This is a rough transcript of my talk on Self-care and Resilience at Intern Orientation 2019
Welcome to the best job in the world!
I was an intern in 1998 and my career to date has included three years as a resident, then five as an emergency medicine trainee, and twelve as an emergency physician.
When I think back on this 21-year span, I think I spent:
About 70% of the time feeling like it was doable, and that I was a decent doctor
25% of the time feeling a bit wobbly and wondering if I was “enough”
and about 5% of the time feeling overwhelmed, maybe even terrified, and wishing that I’d become an accountant…
Let me start by telling you about one event that belongs in that 5%.
It was Oct 2002, and I was a first-year EM registrar in my first year at Gold Coast Hospital. It was a heaving, chaotic place to work – the workload was constant and it was intense. Ten months in, I was spent. I had an experience that I didn’t understand at the time: tears streaming down my face while I felt a total emptiness inside, a paradoxical inter-current sense of emotional overwhelm but emotional detachment, a feeling like I was achieving very little despite working very hard.
My boss, David Green, rescued me. The single most effective thing he did was to tell me that he’d “been there”. He normalized my experience, shared his own, and firmly guided me through some time off, recharge and recovery. Greenie told me at the outset of my experience that he felt that I would do something valuable with it one day – that it would equip me to support other people who might experience it.
And that’s pretty much what I’ve been doing for the last couple of years – really just working to try to normalize the conversation around wellness and around struggle.
But what can I achieve in this short time?
As new graduates, you’ve had a much more tangible and meaningful taste of working in medicine than I had had at the same stage. You’ve spent a lot of time in clinical rotations, being an active part of the teams you’ve been attached to.
But I’m still mindful that many of the messages I’m hoping to impart won’t really feel relatable or applicable to you given your life and work experience so far.
In a sense, you are in a transition period (albeit a very rapid one!), shifting from the front passenger seat into the driver’s seat. And until you are properly in the driver’s seat, Monday next week, some of these messages may seem a bit distant to you. It is often said that wellbeing and resilience are not things one cares about until theirs are assaulted.
What I hope is that the messages will park somewhere in the recesses of your mind, where you can retrieve them and mull them over when you need them. I’m hoping that you’ll remember that someone mentioned something about self-care, struggle or resilience back in your orientation week. And I’m hoping that even if you can’t remember the detail of what was said, you might just remember that the talk gave you permission to experience struggle, and it gave you permission to talk to someone about it.
The messages are going to be:
- It’s okay to struggle
- Build your supports before you need them
- When the time comes, share vulnerability and empower others
So why dedicate a whole session in your already-loaded Orientation to the topic of self-care?
Because we, as a profession, are increasingly recognizing the importance of it.
During your welcome over the last few days, we will have discussed how you are now standing at the pinnacle of privilege. You are about to embark upon a career that will bring you not only the fulfilment of serving mankind, but will bring you success (and money). And with that all comes also the privilege of how society perceives you – simply because you are a doctor.
But there is a trade off for that privilege… As doctors, we struggle with depression, anxiety, burnout, and even suicidality.
Sometimes even the best job in the world can suck a little.
We have some hard data to illustrate this from Beyond Blue (2012): we experience much higher levels of psychological distress and suicidal ideation than the general population, and higher also than other healthcare professionals. We score high on burnout inventories, and those that are younger are at greater risk.
In addition to the hard data, I also have some soft data – basically my experiences over the last few years of attempting to help people through hardship and adversity.
But still – so what? Shouldn’t we just suck it up and get on with it?
Well to a large extent, that’s what generations of doctors before now have done:
Why?
Because being seen to struggle, we think, is a sign of failure or of weakness. It may suggest that you may not be “cut out” for this job.
What does being well even have to do with being able to do your job?
And if being well is related to being professional, surely that’s far less important than being technically good at your job?
But what if I put to you that the soft stuff (wellbeing, professionalism) isn’t actually soft?
I firmly believe that so-called soft skills cannot be separated from hard skills – that one cannot be an effective clinician if one cannot connect effectively with colleagues and with patients.
And in order to connect effectively with others, you have to connect effectively with yourself. This means that you have to know yourself and that you have to look after yourself – that you have to be “well”.
In my experience, being “unwell” predisposes you to being – well, not very pleasant to work with – you may be impatient, intolerant, abrupt, even unreasonable. This in turn erodes relationships with colleagues and with patients. Without relationship, it is difficult to deliver effective care.
Being “well”, by contrast, predisposes you to having strengths with team-work, communication, leadership. It enables you to demonstrate empathy and compassion. This helps you to deliver effective care.
These strengths directly translate into better clinical performance, be that via being able to focus while conducting a procedure, or having enhanced situational awareness while being a part of the MET team, or being clear when communicating a management plan with a patient and their family.
And so to the messages:
Message 1 – It’s okay to struggle
I promise you won’t be the first or the last.
Years ago, an intern told me that her Mum said that her biggest problem was that she compared her insides to everyone else’s outsides. Do you do this?
During med school, or even during orientation week so far, have you looked around and thought that everyone else looks so capable and confident? During your cannulation workshop, or prescribing skills station, has it felt like everyone else was totally on top of this while you felt like you were totally floundering?
I want to tell you two things:
Firstly, that person that looks so amazingly capable and calm – there’s a good chance they’re feeling a bit wobbly on the inside, just like you.
Secondly, when other people look at you, there’s a good chance that while you’re feeling shaky, you look totally confident to them.
Don’t allow your inner critic to take you down a storyline of inadequacy and being “lesser than”. YOU ARE ENOUGH. You wouldn’t be sitting right here, at the threshold of your medical career, if you weren’t. No matter how much you think you bluffed your way through Med School, reliable people decided that you were enough.
Be kind to yourself, manage your expectations – of yourself and of this job. Just like “orange is new black”, good enough is the new perfect.
One of the things I struggle with these days is work-life balance.
We tend to describe these two facets of our lives as something separate and exclusive from each other. Like our work isn’t a part of our life; or our life isn’t a part of our work – that there is an opposing tension between them.
As part of this I struggle with boundaries also.
But I have come to the reconciliation that it’s okay to blur these boundaries, and in fact – for me – it’s important for my home-self to seep into work (to bring my whole and authentic self to work), and for my work-self to seep into home (for my professional identity to influence my interactions on the home front).
For me, particularly once I became a working parent, this helped alleviate the sense of conflict between the two. I now aim for work-life harmony rather than balance.
There is a good chance you will experience struggle. It won’t be a sign of weakness or failure. When you do, access help; a GP, the Medical Education Unit, the Qld Doctors’ Health Program (QDHP) and/or the Employee Assistance Service.
Message 2 – Build your supports before you need them
(A) On the work front:
Establish relationships – with everyone on your team, medical, nursing, allied health, administrative staff, the wardies and the cleaners.
Establish regard and reputation.
Because when you are surrounded by people who firmly believe that you have integrity – basically, people who will have your back – you have a massive safety net. These are the people who will help turn your potential errors into safe practice, and if a matter is ever in doubt, will believe in your intention.
(B) On the personal front:
Establish a safety net of people that will prop you up when you need it.
Invest energy into these relationships – make them mutually beneficial.
So that when you need them, these people will be fully capable and willing to support you.
Some people talk about having a “failure friend” – that friend they can call upon from the depths of their shame and humiliation. To debrief about the disastrous event that befell you. That friend whom you trust to listen carefully; who allows you to wallow for a bit, but who then honestly sets you back upon the right path, whether it’s helping you to gain some perspective on the issue, or to reflect on what you might learn (and do better) from the experience.
The more I think about what it is that keep us “well”, the more it crystalises for me that a sense of community and of belonging is vital for us. As humans, we are hard-wired for connection.
One of the most dangerous things that can happen to you during your medical career is to find yourself isolated –
because you are working long-hours;
because when you’re off, you’re too tired to meet for lunch or go play a team sport;
because you’re busting a gut to complete an audit to add to your CV;
because you’re so grumpy or sad or overwhelmed these days that the last thing you want to do is expose your friends to your moods.
Being isolated amplifies every negative emotion. It leads to a loss of perspective. It is the path to despair, and to hopelessness.
Avoid it at all costs:
Maintain your connection with your family.
Keep in touch with your friends, in and outside work.
Keep physically active, preferably in a social setting.
Put down your phone, meet a friend for coffee, and have a proper in-person conversation – like with eye contact and everything.
Message 3 – As you progress month by month and year by year, and when you’re ready, share your vulnerability and give others permission to struggle – allow people a glimpse of your insides
Try out those words, “I’ve been there”.
This will be a work in progress – it’s difficult when you’re just starting out and finding your own feet – but as you get some runs on the board, remember this opportunity to be a little generous. It empowers others and gives them permission to struggle – and I promise you that it starts to empower you back in turn.
As I’ve “grown up”, I have accumulated dozens of observations and interactions in my personal and professional life that have reinforced this concept for me.
Over time, I have been open about the stuff that I struggle with:
– being good enough even though I work part time
– not being quite as slick with procedures as I used to be
And over time, I have experienced those with whom I’ve shared these vulnerabilities start to share theirs with me:
– the female colleague who always comes across as indestructible has sought me out to debrief a difficult interaction
– the male colleague who was never keen to engage in conversation now softens up every time I ask him about his growing kids.
Often, these start out as “small talk” conversations, but they build connection and trust (because they are driven simply by kindness and curiosity) so that when the “big talks” need to occur, this connection is already established.
These three messages are related to how we might build Resilience. Now, make no mistake:
You. Are. Resilient.
If and when you struggle down the line, it is unlikely that it’s going to be because of a lack in resilience. It is more likely that you will struggle because of external factors in your work life or your home life or both. But still, it is worth thinking about how we can enhance our resilience.
I think two of the most important approaches are to do with Self-awareness and Purpose.
Self Awareness
Self Awareness is having a clear perception of your personality, including strengths, weaknesses, thoughts, beliefs, motivation and emotions.
Self Awareness allows you to understand other people, how they perceive you, your attitude and your responses to them in the moment.
During my time as Director of Clinical Training, there were countless times where my job was to address difficulties between ward staff and a junior doctor. Usually, the situation was that the doctor was perceived to be unapproachable, unhelpful, or unavailable – for a variety of reasons. Almost always, when I gave the doctor this feedback, they had been unaware of how they had been perceived, and in fact grateful to be told. Almost always, they were able to adjust their behaviour, and how they came across to people – and the difficulties were resolved.
So: know yourself. Make an effort to observe your own behaviours through other people’s response to you. Recognise if you’re grating on them, or bringing out the worst in them. And work out what helps you come across in the way that you intend – in a way that is effective, both for getting the job done and also for building a positive regard of yourself.
Purpose
Purpose comes from the recognition that we belong to and serve something bigger than ourselves. How lucky are we that this is inherent to the job we are paid to do! We have a purpose every time we show up to work.
But also find purpose and meaning outside of work, or at least bigger than work. Medicine cannot be your sole reason for existence.
Work on creating the big picture for yourself – and working out your place in that picture.
To close…
I put to you that the “soft stuff” is actually the core stuff.
I hope that if and when you need it, or if a friend or colleague needs it, that you might remember some of the messages: It’s ok to struggle. You will get through it.
When I think back on this 21-year career span, I think I spent
About 70% of the time feeling like it was doable, and that I was a decent doctor
25% of the time feeling a bit wobbly and wondering if I was “enough”
about 5% of the time feeling overwhelmed, even terrified, and wishing that I’d done something else –
and 100% of the time feeling that I was doing something meaningful, fulfilling and purposeful.
Remember your meaning and purpose, do what sustains you to continue to achieve this, and it will carry you through what I hope you will also be able to describe as the best job in the world.
