctors' experiences of 'mental illness'.

Their intended audience is doctors, medical students and NHS management. Their goal is to fuel a debate on the mental health of health professionals – to raise awareness, encourage appropriate action and support, and reduce stigma.

The book arose from the work and discussions of the Doctors' Support Network (DSN), a self-help forum for doctors. Petre Jones edits contributions from 24 doctors, active in a range of fields from general practice to psychiatry, with a forward from the President of the Royal College of psychiatrists. The contributions are distributed across three parts. The first contains ten autobiographical case histories of 'mental illness', a thematic summary and treatment issues. Part two covers topics like stigma, discrimination and GMC procedures, and some poems. Part three covers practicalities like flexible working, financial issues and support organisations.

It was interesting to read a current and inside view of the medical profession's attitude, albeit from a small cohort, towards 'mental illness' amongst its own ranks. I found the first section an absorbing read, although disappointingly focused on 'absolution in chemicals' to paraphrase Helman. The second and third parts were less interesting for me than may be the case for the intended audience.

In his introduction Jones is careful to clarify that this book is not about 'burn-out or professional exhaustion' but about 'diagnosable, label-able mental illnesses'. I found this distinction confusing as most contributors talked of overwork, burn-out and depression as well as, in some cases, 'label-able mental illnesses' such as bipolar disorder, bulimia and self harm.

Setting the scene, Jones enumerates data about depression and suicide rates in doctors and some of the stress factors – the intensity of the work, the responsibility and the emotional wear and tear from dealing continually with critical life events. He says there is minimal workplace support and nothing that equates to the supervision that psychotherapists have. The potential impact not only on doctors themselves but on their patients and the NHS is highlighted.

Jones asks why some doctors succumb to mental illness and not others - he invokes research showing 25% are vulnerable. He briefly considers a relationship between choice of career and 'psychological scenarios'. He suggests it may be 'occupational therapy for some' and invokes ideas from Bowlby (compulsive care giving) and Malan (helping profession syndrome) but these issues are not elaborated or re-visited later in the text. So his question of whether the high rates of mental illness arise from the nature of the work or the people drawn to it, is left open. It may be relevant that in half of the case histories people reported depression and/or low self esteem since childhood but this is not pursued.

Several contributors describe the medical culture as macho and requiring doctors to hide or minimise their difficulties, combined with a widespread compulsion to work very hard. They experience shame for failing 'to live up to the myth of the invulnerable doctor' and fear of being judged harshly by their colleagues and by the GMC – a very real possibility for a doctor with a mental illness diagnosis. Given this context their bravery in coming out as 'their to human frailty and illness like anyone else' is to be applauded.

Although a key theme of the book is that mental illness need not be a bar to a medical career outcomes for the ten case histories varied considerably. Some continued working full time throughout their illness, others took considerable time off and one has been out of work for six years. Most resumed work afterwards but in a different way - several changed jobs within the profession (typically to a lesser job, in career terms), some adopted part time work (also a downwards career move). One describes himself as continuing working with a 'severe mental health problem', another accepts he will 'never be happy'. Put in a more positive light, many had found new ways of living and working more conducive to well being. Several said their experience had taught them to be more sensitive to depression in patients.

They attributed their difficulties mainly to stress at work and performance anxiety but also to life events and genes. Half said there was a family history of depression or mental illness. The overriding impression is that they all believed strongly it was an illness, or a disability, and mainly a biological / chemical problem.

Everyone took medication of some sort, as the first and principal remedy. Outcomes varied. Some felt worse, some said it had no effect, some felt better. The majority all remain on medication, in some cases many years later, even those who said they felt no better or happier. There is no discussion about the value of medication and its side effects. It is viewed as inevitable.

Only half tried therapy (mostly CBT). Lest we existential therapists jump smugly to the conclusion that this is why they did not recover, the only two who reported a return to full health and their original choice of work had both undergone ECT and no therapy. Perhaps this reflects Helmans' wisdom about working within people's system of ideas and beliefs, and placebo effects.

For the majority a definite diagnosis seemed to be important. One sounded indignant that at 35 he was 'still unlabelled' but later on was piqued when a psychiatrist announced he had a personality disorder 'for no apparent reason'. Another was concerned that his psychiatrist was baffled by symptoms that did not fit the text book. To invoke Helman again, they appeared to seek comfort in diagnosis, like a 'spirit possession' bringing 'relief in the idea that it's not their fault' even if the meaning of the illness remains obscure and the suffering continues.

The book's aim of presenting what it is like when illness strikes well and it could be a source of comfort and useful information for doctors and students interested in this topic.

Whether it will succeed in provoking NHS management to take action I am doubtful. I imagine only the 'converted' would read this book. It is presented in a self-help format rather than one that would help achieve this goal. The narrative, experienced based style leaves the reader to pick the bones from the text and what is needed is a section making explicit and summarising their ideas for action.

I also doubt their goal will be achieved of converting readers to viewing mental illness as 'no more taboo than a broken leg'. The book presents a picture of emotional and psychological stress and disrupted, thwarted lives that is hard to equate to being a doctor with a broken leg or a hernia – the qualitative differences are made very clear. But it is to be hoped that their bravery in telling their stories will encourage greater readiness in others to seek help before spiralling down into a much worse situation. Its main achievement is likely to be attracting new members to the DSN for mutual support and information.

Most contributors do resolve their difficulties, at least partially, by changing their way of being. They view life and work differently as a result of their experiences and they nearly all make profound changes in order to minimise the things that stress them. The book contains stories of courage and heroism but this is downplayed and portrayed more as a sad situation than as a triumph over adversity, an adjustment to life and a more realistic engagement with one's possibilities and limitations.

There are many assumptions in the book left unchallenged and unexplored which I found frustrating. For example, the notion that being a doctor is more stressful than being a non-medical professional. Jones says admission rates for mental illness for doctors is higher than for other professions but maybe doctors are more prone to construe such difficulties as illness and to seek admission.

I have worked with many professionals in distress, ranging from lawyers to vicars. Most of the issues raised here are common to all. Other professionals also face discrimination and stigma and the possibility of losing their jobs if they can't 'cut it' in the workplace. Many also work with clients facing critical life situations. Most also fear no longer being a member of their profession because like these doctors 'it becomes who you are'. The intense workload, the responsibilities and the cost in well-being are overwhelming to many. The authors of Doctors as Patients are surely right to raise the difficulties of modern professional existence but, I feel, wrong to imagine that they are alone in facing these or in some way special. Although there is a tradition of support built into psychotherapy (i.e. personal therapy and supervision) I wonder how psychotherapists fare in comparison with medical doctors and other professions.

Perhaps it's more a story of our times.

Diana Pringle