Tag Archives: wellbeing

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

More doctors should engage with arts and health

An article I co-wrote “More doctors should engage with arts in health” was recently published in BMJ careers. A longer version is below. Many healthcare professionals are interested in the arts, as part of their own wellbeing as well as their patients. It may not be clear how to align this interest with day to day work, and arts in health practice can therefore seem inaccessible to clinicians. We hope to bridge this gap with an introductory training event, the first of which will be on 30th June at the UCL Macmillan Cancer Centre, and has been approved for 3 RCP CPD points. Read more about it on the LAHF website, and book tickets via EventBrite.

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What is good health?

Doctors spend their professional lives trying to help their patients achieve good health. Although many start medical school with an idealised image of medicine as cure, most rapidly realise that despite phenomenal advances in science, cure is seldom possible. This is partly due to the nature of disease and the inevitable frailty of the human body, and partly due to the fact that none of us exist in a vacuum, and our potions and pills do nothing to change individual patients’ contexts or experience of illness. In fact ‘illness’ is almost impossible to define, as we medicalise more and more natural life processes and events. How can medicine address modern day phenomena of socioeconomic inequalities, lack of housing, poverty, loneliness, ageing, grief, disengagement from society, struggles with sexuality, or finding meaning in life? Should it? The role of the doctor has historically been to promote, maintain and restore health where possible, and to relieve suffering, and offer comfort to all. In this context, wellbeing as a concept that extends beyond a narrow definition of health becomes increasingly important. The WHO definition of health acknowledges this, and states that health is “a complete state of physical, mental and social wellbeing, and not merely the absence of disease or infirmity.”[1]

The Gallup Global Wellbeing index attempts to quantify aspects of wellbeing and compare across borders, languages and cultures. It defines five elements of well-being;

  • purpose (liking what you do each day and being motivated to achieve your goals)
  • social (having supportive relationships and love in your life)
  • financial (managing your economic life to reduce stress and increase security)
  • community (liking where you live, feeling safe and having pride in your community)
  • physical (having good health and enough energy to get things done daily)

Medicine, as traditionally imagined, only addresses the last of these. Perhaps the social and creative potential of the arts could be harnessed to support the other elements and help physicians to generate a more holistic approach to health in our patients and communities.

What is arts in health practice?

Over recent years, there has been a growing understanding of the impact that taking part in the arts can have on health and wellbeing. By supplementing medicine and care, the arts can improve the health of people who experience mental or physical health problems. Engaging in the arts can promote prevention of disease and build wellbeing. The arts can improve healthcare environments and benefit staff retention and professional development. Arts in Health practice includes a wide range of approaches, projects, disciplines and professionals. It is much broader than what would traditionally be understood as medical humanities.

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What is the evidence for the impact of arts and health initiatives?

The arts have been recognised as central to wellbeing, but there is a lack of engagement from health professionals. Multiple contributing factors include: a lack of curricular time in undergraduate and postgraduate training for arts and health; a lack of interest, expertise, and leadership from clinically trained professionals and educators; poor funding; and institutional priorities. Although many successful arts in health projects exist, with years of experience and anecdotal evidence, those trained in positivist empirical scientific disciplines demand randomised controlled trials and objective evidence of impact before they invest time, energy, and crucially money, in initiatives that may be seen as ‘soft’. This stance, and the tendency to see arts engagement as ‘an intervention’ rather than a part of a long-term personal and therapeutic activity, leads to the prevailing narrative that a link between engagement in the arts and measurable physical and psychological outcomes is lacking. In fact such evidence already exists; there are numerous examples of the measurable impact of arts on health and wellbeing [6-9], in addition to specific effects of individual programmes which include RCTs [10-12]. (Table 1). A DoH working group in 2007 recognised this and stated “the arts are and should be firmly recognised as being integral to health, healthcare provision and healthcare environments.” [13]

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Dr Gorden-Nesbitt of Manchester Metropolitan University reviewed the evidence for longitudinal effects of the arts on health and concluded “Taken together, the research demonstrates a positive association between engagement in high-quality arts activities and life expectancy, disease resistance, (and) mental acuity .” Possible mechanistic explanations include enhanced social capital, psycho-neuroimmunological responses, and epigenetic phenomena [6].

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Why now?

Despite concerns about funding cuts to both healthcare and the arts, now is an exciting time for arts in health practice. There is increasing political interest in the area, with a recent All Party Parliamentary Group convened to explore Arts, Health and Wellbeing. The recent changes to the commissioning landscape are highly relevant. The Health and Social Care Act (2012) established Health and Wellbeing Boards with a remit of improving the health and wellbeing of their local populations. They have strategic influence over commissioning decisions across health, public health and social care, and offer potential for more cohesive, less silo-ed working. Importantly they have a remit to consider the social inequalities within their area, which remain huge determinants of health. Virchow famously stated “Medicine is a social science, and politics nothing but medicine at a larger scale.” [14] And as Dr Gordon-Nesbitt reflected “Whilst the arts and health inhabit two distinct policy areas, and the particularities of each field needs to be borne in mind, both health and the arts are inherently political. It follows that arts/health is a political movement…” [6]

How can you get involved in arts in health?

Having been won over to the inherent value of the arts, and the specific value of arts in health, how can you learn more and get involved? A number of options are open to you, dependant on your personal interests:

  • Seek out information on local arts in health projects and take the opportunity to see them in action (the LAHF directory is a great place to start)
  • Read more about Arts in Health, and the evidence base for enhanced health and wellbeing (see references below)
  • Attend an event such as Medicine Unboxed, or Creativity and Wellbeing Week, to meet those involved in the field and find out more about the huge diversity of organisations and activities
  • Contact your Trust’s arts manager/co-ordinator and find out what is happening locally
  • Consider how you could incorporate the arts and enhance teaching you already have responsibility for, at an undergraduate or postgraduate level
  • Advocate for including the arts in service reviews, whether this be participatory projects, physical environments, or arts therapies. Use examples of other projects, including The Kings Fund’s “Enhancing Healing Environments” to help your case.

For those with a particular interest in the field new ways to engage need to be developed. The London Arts in Health Forum are developing an introductory course for health practitioners who wish to learn more about the theory and practice of arts in health. The first of these will be on 30th June at the UCL Macmillan Cancer Centre and has been approved for 3 RCP CPD points. Read more about the event on the website and book tickets via EventBrite.

As Sir Peter Bazalgette, Chair of Arts Council England said, ‘When we talk about the value of arts and culture, we should always start with the intrinsic – how arts and culture illuminate our inner lives and enrich our emotional world. This is what we cherish. But while we do not cherish arts and culture because of the impact on our social wellbeing and cohesion, our physical and mental health […] they do confer these benefits and we need to show how important this is’. [6]

By facilitating front line health workers to become better equipped and engaged with arts in health, we can start to open opportunities for more individuals to reap the benefits of the arts, in all its forms. This has the potential to enhance life for us all: doctors, patients, public, and society at large.

  1. WHO. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June 1946, and entered into force on 7 April 1948.
  2. Bircher J. Towards a dynamic definition of health and disease. Med. Health Care Philos 2005;8:335-41.
  3. Saracci R. The World Health Organization needs to reconsider its definition of Health. BMJ 1997;314:1409-10
  4. Department of Health. (1999). SavingLives: Our Healthier Nation. London: Stationery Office, (Cm 4386): 159pp.
  5. Smith R. Spend (slightly) less on health and more on the arts. BMJ. 2002 Dec 21;325(7378):1432–3.
  6. Gordon-Nesbitt R. Exploring the Longitudinal Relationship between Arts Engagement and Health. Available at: https://longitudinalhealthbenefits.wordpress.com/ accessed 20/09/15
  7. Arts Council England, The Value of Arts and Culture to People and Society: An Evidence Review (London: Arts Council England, 2014).
  8. Bygren, L. O., Konlaan, B. B., & Johansson, S. E. (1996). Attendance at cultural events, reading books or periodicals, and making music or singing in a choir as determinants for survival: Swedish interview survey of living conditions. BMJ: British Medical Journal, 313(7072), 1577.
  9. Bygren, L. O., Johansson, S-E., Konlaan, B.B., Grjibovski, A.M., Wilkinson, .V., & Sjöström, M.‘Attending Cultural Events and Cancer Mortality: A Swedish Cohort Study’, Arts & Health, 1, no. 1, March 2009, pp. 65–6.
  10. Iwasaki, Y., Mannell, R. C., Smale, B. J., & Butcher, J. (2005). Contributions of leisure participation in predicting stress coping and health among police and emergency response services workers. Journal of Health Psychology, 10(1), 79-99.
  11. Särkämö, T., Tervaniemi, M., Laitinen, S., Numminen, A., Kurki, M., Johnson, J. K., & Rantanen, P. (2014). Cognitive, emotional, and social benefits of regular musical activities in early dementia: Randomized controlled study. The Gerontologist, 54(4), 634-650.
  12. Petrie, K. J., Fontanilla, I., Thomas, M. G., Booth, R. J., & Pennebaker, J. W. (2004). Effect of written emotional expression on immune function in patients with human immunodeficiency virus infection: a randomized trial. Psychosomatic Medicine, 66(2), 272-275.
  13. Department of Health. Report of the review of arts and health working group. London: Department of Health, 2007.

Those who go; those who stay

A large proportion of my life is spent within the walls of the hospitals of North East London. But when I’m not at work, I can often be found in one of London’s fantastic art galleries. Art is essential for my personal wellbeing, and a great way to dissociate myself from the trials and tribulations of being a doctor.

But every so often these two worlds collide.

Those who go

A few years ago I went to an exhibition at the Tate Modern on Futurism. It was a fantastic exhibition, highlighting a brief but incredibly influential period of modern art. I was profoundly struck by a specific piece: a tryptych by Umberto Boccioni entitled “Farewells; Those who go; Those who stay,” now on view at the Museum of Modern Art in New York. Not only is it beautiful, but the artist effectively captures the emotions inherent in farewells. It has stayed with me ever since. I was reminded of this piece recently after a particularly emotional on call shift.

I was having a long overdue cup of tea and updating the patient list when the screech of the arrest bleep demanded my attention. I rushed to the appropriate ward and arrived in time to see the patient lose output. The team got to work quickly switching from BLS to ALS, and we attached the defibrillator to see what no arrest team wants to see: PEA, a non-shockable rhythm. After a rapid intubation and several cycles of good quality continuous chest compressions with appropriate drugs given, the rhythm remained PEA. The arterial blood gas showed no reversible causes and several poor prognostic indicators. From the information we had available we concluded the patient had died and was not coming back and we stopped attempting to resuscitate them.

There is always a strange moment at the end of an unsuccessful resuscitation as the cohesive, united team, at one within the all-consuming emergency, shifts; and becomes, once again, a group of individuals. Each one takes a deep breath, psychologically removes themselves from the situation and walks away to continue with their shift.

As I took my own deep breath and stepped outside the curtains, I became aware of the patients and relatives in the bay. I had been preparing myself to speak to the patient’s own family and explain what had happened, but I had not considered the effect on those who had just witnessed the death of a fellow patient, behind the mysterious veil of the blue curtain.

Those who stay

Those who stay

Whilst we acknowledge the loss of “Those who go” I wonder if we provide enough support for ‘Those who stay’. On this occasion, after talking to the family directly affected by the death I went to speak to each patient and relative in the bay and tried to offer some comfort and reassurance. They had many questions, and I was not able to answer them all due to confidentiality. But it did open up the opportunity to talk about life and death. It led to a particular patient expressing his worries about his own diagnosis, and the opportunity for me to clarify the information we had available on his prognosis.

Talking to the patients and relatives who witness a cardiac arrest is not my usual routine, and it is unlikely I will always have enough time to do so. I know that nurses often fulfil this role but I wonder whether as clinicians we are guilty of relinquishing our responsibilities and not providing effective holistic care. I searched for evidence of the impact on hospital inpatients of witnessing death, and interventions to support them. I found very little. One study looked at hospice patients, and another patients with schizophrenia: quite specific and different populations. My knowledge in this area thus remains in the realms of anecdote.

In the 1912 catalogue of the Futurists, they claimed ‘We thus create a sort of emotive ambience, seeking by intuition the sympathies and the links which exist between the exterior (concrete) scene and the interior (abstract) emotion.’ This seems particularly apt as we try to navigate the emotions provoked by witnessing death and grief, and maintain control over the concrete scene of the hospital ward.

As doctors we should all aim to provide holistic care, but must consider what this really means. Holistic care extends beyond the acute illness; beyond the individual patient; to all those affected by illness: patients, relatives, colleagues and ourselves.