We need to treat junior doctors better

We see so many stories in the news about this and compassion fatigue settles in. But you only have to look left and right to understand how many people struggle with working in the health care system today. And it’s not just junior doctors. It’s seniors, nurses, paramedics, and all the other hard workers in this amazing service that saves lives and keeps all of us healthy.

But the sad reality is that it takes time to fix underfunded systems, to change cultures and to maintain humanity in large organisations. The truth is that it’s up to all of us. And it starts with kindness.

Be kind to yourself. You are doing an amazing job. Don’t lose perspective of that. The stress and expectations are as much or more than they ever were. Don’t underestimate how well you are doing. Raising a family while doing all this? You’re fucking awesome!

Be kind to others. It’s easy to be drawn into the negativity that can pervade our work places. Bringing others down by gossiping and criticising those we work with harms ourselves as much as it does them. There are a million reasons to praise each other every single day and we don’t do it enough.

Be realistic. In expectations of yourself and those around you. Change in healthcare shifts at a glacial pace, so consider your career decisions carefully. There’s unlikely to be a substantial increase in healthcare funding anytime soon, the population is becoming more unhealthy and patient expectations are at an all time high. Choose your path wisely.

If we work together and start with kindness, we can make a difference to the system that we work in. Feed the fire in yourself and those you work with.

Feed the fire: a challenge to all doctors

The ills of the medical profession are well documented: we are prone to burnout, anxiety and depression; suicide is twice as common in doctors as compared to the general population. We aren't very good at talking about our emotional problems, not very good at decompressing or comfortable revealing what we feel may be perceived as a weakness.

Other factors contributing to burnout are a loss of control in daily work life, more and more to fit into the same work hours and greater knowledge than ever to incorporate into practice. Junior doctors are subjected to changes in rosters, pressure to complete seemingly pointless mandatory competencies and training pressures with sometimes a bleak outlook for career prospects. Work pressures lead to less social interaction with colleagues and fewer relationships in our home life. 
 

Where is the solution?

Doctors understandably look to the hospitals and management to provide support and bring change to the workplace culture that seems to be responsible for this situation. Some of these are absolutely organisational issues and there needs to be work by medical and non-medical managers to address them directly.

But, I put a challenge out there to all of us as a profession - from Intern to Consultant: What are YOU and I doing about it?

Contrast the fresh-faced medical student or new intern on their first day of the job, compared to the PGY 6 medical registrar or consultant running a 1:2 service. That first day we started work, holding the shiny badge that finally labeled us ‘Doctor’, did we not have a fire inside our belly that was insatiable. We knew exactly why we were there and what we had to do - or at least we were driven to find out. Our fire is what motivates us to come to work every day, it inspires us to grow, to invest deeply in what we do and the teams around us, it helps us create meaningful therapeutic relationships with our patients.

And then came the long hours, the shame culture of medicine, the loss of autonomy, unreasonable patient expectations, the bureaucratisation of our daily work, electronic medical records, personal debt and the social exclusion. Unsurprisingly, for many that fire inside is now but a smouldering ember. 

We spend our career focusing on education, research, acquiring clinical skills and post graduate qualifications. A good senior, a good peer is someone who helps in one of these areas. But who takes care of the fire inside? This internal quality, the unnamed essence of our WHY needs just as much support and nourishment as our intellectual development receives. Yet we neglect it, assuming that the smothering of the fire is an inevitable consequence of modern medicine. And this is where our responsibility to ourselves and each other lies.

We need to give attention to the fire in ourselves and our colleagues. The same actions that feed the fire, provide a shield of resilience around it. They make the daily work pressures manageable and protect us from burnout (now you know why it's called that!). We will still be busy, but how we are with ourselves, each other and our patients is fundamentally maintained.
 

How do we do this?

Image: France Corbel, with permission.

1. Praise the good. When did you last have someone go out of their way to tell you how good a job you did at work? Forget the feedback sandwich: we need to actively seek out the positive to praise in peers, those more junior to us, including medical students and the wider healthcare team around us. On our radar, every single day. When so much of what we hear is negative, how good does it feel when someone acknowledges your hard work with a compliment? You can feed the fire of the team around you through recognition of a job well done. The more genuine and specific the feedback can be, the better. And the positivity will make you feel good too.
    
2. Self-care. You know about this - taking time out for recharge. We tend to think of resilience looking like a boxer in the ring, broken yet fighting through one more round. In fact, resilience is about working hard, taking dedicated time out for rest, and then working hard again. Rest periods mean both within a busy day and time off using recreation leave allowances each year. Your work is never ending, taking time out for lunch away from the workplace will re-engergise you for a more effective afternoon than had you just worked through or eaten lunch at your desk. Exercise, diet, meditation, rest and social support networks outside of work are the cornerstones of self-care.
    
3. Reflection. Take some time to reflect on the good that you do each day. A journal can be powerful for this, and journaling has other benefits related to problem solving and well being. Each day write down the positive that happened, how you helped people, your successes. When I was a registrar, I had a folder of ‘Thank you’ cards that patients had given me. After a stressful event or when my confidence had taken a hit, I would read through the cards to remind me of the good that I do, of the positive effect I have on people’s lives.
    
4. Compassion and kindness. It sounds simple and corny but sustained kindness and compassion in the care we deliver, along with the mentoring of compassionate care and values-based practice is imperative for doctors to grow into lifelong happy, resilient practitioners. Be willing to call out bullying and harassment when you see it. If you are junior and aren’t able to directly address it, then tell someone who can. 
    
5. Team-building and social events. The time we spend together when we aren’t under the pump gives us the unity and trust to take the knocks together, look after each other and work together effectively as a team. How this looks in practice can vary, from team coffees before clinic, lunch together or drinks after work or in the evening.
    
6. Mentoring. You need a mentor. Someone who you can open up to, talk about your first death on the ward, the kid that died in ED after you worked on her for 2 hours and your fears about whether you can cope with the next rotation. Emotional support comes in many forms and a mentor can be important for more than just career advice. For senior doctors, being a mentor will help you realise how much your experience is valued; there is little that is more rewarding in this life, than being an inspiration to others.
    
7. Support each other. When your work is done, do you look to help your colleagues? Can you make your night registrar’s evening easier, ensure the script rewrites and discharge summaries are done by 5pm Friday to help the weekend team or lend a hand when your work is done and the clinic is still going? These are the small sacrifices and compassionate support that helps all of us feel better about our hard working day.
    
8. Gratitude. Research strongly correlates gratitude and individual wellbeing and happiness. An attitude of gratitude can be applied to the past by re-living positive memories and in the present by not taking our own good fortune for granted - we need only look to our patients to see how fortunate we are. Gratitude helps us maintain an optimistic and hopeful attitude for the future.
   
   Gratitude can be cultivated by writing a thank you note of appreciation to someone who has had a positive effect on your life. It can be a brief daily journal entry, where you explicitly reflect on and write down the good things that happened to you and what you are grateful for. Gratitude may be cultivated through prayer if that is important in your life.
    
9. Re-write the shame tapes. Brené Brown is a social sciences researcher who has extensively studied shame and vulnerability and her research is very relevant to the culture in medicine. Shame tapes are the messages of self-doubt and criticism: ‘If I was a good doctor, I would have got that arterial line in.’ ‘I’m never going to make it as a consultant.’, ‘I’m not good enough. I’m a fraud.’
   
   Brown defines shame as ‘An intensely painful feeling or experience of believing that we are flawed and therefore unworthy of love and belonging. A fear of disconnection.’
   
   Shame is the difference between:
   
        ‘I made a mistake’ or ‘I had a complication’
        and
        ‘I am a bad doctor’  ‘I am such an idiot’  ‘I am a failure’
   
   To tackle the shame culture of medicine, when something bad happens:
    

   Reach out to someone you trust, someone who cares for you. Share the experience.

   Be kind to yourself and speak in the way that you would to reassure someone you care for: ‘You are OK, you're human. We all make mistakes.’ We would never speak to someone the way we speak to ourselves during a full on shame attack.

   Own it - you get to write the ending. You might have made a mistake or had a surgical complication or missed a diagnosis. Admission, acknowledgment and attention to growth from the event is highly correlated with a positive result next time. The alternative is to protect ourselves by blaming someone else, rationalising it away or internalising the feelings. This path leads to negative outcomes like depression, addiction and bullying.

10. Be vulnerable. When the consultant surgeon speaks to his team about the time that he screwed up or the complication that he had, he lets down the shield that guards his vulnerability. Not only do others learn from the clinical story, but they feel validated in their own areas of perceived weakness. As Brené Brown discovered in her research: 'Vulnerability is the last thing I want you to see in me, but it’s the first thing I look for in you.' We all have shields to protect our vulnerabilities, but in truth we can only live a wholehearted life and positively influence those around when we let down our shields without fear of vulnerability.

We need to feed the fire inside ourselves and each other. We have to write this into the medical curriculum, talk about it with our teams, teach the medical students and bring the actions to our work every day. Then we will have truly done our part in addressing the dark side of modern medicine.

Danny Tucker

Patient complaints, adverse outcomes and litigation

Unfortunately, you don’t have to be a doctor for very long to be involved in a patient complaint. It happens to every one of us and it can be a cause of great stress and self-doubt when a patient is unhappy with the care we have given.

Here I want to outline the most common cause of patient complaints and secondly how we resolve them so that everyone can move on positively. I’ll also touch on how adverse outcomes might be investigated and dealt with.
 

Clinician support

When you are in the midst of an adverse patient outcome or complaint, it can be difficult to see that it is rarely about you as doctor, or individual. None of us come to work with the intention of making people upset or causing harm. When it happens, I can't emphasise enough the importance of a supportive mentor or senior colleague to help keep things in perspective and guide you through the process. How we deal with complaints and adverse events is intended to be aligned with strong support for our staff; this is not a witch-hunt or a punitive process.

If you don't feel your immediate senior is being supportive or offering the help you need to negotiate this, find someone who can help you get access to the assistance you need. If you are a junior doctor, then it might be your College training supervisor if you are on a specialist pathway. The Director of Clinical Training is another resource for anyone who isn't sure where to turn for help. 
 

Why patients complain

The most common cause of patient complaints are:

1. Treatment - 35%
2. Communication - 22%
3. Access to services - 15%
4. Issues with the hospital environment - 13%
5. Medication - 5%

Treatment complaints are usually about perceived inadequate, incorrect or poorly coordinated treatment. Poor staff attitude or communication skills are a consistent complaint that occurs across all areas of the hospital. Patients not only expect to get the right care at the right time, they expect staff who take care of them to be kind, empathic, open and honest – qualities that we would all look for in professionals caring for ourselves or our own family.

Access complaints relate to waiting times and service availability. The single most common issue with the hospital environment is about car parking and medication complaints relate to prescription errors, dispensing and drug administration on the ward.

Adverse outcomes

Healthcare will always have adverse outcomes – we can never remove the risk completely. In practice, half of these are not preventable and very few are due to negligence.

The aviation industry has reduced avoidable errors, by:

1. Expecting human error
2. Challenging the blame & shame culture
3. Identify the ultimate cause of errors to prevent recurrence
4. Normalise respectful assertiveness among staff
5. Hold people accountable for non-compliance with policy, not for errors
6. Openly share, analyse and learn from incidents and near misses

Many of these are appropriate to health care and have been adopted into our risk management processes.

Immediate response

Once you know someone has had an adverse outcome or is unhappy with an aspect of their care, there is often an opportunity for front-line doctors to ‘nip it in the bud’ and resolve the patient dissatisfaction.

There is a natural tendency to not want to be around people who are unhappy, especially if we have been involved in what might have been the cause of their pain – such as a complication of our care.

It is important to know that this is the time your patient needs you to be there. When an adverse event occurs, we need to increase the attention they receive. Firstly, to ensure that care from here onwards is optimal and secondly, so they know that you acknowledge what has happened.

This isn’t easy, but it’s good medicine and will result in fewer formal complaints and litigation. Always involve seniors if you have a sense that someone is unhappy and document everything well. Litigation is fortunately rare, but defending yourself is much easier when you have documented your practice and any steps to remedy the situation.

If your patient has any degree of cognitive impairment, is elderly or has heavy family involvement, help your team arrange a family meeting to ensure everyone understands what has happened and what is being done from here. They can nominate a representative to receive regular updates on progress. Beware the unhappy daughter!

It’s important to enter adverse events into the local risk management database, e.g. RiskMan or PRIME. This will allow the clinical governance team of the hospital to seek patterns of adverse outcomes with an underlying cause that might not be obvious to individual teams. It will also ensure that the appropriate response is made and staff are supported.

Team debrief

Where a major event has taken place, teams should come together for debriefing. This should be facilitated by a senior clinician, and is about running through what happened, people’s experiences since the event, emotional and personal responses they may wish to share and have acknowledged. The initial debrief isn’t about an investigation or chain of events – it’s about supporting staff and making sure they have access to the resources they need. 

What next?

When formal complaints occur, the department Director will go through the following:

1. If it can be solved quickly with a telephone call and immediate rectification, that is often the easiest way forward – e.g. complaints about waiting list or if the patient is seeking a second clinical opinion.
2. Where possible, we contact the patient as soon as possible so they know it is being dealt with. Even if it’s something complex that will eventually be a face-to-face discussion, the sooner the patient is contacted, understands that it is being looked into and given an idea of a time line, the better. This can also give us a chance to understand which area of the complaint is particularly important to the patient and what they’re actually looking for (acknowledgment, apology, rectification, compensation, legal redress, etc.). You cannot over-communicate when dealing with a complainant and often a swift initial contact defuses anger.
3. Understand what happened: review the case notes. Talk with, and support, those involved to consider whether the complaint has highlighted an area where we might consider changing practice to prevent recurrence. Is the complaint unreasonable or does the complainant have unrealistic expectations?
4. Decide on how to proceed. Is a telephone call/explanation enough? Should the patient come back to see their clinical team to resolve misunderstanding? Is this a clinical incident that needs entry into RiskMan/PRIME reporting system? Do we need to do an Open Disclosure and if so, who needs to be there?
5. Written response or face-to-face? A written response is often appropriate, but for complex cases, a letter cannot convey the nuances of judgments that were made without being long and cumbersome. In these situations, a face-to-face debrief is better. Often this involves both medical and nursing teams.

Some people want a letter in response to their complaint: see this post for full details of an approach to this.

A face-to-face meeting after a complaint might be a conversation to hear their complaint and to outline how the we are going to respond to the issues they have brought up.

Formal Open Disclosure is a framework that describes how clinicians communicate with and support patients, families and carers, who have experienced actual harm during health care. The 8 guiding principles of OD are as follows:

1. Open and timely communication
2. Acknowledgement that an adverse event has occurred
3. Apology or expression of regret
4. Supporting, and meeting the needs and expectations of patients, their family and carers
5. Supporting, and meeting the needs and expectations of those providing health care
6. Integrated clinical risk management and systems improvement
7. Good governance – system accountability at a senior level to ensure appropriate changes are implemented.
8. Confidentiality

Litigation

Litigation is a stressful occurrence for all involved. It is hard on health care staff and locks patients and their family in the angry phase of a grief reaction. Why do they do it? The reasons aren’t as simple as the obvious answer of ‘for the money’. They do it:

• To find out what happened and why. It can be a sign that they aren’t getting their concerns addressed elsewhere.
• Acknowledgement, acceptance of responsibility and an apology
• To enforce accountability
• To correct deficient standards of care
• Financial compensation – for accrued and future costs

There is good evidence that high quality communication with our patients from the outset – including formal open disclosure if appropriate – will reduce the risk of litigation.

Hospital investigation process

Briefly, adverse events that are entered into a risk management system are allocated a Severity Assessment Code or Incident Severity Rating (SAC/ISR 1-3). Minor adverse events will be investigated and dealt with by the department Director or Nurse Unit Manager through clinical review and actioned as above. More serious adverse events are formally investigated by clinicians and Patient Safety teams that use formal review processes such as Root Cause Analysis (RCA). This is a non-punitive way to assess if there are any system issues responsible, and how similar events can be avoided in the future.

So what can I do to avoid all this?

How do we as individual doctors reduce the risk of patient complaints and adverse outcomes? Going back to the list of reasons that I started with:

1.  Provide high quality care: involve the right doctors (and the correct seniority), consider the appropriate differentials, refer to other teams as needed, order the indicated tests, follow up the results and ensure they are acted upon. Attention to detail. Communicate well with GP’s.

2.  High quality communication skills and emapthy – patients are looking for your humanity, a genuine connection that shows they are more than a hospital number, test result or the NSTEMI in bed 14. Put simply, treat them how you would like yourself or your mother or sister to be treated. As an individual with individual concerns to be addressed. The health care environment is often a disempowering or even frightening place for people - help them navigate it with compassion.

3.  Facilitate the access to the services they need. It can be challenging to look at the bigger picture of a complex patient’s health needs in a system that's organised around organ-based specialisation. Acknowledge this and try to take it into account when planning your patient’s care.

Finally, some health care challenges seem to be absolutely insurmountable. Could anyone possibly fix the problem of car parking?

Danny Tucker

Shake your patient's hand and embrace the power of touch

I always enjoy posts from Psychology Today. This one is ‘What can you learn from a handshake?’ Medical students I've taught will know the importance I put on shaking your patient’s hand when you first meet them. I’m a believer in the power of touch for creating strong relationships between people, as well as a therapeutic tool in medicine on a number of levels.

Touch has been shown to be linked to interesting outcomes in non-medical situations. In psychological experiments, a light touch on the arm when asking people in the street to complete a questionnaire led to compliance rising from 40–70% (1). A second touch during the interaction led to even higher compliance. When an experimenter asked for help picking up an object they dropped, a light touch on the arm led to assistance going from 63% to 90% (2). People were more likely to be honest about money found in a public street when questioning was accompanied by a light touch on the arm (3) and waiting staff in restaurants will receive better tips if they touch diners when returning their change (4).

It was the touch of percussion documented by Leopold Auenbrugger (5) in the late 1700's, that moved medicine beyond the barber surgeons offering empirical treatments of blood letting, cupping, purging or gruesome surgery. Shortly afterwards, the stethescope was discovered by René Laennec in Paris and suddenly the barber surgeon gave way to a physician, making use of his skills of diagnostic touch.

As doctors, I think we are guilty of gradually eroding the amount of touch we offer our patients, especially as diagnostic technology seems to offer more accurate alternatives. If we are not careful, the attention to our ‘e-patient’ on the typed hand-over sheet, ward flow software, in lab results and MRI scans is going to replace the important diagnostic and therapeutic tool we all learned in medical school. Clinical exam is a ritual of exceeding importance, where you will discover pathology often more quickly than through CT or ultrasound. Avoiding a thorough examination also compromises the patient-physician relationship, which we know underpins our treatment.

The handshake provides this first connection with our patient, marking the beginning of that relationship; a contract of trust, accompanied by eye contact and a genuine greeting. The quality of the handshake tells each party something about the other. During the course of the history, when the patient relates the details of her illness or a life experience, the doctor’s hand on her arm or shoulder during a moment of distress demonstrates to her, that her physician empathises and is there to support her.

Keep touching your patients, shake their hand when you meet them. And make it a firm one.

1. http://link.springer.com/article/10.1007%2FBF00987054
2. http://www.ncbi.nlm.nih.gov/pubmed/14658752
3. http://www.sciencedirect.com/science/article/pii/0022103177900440
4. http://psp.sagepub.com/content/10/4/512
5. http://en.wikipedia.org/wiki/Leopold_Auenbrugger

Danny Tucker

Resilience for doctors

Doctors are resilient. Let's face it, you wouldn't have got this far if you weren't. Medical school and medical practice is grueling and we all have more than our careers to deal with. Discussions around individual resilience should not infer that the main of the issues around doctor wellbeing today is to be put back on doctors. Health care organisations must address their contribution to the issues that are faced in modern medicine. That means reasonable work hours and intensity, supportive education and mentorship programs, strong leadership and - importantly - senior as well as junior doctors taking care of the fire that burns inside of all of us.

However, understanding resilience and how to cope with the challenges that medical life presents us cannot be ignored. We all have to learn and grow.

What does resilience mean to you? When I first started thinking about this, it was a clear example of medical ‘anti-resilience’ that grabbed my eye. The satirical GomerBlog always tips the fine line between intellectual irony and uncomfortable truth. And their article ‘Optimistic, Bright-Eyed Med Students Eager to Transform into Jaded, Burnt-Out Physicians’ was spot on.

"Everyone looks forward to real-world medicine slowly 'breaking the souls' of those 'unsuspecting, foolish med students' and reminding them that the 'system is broke beyond repair' and that becoming a doctor 'was a huge mistake'.”

They eagerly wait for these aspiring medical students to spread their wondrous wings… and then crash and burn into a fiery, molten, but gorgeous mess of debt, despair, and regret.

“There’s nothing I want more than to become the worst version of myself that is humanly possible,” added Joseph.  “Isn’t that what we all want for ourselves anyway?”

So what of resilience, and how can we avoid becoming that fiery, molten mess?

The term resilience is borrowed from the language of physics - the ability of a material to suffer stress or external pressure and to return to its original state, without becoming deformed once the stressor is removed. In psychology terms it refers to an individual’s capacity to resist adversity without developing physical, psychological or social disabilities.

It is widely recognised that excessive stress and burnout particularly affects doctors early in their career. Senior clinicians have usually developed resilience strategies to deal with the aspects of our work that cause the most anxiety. These stressful events include challenges such as high intensity workload, excessive bureaucracy, resource constraints, high patient expectations and complex ethical or moral issues. Proximity to death and repeated exposure to morally challenging situations can be a cause of distress if not managed actively.

Like palm trees, resilient individuals face adversity without permanent injury

Being resilient however isn’t about being indestructible - it's simply the capacity to deal with life events, to see problems as opportunities for personal growth, to recognise individual and collective resources and to continue to act ethically and responsibly. Strategies for maintaining resilience include self-reflection, creativity, humour and optimism.

Essentially, resilient individuals are able to recognise that they can have a positive impact on a situation, that some components of the ‘system’ can be controlled or influenced by one’s actions and that persistent effort is worthwhile. They also acknowledge that set-backs are inevitable and surmountable and do not need to cause excessive anxiety or withdrawal.

Dimensions of resilience established from published literature include self-control, self-efficacy, ability to engage support and help, learning from difficulties, and persistence despite blocks to progress (Howe A et al. 2012).

Considering the above dimensions and overall aims, I believe that to become resilient clinicians, we need to focus on 4 main areas of our lives:

1. Self care and social support
2. Reflective practice
3. Professional support and debrief
4. Personal growth
    

1. Self care and social support

A recent HBR article made the point: we often take a militaristic or ‘tough’ approach to resilience and grit - thinking of a marine slogging through the mud or boxer going one more round. But persistent effort doesn’t build resilience. One of the keys to resilience is trying really hard, pausing for a period of recovery and then trying again. Self-care encompasses a range of practices both during our working day and between work periods. If you want to build resilience, you need adequate internal and external recovery periods. Internal recovery is short periods of relaxation or time out of the day when you approach mental or physical exhaustion. External recovery is the time you make for rest between shifts and on recreation leave.

Where possible take time during the day to step away from the stress of your workload, have lunch with your friends, not while you do the discharge summaries or review results. Make sure you take all of your annual leave each year, and use the time to genuinely recover and build strength. Social support during both these periods is important and making time for creativity and non-medical activities that you enjoy will recharge you for your working week. Attention to diet and regular exercise is part of self-care. 

Switching off can be difficult and if you just change your attention to political commentary or arguing with people on the internet, then your brain isn’t getting the rest it needs. We've all been in the situation where we lie in bed, unable to fall asleep thinking about the stresses of the day, finally waking the next morning completely exhausted. Rest is not the same as recovery. One of the most rewarding investments to relaxation & recovery is to practice mindfulness meditation. Just 10 minutes can quieten the chattering monkeys and reset arousal levels down several notches. Start with the mobile app Headspace. 
 

2. Reflective practice

This isn't something doctors are generally very good at. Medical schools have introduced the concept into their curricula, but in postgraduate medicine it has failed to become established as a daily routine. Most of us do some type of reflective practice without necessarily labelling it as such. We learn through trial, success or failure, internal reflection on what worked or didn’t, and then consideration of how to do things better next time. Most medical Colleges have a reflective practice tool that is based around the 'What?, So what?, Now What?' model (RACP, RANZCOG examples & templates here). This is a semi-formal approach that encourages doctors to spend a brief amount of time each week reflecting upon what went well at work, why that might have been and how challenges might be overcome in the future.

The reflection should include not only task-orientated or medical skills, but also the domains of team working, relationship management and learning style. This lends itself well to the use of a journal to record the activity and this can be held on a mobile or desktop device - preferably one that syncs. Example apps for this include Evernote and Day One. There is good evidence that regular journaling brings positive benefits. Even if you don't use a template, simply write down one or two things that went well each day and reflect on your motivations for being a doctor. Very quickly you will realise just how much you are able to positively influence the lives of others, and ultimately draw on that perspective to help you withstand the challenges that inevitably come your way.
 

3. Professional support and debrief

It is critical for doctors to receive feedback on performance and development. We need to understand where we are succeeding and where to direct our efforts for improvement. Junior doctors change work teams frequently and this is a serious barrier to quality feedback. It is important to have both short and long-term mentors to support you. If you are on a 10-week rotation, hopefully by week 2 you will know who can support you and give constructive feedback. Set up a regular meeting, even if it’s over coffee once a week or fortnight. Talk through current challenges and review how your work is going.

When ethical, moral or emotional challenges occur, talk them through with your colleagues and mentors. Sense-making conversations about these ’soft’ issues are an important way to avoid the build up of emotional stress. Medicine is full of situations where ethical norms are challenged and we all need to work through them. Where many members of a team are involved, ask seniors to facilitate a multidisciplinary team debrief.
 

4. Personal growth

It’s easy to fall into the trap of believing that medicine has all the answers. We've all been on a similar conveyor belt of medical training for many years. When we look outside our profession or immediate area of expertise, the change can be refreshing. We all own mental models - a prism through which we view and make sense of the world. Don’t get too attached to what you believe to be true - more often than not a new perspective can bring rewards, both personally and professionally. 

For me the areas of personal growth that are important include self-reflection, understanding and strengthening emotional intelligence and competencies in the area of writing, leadership and mentoring. My current wider reading includes books and blogs of Scott Young, Cal Newport (my review of his latest book), Brené Brown (videos: the power of vulnerability, shame and latest book), Harvard Business Review and books and writings from The School of Life. When I come across articles that are of interest I export them on my mobile directly to an Evernote folder for later review. Here’s my current Personal Development Inbox. Make a start on your own wider reading in areas of personal growth that are important to you and you’ll find it helps at work too.
 

Supporting others

As doctors, every one of us is in a position of leadership. Even if we don’t have immediate ‘reports’, we mentor medical students, we take the lead in relationships with our patients and we have leadership roles in multidisciplinary teams in theatre, on the ward and in other areas of our practice. How are you helping nurture resilience in those around you? We need to work on our own, teach those around us and bring resilience into our workplaces to build heathy teams.

Danny Tucker

Dealing with difficult feedback

Usually, when we receive feedback at work, it's helpful and presented in a positive, constructive way. But sometimes we don't like what we hear...

In an ideal world all supervisors would give feedback rationally and from a place of nurturing. Unfortunately, not all doctors are well versed in the best way to provide feedback, so occasionally it might come across as more harsh than was intended.

You can’t control the content or the delivery of feedback you receive, but you can control your own response. And by doing this, you can make the most of appraisals and reduce the chance of conflict too.

So what does this mean in practice?

1. Rein in your emotions. When we’re on the receiving end of disheartening criticism, our natural reactions can range from disappointment to rage. We might feel that our character has been called into question or that it’s about us as a person. It isn’t – it is about performance over the last few weeks or months. Take a second or two to breathe deeply and avoid that first reaction, which you will likely regret. Control your fight or flight response.
    
2. Remember the benefit of feedback to your development. And your supervisors intentions – even if the way in which it’s delivered isn’t ideal. Accurate and constructive feedback can still come from flawed sources.
    
3. Listen for understanding. Having controlled your initial emotions, you can now be open to hear what is being offered. Allow them to say all they have to without interruption and attempts at responding along the way. Quieten your monkey mind and genuinely listen – rather than internally formulating your response.
    
4. Say thank you. OK, this can be hard! It is actually difficult being on the giving end of feedback too, so look your supervisor in the eyes and be deliberate. ‘I really appreciate the time you’ve taken to talk with me about this.’
    
5. Summarise and deconstruct. Now you are in a position to summarise what they have said to demonstrate that you’ve listened – and to clarify for yourself. Ask questions to understand exactly what they feel needs improving. Was this a one-off issue or has it occurred more than once? Ask them to break down broad feedback (‘you’re lazy’) into specifics that can be addressed (ward round jobs are taking too long, and you’re often late to clinic). Seek specific solutions to address the problems that have been identified.
    
6. Explain your perspective. You might not need to respond if you accept what has been suggested without need for explanation. But when you do, it shouldn’t be a counter-attack so avoid being defensive! If you’re criticised for not doing your discharge summaries on time and there are external impediments to this happening that are beyond your control, explain what they are and ask your boss to help find a way to overcome them.
    
7. Agree an action plan. Before you leave, agree together what this might look like – and if necessary, arrange a follow up meeting out of the feedback session to work on the issues that have been identified. Supervisors are there to help you find solutions not just for feedback, so be sure to hold them to that. And hold yourself accountable too – set a timeline so you have something to work to.

Constructive criticism is the only way we can learn about our weaknesses and improve. If we’re accepting and gracious rather than defensive, our personal and professional development will benefit. Every consultant, manager and Director has an annual performance appraisal too, so you’re not alone. And they're not going to go away!

Danny Tucker

Suicide and the medical profession

An article was published this weekend in the Sydney Morning Herald by an anonymous Sydney junior doctor who told of 3 medical colleagues who have committed suicide. The doctor describes the situation of unaddressed mental health issues affecting doctors as medicine’s 'dark secret'. Various international, national and Queensland-based research has examined doctor suicide rates in comparison to the general population, confirming that medical professionals - especially female doctors - are at higher risk. And work-related problems are most commonly associated.

The Beyond Blue National Mental Health Survey of 14,000 doctors and medical students found that although levels of mental distress was high, a large proportion of those affected do seek and receive help, and for them the subsequent impact of stress on work and home life was relatively modest. So seeking help does work.

The transition period as Interns from study to work is recognised as a particularly stressful time, and is associated with more distress and burnout than later career life. Unfortunately, stigmatism persists with 40% of those surveyed believing that individuals affected by mental health issues were perceived to be less competent.

So what does this mean for junior and senior doctors?

1. We must acknowledge that this is not just about doctors currently on the brink of contemplating suicide - we need to work on support structures so that it doesn’t reach that point, and help everyone deal with workplace pressures.
    
2. Hospitals need to address environments that place unreasonable stress on all staff.
    
3. Despite having highly stressful jobs and heavy workloads, doctors are resilient - we need to build on this resilience, talk about what exactly this looks like on a day-to-day basis. This conversation needs to include both junior doctors and their supervisors. I will write more about medical resilience soon.
    
4. Recognise that we all own this. Hospital managers and medical administrators can only do so much about workplace culture. How we speak and deal with each other, how we support one another and make time for our own self-care is so very important.
    
5. Know that you are not alone. There are ways to reach help and we need to encourage our colleagues to access them. If they don't know who to reach out to, then we need to help them talk to a friend, mentor or trusted supervisor who can assist. Be that person who makes a difference in someone else's life.
    
6. Medical leadership teams at hospitals throughout the country need to be talking about these issues and working out how they can bring about genuine change.
    

Today I wrote to our Interns about these issues - together we as a profession need to find a way to move the culture in medicine to something more wholesome and compassionate.

Danny Tucker

If you need urgent help:
Lifeline: 131 114
MensLine: 1300 789 978
beyondblue: 1300 22 4636

Discuss...

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