EP139: Good Enough: Redefining Standards for Doctors and Mothers

The Emotional Realities of Medicine: Conversation with Dr. Caroline Elton

In this insightful episode, Dr. Caroline Elton, author of Also Human, explores the psychological and emotional challenges that doctors face due to high societal expectations and insufficient mental health support. The discussion addresses how these pressures contribute to burnout and the importance of recognizing and accepting imperfections, akin to the concept of a 'good enough mother'. Dr. Elton sheds light on the stresses of balancing a medical career with personal life, particularly for female physicians, and the cultural pressures within medical training and hospitals. The episode also delves into the necessity of emotional detachment for medical professionals, the concept of 'splitting', and the value of systematic, confidential mental health support. It emphasizes the role of senior clinicians in reducing mental health stigma and advocates for open discussions about mistakes and personal growth, benefiting both doctors and their younger colleagues.

00:00 Introduction and Guest Introduction

01:06 The Unrealistic Expectations on Doctors

02:08 Psychological Impact on Doctors

02:34 The Concept of 'Good Enough'

05:14 Gendered Challenges in Medicine

08:02 Medical Culture and Psychological Toll

11:38 The Concept of Splitting in Medical Training

12:34 The Importance of Reflective Practice

13:02 Group Reflection and Its Impact

13:37 The Role of Feedback in Medical Practice

14:50 Addressing Physician Mental Health

16:46 Support Systems for Doctors

19:00 The Importance of Second Chances

20:04 Balancing Personal and Professional Life

21:02 Final Thoughts and Reflections

Transcript

Christine Ko: [00:00:00] Welcome to today's episode. I'm delighted to have Dr. Caroline Elton with us. Dr. Elton is a psychologist who has spent over two decades helping doctors navigate the emotional and psychological challenges they face in their careers. With academic credentials from Oxford University, the University of Pennsylvania here in the U. S., and University College London, she combines rigorous training with an empathetic, human centered approach to career support. Dr. Elton is the author of Also Human, a deeply insightful book that explores the emotional lives of doctors arguing that they face unrealistic expectations from society and insufficient mental health preparation from their training. The book is based on case studies and decades of experience. I'm so pleased to have her with us today to talk about the hidden psychological toll of being a doctor and what we can do to better support doctors. Caroline, how are you today? 

Caroline Elton: I'm good. Thank you. [00:01:00] I'm delighted to be, um, talking to you here from London, Christine. 

Christine Ko: I'm going to start off with a really important question. Why do we hold doctors to an almost superhuman standard?

Caroline Elton: The reasons are complex. Doctors are often held to an impossible standard. The most basic reason is that as humans are deeply relational animals, we need to feel safe. We need to feel that we're held in mind by somebody who can look after us. And that stems from earliest infancy, but stays with us throughout our life. A second factor is that doctors, to some extent, have become a victim of their own success. Because if you think what medicine has achieved in the last hundred or 150 years, if you can think about vaccination and the lives changed by that, if we think about treatments for cancer, for heart disease, if we think about the incredible things that can happen with organ [00:02:00] transplantation, that I think has also contributed to the kind of notion that doctors should be superhuman.

Christine Ko: What psychological impact do you think that this has on doctors? 

Caroline Elton: Doctors are also human, hence the title of my book. And I think that if they are aiming for and feeling that it's achievable and appropriate that they should be superhuman, they are going to burn out. There's a very famous psychoanalyst of the forties and fifties. He was a pediatrician and psychoanalyst, Donald Winnicott, British, who talked about mothers being good enough rather than perfect. And he talked about that actually in terms of not only the mother trying to be perfect, but also in terms of the child needing to learn over time. We're not talking about in early infancy, but gradually over development, the child [00:03:00] developing a more realistic idea of their parents and also learning to manage those disappointments because as they go from the sanctuary of the home, when they go out to nursery, where they're going to be one of many, and into a classroom later on, it's important for both partners to be good enough, not perfect.

Since Winnicott talked about the good enough mother, there is, if you look in the medical education literature, there are papers about the good enough doctor. And I think it needs to be talked about more. That's not saying doctors should be sloppy. Just as there are things that mothers can do that are neglect. It's not an excuse for dangerous parenting or dangerous medicine. But it is an excuse for an understanding. Perfection is humanly impossible. 

Christine Ko: I do like that parallel. I do struggle with the expectations I have on myself as a mother or parent and the expectations as a physician.

[00:04:00] More recently, I've been thinking it's the same thing. Did you watch the movie Barbie? 

Caroline Elton: The movie Barbie. Yes. 

Christine Ko: America Ferrara has that speech of, oh, it's so hard to be a woman. You have to sort of achieve this perfect standard and that's impossible. I feel like I need to be perfect and non human as a mother, I need to be perfect and non human as a physician, I need to be perfect and non human as a woman. It's almost like a message that's tripled over all three identities that I have. I listen to it. 

Caroline Elton: We should have t shirts, Christine, saying, Proudly Imperfect. Humanly Imperfect. It's complicated because obviously there is appalling parenting out there. I'm not advocating for that. And there is appalling medicine out there. There are things that should never happen. Often in both situations, but clearly in the clinical sense, often when they do happen, there are systems failures. That's why medicine has learned so much. [00:05:00] And that's all at our Gawande's checklist type of approach from understanding, from the airline industry, how you can put systems in place in theater and in other procedures.

But I think this notion of proudly imperfect. I think it's not trivial, actually [Yeah], because the burden it can put on women... We are far from a position where men and women are equally sharing domestic labor, both running a house and looking after any children. The burdens on women are greater. 

Christine Ko: Is it like that in the UK as well? 

Caroline Elton: Absolutely. Looking at it through a gendered lens, we know both in the UK, US, Australia, that the suicide rate is particularly high in female physicians. Some of these issues around perfection are probably part of that, not the only part, but I also think the difficulty of balancing [00:06:00] the additional responsibilities is key here. The, the point In your career, you're supposed to be thrusting your career forward in those early years after leaving medical school. For a woman, those are the years when they're thinking about maybe starting a family and that is really tough. I write about it in the book about some American hospitals offering to freeze the eggs of physicians; those physicians know that's not the best way to get pregnant. It's really tricky, but one of the things that I would love to see: if you wanted things that move your career forward, maybe you could pick that up when your children start school. We should be able to put our foot down on the gas at different points. 

Christine Ko: Yeah, it's hard. In medicine, at least the training in the U. S. is very proscribed. There's a way to do it. And it's hard to not do it that way. Very difficult. There's not very much flexibility. 

Caroline Elton: We [00:07:00] have greater flexibility in the UK and I'm proud of that, but it's still problematic and comes at a cost. I have seen med students who started at 17. Some of them are just too young. You probably look back at who Christine was at 16 and 17. You may have thought that you were very grown up and mature and you knew about the ways of the world, but looking back now, you probably think maybe I wasn't quite as mature.

Christine Ko: Oh, absolutely. I was 20 when I started medical school, and I look back now, to your point, when I look back, I was too young. My oldest child is 17 and I look at her. I'm like, yeah, it's like a mom's view. I'm like, yeah, you're just a kid. Like what major life decision would I want you to be making at 17? And I think, no. 

You know, I think a lot of times, I do expect perfection of myself. I didn't really fully even know how to say that. I felt a certain amount of shame that I knew I was falling [00:08:00] short. I don't think that's unique to me. Can you talk about the culture in medicine, medical schools, hospitals?

Caroline Elton: This is stuff I observed in my work because I had an NHS funded role supporting doctors. And now I have a role as well in a medical school. There is definitely a culture in medical school which is creating an ethos of that med students are different, they're special. It's really important to unpick this thing about the culture that doctors have to be special. I look at it in a different way as a psychologist. Psychologically, when you're training as a student and then later as a practicing doctor, you are confronted by the most difficult things that can happen in life. Disease, disability, destruction of lives, death. You're confronted by patients' hopes and fears. [00:09:00] And very little thought is given to the potential psychological toll that this can have on students and doctors.

One of the ways that we have of dealing with difficult things is something that psychologists call splitting, us and them. Medical school training reinforces, the us doctors, them, the patients outside there. Because pretty much anything that you see happening to patients could happen to you or somebody you love. So anything of all the really difficult stuff, it could happen to you or to those you love. And it's just too much. It takes time and psychological work to be able to navigate a way of dealing with that stuff whilst also really [00:10:00] keeping in mind that this awful stuff could happen to you or those you love. You just want to "other" them. That's the patient world. This is our world. Now this is really brilliantly described and I quote it in the book by an American psychiatrist and psychoanalyst. I remember my first day of medical school as a young medical student with horror. We were casually introduced to our cadavers without any preparation or discussion. My first cut into the cadaver was the first of many traumatic experiences in medical school that changed me. I was being prepared psychologically to be an objective doctor. I now believe that this frightening experience with no preparation began the unconscious psychological defensive split between the patient and me. Cadavers, our first patient, were made very distinct from us, the healthy, immortal medical students.

The notion that doctors think they're special, they think they're above everybody else. I [00:11:00] think that we need to take the blame away from the doctors and understand how the system is doing that. As Norman Straker explained beautifully, they're doing that because to some extent it's necessary. You can't be overwhelmed by patients' suffering all the time and unable to do your job. But you would be more empathic. You would be able to both do your job and sometimes hang on to the suffering of the patient if you were given the time and the space and the role models for doing so.

Christine Ko: There's so much to unpack there. This concept of splitting. When you're first a medical student, it's a joke, a funny thing that happens is when you start reading about diseases, you think you have every single one of them. Yeah. So that's probably right before the, before you've established splitting. And for me too, it's true. I never thought about it that way, but my first "patient" was a cadaver. We [00:12:00] had a very nice ceremony at the end of our autopsy course, where we each were supposed to write something about the whole experience. It wasn't graded. If you wanted to keep it private, you could. I look back on that, and I would say that's the last time that the system really was set up to say, you as doctors need to think about the impact of the experience that you just had. It was very important to me, significant. I still think about it today sometimes. 

Caroline Elton: We just need to normalize that sort of supportive reflection. I've worked in a number of different med schools over the years. The R word, reflection, is always a dirty word. They hate it. 

Christine Ko: I hate it too. 

Caroline Elton: I have to do it as a psychologist and I can't say in all honesty, yeah, reflective [00:13:00] writing. Go for it. I don't. Reflection has become an individual activity, whereas actually, there's nothing saying that it couldn't be done in conversation or as part of a group. If I think of moments in my own career where reflection has really changed practice , I had to get two pieces of feedback from others in two completely different settings, for anything to really change within me. I think we need more feedback from others. Otherwise, you're just rummaging around in your own head. And I'm not sure how useful that is. 

Christine Ko: Yeah, I think you're right. The reason for me, it's helpful to do it in group setting because I forgot to mention that reflection on how we experienced the cadavers and the autopsy and the whole course and patients donating their bodies. We had this candlelit ceremony, and it was a group thing. And that is one of the things that I found very impactful because it was a group, and I think I didn't feel [00:14:00] alone. 

Caroline Elton: Let me just see if I can find this, Christine, but this is a book I quote from a lot, and it's written by an emergency medicine doc, junior emergency medicine doctor. She's an Irish doctor, Aoife Abbey. But she'd made a mistake, a serious mistake, and a patient had died, and it is eating her up, and she goes to talk to her more senior doctor. He's very supportive, but busy. And then she goes back and for a second time. I sat down and he the senior doctor told me that I must always be brave and responsible enough to look at and examine my mistakes honestly but that is not the same as punishing yourself. He told me about the risks that comes with increasing seniority in medicine, and then he told me about his own mistakes, and I no longer felt so alone.

So that if you're asking for what is the most protective thing? There are a lot of things, but one of the most protective things is a [00:15:00] doctor being part of a social network where they can receive support and also actually give support to others. Aloneness is corrosive of mental health. 

Christine Ko: It goes back to what you said in the very beginning about feeling safe and feeling held, that whole mother child relationship.

I don't think we're, I love being alone, like by myself, actually I'm an introvert. But I don't want to feel like I'm like all by myself.

Caroline Elton: You want to be alone by choice.

Christine Ko: Yes, absolutely. 

Caroline Elton: Those moments when you want to be alone, but when there's stuff you need to share, you want there to be people there.

Christine Ko: Yeah. So I think we've been touching on the fact that it's hard to ask for help. It's hard for me to ask for help because I have an unrealistic expectation that I should just do it by myself. And I feel a certain amount, at least definitely in the past, I felt [00:16:00] a lot of shame at not being able to do it myself.

But I think going back to the splitting, that's also that there's also a misconception, at least for me, that I have more insight into myself than I really do. Especially when I was younger. I don't think I, as a 17 year old, 20 year old, I didn't have very much insight necessarily sometimes into my major decisions. And so if you're splitting, and you don't know that you're splitting, I think that also can become part of the problem.

Caroline Elton: Yeah it can become part of the problem. 

Christine Ko: You did mention that the physician suicide rate is actually higher in women. I may have known that and I forgot, but maybe I purposefully forgot.

Caroline Elton: Yeah. It's not a nice thing to remember. 

Christine Ko: How can doctors advocate for themselves and for each other to try to address the rates of suicide, the rates of burnout, the rates of depression? But hopefully, even before that, before you get to that point, what can [00:17:00] we do?

Caroline Elton: There's lots of things one can do. So here in the UK, I don't think it exists in the same way in the US, but here in the UK, we have an NHS funded, a mental health, confidential mental health service for doctors. That's something systematic that needs to be tackled. There needs to be services, confidential services. There's a charity in the UK called the Doctor's Support Network, and they have run a huge anti stigma campaign. And, if you can get senior clinicians talking about the fact that they've had a period of depression or whatever, it's going to be harder if it's bipolar or whatever, but if you can start the conversation with more senior doctors talking about their own, that's another really important thing that needs to be in place. And then I suppose we also need more flexibility in terms of being able to be less [00:18:00] than full time, because they're not enough hours in the day to be doing what they're trying to be doing. And I think it's interesting to also think about with women, it may be that particularly if they're training in a specialty where maybe they're not so many women, they're more likely to get isolated, I think. That's an absolute killer. 

Christine Ko: Yeah, it all just comes back to what you started with this concept of there being another person, at least one other person, where you feel safe, where you can feel held. Sort of mentally psychologically, whether that's a therapist, through this NHS mental health service, that's free and provided to all physicians or a friend or a parent or other family member or something. Or, as you described with emergency physician, who had made the error, and then she was able to go to her supervisor, and he made her not feel alone.

Caroline Elton: Not the first time. The first time he was busy, and he said, Oh, I'm really sorry, but that happens [00:19:00] sort of thing. 

Christine Ko: Isn't that great though, that she went back to him a second time? That applies to me in all, in many of my roles, how I treat myself. Can I give myself another chance? How I treat my child. Can I give my child another chance? Can my child give me another chance? Can my patient give me another chance?

Caroline Elton: That's also not perfect, is it? And it was fine, because the senior, the supervisor was busy first time around. Yeah. But he didn't beat himself up for that. She didn't beat him up for him. And as you said, there was a sort of optimism, a hope that it might be a different encounter the second time. It does link to the perfectionist. idea. The supervisor wasn't perfect, and he was just pleasantly reassuring.

Christine Ko: Yeah. 

Caroline Elton: And then they had a very authentic encounter. She can start to think, this guy's, he's a senior guy. I respect him. I see him in on the wards. He's a great clinician. And that happened to him. And she can start to expand [00:20:00] her idea of what it takes to be a good enough doctor.

Christine Ko: Yes. Yeah, I think the same thing really does apply between parents and kids, too. Yeah, absolutely. Especially when they're younger, think, oh, my parent can do no wrong. They quickly learn that, oh, no, my parent can do a lot of stuff wrong. And, I think to be able to talk about that in your home life. Which I didn't when I was a kid. But if you're from a family that does, I think then it serves you well in other spheres of your life too. 

Caroline Elton: Understanding what it takes psychologically to be a doctor. It's not like our brains aren't a hard drive that we erase when we go to work, wipe it clean. And then off you go to work. We take all the immediate thing, the row you had with your partner or your children over breakfast, but also the longer term, all you take that to the patient encounter, to the encounter with [00:21:00] colleagues.

Christine Ko: Yeah. This has been wonderful. Do you have any final thoughts?

Caroline Elton: I've really enjoyed it, Christine. I'm gonna go and print myself a t shirt, proudly imperfect. The more that one can talk about this stuff and the nice thing about being older is that people can, I'm sure some people just think I'm an old fart, but it's also the fact that if you can be older and have achieved a certain amount in your career, but you're saying this, it's helpful to younger colleagues.

Christine Ko: Absolutely. I think that's totally true. Thank you for saying that. Thank you so much for writing your book, for spending time with me, and explaining all of this stuff. 

Caroline Elton: It's been a pleasure.