“One runs away to find oneself, and finds no one at home.” Joan Didion.
Stress, burnout, moral injury. These are words that occupy time and space in much of what we read at the moment. Whilst there appears to be an epidemic of workplace distress in every occupational setting, nowhere seems to be as besieged as healthcare. But what is at the root of this? Pointing the finger at the organisation, the professions, it’s regulators and paymasters is vital, but does not do much to change things in the short term. Oppression is usually top down, but recovery is bottom up. It starts with us. So let’s look at what is happening to us, that we can perhaps address, while we also work on the bigger picture.
It’s about self respect.
We have run out of it. Those of us who have reached that dark place that forces analysis have been knocking at our own doors to find there’s nobody home, to refer to the quotation at the top of this page.
If the erosion of self respect is the primary result of moral injury at work, then what can we do about it? What is self respect and how is it affected by the world in which we work?
“Self respect has nothing to do with the approval of others – who are after all, deceived easily enough” says Joan Didion in her 1968 anthology Slouching towards Bethlehem. 1. This resonated loudly for me but medicine and its practice has everything to do with pleasing others – patients, families, colleagues, seniors, targets, the hospital management, and often it is impossible to please all of these simultaneously, as they, curiously, often have different agendas and priorities. I agree that people are easily deceived – the clinician who is charming and friendly and well dressed is often preferred by colleagues and patients to the one who is less approachable, but more efficient and more effective.
Didion claimed self respect had nothing to do with reputation, which, as she said Rhett Butler told Scarlett O’Hara, people with courage can do without. In a state sponsored, non competitor based service, it would seem odd that reputation matters beyond being good enough, but it does. We cannot seem to remove the competition element from the NHS, even though there is no competition in its provision. Trusts, doctors, nurses, other professionals are pitted against each other, but the patient has no alternative to the NHS. The NHS seems to live (and die) on reputation since Trusts were put in some kind of macabre quiz show competition with each other. False parameters, targets, 4 hour waits, 2 week referrals, 18 week waits, CQC and its circus-like cavalcade all create a competition market where there is none, there is no need for one and the money spent on competing is money that is taken away from patient care. Is that not enough to erode one’s self respect to start with? We are employed to do a job that matters less than the meta job of looking good, ticking boxes and jumping through more and more arbitrary hoops?
So perhaps reputation is key in medicine not because of the need to compete, but due to the need to conform. Medicine is a normative practice, as indeed are all professions due to their self defining adherence to strict rules and practices. Just as the law is established partly through test cases, so medical practice is often also created on an evidence base of one.
The best lecture I have attended was by an eminent trauma surgeon and professor from California in his homeland of Cyprus, on the subject of dogma in trauma medicine. Despite his profession worshipping exclusively at the altar of “Evidence Based Medicine” he illustrated how much of their practice had arisen from a series of desperate stabs in the dark in 1922, 1943 and other arbitrary dates, and has subsequently passed into common practice with no evidence base at all. At another recent international meeting a colleague berated the medical audience on their continued criticism of a proven educational model when they themselves were fanatical about the use of pulse oximetry, for which there was far less evidence.
But what does this have to do with self respect?
How can we maintain our self respect, our “willingness to accept responsibility” for our own lives, when there is so little self respect in the medical world around us?
Self respect is a discipline, a sense of one’s intrinsic worth, but that is difficult to maintain when the goal posts keep shifting, the landscape is continually moving and when you ask where the lighthouse has gone, you are told it was never there to begin with. Maybe we are all being gaslit by the ever changing realities in which we are forced to work?
So what happens when the self respect is gone? When there is no way to know if we are in fact having a prolonged nightmare and may wake at any moment? Didion says we become locked within ourselves, paradoxically incapable of either love or indifference. Certainly I am less afraid when I can still feel the anger; but when it goes, and I am left with nothing, that’s when I know rock bottom is not far away.
Being locked within ourselves is complex in itself, so not easy to escape from. On the one hand, claims Didion, we are “forced to despise those who have so few resources as to consort with us, so little perception as to remain blind to our fatal weaknesses.” I remember at my lowest, feeling bitterly disappointed in some of my nearest friends for their inability to even hear what I was trying to say, as though I were yelling from a great distance, through a smog filled, sound proofed, subterranean tunnel.
On the other hand, says Didion, we are peculiarly in thrall to everyone we see, curiously determined to live out – since our self image is untenable – their false notion of us. Oh how that way leads to madness! Losing that sense of who I was, of what I believed in and thrashing about in deep waters, I found myself clinging on to the only life rafts I could find, fleeting childish rubber rings that would only sustain me for a few minutes if I sold my soul to their individually devilish demands.
Pleasing others will never lead to long lasting self respect. “We flatter ourselves by thinking this compulsion to please others an attractive trait: a gist for imaginative empathy, evidence of our willingness to give.”
And how true I have realised this is. To give under the conditions set by another, conditions which contravene our base values, is corrosive. It’s not giving. It is capitulating in a war that hasn’t yet been declared. It is grieving before a death has occurred. It’s betraying all we have trained for, all we stand for and all we believe in. Unless we give what we want to give, what we believe we should and can give, in a system that suits and reflects our morals, values and beliefs, we are not giving; we are giving in. Like a collaborator to an occupying force, but without the life saving benefits. We sell our souls to the devil.
And every day clinicians do this. Every day awards are given to or shame is bestowed upon people who are doing their best, acting with morality, integrity and according to their training, but who find their work is not consistent with those arbitrary measurements of the quiz show world. Didion sums this up, from decades ago: “We play roles doomed to failure before they are begun.”
If that doesn’t erode our self respect, nothing will.