The value of listening

Spring 2001

I lay on the small bed, staring at the ceiling. He wasn’t usually this late.

I had been an inpatient for 2 months by now and knew the drill. He came in the evening, wearing his suit, straight from his practice in town I assumed.  Generally he would knock, then push the door open and perch on a chair squeezed in between the small table and my wicker bed. I would talk. He would act interested. Then he would leave. He rarely, if ever, said anything.

Once in a while I would go to his office. He’d peer over his imposing wooden desk, fountain pen poised over crisp white paper, waiting for me to utter something worthy of scrawling on his pad. On my way back to the ward I would push my way through the overcrowded smoking room, acrid smoke stinging my eyes. At the top of the stairs I’d shuffle past the nurses’ station and slip into my room unnoticed.

I lay waiting but the consultant didn’t come that night. Instead his registrar appeared as I was getting into bed.  Embarrassed, as I was wearing particularly hideous yellow pyjamas, I pulled my duvet up to my chin and shuffled down the mattress. He sat down and started talking to me. I can’t even remember what we talked about but I remember him.  I remember him because for the first time, someone had seen beyond my label, beyond my diagnosis. He saw me.

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Earlier that Spring, the anorexia had reached a point where I couldn’t carry on. My weight was at a critical point. My periods had long stopped. I had been started on antidepressants with little effect. My poor mother didn’t know what to do. I agreed to be admitted but there were no local eating disorders units for me to go to. The postcode lottery meant that this hospital, over an hour from home, was the only place I could get a bed. Somehow it seemed better than nothing.

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Nearly 20 years have passed since I lay on that bed in the psychiatric hospital. A vulnerable teenager locked behind huge iron gates; not allowed to leave.

I can still see people’s faces: the middle aged lady who sat beside me describing her suicide attempt, the bearded man who sat on my bed and cried.

I remember.

I remember the face of the young woman I befriended who then tragically took her life. I remember it all. That was my normal.

And as I replay these images like an old movie in my mind, I see the registrar. The only doctor during those three months who saw me, who listened and who reached out to a young lonely teenager.

 

Be that doctor. Listen to your patients. See beyond their label. See them for who they really are.

“We all need somebody to lean on”

In the run up to returning to work I tormented myself for days about how I was going to explain my absence to my colleagues. What words could I use to justify being off sick for a year? Should I make up some excuse, pretend I had had another child? Perhaps if I was suitably vague people would get the hint and not ask. A friend jokingly suggested I should explain I’d had really infectious and deadly disease and then cough all over them!

Facing my colleagues was the real hurdle of returning to work. The medicine per se felt like the bit I could do. The rest…. I was returning to a culture that didn’t get me. I was a broken doctor, a doctor who couldn’t cope. A failure.

This is genuinely what I believed.

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Whilst I had been off work things had got pretty bad. Large crowds, busy places and travelling on my own had all become fraught with panic and overwhelming upset. I had isolated myself in order to avoid triggers. I had a few ‘safe’ friends, but gatherings with more than three people…. arghhhhhh. I can still feel it now: tightness in my chest, an irrational fear mixed with dread and panic. Unsurprisingly, I wasn’t exactly relishing the idea of returning to work and having to face a room full of people I didn’t really know.

The first few times I uttered it I remember my voice sounding wobbly: “I have been unwell and had some time off sick.” It sounded so wrong, so foreign. Admitting vulnerability is not something that we do as medics. You could see in people’s response that it isn’t something we are used to hearing  either. A sort of embarrassed “Awww” followed by silence. Why do we find it so hard?

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After a few weeks of being back I started to talk a bit more. I found myself using the phrase “Mental health problems” and surprisingly, nothing bad happened. I began to realise that the worst mental health stigma was in fact what I was inflicting on myself. As I looked around, I saw other doctors struggling, trainees talking about the pressures, the rota gaps, the constant unrelenting demands on them. And then I found Twitter, which has given me access to people, ideas, discussions, support that I cannot begin to describe. My twitter world has made me realise I am not alone. I am not broken. I am human.

With that in mind, I decided that I would speak out. Silence had got me nowhere. Now it was time to share my story. As I described my experience, I hoped that someone somewhere might take solace from knowing they weren’t alone.

And so I talked. I talked to colleagues over coffee, I listened to them share their struggles. I talked at departmental and regional teaching sessions. Because mental illness can happen to anyone and no one should feel ashamed of it. And as I talked, I felt empowered.

Disclosure isn’t for everyone and potential consequences need to be considered carefully. I certainly haven’t shared all the details of my history and what I speak about varies depending on the situation.

But the shame has gone. I feel like I now have permission to be me.

De-stigmatising mental illness in doctors is clearly not going to happen overnight but we can all make a start. Dare to share how you feel. Talk to your colleagues about what you do to relax or wind down after a busy day. Discuss mental health. Prioritise well-being. Let’s face it, if we don’t, no one will.

And in the words of Bill Withers:

“Sometimes in our lives
We all have pain
We all have sorrow
But if we are wise
We know that there’s always tomorrow

Lean on me!
When you’re not strong
And I’ll be your friend
I’ll help you carry on
For it won’t be long
‘Til I’m gonna need
Somebody to lean on”

 

My patient died, yet this is how I find out?

As medical students and again as trainees, a lot of time is spent perfecting the art of breaking bad news. Many of us will have seen it done badly and as uncomfortable and horrible as those situations are, we remember them. Why? Because we absolutely swear never to do it like that.

Over the years, I have gained confidence in my communication skills. I know I can lead these difficult and distressing conversations but despite the experience, it never, ever, gets easier.

For each family, that moment is life-changing. The way in which you deliver that information has repercussions for the rest of their life: the words you choose, your tone of voice, the way you sit, your facial expressions… You slow down, you give them time, you listen, you offer them a shoulder, a tissue, a cup of tea… you do whatever you can to make a seriously shit experience just that tiny bit better.

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So why is it that we don’t do this for each other?

A while ago, I looked after a child who was normally fit and well. He had become ill very quickly. The team had worked hard, doing our best to keep him alive. By the time I went home that evening, the boy was doing better. I was exhausted and thankfully had a few days off after this. When I was next on the ward, I heard a couple of nurses talking as I wandered through. In and amongst what they were saying they seemed to be referring to a recent death. I enquired who they were talking about.

“Oh haven’t you heard, (….) died a couple of nights ago.” They were talking about the boy I had looked after; the one I thought had pulled through; the one who seemed stable… They went on to tell me the clinical ins and outs of the situation. I stood there feeling overwhelmed: deep sadness for him and his family, guilt, uncertainty, what if I had missed something. I started running things over, should I have done something different? And before I had time to begin to process this the ward round commenced.

This is not the first time that I have found out about the death of one of my patients like this: a passing conversation on the ward, finding a bed space unexpectedly empty, a conversation at handover in front of 15 other doctors etc. Finding out like this really disconcerts and destabilises me.

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Why is it that we spend years learning to break bad news to our patients in a sensitive and empathic way, yet when it comes to ourselves and our colleagues, there is very little thought put into how we discuss it. Losing a patient is challenging, no matter where you are in your career. It highlights our personal vulnerability: the sadness of losing of someone we knew well, a reminder of struggles in our own life, self-doubt and questioning of our practice, guilt, a trigger for mental health difficulties.  All of this is completely normal, yet somehow it is overlooked when we talk to each other.

Looking out for each other

A few years ago, I looked after a little boy with a long term condition. He frequently attended the paediatric ward and the staff had all got to know him well: hilarious, witty, cheeky, brave and truly inspiring. He was my favourite. A few months into my maternity leave I received a call from one of my fellow registrars. She thought I should know that this little boy had died a few days earlier. I remember holding my trolley tighter, tears rolling down my cheeks in the supermarket car park.

I look back and realise how much that phone call meant to me. I was able to grieve at the same time as everyone else rather than having to wait until I returned to work to find out. That colleague gave me permission to feel. We are humans after all. It is OK to feel.

So, maybe next time you lose a patient, think of a colleague who deserves to find out in a more sensitive way than overhearing something on the ward or realising there is a missing name on the handover sheet. Give them a ring, check they are OK. Allow yourselves to grieve the loss of a patient. #ItsOKtoTalk

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To admit or not to admit- That is the question (Part 2)

Does admitting vulnerability have to be a bad thing?

I remember a patient I looked after several years ago. She had been admitted to a general paediatric ward with the medical complications of her eating disorder. The idea of nasogastric feeding terrified her. She sat sobbing on her bed. Although I never needed artificial feeding when I had anorexia, I could totally 100% relate to what this girl was going through.

It was a strangely quiet night shift. I had the option of getting some sleep but instead I sat with the girl and we chatted. She cried- I held her. She talked- I listened. As I left the room she said “Nobody has ever got it like that before. Thank you”. The following morning her mother came to find me. She was so grateful for the time that I had spent with her daughter but she had seen through my empathy. “You understand in a way that others don’t, like you know what it is like. Have you had a sister with it or something?”

In that moment I didn’t know what to say. I worried I had crossed the boundary of professionalism, thought I would get into trouble. I don’t even have a sister… I could make one up…… But somehow honesty was the only way. And so I explained that I had suffered from anorexia as a teenager, that I had been in hospital for 3 months and that things had been tough. But I could also tell her that I had come out the other side and now had a healthy relationship with food. The mother looked at me and tears started rolling down her cheeks. I immediately regretted what I had said.  She unexpectedly leant forwards and hugged me. Into my ear she whispered “Thank you, thank you so much for giving me hope.”

Admitting vulnerability doesn’t have to be a bad thing.

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Opening up with patients

All too often in the healthcare sector, we refer to vulnerability as a negative attribute. We are expected to pick ourselves up, brush ourselves off and get on with things. Stigma silences us. In their study, Malterud and colleagues demonstrate that vulnerability can be beneficial in the doctor patient relationship.

Clearly there is a boundary when it comes to sharing our own struggles with patients. After all, we remain the professional in the relationship and as such, need to be aware of how the disclosure may impact on that. Revealing insecurity doesn’t have to be done by spelling things out though. Thoughtful questioning and understanding can be sufficient to help the patient feel valued.

However, opening up can leave us feeling exposed. I was convinced that I would get into trouble for my behaviour. I worried about it for days. What if someone at work found out? What if they thought I could no longer be a good doctor?

It turns out nothing happened. Of course it didn’t. I did nothing wrong. Being true to ourselves isn’t always such a bad thing.