Maintaining Interest

Maintaining Interest

Wednesday, 22 February 2006

On a sleepy afternoon at a training weekend for registrars about to go out in the world as psychiatrists, Albert Rd Clinic psychiatrist David Leonard's turn to present, had come up. He hooked up his powerpoint and stood to give the unassumingly titled presentation "Maintaining Interest".A transfixing hour or so later the room sat blinking, at the thoughtful distillation of nearly four decades of clinical practice, training registrars and running various services.The word went out amongst the registrars of a "not to miss" presentation that answered all the questions that we hadn't even thought of yet.David kindly agreed to make the presentation available on anzapt.org, but so as not to disadvantage all the technophobes we have converted it to an article for easy degustation...Enjoy.

Interest and survival are inseparable..

"Maintaining interest is intimately connected to commitment and survival. If you're not interested in what you do, you become vulnerable to burnout, but it might also be a sign of burnout"

So how hard is it it to keep interested?

"Not hard" argues David, "psychiatry is connected to so many areas, and knowledge in all areas is burgeoning. After so many years in the field there's a real excitement at seeing the gaps filled in, such as in the areas of trauma research. Musing with a similarly ancient psychiatric friend recently, on progress over the last 40 years, we agreed how exciting the next 40 years were likely to be and how we would love to know what answers the future would supply."

"On the other hand psychiatry is clearly not a cause of joy for all. Many psychiatrists drop by the wayside. We know that in the US, for instance, suicide rates are held to be twice that of other physicians. In the UK there is a shortage of psychiatrists because so many retire early. Further, we all know of the high rates of substance abuse and depression in psychiatrists."

Over the years David has observed many different approaches to maintaining interest and survival, and has loosely grouped them 5 ways:" There's the psychiatrist who happily choses immersion and unbalanced absorption. Then there is the psychiatrist who sees psychiatry as important but having equal or lesser billing to other important activities in their life, such as parenting, creative pursuits, sports or politics. Then we meet the individual who sees psychiatry as an important sideline to more interesting things or the psychiatrist who sees it as a bit of a drag, but an activity that pays the bills. ""Finally there is the long suffering practitioner who sees psychiatry as a torment, walking around with a face and demeanor that cries " let me out of here"."

"The key is to find a balance that is right for you" David expresses a concern that psychiatrists can become the equivalent of Marx's "Craft slaves" where devotion and commitment to patients and the practice of psychiatry becomes part of the mechanism that keeps an over burdened mental health system afloat to the psychiatrist's cost

" There's no one right way of doing it. You don't have to be slavishly committed to be a perfectly adequate psychiatrist but, in general, it's important to be doing what you like , as much as you like, and to feel you do it well.

Psychiatry provides many sub-specialties which suit a diverse range of personalities and talents."David adds that the end of formal training provides the opportunity to pursue and develop your own interests.

Setting the stage...

"From the outset it's important to make sure that psychiatry is the right career choice. Embryo psychiatrists tend to be able to tolerate uncertainty better than, say embryo surgeons. It is obviously desirable that they have a capacity for psychological mindedness and rate reasonably on compassion and empathy. Mind you there are quite a number of very successful psychiatrists who fail on those counts. It is important that doctors heading into psychiatry have a good supporting structure, particularly family and friends and professional networks. Some are helped by religion or spirituality.

The motivation needs to be right although we could argue about what that is. Few would go into psychiatry to become mega rich and it is important not to burden yourself up with huge debts as that will distort your priorities. So don't commit to the BMW or the Toorak mansion too early in your career."

" In choosing a career in psychiatry there is an endless list of challenging transitions to be negotiated from day 1."

The list is exhaustive but David describes a particular First Year Syndrome:

"In the process of moving from a medical model to psychiatry, first years often find there is quite an attack on their previously established role. Many of the skills they have acquired to date are less valuable, and they can feel quite anxious and confused about this. It can sometimes even take on the form of a kind of grief reaction."

" The transitions don't end there. Within psychiatry itself there are transitions as the trainees experience exposes them to different models such as biological, sociological, learning theory, family theory and all the different psychodynamic schools.

The levels of responsibility constantly change, from registrar to senior registrar, junior consultant to senior consultant and consultant to leadership roles. Then there are the transitions from public to private, and for doctors from another country -a transition of place and culture."

As this journey is negotiated there are also challenges encountered of personal change."Immersion in psychiatry often challenges long held beliefs and this affects not only yourself, but also family -especially in the early years of training or at the time of transitions.

One risk to be avoided is of appointing yourself, or being appointed as the therapist to family and friends. This can have a big impact on both personal and professional life"

When it comes to the actual content of psychiatric work there is the problem of facing challenging clinical problems which are personally distressing to us.:

"The suicidal or suiciding patient can really attack our feelings of omnipotence. Hearing tales of others' traumas can lead to vicarious traumatization -a sort of PTSD by proxy"

The contagion of others psychopathology can affect us in many ways for example via projections where we are alternately idealised or turned into monsters. Identification with the problems of patients or their projections can cause difficulties.

Grandiose rescue attempts can cause great stress, where young and not so young psychiatrists commit themselves to goals which are really not achievable."

These all present as hard enough challenges but often they play out amidst the further strain of coping with "the system".

"Often resources are scarce or frankly absent and some units or services work amidst a culture of blame -which is nicely couched as "accountability". Increasingly practitioners encounter a kind of " documentation madness" with an emphasis on defensive medicine.

So we get stressed...

Not surprisingly, many people get stressed. "This is a syndrome that emerges when an individual's capacity to meet demand is overwhelmed."

The obvious contributors start with the workload. This doesn't necessarily just come from " the system". It can result from our own expectations of performance i.e only the "good" people suffer stress - if you don't care it is hard to get stressed. Others' expectations can add to that load.

Coping strategies are important but don't help if there are constraints on their use. An individual might have the very best coping strategies such as being assertive about their rights, but if they are working in an environment that can't tolerate or even punishes this, then they are no longer useful.

Adverse work environments where there are bullying, harassment or mobbing compound the pressure of the work itself, whereas more supportive managements and supportive mentors can help you to survive.

"Early signs of stress include anxiety, irritability or depression, loss of commitment, interest and /or performance. The "stress" ripple can spread further to impairments in personal effectiveness and relationships.

Other symptoms can include somatic disturbances and physical illness or substance abuse and psychiatric illness.

None of this is unfamiliar stuff in our patients but spotting it in ourselves is more difficult but equally crucial."

And so onto burnout...

David describes burnout as a persisting chronic stress syndrome resulting from attempts to cope in an ongoing defeating and adverse environment. It can occur in individuals , teams and groups -even whole departments or services.

"The main features are detachment, especially from clients and staff and physical and emotional exhaustion.

Maslach, the burnout guru, describes loss of satisfaction or sense of accomplishment as prominent, where learned helplessness and hopelessness become established.

The tell tale signs of burnout to watch for are cynicism, sick jokes and derogatory remarks about patients,and a loss of compassion. Another sign is avoidance, be it shirking, "sickies" or not taking on any extra activities -a kind of state where the clinician stops caring or volunteering. There can often be a pervasive feeling of tiredness and reduced personal effectiveness or high emotional arousal and even the presence of a formal psychiatric disorder."

The settings most likely to lead to burnout are those where there is a demanding work load and poor resources. Another is where the work is unrewarding, with lots of poor outcomes, little positive feedback and bad conditions. Not having clearly defined or attainable work goals also contributes, as does a work environment that doesn't have a clear direction and there is a compensatory focus on meaningless procedures such as mountains of irrelevant paper work.

If you add unsupportive, irrational or persecutory management. psychopathic leadership and low morale in the service, and your colleagues, you're well on your way to providing a great setting for ensuring burnout. If you want to be really sure you might add in mobbing. Mobbing is a strategy organisations reserve for dealing with people, particularly newcomers, who are doing such a good job they run the risk of showing up the less gifted others. The system finds ingenious ways to put people ,who provide such threats, out of action.

What about core values and burnout?

An important aspect to understanding burnout is to look at it's relationship to core values.

"Our core values lie at the heart of our practice. I like to think that any place I work provides a standard of care that I would find acceptable were a close family member the patient, and where I am able to treat people in a manner that respects their rights and dignity and employ the highest standard of technical competence.

The persistent need to compromise with core values due to external restriction is frequently encountered on the road to burnout. I think as doctors we are conditioned by our professional role to keep on trying even when lack of resources and infra structure ensure our efforts are futile."

"Ultimately this leads to feelings of disempowerment, self recrimination, withdrawal, cynicism and ultimately a deteriorating performance."

"The "off-stage" factors in burnout can make a big difference either way. Relationships and domestic situations can contribute both positively and negatively. Each individual will vary in their vulnerability and resilience. Education and knowledge can act as protective factors. Insight into what is going on in the system, and the traps lying in wait, is helpful and it is especially important to have accessible escape routes -something not always easily available for registrars, who often have little choice but to toe the line."

So, what to do to maintain interest, prevent stress and burnout and survive?

Well, a good starting point is to draw on experience, yours, mine and others. Start with a SWOT analysis so list your Strengths, Weaknesses, Opportunities and Threats. On the afternoon the group thought about this and most of the following areas were covered.

ANZAPT would like to thank David Leonard for his thoughts and advice. A link to the original powerpoint presentation is available to vouched trainees and psychiatrists in the forum.

Deeta Kimber