"The Doctor's Art" is a weekly podcast that explores what makes medicine meaningful, featuring profiles and stories from clinicians, patients, educators, leaders, and others working in healthcare. Listen and subscribe on Apple, Spotify, Amazon, Google, Stitcher, and Podchaser.
For all the deeply rewarding moments medicine offers, it is also a profession often intensely challenging on both systemic and personal levels. This week's guest is Caroline Elton, PhD, an occupational psychologist who has devoted her career to counseling doctors and medical trainees in the National Health Service and various medical schools in the U.K.
She is the author of Also Human: The Inner Lives of Doctors, which discusses the physical, mental, and emotional toll of medical training and practice. Among other issues, she writes about how doctors deal with guilt and shame, gender and racial discrimination in healthcare training, the erosion of the clinician-patient relationship in modern medicine, and how clinicians can build emotional resilience.
Over the course of her conversation with Henry Bair and Tyler Johnson, MD, Elton shares what led her to this work, exposes the many shortcomings in how doctors are trained today, and explores how we can create a more humane path forward.
In this episode, you will hear about:
- 2:04 What led Elton to her unique work in counseling physicians
- 10:01 Reflections on both the compassion and the callousness Elton witnessed as she observed physicians (her patients) in their working environments
- 15:16 A review of medical training in the U.K. versus the U.S.
- 19:51 A discussion of Also Human: The Inner Lives of Doctors and the concept of moral injury
- 25:00 The kinds of patients Elton sees in her present work
- 27:03 How institutional cultures can come to valorize toxic, brutal expectations placed on physicians
- 32:49 How Elton managed her first patient, a doctor who was planning on quitting medicine just weeks after beginning her postgraduate training
- 38:20 A discussion of how sexism and other forms of bigotry factor into burnout
- 43:37 Why the screening process for selecting future doctors should be improved
- 48:00 How a trainee can prepare themselves for the psychological demands of a medical career
- 50:34 Advice to administrators and executives on how best to serve the psychological demands of their medical workforce
Following is a partial transcript (note errors are possible):
Bair: You are unlike many of our guests, in that even though you are not a clinician, you have an intimate perspective on many of the issues we often discuss on this program, such as moral injury and burnout. Can you tell us what first led you to a career in psychology and how you came to focus specifically on helping doctors who are struggling with their work?
Elton: In terms of how I first got interested in psychology, I think this was something that interested me really from a very young age. I was interested in what was going on in my mind, what was going on in the minds of those around me, what made people tick. And I think that at least in part, that was due to the experience of growing up with a brother who was 9 years older than me, who was profoundly autistic.
And interestingly, in the literature, there's evidence that those who grow up in a household with an autistic sibling are more likely to go into the helping professions: teaching, psychology, medicine. So in terms of my draw towards psychology, I think that the experience of growing up with my brother was a very big thing.
As to how I came to support doctors, you know, I certainly didn't finish either my first degree or even my second degree, thinking I know what I'm going to do. I'm going to go off and help the medical workforce. So, for me, I could identify kind of three big random events that led to me ending up in what I'm doing. The first is when I was doing my PhD in psychology in the department of academic psychiatry in one of the big London teaching hospitals, University College London, I hit a bit of an impasse. I was actually researching something very different from what I do now.
It was a health psychology PhD and I realized I'd made a miscalculation as to how long it was going to take me to get a sample and that I needed to approach other hospitals in order to get an adequate sample and all of that. I'd had to go through the Ethics Committee process again. So, essentially, I was in a bit of a hiatus and an opportunity came to work as an education advisor.
Briefly, I had been a secondary school teacher before becoming a psychologist, and I took this opportunity to work as an education advisor whilst I sorted out my PhD impasse. It was supposed to be for 6 months but actually did it for a couple of years and then went back to my PhD, finished my PhD. So that was random event number one, which really only became relevant with random event number two.
I had finished my PhD and I was looking for postdoc positions. This was 25 years ago, and a job caught my attention that I hadn't thought of going into this line of work, which was in medical education. And the focus of the job was to improve the quality of teaching that hospital doctors gave to their medical students, to their residents or trainees, as we call them. And it was an incredible job in that it turned the usual model on its head because, typically, at least in the U.K., hospital attendings, hospital consultants, as we call them, what we do is that you'll scoop them up and you'll send them off to a lecture or workshop or whatever on kind of pedagogical theory, pedagogical practice.
And this innovative project turned that, it flipped it over, and said, why are we doing this? Why are we taking the attendings from their work? Let's send an educationist or a psychologist to the attendings. That way the attendings didn't need to cancel their clinical work to come to a lecture on education. But also, and more importantly, the conversations that we had were really detailed and specific to the actual reality of teaching in a clinical setting for that particular clinician. Because if you're a forensic psychiatrist or you're a pathologist or you're a surgeon, your training challenges are likely to be very different.
So I saw that job and it looked interesting and you needed to be a teacher. Tick, I'd done that for a few years. You needed to be an education advisor. You needed to have had experience of training other teachers, which I only randomly had because of the interim job whilst doing my PhD. And you needed a PhD, which I'd just finished. So I applied and I got it. And that was my initial introduction to medical education and it was a phenomenal introduction, a phenomenal one, because for a non-clinician, I just, you know, I got scrubbed up and went into theater and watched how that surgeon was teaching their trainee.
I sat in on a supervision session with a psychiatrist, with their junior doctor talking about the suicide of a recent patient and the senior psychiatrist kind of coaching the junior through that. And I'm watching and then later coaching the senior psychiatrist. I went everywhere and anywhere, and it was just incredibly interesting at times, very challenging. And the most extraordinary introduction to the practice of medicine that a non-clinician could ever really get.
Because I had changed from a teacher to a psychologist, I got interested in the whole process of thinking about one's career from a psychological point of view. And when I finished my PhD, I did a vocational psychology, occupational psychology, we call it, both terms are used, training. And in my early years working in medical education, I got involved in occupational psychology and career coaching and I was coaching everybody other than doctors, and I was doing this educational observation work and I had two parallel unjoined-up streams.
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