This is the 79th #WILTW
There are many things that make medicine an immensely rewarding career. It may be the ability to meld scientific endeavour with artistic application, the enjoyment of human interaction or the diversity of challenges that pathology, of any type, brings with it.
Medicine can also be extremely hard. Not just physically but emotionally and often spiritually (whether religous or not). There are periods when, if you let it, it can become all consuming. Some of this might might be self induced, “I must stay late to finish this project or paper” but at other times just a consequence of the pressure and scale at work. Winter can be a tough time with large patient volume, a proportionally higher risk of missing subtle serious illness and often greater patient or family anxiety due to a system stretched to capacity.
Before a busy shift this week I felt a great sense of unease. The joy of medical practice had gone. Replaced by a sense of almost resentment and resignation at the demand of managing a department that would likely be full to capacity. I have previously been proud of my resilience, a concept I first heard about through social media. I was introduced to the flipside of resilience in a fantastic post by Jonathon Tomlinson. It was actually on empathy but a spin out conversation led to a discussion on burnout. If I had not read this I may have put my state of mind down to tiredness. Although it remains perfectly possible that I was simply exhausted the advantage of putting aside the time to write this weekly blog has enabled me to actively sit down and reflect on where I am truly at.
Burnout can be a dangerous thing, just as much for your patients and colleagues, as well as yourself. I score highly on burnout scores so I think I would be in denial if I put my feelings down to recent winter pressures. I am also actively aware I can put in place mitigating factors to protect myself. This is one of the most uncomfortable #WILTW I think I have written. Whether I am being brave or stupid I don’t know but in doing so I feel a small weight has been lifted. I can avoid burning out by being aware of its signs and symptoms and am grateful to Andy Bradley in this regard (his great Ted Talk has been instrumental in developing my own mindfulness). In order to respond, you must recognise, a vital first step in a learning process.
What have you learnt this week? #WILTW
Other resources:
Burnout: Why it is not a fair fight
Burnout in the ED: Too tired to sleep, too wired to weep? [St. Emlyn’s]
Sustainable working practices and minimising burnout in Emergency Medicine [Journal of Hospital Medicine]
An important and courageous blog, Damian. Thank you for revealing your emotional ‘milieu intérieur’ to us.
I am in the process of writing a blog on the same subject, from a slightly different, and complementary, angle. I’ve been in the profession 35 years, and I’m sure that burnout has always been there. Have things changed much? I believe so.
Why?
Partly because the demands have increased. The stakes are now much higher. Technology means that we can achieve things now I wouldn’t have dreamed of as a medical student – retrieving clots from inside the brains of stroke victims; designing and growing bespoke prosthetic tissues; controlling heart rhythms with ‘smart’ pacemakers; visualizing mental activity in people; remote and/or robotic surgery; to name but five. Patients (rightly) have become more aware of what is best for their management. This is combined with greater sanctions in place for those who do not deliver adequately. Finally, resource constraints mean that we are charged with doing all this within an inadequate envelope, resulting in haste, corner-cutting, and at times chaos.
This is compounded by the increasing atomisation of groups, specialties and teams. As a junior doctor, I spent 6 months with a team, all of us were there every work day unless on leave or sick. Now, I nominally have two registrars, two and a bit SHOs and two FY1s whom I share with a colleague. However, because of their complex shift patterns, combined with staffing shortages necessitating frequent reallocations to different teams, I have worked with a different combination from the ‘squad’ each week (and sometimes more than once in a week).
Last year I became increasingly aware that I was burning out. I have good home support systems, and a range of recreational activities which normally refresh me. Despite these I was struggling. My usual inner ‘incorrigible optimist’ began to fail at times. I’ve never been a great paper pusher, but I increasingly I resented the administrative trivia visited upon me. However, I was lucky. Knowing that I would reach retirement age next August, I had an exit strategy. I was able to come off the acute on call rota and go part time for this, my last year of work. I could then leave it all behind. Knowing that was a huge relief. Finishing on call work and changing to part time this August lifted most of the burden. I was on the last lap; the finishing tape was in sight.
That said, I have experienced feelings of sadness at the prospect of giving up what has defined me, what I have enjoyed, and from which I derived great fulfilment, for the past 35 years. I have also felt feelings of guilt at leaving more work for my colleagues in the department, and adding to the pressures making our patients’ experiences less satisfying.
It alarms me that with streamlined training programmes, doctors can end up in career grade posts earlier than before. Changing patterns of life expectancy and population structure have forced the retirement age to be increased. This means a significantly longer duration in a career, with less in the tax-free pension pot at the end, and (at the time of writing) the prospect of a more punishing, and likely less well-rewarded, job plan. The prospects for averting burnout do not look good!
We doctors are notorious for not looking after ourselves well. The fact that we have very high substance abuse rates attests to our vulnerability. The GMC has started a campaign of resiliency. This is to be welcomed, but I would argue it’s treating a symptom. Disappointingly, my concerns suggesting a broader approach to burnout were rejected by the GMC as being part of their responsibility.
We need to change the system in order to undo, mitigate, or bypass as many of the above factors as we can. Different components will take different time frames; for example with the best will in the world, even if medical school places are increased significantly from next autumn, the impact on career grade posts will be no earlier than 2030 before there’s a bulge in consultant geriatricians coming out at the end. We only have to wait until 2026 for extra GPs start appearing – assuming there are no changes in the interim to extend their training duration beyond 3 years!
A multi-faceted approach is needed. This should include (but is not confined to):
– training individuals to help themselves – as you set out in eloquently – your blog
– training individuals & teams to look out for each other
– risk assessments of components of the system bearing on this
– setting up systems to screen for and deal with early burnout
– undertaking research (both diagnostic and interventional) to inform the above components
On the positive side (the internal optimist peeks out…) this will yield rich lodes for educational and management researchers to explore and mine. It must surely also improve both the standing, and standard, of qualitative research – a key part of ‘making the important measurable’ and a discipline hitherto kept well in check by the old school ‘quantitativists’. A new era beckons!
Part of me is relieved I will be leaving all this behind me soon. Another part is extremely concerned about those following in my footsteps. Maybe this says more about me than the profession?
Kindness – both to others and to self – is at the heart of good medicine. Burnout brings with it compassion fatigue, disaffection and submission. I do not want myself or others to be faced by health care workers in this state. I do not want to have fellow human beings trying to work in that state!
Thank you for opening up this Pandora’s box. It needed to be!
Thanks for the link to my post about empathy. There is another post specifically about resilience and burnout here https://abetternhs.wordpress.com/2015/09/16/resilient-general-practice/ and I am working on a big piece about doctors’ anxiety right now