Author: Joanna Cannon
This book is a moving narrative of how the idealistic dreams of a very passionate doctor were almost blighted by the insensitive culture of medicine. It is a disheartening account of how the author, coming to medicine relatively late in life, negotiated a healthcare system rife with failings, and steeped in heartless practices. The author reveals the harrowing pressures of practicing in the British National Health Service, with job demands that were so inhuman that they pushed her to breaking point. But she also depicts the steely determination which saw her through this very discouraging phase of her life. The autobiographical account also paints the author’s varied, and occasionally tragic, experiences before she started medical training. The book is remarkable for its recommendations to improve the quality of patient care, and to prevent the healthcare failings that lead to physician burnout.
The book’s major theme is the the harsh reality of practicing as a medical doctor, and the author graphically illustrated the physical and emotional consequences that often result from this. She recounts how ‘a job I had been so determined to do, and so desperate to be good at, had turned itself into my nemesis‘, and how her long-nurtured dream of become a good doctor ‘turned into a nightmare so vivid and so brutal‘ (page 3). At her lowest ebb, suffering from burnout, she was plagued by obsessive compulsive symptoms, poor appetite, and inadequate sleep, and at one stage she said ‘my goal each morning was to somehow arrive at the end of the day without losing my mind‘ (page 113). The grave emotional impact of her work was evident throughout the book, such as when ‘the misery and the death and dying…whittled away at me until there was nothing of that doctor left’ (page 114). She however made the very important point that the effects of burnout may not be visible to observers, as it is often hidden ‘behind a still and mirrored surface’ (pages 114 and 117).
The book did an excellent job of exploring the reasons why, for many doctors, medical practice turns out to be a bitter and cruel reality. A major factor the author identifies is the resource-limitations of the British National Health Service under which she practices, saying that the NHS ‘bends and breaks under the strain of the endless demands placed upon it’. She argues that, by disempowering doctors, the system stifles their dreams of becoming ideal physicians, and hinders their efforts at making a difference to their patients (pages 103-104). Beyond the systemic factors that make experiences of doctors unpleasant, the author also exposed the cruelties which hospital staff and fellow medical doctors mete out to each other; an example is the consultant who rebukingly listed her inadequacies, thereby ‘carefully dismantling the very last pieces of my self-belief, reducing me to nothing‘. She pointed out, rather sadly, that these ‘quiet and petty cruelties…took my sense of loyalty and allegiance, and removed it, piece by piece’ (pages 116 and 114).
The most important concern the book highlighted is the failure of healthcare to address the emotional dimensions of medical practice. Indeed, early in her training, the author discerned that ‘in medicine and surgery…you do not ask people how something feels‘ (page 13). She also discovered how little time doctors have to process their thoughts and feelings about the numerous tragedies they encounter, consumed as it were by the ‘dangerous pace’ of their work. This, she argues, is compounded by the expectation that doctors should not become emotionally invested in their patients, and that they should rather shield themselves from their suffering (page 33). She condemned this unwritten taboo of medicine, arguing that ‘sometimes, walking across that space towards a patient is the only thing we are able to do for them’ (pages 63, 34, and 71). Indeed it is her dissatisfaction with the lack of emphasis on emotions in both medicine and surgery that reinforced her decision to work in psychiatry; there she was able to start mending herself by witnessing ‘small moments of compassion‘, and learning ‘about the resilience of the human spirit’ (pages 156-157).
Perhaps the most helpful aspects of the book are the author’s recommendations to doctors on how they may improve the emotional care of their patients. For example, she highlighted the importance of giving their patients hope, because this is ‘the most important ingredient with which to mend a damaged life’ (page 32). She cautioned doctors to choose their words carefully when speaking to their patients, stressing that ‘some words are so heavy that, whether you mean to or not, handing them over to someone else can change a person forever’ (pages 39-41). Her recommendations were particularly instructive with regards to how doctors should handle matters relating to death, a subject which, she observes, remains ‘silent, hidden away behind curtains and codes and acronyms‘. She encouraged doctors to speak more openly about death, and to resist the urge to ‘rage and fight and argue with death until the very end, as if it acts as some kind of barometer of our usefulness‘ (page 52). On the contrary, she advocated the palliative care approach to death, which is to have ‘honest, open discussions‘, and to give the dying ‘a sense of choice of empowerment, not an air of defeat‘ (page 53).
Whilst the overall tone of the book is serious, the prose is often striking for its humour. This was evident, for example, when the author described how difficult it was to keep up with the fast pace of a surgical consultant on his ward round: ‘we scrambled behind him, trying to keep up, arguing with unruly cubicle curtains, which were no sooner drawn to, than he was on his way again-and the notes trolley became a vehicle of chaos‘ (page 83). In many paces, her wit takes on a sarcastic tone, such as when she said ‘there are different kinds of registrars-those who enjoy bleeping you every hour to find out exactly what you’re up to, and those who like to walk the corridors alone’ (page 87). The prose is also elevating in many places, for example when the author described the depth of her burnout: ‘it felt as though the frame of my existence-the fragile scaffolding that held me together-was beginning to snap and splinter, and if no one reached out to help, if no one noticed, the very sense of who I was would soon be spilled from me and lost forever‘ (page 1).
This relatively small book is full of insights into the failings of medical training and practice. It particularly highlights the causes, manifestations, and consequences of burnout, and it makes recommendations to health care on how best to redress the emotional deficits that underly it. The author’s criticisms of the British NHS is somewhat harsh but it underlies a serious concern of how systemic issues compromise the physical and emotional health of doctors, and how they impact on the quality of care doctors provide their patients. The author’s impression that compassion is more prevalent in some medical specialities than others is perhaps too anecdotal, but the comment is a call to all medical specialties to improve the culture of practice within their teams, and in their interaction with patients.
The depiction of the emotional toll of medical training and practice is harrowingly graphic. The author identified the causes and consequences of burnout, and she addressed the remedies in detail. The subjects the book addresses are very topical, and they are equally relevant for practitioners and healthcare organisations. The author’s passionate compassion for patients runs throughout the book and is a model to emulate. I recommend the book to all doctors.
Publisher, Place, Year: Profile Books, London, 2019
Number of chapters: 22
Number of pages: 163
Star rating: 5