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The Importance Of Structure For Doctors

Published on: 23 Feb 2023

tips for a consultant

AUTHOR: Dr Lesley Morrison

Rarely did I ever start a day as a family doctor without a list. Often I cheated and, above “ring Beth D”, “sort out agenda for meeting”, “discuss Mike S with physio”, I wrote “have cup of coffee”, had the cup of coffee, ticked the list and felt I’d achieved something. I’d started the day; I was in control. 

Of course, into the day piled all the uncertainties, the unanswerable questions, the doubts, but underneath it was some sort of structure that I could refer to that was mine, not imposed by the health authority or the management or the government or even by the patients – mine.

At times of crisis and uncertainty, structure is useful. Much has been written during lockdown about the value of developing a routine, of having, amid all the chaos and change, a structure, a pattern to the day. This has applied mainly to those working from home, trying to manage new boundaries and different timescales, to juggle family and work at close quarters. It also applied to those with no work and no family, trying to manage loneliness and long, empty days.

Some structure, albeit a list of mundane tasks, helps to provide an anchor and some comfort and is a useful tool for emotional wellbeing. The image that springs to my mind is of a tent which has lost several of its tent pegs billowing in a strong wind, unstable and in danger of taking off. The more pegs can be secured to pull it down to earth, the less likely it is to blow away – but it needs at least one sturdy peg to secure it. 

For those on the frontline, having some routines in the day helps to stabilise things and provides some sense of control in what often seems like a maelstrom of activity and demands. The balance between automatically obeying the protocols and rules, and engaging your creativity and individuality to create your own structure, can be a difficult one.

Safety, of yourself and your patients, always has to be paramount but, since you are a human being, not a machine, each of you will respond to different situations differently and interpretations of the protocols and rules may vary. It’s appropriate to question the rules if they seem illogical or harmful, while being prepared to acquiesce to them if they are sensible and designed for the common good. Or, more pragmatically, if your contract requires it.

One of the most significant people in my life was Miss Drennan, whom I met when I was nine. She was the young peripatetic art teacher at my very staid 1950s primary school. One day I was painting, as requested, a group of my classmates. When asked what colour Penny’s face was, I obediently replied, according to tradition, “Pink.” 

Miss Drennan asked me to look. Could I see green, yellow, brown? I could, so I painted them and I won a prize. The message for the nine-year-old me? It’s OK to interpret the rules to make them better reflect my reality. Perhaps Miss Drennan also sowed a very early seed of my interest in the arts and humanities in healthcare? 

Of an understanding that, in order to feel truly well, you need to feel understood, appreciated, listened to: you need to have your individuality and your creativity encouraged and valued.

Occasionally rules are better broken. The way individuals in the pandemic responded to the need for a strategy structure tended to reflect their personalities. People with a natural tendency to question found it harder to automatically follow it, while people with a tendency to conform found it easier. 

People who don’t deal well with uncertainty might have been fastidious themselves and found it hard to accept people who interpreted the rules more casually. 

Some people were accepting of rules that appeared to protect them and their families but less keen on rules designed to protect the population. Rules about isolating and staying at home which might have protected the physical health of the population may have seemed detrimental to others’ mental and emotional health.

There were also numerous, very obvious examples of people in power flouting the very rules that they had imposed and using clever language to try to extricate themselves. Without integrity, honesty and trust in political leaders, attempts to keep people on board with the health messages were undermined. 

The messages began to seem meaningless and the lack of respect shown to the general population irksome, to say the very least. During full lockdown, a behavioural framework was imposed which was restrictive and tough but universal.

When lockdown was eased, the structure became less clear and more complicated, and individuals felt justified in interpreting the rules for their specific situation. What difference would it make if I met a couple of socially distanced friends in the park? My children haven’t seen their grandmother for weeks. 

Surely no one will notice if we call in briefly, and at an appropriate social distance? But others might notice and then how could you, as a public figure, if only in your local community, advise people otherwise without seeming hypocritical? Potentially a good example of your personal and professional personae coming uncomfortably close?

For many years prior to the pandemic, the general public’s trust in doctors had been eroded. Sometimes by information rightly coming to light of poor care and mistakes, and sometimes by doctors being cynically lumped together with the professionals and experts that a populist view maintained were elitist and surplus to requirement.

But during the pandemic, frightened people have been glad of sound medical and scientific advice and deeply grateful for selfless care and clinical expertise. They want a plan and a structure based on fact and provided by people they traditionally trust. 

In doctors’ day-to-day work, all its variety and irregularity is a potential source of stress and of feeling out of control, so trying to create some sort of structure is important. Having a scaffolding on which to hang tasks, urgent requests and emergencies can provide security and help you to feel that you’re not simply being swept along on a tide of demand. Lists are good. Ticks on lists are even better. 

Meal breaks (with nutritious food) may not always be possible but are definitely desirable. Starting the day with a meditation or simply a few quiet minutes helps to make the day your own and create a sense of structure and control. Getting up from your desk and stretching every half hour, making sure that you get outside and breathe fresh air (if it’s available!) at least twice a day are all good.

Whatever you decide to do, whatever shape your scaffolding takes, use structure as a tool for wellbeing. Then you make maximum use of the space that’s there and your creativity can flourish.

Great Place, Great Potential - NHS Somerset

 

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