If you are only just surviving or coping in medicine, there are skills you can learn to help you flourish.
Would you know a thriving doctor if you saw one? Have you noticed that some of your colleagues seem to suffer more than others in their medical life?
Perhaps you’ve noticed that some of your medical colleagues don’t seem to suffer at all because of their work. Some of them even seem to have worked out the work-life balance thing and are enjoying their work. What are they doing differently?
There is plenty of evidence that the skills of wellbeing can be learnt and that these skills can help you do much more than be well.
Your state of wellbeing exists on a continuum that runs from “burned out” to flourishing”:
A burned-out doctor has lost their joy and meaning in work. They feel exhausted, are cynical about most things (especially healthcare), and may also be hostile towards people and things they previously cared deeply about. In this state of being, the doctor feels undervalued, taken for granted, abandoned or ignored, and helpless to do anything about their situation. A doctor who is burned out has lost their sense of efficacy and, by definition, their sense of agency. They say things like “Who cares?” and “What s the point anyway, it won’t make a scrap of difference”. Their thinking has become narrow, their emotions are painful, and their capacity to effect change is diminished.
The most common responses to burn out are to retract, avoid and in the worstcase scenario for the doctor, give up. As a result, the doctor will usually take some leave. But burnout is more than simple exhaustion. On returning to work, the burned-out doctor often feels their symptoms again within a very short time, perhaps even with the first patient they see.
Psychologist Corey Keyes defined the opposite of flourishing as languishing in 2002, saying this meant an absence of mental health. Keyes described this absence of feeling good about your life as “emptiness and stagnation”, experiencing life as “hollow, empty, a shell and a void”. Languishing describes a loss of interest in life and is characterised by feeling listless, apathetic and low on energy. Languishing is not a mental illness, but it does describe that feeling of not being as well as you can be, and it does increase your risk of a major depressive episode. Doctors languishing in their career have told me that they are stuck with little or no career advancement, and little challenge in their life except to remain remotely interested in work that has become dull.
The languishing doctor may feel some sense of their own agency, but they lack the energy to activate it or don’t feel connected enough to any sense of purpose to be bothered.
There are lots of metaphors for surviving medicine. The doctor who is surviving looks okay and might even feel okay some of the time, but they are like a duck paddling frantically under the water.
When someone describes themselves as surviving, they are actively engaged in their work and generally have lots of energy. However, this person is acutely aware that they are spending more energy than they are creating. This leaves them depleted and they may not be fully functioning as a result. They feel in need of time or space for rest and recovery but feel thwarted by the demands placed upon them. In survival mode, doctors are more aware of their risk of making a mistake and will comment on their fatigue, their sense of imminent collapse and question how much longer they can keep working like this.
This mode of operating has been lauded in medicine, worn like a badge of honour. Surviving medicine is seen as an achievement, but it is not sustainable. These doctors feel frustrated that they do not have their worklif e balance worked out and guilty that they should be able to do more. For some it’s more work and for others it’s more activity or time away from work. These doctors likely experience some of the PERMA elements in their life sometimes.
People who are coping are engaged in their own life. These people are actively seeking ways to manage themselves within their context. These doctors are able to invest in themselves, to consciously choose how they think, feel and behave. They believe in principle that they can meet the demands of their life or find the resources they need to be able to do so.
Coping skills help you deal with the stress in your life. When you are able to do this, y ou usually feel better psychologically and physically. A coping state implies you are managing the realities of your life for the most part. A doctor who is coping will be more likely engaged in their work, giving it their energy and also feeling energised by it. A coping mindset is one of personal agency.
Some coping behaviours are better than others, so it is important to enquire about how you are coping. Strategies that give quick relief but do not really attend to the problem might be considered more survival strategies than coping strategies. For example, misuse of alcohol and drugs is a poor coping strategy; asking for help is an example of a useful coping strategy.
Felicia Huppert and Timothy So from the University of Cambridge defined flourishing as “the experience of life going well” with a “combination of feeling good and functioning effectively” . A flourishing person has high emotional, psychological, and social wellbeing. The simplest way for you to establish if you are flourishing is to ask yourselfwhat makes me truly happy? And then reflect on how much of the time you feel this way. Other words that might help you describe your personal experience of flourishing include thriving, prospering, g rowing well, and blossoming.
This does not mean there is no challenge, discomfort or adversity in life. It means that the flourishing person is well resourced internally and has the support network to allow them to respond effectively to whatever life throws at them.
The flourishing adult has a variety of interests and the energy to pursue them. They are responsible and accountable for their life, including their selfcare, and they are aware of their internal and external environments, responding to them constructively. A flourishing doctor is upbeat, enjoys their work, feels li ke they have got the worklife balance sorted more often than not, is committed to partnering and collaborating with others, values their relationships, is emotionally in tune, and has a ‘can do’ mindset most of the time. They are able to manage their own internal responses to their work as well as the external environment (including the complexities of healthcare) effectively.
It is important to clarify that flourishing is not the opposite of mental illness. A person can have a diagnosis of a mental illness and still flourish.
What behaviours will cultivate wellbeing?
Here are the four constituent behaviours defined by Davidson and his team that they suggest you cultivate for your own wellbeing.
1. Resilience – the rapidity with which you recover from adversity. People who have more rapid recovery from adversity, who get back to baseline quicker, have more wellbeing. You can modulate this circuitry with regular formal mindfulness practice. The research so far suggests you will need a lot of practice to make this change visible in your brain circuitry, but nevertheless it can be done. The key here is regular practice, 10 minutes every day is a useful goal. Regularly activating the neuronal connections makes them more e%cient.
2. Outlook – having a positive outlook for the world, being able to recognise the innate basic goodness in others and being able to savour positive experiences. People with depression show activation in this circuitry but it is fleeting. People with more wellbeing have more extended circuit activation. Loving kindness meditation (metta) can alter this circuitry quite quickly with a relatively modest dose of practice. Davidson’s team have seen this circuitry change in randomised trial research within two weeks at 30 mins of practice per day. These circuitry changes were also predictive of prosocial behaviour, helping people connect.
3. Attention – maintaining your attention on the activity you are currently doing. Killingsworth et al have demonstrated that a wandering mind is an unhappy mind, with adults not paying attention to what they’re doing 47% of the time they are awake. Davidson and many others have demonstrated that contemplative practices like mindful meditation are vehicles for changing the neurocircuits for attention so that focus improves.
4. Generosity – engaging in generous and altruistic behaviours activates circuits in the brain that are key to fostering wellbeing and are more enduring than other kinds of positive incentives. In other words, kindness towards others activates wellbeing circuits.
Sharee Johnson is a psychologist and executive coach; this is an edited extract from her book The Thriving Doctor, available at Booktopia, Amazon and at https://learn.coachingfordoctors.net.au/thriving-doctor