Caroline Elton Ph.D.

Also Human

How Doctors Choose Their Patients

A psychologist's perspective on medical career choice

Posted Aug 01, 2018

When a patient has a colonoscopy, a thin flexible tube is inserted into their anus, and passed up their rectum into the colon. This allows the doctor to examine the inner lining of their large intestine for tumors or areas of inflammation. After my mother had this procedure a couple of years ago, she was left wondering why any doctor would choose to spend their time looking inside a patient’s intestines. "What could possibly be the attraction of gastro-enterology?" she asked.

I suspect that my mother wasn’t alone in having these thoughts. It is probably not unusual for patients to ponder why their doctor has ended up treating a particular part of the body – especially when that doctor’s work involves examining parts of the body associated with excretion, or carrying out tasks that cause their patients pain and distress.

If you took this one step further and asked a group of patients with cancer why they thought the doctors treating them had chosen oncology, or asked patients with multiple sclerosis why their doctors had chosen neurology, I imagine that they would come up with some sensible answers. Drawing on their own experience of choosing their careers, patients would probably suggest that these doctors had opted for their particular specialties because they had enjoyed studying these subjects at medical school or they had been influenced by senior clinicians who had encouraged them to train as oncologists, neurologists, or whatever. And these patients would be correct, as research has identified both these factors as being important.

What remains much more hidden, however, from both patients and the doctors themselves, are the ways in which the landmark events of our lives (illnesses, deaths, divorces) together with the dynamics of the family that we grew up in (relationships with parents, grandparents, siblings) pattern the choices that we make about work. And this doesn’t just apply to doctors. It applies to everybody who has even the smallest element of choice in the what, how, and where of their working lives.

Work is an outlet for our hopes, dreams, regrets, and fears. We see this most clearly with creative artists: Frida Kahlo’s paintings of her recurrent miscarriages; Eduard Munch’s "The Scream" depicting his terror of falling prey to the mental illness that debilitated his sister; Sylvia Plath’s The Bell Jar recounting her own experience as a psychiatric patient. Artists of all media express their central emotional dilemmas, through their work. But this process isn’t confined to artists; although not everyone can draw, or paint or write, we all use our work, to give voice to the emotional undercurrents that define us.

I once had a client who qualified as a careers counselor and got a job working in a university careers service. A few months into his first job, he decided that he was more interested in helping students sort out serious debt issues than assisting them with their career decisions; with no particular training, he switched to working as a student debt adviser. The client had previously told me about the difficult relationship he had with his father. But this job change made much greater sense to me when he later confided that in addition to running a small shop, his father also worked as a money lender, making a considerable amount of money through this activity. Although my client hadn’t consciously made the link, opting for work that involved helping people who were in serious debt could be seen as a reparative act. The father made money by charging interest on loans. The son tried to help people who fell into debt.

It is extraordinary to see how echoes from childhood can be discerned in the career decisions that everybody takes—and this includes doctors. So in my new book, Also Human, there’s a chapter that looks at the influence of childhood events on the particular specialties that doctors choose. For example, I describe a client who decided to go to medical school immediately after the death of his sister from leukemia. Even though the doctor treating his sister advised him that it was too soon to make this decision, he still went ahead. Right from the start of medical school, this individual only ever considered one specialty – obstetrics. And despite the fact that he found the unpredictable nature of the delivery room unbelievably stressful, he continued for many years. In the sessions we had together he came to see that his choice of obstetrics represented an unconscious desire to bring new life into the world – a desire which stemmed from the overwhelming tragedy of losing his sister at a young age. While this might have worked out, in his particular case, his overwhelming motivation to replace loss with new life meant that he overlooked the fundamental ways in which he was unsuited to working in obstetrics.

This is just one example of many but it illustrates the fact that doctors, just like their patients, are also human.