What is a patient?
The question may seem simple, but the answer is less so. The definition of a patient, according to the Collins dictionary, is separated into two. A patient is a person who is receiving medical treatment from a doctor or hospital. However, the Collins dictionary also defines a patient as “someone who is registered with a particular doctor”.1 This introduces the concept that a patient may not always be actively in this role. The Cambridge dictionary goes on to include treatment by dentists in the definition and adds the temporal concept by saying that this treatment is “when necessary”.2
Who is a patient?
This leads us to the question, who is a patient? The easy answer is all of us have been or are a patient depending on the definition used and also our current situation. The issue for clinicians is that if we are patients, does this mean we are no longer doctors or nurses? Are the two roles incompatible? The GMC or General Medical Council states that bar minor ailments, doctors should not be making their own diagnosis nor treating themselves.3 But there is a step that precedes this, the realization that one is a patient or has an illness at all.
It is true that doctors, like everyone else, may be slow to consult, especially if they think that their ability to work as doctors may be compromised. There are different services available specifically for doctors with addictions of all types, such as the PAIMM program in Barcelona. With over 20 years of service, they have given a lifeline to many patient doctors.
More recently, with the COVID pandemic, there has been more acceptance of the mental as well as physical load that clinicians of all types carry. Telemedicine and other types of consultations for this are now mainstream and increasingly spoken about. Whether through your own doctor or physicians association, there are many options available.
Becoming a patient gives the doctor a new perspective which can then be a positive addition to their own practice. At the Barcelona College of Physicians or COMB, there is a think tank that aims to build on these experiences. Janus, the Roman god with two faces, represented transitions and dualities. Based on doctors’ experiences who in their literal positions as patients hope to empower patients in all aspects of their journey. From painting the emergency department ceiling in colours to having more collaborative round tables in offices, the objective is to rehumanize medicine. In the NHS, you can find a similar project; the Re-humanising blog gives a voice to the stories of patients we see or our own experiences as clinician-patients. Take a look, and you will find something that will resonate and which is not always easy to talk about, even with those going through the same experiences.
Moral injury
The reasons that doctors and other healthcare professionals become unwell are multiple. From specifically work-related risk factors such as shift work to diseases present in the non-medical population, we can all become unwell at any point. However, there is also another aspect that is not talked about so often. Moral injury. In order for moral injury to occur, the individual must feel like a transgression occurred and that they or someone else crossed a line with respect to their moral beliefs.4 Guilt, shame, disgust and anger are some of the hallmark reactions of moral injury.5 These are definitions that come from the world of war veterans, but healthcare workers, who at times may be working in settings comparable to that of warfare, are also subject to moral injury. Burnout has often been used to describe healthcare worker distress, but this refers to a situation where there has been excessive demand on resources and strength.6 What we may be looking at is instead moral injury which has a different origin and solution. Dr Wend Dy Dean explains that “as clinicians, we are increasingly forced to consider the demands of other stakeholders—the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security—before the needs of our patients.”7 Specifically in the COVID pandemic moral injury may be caused by the inability to enable loved ones to be present at the death of their family member or feeling let down by others with respect to their own personal safety whether it be PPE or face-coverings.8 Recommendations for the healthcare setting include preparation for the likely moral injuries they will face,
processes to support shared team decision making and responsibility, peer support mechanisms and programmes so that staff reporting psychological distress should be identified early and offered specialist support.8
Resilience – institutional, not individual
Resilience is another term that is much used when referring to the stresses facing healthcare workers. Measures offered to improve resilience include mindfulness training or lifestyle changes.9 There is, however, increasing criticism of this approach which leaves it up to the individual to increase their resilience when the causes of the stresses are institutionalised.7
Portfolio careers.
Numbers of clinicians of all types thinking about leaving medicine completely or partly are at an all-time high.10 However, this may not need to be the way to get past a work situation that no longer feels sustainable. There are many reasons why medicine no longer feels fulfilling, including, dare I say it, boredom.11 Identifying the cause of your frustration is the first step. You can use a career coach specializing in medics, or you can use a tool such as the SCAN career planning model.12 This model consists of self-awareness, career exploration, arriving at conclusions and looking at your next options. Although more prevalent in certain countries and certain specialities such as family medicine, there is actually no medic who could not make this work for them. Often in medicine, we have followed a set path, and our non-medic friends can be the ones to show us how a job is not a job for life but rather a stepping stone and acquisition of talents. Recruiters can see your potential and transferable skills. Looking at your career through the eyes of someone else non-medical can open new doors without leaving medicine altogether.
What to do?
- No shame – talk to yourself as a patient.
- COMB resources or BMA – specialized in doctors as patients.
- If you see someone else, you are worried about talk to them about it.
- Know your place in the universe, understand the concept of moral injury and how it may not be a case of being more resilient.
- Leaving medicine may not be the only road ahead, think of harnessing your expertise and strengths to create a portfolio career.
Resources
Bibliography
1. Collins English Dictionary. Patient definition and meaning | Collins English Dictionary. https://www.collinsdictionary.com/dictionary/english/patient.
2. Cambridge English Dictionary. PATIENT | meaning in the Cambridge English Dictionary. https://dictionary.cambridge.org/dictionary/english/patient.
3. General Medical Council. Managing your health condition – GMC. https://www.gmc-uk.org/concerns/information-for-doctors-under-investigation/support-for-doctors/managing-your-health/managing-your-health-condition.
4. Litz, B. T. et al. Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review 29, 695–706 (2009).
5. Norman, S. & Maguen, S. Moral Injury – PTSD: National Center for PTSD. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp.
6. Freudenberger, H. J. The staff burn out syndrome in alternative institutions. Psychotherapy 12, 73–82 (1975).
7. Dean, W., Talbot, S. & Dean, A. Reframing Clinician Distress: Moral Injury Not Burnout. Federal Practitioner 36, 400 (2019).
8. Gov Wales. Technical Advisory Group. Moral injury in health care workers during the COVID-19 pandemic. https://gov.wales/technical-advisory-group-moral-injury-health-care-workers-during-covid-19-pandemic-html.
9. NHS Professionals. Health and Wellbeing. https://www.nhsprofessionals.nhs.uk/Health-and-Wellbeing.
10. NHS faces exodus of doctors after Covid pandemic, survey finds | NHS | The Guardian. https://www.theguardian.com/society/2021/may/03/nhs-faces-exodus-doctors-covid-pandemic-survey.
11. Rimmer, A. How can I avoid getting bored mid-career? BMJ 371, (2020).
12. Portfolio Careers for Health Professionals | London. https://london.hee.nhs.uk/professional-development/careers-unit/careers-resources/portfolio-careers-health-professionals.
Dr Alice Byram 