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Episode Transcript

Dr Rachel Morris: Do you struggle to say ‘no’ to things? Do you want to set boundaries and create limits around your work, your availability in your time, but you feel terrible when people don’t get it or don’t like it? Do you beat yourself up when people aren’t happy or criticise you, even when it’s not your fault? And does this sometimes make you feel helpless? Like you have no choice?

This week, the tables are turned, and Dr Sarah Coope, GP, coach and medical educator joins me on the podcast to interview me about what I’ve seen and learned through the COVID pandemic about workload, setting boundaries and dealing with criticism through chatting with guests on the podcast, delivering our Shapes Toolkit, resilience and productivity training and coaching doctors. We discuss some of the deep-seated reasons why we might be reacting so badly and why it’s hitting a raw nerve. We chat about why recognising our limits and enforcing our boundaries can be so uncomfortable and difficult and how we can find ourselves ping-ponging between the rescuer and the victim mentality by either taking too much responsibility or taking not enough control over our situation.

So, listen to the episode if you want to find out why the stories in our heads may be increasing our stress and exhaustion, how to tell when the boundaries you’ve set are working and some better and simpler ways to deal with public criticism and private disapproval.

Welcome to You Are Not A Frog, the podcast for doctors and other busy professionals who want to beat burnout and work happier. I’m Dr Rachel Morris. I’m a GP, now working as a coach, speaker, and specialist in teaching resilience. 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. We hardly noticed the extra long days becoming the norm and have got used to feeling stressed and exhausted.

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. It is possible to craft your working life so that you can thrive even in difficult 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 love what we do again.

Thank you to so many people who’ve shared the podcast with friends and all the listeners who have emailed, giving me feedback. I always love to get emails from people telling me how the podcast has helped them. And I feel so grateful to all the amazing guests who have shared their time and their wisdom.

Now, I’d love to hear from you. Is there a particular topic you’d like to see covered? Are there any guests you think we really need to get on? Or would you like to come on the podcast yourself if you’ve got something to share? Or an interesting take on how to beat burnout or work happier? You may also have some questions you’d like answering. If I can’t answer, then I’ll probably know someone who can. So, just get in touch with me at hello@youarenotafrog.com.

And finally, if you’re enjoying this podcast, please tell your friends and colleagues about it. Or perhaps share your favourite episode with them. And please leave me a rating and a review if possible. This really helps the podcast to be discovered by others, and it also makes me really happy. On with the episode:

So, it’s brilliant to be on the podcast today with Dr Sarah Coope. Sarah is a senior medical educator at Medical Protection Society. She has a background as a portfolio GP and is a very experienced trainer, educator, appraiser. You name it, I think you’ve done it. Is that right, Sarah?

Dr Sarah Coope: Yeah, I’ve done a mixture of things in my portfolio career, Rachel. Great to be here with you today.

Rachel: And, I think this is gonna be a slightly different podcast today. Is that right?

Sarah: I think I persuaded you to let me interview you today, Rachel. So, yeah! That’s the aim of today’s podcast.

Rachel: Oh, good grief. Okay, well, let’s see how this goes. It’s weird for me, being the interviewee rather than the interviewer. I feel like I’ve completely lost control.

Sarah: Well, I have a few questions up my sleeve of what I thought might be interesting is we’re to look back over the pandemic. Obviously, it’s presented huge, huge challenges, isn’t it, for all of us out there? But just really thinking about the podcasts that you’ve recorded over the pandemic and the conversations that you’ve had with doctors and other professionals, what would you say the overarching challenges are?

Rachel: It’s really interesting. Because it’s changed. I mean, initially, it was just like, ‘Ah, what can we do to help? How can we help people survive this massive crisis that we’re all going through?’ It’s very much focused on well-being, you know – how to keep yourself well? Mental health, how do you prevent stress and anxiety? How do you keep your family safe? How to not spend all your time scrolling through the newsfeed worrying about what’s going to happen? How do you cope with [the] grief and trauma of the crisis?

Because certainly, for doctors, there was a lot of grief and trauma and guilt and moral injury, as well. Certainly, looking at that. And then, we started to look at time because people then became… After the initial, everything locked down, haven’t got anything to do. Well, apart from that you’re on the frontline, working, but there are a lot of people that couldn’t work because we couldn’t see patients for a little bit. So apart from on the screen, mostly, it then became more, ‘How do I manage my time in a virtual world? How do I cope with the isolation and the lack of connection? How do I do it? How do I continue to act so professional and deal with my family and my friends and support everybody? And how do I support my team without burning out myself?’

I noticed that a lot of leaders were just running around like headless chickens trying to be all things to all people. And it didn’t go very well for lots of people. So when you look back, you can see the shift, as opposed across initially, that response to, ‘Okay, crisis mode! How do we cope with that? What has been thrown at us into, then, how do you manage your time? How do you manage resources? How do you look after yourself? How do you look after the team, people around you?’ And I guess just that whole sense of it was a massive transition, wasn’t it, in such a short space of time.

Sarah: When you think about the podcast, when you’ve had loads of amazing inspiring people on here on the podcast, anything that stands out at you in terms of key messages that really landed well for professionals, do you think during that time?

Rachel: I think that the first key message that landed well, which is one that my colleague, Caroline Walker, who, the joyful doctor, we’ve done a lot of joint working through COVID. And that’s been one of the joys for me over COVID, is all the collaborations and things like that that we’ve done with people like you, as well, Sarah, which has been fantastic to have you on the podcast. Caroline was very much talking about ‘it’s okay to not be okay’. Every time I spoke to her, she’s like, ‘All right, we’ve got to normalise this. We’ve got to normalise this for people. Say this is what you’re experiencing, and it’s okay’.

Because I think as healthcare professionals, we don’t think it’s okay not to be okay. And we don’t think it’s okay to have feelings since before, anything’s difficult. So a lot of it has been about, it’s okay. It’s okay to be struggling right now. In fact, it’s not even, it’s not just okay, it is normal to be struggling right now. So a lot of the emphasis has been on the normality of the struggle and what’s been going on, and then, some of the other standout things. For sure, there’s been so many. But I think the thing that listeners, things they’ve appreciated the most, actually, is the stuff about getting out of the rescuer mentality and ditching the saviour complex and handing the naughty monkey back, which is all about not feeling over-responsible for everybody because I think we really did feel responsible for everybody.

Let’s face it, in a global pandemic, it is the healthcare teams that are responsible for people. So, in many ways, we were, but that can be definitely overplayed. A lot of the themes have been about helping people create appropriate boundaries in which they can step back, and rest and look after themselves. In order, they can go on and keep caring for other people. And I was quite surprised about how much the stuff around being a rescuer has really landed with people and how people didn’t really know about that stuff. Actually, that shouldn’t have really surprised me because I didn’t know about it until I learned about the Drama Triangle only a few years ago. For me, it was like, ‘Oh, my goodness!’ And then, you start to look through that lens and realise how much you are in rescuer mode and how much you think you are responsible. And you should be doing this, and you should be doing that. So that’s been one of the big surprises for me.

Sarah: I think there’s kind of key messages around normalising what feels abnormal to normalise the struggle is really, it’s been really helpful to people, hasn’t it? I know in medical protection, when we run webinars, and we get feedback from people, just for them to know they’re not alone has been really powerful. It doesn’t change the situation that you’re in, but it just really helps to know, yeah, you’re not alone in this. I think that’s really key. But also, like you say, that self-awareness. So thinking about things like the Drama Triangle, what role we can play — so the victim, rescuer, perpetrator. You say that we know about that, we don’t recognise what’s happening. And the other thing you said about being over-responsible. What sort of things are you recognising or from what conversations you’ve had, what sort of things are people being over-responsible for?

Rachel: I think people are feeling very responsible for their teams and very responsible for the well-being of the people they worked with, almost to the point of if-then, something went wrong for the people that they work with, feeling it was their fault, or feeling that they could do something to make it right. Or if someone they were working for were having a hard time or actually, even being a bit difficult or obstructive. They’d be bending over backwards to make it okay and make everybody happy. And we know that you can’t make everybody happy all the time. You cannot please everybody all the time, but feeling absolutely awful when you couldn’t do this impossible task and questioning over-responsible patients, I guess, in a way and bending over absolutely backwards to please their patients and to do what the patients needed and to keep the service going. And then, when the patients don’t get exactly what they want at exactly the time they want and start complaining, feeling absolutely devastated about it.

Almost like it’s a personal criticism. ‘It’s my fault, and now they’re upset’, and it’s been quite interesting. So I’ve been watching it from a little bit, from afar, thinking, actually, we’re getting incredibly upset about this dreadful media coverage. And quite rightly so with the way that the public sort of turned from clapping the NHS to then complaining about everybody and saying, accusing GP surgeries of not being open on our colleagues. But on Twitter, it examines a patient. This patient was putting on his shirt. The patient turned around to him and said, ‘So when are you going to open?’

Sarah: Really?

Rachel: But people were quite surprised about the angst and very, very upset about it. I just looked at it and thought, ‘Of course, they’re angry and cross. Look what’s just happened to them over the last year. It’s nothing to do with you’. But we take it very personally because we feel responsible. If we feel responsible, and someone moans, then we get very, very upset. If you’re not feeling responsible, and someone moans, you can then empathise and go, ‘Yeah, isn’t that dreadful? I’m so sorry that you are now stuck down that waiting list, and you can’t get everything you want done straight away. I’m really sorry. But that’s the way the system is’.

But instead of that, we’re going, ‘Oh, my gosh, this is awful. They shouldn’t be saying that’, and working so, so hard to try and meet everybody’s needs and burning ourselves out without realising that perhaps, we do need to put ourselves first in order to be able to provide the service that we want.

Sarah: And that’s interesting, isn’t it, recognising the difference, perhaps, what’s going on, I wonder, for people who do feel over-responsible compared to perhaps, those who don’t. Not at all, so they’re not caring for the patients in any way. As we sort of said, and maybe actually taking less responsibility for things that are not within your control can actually be helpful.

What do you think people who perhaps take over-responsibility for, what do you think they might be telling themselves that they do that?

Rachel: I can tell you exactly what they’re telling themselves because I have these thoughts quite regularly. ‘If no one else does it, who’s going to do it? I’m the only person who can do it. It’s all on me’. So there’s that. ‘If no one else does it, it falls to me’. Then, you’ve got the deeper level of, ‘And then, if it goes wrong, I’m going to look bad. It’s going to be my fault. I shouldn’t fail. I shouldn’t make any mistakes. I’ve got to be 100% perfect all the time’. And sometimes, we’re telling ourselves that it’s not okay for people to be crossed at us. It’s not okay for people to be upset with us.

I’ve been thinking a lot about this whole boundary thing recently because I did the podcast with Rob Bell about having the saviour complex. And he just said that you’ve got to make peace with your limits. I’ve been really thinking about what does making peace with your limits actually look like? And one of the things about making peace with your limits is being able to put the boundaries in, and then, accept the consequences of those boundaries.

I was listening to another really good podcast, with Glennon Doyle, who’s a very famous writer. It’s called We Can Do Hard Things. It’s a really good podcast, and she was talking about boundaries. And she’s had lots of boundaries. She’s had issues with addictions and things in the past. She writes all about that. And she said that in the school playground, she doesn’t like interacting with lots and lots of people. So she deliberately said, ‘When I go to school, when I go to parents’ evening, I’m there for my kids. I’m not really there to interact with other parents’.

So she sort of just focused on her kids and kept herself to herself. Then, her child had an issue, had a problem. And she called one of the other mothers. And she said to her, ‘Well they’ve been having this issue for a year’. And she’s like, ‘How come you didn’t tell me about it?’ And the mother said, ‘Well, I find you quite unapproachable’. And she said she was devastated by this that this mom found her unapproachable, whatever the word is.

She then phoned out her colleague, who said to her, ‘Okay, so do you… do you want to be approached in the playground?’ She said, ‘Well, no, not really’. And they said, ‘Well, congratulations, it’s worked.

Sarah: Achieved the goal.

Rachel: Yeah, you’ve achieved it, right? But you don’t like the consequences of that’. I think that’s the problem. Sometimes, we’re like, ‘I want to have some time and space. I really need a rest. I need to leave work on time. I need my partners to give me a break’, or whatever. And you put that boundary and say, ‘This is what I need’. And then, people might say, ‘We don’t like that. We don’t like that. We want you to work an extra session’, or ‘We want you to work longer’, or ‘We want to see you straight away’. We don’t like the fact that they don’t like it. But you know what? That’s what making peace with your limits is about. Does that make any sense? This is the first time I’ve actually said this to anyone.

Sarah: That’s really helpful, Rachel, because I think what you said there is around the importance of setting boundaries in order to manage what you are responsible for and what you’re not. But recognise that when you set boundaries, there will be, often, a negative… Well, there’s a positive consequence because that’s the protecting yourself consequence, isn’t it, that you do set the boundary because you need to protect yourself.

But yet, there’ll be a negative consequence, often, because other people will push against those boundaries. And often say ‘Don’t be a parent to use’. It’s your job as a parent to set the limits. It’s the child’s job to push against the limit but your job to hold that fast. I think that’s often really helpful to keep in mind.

But it’s true when we set a boundary in terms of what we will and won’t allow in our lives or what we can and can’t give. Other people don’t like that boundary necessarily. But they’re not taking it personally, in that way, I think, is really important… I was reading something the other day that said about the importance of setting boundaries and staying connected. And you talked about that earlier, when you were saying about empathising for somebody who maybe found it hard to get an appointment at the GPs, for example. So you’ve set a boundary, and then the person will push back against it. I think the important thing to do then is to empathise with that resistance without giving in to the boundary.

Whereas, I know it’s very tempting sometimes when somebody pushes against the boundary to distance because it’s unpleasant to see the consequence. And actually, rather than distancing, it’s hard to stay connected but not giving in. I don’t know what you think about that.

Rachel: I love that concept. Yeah. So empathise and hold the boundary. ‘I’m so sorry. I can’t see for a couple of weeks. I really hope things go okay’. And there’s always the other options if you need that.

Yeah, and I think with the boundaries, we are such, I’m gonna say, people-pleasers, but that sounds really derogatory. We’re not people-pleasers. We’re actually hardwired to want connection and want belongingness to a group. So being accepted and being liked by the gang is actually an existential thing for us. So, it’s not sappy to be a people-pleaser, it’s actually what our brains are looking for.

But we just need to accept that we are, like I said, we can’t please people all the time. When people push against it, we don’t like it. And then, what happens is, even though it’s not personal, we make it personal because it then hits on some of our deepest insecurities. So if you say no to someone, or you can’t work any longer, then it’s like, ‘Oh, maybe I’m not a good doctor. Maybe I’m lazy. Because the last thing I want to be is lazy’. And you start thinking, ‘Oh, crumbs, maybe, that’s it’. And then, we start with the should-ing, and they all ought-ing.

Something else I’ve been reading recently is this whole indoctrination about what we should and what we ought to do. I think, as doctors, we have a huge amount of indoctrinated thinking about what we should be like, as a doctor. We should always go the second mile. We should always make the care of our patient our first concern. As we know, it says in GMC duties of a doctor. And of course we should, either always… Well, it’s interesting, I’d like to know what you think about this. Of course, you need to keep patients safe. But does always putting the patient first mean we stay three hours late when they could have waited another week? I don’t know.

Sarah: Yeah, it’s not an easy answer to give, I suppose, into the part and fast guidance to that. But I think it’s a huge situation will be different when to but I suppose it’s always weighing that up and thinking, rather than ‘I should do that’, is thinking in some situations, yes, we should respond to an emergency. We should respond to things that can’t wait. But just slightly sidestepping that, I guess I’m thinking, if I catch myself saying I should do something, I’m learning to just challenge that thought and thinking, ‘Well, I could do that because I’m choosing to do this. So sometimes, you think, ‘Well, I could see that extra patient because I’m choosing to see them now because I want to check with myself that actually, they haven’t got a serious condition. Or I could actually say no to that. Because I’m choosing whatever else I’m choosing’. And just challenging that should and thinking, ‘I could, and I’m choosing’. And it was like yes and no, ‘If I say yes to that, what am I saying no to? And if I say no to that, what am I saying yes to’, and recognising that choice. But I think it’s not easy, is it, to set those boundaries in those situations?

Rachel: Yeah, really? No, I was gonna say I’ve also had this concept recently called ‘Hippocratic Oath-shaming’.

Sarah: Tell me more about that as well.

Rachel: I just read it. I can’t remember where I read it. So apologies if I’ve nicked it off somebody. But it was about how sometimes we use the Hippocratic Oath to shame ourselves and our colleagues, like actually, ‘Doctors should care for people. They should be completely selfless. They should be like this. It should be that’. We completely overdo it. And that’s where we circle back to the saviour-rescuer complex because when we think we should do that, we then think we’re the only people who can do that. And we should be caring for the patients rather than the patients actually caring for themselves and taking some responsibility for themselves.

I think you can apply that to our teams and our colleagues as well. As a leader in healthcare, often we think, ‘Right, I’m the only one that can sort this out for my team’. Actually, they got responsibility to sort stuff out for themselves as well.

Sarah: Yeah, I think a lot of what you’re saying now really resonates with me in terms of the work that I’ve done when I’ve been coaching doctors in the past, and you often get into like a core, I’ll say, core self-beliefs. So people often have, from growing up, from experiences, either at home, or at school, or in early adult life, a core self-belief, as in, ‘I’m not good enough’. And things you were talking about before. But when you get a complaint, ‘I’m so incompetent’, this is like a core self-belief, which rears its head sometimes, isn’t it?

It’s triggered off by either somebody who is angry, or somebody who’s upset with you, or someone anxious around you. It can trigger off that core self-belief. I think, often, we’re not really aware of how that underlying belief about ourselves is still often driving the bus in terms of our behaviour and our thinking. It can be quite freeing, often, to get to the bottom of that, sometimes, recognise when that comes up. Actually, how true is that really? Because I think that also drives a lot of shoulds and oughts because I’ve tried to do those things in order to avoid feeling not good enough and doing those things because I don’t want to feel that I’m rejected. And yeah, I don’t know what you think.

Rachel: 100%, I was reflecting on this recently. I had this patient who came and sat down. I’d never seen her before, right? I welcomed her in; she sat down. She said, ‘I don’t know what I’m doing here to be honest. I’ve never seen a doctor who’s any effing good. And you’ll be no effing good either’.

Sarah: Right. Nice.

Rachel: There you go.

Sarah: You know what? It didn’t really bother me. Obviously, it was rude. I was like, ‘Okay, very rude woman’. But it didn’t cut me to the core because I’d never seen it before, right? She had nothing to say about if I was any good as a doctor. She has no experience with me. So I could just go, ‘Okay, that’s obviously your issues. Nothing to me. Now, if that same patient had come in six months later, sat down and gone, ‘Well, you are no effing good’. Even if I’d done my best and brilliant medicine with her, I would have been really upset. It would have really cut me to the core because perhaps, deep down there is a belief that maybe I’m not as good as I could be. And I haven’t kept up to date as much as I could have done. Maybe I’m not as empathetic as I could be.

The stronger our limiting beliefs are, the more things are going to touch a raw nerve and shine on that nerve when people say things, and then, the more we’ll react to it, and the more defensive we are. Maybe that is what’s been going on with patients accusing us of not being open and not seeing them. Maybe that’s a bit of a raw nerve because GPs aren’t able to see patients in the way that they would want to. They don’t like that. And then, when a patient accuses him of not doing that, it’s even worse. And people aren’t able to spend as much time doing stuff as they would want to. It just all goes with spirals, just spirals! It’s so difficult. It’s changing those limiting beliefs about yourself. That’s difficult to do, actually.

Sarah: It’s really hard, isn’t it? But I think the first step is being aware of it. I think that’s the first step because once we’re aware of something, we have a choice as to whether we still believe that about ourselves. And if it helps thinking, ‘Where did this come from? Maybe that was true, then it was a misinterpretation, perhaps, of something that happened when I was younger. But actually, no, where’s the evidence against that?’ Sometimes it’s helpful to think, what else you can see that really goes against that.

And then, it’s also recognising there’s often anxiety behind a lot of it. So I think a lot of the behaviour, it doesn’t excuse it of patients. They’re saying things that are really unpleasant, but a lot of it is anxiety on their part, isn’t it? Again, this comes back to where we can stay connected and empathise, as you said, but hold fast to those boundaries as best we can.

We talked quite a lot about the rescuer sort of mode, haven’t we? The other part of the Drama Triangle is the victim mode, isn’t it? Any key messages or anything that’s come out of conversations you’ve had or experienced over the past time that you can use that’s helpful, helpful wisdom for people who might find themselves in that victim mode?

Rachel: I think it’s always really dangerous — the victim mode, because I would hate anybody to think I was saying that they were acting like a victim in these really, really hard, hard circumstances. But I think what doctors can have, and I guess other professionals too, is a learned helplessness that, ‘Nothing is ever going to change. I just have to suck it up. And I have no choice’. When you start to think like that, you then start to feel like a victim. And the victim mentality is very much, ‘I have no choice. I have to do this. I can’t change anything. I’m completely powerless’.

A lot of what I’ve been doing in my work that I’ve been seeing, either with one-to-one coaching or working with teams and training and through the podcast is actually asking people, ‘What are you in control of?’, ‘What could you change?’ Because I think we have control issues. We either try and control too much that we can’t control, for example, patient demand. I really don’t think we can control patients’ demands. I think that’s a much higher pay grade than ours, different level altogether. Can I control what patients think of me? No! Can I control what’s going on in my team’s personal lives? No! Can I control what they think of me? No! What can I do? So I can make some choices for myself.

Once I start thinking about ‘What could I do differently?’, that is when you become a little bit more powerful. And that’s when you start to step out of the victim mode. I guess that’s what the whole You Are Not A Frog podcast is about, right? It’s like, what are the small things that we can actually do? It’s really hard because one of the things that I am very, very conscious of is resilience victim-blaming. So with the whole resilience well-being industry and training and stuff, it can sometimes be seen as, ‘Right, the system’s difficult, but the problem is with you. You’re just not resilient enough. So what we’re going to do is just give you a bit of training, make you resilient to cope with it, and it is your fault’. I 100% disagree with that. It is not your fault. However, I also believe that there are skills that you can learn to make it better.

Someone gave me a really good analogy of this the other day. Resilience is not being repeatedly punched in the face. It’s not teaching someone to put up with being punched in the face. It’s teaching people what they can do to avoid being punched in the face. For me, that’s what taking control and resilience training is all about, is what can you do for yourself while other stuff also happens to work on the system in which we work. And it’s really important to be addressing the system in which we work and changing things. But as one human being, you can only do what you can do, not much you can do outside yourself.

So I think with the whole getting out of victim mentality, looking at what are you in control of? And where are you overstepping your control, trying to control what you can’t? Where are you not using your choices? Because we always have a choice. And this is something that’s really hard to get a hold of.

In fact, a coach I was talking to, she took it to the extreme. She said she was doing a talk. And she did this whole thing about control, what you control of, what aren’t you, and you’ve always got a choice. And someone came up to her and said, ‘I don’t have any… I don’t have a choice. Well, I didn’t have a choice. I’m South African. And in my day, you had compulsory conscription to the army at age 18. So I had to get in the army. I had no choice’. And she said, ‘Well, what would have happened if you didn’t go in?’ He said well, ‘I’d have gone to jail’. She said, ‘That’s your choice. Jail or conscription’.

That is a horrible choice, right? He didn’t like that choice. There was that choice. And mostly, we have a choice about stuff. There are some situations which are awful. And that’s not what I’m talking about. I’m talking about daily work situations. So, you know, when you leave, you do actually have a choice. But you might be choosing to leave work undone or to do certain things, and that will have consequences. But it’s like, what consequences are you prepared to put up with? What are you not prepared? It’s like you said, if you start to then use the language, ‘Will I choose to do that better and see that patient so that I won’t have to do it on the other day or so that they are safe?’ Let’s say that that’s much more powerful than ‘I’ve got to’.

Sarah: Yeah, that makes a lot of sense. I think what you’re talking about there is empowering people, isn’t it? So normalising that it’s really understandable to feel sometimes, we are a victim in the situation that we’re in because it feels like a lot of things being done to us as GPs or in the medical profession. But then, actually, that doesn’t tend to take us to a place of feeling empowered, doesn’t stop, really, going down that spiral. So instead, stopping and thinking, ‘Okay, this is all happening to me, around me’. But as you say, ‘What can I do to empower myself?’ Going back to that choice around, ‘I’m choosing to do this because I want this’. Recognising that there’s always that two-way option, I think, is really, really helpful.

For many people, they get stuck at making positive change and maintaining that positive change. I can often end up self-sabotaging. I don’t know. Do you wanna talk a little bit about that?

Rachel: Self-sabotaging. How do we self-sabotage? Oh, I don’t know. I’m not a real expert on this whole self-sabotage. And I’m sure there are some deep psychological reasons why sometimes we do it. I think the biggest way that professionals self-sabotage is by taking on too much. You start off with good intentions. ‘I’m going to do this’. And then this other thing comes in, and you say, ‘Yes’, and this other thing comes in, you say, ‘Yes’. And soon, you haven’t got any time to do that thing that you said you were gonna do. And then, it’s just impossible to do it. And then, you don’t feel successful at anything.

I think that’s one of the main things — the main messages that come out from any talk I tend to do is actually, you need to do less. You need to start saying no to stuff so that you can do a few things well. Once you start to say no to stuff, and you start to limit stuff, and you start to… A lot of it is actually staying in your zone of power. Because a lot of the time, we just can’t do everything.

I’ve been working with a few PCN directors recently. And a lot of them are saying, ‘How do I do this and that?’ And it’s all out of their control. An awful lot of the time, it’s just recognising that that’s out of your control. So what can you do with what you’ve got, and then, just leave the rest of the stuff. And by leaving the rest of the stuff, you actually become much more powerful because then you can focus on what you can control. I think that one of the ways we self-sabotage is by beating ourselves up about the stuff that we can’t see because we have no control over and actually becoming overwhelmed as a result. So it comes back again to that focused intention and being intentional about what is in front of you.

Now, I say, just do the next thing, meaning, be intentional about the next thing, rather than, I think, spreading ourselves so thin because there’s often a multitude of tasks that need our attention. I think there is often that sense of dissatisfaction because we can’t do it all. I feel like we’ve done it all well. So there is that sense of, again, just stopping and taking stock. I think if they can write, ‘What’s the most important thing right now, prioritising what needs my attention, how to do that’.

Sarah: We’ll talk quite a bit around, I suppose, boundaries and saying no. I think saying no can be a real challenge for many people in the caring professions. Any other tips around how to say no well? We’ve said about setting boundaries and sticking to your boundaries. But sometimes, it can start before that in terms of what stops people saying ‘No’. I don’t think having conversations, we build podcasts that’d be really helpful.

Rachel: I think that a big tip to people saying ‘No’ is themselves. It’s the stories that they’re telling themselves in their head. I think it’s quite hard. But I think because I do talk about the amygdala a lot. The amygdala being your threat detection system that will detect a physical threat, hierarchical threat, or a group threat. So the belonging threat. Because when we lived in caves, if the tribe didn’t like us, and we got chucked out, we’d probably die of exposure or eaten by a bear or both.

So, we really hate saying ‘No’ to people because that might upset them. They might think badly of us. And they might throw us out of the cave. And we might then die of exposure. So when someone asks us to do something, unbeknownst to us, our amygdala can certainly get, ‘Oh, hang on. Hang on. You’ve got to say “Yes” too. Because if you say “No”, that’s going to be really dangerous. And you’d probably be quite good to do it, and you really ought to do it. And you’d be a really bad doctor if you weren’t doing that.’, and ‘Who do you think you are?’ and ‘Blah, blah, blah, blah, blah’. So you’ve got these stories in your head that put you into your sympathetic nervous system, fight, flight or freeze thing, and you find yourself going, ‘Yeah, yeah, that’s fine. I’ll do it,’ just to leave the discomfort sometimes. It’s much easier to say ‘Yes’ than to say a firm ‘No’.

So, I guess the biggest tip I’ve got for saying no is to give yourself a pause. When you’re in that situation. Hit the pause button. Just have a phrase. Have something you can say. Say, ‘Can I get back to you? I need to think about that’. Sounds great. ‘Can I get back to you? I need to check my diary. Let me have a think. I’d love to say “yes”, but I just need to make sure I can actually properly say yes and got the time’. Give yourself that pause. Go wait till you get out of your sympathetic zone. Calm yourself down. Think about it. ‘Do I want to do this? Do I not want to do this? Am I the right person to do this? Do I have the time to do this?’

One thing we talked about all the time in our — Carolina and I run a Permission to Thrive CPD webinar membership community for doctors — one of our mottos is it’s either a ‘Hell yeah!’, or it’s a ‘No’. They’re like, ‘We’ve got all these opportunities’. It’s either going to be ‘Hell, yeah, I’m going to do that’. If it’s a, ‘Yeah, that sounds okay’, then that’s a ‘No’. That’s a ‘No’. Go for the ‘Hell yeahs’. Avoid the ‘That might be quite a good idea’. But take the pause in order to think about… And sometimes, it’s also, then, easier to say no in an email or by text or something like that. That sounds like a bit of a cop-out. But actually, you can just say, ‘No, I’m sorry’.

Also, I would say to people, don’t explain. Don’t explain too much. Say, ‘I’m really sorry. I can’t because I just really need a break this week. And I really can’t go out for another night. And I’ve got to see the dog and blah’. Just go, ‘I’m so sorry. I can’t do it’.

Sarah: So I think those are really helpful tips because it is something that it takes practice to get used to doing, doesn’t it, to say no? I can’t remember where this came from, but I remember it quite well. An act, act… Acronym. So ACTS, so for saying, there’s A was Acknowledge the Request. So, saying, ‘Okay, so what you’re asking me to do is X, Y, Z’. C is Clarify. So just clarify the request to make sure that you have got it right, because sometimes you can misunderstand the request. And T is Transform. So that might be possibly saying, ‘I’ll get back to you at a later date’. But it could also be transformed into, ‘Well, I can’t help you with that this time. But if you find yourself in a similar situation in three months’ time, let me know if that’s something you would be willing to do’. So transform it, so sometimes without jumping what else in it, might be, ‘Actually, I know someone else who would really love to do that’. And you could transform into recommending somebody else, but you have to be careful about that one. And then, S is Making a Suggestion, sometimes, for an alternative. But that’s a quite helpful framework, I think, of how to structure your ‘No’. But I think the most important thing is give yourself time, especially if you’re somebody who is a knee jerk. Yes, yes, I think it’s really helpful.

Rachel: My problem is I say yes to things because I genuinely want to do this. And I’m really interested. ‘Yeah, that’d be good. Yeah. Yeah. Yeah’ And then I come back to it, ‘Oh, no. What did I commit to?’ Another principle that I think is really helpful is say ‘Yes’ to the person and ‘No’ to the task. So it’s like, ‘Oh, I’d love to help you. That sounds like a really interesting project. Wow, you know, that’s it. I’m really sorry. I don’t think that I can do that. That sounds great. And if I could help in any other way, great, let me know’, type things.

So you’re really affirming the person, you’re just saying ‘No’ to the task. Because often, we feel we’re saying ‘No’ to the person, but we’re not. We’re just saying no to the thing. So that goes back to the boundary again. You’re setting there with a boundary. But you’re remaining connected by saying yes to the person. I think that reinforces that concept, isn’t it? Yeah, gosh, it’s almost like we planned this conversation.

Sarah: Just thinking back then what? What do you think people now might do differently at the start of the pandemic, if we were going back in time with what they know now? So think about perhaps leaders. It’s a hard one, that one, so to speak generally. But, I don’t know. What would you think people might do differently at the start if they knew what they knew now?

Rachel: I think, perhaps, plan that you’re in it for the long haul. I think we thought it’s gonna be a pandemic, don’t know how dreadful it’s going to be. And then, it’s going to be over. We’re going to go back to normal. It’s an interesting one. I think setting some goals for their team that work more around workload, well-being and resilience, it’s obviously important to keep physically safe at any time. But I think there wasn’t enough emphasis on how we can long-term sustain ourselves rather than short-term sustain ourselves.

And I think there… Talking to the national leadership, it’d have been much more communication with patients around what is possible and what isn’t possible and what the role of the doctor is. I think I would want leaders to be able to say to their teams, ‘This is okay. It’s okay to say “No” to stuff. It’s okay to set boundaries and prioritise their work a little bit more.’ So people weren’t weren’t feeling just so, so snowed under with it and just help… Have doctors know they’re doing an absolutely fantastic job. And just to hang on in there, and it’s okay to look after yourselves and put those boundaries.

I think we know that. But, the thing I’d really like people to know is when people kick against your boundaries. That’s okay. It means they were. Let’s celebrate that rather than get really upset about it.

Sarah: So from there, actually, if I’m going to turn the tables and say, what’s your three top tips for your listeners this week?

Rachel: From everything we’ve been… Talked about, I think, first of all, recognise when you’ve got that sort of rescuer complex, that superhero complex, when you’re thinking, ‘No one else can do it. It’s all down to me’. And that’s difficult. So one of the things I did want to say earlier was, I do recognise that when you’re a partner, when you’re running the show, when you might be the only person there, it’s even harder when that has an element of truth to it. But you need to, sometimes, and this is really hard to say, if you’re continually absorbing the stuff and doing it yourself, and no one else is seeing that there’s a need or a problem, no one else is able to fix it if you’re the one that’s fixing it all the time. So you’re just hiding, hiding, hiding the problem.

I think, according to Jeremy Hunt’s report… It wasn’t, it’s the House of Commons report into the well-being of healthcare staff. There was a comment in there that healthcare staff in the NHS and health and social care, they absorb so much extra work that they’re not paid for that if at any point, they stopped doing it, the entire system would collapse.

Sarah: To the extra absorbing, yeah.

Rachel: It’s the extra absorbing. I think doctors have been doing all that extra absorbing. The problem is, they’re collapsing, not the system. We don’t want anything to collapse. So there’s got to be alternatives. But maybe, we need to be having those boundaries. They actually know that exists, and push the problem up. So that actually change has to happen. That’s my first tip, I think. I’ve got probably about four different tips.

The second one is, work out what your boundaries are. And then, don’t get upset when people don’t like them – when you enforce it, then people react badly because that’s their problem, not yours. And then, thirdly, would be about this whole taking things personally that… Check the stories that are going on in your head. Check what limiting beliefs you have about yourself that things aren’t triggering, and then question, ‘Is that true?’

One way to question is just get together with some friends. I think that’s probably the other thing I would say to people in the pandemic. Get your gang around you right now. Know who your team are. Regularly connect with them. If you’re locked down, go on Zoom. If you’re not locked down, go out into it for a walk. As soon as you can go out, sit around a fire pit, have a drink, and compare notes. Just get out and connect with your team. Not people that are gonna suck the life out of you all the time but people that really get it, that can support you. Because like you said, knowing that you’re in the same boat as someone else doesn’t remove your problems, but somehow it makes it sort of easier to cope with it.

Sarah: Yeah, those are really helpful tips. Thank you, Rachel. Well, thank you for letting me talk with you today and turn the tables, as I said. I hope that’s been helpful for people. Just look back. And then, also taking your wisdom, your reflections, your insights, I think, taking it forwards and recognising that’s the whole thing about the marathon. Sort of, ‘not a sprint’ analogy is really helpful. I think, like you said about making peace with your limits, that really resonated with me. Also the sense of pace and balance. Does it feel like we have a lot of control over pace and a lot of control over getting the balance?

So again, just looking for those two things, and in the pace of things, what can I just slow down a bit? And then, the balance? What do I need to perhaps, increase in order to give me some restoration, some time off, some sense of better balance? Because I think a lot of people are feeling that there isn’t that balance there. So just one small shift that moves you in that direction. And that’s what made me think about when you were talking through those things, or yeah…

Rachel: Certainly. Thank you for asking those difficult, difficult questions. I think that’s been useful for people listening. We’d love to know people’s thoughts, actually. I think we should get you back, Sarah. I think we could maybe take people’s questions about any of this, and I’ll collect them all. We’ll get you back, and we’ll maybe go through them and answer them. How would that be?

Sarah: Yeah, that sounds great. I look forward to that.

Rachel: Brilliant. Great, thank you so much. Thank you. Bye.

Sarah: Bye.

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