June 1st. #CrazySocks4Docs. But not just for Docs only. This day is for nurses, dentists, pharmacists, social workers, physiotherapists, psychologists, dietitians, speech pathologists, audiologists, respiratory therapists, anaesthesia techs, paramedics, medical students, veterinarians and all other specialties that work in the health care industry for patients.
Doctors are dying by their own hands. The overall physician suicide rate cited by most studies has been between 28 and 40 per 100,000, compared with the overall rate in the general population of 12.3 per 100,000. Overall, then, doctors are more than twice as likely as the general population to kill themselves. In the US alone doctors are committing suicide at the rate of one doctor a day. The causes are multifactorial: mental health, physical illness, depression, burnout, work stresses, etc. This is certainly occurring not only to physicians but also to others in the health industry.
Society places high expectations on Doctors and Health Professionals to be faultless. In reality, Health Professionals are merely human beings. Highly trained human beings overworked and enslaved by a high-pressure health industry.
This June the 1st, let’s elevate the conversation on the Health of the Health Care Professionals themselves. Wear odd socks to highlight the need for health care workers to care for each other’s health. Wear odd socks to start a conversation.
If you are asked “Why the odd socks?”
You say:
To Remember the many Health Professionals who have died by suicide or in the line of duty.
To Raise awareness of mental health issues among Health Professionals, and
To Reshape the culture of the Health Care Industry with Hope and Humanity, so that health care workers are given the space to care for each other.
No, it has nothing to do with fundraising. It’s idea-spreading, conversation-starting & culture-changing. I know this all sounds idealistic to the point of being silly. The more we talk about this the more we can end the stigma, the more we can bring this dark subject into the light, the more we can create a culture of acceptance and support. Show your socks to those in Medical Admin. Good patient care is dependent on good carers. Investing in the health of the Health Care Workers is ultimately investing in the health of their patients.
Not compelled? At the very least, you can just have fun with some funky socks on June the 1st and tell others that you care about those whose vocation is to care for others.
I hope your socks will lead to fruitful discussions that would practically benefit the health of those Health Care Workers in your ward, clinic, operating theatres and departments. Ask each other: how can we make Health Care better for Health Care Workers and their patients? The solutions in my operating theatre will be different to the solutions in your ward or someone else’s clinic. The first step towards a solution is to start talking about the problem. Let’s get talking.
Dr Geoff Toogood @gdtoogood is the founder of Crazy Socks 4 Docs Day. #CrazySocks4Docs. Read his story here. My role is to elevate and leverage this message. I gain no financial profits or occupational benefits from promoting this message.
Where we are today in health care is the product of our contemporary society. The drive to modernisation and industrialisation is palpable. Clinicians after clinicians have detailed the despondency, despair and desperation they feel when their clinical work is suffocated by bureaucratic burdens from Health Administrators. Read the comments from Episode 1: The Dark Side of Doctoring. This is not only for doctors and not limited to Australia alone.
It does not have to be this way. You did not go into years of training and sacrifice just to be strangulated by non-clinical tasks, programs, guidelines & protocols. We have sadly seen many colleagues who succumbed to the pressure by becoming hardened, calloused, depressed, angry, anxious, irritable, rude, disrespectful, short-fused, disillusioned and even suicidal. It does not have to be this way. For the sake of our patients and future generation of doctors, nurses and health care workers, we can shift the focus back on to the patient.
There is an elephant in the room. The elephant in my operating theatre is different to the elephant in your ward or the clinic. For some, it is a clunky Electronic Health Record software. If you have to keep on correcting and teaching a whole hospital full of well-educated doctors and nurses how to use the computer, then there’s something not user friendly with the computer. For another, it is the multi-layered paperwork process that hold back good treatments for patients. For yet another it is the unspeakable culture of bullying and harassment. It is not a single problem with an easy solution.
This is not specifically about mental health issues. Caring for the mental health of clinicians is critical and essential. If you do have mental health conditions, please be connected to your GP or mental health professional. There’s an army of mental health supporters available. But many health care workers do not have mental health problems. This is about the workplace environment of the Health Industry that can create, exacerbate or prolong mental health problems. This is about the many of us who sense that Loss of Control, Loss of Support and Loss of Meaning in our daily work experience. That sense of hopelessness and helplessness in the Health Industry may not be fixable with more cognitive behavioural therapy or more anti-depressants in some situations. And it’s certainly not fixable with more guidelines, systems or processes.
May I suggest 3 small things we can change? They’re paradigm shifts that I hope will help guide your thoughts and spark conversations in your wards, clinics and operating theatres.
1. Change your Hierarchy
The possible antidote to Loss of Control. It’s no secret that there is an epidemic of Health Administrators. The following graph has been criticised as having poor accuracy, but the message is still the same, and the picture is clear. This graph is reproducible in any country. Is this justified? Is the elephant in the room the Middle Managers? Is this contributing to the deep sense of Loss of Control that many doctors and nurses experience?
Let me be clear. We need Medical Administrators. We need someone to Administer Health Care in a complex industry. However, we need evidence and justification that their presence in the hospital add efficiency and efficacy rather than simply adding bureaucratic complexity and complacency. Over time, the control of health care has been taken away from the blood-stained hands of clinicians and placed into the cufflinked hands of men and women in suits. We started off by employing Administrators to make our health care provision more efficient so we can be released to perform our clinical duties better. Yet we’ve ended up with a model that says Executives at the top, doctors and nurses at the bottom. And somehow we still end up carrying the burden of paperwork.
Who is at the top of your hierarchy? It should not be a CEO. It should be the patient. The CEO should be at the bottom. He or she should be the one facilitating, empowering and encouraging the work of everyone else in the hospital, not dictating it.
Dear Medical Administrators: I don’t work for you and you don’t work for me. We both work for the patient together.
Patients did not come to the hospital to see a Medical Administrator. They came to see a clinician. A doctor, nurse, speech pathologist, dietitian, audiologist, physiotherapist, etc. Strip off your hierarchy and understand that the most significant encounter that the patient came for is that face-to-face encounter with their clinician. The entire hospital exist for that encounter. Therefore make that encounter the focus of the system. Don’t add unnecessary layers of bureaucratic or systemic restrictions. The goal of hospital administrators should be to facilitate and empower doctors to be doctors and nurses to be nurses. Whenever a new computer program, a new process, or a new system is introduced to the hospital, clinicians need to be able to ask “Is this good for the patient?” If it isn’t, then it has to go back to the drawing board. If clinicians are bogged down and distracted by relentless paperwork, clunky medical software, and unrealistic key performance indicators, they can’t do their jobs properly. They won’t be playing their best game. Their morale suffers, the hospital suffers and ultimately, patients suffer.
It’s a mental shift for the doctors too. Doctors used to be the priests of ancient times. Whatever doctors said got done. We just can’t do that any more. Health and health care is way too complicated for any doctor to do it alone. I’m glad it is so. No longer is the doctor the repository of knowledge. We now work in teams. I’m no more important than the other specialty. Nurses are not my handmaidens. Nurses don’t serve the patient before or behind me. They serve beside me. Nurses, you are not the guardians that stop doctors from killing patients. You are fellow specialists with distinct and complementary roles. Even though sometimes the Doctor ends up being captain of the ship, a good captain will allow every crew member to function at their best.
In my simple surgical mind the hierarchy is basic. Patients at the centre, clinicians around them, and health administrators as the facilitators of service, empowering the clinicians to do their work unhindered. Strip away any unnecessary processes that interfere with the Clinician-Patient encounter. The CEO, Nurse, Janitor, Kitchen Staff, and Admin all need to know that they came to work for the patient.
2. Change your Habit and Habitat
The antidote to Loss of Support. When we talk about Loss of Support, often the answer is official support programs and help lines. Every Institution, Professional College and Hospital have dedicated help lines for staff and members. Although they are necessary, very few actually tap into those services. I struggle with the practicality of calling an anonymous helpline and speaking to them about the emotional struggles I have with Electronic Medical Records or overbooked clinics. I want to talk to the people at my workplaces because they are the ones who understand my struggles. But who do I talk to? Everyone seem overworked, preoccupied and distracted at the same time. And it seems that for many, the solution to the workplace problem is a holiday. That’s like walking out of the room to the beach and then coming back to find that the elephant is still there.
Can we look at our workplaces and think about simple creative things to make our work more enjoyable and meaningful? Can we agree that we all want to come to work to enjoy caring for patients?
The greatest asset of a hospital is not her location, reputation or state of the art equipment. The greatest asset of a hospital is her staff. If a hospital treats their staff well, the staff will treat their patients well and their patients will treat the hospital reputation well. Investing in the well being and morale of staff members will reap long term results.
Improving staff morale has to happen at multiple levels. There has to be roster regulations to prevent dangerous overworked doctors. There has to be limits to daily activities. You cannot increase productivity at the expense of sanity. You won’t fly an overcrowded plane, why do we allow an overcrowded operating list run by people who do not know the procedures. It’s dangerous.
At a more practical level, investing in staff does not have to be expensive or prescriptive. What about tweaking little activities and changing their Habits. Start shifts 15min early with coffee. Do a work stop “10 min at 10” and get all the nurses in the tea room to chat. Celebrate birthdays. Go out for drinks. I used to work in a hospital where we would go for coffee after Multidisciplinary Tumour Board Meetings. We looked forward to the Group Caffeine Therapy. Monthly journal clubs with meals together. Have a reward system. Have a formal Thank you board. Instead of recording Risk Incidents, how about recording Good Incidents. Do FitBit challenges together. Set up Facebook and Twitter groups for private chats. A few years ago I wrote my own personal challenge “30 Days to Better Doctoring” and there may be a few other ideas there. Better still, why don’t you set up a white board in the staff room and let your staff make suggestions on simple activities at work that can improve morale. You don’t have to be a Head of Unit to do this. You can change the Habit of your team over time.
To measure the pulse of a hospital, don’t go to the Boardroom. Go to the staff cafeteria. I dare every hospital administrator to take off their suits and put on scrubs. Walk into staff tea rooms anonymously, sit and listen to the conversations.
Sometimes, changing the Habit require changing the Habitat. Does your hospital have a quiet room where the CEO and the Janitor can sit quietly on the sofa? Does your hospital have a play room where the secretary can sit on the bean bag watching TV next to the radiographer? There are studies to show that workplace environment influence workplace productivities. Make hospitals hospitable. Having hot foods, snacks and crackers would lift staff morale and trigger opportunities for conversations much more than signing them up for more wellness programs or getting them to watch more self-care videos. And good coffee. Please, we all know that good coffee is the lifeline of all hospital staff.
We are simply overworked humans in a complex health care industry. We need practical support that can come with a good friendly chat over coffee. We care for sick patients. Allow us the Habit and the Habitat to care for each other.
3. Change your Heart
I know. Why should a surgeon talk about touchy-feely heart stuff. I am a champion whinger. If there is ever a competition on whinging and whining, I would be world number 1. Whinging and whining is cathartic and therapeutic. We all do that sometimes. But in the midst of that whining about workplace problems, I need to remind myself that I am caring for some truly unfortunate patients who have been plagued with diseases. I have operated on kids in their first day of life and on adults in their dying days. I have said goodbyes to patients and been invited to their funerals. I have had letters of thanks.
I am grateful that I have been given the awesome privilege of being a surgeon. I’m not removing tonsils, I am giving this child and her family the gift of sleep. When I’m reconstructing a face that has been disfigured by cancer, I am giving my patients a tangible hope that life would be better after the operation. When I operate on the ear, the tongue or the voice box, I am returning to my patients some of the most basic senses of being a human.
The road to being a surgeon is tortuous and torturous. Being deprived of basic human needs such as sleep, social contact and a routine is torture. But I chose it. I chose this path. I expect to be trained hard and to work hard. My years of training mean that I can wake up at 3 am and save an exsanguinating patient if I had to. Resilience is built into the training. When the mindless administrative bureaucratic elephants sit on my chest, I need to remind myself that I’m here for the patient. When I’m close to the edge of bureaucratic burnout I need to be thankful for this crazy job I have.
Perhaps the antidote to a Loss of Meaning is an attitude of gratitude. You can call it what you like. A sense of purpose, a calling, a vocation. You can link this to something bigger than yourself. I know where I stand when it comes to that. As a Health Care Worker I dispense hope and care to the ill patients I see everyday, together with my colleagues. Sometimes that care comes in the form of medicine or surgery, other times that care comes in the form of my words. Every day my words and actions have an influence on others. And that’s something I am thankful for. Here is how my Ikigai looks like. Yours may be different.
Perhaps the secret to an attitude of gratitude, the antidote to the Loss of Meaning is loving what you do more than doing what you love.
To the many Medical Students and Junior Doctors who have asked me, the answer is this:
Yes, I cannot think of being anything else but a surgeon.
Episode 2. I’m a surgeon. A simple one. I didn’t intend to trigger an outpouring of emotions. I didn’t plan on ever ‘going viral’. But since I wrote The Dark Side of Doctoring 4 days ago, I have had a huge amount of response. On top of the 150,000 hits on my article and the phone calls from several News Agencies, nurses in clinic and theatres have asked if I was OK. I was visited by the Head of ENT Department and the Head of the Division of Surgery. I was contacted by so many fellow doctors, nurses, clinicians from places as far away as Singapore, Sweden and South Africa. My email inbox has been flooded by many doctors, nurses, medical students and their partners who wrote about their own personal struggles in the institutions that they work in. Just take a peek at the comments section to that original article. Heart-breaking.
I have cried over so many of these personal stories. I am seeing many doctors, nurses and medical students in distress. I am seeing a generation of health care workers suffocated and strangulated by their circumstances. (If I haven’t replied, I will!) The conversations are already happening. Much of it online because they’re afraid to do it in real life.
The message from all these responses is clear, “I get you. I feel the same way too. I am not coping with this industrialisation of Medicine.” The article has triggered a universal emotion that many health care workers feel about the state of their vocation. I hope it has catalysed an awareness of this issue in medical institutions where you are.
Now that the Dark Side has Awoken, can we talk about this openly? If you are a Health Administrator, can you please listen to your Clinicians (that includes physiotherapists, audiologists, speech pathologists, Ambulance officers, etc) on the frontlines? We don’t need more programs, initiatives, directives, protocols, videos to watch or numbers to call. We know that those kind of help are available. We need workplace morale to be lifted. If you’re not going to start at the top, we are going to start from the bottom. Elevating workplace morale does not have to be expensive or prescriptive. It can be creative.
If you’re a health institution or health administrator or health leader in anyway, be courageous enough to tackle this elephant in your institution. Be courageous enough to champion this issue. You might save the reputation of your institutions, reduce sick leave, improve workplace environment and possibly save some lives.
I have some ideas about what we can do down at the trenches. We don’t need to halt the Industrialisation of Medicine. We can Humanise it. We can inject compassion into this Business of Medicine. We can regain some measure of control, support and meaning in Medicine. For the sake of our patients and the future generations of health care workers, can we please talk about simple, creative, compassionate human solutions to this problem?
Episode 1. I’m a surgeon. I’d like to think that I’m resilient and well adjusted, having gone through medical school and rigorous surgical training. I’ve been a doctor for 13 years and much of that period has been spent training to be as good a surgeon as I could ever be. I have great family support, a physician wife who understands my work and I’ve never been diagnosed with a mental illness.
The suicide death of Dr Andrew Bryant, a Brisbane gastroenterologist last week hit a raw nerve. His wife wrote this honest and courageous letter.
Although I’ve never had serious suicidal thoughts, I – like many other doctors – have been through many dark seasons. Depression, anxiety, burnout, suicidality, hopelessness, lethargy, anhedonia, feeling flat, worry, and the like are all different flavours of the same phenomena: the negative human response to internal or external stressors. Of course, the causes are always multifactorial. It cannot and should not be oversimplified to family history, genetics, behavioural deficiencies, bad environment or poor social support.
When I carefully dissect my dark seasons, some common themes often emerge. Work is often the critical exacerbating and perpetuating factor in those dark times. Because as a surgeon I spend the vast majority of my lifetime at work, what happens there influences all other aspects of my life including my marriage, family and social life.
Here are 3 common things that have thrown me into some dark pit of despair:
1. Loss of Control
I have lost control of my days. I had worked in a hospital where I was oncall 24/7, 12 days out of 14. I had fortnightly weekends off. When I was preparing for surgical exams, I’d be working and studying from 6.30am to 10pm everyday, seeing my family only on the weekends for lunch. I had worked in a hospital network that covered 4 campuses and drove 500kms a week when covering these sites. I had worked in a hospital where I didn’t get home for days at a time, sleeping overnight in hospital quarters, outpatient clinic benches and in my car. I used to have my sleeping bag, toiletries and change in the boot of my car because I didn’t know if I was going to make it home some nights. Plans change every single day at work because of emergencies. I can’t even be sure what the next hour will bring when I am on call. You might ask, why can’t you work less? It’s not as easy as that. If I decide to work less, who is going to cover the hospital? If the hospital aren’t employing other doctors, we can’t allow patients to go uncovered. I accept the fact that I have a duty of care to be on call. The intensity and personal damage of these on call periods are often forgotten.
Not only that, we are losing control of health care in general. Everyday, there’s a new form, a new guideline, a new protocol, a new health software, a new policy all dictating, restricting and modifying clinician activities. Some of these policies are written by people who do not see patients. There’s a whole paid industry dedicated to restructuring what doctors and nurses do to reduce costs and increase output.
2. Loss of Support.
Just imagine. I start my days at 6am. I wake up to an email alerting me of the number of discharge summaries that haven’t been completed and the various computer based modules I have to complete (hand washing, privacy, lifting patients, etc). Round starts at 7am. I see 15-20 patients with various travel forms, certificates, scripts that need completing. All to be done via the electronic health system, clunky, not user friendly, takes a long time to log in. Then I start an overbooked operating list at 8am. There are 7 cases booked. I have no say on who gets on the operating list and the order of patients. The first patient haven’t been checked in. The diabetic one is hypoglycaemic. The infant is cranky. The autistic child is running away. The interpreter is not here yet. The computer is still not logging in. The password is expired. I used to be able to arrange the operating list because I know that some operations take longer than others. But now, the bookings office determine that that all my tonsillectomies take 14 minutes because that’s the average time recorded on the computer. The moment I scrub in, the timer starts. The moment I unscrub timer stops. Click. Click. Click. Because the theatre bookings does not take into account the interpreter time, pre-med period or transfer to ICU, the list is running late. The nurse in charge is breathing down my neck to finish on time. I still took about 14 minutes on each case, but the team is delayed by external clinical reasons. The theatre team is anxious to finish, everything is rushed, and mistakes are bound to occur.
In the mean time, I field 12 phone calls from ED, GP and other units. By now there are 3 patients waiting for me in ED and 1 being flown in from another hospital. The operating list is finished late. I rushed to ED, and gulped down a cup of instant coffee. Then I arrive late to the afternoon clinic, which again is overbooked. Clinic nurses are not happy. I see 8-10 patients while taking more calls. I try to discuss complex surgeries with patients but I keep getting interrupted by calls and paperwork. Then I run back to theatre for an emergency case. By this time I’m set up for failure. I’m tired, cranky and my head is full of jobs to do. I do the afternoon round, see more consults, admit more patients and dictate letters. I have taken up to 70 calls on a 24h on call period. By 6pm I’m totally exhausted. I grab a packet of chips, ginger beer, and start working on the papers I was meant to write up. I review the case notes for the next couple of days. I get home between 7-8pm. Grab dinner and put the kids to bed. I get called back in and I take a patient to theatre for an emergency procedure. I come back just after midnight and sleep. I get called four more times between midnight and 6am.
6am. Repeat.
I have lost control of my days and I have lost support. When can I actually find support? I don’t have time to talk to my colleagues about life. I don’t have time with my family. I don’t have time to catch up with friends. Social ties are lost when one stepped into medical school. I’ve lost count of the number of significant life events I have missed (birthdays, anniversaries, reunions, school recitals, first walks, etc.)
I delivered my third child with my own hands because the obstetrician was stuck in a traffic jam. The following morning I went to work because if I didn’t 12 patients have to miss their surgeries, 2 anaesthetists and about 8 nurses will miss out on their day’s income. More importantly, admin would not be happy because a cancelled operating list is a huge financial loss to the hospital.
I know where I can get support, but practically, when and how am I going to get that support?
In addition, doctors who scream for help may be formally reported, therefore having restrictions placed on their practice and then incurring higher medical indemnity fees in some situations. Trainees who ask for help may be labelled as underperforming and have to be commenced on probation or remediation. We may not have practical access to the support that are often advertised.
3. Loss of Meaning
Interestingly, the above physical and emotional stressors are reasonably manageable to me. I’m understanding my own physical and emotional limits. These stressors induce exhaustion, but the excitement of the work and the intellectual challenge of the job bring a lot of personal satisfaction. I do get emotionally shaken at times because I deal with dying cancer patients, emergency airway disasters and sick complex children, but I get by.
I am realising more and more that what brings me greatest distress is the relentless administrative pressure which take away the meaningful clinical engagement I have with my patients. And I wonder if this is what many young doctors are experiencing as well. Medicine used to be a meaningful pursuit. Now it has become a tiresome industry. The joy, purpose and meaning of medicine has been codified, sterilised, protocolised, industrialised and regimented. Doctors are caught in a web of business, no longer a noble vocation. The altruism of young doctors have been replaced by the shackles of efficiency, productivity and key performance indicators.
I have little say in organising my very own operating lists or clinics. Even the power to re-order the operating list has been taken from the surgeon. The thing that I love doing (operating & seeing patients) is being measured, recorded and benchmarked. The clinics are overbooked to get numbers through. The paperwork for each patient encounter is increasing with each passing year. There are so many other non-clinical departments dictating what I should do and how best to do it. The mantra is “cost-effectiveness and increased productivity.”
I went into medicine knowing that I will have to sacrifice much for the sake of my patients. What I am realising is that today in modern medicine, a doctor is just one of the many commodities in this complex industry. It’s no longer about the patient. It’s about the business of hospitals. Patient satisfaction officers, Theatre Utilisation officers, Patient Flow Coordinators. These are all business roles.
As a surgeon I spent a year in a hospital where I smiled on the way to work and I am so grateful for my job. I looked forward to long days because I knew what I was doing was significant. Another year in another hospital, I dreaded going to work. I hated being on call. I was burned out and I couldn’t control my emotions at work and at home. I’m not inherently an offensive or rude person, I’m just a person pushed to the limits and set to fail because of the circumstances around my work. Same surgeon, different jobs. The forces that pushed me to losing control of my emotions are likely the same forces that might push some of us to suicide.
To some hospitals and their business, I’m not a Surgeon. I’m just an employee. Overworked, burned out, replaceable. The noble call to Medicine has been suffocated by the bureaucratic force exerting itself as the medical industry.
June 1st. #CrazySocks4Docs. But not just for Docs only. This day is for nurses, dentists, pharmacists, social workers, physiotherapists, psychologists, dietitians, speech pathologists, audiologists, respiratory therapists, anaesthesia techs, paramedics, medical students, veterinarians and all other specialties that work in the health care industry for patients.
Doctors are dying by their own hands. The overall physician suicide rate cited by most studies has been between 28 and 40 per 100,000, compared with the overall rate in the general population of 12.3 per 100,000. Overall, then, doctors are more than twice as likely as the general population to kill themselves. In the US alone doctors are committing suicide at the rate of one doctor a day. The causes are multifactorial: mental health, physical illness, depression, burnout, work stresses, etc. This is certainly occurring not only to physicians but also to others in the health industry.
