But the essence of good medical practice is still total focus on the patient in front of you – their medical, family and social problems. Some doctors mistakenly think their job is to focus only on the bio-medical aspect of their patients’ illnesses. Taking a genuine interest in your patients’ family and social backgrounds is a well-known antidote to burnout. Mulling over a letter of complaint, a lawsuit or a grievance leads to loss of focus and a likelihood of making mistakes.
And there are many pathways to disaster – overwork and perfectionism being a couple. It’s not surprising then to find links of burnout to burnout’s Black Swan: suicide.
A person I’ll refer to here as “Pip” was appointed as a consultant physician in his early thirties at a London hospital. He was a big man in all senses: a bit overweight with a marvelous sense of humor, articulate, witty with a formidable command of English. He chaired committees with the bulky presence of a Churchill, speaking with clarity and authority. Woe, betide a waffler. Residents loved him. All respected him.
“A camel is a horse designed by a committee,” he loved to say, glaring round with a grunt and a fist thump on the table and then an all-encompassing chuckle. This now well-known definition took on the cast of wisdom to us juniors.
He was a first-class doctor, kind and gentle with patients, an expert historian and a master of physical examination, always listening patiently. As for his expertise, he was at the top of his career. His protocols are still used today.
As a junior resident, he taught me a lot – not to dismiss strange new ideas but to consider them carefully, to look at all available evidence and make management decisions decisively. He hated woolly thinking. The only non-Churchill thing about Pip was the way he’d periodically push his glasses back on his nose with his forefinger, a gesture of slight self-consciousness. It made him very human.
I last met Pip in India in the late 1980s where we were participating in a technology transfer meeting. “Paterson,” he boomed, “I have a bottle of duty-free. Let’s catch up.”
In the early 90s, he was asked to join a British team investigating a regional “cancer help centre” regarding their anecdotal claims that a regime of diet and counselling could produce as good (or better) results as the chemotherapy used at that time in patients with advanced cancer. In this study, patient survivals in the help centre were compared to survivals of apparently similar patients at major cancer centres. He was the only clinician on the team.
The Lancet article summarized: “For patients metastasis-free at entry, progression-free survival in the ‘cancer help group’ was significantly poorer than in the controls (progression rate ratio 2:85). Overall survival in the counselling and diet-only group was also significantly inferior to that in the control group (HR 1:81)."
This made global news. Pip was interviewed on TV and radio. He called the regional program claims of improved outcomes “bogus.” The study was a simple comparison, but there had been limited stratification in the study – the regional cancer help patients were not clearly comparable to the control cancer centre’s patients – a major caveat in comparing different series of patients one to another.
Pip (not the principle investigator), in a rare mistake, seemed not to have carefully reviewed the study methodology. How easy it is for us to agree with anything that supports our prejudices. Was he depressed (or burned out) at the time of the study and his usual vigilance lowered? The sad thing here was that Pip was a supporter of good nutrition and patient support groups – but he always insisted on proper assessment.
When the question of comparability of patients came up, the study statistician admitted that he had not properly stratified the patients. From elation after the widespread applause on the article’s publication and his successful TV interviews exposing a bogus therapy, Pip slid to the depths of despair. He called himself a fraud, a fool, a failure. He was finished, an unrecoverable, disgraced doctor, he said. Two months after the article publication (n.b. the paper was never withdrawn), he was admitted to hospital in a fragile state. This psychiatric admission seemed to confirm in his mind his total failure. He discharged himself and was found dead at home.