Rethinking Doctors Wellbeing Interventions

We have a complex problem. There really is not a single simple solution to the issue of clinician burnout and the poor wellbeing of today’s doctors. We need to accept this. The proponents of yoga and meditation need to know that no amount of mindfulness can fix an abusive hierarchy. Those who think good legislations can stop problems from happening must know of recent examples where unit leadership have failed to enact those regulations and allowed junior doctors to suffer from poor working conditions. The Royal Colleges feel that this is not within their jurisdiction, although in practice, Members and Fellows of the College are the standard bearers on the ground. Mental health of doctors is one of many specific challenges that need to be addressed specifically. Culture cannot be changed by legislations alone. Individual counselling relieves downstream effects but has little effect on upstream problems. Human resources and institutions are caught in a tangled web of limited resources and increasing demands placed upon doctors. Let’s agree that no single simplistic solution can fix this complex problem that has been years in the making. No one intervention is better than another. We need complementary approaches to the many elephants in the room.

There is hope. More and more we are realising that a multifactorial multipronged approach is needed. There are champions of change all over our institutions. The time is right and we are almost at that tipping point for change. We’ve heard of enough suicides and we have hurt alongside their families and communities. We have seen the data on doctor depression and burnout. We are agitated for change. The next few years will see an optimistic cultural change. There will be pockets of delay for sure. There will be small battles occurring everywhere. Change is not easy for many and a change of habit is hard for all.

Conceptually speaking, this is how I think about the levels of intervention that we can apply to our problems. All of us doctors are down at the pointy end of that pyramid: frontline, engaged with the patient and community. But some of us doctors and non-doctors are also at other levels of governance and can exert powerful influences. There are many interventions that can be applied directly and indirectly affecting the doctor at the front line. It would be so exciting to see these interventions applied at all levels.

1. Individual

Personal health and wellbeing. Family. Exercise regime. Meditation. Mindfulness. Pilates. Yoga. Spiritual health. GP. Counsellor. Psychiatrist. Holiday. Social activities. Hobbies. Debriefing. Personal coaching. Mentoring. Personal philosophy. Altruism. Humanitarian activities. Time management. Goal setting. Personal development courses. Nutrition & Hydration. Sleep Hygiene. Journal writing, practicing gratitude.

2. Departmental

Social networking. Leadership development. Mentor training & support. Admin support. Departmental activities. Crisis Leadership training. Media and Communication training. Leadership coaching and relief. Rostering support. The Department Head is a critical player in the wellbeing of doctors in the department. Studies show improvement in leadership has positive effect on staff wellbeing. Staff wellbeing should be a priority for the Head. Staff wellbeing should be a measure of efficiency of Unit Leadership Role. Leaders should be given training in this arena. Every doctor is accountable to a Unit Leader. Every Unit Leader has immediate influence on frontline doctors.

3. Institutional

HR roster support. Resources for relief and cover. Training and support. Staff development. People and Culture Development. Wellbeing Leads and Wellbeing officers. Wellbeing campaigns and programs. Wellbeing Lectures and Grand Rounds. Schwartz Rounds. Formal Staff Health and Wellbeing clinics. Debriefing and crisis timeout programs. Institutional Cultural Change. Investment on Unit Leaders. Organisational Science. Organisational Psychology. Systems thinking. EMR, Computers, Productivity systems. Remove technologies or systems that may reduce clinical efficiency. Empower doctors to rearrange workflow to enable interface with new technologies. Doctors lounges. Quiet Rooms. Align organisational values.

4. Regional and National

AMA, Specialist Colleges, Health Departments, Medical Schools, Medical Defence Organisations, Kindness and Change Campaigns. Doctors Health Clinics. Regulations, Legislations, Laws, Policies, Accountabilities. Big picture cultural standards and code of conduct. What is decided at this level affects and protects the individual doctors even if the authority has no direct jurisdiction. For example, The College of Surgeons may not have direct jurisdiction over the roster of a resident doctor, but The College may exert influence over their Fellows working within that institution. An MDO may not have direct jurisdiction over the working conditions of doctors, but they may exert influence from a legal risk point of view to effect change when a matter is notified to them. Consider effects of Mandatory Reporting on Clinician Wellbeing. Cultural Change from the highest levels of leadership.

This is a big picture conceptual thinking. We need to address this problem with a multipronged approach. We need champions of change at every level. Sometimes we may be coordinated, other times it takes too long to wait for coordination. We may have the resources, or more likely, it may take too long to wait for resources. Many of these interventions do not need to be expensive, exhaustive or intensive. The time is right. There are significant actions that can be taken locally.  It may begin with just a simple conversation over coffee amongst champions of change in your unit. Throw around some simple ideas relevant to your unit.

We need compassion, courage and collaboration for change.

The above is not a definitive list. What other interventions would you add to the list? What has worked in your institutions or country?

Reading Materials for Discussion:

  1. Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017;92(1):129-146.
  2. Callahan K, Christman G, Maltby L. Battling Burnout: Strategies for Promoting Physician Wellness. Adv Pediatrics. 65 (2018) 1–17.
  3. Beyond Blue. National mental health survey of doctors and medical students. Melbourne: Beyond Blue, October 2013.
  4. The Dark Side of Doctoring.
  5. Context of Clinician Wellbeing.
  6. Elephants in the Room.
  7. Put on your mask first.
  8. https://das.bluestaronline.com.au/api/prism/document?token=BL/0823
  9. http://www.massmed.org/News-and-Publications/MMS-News-Releases/Physician-Burnout-Report-2018/
  10. https://www.ruok.org.au/
  11. https://mhfa.com.au/

RCH Grand Round Intro to Clinician Wellbeing

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Introduction presented at The Royal Children’s Hospital Grand Round Feb 2019.

Grand Rounds are about the big things that matter most to our patients. Grand Rounds are about milestones of the past, victories of the present and forecasting of the future. At their core, Grand Rounds are about the things that would make our patients’ lives better in Melbourne and beyond.

I commend the RCH for choosing the matter of Clinician Wellbeing as the Opening Grand Round topic this year, because the wellbeing of clinicians directly influences the work of clinicians and therefore the wellbeing of our patients.

I know what you’re thinking. What a fluffy touchy feely subject. What a new age subject. What a politically correct subject. We should really be talking about things that are of greater cosmic importance, such as the beauty of the human larynx, the acoustic intricacies of the middle ear or the exquisite grace of a neck dissection. We could talk about them all day. But today I would argue that of all the topics that will be discussed over this coming year, this is the one that will hit closest to home. This is the one that would potentially alter the course of our community as a whole. Because unless we appreciate the human cost of a clinician burnout, the financial loss of disengaged clinicians or the devastating loss of a human life to suicide, we will not make peace with our present to change the future.

A word of warning. We are entering into a space full of raw emotions. I understand that for some of us, this topic is very personal. You’ve been burned out, exhausted and depressed. You may even have contemplated suicide. You’ve sacrificed everything to be where you are, and yet it is not enough. You have faced bullying, harassment and discrimination. You sit in a room full of high achievers all suffering from the same impostor syndrome wishing we were half as good as the person sitting next to us. I too know the Dark Side of being a Doctor. I have been deeply burned out. I have lost a friend and colleague to suicide. The wounds of training are still raw. Hear us out. There are formal avenues of help available. Please access them. And there are informal ones too. Your colleagues and many like us are here to help you.

But this is the community where we need to audit our own morbidity & mortality. To use a surgical language, we need to debride this wound, bring it together gently and allow it space to heal. We need a good scrub and a good think about where we should go as a community. We hope that this Grand Round is the first catalyst to an open conversation and future action. Note that I use the term clinicians to include all clinicians because this problem is not confined to doctors. Allied health and others face similar problems too. Medical culture affect nursing culture and vice versa. But today we will be focusing on challenges and solutions unique to doctors.

Catherine Crock, Jane Munro and many others including Heads of Units and the Executives have done a lot of work in this arena. My job today is simple. I am the surgeon so I get to be the problem. I was an easy pick to set the problem because you know, the surgical ABC is Arrive, Blame, Criticise. I am surgically trained to find the problems.

3 words today for you to think about:

Context

Culture

Challenge

 

Context.

Do we really have a problem in health care or is this the song of an acopic generation? Let me remind us that Medicine is not what it used to be. There is no longer the ease and simplicity of the Doctor-Patient relationship. It is now the Doctor-EPIC-patient relationship. Between me and the patient stands technology, KPI, research, publications, funding, grants, ethics, admin, resource allocation, bookings officer, legal restrictions, social media, data collectors, patient advocate, lawyers, etc. The explosion of knowledge means that the typical resident today has to deal with way more digital pings, complex conditions and treatment regimes compared to doctors in the past. We are asking today’s doctors to be doctors, data collectors, social advocates, information officers, legal experts, and technological wizards. We’ve lost our sense of control over our work. We’ve lost our sense of support. And we’ve lost the meaning of our work.

Given the ever-increasing knowledge base and expectations on doctors, no wonder we have been hiding this elephant in the room.

Here are some stats we don’t really want to hear. Based on Beyond Blue’s survey. 1 in 5 of us has had a diagnosis of or treatment for depression. 1 in 4 has had thoughts of suicide and 1 in 50 has attempted suicide. Do not dissociate yourself from these stats. In an auditorium like this, depression and suicidal thoughts abound. Mental health is one elephant in the room. This needs to be acknowledged and professional support from psychologists and psychiatrists need to be sought. Engage your GP and seek formal assistance.

There is another elephant. A separate and possibly bigger issue of burnout. Burnout is not depression. They may be correlative or associative, but they’re not the same thing. Depression is a mental health diagnosis based on DSM5, ICD10 criteria. Burnout is not a psychiatric diagnosis. It is a psychological state due to chronic occupational stress characterised by emotional exhaustion, low professional efficacy and high cynicism. We’re mentally exhausted, we are not efficient at work and we gossip cynical about other units. Based on some studies, at any one time about half us meet the criteria for burnout. Which means that half of our doctors in this hospital may not be functioning safely or at full capacity. That’s bad for patients and bad for business.

Who gets burned out? Front line doctors and certain high acuity specialties. Paediatrics sit somewhere in the middle. What causes burnout? You would think that compassion fatigue would be a major contributor, but no that’s actually second lowest. The top four reasons for burnout has nothing to do with patients. They’re bureaucratic and clerical challenges.

How do we beat burnout? Much of the simplistic reductionist solution thus far has been directed at the individual level. It is imperative that we doctors look after ourselves. For the first time last year, The Physician’s Pledge drafted by the World Medical Association specifically says that I will attend to my own health and well being in order to provide care of the highest standard. If we can’t look after ourselves, we can’t look after our patients.

But that is not enough. The huge problem of doctor burnout and mental illness can’t be fixed with more yoga or meditation classes. They are important but they can’t be the only solution. When the boat is sinking, we need to find solutions together, not argue over jurisdictions and rules. This isn’t a junior doctor specific problem, because seniors burn out. This isn’t a Royal College specific problem, because doctors interface more with the working environment than they do with the College. This isn’t a specialty specific problem because it affects all specialties and how we engage with each other. This is our problem. It’s our institution, our HR, our college, our specialty, our leadership, OUR problem.

Which takes me to the second point.

 

Culture.

You can have the best workplace regulations and protocols, but if it is embedded in a culture of overtime, unpaid labour, hierarchical abuse, it will fail the doctors. Institutional culture eats regulations and protocols for breakfast. Hierarchies are not inherently bad. It is the misuse and abuse of that hierarchy that is bad. I extend a warm welcome to the new registrars, residents and consultants starting this week. Within the next couple of weeks, you will discover the RCH culture and perhaps you can tell us whether our values align with our culture. Is this a place where every person is truly valued and supported to reach their fullest potentials for their patients? Is this a place where people tiptoe around senior doctors or is this a place where the senior doctors make room for the younger ones to thrive and grow?

Having worked in Canada, Brisbane and Auckland, the impact of organisational culture on staff wellbeing is significant. There is a general global medical culture, but there are also specific local cultures. Each department within RCH has a slightly different culture. This departmental culture is set by the Leader, the Language and the behaviour within that department.

Therefore our solutions to burnout must not only address individual factors but also institutional factors. This is where Executives, HR, Heads of Units and Supervisors come in. We need formal systems, programs and structures to act like a safety stretcher to support our colleagues. The difference between your garden and my backyard weed-infested forest is that your garden is planned and tended carefully. We need to plan and tend to our institutional environment so our colleagues can thrive. Multiple papers have been published with evidence-based recommendations of various kinds. Addressing the institutional factors is critical in changing culture. Jane and Cathy will have some concrete suggestions. These programs and activities are simply scaffolds. They’re there to support culture. If we have a strong positive workplace culture we won’t need to rely too heavily on these scaffolds.

 

Challenge.

Finally, having seen the context and appreciate the culture, we have to face our challenge. What is our challenge? To be a great children’s hospital, leading the way. A lot of work has been done by Dr Munro, Dr Crock and many others behind the scenes. There is a groundswell of support. There is a positive momentum being felt amongst our colleges and institutions. None of us are experts in this arena, but if we are going to be a leading children’s hospital, we need to take the risk and embrace this challenge. Our investment on doctors’ wellbeing today will bear fruit a long way into the future. We can be a beacon of light on this matter. We can show others how it can be done. The Clinician Compact is one way of defining those things that matter to us. This is our DNA and this is how we can change the narrative around doctors wellbeing. So far the narrative has been about hierarchical abuse, depression and suicide. I strongly believe that the RCH as a major player can create a momentum to reach the tipping point to change the narrative into a positive one here in Melbourne and beyond.

Ultimately, our patients deserve exceptional care delivered by fully engaged compassionate doctors who are free from burn out. The core of our strategy is to unlearn and relearn what it means to be human and how to be humane together in health care. I shall hand over to Dr Jane Munro for some practical advice on how we can thrive together in this space…

Put on your mask first

img_5545-1Article published on Surgical News, a publication of the Royal Australasian College of Surgeons, Vol 19 No.10, Nov-Dec 2018.

As frequent flyers, many of us will be able to recite the safety briefing routinely broadcast at the start of every flight. Part of that briefing goes: “In the unlikely event of an emergency, oxygen masks will drop from the panel above you. Put on your oxygen mask first before assisting others.” The practical and critical reason is that if you don’t get your own oxygen first, you will not be able to help others. In the unlikely event of an in-flight emergency, you need to help yourself before helping others. Similarly, in the likely event of routine regular excessive surgical demands, we too need to put on our own oxygen masks first before helping others.

As surgeons, we took the oath to place our patient’s needs as priority. This is often done at the expense of our own health. The RACS Fellowship pledge begins with “I pledge to always act in the best interests of my patients”. This is certainly a noble pledge that underpins all of our motives, but it can be also be detrimental to our own health when we repeatedly pursue excellence and perfection for our patients at the expense of our own health, physical and mental, and our families. In our pursuit of the best interests of our patients sometimes unwisely we neglect our own. As a byproduct of our training we put on the oxygen masks for others first. Could this be one of the reasons many of us are struggling to give our best to our patients? Could it be that many of us are struggling with emotional exhaustion, inefficiency, cynicism, and burnout because we have forgotten to put on our oxygen mask first?

The World Medical Association Declaration of Geneva for the first time in 2017 included self-care as a critical part of being a doctor. The Physician’s Pledge begins with the same noble standards: “As a member of the Medical Profession, I solemnly pledge to dedicate my life to the service of humanity.” But further down it adds: “I will attend to my own health, well-being, and abilities in order to provide care of the highest standard.” This is a small step but a big leap in terms of thinking about how we care for ourselves and each other. Put on your mask first.

What’s your oxygen mask? Many surgeons are already doing this well: painting, sculpting, wine-making, travelling, bike-riding, running, triathlon, music, writing, etc. Many surgeons are well and truly gifted and accomplished in non-surgical arenas. What is done as a rejuvenating hobby outside the operating theatres and the wards fuel the passion and excitement for the work within the operating theatres. Various different techniques of self-care have been shown to be beneficial in improving doctor wellbeing so that we can provide care for our patients1. Doctors who find value in what they do are less likely to have symptoms of burnout. Physicians who spend 20% of their time on the aspect of their job that they find most meaningful have a significantly higher job satisfaction rate. Intrinsic motivators (meaning, personal philosophy of practice, commitment to Medicine) were found to play a large role in career and life satisfaction compared with external motivators (eg, income, work hours). Self-reflection with journaling or small groups that discuss difficult and traumatic situations without judgment are beneficial. Physical exercise, emotional and congnitive resilience training, mindfulness meditation and Cognitive Behavioural Therapy have all been shown to improve doctor wellbeing1. In addition to finding institutional solutions to institutional problems2, the evidence is clear that various self-care techniques are beneficial in reducing burnout, improving our mood, job satisfaction and engagement with work1. For many of us, having a GP, mental health professional, coach or mentor is a necessary critical lifeline. The RACS strongly encourages all Fellows to be regularly engaged with a GP. We know that those self-care methods work. We just need to do it.

Now that we have put on our own masks first, how do we assist others with their masks? It’s enshrined on our Fellowship Pledge: “I will be respectful of my colleagues, and readily offer them my assistance and support.” How do we practically do that? In the elective routine day-to-day activities, we need to continue to provide safe spaces for social engagements. As modern surgery demands longer and flexible hours, we get less time to connect with our colleagues. The busier we are the further we are travelling from each other. The loss of doctors’ lounges and departmental offices have also meant that traditional safe spaces for social connections have disappeared. Carving out a safe space or time to recreate social connections would be beneficial. Post-MDT Meeting coffee, cake break during clinic, fortnightly departmental drinks, early birds breakfast before grand rounds, and reclaiming a social space for chats are possible interventions that any surgical department can do. Studies have shown doctors who set aside time to cultivate meaningful relationships are more fulfilled and engaged3. Building a regular departmental social support in the elective will prepare you for the emergency.

How do you render emergency assistance to a colleague who is struggling? The R U OK website4 has good simple advice on how to start a conversation. It is highly recommended. They suggest 4 simple steps: Ask, Listen, Encourage Action and Check in. Before asking, think about your own headspace and readiness. You may not be the right person at the right time to do it. If you feel ready, know that you should not intent on ‘fixing’ someone else’s problems. Choose a safe time and space for that question. Then secondly listen without judgements. Thirdly, Encouraging Action provide options of connecting with professional support or assisting the colleague to find their own practical solutions. Finally, checking in after a few days to ensure that your colleague is safe and well. Being aware of these simple steps is in effect helping your colleague with their oxygen mask. Each time a colleague helps me with my mask, I become more engaged as a surgeon and my patients benefit. Ultimately, we are not mental health professionals. Your colleague may need a formal therapeutic relationship with a professional. Our role as colleagues is to render assistance and to be a bridge to that formal support.

Just as First Aid proficiency is part of medical competence, there are formal skills on providing Mental Health First Aid in emergencies. Mental Health First Aid Australia5 is an organization that provide courses readily available in every state in Australia on developing these skills. They’re evidence-based courses developed by the University of Melbourne’s Population Mental Health Group. One in five of us suffer from a mental health condition. Therefore it is proper that we upskill ourselves in the area of providing first aid in mental health emergencies.

In the likely event of routine regular excessive surgical demand, we need to put on our own oxygen masks first before assisting others. Once we have put on our masks, we can then readily offer assistance to our colleagues through elective social support or urgent courageous compassionate assistance if so required. It’s part of being a Fellowship.

References

  1. Callahan K, Christman G, Maltby L. Battling Burnout: Strategies for Promoting Physician Wellness. Adv Pediatrics. 65 (2018) 1–17.
  2. Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017;92(1):129-146.
  3. Quill TE, Williamson PR. Healthy approaches to physician stress. Arch Intern Med 1990;150(9):1857–61.
  4. https://www.ruok.org.au/
  5. https://mhfa.com.au/

Mental Health and the Medical Journey

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Interview with UQMS from June 2018. This is the pre-publication unedited version.

Could you tell us a bit about the experiences in your medical journey?

I completed my MBBS through The University of Melbourne as a postgraduate student. I did my residency all over Victoria. I accentuated these experiences with Medical trips to Fiji and West Timor to add a little flavour of Global Medicine. I got myself a PostGrad Diploma of Surgical Anatomy and a Master of Public Health and Tropical Medicine during residency. I entered General Surgery SET training and then Otolaryngology Head & Neck Surgery Training Program. I did one year of Fellowship in Canada in Head & Neck Surgery and then two more fellowships in Paediatric Airway and Head & Neck Surgery in Brisbane and Auckland. It has only taken me a short 13 years from graduating Med School to working as a Consultant Surgeon. I guess I’m a slow learner. It has been arduous and fun. My wife, an Infectious Diseases Physician, thinks I’m crazy.

The very successful launch of #CrazySocks4Docs in July last year really transformed the climate of conversation on mental health between health professionals nationwide. Now that a real conversation has sparked, what other improvements would you like to see from this year’s campaign? What worked well last year?

It has indeed been encouraging to see the effect of the Mental Health Awareness campaign. I am delighted to see and hear that this issue is often at the forefront of our minds and more importantly in the public arena through several news, radiology and television subject. This is good. The more we talk about Mental Health among clinicians, the more we dispel they dark myths around it and the more we can normalise the experience and challenges. The results of awareness campaigns are often hard to measure in numbers or dollar value. However we are confident that Colleges, Medical Institutions and Medical Schools are working through this issue as seen through the evidence that it is a topic included in Grand Rounds, conferences, Plenary Sessions, and Hospital or College Newsletters. The next step is to look at practical solutions that will look different in different contexts. There are no single simple solutions to mental health care in the health care industry. It requires legal, state-wide, institutional, departmental, even practical roster solutions if we wanted to be serious about managing this challenge.

Can you tell us more about your planning and campaign with Dr Geoff Toogood, and what initially inspired the two of you?

You better speak to Dr Toogood directly if you wanted to get the story from his end. It was an organic spontaneous awareness campaign. This came at a time when I was dealing with my own occupational burnout. I had always worn crazy socks from even way before it was cool. I supported the idea behind the campaign and all I did was leverage it to the wider community through social networks. At the end of the day it was for Dr Toogood to inspire discussion around this issue. There has been many people who have been working hard in this arena for many years (psychiatrists, psychologists, counsellors, etc). He used a simple object as a point of discussion to leverage the message to the general public.

Despite the positive conversations surrounding mental health happening internationally, the fear of judgment is still a prohibitive factor to individuals sharing their personal experiences. How can we create an environment in which we are more comfortable talking openly?

In essence, the two major limiting factors are regulatory (Mandatory Reporting rules in some states) and cultural (“doctors are not meant to be weak”). The good news is that the regulatory side is being worked through at the moment because there is a lot of confusion around that. We need to accept that a doctor seeking medical treatment for mental health can be a safe and effective doctor just like any doctor with cardiac or neurological condition. A well-treated mental health illness is a stable condition. Having a mandatory reporting rule may become a hindrance to other doctor seeking help. This hindrance places the doctor and their patient at risk. It is the undiagnosed untreated illness we should worry about, not the ones who present to their GP and mental health professional. Of course, if a Mental Health Professional is deemed unsafe, they can be reported, but to have a blanket rule that is poorly interpreted is not necessarily helpful. The second issue, cultural, is a little more insidious and hard to change. The medical community has an unhealthy expectation of perfectionistic heroism. It’s ingrained in our selection process and training. We pick the best students, compete them against each other in med school, put them through horrendous jobs that mess with their body clock and social life, expect them to never fall sick and always be perfect. Very few remembers the 99 great things you do, but you get crucified for the one time you drop the ball. There are no back ups on the system as well such that when we have to take a day off sick, other docs have to cover our jobs and therefore we feel bad. Cultural change takes time. Awareness, acceptance and admission to the problem is the first step. Leadership is the biggest catalyst to this process. We will get there. We will change because I have seen the process of change occurring in so many places. But it will take time. You can’t change culture overnight.

There is a paradox within healthcare that doctors and medical students often ignore their own health and wellbeing. Is there any way to recognise burn-out before it becomes a real problem?

Absolutely. Just as much as we need to look after our physical and cognitive health, it is imperative that we learn to look after our mental and social health. Let me also point out that mental illness such as depression and workplace illness such as burnout are two different conditions requiring different treatments. They’re obviously related, but the way we manage them differ. Burnout is a state of chronic occupational stress characterised by emotional exhaustion, cynicism and lack of effectiveness. Depression on the other hand is a DSM-V ICD-10 diagnostic category of mental health condition. Diagnosing, investigating and managing burnout is not the same as managing depression. With regards to depression, we need to encourage our colleagues and ourselves to seek assistance from a Mental Health Professional and we need to remove barriers to this. With regards to burnout, we need to consider workplace factors that contribute to the condition, such as roster safety, leadership initiatives, support systems, positive culture and the like. We must look beyond the individual and pay careful attention to the workplace environment as well. It is not that difficult to spot a colleague who is emotionally exhausted (angry, irritable, sad, etc), highly cynical (sarcasm, repeated complaints, etc.) or with poor effectiveness (uncompleted tasks, delayed jobs, etc.). What is harder is knowing what to do about it.

We dedicate so much time towards learning how to diagnose and treat our patients, how common is it that we miss the signs displayed by our struggling colleagues? What can we do now as students to be better doctors for our friends and family?

We are trained to help patients. Medical school curriculum does not train us to help our colleagues. In fact, all that I was ever taught was to report, not help, a struggling colleague. We need to change this. Firstly I would encourage each student to strengthen their social network within and outside of medicine. Having a strong social network will keep you in a safe place when things at work is difficult. You need medical friends who understand the daily struggles you have and you need non-medical friends to give you a greater perspective on life. Secondly, in the same way you commit yourself to understanding how to manage a cardiorespiratory arrest, commit yourself to understanding how to assist your colleagues. Every institution, colleges and state has some sort of a Guide to Clinician Wellbeing. Read them. There are many resources available locally, on the internet, on paper publication, and phone lines for assistance. There are many lectures, talks and other sessions in conferences around this matter. Educate yourself and you will have the tools to be of great assistance to your colleagues. You may just save a life.

There are a lot of medical students who are passionate about advocacy but feel that they do not have a tangible way to make a real positive change. What are your tips on overcoming this barrier?

This is why I believe that the future of medicine is bright. I see a generation like yours rising up within the ranks of medicine. A generation that is committed to a greater cause, passionate about being global citizens and has a strong sense of social justice. In addition, you are also powerfully connected. The old cliché does apply: start local, go global. You are more powerful and influential than you think you are. You are already well educated and well trained. Go find a local need and fight for it through simple means such as media communication. Advocate for the patient in front of you. The car park is too expensive for patients? Write a note to the private car park company as a medical student group. You want to see more female role models in Medical Education? Write to the Dean and ask to have more female lecturers and tutors. Research funding is poor? Activate your social media network and crowdfund for a research focus. There are so many simple little ways that you can do locally. The problem is that sometimes we want to see big results quickly. Advocacy takes time. Small snowflakes over time turn into avalanches. Pay attention to and change the small things. The bigger ones will follow.

What is your definition of advocacy? How can we all become advocates for better outcomes?

Advocacy is helping others lead better lives. Focus on others: your colleagues, your patients, your community, your institution. Advocacy ends when we start thinking “What’s in it for me?” True advocacy means that we fight for another person. Sometimes, there’s just nothing in it for me. If you’re lucky enough to be a student and a doctor, by societal perspective, you are lucky enough to do something for others without any immediate benefit. The legendary advocates are almost always those who sacrifice personal comforts for the sake of another person or community.

How do you juggle life as an ENT surgeon, dad, speaker, blogger, and advocate? What do you do to look after yourself?

I do juggling terribly. I’m still learning. I’ve never done any or all of these before. As a doctor, our career trajectory is full of detours. Just embrace it. I am lucky to have an awesome family who are made up of my best supporters. To look after myself I do regular quiet times to read and think, personal journaling and weekly social gatherings. I balance my need for social connection with private moments. I need regular times alone.

Do you have any advice for students who aspire a future career in surgery?

It’s the toughest yet most fulfilling career ever. Sorry I’m biased. I still often pinch myself. I can’t believe that I get to do some crazy things on a daily basis that very few people ever get to do. First advice is this: every specialty in Medicine and Surgery is noble and fascinating. There is no one specialty better than another. You simply need to find some specialties that suit your interests, curiosities and personality make up. Find a few, and look into them. Direct your studies, research, electives into some of them and figure out if they suit you. If you’re good, whatever specialty you end up doing, you’ll make it awesome. Secondly, don’t be fooled by media portrayals of specialties. Emergency Medicine is not always like ER. Surgeons are not all like those on Grey’s Anatomy, and Physicians don’t do what Dr House does. What you think happens in a particular specialty is not what really happens. See what the registrars and consultants do on a day to day basis. Appreciate the mundane in those specialties. There are a lot of mundane routine work in every specialty. Can you handle them? Thirdly, look at the people in those specialties. They’re going to be your workmates for life. You better like them. I was initially interested in another surgical specialty, but I didn’t like the community attitude in that specialty. I chose ENT because of the work and the people. I not only like ENT Surgery, I like ENT Surgeons.

The road to medical school involves getting through years of academic competition. How important is it to understand that medicine ultimately isn’t a race, and that our future success cannot be solely quantified by grades?

If this was a race, I’m definitely one of the biggest losers. I’ve lost count of the number of times I didn’t get my first preference, had research rejections, failed exams, missed out on surgical selection, etc. Competing with others and with yourself destroys the joy of Medicine and Surgery. There is no need for competition because it is not. You do have to get the grades and make the cut because we have to be excellent at what we do. No questions. We study and work hard not to pass exams but for that day when you are the only person standing between a patient and their disease. We must strive for excellence. But the measure of excellence is not solely in the Academic grades realm. Grades are not the full measure of a doctor. Patients won’t know that you got an A for first year Biochemistry on the Kreb’s cycle, but patients do care that you are competent, compassionate and collaborative. Gain competence through collaboration, not competition. Gain compassion through your own good self-care. You can’t give out of an emptiness. The biggest reward in Medicine is not grades or academic awards. The biggest reward in Medicine is grateful patients.

Big Weekend

Boys Big Weekend!

My son is turning 10 this week and we’ve decided that we need to do the big talk. You know, adult topics he will have already been exposed to during his school conversations.

I can’t leave it to chance. I can’t let the internet or his friends be the main influence to his young mind in these matters. I’d like to provide a safe place where he can run to for opinions, clarification and standards. And as boys go, we need to do stuff together before we can open up and chat. Here’s what we did in Melbourne over the weekend and if you’re a dad to a pre-teen son or daughter, I’d be happy for you to copy and paste this weekend itinerary to your schedule so you too can chat to your son or daughter about the big stuff.

SATURDAY

7am Ward Round at RCH and St.Vincent’s Private (This is optional)

9am drive to Lysterfield Park (Horswood Rd car park) for a morning of Mountain Bike Riding. Good entry level track with a few areas for skills practice with small hills and jumps.

1pm Head towards Australian Rainbow Trout Farm at Macclesfield. You will pass through Emerald. A few good cafes there for lunch and a Woolies for last minute camp groceries.

2.30pm Fishing at Australian Rainbow Trout Farm. You can fish for a small trout, a golden trout, a rainbow trout or even Atlantic salmon. My son caught a beautiful brown trout. It’s an easy catch so try the hard lake first before moving to an easy pond. They’ll gut and fillet the fish your son/daughter catches. And that’s dinner cleaned up for you.

4pm drive to Healesville Camp ground. (We chose an unpowered tent site at Big4 Healesville. You can do cabins, belle tents, pods, AirBnB, Bed & Breakfast, etc. Choose your level of comfort). We chose camping because the act of setting up and staying in a tent would be fun.

6.30pm dinner. My portable stove nearly blew up on me. Good thing the camp had a kitchen, BBQ hotplate, fridge, etc. We cooked some noodles, spam and the fish he caught. He loved it. We brought some vegetables, but being boys, we forgot to eat it.

8pm: walk around and marvel at the glorious stars above the gum trees. And then STAR WARS in the tent on the iPad.

SUNDAY

Breakfast of champions: bacon and eggs. (And the cup noodles he wanted.) Kick a few balls and ride bicycles around the camp ground. Feed some birds and play in the small creek on camp site. Pack up tent.

11am drive to Healesville, stopped by some shops and art galleries.

1130am Gin tasting at Four Pillars Gin Distillery (This was for daddy! If you’re not into Gin, you can swap that with Innocent Bystander brewery/winery 5min away, or a lunch at any of the fantastic Healesville foodie places. Lots to choose from.)

1.30pm Trees Adventure Glen Harrow Park Belgrave for tree surfing/zip lining. (This was actually a birthday party of his schoolmate, but the activity fitted perfectly to our schedule.)

5pm Head to SkyHigh Mt.Dandenong, Observatory Rd overlooking all of Melbourne. Here we parked the car and finished up the CD we were listening to and had a quiet moment to chat about everything else we’ve talked about over the weekend.

6.30pm back to Melbourne for Pizza dinner at his favourite restaurant.

If you notice, the drive between places are only about 30-45 min long. Lots of activities to do together (mountain bike, fishing, camping, movie, zip lines).

And most importantly, the soundtrack for the weekend. I cannot recommend enough this resource from The Parenting Place NZ. We found out about this when we were in NZ. ABSOLUTELY FANTASTIC. The way the topics are approached is spot on. Very safe and very appropriate. Check out the list of topics on the pics below. DOWNLOAD their resource now on iTunes Store (search The Parenting Place, The Big Weekend) and have a listen yourself. You’ll know why I highly recommend this for boys and girls, dads and mums of pre-teens. And because it’s kiwi, we smiled and remembered our own kiwi experience.

There you go mums and dads. The big weekend is not just for boys, the girls can do same and modify the activities to appropriate options around the same areas we’ve visited. Instead of mountain bike, have a walk around the beautiful Lysterfield lake. Instead of fishing, go visit some nice tulip and art gardens in the Dandenong ranges. Do whatever your boys and girls would like. I plan to do the same itinerary with my daughter in the future. Why should she miss out on these adventurous stuff? Take the plunge and talk about these stuff with your kids.

We as parents need to prepare them for their turbulent teenage years in the current society we live in. Don’t let the internet be their guide. Let’s be that safer and stronger influence on our kids. This weekend and it’s soundtrack just gets the ball rolling. I can’t answer every question he has and he will have more to ask in the future. The key is opening that door and letting him know that his parents are safe people to go to.

Let me know how you go!

Podcast with RACS

https://omny.fm/shows/racs-post-op-podcast/grappling-with-burnout-mental-health-and-instituti

Crazy Socks 4 Docs, What Next?

socksWhat happens beyond the socks?

As #crazysocks4docs rolled around the world recently, there were some negative comments thrown against the campaign. Generally they fall into one of these categories below.

Crazy socks? That’s making the whole doctor suicide problem a little trite, don’t you think?

The problem of physician mental illness and doctor suicide is a taboo in many places. It’s a well known problem that no one wants to talk about. We lose one of our own to suicide in such a regular frequency that we become apathetic to it. If we don’t talk about it, how can we expect anyone to start to find solutions to it? How do you even start this conversation? Find creative ways around the issue. Rather than using the old fire and brimstone scare tactic, “You change or you die,” use a more acceptable language and a captivating strategy. I support the crazy socks campaign because it captivates a community around a simple lighthearted object. It is an inroad access to prime a conversation. The socks is not the end point, it is the starting point on a long journey of change that begins with a conversation.

How can socks fix mental health problems? What has socks got to do with it?

Of course socks don’t fix mental health problems. Socks is just the object to get people talking, much like the Pink Ribbon for Breast cancer, the Blue Ribbon for Police Memorial Day, the Red Poppy for ANZAC Day, the Jeans for Genes, the Pink Shirt, the Red Nose Day. None of these objects in themselves are cure, but they are objects around which conversations can occur. With these objects, we bring out dark taboo matters for discussion. Many who have suffered in quiet say, “I suddenly realise that I’m not the only doctor suffering with mental health condition.” The talks beyond the socks matter.

Why would you focus on socks when the real problem is 100-hour weeks, bullying, discrimination, toxic workplaces?

Wait a minute there. You are confusing many separate but interconnected issues. Let’s not get ahead of ourselves. #CrazySocks4Docs campaign is about de-stigmatising mental health issues in clinicians, not about rosters, bad leadership or Institutional illness. That’s a different elephant altogether. Each of the following are issues that matter but they’re not the focus of Crazy Socks campaign: discrimination, bullying, harassment, toxic workplace, poor leadership, poor working environment, unreasonable rosters, mounting debts, limited job options, etc. These factors may lead to burnout (a psychological state of emotional exhaustion, poor efficiency and high cynicism) due to chronic occupational stress which may cause or worsen depression. However, they are not the main focus of the campaign. We tackle one elephant at a time. We devise unique, creative and courageous solutions for the other elephants, one problem at a time.

crazysocks4docsNow what?

Don’t rain on someone else’s parade.

Don’t shoot friendly fires. You do not need to criticise a campaign that started with no financial support or administrator-initiated strategies. This came from the heart, from a clinician who suffered with mental illness. For a campaign that started organically through social media and has literally reached numerous countries and covered every continent (yes, Crazy Socks in Antartica), this has captivated and has been supported by many Professional Specialist Colleges, Universities and Hospitals around the world. This campaign has given many clinicians a simple object for starting a conversation in their workplaces. It has unified the message.

This is how you turn the tide. Not by putting a knife to the throats of leaders or administrators, or criticising another campaign, but by getting the community on the same page, talking around the same topic and preaching the same message. Snowflakes that become avalanches of change.

The socks is just a ploy to get you talking to your colleagues and leaders.  The socks came with a memorable message:

De-stigmatise mental illness in clinicians. 1:2 doctors burned out. 1:4 doctors have been treated or diagnosed with depression. 1:5 doctors have contemplated suicide. 1:50 has attempted suicide. Go to your colleagues with these numbers and change the way you work together. Go to your leaders with these numbers and work together to find courageous, creative, collaborative solutions.  Remove the stigma. Remove the cultural, cognitive, regulative and legal barriers that stop clinicians from seeking help.

I have lost a colleague to suicide. I work with those who have been diagnosed with depression. I know some who have attempted suicide. Half the colleagues in my department are burned out. These are real numbers affecting patient care!

I have seen through this campaign consultants and attendings giving away care packages to their trainees (That’s a sure way of making the matter departmental and unmissable!). I have seen Chiefs of Surgery supporting the campaign (Top down support!). I have seen Professional Colleges and Universities come out to support this initiative (Public messages of support). I have seen media outlets sharing this message. I have been interviewed by national radio, quoted by media and presented at Grand Rounds, just as many others have done. Most importantly, many clinicians have come out saying “I thought I was the only one struggling. Thank you for giving me courage to share.”

There is a momentum towards a tipping point and I’m not the only one speaking the message. Every talk, every tweet, every article, every conversation, every campaign (no matter how silly you think) count as nudges on the long journey of change. There will come a day when we do not need this campaign. Just as campaigns go, this too will become less relevant over the next few years as the matter is openly discussed and tackled. But until then, we are on the same boat. We work together to get the message out. My role was to leverage the message and amplify it. My job is done. I don’t think I need to do anything next year because there is now a groundswell awareness already.

What do you do on Monday? You hold them to account.

“Thank you for your support of Doctors’ Mental Health Initiative. Can we talk about some possible solutions? These solutions do not have to be expensive or extensive.”

I have always worn crazy socks for years and will continue to wear them. The message doesn’t end on June 1st. It just got louder then and continues.

Why don’t you share some practical ideas about how we can make a difference in our departments and institutions?

Crazy Socks 4 Docs

crazysocks4docsWhy do I support #CrazySocks4Docs?

One in 5 Australian doctors have been diagnosed with, or treated for, depression1. One in 4 have had thoughts of suicide. Almost half of all doctors are emotionally exhausted, burned out at work1. Forty percent of surgeons meet the criteria for burnout2. This is an elephant in the room sitting on the chest of us doctors. It takes courage to acknowledge this elephant. It takes even more courage if you are the one in 5 who turns up to work faithfully with a well-managed depression. It’s time for us to shine a spotlight on this endemic issue of mental health amongst us. There is a momentum and a societal support for this elephant to be tackled. The first step is raising awareness. Some of us have been wearing funky socks since before it was fashionable. Now there is a purpose to your sartorial style. #CrazySocks4Docs Day on First of June is an initiative to raise awareness of Mental Health amongst Clinicians. This campaign was started last year by Dr Geoff Toogood, a Melbourne Cardiologist. Wear mismatched crazy socks on the first of June and show them off proudly.

If I’m asked why the crazy socks? I say

  1. To Remember those who have died. I have lost a friend and colleague to suicide.
  2. To Raise awareness of Mental Health among Clinicians. One in 4 of my colleagues today have thought about suicide and one in 5 suffers from depression.
  3. To Reshape the culture of health care. We are human beings. We may be highly trained specialists but we are still human beings with similar struggles as our patients.

Awareness must lead to Actions, otherwise it will simply lead to Apathy. Awareness means that we respect and support our colleagues with mental illness and we support and encourage each other to engage with our GP, counsellor or other mental health workers. Awareness means that we begin talking about potential solutions to the elephant. It will involve more than setting up resilience training videos. It will require efforts at various personal, departmental, institutional, legal, state, federal and political level. It will require addressing workplace factors that negatively impact on mental wellbeing. The solutions have to be compassionate, creative and courageous. There are many stalwart warriors who have been fighting in this arena for years: psychiatrists, GPs, policy makers, families of those who have suffered, etc. We honour their work. This momentum is due to their hard work. Every talk, every lecture, every article, every workshop, every tweet, each one a small sacrifice that builds a momentum. Ultimately, improving the physical and mental wellbeing of clinicians will improve the care and the outcomes delivered for our patients. Our patients deserve physically and mentally healthy doctors caring for them.

References

  1. National Mental Health Survey of Doctors and Medical Students. October 2013. Beyond Blue. https://www.beyondblue.org.au/docs/default-source/research-project-files/bl1132-report—nmhdmss-full-report_web
  2. Dimou FM, Eckelbarger D, Riall TS. Surgeon Burnout: A Systematic Review. J Am Coll Surg. 2016 Jun; 222(6): 1230–1239.
  3. Image credit to @perkieturkey, New Zealand Anaesthetist.

Broken Doctors, Broken Systems

Broken Doctors, Broken Systems: Clinician Mental Health in Context.

Modified from a Plenary Talk at Combined Annual Scientific Congress of the Royal Australasian College of Surgeons and Australian and New Zealand College of Anaesthetists. May 2018. @DrEricLevi

Broken Doctors Broken Systems.jpg large

How do you deliver the best care for your patient? More importantly, how do you deliver the best care for your patient in the context of institutional and individual challenges? The problem of clinician burnout and mental health is well known. As individuals and institutions, we have been grappling with this issue for some time. We have had many interventions with variable successes. Are we thinking correctly around this?

I would like to change your mind on this matter. I have no disclosures. I do have a disclaimer. I am not a psychiatrist or a mental health professional. I am a surgeon on the coalface. I have been hit by friendly fire and covered in mud. I would sincerely like to share my thoughts as a front-line worker and offer three possible practical action plans that are not necessarily expensive or extensive to tackle this issue.

Doctor wellbeing and doctor suicides are uncomfortable topics for many of us. We are trained to diagnose, treat, gas, tube, stabilise, fix patients. Unlike our colleagues who are GPs and Psychiatrists, we are uncomfortable with this “wishy-washy, touchy-feely” stuff. We know it is important somehow but we don’t know how to approach it. We are not trained to help our colleagues. We don’t know how to respond to a struggling colleague. There is a certain awkwardness when we see our colleagues struggle.

Doctor suicides.jpg large

We know that there is an elephant in the room but we don’t really know what to do with that elephant. The data is clear and has been covered in many other places. Doctors are struggling, and they are struggling quietly. (National Mental Health Survey of Doctors and Medical Students. October 2013. Beyond Blue.) These are the numbers we know in Australian Doctors in 2013 based on Beyond Blue survey of over 12,000 doctors: 1 in 5 has been diagnosed with or received treatment for depression. 1 in 4 has had suicidal thoughts. And 1 in 50 has attempted suicide. The risk with us looking at these statistics is our cognitive dissociation from this statistic the same way we look at other statistics and say “those numbers are for the patients, not for me.” No, this is our statistic. This is us in this room. This is the state of our health care community. In a typical Surgical or Anaesthetic Department, there will be someone who has had thoughts of suicide and perhaps someone who has attempted suicide. Females are at higher risk, and the specialty hotspots for suicide are GP, ED and anaesthesia. However, it’s not a gender issue because males commit suicide. It’s not an age issue, because consultants commit suicides, not just trainees. I am mindful that there may be some of us struggling with these thoughts this week, or even right now. If that is you, please hear me. You really matter. You really do matter to your community, to us, and to our patients. Please share your burden with a trusted colleague, a GP or a professional mental health worker. Help us help you to be a better doctor for your patient.

In view of this elephant in the room, self-care and managing mental health is indispensable. It’s so important that for the first time last year, the World Medical Association has included self-care as part of their Physician’s Pledge on the Declaration of Geneva. The Physician’s Pledge is the modern version of the Hippocratic Oath. In 2017 it begins with: “AS A MEMBER OF THE MEDICAL PROFESSION, I SOLEMNLY PLEDGE to dedicate my life to the service of humanity”. And then further down the pledge it says: “I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard”.

I cannot stress enough the importance of mental health and self-care in our caring profession. This is why resilience training, personal coaching, having a GP or a professional mental health worker are important and have been shown to improve the way we deal with workplace stresses. If you suffer from mental illness, getting good treatment is critical to your delivering care of the highest standards for our patients.

The big question I would like to pose is this: Is that enough? Is resilience training, mindfulness & coaching the solution to our problems? For that particular elephant, yes.

May I change your mind? I’d like to suggest that there may be another elephant in the room? If we call the first elephant mental health, can I call the second one Institutional Health?

I am sure you know what I mean by institutional Health: Workplace conditions, relational toxicity, administrative intrusions, time pressures, excessive workload, resource limitations, competition for jobs, poor job satisfaction, poor job engagement, bullying, harassment, sexism, job maldistribution, etc.

Screen Shot 2018-05-13 at 5.15.38 PMBurnout. This is Australian data again from the same Beyond Blue Survey. Burnout is defined as a psychological state characterised by emotional exhaustion, low job efficacy and high cynicism or depersonalisation, due to chronic occupational stress in the caring profession. It is not a DSM5 or ICD10 mental illness diagnosis. It is a psychological state due to workplace stress. Workplace factors have strong association with burnout. Half of us are emotionally exhausted, 1 in 6-7 not effective, and half of us are highly cynical. Burned-out doctors are bad for patients, and bad for business. They’re ineffective. They may order more unnecessary tests, take longer to complete tasks, make mistakes, and do not deliver high standards of care. How can you care for a patient when you are emotionally exhausted and cynical?

What is the relationship between mental illness diagnosis of depression and workplace illness of burnout? We are still exploring that. Some say causative, others say associative, still others say they are overlapping conditions, and some say they’re essentially the same thing. Perhaps they’re different conditions due to their aetiology or cause, but may result in a similar constellation of symptoms. For example, you can have depression and not be burned out by work. On the other hand, you can be absolutely burned out at work and not have the DSM5 diagnosis of major depression. This is why some people find that a change of work environment results in a significant change of emotional state and engagement at work. This is why a doctor with depression that is well managed can be an effective engaged worker that delivers high standards of care. This is exactly why we need to tackle the issue of mandatory reporting in some Australian states. A doctor with mental illness does not equal an unsafe doctor. A doctor with mental illness may provide a safe and efficient care just the same as a doctor with cardiac or respiratory illness.

There is an elephant in the room we’ve called mental health. But there is another elephant sitting on the chest of our clinicians that I would call institutional health. How did we come to this? How did we get the best and brightest, the A-students in high school and university, the ones who worked hard through school, medical school, specialist training, how did we end up then with doctors who are burned out and ready to quit medicine or quit life altogether?

Some of you might think “Oh, just toughen up princess. I used to do longer hours than you.” Perhaps that is true, but it’s not the duration but the quality of the work that has changed over time. Limiting work hours have made no difference to rates of burn out. Our patients are getting more complex, new diagnoses and treatments are being discovered everyday, the administrators and lawyers are intruding our work space. In the past, daily work may have included a higher proportion of clinical work. Today, much of our work is non-clinical. It’s data entry, paperwork, organisational, research, etc.  We actually spend very little time with patients. Medicine is no longer what it used to be. You have to log in 27* times before you see a patient and choose one of 273* algorithms or protocols for your patient (*not real data). The link between workplace stressors and clinician burnout is confirmed through several studies already.

Last year I burned out spectacularly. I was snappy and I was a horrible person to be with and work with. So like a good Generation X doctor, I wrote a blog. I titled it the Dark Side of Doctoring. The blog was triggered by a suicide death of a Brisbane gastroenterologist but it hit me hard because I was in a dark place. I wrote mostly to pen down my emotions, but somehow it went viral and was read 288,000 times. That is, more than a quarter of a million people have read that blog. A lot of clinicians simply identified with the feelings I had. The content was simple. I spoke about the 3 things I lost during my surgical training and my life as a surgeon

Firstly: Loss of control. Everyday my life is dictated by clinics, operating theatre and emergencies. We are slaves to our pagers and on call roster. Every year I get moved to different hospitals. Every day I am pressured to do more. I am told where to be, what to do and who to operate on.

Secondly: Loss of support. I was studying and didn’t see my family. I miss out on birthdays, anniversaries, family holidays. I didn’t have anyone to talk to because everyone was busy. No one understood the pressures of the work I do

And finally, but most importantly, I had a loss of meaning. I lost the purpose of my work because it all became a burden. What really matters, patient care, is lost in the noise and buzy-ness of work.

Screen Shot 2018-05-13 at 5.16.04 PMI started surgery with this idea in mind, that surgery was my Ikigai, a Japanese concept. What I love, what the world needs, what I can get paid for and what I’m good at, all overlapping and I find meaning through surgery at the centre. I lost all that. The truth is many of us in this room would know that such is the noble calling and purpose of our work. But we lost it. We lost what mattered. But it wasn’t a sudden thing. It was always small little things during the day over many years that slowly push us closer and closer to the edge. The loss of control, the loss of support, the loss of meaning, the exams, the research deadlines, the gender inequity, the toxic workplace, the bullying, the resource limitations, every small thing brings us closer to the edge of quitting. Daily, chronic, repetitive emotional microtrauma. It’s like the analogy of the frog in the boiling water. Every microtrauma we experience every day is another degree up on the water temperature. We can’t keep training the frog resilience. It is not enough. We need to fix the boiling environment. Resilience is a personal solution. We must design institutional solutions to institutional problems. That’s why holidays aren’t enough. We can’t just leave the room for a bit and hope the elephants will go away. You’ll be back in the room and still face the same elephants.

Screen Shot 2018-05-13 at 5.16.37 PMThe good news is that we can do something about institutional health. But it will take ownership of the problems and courageous leadership towards solutions. We must go from “They change or they die” to “We change or we die.” This is our problem as healthcare community and we need to find practical solutions ourselves. Other institutions are already ahead in this journey and have given us some ideas:

Shanafelt

Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Tait D. Shanafelt, MD, and John H. Noseworthy, MD, CEO. Mayo Clin Proc. 2017;92(1):129-146.

This paper is a must read for all of us, whether or not we are in positions of leadership. It provides multiple practical ways of measuring institutional health and suggests 9 key strategies on tackling this issue. Resilience training is number 8. The rest are aimed at the other elephant. The solutions are absolutely practical. There are measurable goals for any department and institution. I implore you to read this paper thoroughly. Summarising it here will not do justice to the excellent paper that it is. It provides multiple practical metrics on institutional health and practical interventions on improving those metrics. Let me reiterate: it is a must read.

There is already a national framework on the matter of Doctors and Mental Health. The ANZCA has some clear plans. The RACS have made great strides in creating an Action Plan for Cultural Change and Leadership from the top. Various Hospitals and Departments around Australia and New Zealand are on active discussion around this issue. I absolutely believe that there is a momentum already occurring around this issue and that we are close to tipping point. I absolutely believe that.

So what can I do now? What practical things should I do?

Here comes the Action Points and homework. Please think carefully about these 3 Cs and how they apply to you, your department and your hospital.

  1. CORE. Find your core business. What is your meaningful work? One way to combat burnout is to ensure that you are doing enough of work that you find meaningful. One fascinating research done and explained in the same paper is the 20% rule. Evidence suggests that doctors who spend at least 20% of their professional effort focused on the dimension of work they find most meaningful are at dramatically lower risk for burnout (Shanafelt TD, West CP, Sloan JA, et al. Career fit and burnout among academic faculty. Arch Intern Med. 2009;169(10): 990-995). Although each 1% reduction below this threshold increases the risk of burnout, there is a ceiling effect to this benefit at 20% (eg, spending 50% of your time in the most meaningful area is associated with similar rates of burnout as 20%). This suggests that doctors will spend 80% of their time doing what Institutions need them to do provided that they are spending at least 20% of their time in the professional activity that motivates them. This activity could involve caring for specific types of patients (eg, the poor, refugees) or patients with a given health condition (eg, becoming a disease expert) or activities such as patient education, quality improvement work, community outreach, mentorship, teaching students/residents, or leadership/administration. To harness this principle, you must know what that 20% activity is so you can facilitate professional development in that dimension. Find your core and modify your work schedules to meet that.
  2. CHAMPION. Find a champion in your department. You do not have to have a leadership position to be influential in your department. It’s a myth to think that you need to be a unit Leader to make a difference. Find the welfare champions in your unit. Someone who could be the welfare officer to initiate some actions for your department. Someone who could keep an eye on measuring the institutional health of the unit. That person could be you or could be your colleague. Tap them on the shoulder and start coming up with simple creative ideas to improve the health of the team. Use that Shanafelt paper as a discussion primer as they have curated and created a list of measurable evidence based interventions. It doesn’t have to be expensive or extensive. Perhaps, you can one day even formalise the role and have a wellness officer in each unit responsible for these matters. Not a social secretary for beer. A wellness officer to improve the health of the unit.
  3. CULTURE. This is the big one. Cultural change will require a departmental, college and state action. One of the key things in any effective change is leadership buy-in and commitment. We are not just talking about the departmental head, but the CEO or the head of the workforce department. This will require some longer-term plans, but it is absolutely possible and doable. There is already a good momentum and I believe we are almost at tipping point. I can give multiple North American examples of how top down leadership has improved patient care and turned hospitals around but I will quote a local example. The Royal Children’s Hospital Melbourne has started this journey a couple of years ago. They came up with a new Clinician Compact. Several key statements that define the values of the organisation are reiterated, like a pledge. They started at the top to include all clinical and administrative staff. This was their way of tackling an institutional elephant to change culture and to improve the care for every child. The College of Surgeons too, have defined a cultural change campaign with the “Operating with Respect” initiative. We have momentum. We can do this to deal with the institutional health elephant.

Now the elephants in your departments in Melbourne, Auckland or Christchurch are going to look different. With the current momentum that we already have, small changes will make big differences. We can begin with finding our personal Core business and meaningful work to improve our personal job satisfaction and efficacy. We can then find Champions in our departments to improve the unit welfare. We can then in the longer-term effect cultural change with collaboration. Dealing with the institutional health will go a long way in improving mental health. We need to tackle the mental health and institutional health elephants at all levels. Individual mental health treatment approaches, Departmental action plans, Hospital cultural change campaigns, Statewide initiatives, National policies and College level directives. Multifactorial approaches to the elephants.

A proverb says, “One generation plants the trees, another gets the shade.” Seed has been planted. Momentum is already built. Many clinicians have been working in this arena for many years. This generation and the next will get the shade.

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We owe this to our patients. Our patients matter and they deserve mentally & physically healthy doctors and healthy institutions.

Downloadable PDF transcript here: Broken Doctors Broken Systems Transcript. Feel free to use and share it as you see fit for your colleagues and patients.