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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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