"I've been there"

"I've been there"

Three words that share vulnerability in order to empower each other.

This article is adapted from my presentation at the ACEM Qld Autumn Symposium on 25 May 2017.

It was the year 2002, when I was a 2nd year Emergency Medicine registrar, that I experienced a version of burnout.  I’d been at my new workplace for 10 months, and the patients just never stopped coming – ever.  By October, I was spent.  In a heap, I was unable to understand my own emotions, let alone articulate them to someone else.

I phoned my boss (Director of GCH ED, David Green) – who was away fishing in Darwin – only out of courtesy to inform him of my intention to resign.  He said “Don’t do anything. I’ve been where you are.  I’m back tomorrow – let’s talk and we’ll work it out”.

In my little head, I thought “Well if the formidable, indestructible, accomplished David Green has been here, then it’s okay for me to be here too.  And if he got through it and did all the important things he did, then I will end up okay too”.

Of course, I’m simplifying the facts a little – and idealising Greenie more than a little – but you get the point.

It gave me validation. And it gave me hope.

But it also planted a seed that the experience had a purpose.  Greenie told me the following day when I met with him that one day I would do something important with that episode.

I’d like to cover two broad themes:

  1. Why Wellness? Why bother? And the answer may be obvious to you but I’d like to put an additional slant to it.
  2. How can we start to fix this? What can we do at individual or team or departmental level while we await action at organisational or national level.

Why Wellness?

What’s the big deal?

There are the big impactful stories like when our colleagues die by suicide – and these events rock our medical profession and our community, as they should. There is a flurry of activity in the media: “Why did it come to this?” “What are we doing wrong?” “When and how will we fix it?”  Based on the statistics, this is the outcome for a small but significant percentage of us.

In parallel with these profound and tragic events however, are the remainder of us.  We won’t die by suicide. We may never be given a diagnosis of mental illness.  We may never be deemed to be impaired clinicians.

But we will struggle – whether a lot or a little, whether frequently or rarely – we will have times when it all gets a little overwhelming.  We experience cumulative fatigue – emotionally and physically.

But still, so what? We kind of know this, we expect it, it goes with the territory.  It is the trade-off for being in a profession that is privileged and prestigious.

We wear our struggles like a badge of honour.

But it’s not pleasant.  And in addition to not being pleasant, it affects our performance – on every level.

I have made the following observations over 20 years of clinical and administrative practice:

I am increasingly convinced that Wellness is intricately enmeshed with Professionalism – that the more well you are, then the more likely you are to possess attributes of leadership, good communication and good team work.  This is probably related to self-awareness and how that links with emotional intelligence.

Furthermore, I am also increasingly convinced that Professionalism is completely connected with Performance.  In medicine, we tend to separate technical or hard skills – the knowledge and procedural prowess required to provide clinical care – from the non-technical or soft skills – like empathy, reliability, conscientiousness.

I firmly believe that the two cannot be separated.

We all know colleagues who are respected for their technical brilliance but who lack bedside manner. When my dad was diagnosed with a meningioma some years ago, I asked my seniors who would be a good neurosurgeon to see.  I remember being advised “Go see Dr X – he’s terrible at talking but he’s a good cutter”.  In the end we saw Dr Y – also respected but with a little softer approach.  I’m glad we chose Dr Y, because so far – touch wood – my dad hasn’t required any cutting.

Wellness = Professionalism = Performance

Wellness is linked with Professionalism.  Professionalism is linked with Performance.

As such, the concept of Wellness should no longer be considered one that is esoteric, indulgent or “a bit fluffy” but one that is an essential component of being a good and effective doctor.

And this should perhaps make the concept – and the crusade for Wellness – somewhat more acceptable to us.

In addition, if health organisations had no other motivation to invest in doctor or all-staff wellness, the increase in performance and productivity (and the cost-efficiency that results) would more than compensate for their commitment of resources.

How can we start to fix this?

We know more about Physician burnout and mental illness than we ever have before.  Even though we still cannot reliably predict suicide risk, we have defined many of the contributing and protective factors.  It is now established that, as a profession, we are stressed and fatigued.

What now? Well, we can keep studying it, gather more data, and confirm what we already know. Or we can attempt to at least start to fix it. The state governments, organisations like the AMA, even ACEM, are moving towards strategy and implementation.

But what can we do NOW, you and I, at ground level?

I assert that we can make a difference by starting to normalise the conversation around us. 

Perhaps simply by using the words: “Are you okay?” and, like Greenie did for me, “I’ve been there”.  I know first-hand the positive impact that these words can have on someone who is struggling.

Validating struggle

But I appreciate that if you’re someone for whom self-disclosing statements like this don’t come naturally, the words might stick in your throat.  If this is you, then I encourage you to “fake it till you make it” – take the risk, and I would hope that the response you get over time might just reinforce their value, and that the act of saying those words might get easier each time you try.

As senior clinicians, we need to lead the charge with this. It is incumbent upon us to initiate, influence and sustain the discourse and action – the talk and the walk – in this sphere.

Our junior doctors are too vulnerable – even more than we – to be expected to step up and start the conversation.   They carry the risk – real or perceived – that expressing difficulty may compromise training and career opportunities.  We don’t carry that risk.

It is said that if you want to fix or change a system, you have to fix it from the inside. It’s the same with building a culture that supports wellbeing – the trainees are not on the inside – WE ARE THE ONES ON THE INSIDE.

Let me give you some examples of what I’m describing.  When you are discussing patient care or an inpatient team interaction on the ED floor, when you are having a chat in the tearoom, when you are walking with a colleague to the staff canteen or the carpark – get kind and curious.

You don’t even need to ask a probing question.  You might start by making a benign statement about yourself: “It always annoys me a bit when the surgical registrar is stuck in theatre and it takes ages for our ED patient to get seen” or “I had a patient yesterday that I diagnosed with AML – I felt a bit crappy about that” or “I still have to sew my daughter a Snow White costume for school after I get home today – and I’m already so tired”.

Give those around you permission to struggle. Demonstrate that a sense of struggle is not a sign of failure or inadequacy.

You might get absolutely nothing back when you make these statements.

But I promise you that the next time that colleague (junior or senior) is feeling a little fragile, it will have increased the chance that they will seek you out to talk to you – because they know you’ve been there, that you will understand, and that you won’t judge them to have failed.

So, to review:

  1. Wellness = Professionalism = Performance
  2. Keep it simple: make your mark simply by attempting to influence your immediate environment. Try out those words “I’ve been there”.

If we are in the business of caring for people, surely ­we must more overtly care for each other. And an inherent aspect of this is caring for ourselves.

There is absolutely nothing we need to wait for. Let’s start now.

See Gold Coast Health’s promotion of RUOk? Day here.