The ills of the medical profession are well documented: we are prone to burnout, anxiety and depression; suicide is twice as common in doctors as compared to the general population. We aren't very good at talking about our emotional problems, not very good at decompressing or comfortable revealing what we feel may be perceived as a weakness.
Other factors contributing to burnout are a loss of control in daily work life, more and more to fit into the same work hours and greater knowledge than ever to incorporate into practice. Junior doctors are subjected to changes in rosters, pressure to complete seemingly pointless mandatory competencies and training pressures with sometimes a bleak outlook for career prospects. Work pressures lead to less social interaction with colleagues and fewer relationships in our home life.
Where is the solution?
Doctors understandably look to the hospitals and management to provide support and bring change to the workplace culture that seems to be responsible for this situation. Some of these are absolutely organisational issues and there needs to be work by medical and non-medical managers to address them directly.
But, I put a challenge out there to all of us as a profession - from Intern to Consultant: What are YOU and I doing about it?
Contrast the fresh-faced medical student or new intern on their first day of the job, compared to the PGY 6 medical registrar or consultant running a 1:2 service. That first day we started work, holding the shiny badge that finally labeled us ‘Doctor’, did we not have a fire inside our belly that was insatiable. We knew exactly why we were there and what we had to do - or at least we were driven to find out. Our fire is what motivates us to come to work every day, it inspires us to grow, to invest deeply in what we do and the teams around us, it helps us create meaningful therapeutic relationships with our patients.
And then came the long hours, the shame culture of medicine, the loss of autonomy, unreasonable patient expectations, the bureaucratisation of our daily work, electronic medical records, personal debt and the social exclusion. Unsurprisingly, for many that fire inside is now but a smouldering ember.
We spend our career focusing on education, research, acquiring clinical skills and post graduate qualifications. A good senior, a good peer is someone who helps in one of these areas. But who takes care of the fire inside? This internal quality, the unnamed essence of our WHY needs just as much support and nourishment as our intellectual development receives. Yet we neglect it, assuming that the smothering of the fire is an inevitable consequence of modern medicine. And this is where our responsibility to ourselves and each other lies.
We need to give attention to the fire in ourselves and our colleagues. The same actions that feed the fire, provide a shield of resilience around it. They make the daily work pressures manageable and protect us from burnout (now you know why it's called that!). We will still be busy, but how we are with ourselves, each other and our patients is fundamentally maintained.
How do we do this?
- Praise the good. When did you last have someone go out of their way to tell you how good a job you did at work? Forget the feedback sandwich: we need to actively seek out the positive to praise in peers, those more junior to us, including medical students and the wider healthcare team around us. On our radar, every single day. When so much of what we hear is negative, how good does it feel when someone acknowledges your hard work with a compliment? You can feed the fire of the team around you through recognition of a job well done. The more genuine and specific the feedback can be, the better. And the positivity will make you feel good too.
- Self-care. You know about this - taking time out for recharge. We tend to think of resilience looking like a boxer in the ring, broken yet fighting through one more round. In fact, resilience is about working hard, taking dedicated time out for rest, and then working hard again. Rest periods mean both within a busy day and time off using recreation leave allowances each year. Your work is never ending, taking time out for lunch away from the workplace will re-engergise you for a more effective afternoon than had you just worked through or eaten lunch at your desk. Exercise, diet, meditation, rest and social support networks outside of work are the cornerstones of self-care.
- Reflection. Take some time to reflect on the good that you do each day. A journal can be powerful for this, and journaling has other benefits related to problem solving and well being. Each day write down the positive that happened, how you helped people, your successes. When I was a registrar, I had a folder of ‘Thank you’ cards that patients had given me. After a stressful event or when my confidence had taken a hit, I would read through the cards to remind me of the good that I do, of the positive effect I have on people’s lives.
- Compassion and kindness. It sounds simple and corny but sustained kindness and compassion in the care we deliver, along with the mentoring of compassionate care and values-based practice is imperative for doctors to grow into lifelong happy, resilient practitioners. Be willing to call out bullying and harassment when you see it. If you are junior and aren’t able to directly address it, then tell someone who can.
- Team-building and social events. The time we spend together when we aren’t under the pump gives us the unity and trust to take the knocks together, look after each other and work together effectively as a team. How this looks in practice can vary, from team coffees before clinic, lunch together or drinks after work or in the evening.
- Mentoring. You need a mentor. Someone who you can open up to, talk about your first death on the ward, the kid that died in ED after you worked on her for 2 hours and your fears about whether you can cope with the next rotation. Emotional support comes in many forms and a mentor can be important for more than just career advice. For senior doctors, being a mentor will help you realise how much your experience is valued; there is little that is more rewarding in this life, than being an inspiration to others.
- Support each other. When your work is done, do you look to help your colleagues? Can you make your night registrar’s evening easier, ensure the script rewrites and discharge summaries are done by 5pm Friday to help the weekend team or lend a hand when your work is done and the clinic is still going? These are the small sacrifices and compassionate support that helps all of us feel better about our hard working day.
- Gratitude. Research strongly correlates gratitude and individual wellbeing and happiness. An attitude of gratitude can be applied to the past by re-living positive memories and in the present by not taking our own good fortune for granted - we need only look to our patients to see how fortunate we are. Gratitude helps us maintain an optimistic and hopeful attitude for the future.
Gratitude can be cultivated by writing a thank you note of appreciation to someone who has had a positive effect on your life. It can be a brief daily journal entry, where you explicitly reflect on and write down the good things that happened to you and what you are grateful for. Gratitude may be cultivated through prayer if that is important in your life.
- Re-write the shame tapes. Brené Brown is a social sciences researcher who has extensively studied shame and vulnerability and her research is very relevant to the culture in medicine. Shame tapes are the messages of self-doubt and criticism: ‘If I was a good doctor, I would have got that arterial line in.’ ‘I’m never going to make it as a consultant.’, ‘I’m not good enough. I’m a fraud.’
Brown defines shame as ‘An intensely painful feeling or experience of believing that we are flawed and therefore unworthy of love and belonging. A fear of disconnection.’
Shame is the difference between:
‘I made a mistake’ or ‘I had a complication’
‘I am a bad doctor’ ‘I am such an idiot’ ‘I am a failure’
To tackle the shame culture of medicine, when something bad happens:
Reach out to someone you trust, someone who cares for you. Share the experience.
Be kind to yourself and speak in the way that you would to reassure someone you care for: ‘You are OK, you're human. We all make mistakes.’ We would never speak to someone the way we speak to ourselves during a full on shame attack.
Own it - you get to write the ending. You might have made a mistake or had a surgical complication or missed a diagnosis. Admission, acknowledgment and attention to growth from the event is highly correlated with a positive result next time. The alternative is to protect ourselves by blaming someone else, rationalising it away or internalising the feelings. This path leads to negative outcomes like depression, addiction and bullying.
- Be vulnerable. When the consultant surgeon speaks to his team about the time that he screwed up or the complication that he had, he lets down the shield that guards his vulnerability. Not only do others learn from the clinical story, but they feel validated in their own areas of perceived weakness. As Brené Brown discovered in her research: 'Vulnerability is the last thing I want you to see in me, but it’s the first thing I look for in you.' We all have shields to protect our vulnerabilities, but in truth we can only live a wholehearted life and positively influence those around when we let down our shields without fear of vulnerability.
We need to feed the fire inside ourselves and each other. We have to write this into the medical curriculum, talk about it with our teams, teach the medical students and bring the actions to our work every day. Then we will have truly done our part in addressing the dark side of modern medicine.