Career focus: Surviving (and even enjoying) medicine

Being attracted to medicine and having a propensity for burnout are two sides of the same coin.
Abi Berger has some tips to help doctors revitalise their lives

Hands up if you recognise any of the following psychological traits: perfectionist, overly conscientious, tendency to seek approval ("people pleasing") and need to control others, great sense of responsibility, chronic self doubt, uncomfortable with praise, and ability to delay gratification. It's a given that most people who enter medicine will hold many of these characteristics.

It's not something that happens to us at medical school--although a lot of what happens there does account for later problems--it's what we medics tend to bring with us. It's what attracts us to medicine in the first place. Acknowledging this helps. Acknowledging it early enough, and adopting self caring practices, will help to ensure that we do not burn out and that we remain safe and competent at our jobs, and we may even reverse the trend of seeking early retirement. Most doctors suffer from an episode of depression at some point in their career, and every medical school should include lectures on "burnout prevention" alongside those on anatomy and physiology.

According to a recent US conference on physicians' health in South Carolina, organised by the American and the Canadian Medical Associations, we doctors are sitting ducks for becoming burnt out. With thanks to some of the conference speakers, here are five practical tips on how to survive, succeed, and sustain interest in a career in medicine.

Tip 1: Make sure you do things other than work

According to Douglas Graham, a doctor with over 20 years' experience of working with the Physician Support Program in British Columbia, the top five "soul killers" are isolation, fear, anger, exhaustion, and shame. A single night on call can easily provide opportunities for all five. One way to recover from such onslaughts is to pursue--not just think about pursuing--tried and tested antidotes. This does not mean alcohol. It does mean making time for things you enjoy­friends, exercise, eating, and finding quiet time for yourself. Making daily "to do" lists that prioritise these activities--and posting them on the fridge and ticking them off--is one way to make them more likely to happen.

These are not added extras, but essentials. If we don't quite get around to doing them, not only are we letting ourselves down, but we will be failing our patients. (If you don't look after number one, you cannot look after number two, three, or four.)

Tip 2: Create your dream work schedule

Remembering that we have options in life is critical. None of us was forced into medicine. None of us is forced to stay in it, once we're qualified. We all have the option to change our mind, yet many doctors (and many others besides) feel trapped and unwittingly adopt the role of victim when it comes to their career.

If you find yourself asking the question "how did I get here?" it's time to assume greater responsibility for your decisions. Remember that we have more control than we think. Identify those aspects of life and work that you can control, and also those that you can't. Now address the issues that you can influence. Stress arises when we cannot integrate the dream of being a doctor with the reality of the job.

Ask yourself if you would like to practise medicine full time, part time, or not at all. Now ask yourself if the answer you gave was an honest one, or the one you think others want to hear. Then make plans on how to convert the dream into reality. It may well be a middle to long term plan, depending on what stage you are at. Do not lose sight of your ideal, but be prepared to review the plan regularly--at least annually.

Tip 3: Learn to say no (and not feel guilty about it)

This is harder than it sounds. Mamta Gautam, a consultant psychiatrist from Ottawa who sees only doctors as patients, got 200 people at the recent conference to follow these instructions: 1. Open mouth; 2. Say "no"; 3. Close mouth (this last is the hardest bit--doctors have a tendency to add things like "but I'll do it anyway" before closing their mouths).

Next, acknowledge the feeling of guilt that often follows saying "no," and then let it go. Gautam argues that the things that really make you feel guilty are probably the best things for you to do. (Note: she was referring to situations where you might feel guilty from an overriding sense of responsibility, like feeling guilty about taking time off work when you are ill; she was not referring to feeling guilty about committing a bank robbery.)

Tip 4: If you need help, go and get it

This probably sounds trite, but we find it easy to tell patients to do this, and for some reason find it virtually impossible to apply it to ourselves. Doctors with problems cause problems for other people. Doctors who drink too much, work too hard, take illicit drugs, become depressed, get ill (the list of "impairments" goes on and on), and do not do anything about it are self harming but also harmful to others. Self medication is as dangerous as ignoring the problem.

The problems are multiplied when an individual is so impaired that they refuse to acknowledge that they have a problem. It is easy to recognise problems in other people, much harder to recognise them in ourselves, and hardest of all to do something about them. This last is as much to do with our inherent qualities as with the messages we pick up at medical school.

Daniel Chapman and his colleagues, from Atlanta, Georgia, carried out a review of all research papers published in national medical journals between 1989 and 1999 about "impaired" physicians, and came up with the following messages for such physicians:

• I am aware of your behaviour and am concerned
• You are not alone
• Help is available
• There's every reason for optimismv
• Seeking help now does not mean you are a "bad" doctor--it will just make you a better one
• Not seeking help can have serious consequences.

Tip 5: Seek peer support

This is something that some GPs in the United Kingdom have been doing for a long time--with or without facilitators. It rarely happens within any other specialty. It is even rarer in the United States. Meetings of doctors that work on the "one-upmanship" principle are self defeating, and informal whingeing en masse is probably not that helpful.

According to William Zeckhausen, a pastoral counsellor from New Hampshire who has provided leadership for a number of physician support groups, finding a group of colleagues to meet with on a regular basis and developing within this group the security to share feelings and concerns (about patients, work, family problems, or anything else) can greatly reduce a sense of isolation and enhance a sense of wellbeing. If you don't want to join or create a group, at least find a mentor.

It is a truism that the higher up the career ladder we go, the more we stand to benefit from peer support. It is lonely at the top. It is more lonely to withhold ourselves from support through fear of stigma. It is important not to deny yourself or your needs.

12 Steps to sanity

All five tips, and their derivations, are referred to indirectly by Michael Kaufmann in his "12 steps for medical professionals." Based on the Alcoholics Anonymous original 12 step programme, the programme that Kaufmann, who is medical director of the Ontario Medical Association's physicians health programme, has come up with for doctors has been circulated to over half the doctors in Canada. He also provides a second list that encapsulates some of the less helpful messages we still seem to pick up at medical school. You don't have to have a problem to find solace in his 12 steps. You simply need to be a practising doctor.

Abi Berger, science editor, BMJ


studentBMJ 2000;08:175-216 June ISSN 0966-6494