Many of us enter medical school having been top of our year group, or at least in the top few. Some of us may never have failed an exam. We start medical school, discover that we are no longer so unique, and find ourselves amongst student peers equally intelligent and high-achieving. I remember being totally bowled over by this when I first started. It was exciting and stimulating, but also at times a little overwhelming.
This realisation, coupled with other factors, can make us vulnerable. The stress of living somewhere new, the possible loss of significant relationships, personality traits that make us so good at performing, such as perfectionism and industriousness, and for some a possible genetic predisposition to anxiety and mood disorders. All load stress onto an already high intensity degree, and later, professional working life.
A working life that demands us to learn to live with stress, rather than learning to reduce it to healthy manageable levels. For example, we adapt to live without sleep, without food, without exercise and without a break (even for the bathroom). We learn to assimilate vast amounts of information required in order to practice, often to find ourselves overturning that knowledge according to a shifting evidence base.
We learn to walk the tightrope of stress. Finely balanced most stay standing in the early years, but many do fall, in increasing numbers, as external stressors increase. Some decide quite sensibly that enough is enough and choose alternative paths.
The rest of us are comforted that this is all worth it. Things will get better – we just need to persevere, work harder, get to the next stage, the next rung in the ladder. Once we are a consultant, or a GP, we will have arrived. We can start to relax a bit.
Learning to just walk the tightrope however is not enough. In 21st century doctoring you must learn to dance on it, walk upside down on it, hop on it and still stay upright. You need to be able to dodge or deflect the curveballs thrown at you (mounting workload, fragmented team working, increased public expectation and greater patient complexity) in order to stay steady. As we know, burnout and mental ill-health in doctors is now a global phenomenon, a public health crisis. Dr Pamela Wibble calls it “physician abuse”.
As these stressors mount and significant life events transpire in our personal lives – becoming a parent or a carer for elderly relatives, undergoing the death or loss of someone close, relocating due to the job change of a spouse – we may start to feel out of our depth or out of control.
To mitigate this, we might work harder. Our stress increases as habits that worked before when we were less stressed become maladaptive. We feel frustrated and angry, continually falling short of the unrealistic expectations that we have set ourselves and others.
We might develop behaviours such as spending longer with patients so not to miss anything, checking or doing things only in a certain way. These behaviours may temporarily reduce stress, but absorb lots of our time, and can affect our ability to perform effectively. This is worsened by lack of sleep, poor diet, and self-medication with caffeine and alcohol.
We may be aware that we are struggling but feel a failure if we admit it. We have coped before. Surely we can cope now? Working harder has always worked.
We continue and maladaptive behaviours escalate. We start thinking of ways that we can escape. It starts to become clear that working harder is not working.
What is the next step?
We can turn to the “dark side” – unhealthy habits such as drugs and alcohol, negative behaviours such as lying and avoidance, mental ill-health or when completely devoid of hope, taking our own lives – the only way to escape the pain and distress.
Or, we can turn to the “light”, reach out and get help. This is not easy. But once you let go and take that white coat off, it can be transformational.
I am really interested in the “fear of failure”. As a doctor, the greatest fear that we all share is arguably the death of a patient because of an error. Some element of fear is healthy as it keeps us sharp and focussed, but excessive levels can be incredibly distressing and actually worsen our performance.
I started writing this post to unpick some of the factors that move this fear from something manageable to something very anxiety provoking. As I wrote, it became clear that this was in part my story. A story I was too ashamed to write earlier.
I write it to you now, having started dealing with my demons, in the hope that it might be helpful for anyone who might be struggling.
I will be writing further posts on what makes us, as clinicians, particularly vulnerable to mental ill-health, and how perhaps we might start looking after ourselves better.