physician burnout

Ten Reasons Why Physician Burnout is so Prevalent.

‘If you study even the smallest bit of science, you will realize that, for all practical purposes, we are nothing. We’re basically monkeys on a small rock, orbiting a small, backwards star in a huge galaxy, which is an absolutely staggeringly gigantic universe, which itself may be part of a gigantic multiverse. This universe has been around for probably 10 billion years or more, and will be around for tens of billions of years afterwards. So your existence, my existence, is just infinitesimal…this is such a short and precious life, it is really important that you don’t spend it being unhappy. There is no excuse for spending most of your life in misery. You’ve only got 70 years out of the 50 billion or however long the universe is going to be around.’

Naval Ravikant in Tools of Titans, by Tim Ferris

On Thursday, I was given the last-minute, unexpected opportunity to give a two-minute pitch about my concept to help reduce rates of stress, burnout, and suicide amongst doctors (and later other professions), and how to increase their wellbeing. As a doctor talking about this issue, I do have a sense of not wanting to make a storm in a teacup. I don’t want to dramatise the situation, as serious as it is. I feel it deserves to be approached with gravitas and pragmatism, without any hint of emotion.

But then, I think, ‘what the f**k? Why are doctors killing themselves?’ It’s a privileged position to be a doctor in the west, no matter which way you look at it. It means that the person has had access to excellent education, has personal attributes to undertake this arduous education, and are, in most cases, guaranteed a job for life, with salaries that are dependable and will provide a secure income. If the doctors are committing suicide, who is going to look after the suffering?

Working in psychiatry, I am faced with suicidality on a daily basis. Suicidality as a symptom of mental illness. Suicidality as an expression of emotional overwhelm and distress. Suicidality with explicable causative factors, and suicidality in the most unlikely of places. The fact is, suicide is one of the saddest plights of the human experience. That one act, or thoughts of, tells a thousand stories of helplessness, hopelessness, guilt, fear, anger, rejection, isolation. It is so contrary to what we consider to be the essence of our human-ness: being hope-finding, meaning-creating, resilience-expressing animals. The act separates us from non-homo sapiens (as far as I know). Something about our exquisitely developed prefrontal cortices which have endowed us with the ability for abstract thought, executive decision-making, and meta-cognition, has also made us vulnerable to states of nihilistic hopelessness.

So why do doctors get to this stage? What are the causes for the preceeding burnout and chronic stress? A recent systematic literature review, reported in Medscape, states that physicians experience the highest suicide rate of any profession, more than twice that of the general population, and over 400 doctors a year suicide in the US. The Australia beyondblue study of medical student and doctor mental wellbeing in 2013 identified that 24.8% of physicians had thoughts of suicide prior to the past 12 months, and 10.4% had thoughts within the last 12 months.

So, here are a summary of what I think are the main factors contributing to chronic stress and burnout, in no particular order:

  1. Doctors have an inherently stressful job. Buddhist philosophy suggests that our main motivation in our natural state is escaping suffering – which, ironically, it argues, creates more suffering. This helps us to understand and empathise with others if we accept that everyone is just doing their best to escape suffering. We can all probably see this in our lives: we work to have money to avoid going hungry or being homeless; we maintain strong social bonds to avoid loneliness. A doctor’s (and many other professions’, some of whom have similar issues with burnout) job is intrinsically tied to engaging in the depths of human suffering. Day in, day out, the job requires engaging with people’s pain, unhappiness, loneliness, fear, worry, depression, and disappointment.
  2. Lack of autonomy. Doctors exist in a constant tension between a) the resources available to them from the health provider; b) what a patient wants; c) what a patient needs; d) what a patient can afford, or what a provider will pay for for a patient; e) legislative and social expectations of what health should/should not do.
  3. Complexity of healthcare delivery. Long gone are the days when a patient attends for a straightforward prescription, or for a surgery – or neither if they cannot afford them. A doctor must dance a complex rhumba which involves a multitude of invested stakeholders. These are informed by international, national, and local recommendations and protocols; by the payers for the health service; by the local service’s resources; by the patient’s wishes. And this often requires a decision to be made in a short period of time looking at an individual patient with their unique requirements and biopsychosocial factors affecting their illness experience. The paradox of choice in treatment is increasing at break-neck speed, and humans struggle to keep up.
  4. Sandwiching. Related to the above. A term I use to describe doctors being caught between patients and the service or provider or political power behind them, and having to mediate that complex relationship.
  5. Evolving nature of healthcare delivery. Doctors are having to become adept practitioners of a new digital world. Again, instead of dealing with the individual patient in front of her, the doctor now has to refer to, record, and involve a litany of digital material via electronic health records. Whilst the glitches are many as they are embedded, many doctors would agree that it may benefit patient care in the long run. But another layer of administration has been added to doctors’ jobs.
  6. Leadership. Leadership within healthcare often comes from a) clinicians who have been in the game a long time, but may not have had formal management training; or, b) non-medical managers who transfer management skills from other sectors. I would argue that management does need to be taught, it is not an intrinsic character trait, and I would argue that healthcare is different from most other sectors in that the commodification of health has multiple ethical and moral considerations. This is not to say that these divides are not successfully crossed; but a lack on either front can exacerbate the stressful expectations of doctors.
  7. Personality types that self-select for medicine. This is perhaps the biggest generalisation here but most good doctors (and we are still working out how to screen that ‘good’ and define what it means), have traits that are associated with high rates of conscientiousness, diligence, integrity, and empathy. These are also traits which are associated with neurosis in its original form: excessive anxiety or obsessiveness. Laissez-faire, non-obsessive doctors tend to come up against issues very early on in their careers which can have negative effects on patient care. These traits emphasise the, ‘I better not get this wrong’, ‘what if XYZ happens? How do I prevent this?’, or, ‘the negative sequelae of this action – or lack of action – could – or could not be – XYZ.’ Essentially, medicine requires working with vast swathes of uncertainty and uknowns, and reassuring a patient in the midst of that, and finding out what can be known, actioning it, and avoiding complications in that course of action.
  8. Shiftwork. There is no need to reiterate the multiple studies and bodies of evidence which outline how bad shiftwork is for physical and mental health in the long run. Now imagine handling an apnoeic (not breathing) neonate at 3am, or repairing a bleeding aneurysm, or talking down a psychotic patient. The effects are inevitable.
  9. Work intensity and competing demands. After five to eight years of undergraduate study, doctors embark on a baptism of fire into life as a junior doctor. This can be anywhere from one to four years, which is then followed by training under a specialist pathway (general practice, psychiatry, general surgery, ophthalmology, etc), which can range anywhere from three to 8 years. Many specialties require onerous exams – which must be studied for for months whilst working full-time, and costs thousands of dollars at a time, paid from a trainee doctor’s salary. Resits are incredibly demoralising as doctors have put their lives on hold to study for them. Many will also have research requirements, which may need to be done on top of the ‘day’ job, or may need time away from the training scheme with a reduced salary. Many doctors will be starting a family during this time, which puts a particular pressure on female trainees (in general), who have to decide how much (if any) time to take away from time-limited training schemes. People are also doing other life ‘stuff’ expected in their respective societies: getting on the property ladder, for example. And many have other commitments: carer role for children or a spouse or a parent with a serious illness. All the while working in a job with shiftwork and all the issues listed above.
  10. The normalisation of chronic stress and vicarious trauma. Finally, doctors are exposed to trauma on a daily basis. This may involve the death of children, or losing a patient unexpectedly, or watching people decline through chronic illness. It can involve seeing people self-harm, and listening to endless stories of every type of abuse under the sun. It can involve hearing about and observing some of the darkest parts of humanity. Unfortunately, the evolution of the culture within medicine has been centuries in the making. There is a hardening and desensitisation expected. The fragile, flimsy line between self-preservation and displaying compassion and empathy is often trodden upon and unrecognisable. People glorify the hours and disasters and trauma and awfulness at times, as a way of coping. Burnt out colleagues, often those who have been in the game a long time, have become so depersonalised and emotionally exhausted themselves that they lack insight into their own dearth of emotional connection. They then externalise anyone else’s difficulty processing something, or a throw away comment about the amount of hours worked, as being a sign of ‘not coping’ and advise them to suck it up because, ‘when I was a junior doctor I worked 110 hours a week.’ I often feel like holding up a mirror and saying, ‘Yes. Yes you did.’ The evidence suggests that even with improvement in absolute working hours for some doctors, that stress and burnout has massively improved. In light of the above issues, I understand why.

It may sound rather bleak, but my own burnout has receded far enough that I have hope. I believe that human connection amongst colleagues can provide relief and strength. I believe that radical transparency, as described by Ray Dalio, can save us from repeating the closed-up, ever-more-cautious, more overwhelmed by the paradox of choice that the modern medical paradigm presents. I believe that medical culture can change. I believe that its leaders can adapt. I believe that empowered patients can better share the risk and unknownness of their own health and healthcare. I believe that AI and VR can get to a stage that some of the mechanised parts of modern medicine – digital health records, diagnostic algorithms contained in doctors heads – can become part of the doctor-patient interaction. Doctors are humans, and their humanness needs to be prized and protected. Patients deserve nothing less when they see their healthcare provider. As Naval Ravikant said, we have so little time in which to live. Let’s make it count, and make it enjoyable.

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The Compassion Conundrum: Navigating Stress and Burnout as a Healthcare Worker

My mission in life is not merely to survive, but to thrive; and to do so with

some passion,

some compassion,

some humour,

and some style.

(Maya Angelou)

He is the best physician who is the most ingenious inspirer of hope.

(Samuel Taylor Coleridge)

To become comfortable with uncertainty is one of the primary goals in the training of a physician.

(Sherwin B Nuland)

In the discussion around physician burnout, a common ‘either/or’ dichotomy has abounded: physicians need to become more resilient, or systems need to change. However, both seem untenable as the sole solutions to this issue. How can physicians become resilient enough to cope with struggling, ever-more stretched systems, where, as the patient becomes a market-oriented consumer, demands are only going to increase? And how can these self-maintaining monsters of systems, change? If a healthcare system was composed entirely of doctors (and there may be some doctors who think this is the case), maybe there would be some hope of the system itself changing to suit them better. But we’re a small cog within this system which, despite being called ‘healthcare’, is focused on pathology, and is affected by political and socioeconomic powers far beyond the cubicle curtains. Healthcare is a self-perpetuating, self-maintaining beast. All the components and individuals and sub-systems act in an interminable rhythm, and it is only disrupted by events of cataclysmic proportions – either good or bad (think WWII and the evolution of the NHS in the UK in 1948. And think of the state of the NHS today.)

In Braving the Wilderness, Brené Brown writes,

Benito Mussolini relied heavily on the line “O con noi o contro di noi” (“You’re either with us or against us.”) The problem is that the emotional plea is often not based in facts, and preys on our fears of not belonging or being seen as wrong or part of the problem. We need to question how the sides are defined. Are these really the only two options? Is this the accurate blaming for this debate or is this bullshit?…The ability to think past either/or solutions is the foundation of critical thinking, but still, it requires courage. Getting curious and asking questions happens outside our blinkers of certainty.

In looking for solutions to this growing problem, we – the doctors, staff, system – need to look beyond either/or scenarios. If I could pick one word to sum up the current practice of medicine, it would be uncertainty. Paradoxically, however, everything about our jobs, and the system, is to deliver certainty to all the stakeholders. Patients want to know, ‘This is your diagnosis. This is the treatment. This is the prognosis.’ But how often does that happen? Even the common cold we need to hedge with warnings: ‘It’s most likely viral, but should your headache worsen, or if it has not resolved in seven days, or you start developing a non-blanching rash, come back and see us…yeah, if the headache gets pretty bad, I mean….well, if it gets so bad, you should probably see someone sooner…if it’s eight days then check in with your GP and maybe get some bloods done…you’ll know if it’s non-blanching…yes, you can get a rash with some types of cancer…’. Etc etc.

Patients come, and rightly so, expect serious conditions to be excluded, and a reassuring narrative to be given which provides a schema in which to understand their symptoms. A break of the lower leg during a footy match in a 22 year-old man needs little explanation; an episode of psychosis in a 50 year-old stay-at-home mother with a vague history of depression, or liver failure in a 27 year-old with a possible family history of an autoimmune condition requires a lot of postulating and hypothesising. It often ends with a summation of, ‘The human body is very fickle. We don’t know a lot about how it works, or why things go wrong. I don’t know why it’s happened to you at this point in time. I don’t know if it’s been precipitated by something you or anyone else has done, and most likely we never will know.’ Or more often, we err on the side of compassion: ‘No, there’s nothing you have done to make this happen.’ In our compassion for our patients, we realise that on top of a life-changing diagnosis, they don’t also need to consider whether there is any personal responsibility for what has happened. It would make us sad to send them away from our clinic, seeing the fear in their eyes, now compounded by potential guilt and regret. In our treatment of patients from every spectrum of society, we disengage any sort of judgement about personal responsibility or lifestyle choice or consequences; this is not our place, we tell ourselves, society tells us, and the system tells us. Just be compassionate, and treat what’s in front of you. And we do (and just internalise the judgement and then spread it around on more acceptable targets – ourselves, management, a colleague who made a mistake.)

What do health services want? They want certainty. They want preventative medicine, then quick, accurate diagnoses if anything does go amiss, with as small a chance of re-presentation as possible, and to find definitive outcomes if they do. Which includes, but is not limited to, treatment, housing, addiction cessation, rehabilitation, unicorn horn DNA.

Primary care wants clear descriptions of what has transpired during a hospital admission, what the patient’s progress was, and what changes have been made in her or his medical management. They want guidance about when to seek re-review or re-admission. They want a sense that the big brother hospital understood that their patient, who comes in weekly with his disabled wife, is depressed, and poorly mobile, and often incontinent, and drinking a lot, and possibly struggling to care as he should for his wife. Do they get a sense that this has happened? Sometimes they will. But not always.

Tertiary services want primary care to provide a catch-all net for all things that have not been able to be attended to in a three-week hospital admission. Despite the physios and OTs and social workers and psychologist and dietitian and (if you’re lucky) specialist nurse who saw them then, it would be great if the GP could encapsulate all that in their next 9 minute post-discharge appointment with the patient. The GP must pick up patients, make sense of multiple investigations and opinions from varying teams, many times who will say, ‘Dx: ???. Re-admit if it happens again,’ and keep them out of hospital as long as possible. (By re-admit, they mean send to ED, where they will be triaged by a highly-skilled, stressed, harried ED physician who is managing ramping ambulances at one end and a bed-blocked hospital at the other end of her department.)

Governments want certainty. They determine how much money they will exact from tax payers, will allot it to a health service, and then need guarantees that no matter what happens, the health provider will provide whatever service is needed. Healthcare executives – who may be doctors or nurses who have been working in this spiralling system for decades – hold purse strings tightly, whilst clamouring clinical departments say, ‘We can’t meet these increasing needs with the same resources we once had.’ The executive, in an act of both self- and service-preservation, sends service-wide emails, decreeing a reduction in this test or that, or a limit on this locum or that nurse pool, and sits in an office, awaiting with bated breath a new financial year with hope that nothing dreadful happens in the interim, and hoping for a magical sum of money that will gift – yes – certainty – for the year ahead. They feel guilt for their colleagues holding the front line; fear of state departments demanding ‘show cause’ for every dollar over or adverse event which should have been prevented; and an internal smouldering of waning energy and stamina.

The junior doctor falls from final year of medical school into their intern year, and certainty becomes an alien concept. Suddenly they have money, no time, reduced energy, waves of anxiety and stress. He or she has moments (hours?) of feeling like not knowing anything and yet feeling like they should know so much, the incongruence of books and supervised placements compared with a lonely night shift handling a moribund patient, a ragged contrast. Registrars, hardened after a few years at the coal face, dig their heels in, do their shifts, study for exams, and possibly squeeze in being a parent or a partner or a carer. The other facets of life which make us human need to wait. Just a year or two. Or three. Or four if the re-sits don’t go as planned. Oh, and the patients receive that registrar’s care and attention, day after day. After day.

And the consultant, the leader of the team. A team which consists of nurses and OTs and social workers and nurse practitioners and medical students and physiotherapists and electrophysiologists and dietitians. Yes, you, gastroenterologist, you are now a leader. Remember that one lecture you received on clinical governance? Yes, that’s you now. You’re paid $300,000 a year, so just do it. And make sure all your patients get better quickly, and completely. And make sure your registrars are supported. And make sure that they are looking after the interns and residents. And remember medical student teaching. And the departmental roster. And accreditation. (Squeeze in the UGIE on the oesophageal variceal bleed at 2am, and work until 7pm the same day, thanks.) And CPD. These must all be done, for sure. For certain. Otherwise, you are unsafe, patients are at risk (i.e. there’s always the risk of people dying due to your actions or lack thereof), and on top of that, your department/hospital/health service will get less money next time round to combat the same problems. Yes, your child’s sick, that’s marvellous. So are your patients. And your registrar. And a quarter of the nursing staff. Pretty rough your marriage has broken up; take Monday and Tuesday off and we’ll see you back on Wednesday (can you cover the following weekend to make up for that? Your colleagues covered you on Monday and Tuesday, so, you know….?)

And the intern can’t eat due to nausea and anxiety. And the registrar can’t sleep due to being messed up coming off night shifts and looking after children, and then studying for exams. And the consultant can’t bear to stand there in front of the team and say that he doesn’t know what to do with Mrs Smith in bed 8 on her fifth admission this year – again. So he sends her back to the nursing home to the GP. And the director of medical services says that she needs you to show-cause for the two locums this month, whilst shrinking inside because she knows that they covered your colleague off sick with stress and you and your other colleagues shrank in shame and exhaustion when it was put to you to cover for him. And she calls the Department with a sweaty hand on the phone, and a shaky voice and assures them that this is short-term and temporary and they are working on ensuring that there is always space in the system to account for this.

And they all – the nurse, the administrator, the intern through to consultant – keep coming in day after day, because the patients keep coming. The intern turns up because he is aware that the resident is covering two wards by herself, and needs help. And the registrar refuses to take her study leave because her consultant is covering for his colleague. And the consultant can’t have another day off, despite his wife going through chemo, because there is a ward of 30 patients waiting, and his registrar and intern cannot be expected to make all these decisions again and again.

So why do they keep doing it? Partly this compassion conundrum, and partly either/or thinking – only the system must change, or it’s just me. Okay, we were all uptight, type A, hard-working, diligent folk who wanted a secure job which ‘helped people,’ and we invested our time and money and energy and relationships into getting where we are now. But the compassion, which we don’t show to ourselves, or extend to colleagues, or would ever show to managers, and which can also be the source of the compassion burnout towards our patients, runs deep, compounded by empathy and altruism and high expectations. We like our patients…but recently, we’ve not liked them quite as much. We got pissed off that they presented with chest pain again, with their poorly controlled BSLs, and an inability to stop smoking. But we followed the protocol, to look after them. And we did get annoyed when the man with decompensated liver failure re-presented, drunk, for an ascitic drain at 3am on a Wednesday. And don’t get me started on the lady with borderline personality disorder who has pulled out chunks of her hair and actually severed her flexor tendons this time, all because of her stepdad who took her innocence as a little girl, which she reminds us and the rest of the ED of time and time again. So we lament society and education and family, and feel like we’re sticking our collective pinky in the growing crack in the dam. But this compassion glues us there.

We stand back and regard the messy humanity that we see before us, and feel discomfort. Discomfort at their distress. Discomfort at our share in this messy humanity. Discomfort at our own messy humanity. We do chest compressions and we hear agonal breathing. We see a lifeless newborn delivered and hear a father’s sobs. We listen to the screams of the woman in resus as the police ask her about the oncoming lorry which has taken her family. We see the 70 year-old without family, with severe rheumatoid arthritis who has fallen, and has lain in her own faeces for three days, and now has an acute kidney injury and rhabdomyolysis.

So we do it, again and again. There are very, very few either/ors in our jobs, but our thinking towards ourselves and our colleagues is either/or. We navigate like a jittery compass, receiving input from multiple stimuli to help us in our decision-making processes. We do another ward round, and learn another software update for the new system which will integrate every man and his dog (sometimes), and we hit the books, and we try to be pleasant to colleagues, and we supress the nagging feelings of failure when we repeatedly cannot do our best. And we blame the management and the system and the state and our boss and our juniors – because, yes, we’re that hierarchical, that a 36 year-old with 8 years experience as a doctor is a ‘junior’ – and the lazy colleague. Only when someone pulls us up for blaming a patient do we shrivel away in shame. For there is compassion there, always, deeply buried though it may be. Buffeted and battered at times, only brought out in its fullness in a rare moment of human connection with a patient, where things are tidy, when they see us, when we see them (if we’re not too hardened).

Burnout is prevalent. Chronic stress is dangerous. Doctors are developing destructive coping mechanisms, which can exacerbate mental illness and can result in suicide. How do we stop it? By dredging up compassion again and again, for ourselves, for our colleagues, for our leaders, for our patients. All of them, including us, (yes, even our patients) do things that exacerbate the load on the system. Some colleagues communicate in bullying and unhelpful and blaming ways – because they too are broken in some manner.

I’m committed to helping doctors (and nurses – for the issues overlap more often than not) to find our compassion again, in the midst of the uncertainy. Without compassion for ourselves and one another, patients will not get the treatment they deserve. The history of our profession has done little to help develop a culture of compassion. The drive for certainty and answers and excellence has been placed above the simple acts of kindness and human connection which make us…human. In this age of ever-increasing uncertainty, and multiple options and treatment pathways and causes and biopsychosocial factors, bumped by genetics, affected and effected by epigenetics, adjusted by climate change, and shaken by political tremors 15,000 km away, the only certainty we do have is that we each possess ongoing remnants of compassion. The most expert diagnostician; the most heroic military trauma surgeon; the most cerebral cytopathologist; the most enthusiastic epidemiologist – all are united in their humanness through their compassion. As a psychiatrist in training, I could provide lots of great explanations for why individuals struggle to access feelings of compassion, but this is not the point: except for the antisocial personality disorders amongst us, or those at the extreme end of some neurodevelopmental disorders, our compassion is present.

We can’t change the system quickly. We can’t change our patients. And we can’t even change ourselves all that easily. But we can use what we have. Let’s leave either/or thinking. Let’s work collaboratively with colleagues to instill compassion. Let’s inspire hope, like Coleridge said. Let’s remember Maya Angelou, the natural phenomenon of wisdom and literature and philosophy and poetry, who was mute for years as a little girl after suffering trauma and subsequently believing that her words could kill, that life is to be lived with some passion, some compassion, some humour, and some style.

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Eight weeks an entrepreneur; the journey thus far.

I feel like I had a rather archetypal entrepreneurial epiphany. It started with a gestational period of a year or so, which came out of a life-changing situation. Ideas came and went, sometimes stewed, but rarely stayed more than a few days. There was a growing awareness of creative, innovative urges, however, which arose during a period in my life where I had the time and space to consider problems beyond my immediate day-to-day sphere and think of bigger picture solutions. A time where I was open.

And then, one night, it came. A night where sleep evaded me as the problem and its implications seemed so clear to me, and the growing awareness that I perhaps held the questions that could lead to the answers. There was a buzz in my body as my mind whirred at the opportunities. I felt alive and elated, champing at the bit to see how this could be applied to a problem that costs lives, happiness, and wellbeing. It also results in billions of dollars’ lost revenue to many sectors around the world.

I’d found my problem to solve. In the past eight weeks I’ve been stealing minutes and hours between being a husband and father and full-time doctor; between maintaining a healthy lifestyle and communicating with friends. There’s always some new information to be gleaned, door to push, and opportunity to explore.

For posterity, I thought it might be interesting to share this journey. If my side hustle works out, it will be live broadcasting to others who pursue entrepreneurial ventures. If it does not work out, it will be a record of my pursuing something to make the world a better place, trying to improve a significant workplace issue, and attempting to provide more opportunity and resources for my future.

My wife just read me this quote from Brene Brown’s latest book, Braving the Wilderness:

I also can’t remember a time over the past year when I asked someone about an issue and had someone reply, “I actually don’t know much about what’s happening there, please tell me about it.” We don’t even bother being curious anymore…In a fitting-in culture…curiosity is seen as weakness and asking questions equates to antagonism rather than being valued as learning.’

Curiosity Disrupted. I’ve been disrupted by curiosity, and I want my curiosity to disrupt where I’m going.

So what have I learned so far?

  1. Hold your dreams lightly; hold your principles tightly. It’s easy to ‘fuse’ with a cause or belief early on, and to feel like one’s self is indistinguishable from it. I read a huge amount the last year about business, self-development, and entrepreneurship – before I even had an inkling I would have an idea to pursue. It laid the grounds for at least the awareness of the undulating path of entrepreneurship. Disappointments and encouragements come quickly one after another in these early days. It’s easy to get hooked into them, to hang all one’s hopes or fears on one or the other. It’s part of the process. It’s up and down in every way. Ride it. See if your dream can withstand it. But most importantly, see if your principles anchor you within it.
  2. Choose early partners with care, based on a sound knowledge of yourself. I feel incredibly grateful for the selfless and generous sharing of knowledge and skills that people have offered so far. I’ve been so impressed by people’s willingness to give of their time and advice, simultaneously acknowledging my passion and enthusiasm, and my lack of experience and skill in this area. It has been a great experience to say, “I don’t know much about this. Please tell me.” I love that I can learn ‘for free’ from other’s successes and failures, and that they are willing to share. I am really happy to have gotten a techy partner on board who is a wonderful human being and is creative. Recognising someone else’s character strengths means I believe that we will be able to navigate the tough parts, disagree respectfully, and say things straight as needed. The last thing needed when founding a startup is interpersonal drama on top of the financial, visionary, and occupational insecurity that need to be addressed. Skills can be acquired; work ethic, too, but much less quickly and a mismatch will cause headaches. Kindness, generosity of spirit, and openness are priceless.
  3. IT WILL ALWAYS GO SLOWER THAN YOU THINK. I was reading Eric Ries’ The Lean Startup from early on. I subconsciously started exerting pressure on myself; I think I thought that I should have a lean MVP out in the world by now, regardless of it being a totally new sector, having no early investment, and working full-time in another demanding job. The last week I have become more cognisant of the fact that buckets of drive and insight into the problem, and an overview of the ROI for the end payers, does not replace the requirement for hard cash up front to get something going. The principles of making things better for people, the intrinsic interest in the subject, and the internal perspective I have on the issues provide me with the drive to figure out how to get those dollahs.

These are some of the salient features learned so far. Beyond this, in brief I am also learning:

  • Listen to all advice closely; take some with a pinch of salt; discard some: and figure out a reliable way of knowing which is which (see Ray Dalio’s ‘Principles’ – believability).
  • Turn the feeling of, ‘shit, I don’t know anything about this’ (e.g. coding, encryption, investing, etc etc) into thoughtful curiosity. Again, hold it lightly. I can learn about something much easier if I’m not feeling like I need to be an expert in it by tomorrow.
  • Avoid negative people early on. This is in bold because it should really be one of the main lessons. Pessimism does NOTHING for exploring an idea. Careful questioning, referencing contrary facts or experience, or being cautious are very helpful. I’m a big picture thinker so I need to be pulled up on details. Telling me that ‘people will never do this or that’, or ‘they’ll never like this’ makes me a) want to disprove it and b) ‘never’ and ‘always’ statements make me very doubtful of their veracity. Humans are grey; organisations are grey; society is grey. Tapping motivation at any of those three levels is essential for creating change. Whether one is successful or not is dependent on lots of other variables. But let’s not ‘never’ and ‘always’ one another.

That’s it for just now (here, anyway. Plenty more buzzing round my head). Hold lightly. Choose people based on character. Embrace delays and see it as part of the process. Be curious, and not afraid to show it. Questions rule the world.

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Well-being in the midst of the fire: how do medical students and doctors look after themselves when the system doesn’t?

I remember the first patient that died in my presence. I had been a doctor less than a year and was working in a national colorectal surgical centre. Before the change of shift, my colleague had told me about a woman that had been admitted. She had been reviewed by a more senior doctor but they were still unsure what the problem was. My memories of the presentation are vague; I think she had recently had surgery, had been in another hospital, and had developed non-specific abdominal pain post-operatively so was returned back to the centre where she had had her procedure. I was at least fourteen hours into a 12-hour shift when I was called by the nursing staff to say that this patient was distressed. When I arrived she was delirious (an acute confusional state that can be precipitated by any number of things – hypoxia, infection, medications, etc). She was calling for her husband and gasping for breath. She was obviously extremely unwell and deteriorating. I started auscultating her chest to listen for signs of acute respiratory distress, and listen to her heart.

I cannot say for certain now – our memories are fickle and play tricks on us – but I think her heart stopped beating whilst I was listening. She went into cardiac arrest. I immediately lowered her bed down (as she had been sitting up), pressed the emergency buzzer, and started CPR on her. The whole situation feels so surreal now. I felt incredibly helpless. The week of on-calls were seven 12-hour shifts, which each easily became fifteen hours, and on day 8 was a half day on which you were supposed to hand over care to the oncoming team. Two junior doctors managed all the acute patients being admitted, and on the weekend, were also managing all the patients of the three or four other teams; well over a hundred patients altogether. The registrars were either in theatre or admitting people in emergency. Consultants would do breakneck speed ward rounds before spending long days operating. It was an awful experience, especially for someone who likes to be in control and have an overview of my work situation. It felt chaotic and haphazard.

The crash team arrived and people sprang into action, following the prompts of the defibrillator. After a while it became apparent that resuscitation would be unsuccessful and the process was stopped. I remember the two medical registrars running the resuscitation comforting one another and affirming that they could have done no better. I was halfway between stunned and completely detached from the situation. I stood there observing. And then my pager went and I was off to the next task.

Looking back I feel sorry for my younger self. I didn’t realise how stressful I found my first two years working as a doctor until much later. I had been high-performing and high-achieving in my studies. It was painful going from being an excellent student to being a doctor where life and death were handled on a daily basis with nonchalance, and treatments were instigated with varying degrees of success and what seemed like blind hope at the outcome, mostly. My first job was in the gastroenterology and hepatology ward at a national liver transplant unit in a country with some of the highest alcohol abuse rates in Europe. Many of our patients had end-stage liver failure. One of the results of liver failure is the inability of the body to produce blood-clotting factors. Chronic alcohol abuse can also reduce the platelets in the blood, another essential component of the early blood clotting cascade. In addition, people with cirrhosis have a few major points in their body which are areas of engorged blood vessels due to back-pressure from their cirrhosed livers. They are sitting blood bombs just waiting to burst. I remember my third or fourth shift as a doctor, being the only doctor there from 5 until 9.30pm. The weight of the sense of responsibility for these incredibly unwell people was overwhelming at times. I remember having to call an anaesthetist because a patient had developed a nose bleed which was not stopping. People in this state hose blood when they start. He was shouting at me to get a catheter to insert in the patient’s nose to place pressure on the arterial blood. I was covered in blood, was trying to hand this slippery rubber catheter with a syringe attached to the anaesthetist, and I couldn’t inflate it. I’m not surprised I had diarrhoea with associated stomach cramps for my first couple of months of work there.

As a doctor develops more experience there is an improvement in knowing better how to handle a sick patient, how to recognise a deteriorating patient, and how to pre-emptively get help when this happens. But then other things come in: working shifts whilst having young children at home; studying for postgraduate exams whilst having young children at home and working shifts; dealing with major family illness whilst working, having young children at home, and ideally studying for postgraduate exams. Whilst working shifts. Getting divorced. Getting assaulted by an aggressive patient. Losing a parent or a sibling. Throw into this that the daily job is constantly dealing with human misery, pain, and trauma (in some specialties more than other), in health systems which are over-burdened and stretched, in societies where health provision is a powerful political and economic signpost, within a culture which is harsh and unforgiving with high rates of bullying and harassment, especially for women. It can be rather brutal.

In Australia, a few days ago there was a technical hitch with the RACP basic physician trainee exam. This resulted in the $1800 exam, which doctors will have studied for months for, whilst working full-time in most cases, which will have required loss of time spent with children, partners, family, and friends, to be deemed null and void. For the pleasure of sitting the exam, it will have required bartering with roster planners to ensure that the examinee was not on night shift the night before the exam, but may have gone onto night shift the day of or day after the exam. It will have involved careful negotiating to try and access professional development leave (which is part of doctors’ contracts) to have some uninterrupted time to study. It will have involved negotiating with clinical teams if you had more than one doctor needing to take the exam at that time. Some will have used annual leave to study and attend revision courses (which themselves can cost thousands of dollars). Holidays will have been delayed.

And now, these trainees’ exams are void due to the technical glitch. They need to sit it again in two weeks.

Peter Donkersley, a medical student at the University of Tasmania, took his life earlier this year. He is, sadly, one of the many of our colleagues: Dr Andrew Bryant, a consultant gastroenterologist in Brisbane; Dr Chloe Abbott, one of three NSW doctors in the space of a few months. And there were three psychiatry doctors in Victoria in 2016, where details were withheld. These are just some of the known ones. There are many whose causes of death will remain unknown or kept private.

In The Medical Journal of Australia we are encouraged to have the ‘courage to act on burnout,’ and these problems are not isolated to Australia. In the US, the Medscape National Physician Burnout and Depression Report 2018 emphasised the extent of the problem. The survey of over 15,000 physicians revealed that 42% of them were ‘burned out.’ An article in the British Medical Journal in 2017 stated that ‘medicine must change its culture to tackle the toxic aspects of medicine that cause and sustain burnout.’ It also quoted a Canadian study which ‘estimates that early retirement and reduced clinical hours from burnout will cost the health system $C213m (£130m; €146m; $167m) in lost future service.’ The findings are echoed in China and New Zealand.

So what can we do?

A 2016 The Lancet systematic review and meta-analysis on interventions to prevent and reduce physician burnout showed that interventions DO work. Fifteen randomised trials including 716 physicians, and 37 cohort studies including 2914 physicians demonstrated that ‘both individual-focused and structural or organisational strategies can result in clinically meaningful reductions in burnout among physicians,’ which can equate to a 10 percentage point drop in rates of burnout, from 54 to 44%. Good…but not brilliant.

Over the last month I have been in the process of laying the groundwork to develop a tool which can be used by individual medical students and doctors to improve stress and burnout, and which can also be used by hospitals and health services to partake in improving wellness. The task is large, and there are multiple barriers. We cannot change centuries of culture and dogma within the profession. We cannot instantly change the systemic and organisational issues that plague all healthcare workers.

What we can do is start prioritising looking after ourselves, and health services, their staff.

To encourage this, I want to employ the use of the tenets of the pursuit of wellbeing as described by Professor Martin Seligman at the University of Pennsylvania in the Department of Psychology. Following the mnemonic, PERMA:

  • Positive affect (or emotion) – how do we make space for positive feeling at work amongst the trauma and distress and pain? We can rely on our morbid sense of humour for so long, but what happens when you go home and there is an emptiness because of the emotional and mental outlay that your job requires?
  • Engagement – doing things which get us into a state of flow, both at work and personally
  • Relationship – ensuring that we have personal relationships which are healthy and remind us of the much bigger world beyond medicine, but improving the authenticity and openness within our professional relationships. Only doctors know what doctors go through; the help we can offer one another is massive
  • Meaning – there is an expectation that being a doctor is an inherently ‘meaningful’ job. It can be – but the meaning is very easily lost amongst electronic health records, HR departments, KPIs, technical glitches, and the hierarchical, punitive structure. How do we imbue our jobs and personal lives with meaning?
  • Accomplishment – it’s easy to accomplish in medicine. But what happens when you’ve accomplished everything that there is to accomplish? What happens when, perhaps, you have not accomplished in your family life, or interests, or health, or hobbies, or psychological health? What happens when you reach your peak professionally? We need to ensure our lives are not empty beyond the practice or hospital walls.

I look forward to sharing more in the weeks to come. In the meantime, please reach out if you are struggling. I’m happy to be contacted here personally, or go to The Doctors Health Advisory Service, or reach out to a trusted colleague.

We’re in this together.

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What does the Harvard Study of Adult Development teach us about the social impact of healthy relationships at work and at home?

In one of my roles (working as a trainee psychiatrist in the public health sector), I am continually asking the question, ‘what is causing this patient to present to me, at this time, with this particular pattern of symptoms?’ I am fortunate in my current workplace – a child and adolescent mental health clinic – that there is a holistic approach to mental health. My colleagues and I work within a schema that throughout the first two decades of life, mental well-being is due to a complex interplay of factors: genetic predisposition, personality traits, temperament, socioeconomic setting, ethnic background, sexual orientation, gender, trauma, developmental history, family structure, other co-existing medical problems….the list is extensive.

This gives rise to the question, how do we support someone in coming to a place of mental well-being with simply medication and talking therapy when there are so many variables? (This is a slight over-simplification; we also engage NGOs, allied health professionals, etc.) It’s clear that we cannot mitigate for societal attitudes to gender or sexual orientation or certain temperaments which may result in adverse effects on those individuals.

The primary role as a doctor, especially in the mental health sector where we measure DALYs (disability adjusted life years) and QALYs (quality-adjusted life years) – both measures of how life is affected by disease burden – is trying to promote the best life possible for that individual.

A lot of our role in the mental health sector is creating connection for people who are disenfranchised; they may be isolated, unemployed, or disengaged from the usual support available in society. This process is often facilitated by therapy, hospitalisation for severe mental illness, and medication. But the biggest role we offer is a relational one. This is a professional relationship, but through which we hope to model the connect that people can potentially have out in the world.

This led me to wonder about the role of relationship in creating happy and healthy workplaces and society. I am interested in social impact, which is a great sign of the growing awareness of our interconnectedness, and that positive flow-down from corporations results in better communities.

Since his TED talk, What Makes a Good Life? Lessons from the World’s Longest Study on Happiness, in November 2015 Professor Robert Waldinger, Clinical Professor of Psychiatry at Harvard Medical School, has been an oft-quoted figure. In his blog he writes,

More than half of the complaints that patients bring to their doctors are emotional in origin. Most often, they include troubled or absent connections with loved ones. Studies have shown that loneliness increases our risk of developing heart disease, diabetes, dementia, and a host of other ailments. A troubled marriage can be as hazardous to physical health as cigarette smoking. Depression is one of the costliest, most prevalent, and most under-diagnosed illnesses in the developed world.

We know that sustained, trusting connections with our physicians have enormous diagnostic and therapeutic value…

Human connections are essential aspects of both illness and cure. A health care system that provides insufficient time and reward for attending to these connections remains doomed to higher costs and lower quality, no matter who pays the bill.

Professor Waldinger knows a thing or two about connection and relationships in his role as Director of the Harvard Study of Adult Development at Massachusetts General Hospital. Briefly, the study was established in the 1930s and the men – and only men, which I’ll come to later – were selected from two different cohorts: the Harvard Cohort (the Grant Study) were 268 Caucasian men from the Harvard classes of 1939-1944. The second cohort, the Boston Cohort (the Glueck study) was a group of 456 Caucasian men from Boston neighbourhoods between the ages of eleven and sixteen. These children and adolescents have been followed up to the present day, and the study has now moved on to the Harvard Second Generation Study.

A mentionable issue with the Harvard Study is that it is a prospective study of men only.  During the studies, once the original men partnered, their wives were also included in the study. In the Second Generation Study, obviously the female offspring of these men will also be included. Does this mean that we cannot extrapolate the findings to women, people of different ethnicity, or sexual orientation? I don’t think it does, but it is helpful to bear in mind that these minority groups will have faced other challenges in life which are unique to them and which Caucasian men, regardless of their socioeconomic or educational background, will not have faced.

The findings of the study, according to Professor Waldinger, were that the quality of relationships was the biggest predictor of someone’s experience of happiness, contentment, and overall well-being – physically and mentally. In his TED Talk, he says:

So what have we learned? What are the lessons that come from the tens of thousands of pages of information that we’ve generated on these lives? Well, the lessons aren’t about wealth or fame or working harder and harder. The clearest message that we get from this 75-year study is this: Good relationships keep us happier and healthier. Period.

Most of (but not all) know instinctively how important relationships are to our enjoyment of life. People who may not have as much desire for close relationship with others are probably outliers on the bell curve, and I’m sure that there are some who would consider themselves emotionally and mentally fulfilled in their solitude. But what the Harvard Study suggests, is that relationships are integral not only to our mental wellness but also to our physical health.

It’s easy for me to apply this theory in the mental health sector, but much harder to apply in practice in mental health and other areas of medicine. Imagine telling a successful man in his mid-50s that the risk of his high cholesterol could be offset by partaking in close and supportive relationships with a life partner and a few steady friendships! This is what the study suggests, although how we determine the bare minimum of what constitutes a mutually close and supportive relationship is difficult.

At an organisational and even sector level, how can we improve our intra-organisational wellness and external social impact by promoting the lifestyle to support these recommendations? How can we reformulate ‘happiness’ and ‘the good life’ as something that is not defined as material possessions, professional success, or achievement based on working to a degree which undermines relationships and physical and mental health? I wonder if we can resist the valuable pull of technology to speed up processes and improve productivity, without it sucking in our humanity as it goes. This is a challenge, but one that we can surely meet as intelligent beings that can recognise the danger of automation and lack of power-off in our lives.

I’ll leave you with the wise words of Holly Butcher, a 27 year-old woman who died on 4th January 2018 from Ewing’s sarcoma. She writes,

It’s a strange thing to realise and accept your mortality at 26 years young. It’s just one of those things you ignore. The days tick by and you just expect they will keep on coming; Until the unexpected happens. I always imagined myself growing old, wrinkled and grey- most likely caused by the beautiful family (lots of kiddies) I planned on building with the love of my life. I want that so bad it hurts. That’s the thing about life; It is fragile, precious and unpredictable and each day is a gift, not a given right. I’m 27 now. I don’t want to go. I love my life. I am happy.. I owe that to my loved ones. But the control is out of my hands…

Remember there are more aspects to good health than the physical body.. work just as hard on finding your mental, emotional and spiritual happiness too. That way you might realise just how insignificant and unimportant having this stupidly portrayed perfect social media body really is…Give, give, give. It is true that you gain more happiness doing things for others than doing them for yourself. I wish I did this more. Since I have been sick, I have met the most incredibly giving and kind people and been the receiver of the most thoughtful and loving words and support from my family, friends and strangers; More than I could I ever give in return. I will never forget this and will be forever grateful to all of these people. It is a weird thing having money to spend at the end.. when you’re dying…

Don’t feel pressured to do what other people might think is a fulfilling life.. you might want a mediocre life and that is so okay. Tell your loved ones you love them every time you get the chance and love them with everything you have. Also, remember if something is making you miserable, you do have the power to change it – in work or love or whatever it may be. Have the guts to change. You don’t know how much time you’ve got on this earth so don’t waste it being miserable. I know that is said all the time but it couldn’t be more true.

 

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Five (+2) favourite quotes thus far from Tim Ferriss’ ‘Tribe of Mentors’

If you’re reading this on your phone, on social media, whilst I share life hacks from a book subtitled ‘Short Life Advice From the Best In The World’ – then shame on you.  Sit down. Turn off your phone. Pour a cup of coffee. Then read the book yourself.

But failing that, here are some of my favourite curiosity-inducing, potentially  life-changing quotes to disrupt your 2018:

1. Kyle Maynard – first quadruple amputee to reach summits of Mount Kilimanjaro and Mount Aconcuagua without prosthetics, champion wrestler and CrossFit instructor. Phew.

If happiness is just above the status quo, bliss is what makes you feel most alive. Expect it will take courage to follow your bliss, and expect it will suck at times. Expect you’re going to have to take risks for it. Expect others won’t necessarily understand.

2. Debbie Millman – the ‘Queen of Branding’, founder and host of Design  Matters podcast (excellent – a must-listen), editorial and creative director of Print magazine, and co-founder of world’s first masters in branding at NYC School of Visual Arts. She also has an incredible life story – check it out here.

Busy is a decision…If we use busy as an excuse for not doing something what we are really, really saying is that it’s not a priority…

One piece of advice I think [a smart, driven college student] should ignore is the value of being a “people person.” No one cares if you are a people person. Have a point of view, and share it meaningfully, thoughtfully, and with conviction.

3. Naval Ravikant – angel investor, CEO of [lots of sexy-sounding Silicon Valley-esque companies I’ve never heard of]. Smart enough to have cashed in on Twitter and Uber. And smart enough to say,

Suffering is a moment of clarity, when you can no longer deny the truth of a situation and are forced into uncomfortable change. Inside suffering is the seed of change…

Ignore: The news. Complainers, angry people, high-conflict people. Anyone trying to scare you about a danger that isn’t clear and present…

Self-esteem is just the reputation you have with yourself. You’ll always know.

4. Lewis Cantley – professor of cell biology and chief of Harvard’s Division of Signal Transduction. He discovered the cell signalling pathway phosphoinositide 3-kinase (PI3K), a significant advance in cancer research. He has also been involved in significant treatments for diabetes and autoimmune diseases.

Choose a profession that is really easy for you to do and that also allows you to be creative…One should not pursue a profession just because it is viewed, at the time you begin college, as the one that will have the most jobs of where you will make the most money. If you are uncertain of your talent, get a broad education that does not narrow your options. The best skill is to be able to communicate efficiently both in writing and speaking…

The worst recommendation [in my area of expertise] is to keep your ideas and data a secret until you have a paper describing these results accepted into a journal. Anytime I have a crazy idea or see an unexpected result, I talk about it with my colleagues to see if they have seen anything similar and whether they think my idea is crazy. This is the fun of science. Multiple scientists with different experiences and expertise can collaborate and get to the right answer much faster than a single scientist.

5. Jerzy Gregorek – born in Poland, emigrated to the US in 1986, and subsequently won four World Weightlifting Championships. In 1998 he earned a Masters in Fine Arts in writing from the Vermont College of Fine Arts. His poems and translations have appeared in multiple places, including The American Poetry Review.

I bought a bracelet for $19.95 with the first letters of each word of a sentence: IARFCDP…They are the key to my personal proverb, a line that brings awareness and helps me see through my own emotional storms. It means: I Am Responsible For Calming Down People. Sometimes it helps me to teach what I need to learn myself…

“Hard choices, easy life. Easy choices, hard life.” Nothing truly meaningful or lasting has ever been created in a short period of time.

5+1 (bonus quotes, because I’m greedy): Anna Holmes – writer and editor who has worked with The Washington Post, The New Yorker, and The New York Times. Creator of website Jezebel which discusses the intersection of gender, race, and culture.

“Follow your curiosity, wherever you can find it.” Embracing a curious mind and always trying to learn more – about others, about yourself, about the world and our place within it – is an important way to express yourself.

5+2: Annie Duke – one of the top poker players in the world. In 2004 she won her first World Series of Poker bracelet. She won the $2 million invitation-only World Series of Poker Tournament of Champions in 2004. Prior to becoming a professional poker player she had a National Science Foundation Fellowship at the University of Pennsylvania to study cognitive psychology. She blogs at Annie’s Analysis on the science of smart decision-making.

Seek out dissenting opinions. Always try to find people who disagree with you, who can honestly and productively play devil’s advocate. Challenge yourself to truly listen to people who have differing ideas and opinions than you do…The fact is, when two extreme opinions meet, the truth lies generally somewhere in the middle. Without exposure to the other side, you will naturally drift toward the extremes and away from the truth of the matter. Don’t be afraid of being wrong. Because being wrong is just an opportunity to find more truth…

Stay flexible and open to opportunities as they come your way…Be open to what the world brings your way. Don’t be afraid to change jobs or careers, no matter how much time you have already put into something. There is no urgency to have it all figured out…

If you define failure as merely losing, then you will think failure is just an outcome. And you might try to adjust your play to avoid losing even though your decisions were great (or repeat poor strategies just because you won executing them once). This would be the equivalent of deciding it is wise to run red lights just because you made it through safely a few times…What matters is the decisions I made along the way, and every decision failure is an opportunity to learn and adjust my strategy going forward. By doing this, losing becomes a less emotional experience and more an opportunity to explore and learn.

Okay, signing out. Heading off to the bush for a few days without phone and internet. It will be all nature, books, wine, and quiet.

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What would happen if we lived compassion in 2018?

On January 1st 2017, I wrote:

This morning, Eva was discussing about aiming to ‘make friends with discomfort’ in 2017. For her, the discomforts are many and multifaceted and are not limited to the discrete physical symptoms associated with treatment for breast cancer. The complex psychological effects of living with this illness and its treatment continue to surprise us, as well as the inevitable emotional instability associated with tiredness and stress and anxiety…[we] discussed further this making friends with discomfort and amended it to making friends with vulnerability and discomfort. The last weeks’ journey has been one of vulnerability in different ways. The sensation of being vulnerable to a life-threatening disease process; the vulnerability towards treatment; the vulnerability of our family to this massive emotional and practical upheaval; the emotional and psychological vulnerability we have all felt as individuals…

The last couple of years we have discussed personal intentions for the year ahead. For example, a couple of years ago my wife suggested ‘making friends with uncertainty’. Of course, by the end of each calendar year we had not risen to such fabulous heights of enlightenment that we had perfected dealing with these complex feelings and experiences. However, like goal-setting, identifying an area for personal growth is the minimal start needed in the process of change. Rather than choosing an arbitrary or completely abstract concept (perhaps making friends with vulnerability is a completely unrelateable issue for you…I would argue it’s not, but that’s another story…) choose something which you see would make demonstrable, tangible difference in your life right now if you learned that lesson. For us, these were concrete, workable concepts that we felt we could pursue in the year ahead.

Last night (New Year’s Eve, in bed by 9.15pm, thank you very much), after writing my first blog post yesterday, I was assailed by the predictable onslaught of doubts and negative self-talk: ‘what the hell are you on about? What is ‘curiosity, disrupted’? What is the deal with that shitting comma? Yes, I know it’s a fabulous grammatical tool which will bamboozle your readers with its utterly disruptive ambiguity, but really? And how pretentious is blogging anyway? Like there aren’t enough blogs in the world. And just because you had a few compliments on last year’s blog (where you obviously hijacked your wife’s experience of cancer to express your own existential angst, you bastard) you now feel like 2018 is begging for another edition of your own naval-gazing self-absorption? What about the Rohingya? Do you think they give a shit about your blog? Go to Mosul if you think you are such a gift to the world.’

Although my own internal, unfiltered, uninvited monologue sounds perhaps rather extreme when written down verbatim, I imagine it’s not too different from that which runs through the minds of us all when we choose to present our wares to the world. For many this can be sharing your creativity, whether that be in artistic form or a presentation to the board suggesting an innovative solution to a complex problem. We are called in our base human-ness to share ourselves. Some choose to do it for artistic expression’s sake; others do it to put food on the table.

Once I’d retired to bed positively bursting with optimism about my latest blog, sans phone (intention number two), I turned to the pile of books on my bedside table: The Compassionate Mind by Paul Gilbert, Tribe of Mentors by Tim Ferriss, Finding My Virginity by Richard Branson, Rising Strong by Brene Brown, The Art of Happiness by the Dalai Lama and Howard C Cutler, The Mindful Path to Self-Compassion by Christopher Germer, and Bringing Yoga to Life by Donna Farhi. (No, you’re not mistaken; it’s like the self-help section of a major bookshop vomited up Bali in the middle of Silicon Valley.) All are in various states of readedness.

I picked up the first one, Paul Gilbert’s brilliant analysis of the old mind/brain v the new mind/brain, and how the biological and social evolution of the human prefrontal cortex has caused all sorts of irritating habits along with its ability to meta-analyse our internal states. He describes three types of affect (emotion) regulation systems in the human brain which he describes as:

  1. The driven, excited, vitality system: this is incentive/resource-focused, and is characterised by wanting, pursuing, achieving, and consuming. It has an activating effect on us.
  2. The content, safe, connected system: this is non-wanting/affiliative-focused, and is characterised by safeness and kindness. It has a soothing effect on us.
  3. The anger, anxiety, disgust system: this is threat-focused, and is characterised by protection and safety-seeking. It can have both activating and inhibitory effects on us.

These systems can also be conceptualised as relatively discrete but closely interlinked neurobiological and hormonal systems.  It’s not difficult to look at ourselves in our day-to-day lives and see how and when these affective systems are driving us. (Affect is a fancy word for emotions in this context.) Emotional intelligence is the concept that by being aware of what is happening at an affect level, we can better gauge what is transpiring both in our own internal state as well as that of others. Again, it is not difficult to figure out why this is important in business, organisational reform, the doctor-patient relationship, politics, romantic and parent-child relationships, etc etc. But how often do we do it?

He later writes,

…We require both a sophisticated and an agreed form of welfare-focused social organization to contain our potential tribalism and abusive power hierarchies, and we must also recognize that, if we don’t understand and train our minds very carefully and learn to be wary of  allowing ‘new brain/mind’ competencies to be directed by ‘old brain/mind’ passions, we’re going to be in trouble…We are a species that has evolved to thrive on kindness and compassion.

That last sentence struck me. We have evolved to thrive on kindness and compassion.

It makes sense on first pass; we know that we ‘feel’ better when others are kind and compassionate towards us…but we rationalise it along the lines of, ‘I don’t live in a world where I can expect to feel pleasurable feelings all time.’ Which is true.

So what does compassion actually mean? Is it a weak sense of gushing over pictures of malnourished orphans on the other side of the world? Is it something only nurses feel? Is it intrinsically related to the maternal and the feminine – that whole stereotyped characteristic which is not championed and modeled by the (generally) male leaders we follow? (A whole other issue and problem which I would love to write about at some point.)

Compassion is derived from the Latin com- ‘togther’, and pati– ‘to suffer’.

To suffer with. To suffer together.

As a doctor, I am galled by the focus on ‘personal resilience’ which is extolled as the answer to the ‘tribalism and abusive power hierarchies’ that haunt my archaic and ponderous profession. A medical school colleague of mine was found dead late at night in the operating theatre changing rooms back in Scotland in August. In Australia, stories abound over the past few years of doctors who have suicided in the pursuit of what was traditionally considered an altruistic and compassionate vocation.

So what would happen if we lived compassion? I have clues and ideals and visions of what could happen, and I will strive in my relationships and professions and society to be a ‘compassion disruptor’. To be explicit: it is not about simply being nice to people or ourselves. Compassion is about stepping out of our comfort zone and proactively engaging with our own, and others’, suffering.

Here are some examples of questions about how compassion could disrupt:

  • In a meeting, a manager publicly humilates a colleague for a genuine mistake they have made. How would you engaging in their suffering affect them? Do you fall on the side of, ‘they made a mistake so they deserve this’, or ‘we all make mistakes and it is not helping the situation by humiliating the perpetrator of it.’ Mike Maples Jr., a partner at Floodgate, a venture capital firm that specialises in startups, says, ‘I find it is better to be focused on honoring the discovery of the truth rather than determining who is to blame.’ Would being compassionate, focusing on the ‘discovery of the truth’ (e.g. a root-cause analysis to identify the chain of events leading to the mistake) rather than lambasting an individual be more helpful?
  • When facing a client, and presenting a solution to the problem they have presented you with, you end up receiving all the credit and praise. You know, however, that a junior associate was the one who came up with the paradigm. The client knows your CEO personally and is likely to mention you favourably. How would compassion towards your junior colleague affect this situation? You know that they stayed late finishing the proposal; how would you empathising with them ‘in their suffering’ change your response? The moral or ethical answer is not difficult to deduce; but would you choose to believe that being seen as charitable and humble is something you would rather be valued for rather than being perceived as cut-throat and win-at-all-costs?
  • As a doctor in a busy emergency department, you are faced with an emotionally dysregulated young person who has self-harmed. They have presented to your ED multiple times, and have a history of cannabis and alcohol misuse. You have treated other family members of this person, who have a selection of forensic charges and substance abuse issues between them. How could the situation be defused by you responding with compassion? How have people usually responded to this young person – both professionals and other family members throughout his/her life? Is acting compassionately likely to smooth the transition of this patient through the ED to the appropriate inpatient setting, or as appropriate to be discharged with follow-up? How does your previous experience with this patient, and other similar clinical scenarios, affect your decision to ‘suffer with’ or to reduce your emotional engagement with this patient?

In 2018, I wonder how we can change our relationships if we acted compassionately? How could we treat ourselves differently (more effectively) if we responded with an awareness of our old mind/brain – that reactive, defensive, safety-seeking part that avoids danger, and which is hijacked by the new mind/brain which chastises us for being in the situation of experiencing those feelings?

If we can change in our intimate relationships?

If we can change in our family relationships?

If we can change in our professional relationships?

If we can change in our societal relationships?

If we can change in our relationship with and to the Other, seeing our selves reflected there?

It could be great.

(But honestly, that f***ing comma.)

 

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