How Honest Reflection Makes Better (And Happier) Doctors

AUTHOR: Dr Lesley Morrison

In the era of Zoom, I got to see myself while I was speaking or participating in meetings as I never had before, and realised to my horror that my facial expression was, well ... very expressive and fluid. If I did not agree with something, it was immediately obvious. 

I wished that I had been aware of this level of transparency during years of sitting in practice, and other meetings, and genuinely thinking that I was keeping my adverse responses to what was being said private. To those whom I may have offended, I belatedly apologise!

Holding up a (metaphorical) mirror to really look at yourself and examine how you are doing and if you are keeping well can be useful. It can also be disturbing; it may reveal aspects of yourself and your practice that you had previously chosen to ignore. 

Honest reflection can take you forward, but it may be painful. It may provide insight into how you care for patients and also how patient care is affecting you.

Medicine can be very rewarding, but it can also be tough and extremely demanding. Unless you look after yourself, it can also come at a high personal cost. We know that it is almost impossible to be objective about yourself, or about anyone close to you, so we need to find techniques that help to gather and objectify the evidence, whether it’s written evidence from journaling or verbal feedback from a trusted colleague. 

In day-to-day work there are many checks and balances about how you are caring for patients, protocols to adhere to and be measured against, formal reflections to submit, but there are far fewer opportunities to take stock of how you are caring for yourself.

Why did you choose to be a doctor? Was it because you wanted to do something socially useful? Because you wanted to help people? Or because you saw it as a challenge? Was it because you did well at school and there was pressure to study either medicine or law? 

Or because your parents (and/or several other members of your family) are/were doctors, so there was an expectation that you would follow in the family tradition? Or was it simply because it would make your parents proud? 

Was it because you wanted a job that gave you a good chance of always finding employment, opportunities to travel and, dare I say it, a good pension? Perhaps it was a combination of several of the above.

It’s a good start if the basis of your choice was that it was something you wanted to do, as opposed to what someone else thought might be good for you. I remember a first-year student in one of my special study component (SSC) groups at the beginning of medical school who, when I had asked everyone to say who they were and what they especially enjoyed doing, had said that he loved to play the violin.

After the first few weeks of the project, it was clear that, although bright, he was struggling to engage. He looked flat and distant. I found a time to have a quiet conversation with him and asked him if, during these sessions, he was thinking about how he would instead love to be playing the violin. Yes, he said.

And it turned out, of course, that his parents had encouraged him to do medicine and he wasn’t at all sure that he wouldn’t rather be training as a violinist. After that conversation he seemed to engage more with the group. Sometimes simply acknowledging difficulty when everyone else seems to be thriving and enjoying the medical habitat can help. Everyone struggles at some point; some just hide it better than others.

In an attempt to keep up to speed with the rapidly developing Covid-19 story, I tuned in to many webinars, and listened to many podcasts. Some were useful and informative and I felt I was learning from experts in their fields. Others were less than useful. 

For example, when senior managers spouted “bureau-speak”, which painfully reminded me how depersonalising and dehumanising working with big organisations can be. Sometimes you can feel like a square peg in a round hole, not fitting and very uncomfortable and worried that, in order to try to fit, you need to sacrifice your individuality. So, how to survive?

Clearly, working in a health organisation, we need to comply with organisational policies, and those of us working in the NHS are connected by the founding ethos of the organisation: to provide equal quality of care for everyone, free at the point of service. But we are all different and we all make distinct contributions. 

Together, we make up the jigsaw of the organisation, but each of us is a piece of a different shape, with different skills, attributes and personalities. And these differences should be celebrated. By trying to push a square peg into a round hole, the peg will break; by trying to force pieces of the jigsaw together, they will be damaged. 

Each of us is unique, each has their own story and each of us needs to feed that individuality, that uniqueness, and keep our spirit and our creativity alive.

The webinar participants who made an impression, who made you want to look up their work 

afterwards, sometimes even to email them, were often the ones who told stories, who referred to patients, highly anonymous of course, but whose experience illuminated the point they were making. 

Observers referred to the “Battle of the Bookcases”, participants often positioning themselves in front of bulging bookshelves, promoting the image of being intellectual and expert. 

For me, the backdrops that got my brain receptors working more effectively were the pieces of artwork, the garden view, the clues as to who this person was, and how they fitted into the jigsaw. You definitely can’t please all the people/patients/colleagues/trainers all the time. And you need to filter critique through the personal circumstances and personalities of the person offering it. 

Patient surveys, intended to provide useful comments, sometimes serve up feedback that is less than appetising. One patient questionnaire distributed by our practice asked the question, “Is there anything that could be improved?” One of my dear patients replied, “The doctor’s patronising manner”. And I thought I was being kind, listening and attentive!

The important aspects of care can’t easily be measured and, because of that, are often unacknowledged and undervalued. When you’re feeling appraised to the hilt and knee deep in recorded reflections (both potentially useful ways of assessing progress but, done to excess and applied in a routine and tick-box way, unsupportive), take a moment to write down in your private work diary (for your eyes only) an appreciative word that a patient said to you or a funny/odd/bizarre incident that occurred during your day. It will help to reinforce the positive experiences and remind you that you are a person and not a number.

As in direct patient care, small acts of kindness by management can make a huge difference. One junior doctor I know had developed a close relationship with the family of a patient who was dying. When he died, his brother wrote to the doctor thanking her, and to the clinical director commending her on her care. 

The clinical director took five minutes out of a very busy day to pen a letter to the doctor, congratulating her and saying how pleased he was that she had upheld the high standards of the hospital. That letter enabled the doctor to feel like a person rather than rota-fodder.

Listen to, and learn from, your patients. A patient I saw in my first surgery in my new practice, Maeve, had just lost her mum. What she said stayed with me: “There’s no one like your mum.” When, at the end of my GP career, I was trying to decide whether to leave my practice to have more time with my mum when she was getting near to the end of her life, I heard an echo of what Maeve had said and it helped me make the right decision.

Finally, enjoy being a doctor. It’s hard and it can at times be demoralising, but it’s a great privilege to share people’s lives and their stories. To care for and be compassionate to others, we first need to be compassionate to, look after, and be kind to ourselves. To deal with others’ stress, we need to find ways of coping with our own. 

Keeping a balance between professional, personal and social pressures can be very tricky. We need to develop and pass on skills and tools for emotional survival. We need to keep looking in the mirror and being honest with ourselves about how we’re doing.

This article is an extract from The Wellbeing Toolkit for Doctors by Dr Lesley Morrison, published by Watkins and available from Waterstones for £10.99