Professional Relations

For those of you who are regular readers you might think that Surviving Work is hardly cut out to co-author a book with two psychiatrists about solidarity in the professional medical classes.  The question of why I thought this was my business, is one I’ve been wrestling with during this summer of social crisis spent in the NHS as my ol’ dad attempted to have major heart surgery. After five cancellations during the heatwave as my little family fell into a deep existential pit my faith in my ability to nurture humanity in healthcare settings hit an all time low. At some point in late July I started to carry a small pillow around into which I could scream after consultations with medically trained staff who neither had the power nor the intention to help my dad. Despite the compassion of the handful of middle aged nurses and young non-clinical staff holding the entire system together, it felt like I’d finally understood that although you can still get treatment in the NHS, actual care has died out. Subject to profound moments of despair wheeling both of my parents along hospital corridors I did have a sad thought that sometimes it would be better just not to care about the state of the people working in healthcare. The work of building relationships at work is never straight forward and this is particularly true for the professional classes. But that’s a long way from giving up on whole groups of workers just because its difficult to find a basis for friendship. Firstly it is very possible to find working class and politically sophisticated psychiatrists with whom to write a book. And it’s equally possible for a very left wing female academic with anti-psychiatry tendencies and a deep suspicion of the medicalisation of social crisis, to learn how to be a better organiser by learning the language and issues of a specific group of workers like doctors. Its an actual fact that a lot of the ideological and class wars we’re fighting at work can get worked through by working together on something that is meaningful and worthwhile.  One of the things about surviving work that is the hardest to learn is how to build relationships with people who are not like you. By that I actually mean any relationship you’re ever likely to have at work. There are some professional categories that seem on the surface to offer a rather barren basis for relationships and as the systems of healthcare are consistently downgraded and de-humanised its easy to just give up on the NHS and have a rant. Far from the idealisations of doctors dished out with almost touching generosity by my father’s generation, right now it’s easy not to like them much at all. One of the great paradoxes of working in the caring professions is that in the current climate many clinicians find it difficult to show the level of care they have for their patients towards themselves. Bluntly, many of them aren’t that well or cared for. Attending to well-being factors, reducing risks and protecting ourselves through activities to deal with stress and maintain physical and mental health are all important. Ultimately, however, protecting yourself at work rests on building supportive relationships. One of the proposals of this book is that the key protective factor for doctors who are not sick is their ability to form relations with the people around them, for both psychological and organisational reasons. Psychologically, we know that being able to talk about how we feel and our experiences at work with people we trust is crucial to managing stress at work. Whether this is done through a chat over lunch or a BMA training course, we know that finding support from colleagues is key. Organisationally, the ability to talk openly with colleagues is often underestimated. Firstly, the ability to raise questions and concerns with colleagues is essential for patient safety, something that is underlined repeatedly in the health management literature. When doctors are not able to communicate with other staff members, patient care and safety can be put at risk. Secondly, most people are not able to create meaningful changes in their working conditions on their own. It is almost always through raising issues with colleagues, both formally and informally, that organisational problems can be looked at rather than buried or denied. One of the difficulties of talking about doctors’ mental health is how to manage the tension between the defences needed to work with patients and being realistic about the mental health problems that doctors are vulnerable to. For many doctors there is a profound nervousness in acknowledging vulnerability and mental health problems, and in many cases they will be unaware that they are living with mental illness. This reluctance is actively encouraged by the demands for certainty, treatment and targets now expected of doctors. There is no room within this system for the clinician to be unsure, make mistakes or underperform.  There is a growing acceptance that one of the occupational risks for doctors is how to maintain a balance between having a strong ego and sense of their own capacities and the specific need for doctors to have a sense of their own limits and need for care. Putting it bluntly, many people driven by vocation, with high intellectual and educational achievements, can become unrealistic about the natural limits we all operate under. There is inevitably a fine line between having a strong ego and creating a ‘super-ego’ that makes punishing demands on the clinician to work heroically under unsustainable conditions.  Although having a strong sense of your capacities is necessary, when this version of the self goes unchecked, it can easily lead to unrealistic expectations and ‘omnipotent’ fantasies about what can be achieved at work. This ‘superhero’ tendency places unsustainable demands on the clinician and results in experiences of shame for those doctors who are not able to cope. This shame is a major block in doctors finding help and addressing problems before they develop into long-term problems such as burnout or serious mental illness. Additionally, doctors who are unrealistic about their own health can become emotionally defended as a way of protecting themselves from psychological stress. Exposure to distress is inevitably part of the job; but when clinicians’ coping strategies result in them becoming cut off from their own feelings, they inevitably become cut off from their patients, as well as undermining self-care. In order to provide good care, you have to care about both your patient and yourself. The reality is that communication between clinicians, especially across disciplines is crucial to good patient care. The research, much of it carried out following the Mid-Staffs scandal, indicates that when we retreat into occupational silos and stop communicating within our teams, more clinical mistakes will happen. For people trained to build relationships with their patients, there is something paradoxically hard for many doctors about building relationships at work. This is in part due to the highly competitive nature of the training – encouraging often highly individualistic and self-sufficient ways of functioning and a reluctance to face up to personal needs and vulnerabilities. It is also a common defence in stressful jobs to manage feelings of anxiety and conflict by withdrawing from other people. Avoiding staff meetings and the staff kitchen are really common ways that people insulate themselves from being exposed to difficulties and conflict at work. This can become another inappropriate defence where retreating from contact with others leads to people becoming cut off from the very people that can support them at work. And that is precisely why the capacities of our doctors to build relationships with each other is a matter of survival for all of us. So, this book is an attempt to wade through the relationality car crash that has happened in healthcare and attempt to find a language of solidarity that doctors can relate to and practically use in their working lives. Practical Management & Leadership for Doctors, by Wattis, Curran and Cotton is available here  This is the Book’s introduction, by Dr Clare Gerada“As doctors we are increasingly asked to take on leadership roles. Leadership is a skill most doctors possess – after all we lead in the hardest of all areas, the consulting room.  As a general practitioner, there is nothing I have done in any leadership position that compares to my morning surgery. Working out which of the 30 or so patient encounters every day require further investigation, specialist input or active follow-up requires all the skills mentioned in Practical Management and Leadership for Doctors. We have to be decisive, organised, skilled communicators and deliver high-quality care – all in 10 minutes. This is, of course, not to undermine the challenges of leading outside the consulting room and today many doctors do take on extended roles in a number of different settings. In fact, as the book points out, almost all senior doctors should be involved in management and leadership in some guise or other, if only to stop bad decisions being made and to influence the system to make it better for patients (Chapter 4).  For those who enjoy leadership, the sky is the limit. During my career, I have held a number of national leadership positions, most notably as Chair of the Royal College of General Practitioners (2010-2013). Leading, whether in or out of the consulting room, is really about managing people, dealing with their expectations and fundamentally understanding that you get the most out of the teams or people you lead by modelling the behaviour you expect from them. I have written in the past about the leadership styles that you see in the current NHS often exemplified by men – leading as if to battle, playing the “heroic leader”. This contrasts with what I feel is most required, and the style I hope I have used most in my career – that is the “Peloton Style”, or dispersive leadership, whereby the workload of leadership is constantly being shared.Whatever style one uses (and in fact, the most likely style is a mix depending on the needs of the day or organisational issue), Practical Management and Leadership for Doctors is a helpful guide. There must be thousands if not tens of thousands of books on leadership, yet this little tome stands out amongst the many aimed at doctors. Firstly, it is written for doctors, by those who understand how doctors think and work. Secondly, it is a useful tool for the busy, jobbing doctor to have to hand, with bite-size chapters, easily accessible help, case studies and summaries at the end of each chapter. Finally, the book is relevant to so many aspects of our working lives: it provides important and timely information on areas which we face every day such as managing change, running meetings, and communicating effectively with staff; it talks to us about the pitfalls as well the joys of leading and how leadership is about engaging others; if we want people to listen to us, we must listen to them (Chapter 5, People skills). The amount of jargon in the book is kept to a minimum and the references at the end of each chapter call us, if we want, to explore particular areas in more detail. The book draws on the work of the late Steven Covey and his 7 Habits of Highly Effective People, and the two books should form part of most doctor’s personal library on leadership. Perhaps my personal favourite is the final chapter, on Balance. For the last decade, I have been the doctors’ doctor, seeing and treating doctors with mental health and/or addiction problems as part of the Practitioner Health Programme. Initially for doctors in the London area only, the service has since Jan 2017 been expanded across England to be available for all GPs. Over the years I have seen thousands of doctors with burnout, depression, anxiety, symptoms indistinguishable from post-traumatic stress disorder, as well as small numbers suffering from bipolar disorder and alcohol or drug addiction. Doctors go through the same difficulties as non-medical individuals (after all, we are not immune to loss, sickness, marital issues or other such traumatic life events). However, the biggest single cause of the mental illness amongst the doctors I see is their work, and in particular the demands placed on them through working in the modern, busy, and demanding NHS. Doctors are trained to work hard and when the going gets tough, their natural inclination is to blame themselves and work harder. Practical Management tells us that “your most important asset is yourself” and how it is all too common for people to succeed in their careers at the expense of a wrecked personal life.  The authors warn us from suffering from “superman or superwoman” syndrome and not to neglect our own humanity and health needs. Whilst we might need to give to others, we also should receive from them, maintaining “the emotional credit line with our partners and others” described by Covey. The authors give us a simple exercise to perform, called the “Self Factor”. This helps us identify our own needs – be they physical, psychological, creative or even spiritual – and how to use this information to prevent burnout and remain healthy in the work place. I use a similar exercise amongst the doctors I see and it is helpful for this book on leadership to acknowledge the human limits of all leaders and not, as many books on leadership appear to do, perpetuate this myth of a super-person able to function always, anywhere and anyhow. This book is light in weight, and heavy on common sense. It should form part of the doctor’s armoury. Even for those who do not see themselves as good leaders are often humble enough to be unaware of their potential leadership qualities. I learnt from reading the book, and I am sure the reader will as well.”