How to Survive a Toxic System – on Both Sides of the Pond

Rachel: Do you get frustrated when all the advice about wellbeing and resilience just doesn’t seem to tackle the root cause of the problem? Being expected to do more and more with less and less? Do you ever feel like giving up work completely, because you just can’t see how the system you’re working in is ever going to change?

Yet you don’t want to leave. You’ve trained for years and years to get where you are now and do what you do. You just wish you could get on with doing what you love without it feeling like an impossible task. In this episode, we’re tackling these wicked dilemmas and answering the question, how exactly do I survive and even thrive inside a toxic system without having to get out or burn out?

Now I heard recently that a study on burnout found that people who work in systems where they’re expected to meet high expectations, but they have very little control have much much higher levels of burnout than those who have to meet high expectations, but also have high levels of control. And for me, this sums up working in most healthcare systems to a tee. High expectations in fact, often impossible expectations with almost no control of the environment, the patient or client demand, government targets, financial costs, etc, etc.

So this week on the podcast, we’ve got a very special guest, Dr. Dike Drummond, MD, a family doctor and burnout specialist from the USA, who was also host of the Physicians on Purpose podcast. In fact, this episode is a joint recording we’re doing for both podcasts. Now, while the US healthcare system is obviously very different from the NHS with its own particular challenges, at the end of the day, we’re all human beings wanting to give our best at work and all of us struggle with the same challenges.

For example, we find it hard to set boundaries, say no and prioritise our own well being. Dike and I discuss the differences between the two healthcare systems and how the particular challenges are showing up at the moment. We think about simple strategies to control the things that we can control like separating life from work, finding our identity in something other than our jobs and taking a good hard look at the assumptions we’re making about the things we ought to do.

So listen to this episode to find out why the level of burnout is so high in healthcare workers right now. And why doctors are often the canary in the coal mine when it comes to our health care systems. And find out the things in your working life that you have more power over than you think you have. And some simple tips to take back control, and even start to love your work again.

Welcome to You Are Not A Frog, the podcast for doctors and other busy professionals in high stress, high stakes jobs. I’m Dr Rachel Morris, a former GP now working as a coach, trainer and speaker. Like frogs in a pan of slowly boiling water, many of us don’t notice how bad the stress and exhaustion have become until it’s too late.

But you are not a frog. Burning out or getting out and not your only options. In this podcast, I’ll be talking to friends, colleagues, and experts and inviting you to make a deliberate choice about how you live and work so that you can beat stress and work happier. If you’re a regular listener to this podcast, you’ll know that we talk a lot about how to say no. And a few months ago, we held an online training all about this. It was designed for those many, many people working in healthcare who’ve told me that they would love to set better boundaries. But if they don’t do the things that need doing, no one else will. In other words, we answered the question, how do you set boundaries when the buck stops with you?

As it turned out, this was our most popular online training ever, with over 1000 people registering for the session. During this training, three things became clear. There are a lot of people struggling to say no. Setting boundaries is way more complicated than we assume. When we learn how to say no, it unlocks so much. If you didn’t manage to make it to this training, then good news. Since this was so popular, we’re putting together a follow up session. Now your limits claim you’re no, it’s going to be happening from 7:30 till 9pm on the 20th of June, and it’s totally free to attend. You can sign up at the link in the show notes or just go to shapes toolkit.com backslash say no today. If you’re listening to this after the 20th of June, you can still sign up to get the replay until the middle of July. Or you can get our free SEO toolkit from the link in the show notes.

It’s brilliant to have you on the You Are Not a Frog podcast. For those people that don’t know who you are, just introduce yourself for us.

Dike: Okay, so Dike Drummond. I’m a family doc from Seattle, Washington in the United States of America, but I did live in England as a schoolboy for three and a half years and have a handful of O-levels and learn how to play rugby and drink warm beer. And what we’re doing is we’re co recording our podcasts here. So this is dike Drummond with the latest edition of the Physicians on Purpose Podcast coming at you from both sides of the pond, Seattle, Washington, and England, the National Health Service in England. And Rachel and I are recording together here. Rachel give you a little intro let’s hear.

Rachel: Yes, I’m Rachel, a former GP. I host the You Are Not A Frog podcast. I specialise in resilience in the workplace for doctors and other professionals and high stress jobs. And yeah, my aim is to — quite a grand aim — to save the NHS by basically stopping people leaving.

Dike: Oh, nice. Yeah, nice. Well, my goal is two-part, to give individual physicians and nurses other people who work in health care, anybody who’s programming is the patient comes first, the tools to be able to recognise and prevent burnout in themselves and others. And then in the organisations that employ these people to give those leaders who have the capacity to create the context and the environment in which people work. Give them the tools in order to build a functional organisational coal mine. We got canaries in coal mines, coal mine burnout prevention strategy. So we’re both sides of that equation.

Rachel: I love your analogy about the canary in the coal mine just just describe that to us. Because I think it’s really powerful.

Dike: Why it’s a coal mine analogy, everybody in the north of England would understand it, right. But if you go back to the time before we had digital air quality indicators, mining was very dangerous, at least in part is because in a coal seam, and a coal seam might be 15 feet high, and they’re jackhammering into that coal seam, there’s bubbles. The bubbles contain one of three gases, carbon monoxide, carbon dioxide, and methane.

In their natural state, those gases are odourless and colourless. So people would die in the mine when a jackhammer would hammer into one of these big bubbles, the gas would come out of the face, and people would just drop. So what they ended up figuring out is that canaries to things a male Canary never stopped singing, because he’s always looking for a mate. And if you put him in a little cage and take him down in the mind, he’ll be tweeting away while you’re working. All you had to do is stop every once want to make sure the birds, okay, because canaries also die in bad air before humans.

So what they always do, and if you Google canary in a coal mine, you’ll see a picture of a dirty face miner with a little canary in a little cage. But they do stop every once in a while and make sure the bird’s still singing. Bird’s singing, they go back to work. But if the bird’s not singing, they check the bird, birds down, everybody drops their tools and runs for the top, gets in the elevator, gets out of the shaft, because there’s bad air down there. And it’s kind of cute. But I even have seen little canary resuscitation devices. Because if your canary saved your life, you didn’t want to leave him down in the mine, you’d bring a little gas mask for it. Nigel! Don’t leave Nigel in the shaft!

Rachel: The poor canary! And what I like about your analogy is I’ve heard you talking about the fact that the physicians, the doctors are the canaries of the health service, right?

Dike: Well, you’ve got people working in stressful circumstances. Now, it’s not the kind of physical stress that you see in a coal mine. But what you have is a context: a mine. And you’ve got people in the mine who’ve always shown stress, because since the beginning of measurements of burnout, physicians, nurses, anybody, again, whose programming is the patient comes first, show a higher rate of burnout prevalence, a higher rate of suicide, all of those kinds of things.

It’s stressful to do what we do, because we chose a long time ago to put ourselves in the path of danger, meaning, we’re going to be with our patients at a time when emotions are strongly positive on occasion, but almost always, we’re going to be there when they’re strongly negative, when people are sick, hurting, scared and dying. So if we’re putting those same people who are sick, hurting, scared and dying, as they come first ahead of us, the threat of overextending yourself is constant.

So if I see in America, we just did a survey that came out about three months ago. We’re here now in March 16 2023, recording this. It was a survey that’s been done by Shannon Felton, the whole gang, the Cabal that does all this research, right. It had been done in 2011, 2014, 2017 and 2021. And the latest survey, so there’s a prevalence and by prevalence, I mean, it’s a snapshot the day this survey was administered 63% of the doctors who took it, we’re suffering from at least one symptom of burnout. So if we’ve got 63% burnout prevalence on any given day, and we know that burnout affects quality, safety, patient satisfaction, engagement, retention, all of that kind of stuff. And I’m pretty sure it’s not any different in the NHS.

What’s happening is 60% of your doctors are bringing their C-game to work every day. And you could forgive your mother, if she read these statistics. And most of the time, the lay press doesn’t know them. But you could blame your mother, if she said, I’m going to go see the doctor today. But it’s just a coin toss on whether I’m going to get good care. She can feel that way. And it’s probably true.

Rachel: Yeah. I’d love to know what’s happening in the US at the moment. I mean, that is that is happening in the NHS, and I’m not sure it’s because the patients think, Well, I’m not going to get good care if I get to the doctor. But actually, at the moment, a lot of them are actually struggling to get to the doctor, because I guess one of the main differences between our system and yours is that we in the NHS are expected to suit everybody, it’s free at the point of need. There is no cap on the amount of people that can expect to have treatments.

Unfortunately, the number of doctors is going down because lots and lots of people are burning out and leaving. So people are having to wait an enormous amount of time quite often now for outpatient treatment, for operations. And GPs are fully open. They are offering appointments and stuff, but some practices are working at, you know, a third of the capacity of the doctors. So the patients are quite rightly getting upset about this.

But it’s not the doctors fault, obviously. But right, we just got this massive staffing crisis and the NHS isn’t coping, I always think it’s a bit like a big sponge. Because healthcare professionals, you just absorb the extra work over the years, don’t you absorb it, and you absorb it. But now our sponges just completely sodden. It can’t absorb anything more. And then it over spills. And for us, it over spills into the emergency department. So suddenly, they’re not coping anymore, because they just have too many people that aren’t going to see their GP, et cetera, et cetera, et cetera. Now, is that what you’re seeing in the US at the moment, or is it a bit different?

Dike: Well, hang on a second, I want to ask you a quick question to follow on there. Isn’t there a strike going on right now?

Rachel: Yeah, yeah, there is.

Dike: Who’s striking?

Rachel: Well, I don’t know all the facts, because I’m not following the news very closely. Everyone seems to be striking in the UK at the moment. The train drivers, teachers, junior doctors are striking about pay. The nurses have been striking, people are being asked to do an impossible job. So for people to actually agree to do what is impossible. It’s just sort of nonsensical. So there’s a lot of striking.

I think the problem is, it’s about being valued. And it’s about actually being able to do a good job, because that’s one of the main problems if you can’t do the job that you want to be able to do because of time, capacity, resources, you end up just firefighting constantly, don’t you and nobody likes working like that. And no one likes to feel that they’re doing a bad job.

If you’re sort of operating in the UK at the moment, the amount of patient contacts that GPs are expected to have in a day is massive. I think there’s been some research, I don’t know if you’ll probably know better than me about the amount of patient contacts that is safe in a day. And it is certainly not 70 patient contacts and lots of GPS that having 70, 80 patient contacts in a day, which is completely unsustainable, pretty unsafe, and there’s no way you can do a fantastic job. You’re just trying to try to put out fires here, there and everywhere.

Dike: Well, and I would say that, if you’re an American physician that you just heard her say, she said 70. She said 70. So you would have in America, apart from a couple of specialties who can do the high volume. So for instance, a combined cosmetic and aesthetic, excuse me, a combined cosmetic and medical dermatologist with three estheticians might see 100 people a day across their practice, but a GP like me, a GP like you in our system here? If you’re seeing 30 patients a day, you are flying.

The challenge here is that one of the challenges here and one of the main differences between NHS and America is the multi payer system and the for profit business plans. And so what ends up happening is in America, if I was going to try and be so low, I would have to have a sophisticated business office behind me that’s capable of processing claims from 40 Different insurance programs that don’t talk to each other. And the insurance programs are bent on one thing: denying payment, because that’s how they make their money, is on what’s left over. So you’ll almost never get a claim paid straight. they’ll deny it, you’ll have to appeal. And that’s what limits solo practice in the States because it takes about 40 to 100 doctors to actually have enough cash flow to employ the 40 or 50 people in the business office that takes the bill every day.

And you might have a 90 day, 120 day delay between the time you bill and you’ll only get 70% of what you billed. So when I talked to my Canadian colleagues, and when I talked to the folks in the GSL, GHS, that NHS that have one payer, it’s interesting. In the 1990s, a long time ago, somebody did a financial analysis and said if we took the US healthcare system, and we simply switched from free for all of multiple insurance companies to a single payer system, if all we did was take it to single payer, how much of the expenditure on healthcare in America would vanish because we don’t need the people? And we don’t need the profit margins of all the insurance companies, we just went to single payer in the 1990s.

That analysis said 50%. 50% of the payments of the flow of cash inside the American healthcare system vanishes from that one thing. But realise that 20% of our GDP goes through this healthcare system, and all the insurance companies are lined up to feed the politicians money if they were ever challenged on a single payer. Crazy. Crazy.

Rachel: Yeah. Absolutely crazy, isn’t it? So? So I think there’s pressures but in a different way. Definitely. I mean, 30, you said that 30 patients?

Dike: 30 patients is rocking.

Rachel: We’d call that a quiet day. A really quiet day. That would be marvellous. If you only see 50 patients in your surgery, you could you could do that, that’s manageable that but the thing is, if we were only doing the things we were contractually obliged to do, and I have this from the LMC, they say, you know, if GPs, doctors only did do the things they were supposed to do.

Dike: The system craters.

Rachel: Well, A) the system, it craters, but B) the doctors would be okay. But there is something stopping us from saying no. And, from working to rule, because actually, there was a report from the House of Commons that came out a couple of years ago now. But it basically it was looking into burnout in healthcare, not just physicians, but all healthcare professionals.

It actually said that the NHS only works on people doing unpaid overtime. And if people started just doing their job, the entire system would collapse. And like I just said earlier, what we’re seeing now is people are still doing the overtime. But once you’ve reached 24 hours in a day, right, you don’t have any more time. And so the system is creaking. And I don’t think I’ve seen it so bad, actually, ever.

Dike: Well, and I can vouch for the fact that a for profit health care delivery system, like here in the states also also counts on the physicians showing up and doing extra work and going the extra mile because the patient comes first. So what you have is, you have in your case, it’s governmental. In our case, it’s business, but these are bean-counting spreadsheet-driven bureaucrats. And I don’t know if it’s like this in the NHS, but I suspect that it is for whatever reason, they’ve chosen to be bureaucrats inside of a health care delivery system. But they’ve never ever seen a doctor do the work.

So what I’ve been in front of groups of physician leaders, so like a whole roomful of 50 CMOs, and I say raise your hand if you shadow your providers, twice a month or more. And in a room of 50 chief medical officers, I’ll get one hand go up. And if you do that in a room of chief financial officers, the folks who are doing the accounting, no hands will go up. So what you have is an ivory tower applying business principles, to a commitment we made as physicians and nurses. That goes way beyond vocation, way beyond paycheck.

It goes I wanted to be, I chose to go to medical school. So did you. I call that the lightworker’s fork in the road. You chose to ally your professional life to the forces of light in the universe as we battle specific forces of darkness: illness, suffering, death, dying, family members crazed attempts to deal with those things. You said I want to be a helper and a healer and I want to make a difference. I need to have meaning and purpose and I don’t abandon my patients. And every bureaucratic, either governmental or business structure that lays on top of that devoted workforce will abuse them.

Because no matter how unreasonable the workload becomes, we keep showing up. And they count on it. Yeah, so in COVID what ended up happening was, we lost a whole bunch of support staff, we lost a whole bunch of doctors. So what we’ve got is the doctors, especially — I don’t know about NHS, but certainly over here — are working with a lot less staff members to help them. So a lot less medical assistants, a lot less receptionist and things like that, but they keep showing up.

Here’s what that looks like on the chief financial officers spreadsheet: our margins just went up. Are you with me? We’re seeing the same amount of patients with fewer staff? And what are the odds? You’re sitting here saying, man, one of these days, it’s going to get back to the good old days, and I’ll have my MA and I’ll have my receptors, what are the odds that that chief financial officer is going to pay to staff you even to the old historical levels, because it’s going to affect the margins.

So there’s a huge financial disincentive to even get back to the staffing levels we had before COVID. It’ll never happen. They’re going to continue to run a tight ship as they always pat each other on the back in the boardroom. And we’re going to continue to overwork. You’ve got unions, I’m not sure that they make a difference in health care like they would in a coal mine.

Rachel: Yeah, so you guys are battling against the the sort of financial controls all trying to make a profit, I guess what we’re battling against is the political system, the politicians that say, well, that the NHS is sacred, obviously, we love the NHS, you know, it’s amazing, go to any other country, you know, the fact anybody gets treated for free, it’s amazing. But nobody will admit, no politician will admit that it has to be limited, that it can’t be free, and it cannot, and good quality, and covered and completely comprehensive. That’s the sort of inconsistent triad.

So what happens with us is that the demand just goes up and up and up and up. And then the doctors, the nurses are supposed to meet the demand. Then if they burn out or, or fail, or there’s a problem, they’re the ones that are blamed. It’s not blamed on anything else. And one thing that’s, you know, I talk about a lot with people, and it’s quite difficult to get people to understand is that, you know, everybody’s so scared of complaints and being up against the GMC and obviously, litigation, although it’s nowhere near as bad as it is, you know, over your side of the pond.

Everyone is so concerned about complaints that it stops them saying no, it stops them putting any boundaries up, it stops them almost practising good medicine. But what they don’t realise is if they don’t say no, they just carry on and on and on. The closer they move to burnout, the more mistakes they make, the worse their consultation skills, their communication skills, their judgement starts to lapse, some they might get stuck in a hole and get a probation or something and then they’re going to be up against GMC, and the complaint is going to be much, much much worse. The problem will be much worse than just a complaint about well, this doctor refused to do X, which wasn’t in their contract anyway, and actually has good medical practice.

So it’s, we just don’t have this realisation that we are affecting the patients, we are affecting ourselves, we’re causing problems by just carrying on in the in the mindset that we have of yes, you’re right, the patient always comes first, which is a very good thing, but it causes all sorts of problems when you’ve never been shown another way to do it, I guess.

Dike: Yeah. And you and I were talking earlier about the relationship you have with your career. So here’s the way I understand it and the way I teach it. When you make that choice at the lightworkers fork in the road to go into healthcare, doctor, nurse, doesn’t matter, into a position where they’re programming is the patient comes first could be any one of the techs, respiratory tech, medical emergency medical technician EMTs anybody you know, just like a field medic and in the armed services, right. What ends up happening is you are then submerged in an extensive training program. That training program is meant to make you an effective physician, an effective nurse and effective clinician to help treat diseases.

But it also is a survival contest a world class survival contest and one of the things you can never ask for in a training program in healthcare is an hour to take a nap, can I go pee, can I go eat lunch that you are you are you are programmed to never what I call never show weakness, meaning never do anything that would make anybody think you haven’t got what it takes. And what ends up happening is people who had you know friends and hobbies and everything in college, they go to medical school and all those things are jettisoned. Because it’s so intense to go through the training program, so you graduate without a life.

You graduate with a laser focus on your career. It’s where you spend all your time, it’s where you expect all your money to come from. It’s where you expect all your fulfilment and satisfaction and happiness to come from. And it can’t. So ideally, ideally, you begin to have a logical choice about your relationship with your career. Are you a doctor 24/7? Or is ‘doctor’ your career and you put on your doctor hat when you go in and see patients and then you have a boundary, a healthy boundary that lets you take that doctor hat off, and be a normal human being in your off hours.

Typically, somebody only learns how to have that boundary and how to have that separation when they go through their first episode of burnout. That’s what burnout is here to do is to give you those boundaries, in my experience. If you survive the crisis, we have to mention that, you know, burnout has a highest and best use, but it also is a true crisis. So I tried to help people avoid burnout by building in those boundaries. And in that relationship consciously, in a time when they’re not, you know, back against the wall, wondering how much longer they can keep going.

Because in that crisis, we lose people. And we don’t have to, but we do. But burnout can be used outside of times of crisis to build a more ideal practice and to help you practise boundaries and saying, we were talking about saying no earlier boundaries and saying no, and all those good healthy things.

Rachel: Yeah, it’s just a shame, though, isn’t it when it has to take a burnout to learn those boundaries. I don’t know many people who have learned to put in good boundaries, without coming pretty darn close to burning out.

Dike: Well, and you were mentioning it earlier, guilt and shame. It’s like hang on a second, if my programming is patient always comes first. And I haven’t learned how to turn that off. And now I’m contemplating doing something for myself, because my back is against the wall. And I’m not sure how much longer I can keep going like this. That’s the little boys.

I’m not sure how much longer I keep going like this, and you start to contemplate doing things for yourself. It’s guilt and shame. It’s that same programming, guilt and shame come crashing in to stop that from happening several times in a row until you’re basically physiologically incapable of continuing.

Rachel: Yeah. And then we have to wait until we literally can’t continue because then it’s almost, well, it’s not okay, but it feels okay to then say right, that’s it, I can’t do it. Because I’m burnt out, we did a podcast recently with Dr Sandy Miles about this, and she was talking about, she had become very ill and felt absolutely terrible because she couldn’t work. She was dumping her colleagues in it, all those sorts of things.

But she had no choice. She was ill. She couldn’t work. Problem is to say no, that’s a choice you’re making, you’re choosing to put someone out, you’re choosing to not be perfect, or admit that you need to rest your choosing to make someone think maybe slightly badly of you, because nobody likes to know, let’s face it. And that choosing to do that knocks on your internal values, your internal sense of identity, internal sense of I am always good at this. I mean, I know American physicians work just as many hours as, as we used to in the when we were junior doctors, you know, I am someone who could work 120 hours a week, therefore, I can carry on.

But if I made or if I’m choosing to say no, I’m gonna go home after 10 hours, what does that mean for me? So when we crush up against our internal values and our internal identity, it’s not just guilt we feel, it’s shame. I am not enough, I am not good enough. And for somebody to choose to feel that shame is very difficult. It’s one thing if you break your leg — I broke my ankle last October, I had to cancel stuff. I felt a bit guilty. But you know, it was out of my control. But if I’m choosing to do it, I would say that is almost impossible unless you have utterly changed the story in your head, the dialogue about who you are and what your identity is.

Dike: Or you hit the wall, can’t go on and have to regroup. And remember too, you’ve got guilt and you’ve got shame. But there’s also the third horseman, it’s imposter syndrome. What did they find out? That and all of these things are our legacies of our training, the programming of our medical education right? Workaholic superhero Lone Ranger perfectionist, it’s what we had to do to make it through the challenges when you graduated from your training program. You were actually free to do anything you want anywhere in the world.

But we were so well programmed as residents that what we did was just look for another set of tracks to step onto and didn’t recognise that we had made it through the finish line. And we are now free. And again if you’re listening to this right now: you’re free. You’re free. I always tell people I can’t leave. I can’t abandon my patients. I can’t do this. I can’t do that. Okay, hang on a second. What would happen at work? If you got in a car wreck on the way to work tomorrow and broke your pelvis? And you’re out to action for three months? What would they do with the patients get seen?

So I just want you to know, most people when they quit their job, if they were to go back two weeks later, nobody’s talking about them.

Rachel: Yeah, you are not indispensable.

Dike: So that when you have that I can’t not see my patients know who’s going to see the patients who’s going to take care of my staff that will freeze you and guilt and shame. But I’m telling you, it is a mirage. You have to step through that.

Rachel: Yeah. It’s so interesting about choice. We feel so powerless. You know, for such an intelligent group of people we can be really fit when it comes to choosing and I know when I’m doing a training sessions, we talk about leaving. Leaving the surgery, you know, we’re not about leaving it for four o’clock. We’re not talking about leaving at halftime, but about leaving at like, six, half, six, seven o’clock, you know, and people just say, I have no control over when I leave.

Really? So no control over when you leave. So who gets up and goes to your car and drives home? And well, okay, well, maybe that’s it, but I just can’t. Well, why can’t you? Well, if there’s like 20 urgents, or extras to see I just, I just have to see them. I just can’t leave them. Well, what you know, who says you can’t? Well, I don’t want to because what if what if!

And like, well, you are still choosing, and it’s this sort of very, very helpless position we’ve got ourselves into of, I have no choice, because the buck stops with me. And I can understand that many people said, well, if I don’t do it, who is going to? But we always have a choice. People don’t like it, people do not like it when you tell them they have a choice because that’s confronting, because it means they actually have to do something about it, don’t they, and they can’t stay in that victim role anymore.

Dike: Well, if the choice is going this way, that’s the trend and the choices that you make, and you acknowledge it’s a choice, that means that you can actually make a different choice. I usually tell people, there’s a saying I learned a long time ago, it goes like this: I teach people how to treat me. I teach people how to treat me. And there’s another one that goes with it that says this, you don’t get what you want in life, you get what you tolerate.

And that combined with if you broke your pelvis, who would see these patients, well, they obviously would get taken care of somehow. So if you’re teaching people how to treat you, you only get what you tolerate. And the people will be seen in your absence. If you can get somebody to intellectually understand and resonate with those statements, then it’s a question of getting their body programming to work in a little bit different way.

I find that doctors are also motivated by just the nature of our personality that if we want, if we are thinking about changing something, doctors always contemplate changing the biggest thing possible. And that is intimidating. It increases your chance of failure. So I asked them to pick their first new action step to be something so small, it’s ridiculous. I mean, I can do that in the next 15 seconds. Okay, do it. Let’s celebrate.

Rachel: Yeah. I mean, when you talk about this sort of thing, you always get the comeback. But you know, what, if somebody genuinely might die, what if it’s going to cause significant patient harm? That just seems to be the pushback that comes comes all the time? You know, on a webinar, I did a little poll. I think I’ve mentioned this to you before, but I asked, ‘Why do you not say no to stuff? What stops you?’ And I got them to vote. Is it because of the patient harm? Is it because they feel guilty? Or they’re worried about what other people might think? Or it will cause someone inconvenience? And only 3% said it was because of the patient harm? 3%.

So that led me to say, well, you know what, if someone’s gonna die, don’t do it. Choose to do something different. If someone is genuinely gonna die because of that choice, you’re gonna make well, don’t make that choice. You know, you could predict your consequences. But mostly, mostly it’s because of our own internal stories and our worry about what other people think and our sheer obedience to the system sometimes, right?

Dike: Well, and I would say that, when you’re stressed, tend to think in black and white terms. There’s no gray, there’s no middle ground when you’re stressed, and people will go to an extreme right? And what I usually talk about is the 80-20 rule. It’s like, what would it be like for you to get home on time 80% of the time. Not all the time, because sometimes there is somebody out in the lobby that you need to take care of or there would be an unfortunate outcome. But what if, you know, three days a week, let’s just do 60%, three days a week, you get home, within half an hour of what you consider to be on time, if we can make some changes that made that difference, How would that feel to you? And they usually soften up a little bit and say, oh, man, that’d be amazing. Okay, well, let’s not worry about never and always let’s go for that. 60%. See if we can hit that little bit.

Rachel: And what about a little bit? What about this sort of thing about dumping on colleagues, because I think that is a massive trigger for us in the UK, because if you don’t, if you don’t do it, someone has got to do it, someone has got to deal with this sort of unlimited demands. And, if I don’t do it, then my colleague who is almost equally as burnt out as me, is probably going to have to do it as well.

Dike: Well, a lot of times, that call rotation, those people who know that they’re responsible for each other’s patients don’t talk to each other. So I believe that this sort of making healthy boundaries, and recognising that we’re a tribe of lightworkers, taking care of a tribe of patients, that if we coordinate our activities and meet outside, you know, if we have a support group that’s local, that we meet, and if we, if we have a once a month, get together, where we have a pint and talk about cases, and thank each other for covering for the time that you, you know, went to the coast or whatever, right? That if we start to do that kind of collaboration as practising physicians, all sorts of things become possible.

The only reason we operate as you know, solo workaholic Lone Ranger’s right, is because that’s the way training was. What do they call collaboration in medical school? Cheating. So, we’re taught to not work with each other. Yeah, we’re taught to disagree with each other almost in a debate style, like a lawyer would, right?

Rachel: Yes. And we do see that in GP practices. I’ve been in to do a bit of team coaching with the leadership team. They’re not a team. They’re just a group of people working in separate rooms who get together and try and make some decisions in a ridiculously small amount of time. They’ve never even looked at how they work, how they work as a team.

Dike: They’re individual gerbils on their own individual gerbil wheel in their own individual office, and the only time they’re outside the door, they pass each other like ships in the night.

Rachel: Yeah. Yeah, exactly. So it’s, it’s tough. I always say to people that are looking to your very close colleagues for approval, and for them to go, No, don’t worry, you go home, you’re doing a great job. It’s sometimes the wrong people to look to, because they are under the same illusion as you, they’re under the same pressure. So like you said, getting that network of people just slightly out of your practice right here. But people that also know what you’re, you’re experiencing, but it’s just a little bit removed.

So if you go off, you’re not gonna be on them, you’ll have something on somebody else, but they can just sense check stuff. And I think as doctors, we do not use those support networks well enough. And there’s so many people around that you could be meeting with really, really regularly. I mean, we don’t use them in our practices, and we certainly don’t use them outside of practices.

Dike: Well, there’s also sometimes a sense of resentment, right? So I spent so much time in this practice, last thing I want to do is hang with a bunch of doctors, right? It’s escapist kind of stuff. But if you don’t, there is a whole nother level of support and effectiveness available to you, if you’ll step towards your colleagues, rather than step away.

Now, here, what we would have is, for instance, a family practice department inside an organisation would share each other’s patients. So there’s actually a collaborative covering relationship. So it wouldn’t be you know, I’ll have your back if you have mine kind of reciprocation that’s available.

Rachel: Yeah. I guess in the UK with the sort of general practice that we have. It’s sort of like whoever’s on call mops up everything. Everyone else sees, sees their list, and you’re just just trying to get through the day really.

I’m just interested in this sense of identity, though, that we get from going through these very, very competitive med school systems and how we help people to shift out of the job being part of who they are into just something around. It is a job because of course, you know, when people just shift too far and it just become a whole money making thing but where, what, what’s the sort of the healthy way of doing it?

Dike: Well, I have several stages that I asked people to consider, right. So the default relationship with your career as a physician graduating from the education system is what I call all-in. Your identity is fused with your profession, as a physician, all of your time is spent in your practice, all of your money comes from there. Anytime you do any reading on your own, it’s about stuff inside your practice, unless you’re on vacation and have totally, you know, kicked that to the curb.

But all-in means if there’s any disappointments, if there’s any overwork, if there’s any professional conflict, if there’s a patient who isn’t liking what you’re doing, because you’re all in infused with that as your identity, it hurts even more, the seesaws are even worse. And the risk of overwhelm is literally 100%.

I personally believe that the average doctor goes through burnout a couple of times in their career. There’s nobody that gets out without going through burnout. Burnout is that point where you get so exhausted, you say I’m not sure how much longer and keep going like this and you make a change in your career. That’s burnout to do that. So the first is all in.

The second is what I call terrarium. So if you remember what a terrarium is, it’s usually a 10 gallon fish tank with a lid and you make a little ecosystem in there. And you can close the lid and it’s self contained. It doesn’t need to be watered or anything like that. So terrarium means put the lid on your practice, meaning go in, do a great job with your patience, do a great job at your documentation, and then get the heck out of there and don’t have anything to do with anything medical until you come back again.

Just like the old, the old thought process of let’s go back to the coal miner, you would punch the clock and go to the pub, right. And you wouldn’t talk about the coal mine. He’s a coal miner, but he’s only a coal miner.

But after he punches in and before he punches out, right? So terrarium, and then some people will do and I don’t know how popular this is in the NHS, but some people will actually terrarium their practice and then take on what they call a side gig. So a little something on the side that they do because it’s exciting, and perhaps thrilling, perhaps even a little income stream that is outside of what they usually get for their practice activities. So we got all-in, terrarium, side gig.

And then the last one would be some sort of transition out of being a practicing physician. Now, there are people, a lot of people, and a lot of wishful thinking about I’m going to quit medicine. But I see very, very, very, very few people actually doing that. There’s a lot of aspirational talk and chatter on the internet about how I’m going to quit medicine. But it’s very rare, typically is a process, I’m one of the very few people who’ve been able to do it. That’s how I know that it’s rare, I rarely talk to somebody who has been able to make the what’s the right word, the transition, the complete transition.

And still, all my patients are doctors. I’m still a doctor and all my patients are doctors at this point. And I use a little different technique coaching and guided imagery and things like that in what I do. But being able to terrarium your practice, there’s another stage in there called a bridge.

So for instance, I’m going to stop what I’m doing now. And I’m going to take a new position, but I don’t see this position as my final resting place, so to speak. I’m taking it to get a break from what I have been doing. It’s a bridge to someplace else. And this bridge is allowing me to support my family and practice my craft as I search, do a little better search for what will be my next practice where if everything’s okay, I’ll go all in there.

Rachel: Really interesting, interesting stages.

Dike: But it’s a conscious choice. I’m going to have a relationship. It’s sort of like, it’s sort of sort of like dating who you’re going to date. If you’re not infatuated with the person, it’s a rational process of you know, he makes good money and I really like him and he’s fun and all that kind of stuff. You can decide who you’re going to date kind of thing.

Rachel: Yeah, yeah, that’s interesting you say that. One of the reasons I called my podcast ‘You Are Not a Frog’ is because it’s out of that. There was a study in the BGP, about doctors leaving the NHS. It was GPs under the age of 50 leaving the NHS and the reasons that they did it. There were all sorts of reasons you know, like the admin load that had a complaint or something but by far the biggest reason was the effects on their well being.

In that article, they compare GPs to frogs in boiling water, you know, the workload just slowly got very, very, very high. I guess with a frog you’ve got two choices, haven’t you? Either burn to death in your pan of boiling water you burn out, or you get out. And those are the only two options that you’ve got.

But I like what you’ve been saying about this sort of the income stream and the side hustle and all that sort of stuff. Because I think, for me, the secret of really working well as a doctor is to have some diversification in your work.

I was talking to someone who has come over from another country to keep her practice up to date. And she had some sort of retraining, she’s just done six weeks in a GP surgery. And she was doing, I think, six or seven sessions a week, and she said, there is no way she could sustain that. Just having done it for six weeks, compared to how it was 10 years ago, you know, there’s no way you can do that full time because you would burn out on the spot.

And I think people are realising that the people that are doing well are the people that are getting that diversification, that sort of side hustle. And within the NHS, the great thing is you can find other roles that you can be like a training program director or you can sit on the College Council, you can go into a bit of research, or you can do teaching, or there’s loads of different stuff that you can do within your job.

But then that carries a little bit of a health warning as well because whilst I say diversification great, because it helps you use a different bit of your brain, it gives you a different team, all that what I see happening is people go Yeah, no, I’d like to do something else will take on that role. And they don’t drop anything. And then I’ll take on this role. And they don’t stop any of their roles, suddenly, they might only be doing I know, four sessions a week as a doctor, but they’ve got 20 other roles. And they’re wondering why they’re never getting time off. And all they’ve done is replaced one problem with another problem.

Dike: Well, that’s again, where you need to have the ability to consciously plan and create this. So one of the things that I showed you is my little picture of a doctor in a whirlwind. Yeah, right. One of the things that doctors need to do is to take some time, and I say weekly, weekly, a few of just a few minutes to work on your practice and not in it to step out of the whirlwind of your practice and look at your roles and responsibilities, your energy level, your satisfaction, look at those things

Because again, if the patient comes first, where do I become? I come? Don’t say second, because it’s last. Okay. So a lot of times there’s even guilt and shame around me asking you the question on a scale of 0 to 10. How satisfied are you with your practice over the last couple of weeks?

I mean, even that can even be blocked by that patient comes first programming. But I asked that question to a lot of people, everybody I meet, right. So let’s ask it. Scale 0 to 10. 10 being couldn’t be any better, 0, meaning it couldn’t be any worse. What’s your level of satisfaction? With your practice? Whatever that is, you may have part leadership position, part clinical, and maybe all clinical whatever is your practice over the last couple of weeks? What’s your satisfaction score? 0 to 10?

What is it? Write it down, write it down and put today’s date next to it. Because potentially, if you want to change things, this is a starting point. Now close your eyes, take a breath, open your eyes and look at that number. Are you okay with that number? Or would you like it to be, let’s say half a point higher. Because you can do that.

However, you would need to plan it because you’re already overwhelmed. You need to plan it. Ideally, you’d need to stop doing a few things to clear some room out so that you could maybe start doing one, one different thing, take baby steps, right. And always be pointing towards what you consider to be your ideal practice.

And if you say, you know, I really like treating kids with ADHD, and if I put the word out to my colleagues in the community, maybe I can see, you know, one in six of my patients in my practice would be ADHD. And I say, Well, how would that feel? It’s like, oh, my, that’d be amazing. Okay, great. What’s the first step in that?

Not the biggest step, the first step, because if you always do what you’ve always done, you’ll always get what you always got. So you got to do something new. And the challenge is you get so tired and overwhelmed by just keeping up with your current habits, that it almost seems like you’re stuck, but you’re not. You have to step out of the whirlwind. Yeah, and do some planning. You have to work on your practice, not just in it.

Rachel: It’s interesting. You say that literally just yesterday, I was recording a podcast about you know, what’s your flight plan? What is your flight plan for your life?

Dike: Flight plan. There you go.

Rachel: Yeah, well, it was just based on a flight. So I got on this plane and it was coming from holidays last year and the pilot, and we were all just about to go, and the pilot got on and said we are just gonna go. But we just found our flight plan. And it’s very different from the flight plan that was filed a week ago by the airline. And we just got to work out what’s going on.

About 15 minutes later they came back. And so lucky they checked because they said, ah, we found out the problem. Someone else filed this flight plan for us, and they forgot to add any passengers.

Dike: Right. We’re going to Dusseldorf, you thought we were going someplace else.,

Rachel: Yeah, so, actually, we’ve not got enough fuel to fly home, we can’t actually fly. So we now have to wait two hours to be refuelled, and then blah, blah, yada, yada, yada, it just sort of carried on.

Because oh my gosh, that is such a good analogy for life, isn’t it, you know, doctors do not file their own flight plans, they let someone else do it. And then they don’t check if they got enough fuel to get to where they want to go. And we ended up just being at someone else’s beck and call because we don’t, we don’t look at what we want to do.

But when he just said, you know, we are too overwhelmed to even do it. I think you’ve hit the nail on the head. When I first started talking about wellbeing a few years ago, you know, I was thinking, right? Well, I want to go into some more training. And I love coaching. And I can go and talk about well being I went into a bunch of lawyers, and I did a lunchtime session on wellbeing. And they just looked at me as if I was completely mad.

I said, right, this isn’t landing very well, what’s going on? I said, oh, well, everything you’re saying is great, you know, but we have no time. And we have to reply to an email within 30 seconds of it coming in. That can’t be true, because like how do you go to the bathroom? Right?

And so that was the first time I went oh, right. Okay, well being is connected to time. You can’t be well, we didn’t get the time. If you haven’t got enough time, you can’t just do more, you’ve got to say no to stuff time is then connected to this whole mindset and back back back, you go to the gets to mindset.

So yeah, it’s really really impossible to even think about making a change or diversifying your career, or planning or putting in flight planning, if you’re completely overwhelmed, and knackered and exhausted.

Dike: Well, and I’ll say one last thing just to set the stage and then I’ve got to run. If you are inside of bureaucracy, be it a governmental bureaucracy or a business bureaucracy, and someone else has the ability to control anything about your work environment, they will always send you new orders that are additive to what you’re doing them. I’ve never ever seen anybody send out a memo that asks people to stop doing something.

They always ask you, we’re doing another quality initiative, you need to do six more keystrokes and five clicks on every patient that has this diagnosis. It’s always additive. And I personally believe that one of the things that’s caused this crest in the burnout, right, is that we are at a last straw moment for a lot of people, they are literally the chaos and overwhelm of the day is literally has them on fumes, right. And it could be that the next missive that makes me do just three more clicks a day drives me over the edge and out.

So whenever you’re planning something different about your practice, my encouragement is always to look for what you can quit. First, I could quit doing this and it wouldn’t make any difference. That’s a great place to start. And here, there’s actually a name for that. It’s called a GROSS project. Get rid of stupid stuff.

Rachel: Oh, I love that.

Dike: Across your practice, what you could do is get your partners and your and your team of employees together and say, here’s a suggestion box write down an idea for something we could stop doing, but it wouldn’t make any difference. Put in the suggestion box and and the smallest number of suggestions I’ve ever seen when somebody runs one of these contests for a couple of weeks is like 40.

But it’s by stopping those things that are not necessary that you clear the space for potentially taking a new action or two that will get you more of what you want. that’ll affect that number and your satisfaction score.

Rachel: Yeah, I love that get rid of stupid stuff. Because often when we’re talking about you know, time management, prioritising people go well, there is nothing, there’s nothing I do that’s not important. I have to do everything. You can’t do everything. So how are you going to square that with reality? Because reality is always going to win, isn’t it? I’m conscious of the time, Dike. On my podcast. I normally end just with three top tips. So if you have three top tips, what would they be for people?

Dike: Give yourself a score for your satisfaction. Put a date next to it. Ask yourself if you’re okay with that. I am old school. Grab a journal every weekend for 15 minutes and journal about your experience of your practice that week, you can’t journal from inside your whirlwind. And if you want things to be different than what they are, I’m going to give you this bias. Look for something you can stop doing that’s really not making a difference or an important difference. Begin to clear some space.

And I’ll give you a fourth. When you come home from work. As your hand touches the doorknob on your front door, take a huge breath in and let go everything that doesn’t need to come into the house with you. Maybe even flutter lips.

Rachel: Shake it off,

Dike: Shake it off. Yeah, shake it off. You got it?

Rachel: Brilliant. Well, my top tips would be: you are not your job, find your identity in something else. And you know, if someone’s gonna die, choose something different, always know that you can choose. You can choose to do something different if you want to. So just because you’ve set one boundary doesn’t mean it’s forever and you can choose. You’re in control and finally for me it’s: watch that story that you’re telling yourself in your head. Watch those, I should, I ought to. It’s bad if I don’t. I’m a bad person. All that if we could get rid of that self talk. We’re half way to solving all these problems.

Dike: Right on.

Rachel: It’s been wonderful chatting with you.

Dike: And you were on both sides of the pond. Yeah.

Rachel: Are you going to come out to the UK till then?

Dike: Well, I hope so. Leamington College for Boys. Leamington Spa in Warwickshire is where I got my O-levels.

Rachel: Oh, there we go. Okay, well, maybe we can get you over. And we could do some sort of event where we get people together who really want to nail this right.

Dike: Sounds good to me. Yeah. Oh, god, it’s

Rachel: Oh, god, it’s been wonderful to talk to you. Thank you for your time.

Dike: You’re very welcome. Thanks for inviting me.

Rachel: Brilliant. And, well, we’ll put the links of how you can get to both of us in the show notes for that, and I’m sure we’ve got the I know you’ve got loads of resources. We’ve got loads of resources. So it’s been wonderful connecting with you and let’s have another podcast soon because I think we probably just scratched the surface.

Dike: Of course. So Drummond and Morris. Morris and Drummond, right. Love it. MD Mad Dog. Mad Dog Morris and Drummond. Yes, both sides of the pond. Have a great day, everybody.

Rachel: Cheers. See you soon. Bye.

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