Uncertainty, COVID-19 and supporting junior doctors | AMA (WA)


AMA (WA) | Stressed Junior Doctor

Uncertainty, COVID-19 and supporting junior doctors

Tuesday July 14, 2020

Dr Anita Smith, Medical Leadership Adviser, Institute for Health Leadership, Esther Dawkins, Senior Project Officer, Institute for Health Leadership and Lauren Hancock, Psychologist, Hancock Psychology

Humans are meaning making machines. We link together information, that is often unrelated, and come up with a story to explain the situation in front of us. We do this subconsciously. Often it is very helpful, as it allows us to make sense of the world. When we are anxious though, the story we create is fear based.

COVID-19 has changed life as we know it. Changes to education, training, how we work, how we can interact with one another, and general uncertainty surrounding how and when things will return to ‘normal.’

For some interns who have just entered the medical field, they may have only had one or two months of ‘normality’. This not knowing is anxiety provoking for most people. For some, it raises some alarm. For some, it only provokes mild concern. And, for a proportion of people, it is very scary and feels very threatening.

That raises the question – how do we support doctors in training (DiTs) during this period of uncertainty?

Recently the Institute for Health Leadership (Department of Health) and the Post-Graduate Medical Council of Western Australia invited psychologist Lauren Hancock to facilitate sessions for the Medical Education Registrars and Medical Service Improvement Program participants on supporting the mental health of junior doctors in times of uncertainty. Below is a summary of the topics and suggestions discussed, aimed at those supporting DiTs over this period.

Communicating regularly

When there is a vacuum of information, our brain starts making stuff up, which can potentially be negative or harmful. We can intercept this process with our staff by over communicating what we know. This may just be touching base regularly to remind them of what we have already said and let them know that we don’t have any further information. This simple reassurance can be enough for people to focus back on what is helpful for them rather than creating scenarios that do not exist.

Focusing on what we can control 

We also have a role in promoting a resilient mindset amongst those who we supervise. The Circle of Concern model (Covey, 1989) talks about the fact that we have:

  • Our circle of concern: things we have no control over
  • Our circle of influence: things we can influence
  • Our circle of control: the things we have direct control over (i.e. what we focus on, how we manage our feelings, how much we notice our thinking, what we do).

Our brains are geared for survival. So, when things concern us, our brain wants to focus on them. Because of this, we can spend a disproportionate amount of time thinking and talking about things, which we have no control over which can create a feeling of helplessness.

But there is an important caveat here. We must acknowledge the full breadth of people’s concerns and experience, before encouraging a more positive focus. If we don’t, and we just try to get others to focus on the positives, then we send the message that feeling the full range of human experience is not okay. That those fears are not allowed to be discussed and must be suppressed.

As researcher Brené Brown discusses, if we suppress our experience of uncomfortable emotions, we suppress our ability to experience the full range of emotions, including joy. We need to feel and acknowledge all of our emotions, both for ourselves and in our people, to keep us mentally healthy (Brown, 2018 ).

So, with yourself and your staff, this means allowing space to discuss the things that are concerning and scary. Then, only when people feel seen, heard and acknowledged, can you shift the focus. Once people feel heard, they are more likely to be willing to change their focus. You can then look together at what you have control over.

Encouraging debriefing with co-workers

In a research project, Dr Steve Brown investigated what sources of support help keep us well at work. What he found, which is consistent with the literature in this area, is that family and friends account for only 7 per cent of the variance, when we are looking specifically at wellbeing in the workplace.

The more significant sources of support are as follows:

  • Co-workers: 32%
  • Supervisor: 31%
  • Organisational: 30%

When we look at which of these are directly in our control, the main one is co-worker relationships. Co-workers understand our workplace context in a way our family and friends cannot. They can also provide immediate debriefing when we need it, so we don’t need to hold our frustration all day. This means encouraging junior doctors to foster these relationships with their peers is crucial to support DiT wellbeing. Such relationships can be a significant protective factor in times of uncertainty and stress.

Identifying stress, anxiety and burnout in yourself and others

Our thinking gives us the earliest clues when our mental health is declining. The challenge for us is noticing our thinking: continually paying attention to what we are saying to ourselves and the stories we are creating.

While we can’t hear what our staff are thinking, we can hear what they say to others. Notice what your staff are focusing on in their interactions with others. If their conversations are becoming more focused on concerns, it is worth enquiring further.

Our thoughts can then play out in our reactions and behaviour. If we have become more stressed, or anxious, or depressed over time, we may not be able to see it. Like the frog in a pot analogy: theoretically, you put a frog in a pot of boiling water, it will jump out. You put it in a pot of cold water and turn up the heat slowly, theoretically, it will boil to death. We humans are poor at noticing these slow changes in our mental health across time.

This is where the people we live with are very helpful. They are great sources of feedback about our mood and behaviour. But, they may have learnt not to offer this feedback unsolicited. I encourage you to ask them for feedback and give them permission to share feedback about changes in your responses or behaviours. They may see your stress, or movement towards burnout, before you do.

The same principle applies to the people who you supervise. It may be obvious to you that their behaviour has changed, but they could have no awareness. As a leader and their supervisor, it is very important for you to have a compassionate conversation with them about this perceived behaviour change. By building this awareness, you could help them put strategies into place now, rather than their mental health deteriorating.

And finally, remember that what appears as anger is often fear masquerading. Keep this in mind if you witness a staff member appearing frustrated or angry. Anxiety could be the emotion behind the behaviour so it is worth having a curious conversation.

Considerations when checking in on co-workers that you are concerned about

Creating the right conditions. If our boss pulls us aside, we may immediately begin to feel anxious. We wonder why they want to talk to us and if something is wrong. We can circumvent this issue by the way we set up our usual work routine. If we have regular, brief, individual chats with staff, then it is less obvious when we need to take a staff member aside to enquire about their wellbeing.

If you think about your work day, what are potential opportunities for this currently? Are there times when you can ask a staff member to assist you? Are there areas where your staff are working alone and you can check on them? What other habits can you create so that it is normal for you to spend time individually with staff members?

If you can create these conditions, the staff member will be more relaxed when you start the conversation. By keeping their stress level lower, you can assist them to hear what you have to say and respond more rationally.

Sit on the same side of the table. This idea comes from Brené Brown and is advice regarding giving feedback (Brown, 2018) . It equally applies to any tough conversation. When someone confronts us about our behaviour, our usual reaction is to feel attacked, then to become defensive. If, instead, we can sit next to the person, literally and metaphorically, we can put the problem in front of us as something to solve together. In terms of wellbeing conversations with your staff, this means normalising the experience of struggling, and looking together at what would be helpful for them.

Start straight. We have all had the experience where someone beats around the bush before they say what they want to say. If you recall how you felt during these conversations, you would likely have noticed your stress level rising as the person continued talking. By the time they finally got to the point of the conversation, your stress level was much higher than at the start of the conversation.

Our goal in difficult conversations is to help the other person stay as calm as possible. If we can do this, we help them retain the cognitive capacity to listen to what we have to say and to respond in a considered way. That is why we need to start straight. It is starting the conversation with why we want to speak to the person, so they are not left wondering. By doing this, we are providing certainty, rather than uncertainty.

With empathy. Brené Brown defines empathy as “feeling with people”, that we have to access that feeling in ourselves, and as such it is “a vulnerable choice”. Sympathy is when we don’t want to “feel with” and instead want to stay cognitive (Brown, 2018) .

We focus instead on trying to distract the person, “silver lining” the experience, or fix the problem which is more solution focused. With tough experiences, the best thing we can usually do is just listen and be present.

In addition to this, a helpful framework to keep in mind when we want to respond empathically is Theresa Wiseman’s four attributes of empathy (Wiseman, 1996).

Theresa Wiseman’s four attributes of empathy include:

  1. Perspective taking
  2. Being non-judgemental
  3. Recognising emotion in others
  4. Communicating that recognition.

Lower the waterline. The best way we can give our staff permission to discuss their struggles, is if we share some of our own.

Address concerns upfront. Your staff member may be concerned about telling you that they are struggling. If you have an inkling of what their concerns might be, then address these upfront. By moving this potential obstacle out of the way, you allow the employee to feel safer in discussing their concerns and focus their attention on the conversation.

Combining these ideas, starting the conversation could look something like this:

“This is a crazy time. I have had times in the last few weeks

where I have felt anxious (lowering the waterline). I wanted to talk to you because you haven’t seemed like yourself lately (starting straight). I know that you can still do your work and I have no concern about your performance. So, chatting today is not related to your work (address concerns upfront). I just want to check in to see how you are going and if there are things we can do to better support you and the rest of our team (sit on the same side of the table).”

Questions. Once we have set up the conversation, the questions we ask dictate where the conversation goes. Being able to ask open questions, that help the other person find their own solution, is a key leadership skill. If the person has come to their own solution, they are much more likely to own it and follow through.

When asking an exploratory question, consider how you start the question. How and what questions are generally good, when and why questions can sound accusatory, but work well if delivered the right way, and any question that starts with, “haven’t you”, “is it”, “don’t you” is not really a question at all: it is a directive loosely disguised as a question.

In having wellbeing conversations with your staff, remember that you don’t need to solve the problem, at least not during this conversation, so focus on asking exploratory questions. In doing this, you help the employee join the dots about what they are feeling and why. They are then much more likely to find their own solutions.

References Covey, S. (1989). The seven habits of highly effective people: restoring the character ethic. New York: Simon and Schuster.  Brown, B. (2018). Dare to Lead: Brave Work. Tough Conversations. Whole Hearts. London, UK: Ebury. Wiseman, T. (1996). A concept analysis of empathy. Journal of Advanced Nursing. 23, 1162-1167.