I didn’t warm to Bella when I first met her. As I described how I worked with clients, I gained the distinct impression that she was somewhat contemptuous of what I was saying. By the end of the first session, I realized that my initial impression was fundamentally incorrect. What I had initially taken to be disdain was actually a potent combination of shyness and wariness.
I had been asked to see Bella by her psychiatrist, who was treating her for depression. A couple months earlier, Bella had become so unwell that she was unable to continue in her first post as a junior doctor. Following a period of treatment (both psychotherapy and medication), her psychiatrist felt that Bella was now well enough to consider whether she wanted to resume her medical career. And that is why her psychiatrist had contacted me and asked whether I would be able to have some sessions with Bella.
To be uncertain about how to write up a laboratory project is one thing; to be uncertain about what to do when faced with a sick patient is quite another.
Her psychiatrist told me that Bella was exceptionally able, winning prizes in both medicine and surgery at medical school. On paper, there were few indicators that she would be totally overwhelmed by the transition from medical student to junior doctor; she wasn’t one of the medical students who had needed to repeat years in medical school because of recurrent exam failure or poor health. But as I talked to Bella in the first session, it became clear that she had experienced mounting dread as her first day of work approached. She knew she lacked the confidence to assume responsibility for treating patients.
Over the years, I have seen a number of junior doctors who became so distressed in their first posts that they had to stop work — at least for a period of time. When you explore their medical school history, you find that, almost without exception, these doctors have had previous episodes of depression and anxiety. These episodes may not have resulted in a psychiatric referral but have been managed by a GP or sessions with a counselor at the university counseling service. And this is what happened to Bella: A couple years earlier, while doing her undergraduate research project, she lost a considerable amount of weight and started to have problems sleeping. Although Bella wasn’t referred to a psychiatrist at that point, she had been to see her GP, who prescribed a brief course of antidepressants.
Bella told me that her undergraduate research supervisor found her annoying, and she ended up being poorly supported. Working on the research project was the first period in Bella’s life when she didn’t know what she needed to do to excel academically. Bella’s supervisor had never before supervised a medical student’s project and was more interested in using Bella as free labor in the laboratory than helping her write up her research. Faced with an unresponsive supervisor, Bella felt desperately unsure about what to do. “I felt on the precipice of failure,” she told me.
To be uncertain about how to write up a laboratory project is one thing; to be uncertain about what to do when faced with a sick patient is quite another. If you make a mistake in your write-up, at worst, your project won’t be awarded the top grade. If you make a mistake when looking after a sick patient, the worst thing that can happen is that the patient can die. A medical student who has become significantly depressed when faced with the uncertainty of writing up her research should have been identified as somebody who might be overwhelmed by the uncertainty inherent in treating patients. However, as Bella was so strong academically, her vulnerability remained undetected. (In the end, she was awarded a first-class grade for her dissertation.)
Final-year medical students have to complete a health declaration form that is forwarded to the hospital where they will be working in their first year. Bella told me that she remembers being uneasy when faced with the form; as the depression she experienced when working on her research project had never been formally diagnosed by a psychiatrist (although she had been prescribed antidepressants by her GP), Bella persuaded herself that she was under no obligation to mention it. She didn’t want to be singled out as different — as vulnerable and weaker than her peers. At the same time, Bella knew that she was being less than truthful on the form, and it added to her sense of foreboding as her first day on the job approached.
An additional blow to Bella’s confidence, prior to starting the foundation program, was that she scored far lower than predicted on her Situational Judgement Test, devised to assess young British doctors’ practical capabilities. Her lower-than-expected (although still average) results added to her sense of mounting dread. A more responsive (and responsible) medical school system might have picked up on the marked difference between her academic performance (where she excelled) and her SJT scores. The latter test maps more closely onto the complexity of day-to-day clinical practice. But nobody other than Bella herself foresaw a difficulty.
In a way, Bella was a victim of her previous success. “I was somebody who had never really struggled academically, and my academic achievements and career were a big part of my identity,” she told me. And, she continued, “It was particularly difficult for me to feel that I was struggling.”
Bella talked movingly about how hard she found it to trust other people, or herself, and she linked this to some traumatic experiences in her childhood. Before she even started her first job, she knew that she would find the psychological demands of clinical work challenging. While she understood what she described as the “mantra” from medical school that one should always ask for help, in practice even minor clinical decisions caused her considerable anxiety. In her second week at work, she was on call at night and had to cover all the medical patients in the hospital; Bella struggled to know when exactly she should be paging her senior (who was in a different part of the hospital) and when she should manage on her own.
A month or so into her first job, when Bella was working in the emergency room, a patient was admitted close to the end of her 13-hour shift. While other trainees might have busied themselves with paperwork until the shift was over, Bella started to attend to this patient. She continued treating him until he was stable and all the necessary tests had been organized. Then, exactly as Bella had been instructed at induction, she went to find her senior to ensure a safe “handover” of the patient. Bella went by the rule book, which explicitly stated that she was not to work more than 13 hours.
The senior, probably stressed with her own workload, reacted with fury, shouting at Bella in front of the whole team, and accused her of being irresponsible. Bella was ordered to stay for as long as it took to continue treating the patient and ended up working a 15-hour shift.
“What really shocked me was that I worked so hard and followed all the rules, but I still ended up getting shouted at,” Bella said.
Feeling too exhausted to drive home, Bella retreated to the restroom, where another colleague found her sobbing in the corner. “I couldn’t bear the fact that she found me crying,” Bella told me. After this incident, she asked to be taken off the night rotation, but with her confidence in shreds, an insidious depression spiraled rapidly out of control.
How is it possible for somebody to slog their way through a six-year medical degree, do brilliantly in finals, and then last just 10 weeks in their first job?
Bella did exactly as she had been instructed to do in medical school — she asked her supervising consultant for help. And his response? “Of course this is how you feel. You’re in your first year of practice. You’re a girl. You’re going to be upset.”
For somebody as proud and determined as Bella, admitting to a senior that she was in difficulty was far from straightforward. “It was a huge thing to ask for help,” she said. “And then only to be dismissed….” Bella’s voice trailed off.
Ten weeks into the job, Bella was so depressed that she was signed off sick and referred to the psychiatrist who later contacted me. As I slowly got to know Bella over the following six months, I gained an increasing respect for her determination, bravery, and openness. She was an extraordinarily impressive young woman. I also learned that, far from being haughty, she actually struggled with an acute lack of self-confidence.
Bella never resumed her career in medicine. As is often the case, although her family was initially disappointed that she wasn’t going to work as a doctor, they were actually far more concerned about her well-being and accepted her choice. It’s a couple of years now since Bella was first referred to me. Despite the fact that in our initial sessions Bella was convinced she would never be able to hold down a job, for the past 18 months she has been employed in a demanding role in the pharmaceutical sector. Judging from our recent telephone conversation, she’s no longer the severely depressed young woman who felt that she had no future.
But Bella’s case still makes me angry. How is it possible for somebody to slog their way through a six-year medical degree, do brilliantly in finals, and then last just 10 weeks in their first job? What does it say about medical school culture if a student feels like they can’t declare a history of psychological difficulties? How could a supervising consultant joke about Bella’s obvious distress?