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What do you do to unwind?

As a health care professional you are encouraged to have some down time. According to research:

Burnout and satisfaction with work-life balance in US physicians worsened from 2011 to 2014. More than half of US physicians are now experiencing professional burnout. Shanafelt TD et al

In the UK, NHS

More than half of salaried and locum GPs suffer from stress as a result of their work. BMA

So if you are in healthcare how and when do you unwind? How do you know it’s working? Are you too busy chopping the wood to think about sharpening the saw?

Picture by Zach Den Adel

Does your confidence get you into trouble?

 

Confidence– it’s just a decoy– it’s the dog that barks because he doesn’t bite.Tomas Chamorro-Premuzic, professor at University College London

As a healthcare professional you’re supposed to have the answers. But how often are you blind sided by your confidence? How often do you test your ideas?

In reality however, there is a very big difference between confidence and competence. Competent people are generally confident, but confident people are generally not competent. There are just good at hiding their incompetence and their insecurities– mostly because they are self-deceived themselves, so they generally think that they are much better than they actually are.Tomas Chamorro-Premuzic, professor at University College London

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Do you say I’m only trying to help?

She was very earnest when I first met her.

I have these terrible headaches. Nothing has helped so far. I know you can fix it.

With all the zeal of a man on a mission I set out to establish a diagnosis for her chronic headaches. Having examined her I performed lots of tests in search of the elusive cause. When no diagnosis was forthcoming we tried a bunch of empirical treatments. After a few days on each prescription she stopped them all for reasons including ‘side effects’, the cost of the tablets or inconvenience. Each excuse was more inventive than the one before. It became apparent that whatever the cause of the headaches we were not going to ‘cure’ them. So I tried a different tack, I recognised that she was bored and unhappy. Perhaps if she dealt with her dysphoria her headaches would be less of an issue. But with each suggestion for addressing her unhappiness she would come back to:

I can’t do much with these headaches.

And yet the odd thing is that she seemed cheerful and able to function perfectly well despite headaches spanning many years. I came to the conclusion that I was the unwilling partner in a game of ‘Wooden leg‘. The lesson was to recognise the invitation to join in the game at the outset and to consider the possibility that my part in the game was I’m only trying to help you.

Picture by Kevin O’Mara

Are you aware when you are flagging?

Are you aware when you are tired? Do you look at your reaction to any situation and wonder if it came from a place of fatigue? How do you deal with that?

When we are tired, we are attacked by ideas we conquered long ago. Friedrich Nietzsche

This study aimed to evaluate the variations in mood states and empathy that occur during the internship year. Consistent with our expectations, results of the first administration of the POMS and IRI demonstrated that interns in this cohort arrived with high levels of vigor, energy, and a well-established ability to demonstrate empathic concern. However, as early as November, we found that significant mood changes were already evident among our cohort. Interns became more angry and depressed. These data support previously reported findings that internship negatively affects personal well-being. Bellini et al

Fatigue and sleep deprivation, associated with long working hours and shift work, impacts on doctors’ personal safety, increasing the likelihood of occupational accidents, road traffic crashes and needlestick injuries. It also increases risks to patient safety through clinical errors. BMA

Picture by Dominique Archambault 

Can you stand to be bored?

Ever since the invention of the smartphone boredom has been banished. But at what cost?

Our results indicate a moderate relationship between smartphone addiction and a self-reported decrease in productivity due to spending time on the smartphone during work, as well as with the number of work hours lost to smartphone use. Smartphone addiction was also related to a greater amount of leisure time spent on the smartphone and was strongly related to a negative impact of smartphone use on daily non-work related activities. These data support the idea that tendencies towards smartphone addiction and overt checking of the smartphone could result in less productivity both in the workplace and at home. Duke E

Can you give that customer, client or patient your undivided attention with one eye on your phone? Is it worth considering if you have a problem?

Picture by Graeme Paterson

Do you perform any rituals during your day?

Do you perform any rituals during your day? Why? What is the value of the ritual?

Despite the absence of a direct causal connection between the ritual and the desired outcome, performing rituals with the intention of producing a certain result appears to be sufficient for that result to come true. Francesca Gino, Michael I. Norton

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Why do you keep me waiting?

We often have to wait in line to be served. In healthcare that happens a lot. If you had to wait an hour or more every time you needed something from somewhere would you continue going there? Why or why not? Does queuing have to be  fact of life in healthcare? How long before someone works out it isn’t necessary and offers an alternative? What will happen to those places that fail to keep up?

Although appointment systems are often designed to avoid doctor idle time (without considering patient waiting time), it is possible to reduce patient wait time without significantly increasing doctor idle time.

Picture by Michael Dales

Why did you change over the years?

Have your attitudes and opinions changed since you started doing whatever you do today? If you have changed, how so? Is that a good thing?

And so I approach the patient/physician encounter as a sanctuary from the rapacious, counterfeit, profit-driven world that I have to navigate through every day. I really am curious about these people who come into my exam rooms. I am interested in their seemingly trifling anecdotes and back stories. I love when they ramble on about some trip planned to Montana or the vegetable garden they had last summer or whatever. I am there as a privileged guest, invited inside, if but for a short while, when they are vulnerable and hurting and completely open and trusting. I have been allowed behind the curtain, and I don’t want to betray them, I don’t want to let them down. I want them to like me and trust me and believe in me. I need this to be true, and it doesn’t have anything to do with high HCAHPS scores or patient satisfaction metrics. Jeffrey Parks

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How do you prepare for disagreement?

Sometimes you might be asked for something that seems entirely pointless. In healthcare almost every speciality has examples of such challenging situations. In intensive care and oncology such issues are most poignant as patients may end up suffering before death:

In a retrospective review, we identified 100 patients of 331 bioethical consultations who had futile or medically inappropriate therapy. The average age of patients was 73.5 ± 32 years (mean ± 2 SD) with 57% being male. Fifty-seven percent of the patients were admitted to the hospital with a degenerative disorder, 21% with an inflammatory disorder, and 16% with a neoplastic disorder. The family was responsible for futile treatment in 62% of cases, the physician in 37% of cases, and a conservator in one case. Unreasonable expectation for improvement was the most common underlying factor. Family dissent was involved in 7 of 62 cases motivated by family, but never when physicians were primarily responsible. Liability issues motivated physicians in 12 of 37 cases where they were responsible but in only 1 of 62 cases when the family was (χ2 5 degrees of freedom = 26.7, p < 0.001).

Seth et al

This scenario may be avoided if it is anticipated as a ‘set play‘. List all the ways you may be adding to the person’s problems and consider how you might avoid contributing to a bad situation.

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Could you do better?

Do you think your work could be better? How? If you think it could be improved what are you waiting for?

The intense debate about how to move forward is a sign that overtreatment matters,” Brownlee says. “We want everyone involved and sharing their expertise on potential solutions. There is room for many political ideologies and beliefs about how to pay for healthcare. The crucial step right now is to get the medical community mobilized around the idea that overtreatment harms patients

BMJ Jeanne Lenzer

Picture by Carlos Ebert