Doctors and identity

For more than a decade I have been leading a confidential service for doctors with mental health and addiction problems (NHS Practitioner Health). What is striking is despite having high levels of mental illness, and working within the medical system, doctors have low rates of presentation to treatment services. Although there are systemic barriers,^{Reference Kay, Mitchell, Clavarino and Doust1} such as frequently moving address or long and irregular shifts that make it hard for doctors to seek help if needed, stigma,^{Reference Cohen, Winstanley and Greene2} shame^{Reference Spiers, Buszewicz, Chew-Graham, Gerada, Kessler and Leggett3} and secrecy^{Reference Adams, Lee, Pritchard and White4} are the main factors that keep them in the corridors rather than the consulting room.⁵

To understand why these are so prevalent we can draw on the literature on identity,^{Reference Elias and Scotson6,Reference Cruess, Cruess, Boudreau, Snell and Steinert7} especially professional identity,^{Reference Jarvis-Selinger, Pratt and Regehr8} a popular theme of study for decades and defined in different ways in different discourses. Most theories propose, in one way or another that individuals proceed through life continuously organising their experiences into a meaningful whole that incorporates their personal, private, public and professional ‘selves’^{Reference Goffman9} and it is in this process that one's identity is formed.

Everyone has conflicting identities for different times and contexts, work or home, with family or friends, as parent or professional. However, for doctors, their core identity, is particularly strong as during training, their personal (the ‘I’) and their group (the ‘we’) are merged to create a single identity referred to as the ‘medical self’.^{Reference Wessely and Gerada10} The German sociologist, Norbert Elias described this phenomena when he argued that each of us derives our ‘we’ identities from the groups to which we belong; and that ‘we’ identities are inseparable from what we might call our ‘I’ identities; ‘who I am’ is always inseparable from ‘who we are’.^{Reference Elias and Scotson6} So powerful is the medical self that doctors find it hard to leave their working identity at the hospital gate or consulting room door and to adopt any identity other than that of ‘The Doctor’. A doctor is therefore something you are, not something that you do.

The medical self, as a mature psychological defence mechanism, protects doctors from feelings of disgust, fear and shame. It also ensures doctors internalise the characteristics expected of their group: altruism, perfectionism and self-sacrifice, as dictated by the first line of the World Medical Association Geneva Declaration ‘I solemnly pledge to dedicate my life to the service of humanity’.¹¹

Creating the medical self

The purpose of medical training is largely two-fold. The first is to make sure individuals learn the vast body of scholarship and expected behaviours needed to do the job. This is the meaning of professionalism and underpins the trust the public has in doctors. The second and occurring in parallel, is the need to absorb the unwritten rules, myths and beliefs, which the profession demands from each other. This includes self-sacrifice, as dictated in the first line of the Hippocratic Oath ‘to dedicate oneself to the service of humanity’. This could be thought of as the essence of vocation.

Group identity

This sense of belonging is an important component of any community of practice, and exerts forceful social influences on its members as compliance with professional norms emerge.^{Reference Cruess, Cruess and Johnston15} For doctors, their group becomes so important that their work (as a healer) becomes centre stage to their lives and for some almost replaces their family, becoming what the psychoanalyst, Jean Claude Rouchy considered to be secondary group of belonging.^{Reference Rouchy16} Our secondary groups provide us with structure and meaning and with roles that reinforce our sense of personal identity. Although medical schools and hospitals might not fit Goffman's description of a physically confined space,^{Reference Davies17} rather, as the anthropologist, Simon Sinclair suggests, they are in terms of time spent within the conceptually and cognitively limited organisation of the profession itself.^{Reference Sinclair18} The individual is, therefore, not so much restrained in a concrete space rather, and one would argue more powerfully, within the boundaries of their collective unconscious.

The medical self and patient hood

Although the rules of medicine's community of practice might change over time, each individual wishing to join this community must adhere to them. Failure to do so can impede career progression, or even risk sanctions or exclusion from the group. This is largely what happens when doctors become unwell as the expectation that ‘Physician Heal thyself’ (Luke 4:23)¹⁸ is a core competent of the medical self. Or in more modern times, as George Bernard Shaw, in the Play, The Doctors Dilemma, wrote ‘the most tragic thing is a sick doctor’¹⁹ and as such is too be avoided at all costs.

Doctors and patients are therefore distinct but interdependent. Doctors need patients to define themselves as ‘doctors’ (invincible, authoritative and so on), and patients need to believe that doctors are impervious to illness, on a pedestal even, to contain their own fear of death. This collusion is vital for doctors and patients and part of defensive interplay of projections between them both.

This is born out in the literature on both patient's perception of unwell doctors, and doctors’ perception of being unwell themselves or having an unwell colleague.

A study asked patients how they perceived their doctor's well-being and whether this belief (as the mental state of the doctor was not disclosed) had an impact on the care they received. The results found patients noticed cues that they interpreted as signs of physician wellness. These include overt indicators, such as the doctor's demeanour or physical appearance, along with a general impression about their ‘wellness’. Patients also formed judgements based on what they noticed, and these judgements affected views about their care; feelings, such as trust, and actions, such as following treatment plans.^{Reference Lemaire, Ewashina, Polachek, Dixit and Yiu22} Patients placed less trust in doctors who they saw as ‘less well’. The same result was found in views of patients if their doctor was overweight. Overweight doctors were seen as less credible or trust worthy than those of normal weight.^{Reference Puhl, Gold, Luedicke and DePierre23}

Even if a doctor appears ‘worried’ this has an impact on the patient's view of that doctor, seeing them as less empathetic.^{Reference Halbesleben and Rathert24} Patients also described feeling less comfortable with and less trusting of unwell doctors, even to the point of seeking care elsewhere.^{Reference Lemaire, Ewashina, Polachek, Dixit and Yiu22} Given that mental health is negatively associated, in the minds of patients, with a doctor's competence and capability it does not behold well for doctors to disclose their vulnerability. This was the case for one general practitioner, who after receiving a complaint from a patient about her online blog describing her bipolar disorder, took her own life.²⁵

For doctors, as discussed, crossing the invisible divide between health professional and patient is therefore a challenge to their medical self and comes with the perceived, and to a large extent, real loss of the trappings of power, knowledge, status and authority defined by this self. In the first instance doctors do not believe they can get unwell. In a study of general practitioner attitudes to their own health, one doctor is quoted as saying, ‘we think we're superhuman and that we don't get ill, or if we do, we can cope with it.’^{Reference Thompson, Cupples, Sibbett, Skan and Bradley26} Another study, this time of junior doctors, quoted a young doctor (who had become unwell herself) reporting that, ‘I had this bizarre misconception that like as a doctor you don't get ill …’ maintaining that ‘… because you're the doctor and they're the patients, and there's some kind of line between you.’^{Reference Fox, Doran, Rodham, Taylor, Harris and O'Connor27}

Over the centuries there are many personal testimonies^{Reference Klitzman28} that describe doctor's disbelief that they could become unwell. These can also be found in fiction, for example, the ‘Fatman’ in the satirical book, The House of God,

Self-stigmatisation among doctors who are not working is common, with doctors describing themselves as failures and internalising the negative views of others, these views of course partly real as they represent the norms of the medical identity.^{Reference Henderson, Brooks, Busso, Chalder, Harvey and Hotopf30} In a study of the impact of not working on a doctor's identity, the authors found that participants described being sick as associated with a fundamental change in their identity and that doctors incorporated negative views of themselves into their new ‘sick self’. Being away from work, especially with mental illness, then left many feeling lost, isolated and sad and another reported that ‘once you try and put that doctor persona aside, I realised there wasn't much left of me’.^{Reference Henderson, Brooks, Busso, Chalder, Harvey and Hotopf30} Doctors attending Practitioner Health often start their consultations by admonishing themselves for being there in the first place, suggesting that they are charlatans and that others are more worthy of the time given aside for them.

Doctors can also be blind to the distress in their peers (as well as in themselves). It is often not until after the doctor's illness has come to the attention of ‘authorities’ that colleagues begin to realise that they missed, in plain sight, signs of distress, such as a colleague smelling of alcohol, obvious weight loss, behavioural change, social withdrawal or even needle track marks. This collusion is part of the medical self.

When doctors do eventually reach a consulting room, they tend to act differently, as they visibly try to regain control of their medical identity, by for example, ‘talking shop’ and underplaying their symptoms. The treating doctor can be embarrassed at treating a colleague, especially if of a more senior rank than themselves. It is not unknown for the treating doctor to organise their own care and/or follow-up – mirroring the Biblical suggestion of ‘Physician Heal thyself’ (Luke 4:23).¹⁸