Is it ‘Normal’ Not to Cope?

Rachel Morris: This is a You are Not a Frog Quick Dip, a tiny taster of the kinds of things we talk about on our full podcast episodes. I’ve chosen today’s topic to give you a helpful boost in the time it takes to have a cup of tea, so you can return to whatever else you’re up to feeling energised and inspired. For more tools, tips and insights to help you thrive at work, don’t forget to subscribe to You are Not a Frog wherever you get your podcasts.

I heard a physio talking the other day about runners, and she was saying that she had this patient that came to see her. He’d hurt his knee, and he’d been to quite a few other physios recently. He had several different injuries, and he said to her, ‘oh, you know what, I’ve seen every single physio in the centre around here, but I guess I’m a runner. It’s just normal for me to be injured.’ She said to him, ‘hang on a sec, it is not normal to be injured. It might be common, but it’s not normal.’

When I heard her talking about that, I immediately thought about healthcare professionals and stress because I can’t remember the last time I spoke to one of my colleagues working in secondary care or in general practice and said, ‘how are you doing?’ and they didn’t say, ‘ugh, really busy,’ ‘overwhelmed,’ ‘it’s getting bad round here,’ and it just seems to be normal. We think it is normal to be stressed.

We think it is normal to work 13, 14, 15 hour days, and we think it is normal for everyone to be resigning and for us to be on the edge of stress and burnout. Now, I read an article recently by Dr Dyke Drummond, the burnout physician from the States. He was saying that 60% of physicians in the States are showing symptoms of burnout. There was another stunning statistic from before COVID that 93% of GPs are suffering from moderate or severe exhaustion.

Now, to me, those statistics are awful. It shows that burnout and stress is common, very common, but it’s not normal. So I just want to talk a little bit in this Quick Dip about what is normal anyway, the effects that stress actually has on our health, and how we get normal so, so wrong — because I think in healthcare, we have a huge problem with normal.

You may feel, as a healthcare professional, that you have that constant feeling of low grade anxiety, that you’re living from one holiday to the next holiday, and you just about managed to destress on holiday before you go straight back into it. To be honest, this is very common amongst people who run their own businesses, amongst other professionals, but just because it’s common, it doesn’t mean that it’s good for us.

We know that stress causes all sorts of problems, particularly chronic stress. We know that when we have high circulating cortisol, it’s really bad for our immune system. We end up getting everything under the sun. We know it’s bad for our mental health. We feel anxious. We feel low. We know it’s bad for our physical health. We know that circulating adrenaline puts our blood pressure up.

Chronic stress is a risk factor for dementia, for cancer, for heart disease. We know that when we are stressed at work and we give up seeing our friends, we become lonely. We become disconnected — that in itself has the same health implications as smoking 15 cigarettes a day. So being stressed and being on the edge of burnout, being near burnout is not just a question of not making us feel good.

Actually, it’s bad for our health, and you know what, it’s also bad for our performance. You may have seen the Yerkes-Dodson curve. This is based on work from the 1920s published in the Harvard Business Review, and it basically shows what happens to a human being, their performance under increasing pressure. So if you think of pressure being along the x axis and performance being along the y axis, as pressure increases, our performance starts to increase. I know that I need some deadlines to get things done.

I know that if my son is lying on the sofa all day with nothing to do, he will get less than nothing done. But as our performance increases, it doesn’t increase in a linear fashion. At some point, it will stop, and at one point, you’ll be at a peak performance with peak pressure. In an ideal world, the line would keep going upwards but it doesn’t. It starts to plateau off and then you actually start to drop in terms of performance, where you start to perform badly.

You start to become ill. You might even be affecting other people, and we know why this happens. There have been so many different studies about pressure, about performance, about focus. We know that after about 10 hours of focusing at work, you’re pretty much good for nothing. So increasing pressure, increasing stress is bad for us physically. It’s also bad for our performance.

We also know that doctors who are heading towards burnout have a 63% higher chance of making a medical error, so this is also about patient safety. Yet, we think it’s normal to be stressed and on the edge of burnout. I think sometimes it’s quite helpful to understand the difference between stress and burnout, and this is how I think of it.

Stress is a very high energy situation. You’re going, going, going. There’s a lot of thoughts going on. You’re fuelled by adrenaline. You’re fuelled by cortisol. You’re constantly thinking about things. You’re working harder and harder to get everything done, and your mind is racing at 100 miles an hour. Now, burnout is very different. It’s when you’ll get up and go, it has literally got up and gone. It has left the building, and you feel utter exhaustion because you’ve literally burnt out your hypothalamic pituitary axis, so utter exhaustion. You then lose your empathy.

Now, Dr Catherine Hickman talked very succinctly about how she noticed she was burnt out, and the lack of empathy she had when she was burnt out several years ago. She tells this story about being right in the middle of burnout and going to pick up her daughter from nursery. As she went to pick up her daughter, one of the teachers came up to her and said to her, ‘oh, Dr Hickman, we’re really sorry, but somebody’s bitten your daughter on the nose.’

Catherine says, she recalls vividly. Her first thought was not ‘oh, my goodness, darling, how are you?’ Her first thought was, ‘oh, another thing I’ve got to sort out.’ So if that’s you, if you find that you’re seeing patients, and you’re thinking, ‘oh, just another thing I’ve got to sort out.’ If you find that your responses to your colleagues are not ones of compassion and empathy, but it’s just ‘oh, here we are, another issue. I’m dreading this. I really can’t be bothered,’ then have a think to yourself, am I on the edge of burnout here?

Then the third symptom of burnout is poor performance, so a perceived poor performance, but I think and we can see from the stress curve that if you are under increased pressure for too long, that actually you will burn out. You will have poor performance. So it’s a feeling of poor performance, and then there is actual poor performance.

Burnout syndrome is now an ICD classified disease by the WHO. It is caused by workplace. So no, it is not normal to constantly be stressed and to be working on the edge of burnout, even if it is common for doctors and other health care professionals. Another problem that we have with normal is our own response. I remember a few months ago, coaching a GP, middle aged man, and he was really upset. He was leading a practice.

They couldn’t recruit people. He hadn’t had a day off for months. He was working every hour. He did not know how the practice was going to survive, and his mental health had really deteriorated. He was feeling awful because of the stress he was under. I distinctly remember him saying to me, ‘what is wrong with me? Why can’t I cope?’ I thought to myself, ‘oh, my goodness, only a doctor would say that.’

With everything else being so tricky, what do we do? We blame ourselves. We say it’s because I can’t cope. But actually, it’s not just doctors. I remember, in a training session, I was talking about the effects of stress on the brain. I was talking about the stress curve and what happens to us under increasing stress because stress has a huge effect on our brain. Firstly, it interferes with your prefrontal cortex, so you can’t think straight.

Your prefrontal cortex is responsible for laying down memories, retrieving memories, for making decisions, for impulse control, and under increased circulating cortisol, it ceases to function properly. Plus, if you’ve got too many things going on in your prefrontal cortex, just like a computer, it will crash. So you’re not getting early dementia, you’ve just got too much going on.

So your prefrontal cortex stops working well, you become much more labile, much more emotional because circulating cortisol also shrinks your hippocampus which is responsible for emotional regulation. You become much, much more reactive to threats and to stress because cortisol increases the size of your amygdala. That’s your threat detection system, which responds to a physical threat, a hierarchical threat, or a group threat, the threat of upsetting people.

Very quickly, you go into your fight, flight or freeze zone, so you’re very, very quickly triggered there when you’re under increased stress. So no wonder we perform badly. No wonder we suffer from anxiety. No wonder we can’t cope when we are under all that pressure. It’s not that you can’t cope. It’s normal. It is a normal physiological reaction. So in this training session, where I was talking about all this, I noticed that a woman had run out of the room.

So when I finished the little bit that I was doing, she came back and I went to talk to her. I said, ‘what’s going on with you? Are you okay?’ She said, ‘I’m sorry, I had to leave the room.’ She said, ‘I’ve just been off sick with stress and burnout, and the reason I had to leave, I was so relieved when you told me that. I thought there was something wrong with me. Now, I realised there wasn’t anything wrong with me. It was a normal reaction.’

For her, just realising that it was a normal reaction was hugely releasing. It’s not something wrong with you. It’s not that you are acopic or weak; it is that you are under stress and strain that physiologically, we were not built to cope with.

So the two problems with normal, we’ve got, A, thinking that it’s normal to be under this amount of pressure, to be coping with this much work. It’s just normal in our jobs. It is not normal. It is common. The second problem with normal we have is thinking that we are not normal when we react badly to it, when it affects our health, when it affects our functioning, when it causes us stress and burnout. Stress and burnout are normal physiological reactions to what has been going on.

Now, the third type of normal I want to talk about is what should a normal response be to all of this, because when I’m coaching people, and they’re saying to me, ‘oh, this is awful. Why can’t I cope?’ The first response doctors and other professionals in high stress jobs go through is either blaming themselves for their symptoms, saying, ‘I’m too weak. I’m acopic.’ Or secondly, blaming themselves for being stupid and putting themselves in that position in the first place, and both of these are wrong. Now, I experienced this in a very minor way last weekend.

Those of you that regularly listen to the podcast will know that I’ve taken up ice skating with my daughter, and off I go every Sunday morning. Now in a bit of stupidity, at the end of my lesson last Sunday, I thought I had mastered this swanky new move. So off, I went to the teacher to show them, got my foot caught, fell over backwards, and I have snapped my fibula, so I currently have a broken ankle and I’m stuck at home.

What was my first response? Well, apart from ‘ouch, get me off the ice. I think I’ve done something really bad to my foot.’ My first response was ‘I’m so stupid. I’m so stupid. What was I doing? Why did I do that? Why did I decide to show off? Why am I even ice skating? I shouldn’t be doing it at my age. I should really give this up. I’ve been so idiotic. I’ve put myself in this position.’ I was sat there and I was utterly, crazily blaming myself for what had happened.

What is wrong with us? We blame ourselves for having the symptoms. Luckily, I didn’t blame my leg for snapping, but I blame myself for putting myself in that situation. But I’ve chosen to do that. I’ve chosen to do ice skating knowing what the risks are. Guys, we choose to do these jobs of ours.

We knew when we train as doctors or nurses, we knew it was going to be tough and that’s fine. That doesn’t mean that it’s our fault when the job is so tough and so overwhelming that it causes us to become ill. It is not your fault. So we’ve got to stop with the self blame and instead flipping to kindness and self compassion, so when we spot some of the signs and some of the symptoms of burnout and stress.

Now, these may be that we are more reactive than usual, it may be that we’re a bit more snappy, it may be that we find we losing our empathy and maybe that we’re feeling really, really exhausted, or we can’t sleep or we can’t switch off. When we recognise those signs in ourselves, the first thought should not be ‘what is wrong with you, why can’t you cope’ or ‘you’re so stupid for putting yourself in the situation.’

The first thought should be, ‘poor you, look what you’re coping with, no wonder you’re feeling like that,’ a bit of kindness, a bit of self compassion. What would you say to your best friend? I bet it wouldn’t be what currently goes through your head. So respond with kindness and compassion, not self blame and negative self talk.

The second thing you need to do is do whatever you need to do to get some help and to restore yourself back to the top of that stress curve, to peak performance. Ask yourself, ‘what do I need right now? What would I advise my best friend, my partner, to do right now?’ It may just be take the evening off. It might be go for a run. It might be have a bath, but it might be go and see your own GP. It might be go to practitioner health. It might be phone a friend and discuss what you need to do next. So what I want you to do is have a look at the stress curve that I’ve put as a free download in the show notes for this podcast, so either you can print it off or look at it on the screen, and then just draw a curve on a piece of paper.

I’d like you to answer a few questions. I’d like to ask you, where are you right now on this stress curve? The next question is how will you know when you’re starting to slip off peak performance on the stress curve? What are your early warning signs? What are you going to do about it? Because it’s a lot easier to prevent burnout than it is to treat it when you’re in burnout. Sidenote, if you are in burnout, then you need to take some time off.

You need to take some time away to rest, to recuperate and get some treatment, whatever you need, and then you will need to reset because you cannot go back into exactly the same environment doing exactly the same thing. Because if you always do what you’ve always done, you’re always gonna get what you’ve always got. That is really, really important. It’s like having lead poisoning, going off somewhere drinking fresh water, then coming back and drinking the water again.

It’s going to affect you in the same way, unless you have made some changes. You’re going to need to get some help with that. If you think you’re starting to slip off the stress curve, I’d like you to list some of the factors which are causing that. What factors are contributing to where you are right now on the stress curve?

Then finally, are there any quick wins? Is there anything that you can do about that right now that will get you back to peak performance? Long term, what do you need to do to make sure you’re not slipping down that stress curve? Just remember, that normal is not pretending that everything is okay. Normal is not being superhuman. Normal is reacting appropriately to the stress you’re under, and normal is working in environments in which you are able to thrive not just survive.