Tag Archives: life

Drawing myself back together

I wrote the blog below as part of a series curated by the London Arts in Health Forum, on art and culture, health and wellbeing. I and the other Trustees are already excited about 2017’s Creativity and Wellbeing Festival which will take place 12-18th June. Excitingly, an edited version of my blog was picked up by The Guardian, who have published it as part of their #BloodSweatTears series. You can read the article on The Guardian website.

The original blog follows.

Talk of low morale and burnout abound in healthcare [1,2]. ‘Resilience training’ has been proposed, to ’toughen up’ workers like soldiers in battle, to reduce sick days and enhance staff retention [3]. But as individuals, institutions and the public at large face the fact that healthcare is incredibly stressful work, that our services are stretched far beyond comfort, and that merely telling those involved in intense physical and emotional work to be more resilient doesn’t work, how can we truly support those who care for us to care for themselves?

Last year I gained some personal insight into this question. As a hospital doctor I am used to working under pressure, and had always felt I thrived on it. But whilst taking time out of clinical training to pursue a PhD, I found that I was intensely unhappy and suffering a range of surprisingly physical symptoms: palpitations, early morning waking, nausea, severe headaches, poor appetite, diarrhoea, dizziness, breathlessness and tremors. My day was constantly interrupted by intrusive negative thoughts; I once walked for 30mins with “I hate my life, I hate my life” on a loop of internal monologue that I feared had no end. I listened to podcasts and audiobooks fanatically but could not drown out these thoughts, and no rationalisation of all the wonderful things I have in my life could make them stop. Admitting that I was not merely unhappy in a job was a struggle. Having ‘depression and anxiety’ branded on my medical file, and acquiring a sick certificate, came as a shock. And after taking the very difficult decision to leave the PhD things did not immediately get better. I was convinced that I had ruined my career, and my life, and that nothing would ever be the same again. I felt that everything was pointless, and daydreamed about getting a terminal illness, or caught up in a terrorist incident. I didn’t want to die, but it no longer seemed like such a threatening possibility, and the option to opt out was appealing.

I wanted to get better and get back to a version of myself that I recognised, and I sought help from everywhere I could. I saw family and friends, and cried with many of them. I made appointments with my GP, an occupational health advisor and a career coach. I was pointed in the direction of a service specifically for doctors, the NHS Practitioner Health Programme [4,5], and embarked on a course of CBT, alongside regular sertraline. And I cancelled every commitment in my diary in an attempt to reset and gain some perspective. I woke up one morning at 4.30am and realised I had no commitments and no deadlines, and I asked myself ‘what do you want to do today?’ The answer, it turned out, was to walk, to watch, to draw, and to knit.

I have always loved to draw and make things. As a child I could entertain myself for days on end with paper, pens and scissors. Creativity is a part of myself that I had suppressed and ignored, viewing it as an inconsequential, frivolous hobby. But giving myself time away from work, both physically and psychologically, I made space for the things I love. I went on long walks through the city and took pictures of streetart and architecture. I went to galleries and lost myself contemplating contemporary art. I spent a weekend with my Mum knitting matching hats, sharing the intense joy of making pom-poms and then proudly wearing our creations. I made christmas cards and decorations and gave them to friends. I sketched and doodled, cut, stuck, sewed, crocheted and collaged. As I reaffirmed to myself the fact that I am more than my work, my internal voices of negativity and fear became quieter and I started to recognise myself again.

I am now back at work, and will be full time from April. I am incredibly grateful for the help I received, and cannot recommend SSRIs and therapy highly enough. But I also suggest finding space in life for creativity. I now rarely have a whole day free to make salt dough sculptures, or master cable knit, or learn how to rag-rug. But I do have time to take a photo, to doodle, to complete 5 knit rows of my latest hat, or to write a sad story using only 3 words. Participating in 64million artists January creativity challenge [6] demonstrated that I could weave creative tasks into my hectic work days. They not only activated a different part of my brain, they activated a different part of myself. With the ability to rise above the minutiae of my day and find more joy in simple things, I became more balanced, more empathic and more content.

Having worked hard to restore my positive outlook and some self worth, I am anxious to prevent a relapse. And so I have made myself a number of promises: I will not give all my emotional energy to work; I will take all my annual leave, however difficult it is to find cover; I will say ‘no’ more often to extra work tasks; I will value activities that make me happy but do not have ‘outputs’; I will make space for creativity every single week; I will schedule art in my diary during my time off and will not cancel due to work; and I will continue to talk about how I feel, as this shows strength not weakness [7]. I see these as essential for my self-preservation, but also essential for my effectiveness at work. By making time for the things that recharge me, I am now more effective – a better colleague and a better doctor.

The wellbeing of workers is a subject that is gaining attention. Companies such as Google are renowned for their perks: free food; games areas; gym memberships; massage credits; time for volunteering; and time to pursue ‘passion projects’ [8]. Those of us in the public sector look on enviously as we routinely work unpaid overtime, struggle to do three people’s jobs in one person’s time, try to do more and more with less and less resource, and remember lunch breaks as a distant memory. But some individuals and organisations are taking a proactive approach: workplace choirs are on the rise [9]; and staff wellbeing programmes are increasingly part of hospital Trust strategies and are gaining recognition through the Mayor of London’s Healthy Workplace Charter [10]. There is growing recognition that burnout not only harms workers, but also compromises the quality and safety of healthcare provision [11]. The Royal College of Physicians have produced a number of reports demanding leadership and action, noting that “investment in NHS staff is not an optional extra, but a vital investment in safe, sustainable patient care” [12, 13]. There is good evidence for the effectiveness of the arts in supporting wellbeing [14], and certainly more evidence than there is for resilience training [15, 16]. Intelligent organisations would do well to embed opportunities for arts engagement in career development and staff retention strategies if they want to maintain productive, compassionate, loyal workforces.

 

So, whether you like to write, to draw, to paint, to knit, to carve, to sing, to sew, to jive, to strum, to film or to yodel, I urge you to value your creativity and make space for it in your life. Celebrate the quirkier parts of yourself, and give them the time and respect they deserve. Be kind to yourself, and stay well. I’ll try to do the same.

  1. Doctor’s low morale ‘puts patients at risk’. BBC News, Oct 2016. http://www.bbc.co.uk/news/health-37777679
  2.  Rich, Antonia, et al. “‘You can’t be a person and a doctor’: the work–life balance of doctors in training—a qualitative study.” BMJ open 6.12 (2016): e013897. Available at: http://bmjopen.bmj.com/content/6/12/e013897.full
  3. Doctors need resilience training like soldiers in Afghanistan, GMC head says. Pulse, Jan 2015. Available at: http://www.pulsetoday.co.uk/your-practice/regulation/doctors-need-resilience-training-like-soldiers-in-afghanistan-gmc-head-says/20008855.article
  4. The NHS Practitioner Health Programme: http://php.nhs.uk/
  5. Gerada, C. “The wounded healer—why we need to rethink how we support doctors.” BMJ Careers (2015). Available at: http://careers.bmj.com/careers/advice/view-article.html?id=20022922
  6.  http://64millionartists.com/
  7. Time to Change’s Time to Talk campaign: http://www.time-to-change.org.uk/about-us/about-our-campaign/time-to-talk
  8. An Inside look at Google’s best employee perks. inc.com, Sep 21 2015. http://www.inc.com/business-insider/best-google-benefits.html
  9. Setting up a workplace choir: resources from Gareth Malone and BBC2. http://www.bbc.co.uk/programmes/articles/4TnMw8yMb2Fhf0bT6Z6hH5X/setting-up-a-workplace-choir
  10. Staff wellbeing programmes recognised through the London Mayor’s Healthy Workplace Charter: https://www.london.gov.uk/what-we-do/health/healthy-workplace-charter/award-winners-healthy-workplace-charter
  11. Salyers, Michelle P., et al. “The Relationship Between Professional Burnout and Quality and Safety in Healthcare: A Meta-Analysis.” Journal of General Internal Medicine (2016): 1-8. Available at: https://link.springer.com/article/10.1007/s11606-016-3886-9
  12. Work and wellbeing in the NHS: why staff health matters to patient care. Policy and Public Appears at the RCP, Oct 2015. Available at: https://www.rcplondon.ac.uk/guidelines-policy/work-and-wellbeing-nhs-why-staff-health-matters-patient-care
  13. Keeping medicine brilliant: improving working conditions in the acute setting. Mission: Health Policy Unit at the RCP, Dec 2016. Available at: https://www.rcplondon.ac.uk/guidelines-policy/keeping-medicine-brilliant
  14. The evidence base for arts in health: a resource of the National Alliance for Health and Wellbeing, available at: http://www.artshealthandwellbeing.org.uk/resources/research
  15. Leppin, Aaron L., et al. “The efficacy of resiliency training programs: a systematic review and meta-analysis of randomized trials.” PloS one 9.10 (2014): e111420. Available at: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0111420
  16. Balme, E., C. Gerada, and L. Page. “Doctors need to be supported, not trained in resilience.” BMJ Careers 15 (2015). Available at: http://careers.bmj.com/careers/advice/Doctors_need_to_be_supported,_not_trained_in_resilience

Health, wealth and the centenarian

Recently I treated and discharged a 101 year old gentleman. Back to his own home. And not a care package in sight.

As a hospital physician I rarely meet this group of older people, living full and independent lives. My view of the over 65s is coloured by my frequent encounters with the most unlucky ones; suffering from chronic disease, dementia, cancer and frailty.  But they exist, these sprightly centenarians and in increasing numbers. And even more common are older people with a lot to contribute to society, but in need of a little support in order to maximise their potential. Between now and 2050 the number of people aged 80 years will almost quadruple to 395 million. At that point, there will be more people over 65 than children under 14.  Our world is changing, but are we ready for this global silver revolution?

As a broad generalisation “western society,” does not value age, experience and wisdom. Our culture is obsessed with youth and a narrow definition of beauty which has no time for those perceived as “past their prime.” But in the last few weeks I seem to have read an abundance of good news stories about older people doing incredible things. On Saturday Live on BBC R4 I listened in awe and fascination to Mary Hobson who took a degree in Russian in her 60s and now, in her 80s is winning awards for her version of Pushkin.

Nicholas Crace, a fantastic 83 year old, found that he couldn’t continue to give blood after 70, but he could donate a kidney. So he became the oldest live altruistic kidney donor in the UK.  He was back to gardening and cycling a week later.  For even more inspiring older people see here and here.

Despite these great examples I fear that in general we dismiss and ignore older generations and that, as a result, we are losing out. As I contemplate entering the later decades myself I am worried I will not have the means to enjoy “active ageing,” defined by the WHO as mechanisms through which “people can realize their potential for physical, social, and mental well-being throughout the life course and to participate in society, while having adequate protection, security and care when needed.

So what are the necessary conditions for longevity, and what defines a happy life? Many people have attempted to answer this question. There is some evidence that those who live long healthy lives have higher levels of glutathione reductase (although I have not found any convincing evidence of a cause and effect relationship). Other research has idenfified genes that seem to influence longevity in multiple generations, including FOXO3A, which also correlates with lower rates of cardiovascular disease and cancer. But of course these reductionist theories miss the complex interaction of the individual, their genes, their childhood, their health choices, their socioeconomic status, their employment, their personality and risk taking behaviour, their social interactions, their self esteem and response to stress.

For over 70 years Harvard researchers have been following 268 men through their lives starting as “well-adjusted Harvard sophomores.” Half of them are still alive and now in their 80s. The study has documented narratives of the participants lives, in addition to collating questionnaires, psychological tests and medical examinations. The primary researcher George Vaillant has concluded that key components of a happy life include close relationships, access to a good education and good physical health. Perhaps more interesting are conclusions such as “objectively good physical health was less important to successful aging than subjective good health. By this I mean it is all right to be ill as long as you do not feel sick,” and “learning to have fun and create things after retirement, and learning to gain younger friends as we lose older ones, add more enjoyment to life than retirement income.” Dr Vaillant heavily emphasises the importance of social support and relationships in healthy ageing, which should ring alarm bells when we consider the lack of any sense of community in so many peoples’ lives, and the social isolation which often occurs with ageing.

The Okinawa Centenarian study in Japan identified several factors that contribute to the population’s high number of centenarians including: a diet very heavy on soya products, as well as fish and vegetables, and low on alcohol, dairy products and meat; commitment to frequent low impact exercise such as tai chi and gardening; close, supportive social networks; and a positive attitude that embraces and celebrates age. This group of people spend, on average, 97% of their lives disability-free. What a contrast to the common perception of the frail, dependant UK nursing home resident, unable to perform the most basic functions for themselves.  Ageing is not something to fear, if we remove the physical dependence and cognitive decline that we perhaps mistakenly see as inevitable.

I will continue to marvel at and celebrate the healthy older people I come into contact with, and aim to integrate some of the advice from Harvard and Japan to maximise my own chances of active ageing. But I also hope that the current period of austerity, coinciding with almost daily revelations of the degree of  inequality in society, and the entrenched corruption of power at the top  is bringing about a gradual reawakening; a shift in our materialistic and individualistic society towards a more caring, human, community-focused future. In my utopian future, age and wisdom are valued above youth and beauty, the gap between rich and poor is a fraction of what it is today, human interactions are treasured more than material possessions, and we all eat soya.

Good health adds life to years 

5 things

This week is Dying Matters Awareness Week 2012, the theme of which is “small actions, big difference”. As part of the campaign, people are being encouraged to take small actions which include:

  • helping someone to write a will
  • showing and discussing one of the Dying Matters films
  • visiting someone who’s been recently bereaved
  • becoming an organ donor
  • documenting your own end of life wishes
  • writing down 5 things you want to do before you die

Some of my friends and family think I spend too much time thinking about death. But because I think about the fact that life will end (hopefully not for a while), it seems so much more precious. So here are 5 things for my bucket list:

  1. See the Northern Lights.
  2. Make the perfect blueberry muffin.
  3. Fall in love. Again.
  4. Read Les Liaisons Dangereuses, in French.
  5. Have a photograph I’ve taken published in a weekend newspaper.
  6. Be interviewed on BBC R4 Woman’s Hour.
  7. Donate 50 units of blood.
  8. Stay in a jungle treehouse in Peru.
  9. Procreate.
  10. Have my portrait painted, naked.

Actually once I got started I couldn’t stop at 5. There’s a lot of life to live.

This Dying Matters Awareness Week I urge you to do something that “makes living and dying well the norm.”

“To live is the rarest thing in the world. Most people exist, that is all.” Oscar Wilde.

A Grief Encounter

Last week was particularly stressful; marked by staff shortages, anguished relatives, conflict over complex discharge processes, and pressure to create beds. The amount of time I spent with each patient on my ward rounds was less that what I, or they, would have wanted but despite coming in early and leaving late there are only so many hours in a day. In weeks like these I often feel guilty as I leave work that I am unable to give more time to those patients and relatives facing the end of life.

More than many other people I know, I am acutely aware of the fragility of life.

Modern medicine is amazing and can achieve results and outcomes that continue to astound me. The satisfaction of discharging a patient with a smile on their face after an admission for respiratory failure that looked like it might be their last; or being able to tell a patient that their cancer is curable, is difficult to describe. But even more difficult to articulate is the sense that the days in which I have the greatest impact, the days that are most rewarding are those in which I’ve had to break really terrible news, and have done it well. Such conversations require patience, time, compassion and, I used to think, empathy. I have seen grief, and its many varying manifestations. But being close to grief is not the same as understanding it and I am often aware of the vast distance between myself and a patient’s relative as we sit side by side in a quiet room after I have delivered bad news. What do I really offer in this situation? I try to communicate the medical facts clearly and sensitively, and give patients and families a sense of what will happen next. I feel sympathy, but am unsure whether I can truly say that I empathise. I have limited life experience and, thankfully, very little personal experience of death, and I find it difficult to imagine what grief feels like.

I recently read a powerful blog from a woman who had seen friends, and acquaintances experience grief, helped them through it and thought she understood. Until her father died. “That night I fought off a panicked dream of the earth falling away under my feet. I realized then, that until that moment, I had never had the right to speak.”  This acknowledgement that there is a gulf of emotion between seeing and experiencing grief is something others have identified, including physicians.

I hope that I can continue to find the time, compassion and words to help patients and their families through the most difficult times in their lives. But, selfishly, I hope that for as long as possible I maintain a degree of distance and lack of understanding and that I continue to sympathise but not empathise.

“No one ever told me that grief felt so like fear.” C. S. Lewis (1898 – 1963)

Last week a man asked me to kill him

I had just told Mr George* that his end-stage heart failure had become refractory to treatment, and I thought it likely he would not survive this hospital admission. He looked at me carefully and said, “Well that’s it then. Can’t you just give me something…end it for me?”

This is not the first time a patient has asked me such a question, and will not be the last. Often the question is more ambiguous, and it is unclear exactly what they are asking for: “can you just put me to sleep?” could be interpreted as a plea to end their life, but could equally be a request for a break from their symptoms or thoughts, with the hope of a more energised remaining time afterwards. It is a constant challenge to interpret such questions appropriately and personalise support and treatment for the needs of the individual.

In this case I did not hesitate in giving the only answer I could. Both the law and the GMC’s guidance are very clear that both euthanasia and assisted suicide are illegal. However, I always feel uncomfortable with the knowledge that I am powerless to alleviate suffering that is not physical. People who are dying have complex emotional and existential needs that a shot of morphine is not going to touch. What often strikes me about patients like Mr George is that the thought that they are dying still seems to be a surprise for which they are unprepared. I wondered whether he had talked about his thoughts and wishes for his death before now, and whether the many healthcare professionals he must have encountered in the year up to this admission had ever broached the subject with him.

Death is an inevitable part of life but as a society we seem unwilling to acknowledge this. As doctors we are as guilty as anyone; complicit in the idea that advances in modern medicine have the potential to cure all. The medicalisation of death and dying have hidden it away behind sanitised white doors; no longer is it commonplace to see a grandparent die at home surrounded by family, as it once was. The secularisation of society has also contributed to a disconnect between life as we experience it day to day, and a bigger concept of time, place and meaning.

As doctors we need to talk about death with our patients and give them the space to express their beliefs and wishes. As individuals we need to talk about death with our friends, partners and families and break the societal taboo. Some believe a “good death” is an oxymoron, but I disagree. For my own death I hope for comfort, dignity and a fulfilling life before it inevitably comes to take me. Life matters. Dying matters.

*names changed to maintain confidentiality