Episode 77: Denial, Displacement and Other Ways We Neglect Ourselves with Dr Andrew Tresidder
Are you taking care of yourself? We are often expected to perform long hours, especially during this pandemic. But we’re only human. We can’t keep on working at 100mph. Burnout, exhaustion and even illness is inevitable if we don’t prioritise our health. Consider the safety rules on planes: put on your own oxygen mask first!
In this episode, Dr Andrew Tresidder joins us to talk about how many medical practitioners and other professionals in healthcare and high stress jobs neglect their health and well-being. We’re so focused on taking care of others that we forget to take care of ourselves but our well-being is vital if we want to keep doing the work we do.
Find out why healthcare professionals need to learn more about health, as opposed to only learning about disease and if you want to know how to focus on taking care of your health and well-being, stay tuned to this episode.
Here are three reasons why you should listen to the full episode:
- Understand how neglect can lead to burnout and exhaustion.
- Learn the pillars of well-being and how you can manage your work and stress.
- Discover the ways stress affects our bodies and why we need to take care of our health.
[04:46] Widespread Burnout Among Health Practitioners
- Medical and health professionals often learn about diseases. They don’t understand health as a holistic concept.
- It’s similar to knowing how to deal with a car crash but not knowing how to prevent one.
- It is why a lot of health practitioners burn out, or worse, get sick themselves.
- The health industry workload gets heavier every year. More people bring themselves to the brink of exhaustion.
- Burnout like this isn’t isolated to the medical field. Burnout is widespread in other professions and industries too.
[07:23] Neglect Syndrome Starts with Denial and Displacement
- When we say we’re ‘fine’, it means being fearful, insecure, neurotic, and emotionally imbalanced.
- Most people’s first response to psychological needs is denial which leads to displacement. This neglect can lead to devastating results.
- It can then lead to distress, despair, disillusionment, and exhaustion. The three occupational issues found in doctors are drink, drugs, and depression.
- All of these are avoidable. We must learn to spot neglect once it happens and immediately take care of ourselves.
[10:05] The Pillars of Well-Being
- Well-being has five pillars: a social connection, taking notice, being active, learning, and giving.
- While giving is a significant part of well-being, Andrew shares and emphasises a sixth pillar: it’s also important to be open to receive.
- A relationship may sound simple, but it means more than having social interactions. It’s about being energised or calmed by others.
[13:03] What Stress Can Lead To
- Stress can lead to exhaustion, which brings distress. It can also lead to higher adrenaline, making us irritable.
- Practitioners need to know these are not symptoms of mental illness. Instead, it’s from exhaustion.
- Neglect syndrome makes people work even harder to compensate.
- Higher adrenaline makes denial easy since it helps us focus on immediate threats. However, we miss our peripheral and long-term concerns as a result.
[15:39] External and Internal Factors of Neglect
- It’s easier to say that we need to manage our well-being. However, the system encourages people to work harder and harder.
- Not only that, people have internal drivers for high achievement. These stop them from being able to relax.
- Studies show that if we overwork ourselves, our performance has diminishing productivity.
- Improving well-being requires changing the management and workplace environment.
- We might know it’s good to pace ourselves. However, there’s still a lot of resistance.
[20:11] Why Resistance Exists
- Doctors and health practitioners often sacrifice themselves to help others. However, they lack the insight to attend to their own needs.
- They often misdiagnose or delay diagnoses about themselves.
- Health professionals are still human. They need to acknowledge this fact and sometimes take independent health advice.
[22:58] Insight Deficit
- Insight deficit occurs when you think you’re invincible and exempt from burnout. It quickly leads to neglect.
- It’s partly a protective mechanism many practitioners develop from going through medical studies.
- Exhaustion is normalised; people only rest when something forces them to do so.
[26:17] How to Gain Better Health
- Medical education should start including health and burnout avoidance as a critical topic in the curriculum.
- Our autonomic nervous system has two aspects: the sympathetic and parasympathetic.
- The sympathetic state activates our fight or flight response. While it’s okay to get into this state, it’s not good to be in a prolonged time.
- The parasympathetic state is rest. Andrew shares that mammals are in this state 90% of the time.
- A lot of things can be considered stimulus to drive us into the sympathetic state. Listen to the full episode to hear more in-depth discussions on how our body acts while in a sympathetic state!
[33:50] Rest Is Imperative
- Decompression from the alarm phase is difficult and creates withdrawal. It would be best if you started relaxing from time to time.
- Do this by taking calming diaphragmatic breaths. Make sure your feet are flat on the floor. Your spine should be comfortable as you breathe.
- Create the habit of rest and permit yourself to relax.
- Before helping others, learn to help yourself first.
[40:50] Andrew’s Tips for Health and Well-Being
- Value quiet time, reflect on your values and take care of yourself first.
- Don’t wait for neglect syndrome to pop up. Preempt it to avoid burnout entirely.
- Learn to ask for help and do it early.
- Listen to the opinions of people close to you. They can notice your exhaustion, too.
- Don’t buy into the stigma that you can’t ask for help.
7 Powerful Quotes
[5:57, Andrew] ‘You’re absolutely right. And the analogy that some people find helpful is that highly trained professionals, doctors, nurses, other professionals, learn about car crashes and dealing with the aftermath. But not about how to avoid them.’
[7:03, Andrew]’I think the whole NHS has been working very hard for the last few months, I mean, for forever, and I suppose over my professional career, it just feels as though the workload has got harder each year.’
[7:49, Andrew] ‘Remember your own oxygen mask before that of others. And I think that carers, whether they’re carers, as mothers, whether they’re carers as professionals, whether they’re driven professionals in any way, we often forget that simple truth.’
[8:35, Andrew] ‘I think the general response is a four letter word: “fine”. And of course, FINE, Rachel, stands for fearful, insecure, neurotic, and emotionally imbalanced, which is a fair description of what’s under the surface for most of us.’
[11:42, Andrew] ‘And the other ones of course, you’ll remember take notice, be active, learn and give.’
[14:39, Andrew] ‘I think the danger for us as a profession is to over-medicalise exhaustion and to recognise for what it is and to recognise that we need not to go there, we need to know how to look after all mammalian physiology and ensure that we actually remember how to keep our tanks filled.’
[15:55, Andrew] ‘And because we compete against each other in exams, we strive to get into the career of our choice, we’re privileged to do that, and the race doesn’t end, it’s ever harder.’
Dr Andrew Tresidder has been a Somerset GP and MRCGP since 1989 and advocates for the mental health and well-being of health practitioners. He is a founding member of the Somerset Clinician Support Service and Appraiser, a Section 12 Approved Doctor, and works on Patient Safety part-time in Somerset CCG. Andrew’s past work includes Prison Medicine and Police work for Avon and Somerset Police and as GP Academy Lead at Yeovil for Bristol Medical School.
As an advocate for health and self-care among health professionals, Andrew wrote the book, Health and Self Care: Inner Balance for an Effective Life, which is also available in free PDF and audiobook versions. He also co-hosts the Somerset Emotional Wellbeing Podcast with Dr Peter Bagshaw to give free, weekly mental and emotional well-being support for listeners!
Interested in Andrew’s work? Check out Health and Self Care for more resources.
You can also reach him through email (email@example.com).
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In today’s high-stress work environment, you may feel like a frog in boiling water. The pan has heated up so slowly that you didn’t notice the feeling of stress and overwhelm becoming the norm. You may feel that it is impossible to survive AND thrive in your work.
Frogs generally have only two options — stay and be boiled alive or jump out of the pan. Fortunately, you are not a frog. You have many more options, choices and control than you think.
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Dr Rachel Morris: How many times has someone asked you how you are? And you’ve replied, ‘Fine, been anything but’. Working in high stress organizations like health care, ‘fine’ can sometimes mean fearful, insecure, neurotic and emotionally imbalanced. And feeling like this may have become the norm for many of us.
So in this episode, I’m talking to Dr Andrew Tresidder, a GP appraiser and trainer who works with practitioner health. He’s got a vast experience of working with doctors and other professionals who have been in denial about their own levels of stress and physical or mental health problems. We discuss our unhelpful defence mechanisms, such as denial and displacement, which can lead us into despair, distress and disillusionment, and how this way of operating has been instilled in many of us from a young age. We talk about the risks to your health, constantly operating in a high-stress state, and share some ways in which we can prevent ourselves and our colleagues from going off the metaphorical cliff edge.
So listen if you want to find out why health care professionals need to learn more about health, as opposed to disease, how to recognise when you’re operating out of your sympathetic stress zone and how to get out of it. And listen if you want to learn about the perils of self diagnosis, and how to really look after yourself.
Welcome to You are Not a Frog, life hacks for doctors and other busy professionals who want to beat burnout and work happier. I’m Dr Rachel Morris. I’m a GP turned coach, speaker and specialist in teaching resilience. And I’m interested in how we can wake up and be excited about going to work no matter what. I’ve had 20 years of experience working in the NHS, and I know what it’s like to feel overwhelmed, worried about making a mistake, and one crisis away from not coping. Even before the coronavirus crisis, we were facing unprecedented levels of burnout. We have been described as frogs in a pan of slowly boiling water, working harder and longer. And the heat has been turned up so slowly that we hardly noticed the extra long days becoming the norm. And I’ve got used to the low-grade feelings of stress and exhaustion. Let’s face it, frogs generally only have two options: stay in the pan and be boiled alive, or jump out of the pan and leave. But You are Not a Frog. And that’s where this podcast comes in. You have many more options than you think you do. It is possible to be master of your destiny, and to craft your work in life so that you can thrive even in the most difficult of circumstances. And if you’re happier at work, you will simply do a better job. In this podcast, I’ll be inviting you inside the minds of friends, colleagues and experts, all who have an interesting take on this. So that together, we can take back control and thrive, not just survive in our work and our lives and love what we do again.
For those of you listening to the podcast who needs to get some continuous professional development house under your belts, did you know that we create a CPD form for every episode so that you can use it for your documentation and in your appraisal? Now, if you’re a doctor, and you’re a fan of inspiring CPD, and you’re sick of wasting a lot of time you don’t have on boring and irrelevant stuff, then why not check out our Permission to Thrive membership. This is a new venture, a joint venture between me and Caroline Walker, who’s a joyful doctor, and every month we’re going to be releasing a webinar fully focused on helping you thrive in work and in life. Every webinar is accompanied by an optional workbook with a reflective activity so that you can take control of your work and your life. You can increase your well being and you can design a life that you’re going to love. You’ve got to get those hours, so why not make your CPD count to CPD that’s good for you. So check out the link to find out more. Now thanks for listening to my shameless plug, and back to the episode.
So it’s absolutely fantastic to have with me on the podcast today. Dr Andrew Tresidder. Now Andrew is the clinical lead for pastoral care, evidence-based intervention and medicines management at Somerset CCG. He’s also a GP appraisal and trainer. And he’s the NHS practitioner health Southwest clinical lead. Well, that’s a big portfolio. Andrew.
Dr Andrew Tresidder: Rachel, it’s a great privilege and pleasure to join you today. And I’m at that stage of my life when I’m fortunate enough to be doing things that I’m really privileged to enjoy. So it’s great.
Rachel: So you’ve had a lot of experience with doctors, mental health doctors, well being doctors caring for themselves or not really caring for themselves, really.
Andrew: Yes. And I sort of often bring this back to personally, because I think sometimes we go through the suffering ourselves. And I’m sure in my 40s, I burned myself out to a certain extent. And we all learn lessons the hard way. We can learn about things, but that’s not the same as learning for ourselves. So I’ve been privileged to work in Somerset with our LMC for a number of years, and we set up an advocacy service in about 2009 to help doctors. I think doctors’ health is really interesting. As a GP, in short, I was very lucky because I practised medicine to the best of my ability, I practised what I learned in medical school. But my patients taught me that health was something I hadn’t learned much about. And there are many aspects to health which I ought to know about, which I haven’t. So I was gently taught.
Rachel: That’s a really good point, we do know we learn about disease, that medical school, though we don’t necessarily learn about those things that are going to keep you physically mentally, emotionally fit and healthy, and a well rounded human being, etc, etc.
Andrew: You’re absolutely right. And the analogy that some people find helpful is that highly trained professionals, doctors, nurses, other professionals, learn about car crashes and dealing with the aftermath thereof. But not about how to avoid. So we don’t necessarily learn about sensible driving, vehicle maintenance, good navigation or the bigger issues of road design. And so when we run into problems ourselves, we tend to medicalise it, or medicalise that issue or pathologise it without actually knowing how to have not got there in the first place. So it’s as though we’re falling, we’re walking towards a cliff. There’s no fence, there’s no signposts a couple of miles back saying you have choices. We fall off the cliff. And there’s lots and lots of shiny ambulances and wonderful hospitals at the bottom of the cliff.
Rachel: Yeah, but it would be much better, yeah, not to go anywhere near that cliff in the first place. Right?
Andrew: Indeed, indeed.
Rachel: And it does feel at the moment, actually, if I’m honest, a lot of us, it’s just walking along the edge of that cliff.
Andrew: I think that our professional, wonderful profession is a great privilege to be part of it. I think the whole NHS has been working very hard for the last few months. I mean, for forever, and I suppose over my professional career, it just feels as though the workload has got harder each year. But that may just be a personal preset. And a lot of people have given of themselves have given themselves above and beyond and there’s quite a lot of exhaustion around.
Rachel: And Andrew, do you think this is just in doctors and healthcare professionals? Or are you seeing it in other colleagues, such as you know, people working in law, senior managers, leaders, people running companies?
Andrew: I think it’s very widespread Rachel, and I suppose many of us have been privileged to go on a plane at some point. And we remember the safety instructions at the start of flight. ‘Remember your own oxygen mask before that of others.’ And I think that carers, whether they’re carers as mothers, whether they’re carers as professionals, whether they’re driven professionals in any way, we often forget that simple truth.
Rachel: Yeah, totally. I’ve been observing that in, I guess, myself and my friends, my colleagues, and it’s not just in the medical profession is in all sorts of other professionals who feel responsible for other people or companies or organizations, or actually feeling responsible for anything. I think we make a huge amount of mistakes, and we’re going to be talking about some of those mistakes today in the podcast I think you’ve got a really interesting take on this. Firstly, Andrew, if I was to ask you how you were or you were, asked me how I was? What’s the general response we get?
Andrew: I think the general response is a four-letter word fine. And of course, fine, Rachel, stands for fearful, insecure, neurotic, and emotionally imbalance. Which is a fair description of what’s under the surface for most of us. So that’s really interesting. So most human beings, their primary defence mechanism against psychological insight into their own needs, is denial. And if you push it harder with health professionals, with people, with managers, with people with busy lives, how are you? They sort of scratch their head and they think, ‘Well, I haven’t thought about that. I’m too busy looking after my responsibilities.’ So that’s the second psychological mechanism. So we’ve got denial and displacement are the two mechanisms that many people use to avoid putting fuel into their own tank.
They’re quite happy to give effortlessly from the tank, but they failed to put fuel into their own. And of course, these two Ds lead us effortlessly into distress, despair, disillusionment, exhaustion, maybe divorce and discipline, and debt. But certainly the three occupational health issues for doctors which are drink, drugs and depression. And tragically as a profession, actually, we have a higher suicide rate than some others so death is sometimes seen by the logical mind when the heart is terribly distressed or there’s untreated mental illness as an option and all of these adopted Ds, and all of these are avoidable because this is what happens when we have the car crash. This is not what happens if we avoid the car crash.
Rachel: Yeah, I’m just looking at that list. It’s a very sobering list. And I can see that distress and despair. I think there’s a lot of people who are really disillusioned at the moment. And also I’m seeing a lot of exhaustion. And interestingly, I was reading the book by Brene Brown, Dare to Lead, the other day. And she’s that, there’s that lady Colonel DeDe Halfhill, who’s the American military leader, was talking in there about, she’d gone to see some of her troops. And she was sort of doing this sort of inspirational talk to her troops. And she was noticing that they were all knackered, they were all exhausted. And she put that down to the fact that they had a lot on a really high workload. And she stopped and she thought, hang on a second, I just read something about this. And she said to them, ‘Look, I know you’re saying you’re exhausted, you’re feeling exhausted.
I just read something in Harvard Business Review that says that actually, when people have exhausted it might not be due to the workload, it might be due to the fact that they’re feeling lonely, and disconnected. Is that true with you?’ And she said, one by one, they started raising their hands, and that just struck me, I thought, ‘Ah, that’s what’s going on right now with everyone’.
Andrew: It’s certainly partly that and the five ways to wellbeing which you can find on the web in many places, the number one is connect. And as social creatures, we actually really benefit from connection. Connection can be, in many ways, we may get onto the autonomic nervous system in a minute and competition and running a race together is fun, but the connection at a social level is a sort of a calmer activity generally. And the other ones of course, you’ll remember are: take notice, be active, learn and give. And having been thinking about those just before our talk, Rachel, I suddenly thought, ‘Actually, it’s take six not take five, it’s all very well giving we also need to learn to receive.’
Rachel: Hmm, that’s interesting. When I teach about the five ways to wellbeing, I always sort of caveat the connection thing and the giving thing a little bit, because I think it’s very easy to think, well connecting that’s great if I’m connecting, that’s the way to well-being that’ll build me up. But actually there were some people in life that just, you connect with them, you’re completely exhausted afterwards. They’re life’s drainers, as it were, not life’s not life’s re-energisers. And I always say to people, you should see those people in your connection not as connecting but as giving. So if you’re going to connect with those people, what that’s doing, you’re giving to them because they’re not giving back to you. So you need to connect in the right way. Not just with a load of people, you know, we are connecting quite a lot on Zoom or over- but That’s not what we need.
Actually, we’ve got a podcast episode on it with Jo Scrivens. Talk about I think, very, very nice people and other deadly perils. So she wants to go back and listen to anything about who we’re connecting with and friends and who re-energises us and who doesn’t. That’s a good one to look at as well. So out of those, these, what else do you think at the moment is particularly pertinent for people, Andrew?
Andrew: I think what’s really important at a healing level or at a convalescence level, and convalescence is not a word that appears in the medical textbooks there now, but it was something that used to be really important in the 1930s, 40s, and before that, when there were no effective antibiotics. So if you had TB, you went to a sanatorium to convalesce. And so there was a whole lost art of convalescence. So I think the most pertinent issue is the exhaustion will bring with it distress. And in my work in practitioner health, I have seen a number of people who have high scores on the GAD and the PHQ, to the point where, they would have, had that been a patient, they would have said, I think, you know, you’ve got a problem. And you should, you know, let me sign you off and maybe some medication, or some CBT, or some talking therapies or whatever approaches appropriate. Doctors particularly will keep on working with those high levels of distress. The wrong side of the stress performance curve, probably with high levels of adrenaline. And of course, adrenaline makes us feel irritable, and can make us feel exhausted and can make us feel distressed. Adrenaline use for too long can lead us into exhaustion, and they think it’s normal and they keep working.
And so this is not mental illness at all. This is just exhaustion manifesting with symptoms and the symptoms of stress actually cover an awful lot of mental illnesses. And so I think the danger for us as a profession is to over medicalise exhaustion and to recognise for what it is and to recognise that we need not to go there. We need to know how to look after all mammalian physiology and ensure that we actually remember how to keep our tanks filled. Because if the gauge is on empty, or it’s empty, it’s even emptier than empty. Because we’ve been giving it all the time, all the red lights are shining, as it were, or flashing. But we’re not taking any notice. And so we work harder. So people often try and drive themselves harder to compensate. And so they become more meticulous, they spend longer hours at work, everything becomes an effort. And it’s very difficult for that person. Partly because one of the effects of adrenaline is actually to give us focused, targeted thinking, we miss the peripheral vision, we can only focus on the immediate threats, and we end up exhausted and our biology is, to use a professional word, knackered.
Rachel: But I’m just thinking, hearing you say that I think that many doctors and lawyers and other professionals in these high-stress jobs, have spent most of their professional careers working in that synthetic zone.
Andrew: Absolutely, and the educational system encourages it. And because we compete against each other in exams, we strive to get into the career of our choice, we’re privileged to do that, and the race doesn’t end. It’s ever harder. I think there are two aspects, Rachel. One is external expectations and drivers, and also internal. And if I can share a personal story, my colleagues, my medical colleagues, throughout our profession, I think you’re a wonderful group where, you know, I think we’re dedicated, we work hard, many who have been striving since the age of 12 because they wanted to go to medical school to get good grades at GCSEs, at low levels and are very hard working. And I have to make a confession at this point. I am, I sort of went through school and didn’t quite know what I wanted to do, and ended up doing Greek, Latin and ancient history. and maths and economics A Levels and got moderate grades. And I have to confess that I got into the guy’s hospital by complete accident on clearing for the prelim year.
So I feel very lucky to actually have a cultural perspective, that’s different because I didn’t strive. I work moderately, but I wasn’t a high achiever. And I realised that many of my colleagues are high achievers, and that’s great. But actually, the only internal driver of high achievement is not a good one. It stops you being able to relax, it stops you being able to be good enough in your own eyes. And other people may say, ‘How wonderful you are, you know, Rachel, look at what you’re achieving in this’ you know. And look at look at so-and-so, you’re a consultant, look at you, you’re a high-flying lawyer look at you as a businessman, as a leader, you know, well done, and inside many of us have that little bit inner voice that says, ‘Okay, so you’ve got, you’ve got the qualifications, you’re doing the job, you’re earning x, y and zed. But they, whether it’s the regulator or your colleagues, whatever they are about to find you out, most of us are also driven by the imposter syndrome. I think most professionals carry the imposter syndrome with them.
Rachel: So that’s what then puts us into this sympathetic fight, flight, or freeze.
Andrew: It’s partly that and it’s partly the demands of the job. So thinking about a GP work or hospital work, doctors are conscientious and they are, often, will want to finish every last detail. And certainly, many GPS these days don’t work seven hour days, or eight hour days or nine hour days. It’s 10, 11 and 12, in order to finish all the results, to do all that yet simple physiology of performance tells us that after hour eight, we are actually, we have diminishing productivity. So the Deming philosophy, W. Edwards Deming, transformed Japanese industry after the Second World War. His message was, it is management’s job to design the workplace so that the workforce can perform effortlessly. So it’s getting rotas right, it’s getting training right, it’s getting staffing right, it’s getting flow of information right, it’s getting the factory floor right. And it is not management’s job to say, work harder, here’s a stick, here’s a carrot, here’s an incentive.
It’s all about getting the environment right, so that we can blossom and flourish with relative ease effortlessly. And there’s a real problem in medicine, because we tend to be the leaders at certain levels, certainly in primary care we’ll often be leading our practises, together with our practise managers. We are also resistant to this sort of truth. And so often certainly in secondary care, a manager will not last a very long time in post. So that’s not meant to sound critical. A consultant may be there for 20 years, a chief executive probably won’t be there much more than five years. And a manager of the department may not be there more than three years. So as a profession we actually have to parent: we can see the long view clinically but we can sometimes get focused just on the patient. And so we need to parent the whole system into thinking health by modeling it and into thinking good design of systems by helping design them by not fighting against them. And we do fight against them, sometimes. We turn a little bit tribal because we because the individual patient is important or and we don’t see the big picture. And we don’t see our own health and we sacrifice our own health.
Rachel: Yeah. And I think it’s fair to say that the environments that most of us work in, are not designed to promote our well being at all. And I’ve listened to some fascinating stuff that’s coming out from, particularly Dike Drummond, who’s, the burnout position, he talks a lot of the time about, you know, you want to prevent physician burnout, 100% you look at the workplace. And you know, and I have heard, I have heard someone talk about the fact that a lot of people in health care are being emotionally abused by their workplace. Which is strong, but interesting,
Andrew: I haven’t heard it thought about like that, I think there are two aspects to that. You may well be right on that. But as health professionals who have learned about car crashes and not about how to avoid them, we will sabotage systems to our own satisfaction, and we turn tribal. And so when people try to introduce wellness initiatives, and I remember talking to the head of psychology at a trust in the southwest, it was a while back and I said, ‘How’s your well being initiatives going?’ And they said, ‘Very well, all staff groups are engaging.’ I said, ‘All?’ She said, ‘But not the doctors.’ And so a profession, we will sacrifice ourselves and not have insight into our own needs. And certainly I’ve talked about this on teaching episodes, you know, I asked people, does anybody ever self diagnosed or diagnose their family, as a doctor, and many of us have, and then there’s anybody missed a fracture. And I have to confess that it’s not mis- but delayed diagnosis has been there on more than one occasion for myself regarding family members and self. And you know, there’s something about not wanting to bother your mates, there’s something about it couldn’t possibly happen, not believing it.
Because as human beings, we go through our own bereavement when something happens and those that bereavement or that losses, means we have to transit shock, denial, anger, guilt, bargaining, depression, and acceptance. And often I remember, when I fell off a ladder a couple of years ago, picking apples in the tree, and I thought, ‘Oh, that hurts, but I can walk,’ and there was quite a swelling that came up like an egg. And I thought, well, I can still walk and wait there, that’s fine. And then the foot went quite black over the next three days. And it took me four weeks to recognise that I had suffered a fracture of my fibula, I was still able to wait there and it had healed itself. And I’ve never had an X-ray. But I have to say it really hurt in bed turning over for three or four nights, I’m sure. Here’s a doctor speaking, didn’t like to bother his colleagues, never bothered to go and get an X-ray. So as doctors, we either minimise for ourselves or we overcompensate, we over magic lies and we worry too much. And it’s really difficult to get it right for ourselves. So we do need to have independent advice on our own health sometimes.
Rachel: Yeah, totally. And actually, the bit I’ve marked a bit in the book that I just wanted to read out in this. This is exactly as you say, this is you speaking in the book, it’s remarkable that a profession that can be so compassionate and insightful into looking after the mental, emotional and physical needs of others can often be blind to its own needs. It’s so caring for others, can produce an insight deficit and how come is, how is it that other professions with equally emotionally intense work, so psychotherapist counselors, etc. and coaches are mandated to have regular supervision, debriefing support to ensure long-term psychological integrity and health. And the medical profession is immune to this. We suspect insight deficit, which fortunately, many are now addressing by accessing proactive support. Insight deficit.
Andrew: And insight deficit, Rachel is what happens if you’re on adrenaline, okay. And it’s also what happens if you haven’t been trained to have insight. And it’s also what happens if you work in a culture of ‘I will cope, I’m invincible,’ and there is a phenomenon called ‘medical invincibility,’ both personal and in the workplace. So I think it’s partly a protective mechanism. Because many of us have been through a medical school where actually in anatomy, we actually had the ‘privilege,’ I put that possibly in inverted commas as a dubious privilege of learning anatomy by dissection. And actually, we so quickly learn. So you know, thank you very much to everybody who’s donated their bodies, because it means that surgeons are good surgeons because they’ve done all that, and all of us have learned. but actually we learn to identify ourselves as separate. There’s ourselves and there’s ill people, you know, we are different. And it’s a partly protective mechanism, quite apart from the fact that the curriculum includes nothing or very little about health, as opposed to an awful lot of our illness.
Rachel: Yeah, it’s fascinating, isn’t it? And I think there’s something else to add in there. And I was thinking, interesting discussion on a Facebook group about this recently. It’s not only that we don’t have the insight. But also if you do have the insights, or you have insight for other people, it then puts extra burden on you to, if you notice someone else is struggling, if you want to, you don’t want to miss it because other people actually don’t want to hear about it. Because if you’re working in a practise, and there’s 100 patients to see, and you can’t say you’re 50 of them, then that’s 100 patients for another person to see.
Andrew: No, and we look after our mates and we try our hardest and, and it was a real challenge. So I’m privileged in my work with practitioner health to have seen a number of doctors who and many of them are completely normal people. And all that’s wrong is that they are the wrong side of the stress performance curve. They have been there for too long, they are running on empty, they are exhausted, and they respond very well to some education about the autonomic nervous system, to some normalizing of that, because it’s not an illness to be exhausted and generated some time off. And the great majority of them actually choose that time to learn about health and how not to fall off the cliff next time because very often, breakdown leads to breakthrough. The tragedy is if it doesn’t lead to any learning, and we end up repeatedly breaking down by making the same mistakes all the time, again, and again.
Rachel: Yes, and I always teach that, you know, you actually want to catch yourself before you get to that breakdown point, because once you’ve broken down, it takes so much longer to recover than it does if you can sort of prevent it from happening in the first place.
Andrew: I couldn’t agree more. But until the medical schools and until all postgraduate courses include health as an important topic. And until we as a profession, think about the medical profession, particularly actually accept that actually, it would be a good idea to learn how to be healthy, rather than pretending that we’re invincible and don’t need to know about that. Until that happens it, we will continue having difficulty. Of course, there will always be difficulties. But we have a system educational deficit of which means that many people end up as casualties.
Rachel: Yeah, in a minute, I want to get onto how we can get out, you know, sort ourselves out and get out of that sympathetic thing. But it’s just interesting. So I used to teach professionalism and we really struggled getting students to want to learn about resilience, because at that point, they thought they were superhuman, and they hadn’t sort of hit up against the struggle. They didn’t know what it was like to be on the walls at four in the morning, completely knackered and not knowing what to do. You know that it’s at the time when you need to learn about this stuff is the time when you don’t know the importance of it. So it is very difficult to actually impress them, you know, you ask any, any sort of GPS of my age. Now, you know, that’s the most important thing to learn how to cope how to do this, but you talk to medical students about it. They’re like, actually, no, I need to learn what I need to learn to pass my exam. Thank you very much.
Andrew: Then perhaps we should be examining people on health rather than illness examining on how to avoid car crashes, because we all have to do driving tests before we’re let loose in a missile. Yeah.
Rachel: Good point. Good point. Well, so what I’m interested in is how we get so you’re really good point that we’re driving along in this sympathetic zone. And this adrenaline zone, we’re a bit tunnel vision, our focus is really strong, because actually, that’s what happens. And we’ve been in this zone for most of our lives. And the problem is, it’s fair and I’ve experienced this myself, it’s really hard just to stop.
Andrew: So very often, we only stopped when we hit the buffers or we hit the wall, metaphorically. And I run through in my 20s, my late 20s. I actually was buzzing busy. And I’m not going to ask the violin to play for the rotas we used to do in those days. But it was a very busy job, and I wasn’t terribly happy in it. And it wasn’t a specialty I was loving. And I caught mumps. And that was really interesting as an adult, I caught it from a child on the ward. And I was exhausted at the time or didn’t feel, I wouldn’t have said I was exhausted but the soil was knackered. This little seed took, and I was three months off work and it took me five years before I was fully back to feeling better.
And that’s why I, fortunately as in my time as a GP in charge, I learned an awful lot about health because I was sympathetic to learning about health because it was important to me. So personal conversion is really important. So thinking about the autonomic nervous system Rachel if we may just for a minute if we look at, so going back to GCSE. going back to A-Level Biology I hope we all remember that there are two aspects: there’s the sympathetic which is nothing to do with sympathy. It’s all to do with fight and flight, danger, alert, alert, red lights and lots of adrenaline cortisol and postpone immediate needs. Blood goes to the muscles diverted from the gut, blood preserved to the heart and part of the brain but not all of the brain. We stopped losing the critical faculties of being able to listen to what other people are saying. We find lots of things as a threat. criticism or advice becomes a threat. And the problem with adrenaline is a little bit of it actually feels quite good. And it’s not until you’ve got quite a lot that you actually start to shake and you get the dry mouth, sweaty hands. And of course, we decompensate, eventually, we not only get the tunnel vision, but with too much adrenaline for too long we get intense fear and we become exhausted. That’s biology.
Now, the parasympathetic nervous system, which is the engine management system of takeover, rest, repair, chill and digest, is actually just as important or perhaps even more important, and if we think of our pets, our cats or dogs or animals in the field, because I live in a rural area, cows or more sheep. Do they spend most of their time on sympathetic alert? Red lights, fight-flight danger, or are they on parasympathetic, chill, rest and digest. And I would postulate that the default system for the mammalian body is 90% of the time parasympathetic tone very high, and a little bit of sympathetic tone, because we’ve all seen how a cat can suddenly jump up from being at rest, and maybe only a few percent, 5%, 10% on sympathetic or less. Now, human beings in the workplace, it’s the other way around.
Biology tells us that if you are and this goes back to Hans Selye’s general adaptation syndrome, if you stimulate rats, was his original experiment. So if you took two groups of rats, the control group lived for a long time, happily in cages doing whatever rats did. The experimental group, he chilled to 4°C as the intervention, and he kept them chilled to 4°C and they had an alarm phase, they ran round, scampered looked ill or whatever, happened where they probably shivered a lot. And then if you kept them with the same stimulus going on, 4°C, they looked normal on the outside, but they all died early. And when they were sacrificed, he found that they had adrenal fatigue, they were all exhausted. And at the point of alarm, of course, they all had high levels of adrenaline going round. And in the middle phase adaptation, the adrenals hypertrophied to be able to cope.
And I suspect an awful lot of us as humans have overactive adrenals, not to the point of pheochromocytoma running, but we’ve got adrenals that are really working with foot hard down on the accelerator to keep the thing going. And of course, we feel exhausted.
Now there is a sting in the tail. And in fact, there are two sting in the tail. One is that whatever the stimulus, you still get the same response of alert. So whether it’s loud noises, whether it’s demands from work, whether it’s more tasks you’re being sent, whether it’s being dehydrated because it’s too long, since you last had a drink of water, whether it’s being sleep depleted, whether it’s being, whether it’s having a low blood sugar, because you haven’t attended to your body and eaten recently, all of these are seen equally as threats by the body and put us on the stress response. And the sting in the tail is that if you take away the stimulus, or stimuli,and allow the organism to go back towards normal, there’s actually a rerun of the alarm phase. So actually, we get. So emphatically the example of this would be, let’s say you have a patient comes in, who’s got dreadful headaches, and you take a history, and you find that they drink no water, or they’ve got recurrent headaches. They drink no water, and they have 15 cups of coffee a day. And then there are no other red flags. And you’re quite happy that it’s not a brain tumour, because people always worry about that. And you’re happy that it could be due to caffeine intoxication.
If you ask them to stop just like that, they will go through a crashing withdrawal and having a migraine that will last two or three days. And so decompressing people gently without going through an alarm phase is really difficult, which is why many people swap one adaptation for another, you know, you stop your coffee and you go running instead or whatever, or you stop smoking news. Anyway. So the problem is that the biology is giving us messages, but we don’t like to hear them. And it’s not nice going through the alarm phase again, because it takes time. It takes a couple of weeks for the physiology to accommodate to being on parasympathetic. And however, there’s something really simple that we can do to put a deposit into the bank of parasympathetic calm, and I would do as long as you’re not driving at this moment, or using heavy machinery or concentrating I would invite you to put your feet flat on the floor to allow your spine to be comfortable. And to allow your hands to relax into your lap or wherever you want and just using your diaphragm using your abdomen. Just take three gentle, regular, rhythmic, calming, supportive diaphragmatic breath, and just notice what happens. Aa nd how do you feel Rachel, after three of those.
Rachel: Yes, amazing. Actually, it does just bring things down, doesn’t it?
Andrew: Well, the problem is the secret because in the autonomic nervous system when we’re on parasympathetic, when we’re on sympathetic drive, our breathing is rapid, like my speech. shallow and chaotic and upper chest. And on parasympathetic, our breathing is abdominal, slow, rhythmic and regular. And all we need to do to put ourselves back on parasympathetic in the moment, is to adopt a comfortable posture, feet flat on the floor, spine comfortable. And take three, four or five, slow, regular calming diaphragmatic breaths. Ideally with gaze lifted, either horizontal or lifted, because gaze down often drops our mood slightly, or lifts. And so gaze horizontal or lifted, and lift our spirits. And then that just puts us back onto parasympathetic. And we’ve made a deposit into the bank of health account in the calm.
Rachel: Love it, love it. So really simple, really easy thing that anybody can do. And I think there are these little things that we can do throughout the day that can help in this podcast episode, all about breathing that we did that we did recently. Richard Jamieson, I think so that’s all well and good, Andrew, it was great.
Andrew: It was the revolutionary art of breathing, wasn’t it?
Rachel: That was it. Yeah. But what I’m gonna say is, that’s all well and good saying that, but then what, how do you then two things put you into your rest and digest system? Because I think as professionals, we are really bad at resting and doing that. I’ve noticed that in myself, you know, I’m always on the go, I’m always running or doing bike rides or doing this and feeling and I sometimes feel that I don’t actually know what to do, to relax, and there’s so much to do.
Andrew: Well, we have to schedule it as important otherwise, we’re consumed by the urgent. And as task driven humans, we will always attend to the urgent rather than think about the important on that quadrant of urgent and important. Not important, not urgent. And the other thing to do is to make it a habit. So I would hope all our listeners we’ve all been really well-trained, and we wash our hands between patients, we wash our hands after going to the loo, we do the washing up after our meals, whatever. These are habits. These are habits of tidiness and hygiene, we have recognised as important and internalised.
If we had the habit of thinking that there was always money in the bank, and then eventually the credit card bills come and they mount up and the cards are declined. We’ve actually deluded ourselves. If we drive a vehicle, and it hasn’t been put on charge or fuel in the tank, and eventually we grind to a halt, we’ve deluded ourselves many of our listeners will be near London, and I suppose I would ask the hypothetical question. It’s a trick question. Where is the most convenient place on the M-25 to run out of fuel? And it’s a trick question because there is no convenient place on any motorway ever to run out of fuel. The answer is not to run out of fuel by making sure there is fuel in the tank. But why is this as human beings that we can be an insight freezone when it comes to our own health, particularly those of us who are professionals looking after other people?
Rachel: Yeah, totally. And we did talk about this with Dr Jess Harvey, who is a GP and a professional athlete, is a very high-achieving GB triathlete. And, you know, she was saying that as athletes, you know, you’ve got to rest, you need to do this. But as professionals, we don’t think we just don’t think we need to. And that’s this, again, this lack of insight. I think, you know, for me, the problem is in my head, I know, I’ve got to do it, I know I need to get more in my parasympathetic zone. I know that rest is really, really important. And I spend a lot of time talking to people about rest. But it’s really hard to sort of convince yourself inside that when you are resting, that’s a really good thing to do. And maybe it’s because we have been used to this drive that we’ve got to achieve. There’s always exams to revise for, there’s always more things you could do for CPD, for appraisal. So do you think it’s more of a giving ourselves permission to do it thing?
Andrew: I think that’s really important to give ourselves permission. And actually, it comes back, you know, back to one of those universal values. And you know, most of us like being here on the planet doing life but sometimes we don’t always love life. And there’s eternal wisdom that says love other people. And you’re most of us try our best to be kind to other people or to respect other people or to love others. But do we do that to ourselves? And do we do that to our body? Our own body, which is our vehicle? It’s all very well loving other people’s cars and putting fuel in their tanks and cleaning them for them.
But if you don’t attend to your own vehicle, and so there is something almost self-sacrificial about us as people that for whatever reason, we either don’t like our bodies or we don’t value them as our special vehicle to enable us to live our lives. And I don’t mean indulge the body. I do mean make sure that the biological imperatives of sleep, hydration, social contact, food, fresh food and adequate food are all important. And they are the base of Maslow’s hierarchy, along with feeling safe. And if we don’t attend to those, we have to be prepared for the fact that our performance may not be what we wanted to be, and our health and our well being may not be what we wanted it. We have to get the foundations of health right.
Rachel: Yeah. So Andrew, we’re nearly out of time. If you were to give three tips about I mean, if you’ve got more than three tips, your whole books were to tip over three tips from following our conversation about how we get over this denial and this displacement that we’re doing in terms of our own health and staying healthy as opposed to living in this constant state of being in the sympathetic nervous system, what would you say to people?
Andrew: I’d say, prize quiet time. And that you can be busy and have quiet time, you can have quiet moments frequently through the day. I don’t mean long, long periods of time, particularly. And you can do that just by breathing calmly and just as we have earlier. I would say, I would suggest that we all reflect on our values, what is really important to us. And also take the phrase ‘own oxygen mask first’, seriously. And that’s not selfish, self love.
Rachel: What would you say to anyone who felt that they are walking at the edge of that cliff and can see sort of impending impending disaster happening there?
Andrew: I would say ask for help early. So, and particularly for medics, don’t overmedicalise but also don’t undermedicalise. Do seek help, and do seek help independently. Don’t necessarily self diagnose. In the book, we’ve put 10 top tips for being a patient, and 10 top tips for doctors who are doctors to patients, and 10 top tips for doctors whose patients have parents who are doctors, which are quite fun ones. Interesting. So there is help there. There’s a lot of information on the web. There’s, of course, our own doctors, our own GP or health advisors. I would say listen to our families, listen to our friends, ask them, What do you think about me and my health at the moment and be prepared for this, rather than take it as criticism. What would you advise? Ask yourself about yourself, what would I advise? As a trusted friend, or as a colleague, what would I advise a colleague who I found in this situation?
And certainly, particularly for doctors, but for all professionals, please don’t buy into the stigma that you, that it’s, that you can’t ask for help. We, many of us carry shame. And so we fail to ask for help. And as doctors, we want to look after other doctors. As practitioner health, we certainly want to look after doctors with mental illness or addictions issues. Health is there, and ask for it. And the BMA has got some great resources on its well being page. And we owe it to the profession not just to fall off the cliff and then be helped, not just to notice as we’re falling and ask for help, not just to notice when we’re at the top of the cliff before we fall off to ask for help, but to learn all the ways that keep us well away from the cliff, going in another direction towards a much more satisfactory destination.
Rachel: Great. Andrew, thank you, thank you so much. It’s easy to think sometimes that, you know, we’re just sort of banging on saying the same thing again and again and again. But I think it’s so needed, because we hear it and then it goes in one ear out the other and then we need to hear again, and then we need to hear it again. And just to say to anyone who’s listened to the podcast, if you’ve recognised yourself in any of this, then do something about it. Don’t just sit back and think, ‘Oh, it’ll be fine’. And I personally found that story of the rats quite alarming. Because what’s going on inside in us with the whole adrenaline, you know, if we could examine our own adrenal organs. I think our own adrenal glands, I wonder whether we might be a little bit shocked and a little bit more worried. And I don’t think we talk enough about the life-limiting effects of chronic stress on our bodies.
Andrew: Thank you. You’re absolutely right. And we’ve put all this in a resource, which is a download, free download from the web, and it’s www.healthandself.care. And I suppose it includes a whole load of experience from a number of us. Probably lots of material we wish we’d learned earlier in our careers. And there are some stretches for the profession as well as one or two stretches to challenge us and so if you do read it, please don’t take it. As read, please use it for debate and to stimulate reflection.
Rachel: Thank you so much. And we’ll put that link in the show notes as well. If people wanted to contact you, how can they find you?
Andrew: There’s an email address on the inside back cover of the book and on that website. Yeah.
Rachel: Great. So we will put that in there as well. So thank you so much for coming on the podcast. That’s been really, really helpful to me, and hopefully we’ll speak again sometime soon.
Andrew: Thank you so much, Rachel.
Rachel: Thanks. Bye bye.
Andrew: Thank you. Bye bye.
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