Every week a new story, article, paper or blog is emerging telling tales of hardship and burnout in the medical profession. Like a cauldron that has been slowly but surely steaming away silently for many years, the lid has now come off and the truth of daily life for many in the NHS is overflowing before us. Doctors have higher rates of addiction and suicide than the general population – a concerning statistic that reveals those who are responsible for caring for others are having difficulty caring for themselves. This is further affirmed by reports of nearly 1 in 2 doctors being burned out and perhaps this is just the tip of the iceberg – doctors are feeling not just burned out but devalued, demotivated, dehumanised, destroyed, flagellated, beaten, bashed, bruised, hurt, exhausted, demoralised, given up, unsafe, unprotected, vulnerable, COMPLETELY WRECKED and perhaps no wonder with all of that, in some cases – suicidal.
In response to this tsunami of discontent and despair in the medical profession, Action for NHS Wellbeing was established in Sept 2013 by Dr Chris Manning and a group of like-hearted healthcare professionals to address these issues and their underlying causes. A web-based forum (Basecamp) was established to share views, articles, papers, blogs and more pertaining to NHS wellbeing. Aims and objectives were established with the fundamental premise that whether we are using or working in the NHS ‘we are all people first and foremost.’ Key objectives include raising awareness amongst policy makers, professionals and the public that high quality care depends on a healthy workforce and ensuring that workforce wellbeing is enabled at both the level of the individual and the system. Quality care will never be delivered unless the staff themselves are cared for, both by themselves, their colleagues and their employers.
This article will cover some of the topics that I have commented on during our Basecamp discussions and are not to be taken as representative of the whole group – as areas of controversy do exist.
Exposing the Rot
In order to heal the NHS and those who work within it, we must first expose the rot, the factors that have contributed to the current cauldron of discontent, dis-ease, dis-affection and dis-harmony. This requires looking at both ‘the system’ which includes not just the NHS but the system of medical training and the medical consciousness along with ‘the personal’ or individual factors that we each bring to the table. What is clear to me is that blaming and /or fixing the system alone is not enough and will not effect a true healing or establish wellbeing in NHS workers. It requires us all to see that we have had a part to play in ‘the way it is’, that we are all to some extent responsible. Accepting we are all responsible, means we can all do something to effect change – we can transform from victims of a harsh, heartless and cruel system to be the agents of change, empowered to play our part in the healing of both ourselves and the NHS.
The current system is toxic, that is clear, and it needs to change. But systems are devised by people and so perhaps the system will only change in a way that is true and for the greater good when people change and begin to have different priorities, which then alters the type of systems they create, what they will accept and not accept. The problem thus far is that the current systems have not made it about people first and foremost – all people.
Money, money, money is the God of many and is the driving force in a system that focuses on targets, costs, savings, time-lines, bureaucracy, red-tape, reputations, political correctness, hierarchy, top-down control and command, numbers and more numbers, quantities and throughput without any consideration given to QUALITY – the quality of care and the quality of wellbeing of the staff who are supposed to deliver that care. The latter in particular has received zero interest – and yet it is fundamental to delivering compassionate care in an environment where those delivering care also feel cared for – by themselves, others and the system.
Medical training, the Medical Consciousness and the Culture of Medicine
Whilst we can all too easily point the finger at the ‘big decision-makers’ for endless rounds of changes, government dictats, ever-increasing bureaucracy, privatisation agendas and destablisation of the NHS (all of which is important and needs to be addressed) we also have to look at our part in the process.
The culture of medicine is toxic and also needs to be exposed. For years the medical profession has enjoyed a certain status in society, we were put up on pedestals and we also put ourselves up there too. We carry the belief that we are somehow ‘different’ or ‘special’ because of the nature of the work that we do. This is reinforced by the GMC stating that medical students are different to other professions and have higher expectations for their behaviour, yet no training is given to enable ordinary human beings achieve these higher expectations – it is just expected! The onus is put onto the medical school to deliver opportunities to learn and practice the standards expected but in reality is this occurring in a way that is truly effective? Thus from the beginning of medical training there is this narrative pervading the medical consciousness that we are ‘different’, ‘special’ even ‘superior’ and have different rules and expectations to the rest of humanity. A sure fire set-up that has us currently falling off those pedestals as we are revealed to be just as human and just as foible as everyone else.
A recent discussion with a group of medical students revealed the types of beliefs that pervade the medical psyche and result in doctors feeling unable to be open about their struggles and difficulties.
Whilst there may be a lip-service agreement that we are all human, in practice there is ‘one rule for the patient and another for the doctor’ and their expectations are indeed high: the doctor has to be infallible, to never make a mistake, to not get ill, especially mental illness or a sexually transmitted disease – or if they do, it cannot be openly dealt with. One said, if you went to a builder and his house was falling down you would choose another builder; ergo a patient does not want a doctor who has been ill/sick/depressed and so forth and thus the doctor needs instead to maintain the appearance that all is well – even if it is a façade. And then we wonder why doctors are addicted, suicidal and mentally ill as they secretly struggle with life and health issues like everyone else but believe they have nowhere to turn?
One of the dominant beliefs that is literally killing our profession and making us sick is that we are somehow different, special or superior to ordinary human beings, with expectations of ourselves that we do not expect of others. We are all people first and foremost and doctors will get sick, mentally ill, have unwanted pregnancies, STDs and misbehave just like other people. As people we can learn how to be more self-caring and to live in a way where these things are less likely, but these skills are not yet part of medical training and until they are, then doctors will be subject to the same ills as everyone else.
If we are to have compassionate doctors tomorrow we must be compassionate with the medical students today. Yet how much of medical training is compassionate? In the transition from first year to final year, the ripe juicy tomato of a medical student bursting with enthusiasm and a desire to make a difference is transformed into a cynical, exhausted and over-worked sundried tomato – sucked dry by the grueling schedules, endless hours of studying and exams.
The system says it’s ok – so long as you get the exam, it doesn’t matter if you are anxious, nervous, depressed, suicidal, drinking too much, eating too much or not enough and so forth – so long as you get the exam. All the focus and attention is placed on the acquisition of knowledge and information without a care for how the person is living and how they are coping. In other words, the mind is given precedence over the body, to the detriment of the latter.
If this is to change then the system needs to make it about people and true self-care needs to be embedded into the medical curriculum – where the wisdom of the body and the heart are taught and not negated as they currently are and are presented by those that don’t just know it, but live it, who walk the talk and don’t just talk the talk in order to provide a true reflection of a lived way that is caring and loving of self and all others equally so. For me, the foundation of this way lived way is based on love, the essence of every human being.
Paracelsus stated that: “The Foundation of Medicine is Love” and
“The art of medicine has its roots in the heart. If your heart is false then also the Doctor in you is false. If it is fair then also the Doctor in you is fair”
“What else is the help of medicine than love?”
Love is currently a taboo word in medicine, seen as unscientific and to be reserved for personal relationships only, in complete ignorance of the fact that love is the ground of our being in which we may move, breathe, live and make daily choices if we so choose or not and is a far cry from the emotional laden, romanticised and sexual notions of love.
If medicine is to progress in a way that is healing and caring for all, then we must reclaim the fact that the foundation of medicine is love, that it is the essence of every human being and that it can be the quality with which we express, perform daily tasks and deliver the art of medicine every day.
In addition to addressing the system factors of which there are many, we also need to look at our own levels of personal responsibility for health and wellbeing and realise there is much that we can do to help ourselves. Yes the systems need to change, but that alone is not enough and there needs to be a concomitant rise in self-awareness and self-responsibility for health and wellbeing. Even within a toxic system there is much that we can do to maintain a good level of health and wellbeing despite the pressures and tensions. It is possible for us to change the way we live so that it supports our bodies to the maximum and we do not get so depleted and drained in the process.
We need to realise we are worth caring for, worth looking after and loving ourselves to the hilt. For we cannot give what we do not have – so how can we give good quality care, if we do not first provide that same level of care to ourselves? Many of us have lived in the illusion that we can provide quality care to others but are just not so good at giving it to ourselves. The altruistic nature of medicine, reinforced by the GMC guidance that the patient should be the doctor’s first concern, all go to reinforce a way of being and living that is detrimental to our own health and wellbeing where we override our own bodily needs, push ourselves too hard, and end up exhausted and drained – putting everyone else first and us last. BUT self-care sits at the heart of care for all and is fundamental to delivering high quality care for all and therefore the doctor must care for him or herself first, such that caring for others just becomes an automatic extension of the lived care they already have for themselves. This means being caring in terms of the foods we eat, the drinks we consume, the quality of sleep we have, how we exercise and our emotional wellbeing. There is much more to self-care than I ever imagined and it is something to which there is no end.
Medical students and medical training prides itself on the level of intelligence required to complete the training. But how intelligent is that intelligence if it produces doctors who are not able to care for their own bodies, where that intelligence is contained? Is there something missing from that intelligence?
What if there are two forms of intelligence – one that we commonly associate with the mind that is based on memory, recall and knowledge acquisition, which thrives on competition but which cares not for the body it is in and can over-ride its many messages – such as the effects of alcohol, smoking or over-working/eating on the body. The second form of intelligence is from the heart and is the lived wisdom of love that listens to and honours the body and cares for self and all others equally so. Someone living from this intelligence could never design an atom bomb or a cruise missile designed to annihilate fellow human beings. It has a unifying impulse that recognises the equality of all and works collaboratively for the greater good of all. It is this form of intelligence that is missing from medicine and medical training today.
Furthermore there is a difference between being empathic and being love. The former as it is currently taught cements the patient in something they are not and is draining to the doctor by taking on emotions, whereas love holds the patient as that love – irrespective of the story that is presented – and enables the doctor to respond in a way that is truly caring and loving, without taking on the emotions and getting depleted and drained. The patient also gets the felt sense that they are more than what they are presenting with; more than the illness and disease, more than the bodily affliction – that there is something greater in them also.
True healing will not be effected by introducing ‘fix-it’ solutions like mindfulness into medical training and the NHS, which is currently one of the buzz-modalities being recommended along with ‘emotional resilience’ training. The latter sounds like a dictat to harden-up, toughen-up and ‘get on with it’ and betrays the highly sensitive nature of every human being. The fact is we get hurt, we take on the suffering of others, the emotions of others and have our own ‘stuff’ and get harmed in the process because we do not know how to handle all that we see and feel in a way that is true. A discipline that gives focus to the mind over the body, to cognition and cognitive processes over bodily feeling will never truly heal or benefit mankind but lead them on a foray away from who they truly are: Love.
People need to know that, as people alone, they are already amazing beings; with no qualifications or degrees needed. If we need two little letters (Dr) in front of our name to feel better about ourselves, then we have not connected with who we are as human beings and we will be at the mercy of the medical consciousness and life as we endeavour to fill up our inner emptiness with degrees, qualifications, achievements, success, awards, cars, holidays, houses and a never-ending list of ‘stuff’. Of course we need those things to do the jobs we do, but they are not who we are nor, should they define who we are. Who we are as people is already far greater and our task is to bring that greatness to what we do, whether we are a nurse, doctor, fireman, policeman, teacher or mum.
What we do is not who we are, they are the roles we play – we are Love first and foremost and it is about bringing and expressing that love in whatever we do. In this way, we can develop a lived quality that is truly caring for self and all others and is not dependent on outer accolades to feel better about ourselves.
There is no quick-fix technique or solution – what is required and what truly heals is a way of living founded on the truth of our being as love, a way of living that is caring in every-day simple tasks, where gentleness, tenderness and kindness are qualities we bring to all our movements, tasks, actions, words and deeds towards ourselves and all others.
This article covers some of the views I have shared with colleagues in discussions on Basecamp. I know there are those who will disagree with them – and that is fine. One of the advantages of Basecamp is having a forum where we can share our different experiences and understandings and at times challenge the status quo and currently perceived ‘way it is’ – for if we do not challenge it and question it then we will never evolve and grow. I have come to understand through my own lived experience that Love is the foundation of medicine and human existence and we ignore its wisdom at our peril – indeed the current maelstrom of discontent and disharmony is perhaps just the reflection of what happens when we do.
© Eunice J Minford