The reason I started writing this blog was to be open about my own struggles with the stresses of working in Emergency Medicine. By writing about my experience of burnout and recovery I hoped to make those who were struggling feel less alone, to help their colleagues understand a little better what they might be going through and to generally reduce the stigma that exists around mental health issues within medicine. To that end it is time for me to be honest again… after just over a year of being back to work, I’ve actually now been out of clinical medicine again for the last ten months. You see, whilst it is important to be positive about how we can recover from mental health issues, we also need to be realistic and honest about the fact it may not be a straight forward journey and for me, for now, it appears I’ve hit quite a bump in the road.
In late June last year, during and evening clinical shift, our Medical Director decided it would be better if I was taken out of the Emergency Department environment for my own good: I was devastated. I thought I’d been doing okay… yeah there were tough days and I sometimes struggled with the frustrations inherent to EM life but overall I felt I was coping pretty well. Apparently not. Colleagues had concerns, were worried I was getting too stressed, and felt something needed to be done. There were no concerns raised about my clinical abilities but it was felt that the stresses of being there were affecting me unhelpfully and I needed to be away from them.
The immediate suggestion was for me to be off work completely for six months but the thought of that was terrifying (professionally, personally and financially) and felt like an overreaction. Given I was working half time in medical education and was both enjoying that and receiving good feedback, I pleaded my case to be allowed to work my full hours there. This request was granted and it is where I remain to this day…the issues around this continuing redeployment are for another blog!
Red eyed and shaking, I handed over a case I was midway through and tried to explain why I was unexpectedly leaving early. As I walked to the car park to drive home I realised I’d now also have to explain to my wife and children why I was back early, explain that I had failed again. I passed a McDonald’s on the route and thought about stopping there for a few hours just so I could get home ‘on time’ and pretend things were fine, avoiding that difficult conversation, but thankfully I managed to avoid that particular cliché.
Having summoned the strength to say something, when I did make it home there was a family friend there so I lied and claimed my early return was due to the department being quiet. I kept up the pretence for the rest of the evening meaning it wasn’t until hours later, as we headed to bed, that I finally had to admit to my wife what had happened…and so began the latest chapter of my Broken Toy life.
When I stop and think about it now I have so many conflicting emotions about what happened. Almost all of them are negative: shame, anger, betrayal and disappointment for starters, but if I am to move on I have to reframe the situation, find something positive to draw from what happened. This is where the blog originated: trying to find the good in what had gone bad. In my writing on this subject I have always tried to be honest about when things have gone wrong, both my own mistakes and those of people around me, whilst steering clear of blame as much as possible. The reason is because I genuinely believe that these errors are due to ignorance rather than malice and they should be used as opportunities to learn rather than a chance to point the finger. As individuals and as a system we need to do better and so, in a spirit of learning, here are three lessons that I hope can be drawn from my experience…
1) There needs to be a plan.
This seems obvious in retrospect but at the time I never really had a good plan for what I would be doing after the initial return to work. Whilst I began with extra support and fewer responsibilities than before, these were slowly and inconsistently altered, not because of any objective improvement in my condition or planned increase in my work load but primarily due to problems with resourcing. The result was that I picked up responsibilities I thought I could do out of loyalty and a sense of duty rather than because it was felt I could or should and then had no easy way of putting them back down again when I was struggling. A clear, objective understanding of abilities matched to workload which is reviewed regularly has surely got to be the basis of any successful return to work program, along with an easy de-escalation plan if progress turns out to be too fast or too far. Without such a plan we are relying upon luck to see us through and that is a gamble we really shouldn’t be taking with someone’s career.
2) We need to look after ourselves.
It is very easy to blame other people…trust me on that… but those of us who have problems need to learn to help ourselves: We need to listen to our own body and mind, understand our own unique responses to stress and take responsibility for modifications we can make. My sleep had started to deteriorate, my eczema was flaring up and I was feeling overwhelmed by life in general. I had actually said to my wife shortly before this episode that the next few months were going to be tough but if I could just get through them then things would start to settle down. Some of this was due to factors seemingly beyond my control at work but there were other factors outside of work and I needed to release some of the pressures here too. However, the big problem is that many of these ‘pressures’ are actually things that when I am well are energy giving and uplifting, to stop them feels like ‘work’ destroying your ‘life’.
I think this is why the idea of work/life balance can be unhelpful as it pits these parts of who you are against each other meaning adjustments are forced to one side or the other and battle lines are drawn. Instead I have started to think more in terms of my life having a ‘graphic equaliser’ where I try to adjust up or down any or all of the aspects of my life depending on the situation. It is more flexible than just ‘work’ or ‘life’ and brings the multiple facets of both ‘work’ (teaching, reading, learning) and ‘life’ (diet, exercise, sleep, volunteering, family, hobbies) in to play.
3) Colleagues need to speak up…early!
I still haven’t had the courage to ask them but I just don’t understand why my colleagues didn’t say anything to me or why they didn’t do something. Perhaps they thought I’d respond badly? Perhaps they didn’t know what to do? Perhaps they were too overwhelmed by circumstances or underwhelmed with resources to initiate changes. Whatever the reasons I don’t think what happened was the correct response…but I also don’t think for one minute it was borne out of a lack of compassion or concern. It might be easy for you, reading this, to think poorly of my colleagues but stop and think for a minute, really think, would you have been any better? Would you have known what to do? Would you have known what to say? Would you have had the personal skills or the departmental resources to deal with a similar situation? My guess is that most of us would have struggled but like every other problem fighting for our attention, if nobody says anything about it then nothing will get done… until it becomes a crisis and then it will be much harder to solve. If you are worried about a colleague, please say something to them. Explain to them that you are worried and ask what you could do to help. If they don’t recognise that they need help or don’t know what you can do to help, be their advocate, take their situation forward for them…you have a duty as a doctor, as a colleague and as a fellow human to do something. Not sure what that might look like, try this blog I wrote called The Story of the Good Colleague or one called How do you Save a Drowning Man? Please, be brave and take a risk, you’d want someone to do it for you, wouldn’t you?