Published in JHH13.1 – Shaping the invisible

I almost left medicine as a fourth year student. Science was ascendant in a system I found dehumanising. In staying, I resolved to change it, at least within myself. Rather than diseases and interventions, my work became centred on people, their capacity for healing change, and the conditions that affected this – within themselves and the surrounding relationships, environments and systems. Such talk was out of step back then, though not with patients then or now – and I found myself immersed in as rich an enquiry into human healing as I dared to imagine as that empassioned younger man. I have been part of change, and now, 38 years on, I have almost left the NHS, making ready for the new.

David Reilly (DR)

Ever since my student days I have felt that medicine, though full of extraordinary people, too often bends its practitioners out of shape. Our emotionally demanding work steers us towards some strange ways of coping, and the casualty rates are so striking that only denial can explain our failure to prepare students better.TheWestminster Centre for Resilience is developing training and exploring ways of reducing doctors’ rates of burnout and mental illness. This summer our symposium will bring together a national group of medical teachers working to build students’ resilience.

David Peters (DP)

DP          According to the research, empathic doctors are more resilient. I suppose being more engaged, more capable of having positive therapeutic encounters helps improve our own sense of wellbeing. 1 We know from experience, as well as from research studies, that this has a positive impact on patients too of course: Balint used to talk about ‘the doctor as drug’.

DR          Yes to all that, but for doctors working in deprived areas with multiple co-morbidity there’s no denying that the systems we work in constrain just how good a job we can do when external predicaments pile up. Aileen McGrane, one of my team, just sent me an email in response to an article about the pressures on GPs in Scotland. She says … ‘the structure of the system doesn’t have room for empathy in a busy time-constrained working day with patients with multiple morbidity. This is why I was so unhappy in general practice and had to leave, if I had stayed and sacrificed my empathy there would have been no doubt that I would have burnt out! Hopefully, this [resilience] work can prompt change within the system itself to allow GPs to work to the best of their ability in deprived areas.

DP          It’s a shame Aileen’s patients and the NHS have lost one more empathic GP. I’m glad she had the freedom to get out: most don’t. The great thing about being a GP is that it’s a job for life, but that’s possibly the worst thing about it too, unless you can find a way to make 30 years of meeting people in distress sustainable. And let’s face it, the primary care frontline is a harder place to thrive than ever it was; perhaps especially so for empathic doctors with high values. Although they’re potentially more effective and enjoy their work more, they are also the ones most likely to suffer burnout2 when as Aileen says, the workplace squeezes out the space and time and needed for whole person care. A lot of great people work in the NHS. My hope is that resilience work like ours will help them find the energy and focus to survive and become part of the change that’s needed.

DR          I think the slide into burnout starts when you feel you’re disrupting your own integrity. Remember that GP survey I did?3 Back then I was trying to wave the warning flag about this. Nearly 90% of GPs in my survey said they felt holism was an essential prerequisite for good primary care. But only one in five felt they could deliver holistic care! And that’s more than ten years ago. If your job involves complex person to person medicine there’s a terrific but mostly unacknowledged tension: you need empathy, you value it and you want to express it. But at the same time you’re the GP sitting with a list of 40 people to see that day. So you drop into survival mode. We can say a lot about internal factors that build resilience and support a truly therapeutic attitude, yet we really mustn’t ignore the external factors; nor that they are intensifying and the situation’s really getting worse. And yet still, when a therapeutic encounter and co-partnership happens, there can be a moment of real opening: a space between two people which makes a therapeutic zone not just for the patient, but for the practitioner too. On the other hand if you’re expecting to deal with complex human problems without the temperament or skills, let alone the time and (yes) funding to open that space, then that’s only going to end in cold-heartedness and eventually burnout.

DP          By structural factors you mean inhuman work[1]loads, austerity pressures, deprivation, soaring expectations of magic bullet medicine, and maybe even people’s increasingly negative views and loss of trust in doctors? Faced with that kind of predicament isn’t it only natural for doctors and those on the frontline to protect themselves psychologically and physiologically?

DR          Yes. You try to protect yourself by a reflex shutting down of the open-hearted inter-personal space. But that can only be a short-term strategy at best, because then you’re cutting yourself off from the energy and values of your work as a doctor. I think that when the kind of doctor we are talking about engages successfully with someone – no matter how grief-stricken, broken, stressed, or how much multiple co-morbidity – there’s a real human to human join[1]up which results in both people feeling better. The practitioner may start the morning clinic in dread, at a logical level feeling, ‘Oh my God, I’ve got so many people to see’, and yet somehow the opening of that engagement space leaves the practitioner in better shape by the end of the morning! But if the system and circumstances make empathy and engagement impossible, and the practitioner is experiencing physical exhaustion, blood sugar dips and dehydration (which is what happens to many of our permanently overstretched junior docs) then no wonder they put up that wall and cut themselves off. But then you’ve cut yourself off from yourself too and your source; from your source of wellbeing and satisfaction in the work.

DP          And your patient will sense that you’re not engaging with them, so the consultation will become more or less dysfunctional: you will know it and they will know it too. I think this points to the fundamental tension at the heart of a doctor’s job. It is wired into our biology that when humans witness suffering, we mirror it unconsciously: because of mirror neurones – as you know David. So we reflexly frown or tense up when we see someone hurt themselves. EEG studies that show how the mirroring system triggers activity in our pain-brain when we witness another person’s pain. But some interesting research shows that doctor’s brains don’t mirror another person’s pain in the same way as a non-doctor’s.

                So what’s bound to happen when, as students without any emotional preparation, we come on to the wards and encounter lots of people who are needy and suffering? Thrown in at the deep end we more or less consciously feel the impact of this mirrored pain and suffering in ourselves. Naturally we have to find ways of tolerating. But if we end up defending ourselves psychologically so that we can do our day job and appear to be coping it’s no wonder if even as students we end up learning to be less empathic.

DR          Well, I wonder if words let us down here. It’s easy to conflate concepts like sympathy, empathy and compassion. But they are not the same and I think this misunderstanding creates a lot of concern and confusion about ‘compassion fatigue’. I’d say the spectrum of interpersonal connectedness begins with sympathy, but it can move into genuine empathy and may even transform into compassion. I believe it’s the sympathy response that depends on a strong mirror neuron effect. Because of the way evolutionary development proceeds by prioritising traits that enhance the chances of survival, we are as you say wired for attunement to other people’s emotional states. So another’s feelings hit us in the way they do, because parts of the central nervous system vibrate in sympathy like a tuning fork would: something like a neurological resonance happens. Then what began as one person’s suffering becomes two. And clearly that’s just no use at all: it’s like a man having labour pains when his wife is giving birth! But with empathy we begin to choose to enter into and understand the other person’s circumstances and experiences. This is something quite different from sympathy, and maybe it’s a stepping stone into the opening of compassion. And I’m convinced this can be a healing space for the practitioner; something that isn’t draining at all.

I think this rapport requires a quality of mercy: a deep wishing for the best for the person in front of you. And secondly, the practitioner has to approach suffering as a natural process, something each person can only learn to experience and hold. If you’re a doctor that means moving away from being the fixer, the pain-reliever; maybe even giving up on thinking you’re the healing catalyst; otherwise, our habitual resistance to the experience of pain and suffering risks making your patient feel worse. Instead, we have to find a way of sitting with that person as they process their own way towards their own release. This practitioner shift, begins when we understand that suffering is natural but that strength is inherent too. And in the WEL programme [www.thewel.org] ‘News Flash Number One’ announces that it’s normal to suffer and normal to get sick, normal to age, normal to die. That’s the way of it. And if the practitioner is sitting there battling on with an internal model that says suffering shouldn’t be happening then yes it is going to create an unbearable tension.

DP          We know that being in the presence of suffering triggers the neurobiology of the threat response. Perhaps then, a lot of what we do in modern medicine and the ways we think about our work acts as a kind of defence against our own and our patients’ suffering. If we can depersonalise diseases with our labels and explain them as rogue cells or the messages of mad molecules, then we can disappear the person along with their suffering body and mind. So ‘the medical gaze’ (was this Foucault?) helps us cope emotionally yet at the same time it has yielded some amazing advances in treatment. Yet sadly, in the process, doctors and patients end up depersonalised. I’d say that may be OK in truly life-threatening emergency situations, but in complex care the battle against the disease and death model doesn’t work. Then, who we are comes to matter a lot. Maybe we need the humility to accept that deep down we are vulnerable, limited and dependent on others. Medical school and everyday culture of medicine as potentially omnipotent teaches us to deny all this, so we can survive by dissociating from sensual, embodied reality. But then we find ourselves unable to tolerate the presence of suffering without it leaving us feeling helpless…even guilty.

DR          What you described as happening externally actually reflects our whole psychological and bodily make-up. The ego believes that to feel safe enough it needs to maintain control. It’s forever striving for unattainable peace in the face of predicaments and circumstances that can’t really be controlled. And so, the therapeutic journey is about accompanying someone out from suffering by engaging with them in order to nurture a releasing process from the ego’s war with reality. As Paul Gilbert says, compassion is a call to action but in these complex situations there’ll be a limit to what can be done externally. If a practitioner can do anything external and practical then let that be done. But in the face of scientific medicine’s many limitations, is there not a lot more we can do to liberate peace and equanimity and a feeling of ease; not just for the sake of the patient’s healing but within our own being too – especially in predicaments we can’t control?

I think that’s partly why the idea of the patient journey has emerged in the last 10 years: of under[1]standing getting well as a process that needs time and which unfolds as a narrative that can be full of unexpected twists and turns. And as I’ve said, it has to be an internal journey as well as an external one, with the outer journey serving the inner journey. But so much of doctors’ training has been the other way round: as if we could achieve inner wellbeing and peace by fixing from the outside. We have lost most of the practical Western inner traditions that might once have embraced this aspect of our journey – for example the early meditation and contemplative traditions (as drawn on and developed by practitioners like Laurence Freeman referencing the desert fathers and mothers of the first to fourth centuries http://wccm.org/sites/default/files/users/images/PDF/ TheTraditionofMeditationLFRead.pdf ). This is a cultural vacuum, and medicine has been the victim as well as an accomplice in that loss. Yet maybe, as contemplative practices such as mindfulness enter the mainstream, science is going to step into this space and create a kind of secular spirituality.

DP          Secular versions of spirituality. This links to something we are working on at our centre: ways of monitoring the physiology of resilience and recovery. It seems as if difficult medical encounters fire up our flight and fight system. When we meet a stranger, there is an initial unconscious threat response. Basic mammalian survival biology. Nonetheless it’s not hard to open a friendly space provided you have time and goodwill on your side. This is important because if one is operating in what Paul Gilbert calls threat-mind, our mirror neurones turn off (making us less sensitive to unconscious cues) and the social engagement system tends to tune out (so body language, expressions and communication style become less friendly). When human beings want to be properly present and open with one another, they need to get out of threat-mind and into parasympathetic[1]dominant affiliation mind. I call it cave mind, because it’s a state of mind and body that evolved so that after hunting, fighting or escaping, we can relax and relate. One way of telling the story of medicine is that it’s become too much about goal-seeking (hunting) and sheer survival when we feel overloaded by targets, workload and emotions (hunted): Gilbert call these high sympathetic arousal states drive-mind and threat-mind.

                So David I think you may be talking about doctors needing to school their affiliation mind, and for healthcare organisations to reduce the burden of threat-avoidance and goal-seeking imperatives that now drive medicine along. But very little is said about the inner journey of the doctor, and how to prepare ourselves for being in the presence of suffering. I think it was Erich Fromm who talked about the difference between being with and doing to. But of course in medicine, we have to do both. Perhaps it’s because we don’t learn how to be with suffering that we so continually struggle to find fixes, even when what’s clearly called for is being with, rather than (or as well as) endless doing to. How can we practice this art of being with? I have found it very valuable to find circles of people with whom I can feel safe enough to share the kind of conversation we’re having right now.

DR          I think it’s a deeply personal growth process for a practitioner. And I would say the fight-flight response you’ve described mirrors the internal struggle – our relationship with our own suffering. I think we have to make peace with our own suffering. But that’s a tall order given that the mind’s evolutionary default mode is threat-avoidance: it tends to back away from too much of that kind of reality! I’m certain though that unless we come into relationship with our own hurt and can learn to accept and soothe it, we can’t equip ourselves to deal with another person’s distress and pain or understand our (in many ways natural) reaction to it. Obviously, this is foundational for building the sorts of effective practice that won’t lead to burnout but could lead to our clients learning and growing. And that’s one of the reasons I scaled up my study of the one-to-one therapeutic relation[1]ship to start working with patient groups. That began in 2004, but in 2010 I began taking it to staff groups in the StaffWEL project too, because I’ve found this dialogue to be absolutely central to helping them understand how the mind resorts to fight and flight, and to find ways of accessing pathways towards nurture. I think so many practitioners are themselves adrift with this, when dealing with other who are similarly adrift.

DP          This is in tune with how I’ve been thinking about doctors’ predicament. I’ve become really aware of how difficult it can be, when something presses my buttons, to notice what is going on inside – the associated physical tensions and sensations as well as the mental and emotional shifts that follow. I can experience a more or less subtle loss of control, a kind of dissociation from good sense. At one extreme – not for me I’m relieved to tell you – this is the proverbial red mist descending, but at the other, when someone is just too exhausted to engage, it’s more of a freeze response: like a rabbit in the headlights. I see the rage response as being at the root of early burnout and the freeze of its late stages. And of course it’s not just in the clinic. The trigger could be a client on a difficult day, but it could also be something in the family or just anything that throws us into threat-mind – which is, as you say the organism’s default mode for our survival’s sake.

DR          You know that old story? You’re on holiday walking through the long grass and you stand on a snake. I use this scenario with people and ask them to imagine this and tune into how their body reacts. But then I continue the story, and say that as they stagger back from what felt like a snake they realise it was only a piece of rope. That’s one of the hooks I use to open this dialogue, using ordinary experience to get a handle on what this reactivity might be. What caused that distortion of reality? Where is that suffering? And of course we come to view our predicaments as snakes. We may get so burned out that we start seeing our clients as snakes. But where is this reaction happening? What’s driving it? And how can I regain genuine self-mastery in this situation, so I’m not just being dictated to by these distorted perceptual frameworks, and reflex reactions? You know, I think that in our culture right now we all need this ability. And to get there we are going to need a lot of support, a lot of understanding, education, practice, mentorship. I don’t idealise the past, but there were avenues of spiritual enquiry in the roots of our culture into equanimity and inner journeying, albeit they later became corrupted into anthropomorphised religious structures.

DP          But as you said before, there’s a real resurgence of curiosity about why we are the way we are and how our culture shapes our perception of the world. And in a culture such as ours many of us feel alternately over-driven or in a state of threat, or trapped. So it’s no surprise if we start seeing snakes where there are only ropes. The culture of medicine itself, the expectations it has raised and the way doctors are trained all seem to encourage states of high-arousal. I’m left wondering how the human race is to deal with its levels of alarm at the state of the world, since the alarm reaction make us ever more prone to fall into threat-avoidance mode and so see snakes everywhere, which of course alarms us all the more!

DR          We’re unwittingly fanning the flames, instead of at least addressing the influence we have over in the bit of the world that we can change, which is our own internal state. I did a workshop recently for 15 senior GPs and the only dream they expressed was of their impending retirement and release! It was in many ways a demoralised group of people. But then one of them told us how his practice had changed since two doctors from troubled parts of the world had joined them. He said their smiles affected everybody around them. These doctors were always expressing gratitude: flick a switch, and the light actually comes on; turn the tap and clean hot water comes out; and to have a job – and a job with some meaning! These two people were not just in a neutral state: beyond just feeling safe, they had somehow built up a state of inner nurture founded on gratitude.

Given that so many NHS staff are now feeling over[1]whelmed, I think the resilience and hopefulness of these two doctors shines like a candle in the darkness. I know we have to address the crumbling structures as best we’re able, but we mustn’t sacrifice ourselves in the process. Therefore we must do all we can to restore our own equilibrium, find strength, nurture our wellbeing. In the StaffWEL project, we accept that we are not about to wake up in a transformed system nor fix it in the short term. So to thrive and do good work we need to learn to restore ourselves.

DP          Yes, though there’s a danger that the word resilience is becoming a tainted brand in medicinal circles. It can sound like it’s about making us Duracell bunnies who can endure the current dysfunctional mess. But actually no, we are talking about the kind of resilience that can help us stay human and empathic in a system that could dehumanise us and industrialise our craft. So we have to find what it is in ourselves that can help redeem medicine.

DR          Yes, beginning with our own practice.

DP          Because that’s the only place you can begin

DR          Yes. That’s the beginning. And from there, act. Being in the snake state doesn’t make us effective agents of change. The ego wants to trick us, to tell us that stressful thinking and stressful states are somehow required to address predicaments. But that’s a lie that renders us less effective.

References

1. Newton BW (2013). Walking a fine line: is it possible to remain an empathic physician and have a hardened heart? Frontiers in Human Neuroscience, 7(233). doi: 10.3389/fnhum.2013.00233
2. Zantinge EM, Verhaak PF, de Bakker DH, van der Meer K, BensingJ M (2009) Does burnout among doctors affect their involvement in patients’ mental health problems? A study of videotaped consultations. BMC family practice, 10(1), p.1.
3. Reilly D (2005) Holism in primary care: The views of Scotland’s general practitioners. A major survey of GPs views on the state of the art of holism. Primary Health Care Research and Development, 6 pp 320–328
4. Decety J, Yang CY, Cheng Y (2010) Physicians down-regulate their pain empathy response: an event-related brain potential study. Neuroimage 50(4) pp 1676–82.