Book Review: Doctors as Patients

Although about the practice of general medicine, Helman describes Suburban Shaman as a 'mosaic of memories' rather than a single story. His aim is to share some of the lessons he has learned from his patients and from different settings about the nature of healing and medical care. There are 24 chapters, arranged in topics such as Medical School, Possession, Boundaries, Healing Time, Shamans, Placebos. Helman is as much if not more concerned with the underlying emotional distress and meanings than with the outward physical ailments he encounters.

A South African, Helman comes from a family of 13 doctors starting with a 'village practitioner' 200 years ago. He grew up and trained in medicine during the apartheid era and he describes some of his experiences in mental health there, such as the Whites Only wards and the different 'culturally appropriate' treatments for Blacks, which led to his belief that diseases are partly a function of time, place and circumstances. For example, Addison's disease, which causes darkening of skin pigmentation, had a particular meaning and set of consequences for 'Mr Pritchard' a White European living in apartheid South Africa.

Helman moved abroad after graduation arriving eventually in London where he worked as a GP. His stories of his encounters with the British public are variously funny, humane and poignant. Like the lonely pensioner whose 'bowel movements are his artwork, his creativity, the daily fruit of his inner self… the greatest source of novelty in a sad and solitary life… "Doctor, I'm still in the toilet. Please come in here. The door's unlocked. I just want to show you something. Something very interesting…"'.

His career includes research at Harvard Medical School, studying anthropology and working in medical aid programmes in the Third World. Along the way he explores his interest in shamans and folk healers and concludes that different types of healer (medical or not) have much in common. He suggests surgical operations can be viewed as allegorical performances where masked actors become heroes confronting the cosmic forces of Disease and Death. He contrasts British folk ideas about 'germs' with traditional ideas about 'spirit possession' - in both cases the patient finds relief in the idea that it is not their fault.

Helman suggests the placebo effect is the weak link in the medical paradigm and declares that most forms of healing are 'theatrical performances designed to enhance this effect'. He believes that to be a good doctor (or healer) you have to be 'a compassionate chameleon, a shape-shifter, a shaman' adapting to the patient's world and working within their system of ideas and beliefs. In the case of an Indian woman who believes her ex-husband has put a curse on her and whose behaviour and beliefs seem bizarre, possibly psychotic, Helman does not diagnose or section her, instead he supports her wish to consult a Vaid and she slowly recovers, although it turns out later the Vaid is a fake, not at all the real thing!

He bewails the gradual demise of the old style family GP, that treated the whole person as well as their disease in the context of their home, family and community, and the rise of what he calls the 'techno doctors' whom he fears have too narrow a focus, too great a faith in technology and a misguided belief in the possibility of ultimate certainty.

He believes medicine is not just about science but also stories, the mingling of narratives among doctors and patients, and the absolute necessity to understand the storyteller as well as the story.

For him medicine is about doubt and ambiguity, ethical dilemmas and the limits of human expertise, and the need to be open to surprises and mystery. Technical skills are necessary but not sufficient. People also want compassion and care, to make sense of what's happened and to be helped to cope. Even where he cannot cure he tries to heal, to restore balance and well being if not health.

Helman was originally attracted to psychiatry because it dealt with non-material aspects of the human condition but he found it was an 'even more secular discipline' offering absolution in chemicals. In disillusionment he came to view it as imposing a medical grid on the human condition, attempting to control its unruly behaviour and emotions. He has read Laing and Szasz and 'other psychiatric heretics', and many ideas familiar to an existential psychotherapist are found in this book.

He takes a sideways look at the hierarchical medical world and its rituals, like the Consultant's 'Grand Rounds' which he views as a weekly mystery play where the Consultant keeps his trainees in suspense while he first elaborates all the dimensions of the mystery and then slowly reveals not only the solution to the (very difficult) puzzle but also his astonishing skill. Helman describes this is as a healing ritual for the doctors themselves, a way of dealing with ambiguity and doubt, where the mystery ends comfortingly in diagnosis and coherence. The meaning of life may still not be clear but at least there is a precise cause of death.

He also records his own experience of being a patient, when he briefly joined the ranks of the 'Trolley People… a new species of centaur: half human, half trolley', and what it's like to be a treated as a collection of organs, 'a Babel of parts' with no person / soul / spirit at the centre, where the 'techno-doctors' have no need to attend carefully to the patient's story because they have their diagnostic machines.

Reflecting on boundary issues in the GP/patient relationship, he describes his own experiences where a folie à deux or collusion can develop, with both participants trying to meet their personal needs through the relationship, where boundaries can become blurred and emotional burnout ensue. He thinks people who are attracted to medicine often have motivations that need exploring if the practitioner is to be good at his/her job and avoid burn-out.

Overall the book is well written and achieves the author's aim of describing and reflecting on a long and varied experience of general practice in the community and the value of remaining open to other ways of healing. It retained my attention because of its existential attitude and acceptance of the value of psychotherapy and many other approaches to healing. In essence it is about integrating modern medicine with the wisdom and insights of traditional healers and aspects beyond the purely physical. The style is succinct, witty and simple but nonetheless an interesting and thought provoking read. Although not an academic book he does include a bibliography with some enticing entries for further reading.

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 'infallible 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 someone well met 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