Good Enough

I remember my first appointment with my psychiatrist. It wasn’t quite what I expected. Within ten minutes of arriving he seemed to have completely sussed me out. He sat forward in his chair and picked up the pen from the table. He wrote the words “Anxious perfectionist” on a white piece of paper.

I stared blankly at the page.

“This is your personality type” he explained. “In fact, many medics tend to be like this.”

I sat, avoiding all eye contact.

“As an anxious perfectionist you have lots of positive traits.”

He started writing a list on the sheet:

  • Very conscientious
  • Caring and compassionate
  • Applies self fully to everything

“But this personality type also comes with a number of not so helpful traits:”

  • Gives 110% to everything
  • Struggles to say No
  • Creates own stress where there perhaps needn’t be any
  • Struggles to accept good enough

Me, scrawled on half a side of A4. I cried. Relief. Sadness. Helplessness.

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I have always felt comforted by success. There is something about performing well that gives me worth and value. When I was quite young I realised that if I tried hard and did well, people seemed to like me. There was a lot going on at home and I needed people to see me, to like. As I got older, the compulsion to out-do myself got worse.

If it wasn’t perfect, then it was simply no good.

This attitude continued through high school and university. With it came great results. I graduated top of my year, I passed my membership exams pretty quickly, got several publications etc but none of it meant anything to me. No pride at all. No self worth for what I was achieving. People told me how well I was doing; all I heard was empty words.

I now know the price I paid for all this. Medicine was my crutch, my way of controlling everything that was going on inside me, feelings that I didn’t know how to deal with, childhood traumas/ that had never been processed. Slowly, I became numb to everything else. Perfection had become a drug.

But then life changed. Two children came along, I suffered with bad post natal depression, started working part time and realised that I could never be the doctor I had been up until then. This strange fear came over me. Grief for the loss of the driven, ambitious and competent person I had been, a feeling of failure. And worst of all… I don’t even know who I am.

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Slowly, like a germinating seed, the concept of ‘good enough’ is beginning to feel more comfortable. Life has changed and with that I need to realign my priorities and expectations. I now have a husband and two children. I have a diagnosis of type 2 bipolar, which unfortunately isn’t going to go away. It is now my job to take care of myself, to stay well and prioritise what is important to me. The only way to do that is to begin to accept ‘good enough’.

If I stop giving every ounce of my soul to being the best mother, the best wife, the best doctor maybe there will finally be space for me to be the best and the happiest version of myself.

Good enough is plenty good.

Living a lie

It is March 2017, I am giving a presentation to a group of about 20 paediatric trainees. Half way through my presentation I realise my jumper is on inside out and back to front. Without thinking I proceed to switch it around whilst still talking through my slide show. This is certainly not something I would normally do, especially given that nobody else could have possibly noticed it wasn’t on correctly! At this point my brain was going at 150mph. I was feeling on fire, full of energy, disinhibited, wanting to take on new projects left right and centre, unable to control the pace at which I was thinking and doing things. And suddenly, for no obvious reason that afternoon I was at the bottom of a pit, feeling completely apathetic, negative and hopeless. Overcome by anxiety I sat worrying  about where I would park the following day, should I take the train, no maybe the car, but if I take the car…. before I knew it I was sobbing.

These huge swings in my mood would occur from one day to the next or sometimes within the same day. I would wake up and look in the mirror unsure of which version of me would look back. By the time I got to work in the mornings, the wonderfully perfected show face was on.  Words would automatically come out of my mouth: “I’m fine thanks” “Yes I had a lovely weekend”. But as time passed, I became more and more exhausted. The show face started to crack. The lows got deeper, the anxiety more extreme. I was falling asleep at traffic lights on the way to work. I knew I couldn’t really continue… I was honest with my GP and my psychiatrist. I agreed to stop work for a bit. But somehow this seemed like the worst possible outcome. The guilt. The shame. The sense of failure. Because ultimately doctors cope, they get on with it and bounce back. But I couldn’t fix this. This was bigger than me.

 

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Fast forward to July 2018, I am sitting in clinic dictating my last letter of the week. My mind is still. My thoughts are clear. I can concentrate. I can think. I look at the list of patients I have seen. Not as many as I used to see in a morning clinic but I try to let that go. Instead I look again and recall how close I was to quitting. How I never thought I could be a doctor again. How bitter and resentful I had become. And at that moment I feel proud.

Proud to be a doctor with a mental illness. I take medication. I am in therapy. Because doctors are human, and humans get sick. With help and support you can find a way through.

Reach out. It turns out it was the right thing to do…

In search of perfection

Some time in 1996

I am 10, maybe 11.

The phone rings one evening.  It’s my flute teacher- she never rings our house. I make polite and slightly nervous conversation and she quickly asks to speak to my mum.

“OK yes, I see, yes, she will be very upset but yes I will let her know.” That is pretty much how the conversation goes.  Minutes after that my mum tells me I have failed my grade 5 flute exam. I cry uncontrollably. Ashamed and disappointed with myself; I have let people down.

I don’t fail things. But here I am. A failure…

 

December 2017

I am sitting in my therapist’s office. It hasn’t been long since my diagnosis of type 2 bipolar. I am still trying to come to terms with what it all means. Grade 5 flute exam all over again but on a monumental scale. Failure. I have let so many people down. I have failed to overcome traumas, failed to be normal, failed to be perfect. Instead here I am, sobbing, in therapy, on medication, off work…

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The medic in me sees my illness for what it is, recognises the abnormal thought processes and feels compassion. The medic knows I am and never have been a failure. The medic knows empathy and understanding, kindness and care.

But the real me, the me that sits in that chair every week… she hasn’t known how to look after herself, how to accept mistakes or how to love herself.  She has been living a life of two extremes.

She still has a lot to learn…

 

But it has to be perfect…

In medicine there is definitely a culture of aiming high, seeking more, pushing yourself, achieving. Constantly achieving. As a trainee there are assessments, appraisals, exams. There is always a need to do more; audits, quality improvement projects, research, publications, teaching, presentations…  not to mention being a good clinical doctor. Somehow bumbling along isn’t really an option. As such, I took the first part of my training very seriously. I threw everything I had at paediatrics, I strived for perfection with each individual patient, each teaching session, each conference presentation. I needed to know I had done my very best. Everything in my life was as ‘perfect’ as I could make it.

Only now, I realise it wasn’t really about perfection. It was about control, about knowing that I had tried my very hardest, I had done everything within my means to get the best result possible. And when the result wasn’t perfect, it simply meant I should have tried harder. But I couldn’t have tried harder. And when I did, I broke.

 

Maybe it’s OK to slow down

My recent time out of training has really given me some perspective. I have had space to understand what is important to me, time to realise that perfection doesn’t exist.

I see junior doctor training very much like a fish finger conveyor belt. The perfect fish fingers make it to the end but the others, well they get dropped off the belt at various stages- be it they can’t pass their exams, they haven’t performed well enough etc.

But suddenly I realise that I have a choice. What if I don’t want to be a perfect fish finger any more? Maybe it’s OK to step off the conveyor belt for a bit. Maybe it’s OK to be different.

There is a whole world to discover, a world that sits in between the two extremes of perfection and failure.

A world where it is OK to just be me.

 

 

Beyond #CrazySocks4Docs

My family and I have spent the last two weeks driving around Switzerland in an old VW campervan. I am not a camper; it isn’t something my family did when I was young. The idea of being stuck in a small metal box on wheels for fourteen nights as I emerged from several years of uncontrolled bipolar did not seem to be a particularly relaxing one. There were certainly moments when I thought “F*** this camping malarkey!” (for example when I smashed my forehead on the cupboard next to me as I rolled over in bed!), but surprisingly, this trip far exceeded my expectations. In fact, I actually enjoyed it.

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Most people enjoy their holidays, look forward to them, count down the days etc… For me, holidays have been a significant source of anxiety for the last few years: out of my comfort zone, unfamiliar surroundings, airports to navigate, small children to keep alive!  The planning of the trip to Switzerland wasn’t much different. I couldn’t be bothered; apathy, disinterest. Every time I did try to engage with it, I became overwhelmed with worry about trivial practicalities. The negativity would set in. I felt passive- a passenger on a holiday my husband had planned and looked forward to.

The fog of anxiety lifted as we drove off the ferry in Rotterdam. That feeling, which I have become so accustomed to, floated into the distance leaving me feeling lighter, more playful and engaged. We spent two wonderful weeks yodelling and eating chocolate on the edge of spectacular Swiss lakes. The girls (almost 5 and 2) simply loved it.

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Half way through our trip was #CrazySocks4Docs day. From the moment that I read about the campaign on twitter, I was determined to spread the word and increase awareness of mental health problems in doctors. Slightly difficult whilst in a van in Switzerlan! Although I can just about ask for a loaf of bread in German, my language skills don’t stretch as far as discussions with the public about the emotional well-being of doctors!

I am one of the statistics: I have bipolar 2. I’ve thought repeatedly about ending my life. I have recently crawled my way back from a dark dark place. Not everyone makes it back. I know the despair and helplessness that those colleagues felt, the bleak abyss where no future seems possible.

Mental illness as a doctor is not a weakness or a sign of failure.  #CrazySocks4Docs was all about that.

 

So, back to the morning of Friday 1st June, I proudly put on the craziest socks we had in the campervan. My eldest remarked that I “looked ridiculous!” I explained to her and her sister what Crazy Socks was and why we were doing it. She turned to me and said “Mummy, we want to do it too. We want to talk about how doctors feel.” Simultaneously, my husband pulled out his fluorescent cycling socks and offered his support. Tears filled my eyes… I felt loved and accepted.

As the day unfolded, twitter filled with support for doctors’ mental health. People from around the world donned their colourful socks and stood united. The message spread. Conversations started. #CrazySocks4Docs was so special. I felt accepted. I felt shame free and I finally realised that it isn’t just me.

Two weeks have passed since #CrazySocks4Docs but the conversation must go on.

This week I went to see occupational health. Yesterday evening I had therapy. I cried. I took my medication before I went to work today. Tonight I will take more. But I am slowly realising that none of this stuff defines me. Because today I was a compassionate and caring doctor. Today I was a Mummy to two fantastic beautiful girls. Today I was a wife to the most supportive husband I could ask for. Today I was more than my bipolar.

Mental health problems are nothing to be ashamed of. Support each other, encourage your friends to talk and dot be afraid to ask for help.

Fire fighting

The bleep has gone off for the third time in the last few minutes. Patients are piling up on the assessment unit waiting to be seen. We currently have no free inpatient beds. Parents are unhappy on the ward. One wants to make a complaint. We are all tired. Nobody has had lunch. Everyone feels stressed and uninspired.  It is 12:00 on Thursday.

As I sit there in that handover, trying to keep track of everything that is going on, I notice how negative we all seem. The language we use. The things that we remark on. The jokes we make.

One of my biggest realisations whilst I was off sick was how easy it is to get swept up in the vortex of service provision, of covering gaps, doing two people’s jobs and just getting on with it. It’s what we are all doing, out of necessity. It seems normal. But it is fire fighting. We don’t have time to notice what is going on around us. We don’t have time to listen and appreciate. We no longer have time to enjoy medicine, we just fire fight.

As the handover comes to a close, there is no mention of the families who were grateful, or the juniors who correctly identified and treated the septic child, the nurse who delivered exceptional care or the patient’s sibling who made a glittery thank you card for everyone. We may not speak of this stuff, but it is there and it is plentiful if you look. Helping each other to notice these things might just contribute to restoring a sense of value and worth beyond that of service provision. We are all human, we deserve to feel valued.

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Two years ago, at the end of my first meeting with my therapist, she handed me a printed sheet about mindfulness. “Have a look at this, I think it might help you”. I took it but was pretty sure a bit of meditation wasn’t going to fix me. Now, some many hours of therapy later, I can really appreciate the value of being present in the moment. For me it isn’t so much about sitting down for 15 minutes and meditating. Instead I am learning to live more in the here and now, focusing on sensations, on my breathing and the things around me. And suddenly I am noticing things, things that have always been there but that were hidden behind the fog of depression and anxiety. For example, the soft deep humming of a bumble bee by the side of the footpath, the high pitched chirping of the birds outside or the gentle whirring of the air conditioning unit.

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On a busy ward, in the midst of a chaotic assessment unit or a clinic that is running late, sometimes we just have to pause and notice things. Let everything else drift past us for a minute or two and appreciate the here and now. As I do this I notice the glittery card made by a patient’s sister propped up on the nurses’ station, hear the laughter of the ward clerk and family who have just arrived, notice and appreciate the kind words of a family who are passing by.

Maybe next time you are in handover, try pointing out something good that happened, something that you noticed in and amongst the daily grind. Let’s work together to find value again as a cohort of doctors. Value comes from noticing all the good in and amongst all the crap.

Returning to work

These last few weeks have been tough. Returning to work after long term illness was never going to be easy.  My anxiety, which had settled somewhat, has got worse again but I suppose that is to be expected.

I have found it really hard to find the words to describe by absence to colleagues or to justify my need for a phased return and supernumerary training. I don’t want everyone to know that I was in a horribly dark place, that I thought about ending it all, that suicide was the only way for it all to stop.  I don’t want them to know that weekly therapy and mood stabilisers saved me. I now carry a label; a label that says Bipolar 2.

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Somehow, I feel really uncomfortable when the words “I have been unwell” come out of my mouth. Self compassion is something I am learning. My brain still diverts automatically to the negative, self loathing chat which takes considerable effort to silence. On a couple of occasions I have muttered something about the current pressures of the NHS completely breaking me. People seem to understand and relate to that and it isn’t completely untrue.

This time last year I genuinely believed that I could no longer be a doctor. I couldn’t see how I could fit back into that environment; how I could continue giving so much of myself in the knowledge that it was compromising my own wellbeing. I felt so bitter about the system, bitter and even resentful towards the patients. This was so far removed from the old version of me; the passionate and dedicated paediatrician who thrived on patient contact and communication, the me who people turned to for advice, the me who I admired.

Pulling myself out of that dark place was, and still is challenging. Hours and hours of therapy, unlocking and reliving traumatic childhood events. Learning new, more adaptive coping and self-help strategies. Stopping, starting, switching medications to re-establish the neurotransmitter imbalance. Crying in cafes. Panicking in stations. Freaking out in a crowd…. I can now see it. I have come a long way. I couldn’t be a doctor then. But now… well , now I am ready to try again.

And so, armed with my newly learnt coping strategies, I turned up on my first day back. Now, don’t get me wrong, I wasn’t expecting a Welcome Back banner and party poppers, but I had hoped there might be someone vaguely expecting me, someone to welcome me or greet me, put me at ease knowing how worried I was. I had had several meetings in the run up to going back. I had planned, possibly over planned it. But I should have told my supervisor I needed him there on the morning of my return, that I didn’t want to walk into handover on my own with fifteen other doctors I didn’t know staring at me. Because the reality is, that although I have worked in this hospital before, everyone has moved on. I don’t really know the current juniors, there are familiar faces among some of the nurses and consultants but there is also a lot of change. And, well, I now realise I am not good with change!

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I may not have quite got the pastoral support from work that I had hoped for on day one, but my friends and family totally made up for it. I got cards, a bunch of flowers and a miniature bottle of prosecco at the end of the day. But it wasn’t about the tangible gifts. It was about the love and understanding that came with them. I could not have got through those hospital doors two weeks ago without knowing those friends were there, in the background, believing in me when I couldn’t. Their love and support meant the world and gave me the courage to face my fears and go for it.

So, look out for each other, go for coffee, chat and think about the bigger picture. As you sit in handover, ask yourself what has happened to the person sitting next to you as they  got up and came to work. Everyone has baggage, we just can’t see it.

 

Do you belong?

We seldom work alone in medicine. Instead, we belong. We belong to a unit, a team, a group. As a member of this network, we gain a sense of safety, we fit in, know our place and gain purpose from it.

Maternity leave made me realise how important it is to belong. Within a few weeks of being away from work, I realised that I wasn’t indispensible, the ward got on perfectly well without me. This was a bitter pill to swallow. It’s not that I had grandiose ideas about my role within the team but somehow I had hoped that I would be missed. The reality is, that someone replaced me and life in the paediatric department went on. But if that was the case, if I no longer belonged there, then where did I fit in?

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I am not naturally one of these yummy mummies; the ones who look fantastic in the park pushing their fancy prams in their super cool sunglasses and skinny jeans. In fact, I am the one who always looks completely frazzled, hair scraped back, child number one’s snot on my sleeve, child number two’s toothpaste smeared on my thigh, generally shouting “hurry up!” or “where is your shoe?”. I found baby groups and other such events pretty intimidating and as slipped into the darkness of postnatal depression I felt less and less like I belonged to the “Mummy crowd”.

Part of my recovery from PND involved returning to work. Once I got the sense of belonging back, my confidence grew and I regained a sense of purpose beyond just existing for my children.

 

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Belonging as a trainee

As a trainee, it can be hard to feel like you belong to a particular department. It takes a while for people to get to know and trust you. Equally, you have to get your head around the workings of the ward, learn the names of all the team members, their roles and temperaments before you can relax into the job.  And then, just as you find your feet and start to feel settled, the end of the rotation appears and you are expected to move on. This is particularly true for FY1 and FY2 doctors whose rotations are less than six months long and for trainees working less than full time who are not there as frequently.

 

So what can we do?

In order for trainees to regain a sense of belonging, departments should re-build a sense of community: sharing experiences, laughing together, eating together, crying together. In my first paediatric job, the whole team went for lunch together in the hospital canteen. It was fun; we would chat, laugh and take the piss. No one talked about work. As such we got to know each other well and created friendships beyond the job. This hasn’t happened in my last few rotations. Lunch has generally wolfed down during an x-ray meeting/ journal club or not eaten at all. There is nothing sociable about it.

 

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Unless we all take steps to rebuild this sense of community, trainees will continue to feel undervalued and “used”. Here are some simple things we can all do, from today, to make a start.

  • Seniors, lead by example. Invite your juniors to join you for lunch: a trip to buy a sandwich together, a bite to eat in the hospital canteen. Not only does it give the junior staff permission to prioritise themselves for twenty minutes, it also allows you to get to know each other. I once found out that my 6 ft 4” male registrar was a champion knitter! #nomorestereotypes

 

  • Make your colleague a cuppa. (There is something really comforting about someone bringing you an unexpected cup of tea). Notice when they haven’t eaten. Recognise when they are tired and allow them to get off home after a nightshift.

 

  • Give your colleagues personal feedback related to something they did. Show appreciation. For example “Thanks so much for trying that cannula earlier while I was busy. I know that wasn’t a great situation to put you in, but you did really well.”

 

  • Try to make sure everyone gets something positive out of a day at work; this may mean pointing out learning opportunities, completing assessments or offering ad hoc teaching. This is about giving trainees some freedom to highlight their own needs and learn accordingly. We are all adults after all, not school children!

 

  • Nights out are always a great way of sharing fun. Similarly, day time events outside of work offer similar opportunities for building team cohesion. The key here is to make sure it isn’t just a bunch of friends sitting in the pub together. Invitations need to be opened up to people who wouldn’t normally come out. These people may need some support or encouragement, but being included may really help them regain that sense of belonging. I am one of those people.

 

There are lots of other things we can do to make our trainees feel as though they belong. The key is starting now. I would be really interested to hear other people’s ideas on this topic. Please comment below.

The BipolarDoc