Passing the Naughty Monkey Back with Dr Amit Sharma

Dr. Rachel Morris: Do some interactions with your patients or clients leave you feeling exhausted and anxious? Do you sometimes feel that you can’t take any more of anyone else’s emotions? This might mean that you’re in charge of too many naughty monkeys belonging to other people, and it’s time to give them back.

In this episode, I chat with Doctor Amit Sharma about what we mean when we talk about taking on other people’s naughty monkey. Why we do it so easily, and why it’s sometimes so difficult to give them back. So listen, if you want to find out what’s effect taking on too many people’s emotions and naughty monkeys has on our physical and mental health. How to stop rescuing other people all of the time, and why it’s important to be okay with not being liked?

Introduction: Welcome to You Are Not a Frog. Life hacks for doctors and busy professionals who want to beat burnout and work happier. I’m Doctor Rachel Morris. I’m a GP turned coach, speaker and specialists in teaching resilience. And I’m interested in how we can wake up and be excited about going to work no matter what. I’ve had 20 years’ experience working in the NHS, both on the frontline and teaching leadership and resilience. I know what it’s like to feel overwhelmed, worried about making mistake, and one crisis away from not coping.

2021 promises to be a particularly challenging year. Even before the Coronavirus crisis, we were facing unprecedented levels of burnout. We have been competitive frogs in a pan of slowly boiling water, working harder and longer. And the heat has been turned up so slowly that we hardly notice the extra long days becoming the norm and have got used to the low-grade feelings of stress and exhaustion.

Let’s face it, frogs generally only have two choices, stay in the pan and be boiled alive, or jump out of the pan and leave. But you are not a frog. And that’s where this podcast comes in. You have many more options than you think you do. It is possible to be master of your own destiny, and to craft your work in life so that you can thrive even in the most difficult of circumstances.

Through training as an executive and team coach, I discovered some hugely helpful resilience and productivity tools that transformed the way I approached my work. I’ve been teaching these principles over the last few years at the Shapes Toolkit Programme because 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 have an interesting take on this. So that together, we can take back control to thrive, not just survive in our work and our lives and love what we do again.

For those of you listening to the podcast who need to get some continuous professional development help under your belts, did you that we create a CPD form for every episode so that you can use it for your documentation and in your appraisal? Now, if you’re a doctor, and you’re a fan of inspiring CPD, and you’re sick of wasting a lot of time you don’t have on boring and irrelevant stuff, and you want to put those 50 hours that you have to do to good use, then why not check out our Permission to Thrive membership? This is a new venture, a joint venture between me and Caroline Walker, who’s a joyful doctor. And every month we’re going to be releasing a webinar fully focused on helping you thrive in work and in life. Every webinar is accompanied by an optional workbook with a reflective activity so that you can take control of your work and your life. You can increase your well-being and you can design a life that you’re going to love. You’ve got to get those hours so why not make your CPD count. Choose CPD that’s good for you. So check out the link to find out more. Thanks for listening to my shameless plug. And back to the episode.

Dr. Rachel: So it’s great to have with me on the podcast today. Dr. Amit Sharma. Hi Amit!

Dr. Amit Sharma: Hi, Rachel.

Dr. Rachel: Great to have you now. Amit is a GP partner. He’s a GP trainer. He’s also the managing partner in his practice. He’s a chair of the West Berkshire PCN Networks, and also the clinical director of the early plus PCN. So that’s quite a portfolio, Amit.

Dr. Amit: Quite a lot of different things. Yes, absolutely. keeps me busy.

Dr. Rachel: Yes, I was going to say, do you ever have time to sleep with all of that lot going on?

Dr. Amit: Yes, yes. Well, probably, that’s what we’re talking about. I guess it’s about managing the time well, and I guess if we didn’t, then we wouldn’t be able to do half of those things.

Dr. Rachel: Great. So I’ve got in on the podcast today. And we are going to be talking about naughty monkeys and how we give them back. Now, I don’t know if people will remember. A while back, I did a podcast with Caroline Walker, who’s a joyful doctor. All about, well, we’ve done one about COVID fatigue, we’ve done one about stress and anxiety. We’ve sit on quite recently about moving on about what happens next and what we do. And she was talking about this thing called the naughty monkey. And that’s very much one of the areas that you’re quite interested in. And I know you’ve done a bit of work around that with trainees and you do some teaching on and stuff.

So just first of all, what is the naughty monkey? And why is that relevant for our listeners on the podcast?

Dr. Amit: The naughty monkey is interesting concept. I think it’s been described by Roger Neighbour, [05:32] amongst others. But essentially, it’s the things that the client, or the patient in our case, is actually bringing to the consultation. So I guess it’s their agenda, but also their burdens that they’re carrying. And the concern I guess is we want to help manage those naughty monkeys, those burdens. But essentially, we want to empower the patient and actually, for them to take those burdens away for them, with them, with the advice and help and support that we can provide.

But the danger, of course, is that those naughty monkeys stay in the room and never leave. And stay with the doctor or whichever health professional, or any profession really, that’s working with people. And you end up keeping those naughty monkeys and they create burdens and weigh you down.

Dr. Rachel: Yes. So I love this concept of the naughty monkey. It just sort of brings up such a great visual image of someone coming in and is that a monkey jumping around your room and sort of destroying everything that is there. And it is true that people come in to see you with stuff. And I remember once. A chap came in, it was a student actually. And he had a dreadful childhood. And I felt so upset after I’ve seen him and I think a friend had just committed suicide or something like that. Something dreadful had just happened to him, and he was incredibly upset. And I felt a wreck for the rest of the day actually after sin. Is that the sort of thing we’re talking about, as a naughty monkey?

Dr. Amit: Yes, absolutely. It could be exactly that type of scenario. It may be more subtle than that. But that’s fairly obvious. I guess there may be more subtle. There may be actually, the patient or the client actually needs help with housing, or they need help with finances, or they need help with their mental health or whatever the issue is. But I guess the key is that they’re leaving that firmly at your door and believing that you will address it for them. And guess not taking it away or feeling empowered to deal with it themselves. I guess in psychology, you would call it transference and countertransference. It’s that sort of concept that they’re working out.

Dr. Rachel: And so we’ve constantly got patients coming in, or clients coming in with their naughty monkeys. And I guess it’s fair to say it’s not just GPs and it’s not just doctors, but this can happen with anyone who deals with people who have problems that need solving. I’m thinking particularly of lawyers as well. People come to them with massive issues and massive problems that they need that they need them to solve. So this isn’t specific for healthcare, is it?

Dr. Amit: No, I think I think any sort of high stress job where you’re dealing with people, and particularly where there is, I guess, a professional relationship. What I’m interested in is actually the professional boundaries and how you maintain those in that relationship. So it’s really anywhere where there is that professional relationship with a client or a patient, and where you’re dealing with them directly yourself.

Dr. Rachel: So I know the answer to this question is fairly obvious. But I’m going to ask you anyway, because I’m sure you have your own particular take on it. What happens if we really don’t give the naughty monkeys back to people if we just end up with a cage full of these naughty monkeys?

Dr. Amit: Well, unfortunately, I’ve seen this in colleagues, where actually, the naughty monkeys are kept in the room. And they end up staying with the person. And what happens is that we become drained, we become burdened by these problems, and are unable to escape from them. And actually, we develop a cycle with our clients and with our patients where they feel that they can unburden by coming to see the professional scene and have some relief from that, have possibly something to help them forget about the sort of problems that they’re having. But the professional themselves is actually then weighed down. And in the short term, you may not notice anything. But in the medium to longer term, it will start to have an effect as you’re unable then to give as much of your mental energy to other patients and clients who need your support just as much as those ones who are unburdening in that way.

So, we eventually, can unfortunately see people actually burning out and leaving the profession or taking on different roles because of that issue. So it’s a really important one for us to tackle and to be mindful of. And it’s something right from the beginning of my career, I’ve been really aware of the need to ensure I’m working within the right boundaries with patients.

Dr. Rachel: And we’ll get really like to explore that in a minute. But first of all, I just like to dig a bit deeper into what these naughty monkeys are, and why it is so bad for us psychologically? Because we’re healthcare professionals or lawyers, we are people who—part of our job is to help people. Our job, to some extent, is to take that naughty monkey and tame it and turn it into a good monkey. But what is it that really burdens us? Is it the emotions of it and the sadness? Or is it the sense of responsibility? Or is it something else?

Dr. Amit: Yes, I think it’s partly about ownership. So it has something to do with that responsibility. Of course, in our jobs, we have got to help tame these monkeys. We’ve got to help support people. As the example you gave Rachel, a really sad example, we wouldn’t be human if we didn’t feel sad or apathetic about that. But those problems are often not for us to own and not for us to take away. And the resolution to those problems, yes, we can advise and help. But often, quite often, the patient or the client themselves has to be the one that takes the steps to actually curing that problem, or moving to a better place.

There are numerous examples, which I’m sure will go on to, that we could give, where actually professionals can inappropriately take on responsibility for actual things that the actual client or the patient should actually, take on themselves, because that will empower them and will be better for them in the long run.

Dr. Rachel: It’s really difficult one, isn’t it? Do you think this thing about taking on responsibility is—yes, we are responsible for a bit of it, aren’t we? We’re responsible for trying to diagnose someone’s healthcare needs and for referring them and things like that. We’re not responsible for if they choose to carry on smoking or what else decisions they make.

So I’ve seen people feeling lots of guilt about patience. And is that because there’s inappropriate responsibility being taken? Because I think healthcare professionals feel guilty about just normal stuff that happens about people’s illnesses. If someone doesn’t get better, they feel guilty. If someone’s got a dreadful stuff going on in their personal life, we can feel a little bit guilty that we cannot, even if there’s no help in the world, that would actually do any. Is that reason? Have you seen that?

Dr. Amit: Yes, definitely. And I’ve experienced that with myself, where part of the reason we do the job that we do is because we feel a burden to help support people. And it really bothers me when I can’t support someone in the way I’d hoped or they don’t progress or they don’t get better, or have a diagnosis that means it won’t get better. That’s really distressing. And again, that’s part of the reason we do the job.

But ultimately, I think we have to have an understanding of our role here. So I often tell my trainees this, but in our job, we’re health care professionals. So we’re experts in health, hopefully, we care and compassionate, and it’s really important to what we do, But we are professionals. And we always talk about professionalism in terms of being punctual, being on time, being appropriately dressed, and we think of that as professionalism. But actually, I think part of that is actually forming professional boundaries with patients and partnering with the patient’s, this concept that actually, the patient is at the centre of their health, not you. As the clinician, you’re guide, you’re a facilitator, to enable them to better health. So your role there is actually to stay within that boundary and not to take on responsibilities that are actually the patient’s.

So that’s a key area to understand our role. And once, overtime, we understand that and start to develop that, then it helps to manage some of the guilt and some of the raw emotions we can feel, which we all go through in our line of work and many other lines of work where you’re dealing directly with the public.

Dr. Rachel: I think there’s two problems aren’t there? Firstly is that we ourselves are inappropriately taking on too much of the responsibility and too much of the need to secure them or to make things better. We’re in the rescuer role if you talk about the drama triangle, you got the rescuer, the persecutor, and the victim. And we sometimes see them as the victim, who are completely helpless or can’t do anything.

The other side to that, though, is that they can be very quick to take on the victim role and give us the naughty monkey inappropriately. During consultation, skills training, I remember the first time I decided to ask about ideas, concerns and expectations. I said, ‘What’s brought you here? And what you’re particularly concerned about? And what do you put this down to in your own mind? What would you like me to say about it’? The first response I got was, ‘Well, I don’t know, you’re the doctor’.

Dr. Amit: Yes, absolutely.

Dr. Rachel: So what do we do? And actually, people are throwing their monkeys, ‘Take it, it’s not mine. I don’t want it. You have it’. Because lots of people do that but look. We are all quite bad sometimes about taking responsibility for themselves.

Dr. Amit: Yes, absolutely. And that’s one of the biggest challenges we have every day, really. And if you think about what drains you at the end of a busy day, it’s actually those kinds of consultations and encounters often, as well as the problem solving aspect of making decisions and diagnosis. It’s that exactly what you described, Rachel.

I think in those situations, the first response I generally have is one of grace. And so I try and build rapport with the patient. So if someone’s saying, ‘Look. I don’t know this is your issue to sort out’. Try and unpack that first. Try and really understand, ‘Okay, then why are you here’? You kind of ‘What has actually led to you coming in today’? But then try and unpack some of the symptoms, if you’re not getting anywhere. Try and build some relationship. Build some trust in the consultation. And then maybe you have to revisit that later on and sort of go back to it and say, ‘Well, actually, look, these are the things that we could do today. These are some of the things I could do. But these are some of the things you could do’.

And I guess, when you’re meeting someone for the first time, that can feel quite daunting to give some responsibility and give someone ownership of their health. When you think, well, actually, they just come to get the advice that they want and they want to be on their way. They just want the advice and get the help, and that’s it.

So that that’s part of the way you unpack it. I think obviously, it gets easier as you get to know people, like anything in life. The more you develop the relationships with patience, the easier that conversation becomes. And we’ll never do it perfectly. I mean, I certainly don’t. And it’s been many patients where I’ve been really, really aware that actually, I’m taking this all on here. And actually, I should be encouraging the patient to do that.

Dr. Rachel: But there’s another reason as well, I think that we do take on too much. And I think that’s fear. And I think fear of complaints is a massive thing. And fear of mistakes is a massive thing, not just in medicine, but in law and many other professionals. Professions that you go above and beyond and inappropriately take on people’s things, because we are so scared of doing something wrong, or someone putting in the complaint about us. What do we do about that?

Dr. Amit: That’s definitely driving some of our behaviours, isn’t it? And driving some of the things that we do in decisions that we make. In terms of complaints, the danger is that we just live and make all the decisions based on that fear. I think the reality is, in most of the complaints that happen are because of communication, and rather than actual decision that was made. That’s not always the case. But if you look at the majority of reasons, it’s communication. So having good communication with the patient. And sometimes actually being honest with the patients about the dilemmas that you face. It’s really important to share some of that risk, and ultimately, you’re going to help them manage that. But actually sharing that and unburdening that I’ve always found has been helpful to try and manage that.

But I think, too, Rachel, another question for me here, though, there’s a fear of complaints. But also there’s a bit about wanting to be liked, and wanting to please and certainly as healthcare professionals, but in other roles as well, we certainly can fall into that. And it’s important, we understand ourselves and understand what our values are really and whether that is part of our personality.

So that’s something I always do, not just with myself and colleagues but with trainees is, look at the psychometric testing, things that Myers Briggs and Honey Mumford, these can all be really helpful to understanding why we behave in a certain way with patients and clients.

Dr. Rachel: I think that is so true. A lot of our behaviour is driven out of wanting to be liked. And actually, that is driven out of fear most of the time because we know that our amygdalas react to certain things, they react to physical threats, they react to hierarchical threats, and they react to people not liking us—threats.

I remember a patient sat down. She came in once in the surgery. And before she said anything, she sat down in front of me, she said, ‘Well, I just want to say that every doctor I’ve seen so far has been no effing use at all. So also you’ll be no effing use’’ And I was just, [gasps], she doesn’t like me. I thought, hang on a sec, she’s never met me. She has nothing to basis about on the right, apart from the fact I’m a doctor. But immediately I was triggered into ‘Oh she doesn’t like me’. We know why we get triggered because in our ancient, when we were living in caves, if we’ve thrown out the group, we would die of exposure. So it’s like a proper threat thing.

But again, yes, it goes down to fear of not being liked by people, not being accepted by the group. So we do things to make people like us. And then you get the thing where you’re overly taking on responsibility because you want them to like you. And then you get into the drama triangle. And the drama triangle I find absolutely fascinating. It’s one of the shapes to talk about a lot and it breaks. You see when teams do it, and doctors sit, they go, ‘Oh, yeah’, because you’ve got there the people that don’t know about it. It was devised by Stephen Karpman in the 1960s. He was Eric Berne’s student. Eric Berne is the father of transactional analysis that we’ve already talked about.

But you’ve got the three roles which you’ve got the rescuer, which I think GPs, most professionals firmly sit in rescuer. Then you’ve got the victim and that probably we see our patients or our clients as the victims that we need to help. Then you’ve got the persecutor, which is the problem that helps them all someone else’s being the problem. And the problem is we just move around. So we start off by wanting to be the rescuer to this poor victim. And then, as soon as we, as a rescuer, can’t give the victim what they want, i.e. saw out my back pain, make it completely better. If we can’t do that, we then get put in the role of a persecutor. And that’s where the complaints and stuff comes. So I think the only way we can really start getting out of it is just to step out of that role as rescuer completely rather than taking on in the first place. So how can we do that?

Dr. Amit: Yes. I think partly, it’s conversation like this. It’s actually understanding your role and understanding this is actually happening. And I think this is why if from the outset, you understand yourself and understand the psychology of the consultation to some degree, that’s really helpful to know this process is happening. And I think partly you have to work on this feeling of being liked, and understanding that it’s okay sometimes not to be liked.

And actually, if every single consultation, every single client liked you and gave you 100% satisfaction, you’re probably not challenging your patients. You’re probably not doing something right, actually. Unfortunately, we do receive complaints. And sadly, it’s become a norm that a doctor or any sort of professional really will expect some kind of complaint. I have to say to the students now that if you never have a complaint in your career, or even over a 10 year period, now, or even any feedback, you’re probably, again, not doing something right, you’re probably not actually chatting your patients, because sometimes patients do respond to that. So I think, having an understanding of the consultation, having an understanding that all these dynamics are at play can really help us to unpack this and change the way we consult. Certainly, that’s what helped me.

I remember coming as a new GP, and the first year having some of these issues that we’re describing, and I think that was a real learning curve for me as an independent GP. I think about a year and I realized that actually, I probably was on that balance on that side of being the rescuer and wanting to go over and above all the time. But understanding these sorts of concepts has really helped me become more self-aware in the consul.

Dr. Rachel: And how would you spot when you’re in that rescuer role and being overly responsible and not taking that naughty monkey on board? What’s the tell-tale signs?

Dr. Amit: So one of the things is to forget how you feel about work day to day. How are you feel after a day’s work? Now there can be many reasons why you might be dissatisfied or feeling tired or struggling at work. There can be many reasons for that. But this is one of the areas that you’ll notice first really is that you are struggling with your workload. You’re struggling to manage day to day. You may also get comments from colleagues. Certainly, that’s often been really helpful in my development, is colleagues are saying, ‘Well, actually, I saw this patient and you’d offer to do this and this and this. And I’m not sure’.

Dr. Rachel: Are you mad?

Dr. Amit: So, and that’s helpful. And you needed an environment, a supportive environment where people are willing to give that kind of feedback and talk to you. And I’m really thankful it works where I work that that culture exists. So I think that’s really important. But yes, it’s that personal kind of dissatisfaction with work may be an initial sign that actually you are potentially taking on too much of the load.

And then having peer review, I think talking to others and saying, ‘Well, actually, look, I’m doing this, I’ve got a feeling I might be taking on too much, am I not be? Let me give an example of the type of thing I’m doing’. Speaking to somebody who’s perhaps of a different personality to yourself can often be helpful to kind of find you find those gaps.

Dr. Rachel: Yes. I think it comes with experience a lot, doesn’t it? I remember in my first job as a salary GP I really struggled when I’d get people coming to me asking for diazepam, which you get, people get addicted or just on small doses of sleep. It’s a lot stricter now than it was. But I would really feel bad about it. I’d say no, but I’d try to negotiate and bargain and maybe give them a couple just to tide them over so that they could reduce down and get off.

And then just speaking to one of the senior partners, ‘Nope. Just never give it just nope. It’s a rule of mine. They know it and you know’. It’s just like, no questions, no queries, she just said that’s just a thing. And it was really helpful just to know that that was okay. And the patient would come in and give their naughty monkey of their addiction. Of course, they just never leave some with addiction with nowhere to go. But they’d say, ‘Well, I don’t want to do that. I don’t want to do that. You just got to do it for me’. And I think that’s a big trap that we can get into is they refused all the other help, and they said, ‘No, you’re the only one that can do it’.

Dr. Amit: Absolutely. Yes.

Dr. Rachel: That happens a lot, doesn’t it? But it makes you feel a bit like, ‘Oh yes, we’re the only person that’s listening to them’. Without thinking actually, they’ve probably tried it on with a lot of other people at the same time. Or maybe not. I mean, it’s so difficult, because these people are in distress, and they’re desperate for help.

Dr. Amit: Yes, but you can take on that special status. And you often find that, ‘You’re the only one that understands me, doctor’. And that’s great. It’s great to have that feedback in one sense. But equally, you have to be careful that exactly what you’re saying isn’t happening, that you are being almost siphoned off from the rest of the world, and all the other people that could be helping them.

One of the things is, with technology, with the notes being so good now, we can actually get a really good sense of when people have been doing that, and it’s really important is we look at the notes before we see people. We look at who they’ve actually consulted with, how many times have they come in with this problem before? And that gives us a really good idea whether we are going to be their saviour on this consultation or in fact, we’re going to have a conversation about setting boundaries.

So yes, you got to judge each case as it comes. But the background is really important. And sometimes, as you said, checking in with colleagues. There’ll be some patients where, I find a consultation, I thought this has been a bit odd. It was being difficult speaking to someone they’re spoken to before, or actually, ‘I had the same story. And I also didn’t prescribe the diazepam, and you’re the doctor they’re trying it with now’. My trainees get this a lot. So all the regular GPs may have set boundaries, and then obviously, you got a new trainee, new fresh green trainee. So you get these patients almost deliberately book with it with the trainee to see if they’ll bend. So yes, it’s a real challenge. But we do need to not be afraid to say no, that’s okay. And direct them to better help.

Dr. Rachel: Yes. And you may get a complaint if you say no to someone. But if you can give you reasons for saying no, and then that’s going to be fine. It’s like you said, you can’t please all of people all the time. I’m thinking you’re probably going to get a bigger complaint if you blow the boundaries, going above and beyond or overstep the mark and you’re helping and something goes wrong then that’s when I’ve seen doctors and other people get into real trouble, when they’ve over helped and over rescued.

Dr. Amit: And there’s a cost to that isn’t it? And there’s a cost to saying yes to everything. There’s a cost to the patient themselves, because they’re not empowered. And full back, they’re not activated to manage their own health, the cost to the clinician, but it’s also cost to the colleagues as well, and other patients. Because if you’re devoting your weekly time and attention to this patient who should be doing more for themselves, it means you’re not seeing other patients who could benefit from your help and support. And with the NHS, that’s part of our thinking, our role as partly as a gatekeeper. And we do need to think about that, and manage our time appropriately.

I mean, that’s the biggest decision we have. I listened to one of your other podcasts on Medics Money founder, and that was really interesting. And that was one of the things that was brought up there is money buys your choices, but your biggest commodity is actually time. And I think it’s the same for us in consulting, we can choose who we invest the time into some extent, and need to use that wisely.

Dr. Rachel: Yes, and I know that the doctors—I think every GP struggles with time. We do, because 10 minutes. We can’t do anything in 10 minutes. But the people that really struggle. I know I’ve been a receptionist. So we were laughing earlier, because actually, the way I met Amit, it was because we were communicating on LinkedIn about something. And I spotted that you’re actually from Brookside Group Practice, which is where I was literally brought up, quite literally.

So for an old blast from the past, so I was actually a receptionist there in my holidays. My father was one of the GPs. And so actually, I remember working with a receptionist and some doctors would take—he would just be over the whole time. you would know that the patient’s with them for hours sometimes, and other doctors would whizzed through with their patients. Now, there’s a balance, isn’t it? There’s definitely a balance. But it’s definitely the people that were really spent a long time and took all the problems on it. I guess in those days, probably. That was more like what you did as a GP, as a real cradle to grave GP. But you can’t do that now because there is too much work, you will get burnt out.

Dr. Amit: Yes, the demands are much greater. And I guess the expectations of patients, quite rightly so to some extent, with all the different diagnostics and treatments we have now are much greater as well. So yes, you can’t really function like that. So it is a big change, actually, I think, in the way GPS is moving forward.

But the other thing is, Rachel, we’ve got a number of other avenues of support and help now. So for instance, with Primary Care Networks, which are groups of GPS, we are sort of now employing people like social prescribers, who are there to help with these kinds of life issues. And they can spend 45 minutes or an hour with a patient properly going through all of these different issues that they have. And that is such a valuable resource. And one that we’re trying to maximize the usage of.

So actually, the GP isn’t the only source of support, there is so much out there in the community, and volunteers, there’s just so much support, if we know how to access it, and when the right time is to use it. So yes, really reducing the reliance and dependency on us.

Dr. Rachel: Yes, I think we have a real hero complex. And when you’re in the rescuer role, you have this hero complex. And I was really fascinated to find outside of—I co-authored Lead. Manage. Thrive! course for Red Whale. And were doing the—working at scale course. And we were talking about the public health determinants of health care. Actually, only 15% of someone else’s health is determined by medicine and the healthcare system. The rest is determined by their housing, by their genetics, by society, by everything like that.

So actually, if you think about health care can only affect 15% of a patient’s life anyway. And you out of that 15% is probably quite smaller as well, because there’s all sorts of other things in there. So we really need to stop thinking we can do much about anything really.

Dr. Amit: Yes, then we’ve got our role to play, haven’t we? But that’s it, we’ve got a role to play. We’re not the owner of the patient’s health care. They’re the owner of their health care and all these other issues around them as well. And I guess that also makes me consider about the role of things like prescriptions. That’s one of the most important things that we can do, is prescribe things. As a hero, that’s one of my main skills I have is to be able to prescribe things and it can be quite rewarding to prescribe and the patients can often have that sort of expectation of a prescription. But sometimes that can be the worst thing to do. Because if it’s something where it’s a mood problem, perhaps, which isn’t severe and doesn’t need—it’s not clinical depression, it doesn’t need necessarily medication. And there are other avenues that could support. Giving them prescription, medicalizes it and it continues to create that dependency.

You give a medication, it’s invariably get a side effect. So you get a phone call about the side effect. You then perhaps think about changing the dose or changing the medication. And you can go into that cycle. And there’s lots of different drugs out there. So you could spend two years conceivably going through this cycle. And I know that because I think I did that once with a patient and thought, ‘Actually, I’ve just spent two years going through all of this. When actually, the problems here are the issues at home. Let’s talk about those’. And that patient actually really unlocked a lot of this for me.

I remember saying to her, ‘Could you just list all the things that you think could help you get out of a situation that you’re in’? She wrote them down for our next consultation, and we looked through it together, and I said, ‘Look, how many of these things do you think I can influence’? And actually, it was just the prescription that was the only thing that I was influencing. And probably, some of the drugs she might have needed, but some of that she probably didn’t. And it was a great learning thing for me and for her. And she said, ‘Well, actually I probably don’t need to come back to see you’. I said, ‘We’ve also got these people called pharmacists, they can also help you with prescriptions’.

But actually, that was a great learning experience for me, as to exactly that the hero complex and using prescriptions to fulfil that.

Dr. Rachel: Yes. And also using prescriptions just to solve the problem, to get people out, as well, because it is the easy thing to do. Let’s face it. Easy thing to do. I remember someone was criticising me for not prescribing some antidepressants. Actually, that’s an easy thing to do. The hard thing to do was to talk about lifestyle changes, and some of the non-pharmaceutical things actually would make a bigger difference.

I’ve got a friend who’s a very, very good family lawyer. But she does everything to try mediation and try get them to sort it out. Court is the last ditch thing. You don’t go—maybe we should be thinking more about medical intervention and prescription as being the last point of call rather than the first one and actually empowering, getting the patient on path to see their own behaviour changes. It’s so important, isn’t it?

Dr. Amit: Absolutely. Mental health is a big one, and I think that’s a big part. But I mean, even with physical health, medications obviously have a massive role to play. But sometimes if we look at the relative efficacy of using different drugs, versus lifestyle change, if we think about cardiovascular health, heart health, for instance. There’s no doubt that exercise, good lifestyle, all these things actually have a much, much bigger impact than any drug that’s ever been invented. So we definitely need to push that agenda with our patients much more and not be afraid to do that.

Dr. Rachel: And at this point, I just want to add the caveat to our listeners that we’re not saying don’t take medication, it can be really helpful for all sorts of mental health and physical conditions, they absolutely do. But I think it’s just getting into the mindset that our patients are able to do stuff for themselves, and our clients are able to do stuff themselves. And for me, this was a huge mindset shift.

So when I teach about the drama triangle on my Shapes Toolkit course, I always talk about instead of a rescuer, we move into more of a coach mentality. And we view the victim not as a victim, but as an activator. Someone who is quite capable of solving their own problems, doing it themselves. And of course, then you’ve got to also view the person, who’s the persecutor, or the thing that’s the persecutor, not as a persecutor, an evil person, but it’s just a challenge or a catalyst.

And for me doing some coach training, learning how to coach just it really changed my life in terms of all sorts of things. Because you immediately start supporting when you’re rescuing, rather than coaching, when you’re trying to fix things rather than coaching. And actually help behaviour change coaching is really, really powerful. And it did, I did just feel like this weight lifted off my shoulders, because for the first time, I think I was really stupid, because I’d practice medicine for what? 10, 15 years thinking it was up to me to solve everyone’s problems, and I suddenly realized that I couldn’t. And it was up to them to solve most of their problems. It was quite a relief at the time.

Dr. Amit: Absolutely. And I’ve gone on a similar sort of journey myself with getting that understanding. And interestingly, I was just doing coaching at the moment, going through the course at the moment, so that’s been really helpful to kind of think through some of these things. And actually, our social prescribers and health well-being coaches, all these roles now exist. And they’ve often done exactly that type of training about health behaviours, and how we motivate people, that motivational interviewing techniques. And this is something actually, as a locally, we’ve actually been doing in our patch to actually help train coalitions on motivational interviewing, even in 10 minutes. What you can do to try and move people forward rather than sort of dependent on you? So yes, it’s a massive, massive deal. And one challenge I think that all coalitions but so many other professionals have.

Dr. Rachel: So what advice would you give to someone, to any professional, who has a client or a patient who’s well and truly dumped their naughty monkey on you? How do you hand it back? What are your top tips for giving that back and making sure it’s not going to stay with you? So the consultation or when you’ve shut down your computer or you leave work?

Dr. Amit: Yes, yes. So as I say, first of all, I think you do need to, obviously, in the consultation, you’ll have unpacked some of it and understood why they’ve come in and understand what the actual issues are. I think I try, and as I say, partner with the patient, and make it clear from the outset that you are a partnership. And for some, maybe easier in the legal setting and other settings, actually having an agreement between you as to exactly how the relationship will develop in certain coaching circles that’s much more familiar. But in the patient setting it can be more difficult. But you do need to have that I think that discussion about actually, ‘Here’s the issues that we’ve got here and let’s share this plan of how we’ll move forward’.

So, one of the phrases that I like to use is, ‘these are the things that I could do to help today and these are the things that you could do to take this forward’. So it’s really clear who’s doing what. Sometimes writing it out can be helpful. Or nowadays, it’s also remote. So for texting. Texting these things can be helpful. But actually having it down as a clear plan for you both really helps.

I think that’s often where there’s issues.There’s perhaps not a clarity at the end of the meeting. And it might mean that that first meeting takes longer, takes much longer than 10 or 12 or 15 minutes. But that’ll have a massive value in the long term because you won’t then be spending that 20 minutes, the next time and the next time and the next time. And you’ve clearly set those boundaries. Not only for the issues that they’ve discussed today, but going forward as well.

So making it clear what you are there for and what you’re not there for. And signposting effectively to other sources of help that there are. To do that you need to be aware of what’s out there. And so when you get those emails about different services, actually, it’s worthwhile knowing what is out there? Who can I refer to? And if you don’t know now, find out. Go and find out, who are my avenues of support? Where could I delegate appropriately for my clients? Because there’s always support. There is always support out there. We’re just often not aware of it. So that’s some of the top tips I would normally use.

Dr. Rachel: Yes, it’s a great… I guess, as you’re saying that I was thinking, my super top tips are very much as a coaching role. You would never come out of a coaching session with actions for the coach to do. I might say, ‘I’ll send you a questionnaire or something that would be helpful’. But I’d never say, right, ‘My action is to talk to that person for you’ or that, never in a million years. But often as a GP go, ‘Okay, well, I’ll do that for you. I’ll phone that person. I’ll write that letter’. I guess if you can get the patient to take ownership and responsibility for doing that themselves that is much, much better. So I like this. I like self-referrals to physio. I like self-referrals to IAPT all that sort of stuff, because it’s the ownership is on them, and they’re much more likely to benefit from it if they do it. So stop doing it for everybody. And I think that applies to all professions.

And before you give advice, I think ask them what they’ve already tried, or what they think they could do about it. That’s a really good… If you’re a manager as well. That’s my top tip for managers who don’t want to burn out. When people come to you, your teams come to you for advice, before you go, ‘Well, this is what you should do’, you go, ‘What do you think you could do? What have you already tried? What are your options’? Ask them.

I think you really need to watch out for pants on the outside syndrome, which is superhero syndrome, which doctors definitely have, lawyers definitely have it. Lots of other professionals definitely have it, that we are superhuman and that our needs don’t matter and that we’re just there to give and give and give because it doesn’t end well.

And then finally, I think something you said earlier was really important is peer support and debriefing with other people. Because otherwise you get into your own sort of echo chamber thinking that this is the right thing to do, or it’s normal. And it’s so helpful when someone comes and goes, ‘Hmm. That was an interesting way of handling that’. You’ll think, ‘Is that not the way you do it’? ‘No’. And then you said, ‘And just a brief note, I’ve had this consultation. I’m not sure I’m feeling like I’ve still got the monkey here’.

Dr. Amit: Yes, yes, yes. I still got the baggage. Yes, absolutely. And at the end of the day, when you debrief, those conversations are just so valuable. And it certainly helped me so much in my development and growth as a clinician. So yes, you’ve got to find people that you can talk to debrief. And in going back to the coaching, you’d have your coaching supervision, for instance, as an analogy. So you do need that input at times.

Dr. Rachel: Yes, and I’ll get on my hobby horse here, but now about how coaches have to have supervision, how psychologists have to have supervision. Doctors, we get an appraisal once a year. Do we have any mandatory formal supervision to talk? You’re seeing 30, 40 patients a day all you’ve got these monkeys jumping around, and there’s no regular mandated debrief supervision. I just think it’s so important that if you can find a peer group to do it with anyone, I think it is really, really important. Even just informally with a friend having a coffee and everything.

Dr. Amit: Yes, definitely, definitely. I think my wife Stephanie is a lot better at doing that. They’ve got a bit of a group of friends who have formed a bit of a balance group. And I think that’s so valuable. We all need it, we all need to debrief. And sometimes it can be helpful to get some context from someone who’s outside of your working environment as well to normalize because you can develop a bit of a culture of practising certain way. So getting a different perspective, someone with a different personality perhaps to you as well really helps.

Dr. Rachel: Yes, 100%. 100%. Thank you so much. That has been so helpful. Really, really interesting. I think we can talk about that for a long time but we do need to stop. Amit, if people want to get in contact with you, where could they find you?

Dr. Amit: Best place is really also LinkedIn, as you found me. So that’s really obvious. I’m just Amit Sharma. No funny nicknames. And my sort of contact details are on there. So email is on there as well. That’s probably the best way.

Dr. Rachel: Great. Thank you so much for speaking to us, then hopefully, we’ll speak again soon.

Dr. Amit: Brilliant. Thanks, Rachel.

Dr. Rachel: Thanks. Bye.

Dr. Amit: Bye!

Dr. Rachel: Thanks for listening. If you’ve enjoyed this episode, then please share it with your friends and colleagues. Please subscribe to my You Are Not a Frog email list and subscribe to the podcast. And if you have enjoyed it, then please leave me a rating wherever you listen to your podcasts. So keep well, everyone, you’re doing a great job. You got this.