This post is based on a talk I gave at the Emergency Medicine Trainees Association 2018 conference in Cardiff. In it I try to give a few lessons from my personal experience across three time frames, prior to, during and after a breakdown. Having spent a lot of time reflecting, I realise that whilst there were (and still are) significant system problems relating to what happened, there are also some things that I could have done personally to try and help myself along the way. So here are are six ways that I believe I could have helped myself in the past and three more that I am working on in the present.
Plan Your Own Development
The Mistake: When I started as a consultant it was 2003 and the Emergency Services Collaborative was getting in to full swing. There was a national push to make emergency care better and the four hour target had just arrived. I spent the next five or six years concentrating on improving my ED, developing the systems, the care, the training… but I forgot about developing me. I didn’t notice this until I tried to move jobs and realised that my skill set was limited to just doing what I currently did very well but I had nothing new to offer, none of the enhanced skills that were now expected in Emergency Medicine. Even now I still catch myself mourning the doctor I could have been had I not neglected my own personal development so badly in those early years.
The Lesson: The only person who really cares about your development is you and you need to plan it because it doesn’t happen by accident. This isn’t just about taking study leave (although that matters) it is about ensuring your development focuses on what is best for you, not necessarily the department. When you have your annual appraisal, you need to write your Personal Development Plan, not your appraiser, and you need to decide what you want to become in the future, both in and out of work. Take control of your development early and continue to prioritise it throughout your career, throughout your life, because, as L’oriel says, you’re worth it!
Leave Space to Grow
The Mistake: One of the difficult skills people tell you to develop is the ability to say ‘no’ to someone offering you an ‘opportunity’ but let me tell you, there is an even harder version of this, saying ‘no longer’. I managed to say no with a reasonable degree of success initially and kept my portfolio of responsibilities to what appeared a manageable load, however, over time, some of these portfolios began to grow due to personal, local or national priorities. This now left me with an unmanageable workload and try as I might to find someone else to take it over, I just couldn’t and so I slowly began to sink under the increasing burden of jobs, none of which I could do well with the time or effort I had available.
The Lesson: It can be difficult to say no to an opportunity or a need, however, you must think about what will happen in the coming months and years, how it might grow on its own or how you might want to grow it over time. Junior doctor teaching might only be 2-3 hours on one afternoon a week now, but if you have a passion for this and want to include the nurse practitioners, start in-situ simulation and develop a local social media based learning platform, that’s going to take at least twice as much time. The same can be true outside of work. Sure, helping out with the under 11s netball team is a fun distraction on a Wednesday evening, but when you become coach, secretary and transport coordinator 2 years later that’s a much bigger emotional drain. Just as a gardener could plant ten times as many seedlings in a pot or a furrow, they don’t because they know those seedlings will grow and need that space to develop. Unlike a gardener, who can just pluck out a few excess seedlings to make space, it is very difficult for us to off load excess work but sometimes for our own good and the good of the project we need to do just that. It may not feel great but to place a burden down and say ‘no longer’ might just be one of the most important management skills you will need.
Take Your Time
The Mistake: It is very tempting to think we need to make a difference right now… this is especially true for those of us in a clinical specialty where that is sometimes actually true! However, the reality is that some changes, particularly significant ones, can take months or even years to truly take place. In the situation I started as a consultant, opportunities to effect change were common and I was running at them all, simple, complex, easy and hard. This took a lot out of me physically and emotionally but it also meant that I didn’t spend time ensuring changes were properly embedded. I had to try and sustain them myself or watch them fail around me which caused frustration, resentment and anger.
The Lesson: I think Critical Care types are more likely to fall for the Kurgan’s ‘It is better to burnout than to fade away.’ school of thought but that is to believe in a false dichotomy. There is a clear third option, a sustained, controlled burn of enthusiasm, providing a creating and sustaining power to a department over the years of a career. You will be a doctor (or a nurse, an ANP or a manager) a long time and you don’t need to get everything done right now. Pick one or two small, easy things to do along the way so you see some changes that keep you motivated but remember to pace yourself through the bigger, more challenging changes that take significant time and effort to come to fruition.
Get to Know Yourself
The Mistake: As I slid towards my eventual breakdown, there were clear mental, physical and emotional changes which really should have been a warning to me that I was in serious need of help. Unfortunately, whilst I was vaguely aware of many of these I really didn’t have a handle on just how many issues there were or how bad they had become… my wife and my colleagues perhaps had a better view but were unable or unwilling to communicate their concerns effectively. This combination left me not understanding the seriousness of the situation and my desperate need for help until it was potentially too late.
The Lesson: Understanding ourselves is so important if we are to manage the stresses of our lives. Taking time out to reflect upon our physical, psychological and emotional selves can help us to notice when these are being challenged, developed or damaged in response to our current life situation. In the last few years I have had to become much more aware of myself as a person. I understand better now how I respond to stress: how I ‘feel’ when I get anxious; the change in my sleep pattern; the patches of eczema that appear; the loss of motivation and growing feelings of ‘what’s the point’. Recognising these and understanding they are a warning allows me to manage my life more proactively and help me to take a step back before I deteriorate further.
We also need to remember that we can only see ourselves from our own point of view. Getting regular, honest feedback from others who know us both at work and at home, can be a great way to maintain an awareness of how we are managing and open up early conversations about support where that is considered necessary.
Ask For Help
The Mistake: Despite what I said above, I did end up asking for help in the end. I eventually self referred to Occupational Health and was advised to try mindfulness… a couple of months later I broke. I ended up at my GPs where I finally got some of the help and support I needed. Back at work, a re-referral to Occupational Health was required and resulted in a suggestion that I might benefit from Cognitive Behavioural Therapy (CBT). I was told that I should go home, Google CBT, find a local practitioner and pay for it myself. As you might imagine, I feel the system might have been more helpful to me in this area!
The Lesson: Asking for help is something many people struggle with but it is important that we recognise our need to do so (see previous lesson). However, if the help is not forthcoming, what do we do then? The reality is that colleagues, departments and even hospital occupational health departments may struggle to offer the help required due to a mix of competence, resources and potential conflicts of interest. GPs are the only people who have you and your needs as their sole concern and I wish I’d gone to mine much sooner. Please, if you need help or have a colleague who you think needs help, try and involve the GP sooner rather than later.
Take Your Time
The Mistake: Having found myself in need of help and finally receiving it, I wanted things to get better quickly. To begin with I was limited by cognitive impairment but when that cleared there seemed no obvious hurdle to my return, at least as far as I was concerned… my GP knew the truth. He said from the start it would take at least 6 months, and he was right, but that didn’t stop me from pushing myself too far, too soon at times and finding out the reality of the situation.
The Lesson: Being sick, being broken, being ‘incapable’ isn’t a great feeling and understandably we want to put those feelings behind us as soon as possible but healing takes time. When we stop and think about it we know this from our experience of dealing with physical illness but our limited understanding of mental illness can often lead to unrealistic expectations of our return to work. It is essential that we listen to the experts, make a plan and move slowly and steadily towards a resolution rather than rushing and potentially finding ourselves worse off than when we started.
The Mistake: I was an Emergency Medicine consultant who could stand in the middle of an ED ensuring it was running appropriately whilst also giving advice to others, seeing a couple of majors, fixing the printer and preparing to go in the the resuscitation room to manage a sick child… surely that is what I will be again. Wanting to be what I was as I continue to struggle with what I am leads to sadness, frustration and bitterness none of which are helpful emotions during my rehabilitation.
The Lesson: It is quite likely that things will never be the same again for me but is that really a bad thing? For all the ability that I wielded in the past, it was only achieved by tearing myself apart from within… do I really want to go back to that? One of the most significant lessons I learned was that I was moving forward to a new situation, not getting back to an old one. What that might look like, I still do not know for sure, but it will definitely be different to my past and almost certainly not what I currently expect. Embracing this philosophy of moving forward has meant letting go of a lot of who I thought I was, painfully so sometimes, but it is an opportunity to connect with who I am now, rediscover parts of who I was and develop who I will be.
Be Kind to Yourself
The Mistake: I am a failure. I am useless. I did not cope. I am a burden. All of these and more are things I think about myself on a regular basis. Every time I introduce myself as an Emergency Medicine consultant I feel a fraud. When I read about colleagues clinical exploits and the pressure they are under I feel ashamed. When I struggle with anxiety as I spend time in a clinical area, my brain clouds up after a morning of teaching or I find my 10k running time so much slower than I used to achieve, I am angry at how weak I have become. Despite everything that I say about allowing people time to heal, everything I have written about caring for others, all my beliefs about toxic work environments and supporting the individual, I am still my harshest, darkest critic.
The Lesson: As healthcare professionals we are working in an environment where the stakes are high and mistakes can have significant implications. Whilst we may accept intellectually that perfection is beyond us we often still feel a professional and possibly even a moral duty to set our compass in that direction. It is hardly surprising then, that we become hyper-alert for deficiencies and find shortcomings or failures a source of worry and frustration… even more so when the inadequacies are our own. We need to learn to be kinder to ourselves, understand that perfection is a crushing load that we cannot bear and that sometimes, often in fact, good enough is actually good enough. I have to remind myself daily that what I am doing, little as it may seem, is better than it not getting done at all and that even if I fail to achieve what I set out to today, trying at all was a success in itself.
Take Your Time
The Mistake: Once I made it back to work (the first time) I started increasing the intensity of what I was doing. Within a couple of months I was intermittently managing the shop floor on my own on a Monday evening, going to departmental meetings and fully engaging with the general management agenda of the department. The vague plan that existed was essentially my job plan, nothing more and within 18 months I was off work again.
The Lesson: Getting back to work is only the first step in what is likely to be a long, slow and bumpy journey to whatever lies ahead. When you return to work set small, relevant steps forward with an agreed supervisor, think of a realistic time frame to achieve these… then double it. Not only that have an agreed step down position, should any increase in load prove problematic, so that you both know this is a valid option rather than something to be pushed for and invented on the spur of the moment just as you are struggling. I write this having walked away from a shop floor education session this morning, because I felt too uncomfortable to even start it, knowing that my supervising colleague and I have agreed that this is what I should do. Moving forward slowly, steadily and deliberately allows us to stumble when bumps occur; rushing headlong means those bumps are more likely to send us sprawling on our faces and leave us bloodied and fearful of repeating the fall. I have no wish to fall a third time.
I hope that these suggestions are helpful to you, perhaps to understand how to assist someone else, perhaps for your own well-being. Whichever the case, as we work in our time pressured, results oriented systems and live in our increasingly busy, 24/7 world, please – Take Your Time and look after yourself.