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.


  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/