Names and some details have been changed to protect confidentiality
Alone and Lonely
Fatima, Accident and Emergency
I came across a leaflet regarding PHP at a particularly low point in my life.
Everything was going wrong. I was away from my family (being an immigrant doctor), I had broken up with my partner of 7 years and I was failing my exams. I had low interest in most things that I used to find enjoyable, I was struggling to get to work in the morning and, worst of all, had lost my ability to perform my job in an acute speciality with increasing clinical responsibility. I remember in particular one moment where I was called to A&E during a night shift and all I could think was that I was not good enough, I would not be able to help the patient I was being called for.
So I decided I needed help. I was thankfully still able to recognise that I was struggling. I contacted one of the confidential advisors within my school. They listened to me carefully and they handed me the leaflet regarding PHP services.
The help I’ve received was TRANSFORMATIONAL. From one session to the other, I remember feeling brighter and better in my own skin. A lot of details are lost in my memory, but I particularly remember how useful it was to discuss my pattern of unhelpful thoughts and methods to break those thoughts down. My thoughts on a board! Although I am a shy and introverted individual, I was able to discuss openly and clearly with my PHP practitioner, who was clearly very experienced and unfazed about anything!
I have no problem admitting that I needed help and that I was offered more that I could have ever hoped for!
Drunk and brought back from the brink of death.
In the early hours of a warm day in Glasgow in June 2008, I had a choice. It was the morning of my surgical exam viva and I was in a hotel room, shaking uncontrollably, retching and generally feeling like death, staring out at yet another grey dawn.
I had a choice as to whether I had another drink – I’d had nothing since the afternoon before, and my body and mind were crying out for it. In the end, I decided not to have a drink that day – I needed a ‘clear head’ after all – and I would battle through.
The day was a disaster. I couldn’t think straight, I couldn’t hold a pen when asked to draw a simple diagram, I couldn’t answer straightforward questions on topics I was familiar with day in, day out. Senior colleagues examining other candidates who knew me well struggled to recognise me…”Is that you? Are you alright? What’s wrong? Should you be here?” I spent every minute I wasn’t in the viva hall in the bathroom, vomiting, shaking and sweating profusely.
In the end, paradoxically, I made the wrong choice. Had I drunk the requisite half a bottle of vodka at 5am – and a little ‘top up’ throughout the day of course – I would have been calm, I would have thought more clearly. I could have drawn anything you asked me. I’d have sailed through that exam, just as I’d pulled the wool over the eyes of colleagues for 2 years whilst I merrily put away a litre of vodka a day.
Something’s wrong, though, when you need half a bottle of spirits before 6am to prepare for the day. Something’s wrong when you dread an on-call, not because of sleep deprivation or the stress, but because you can’t have a drink in the evening, let alone the morning. Something’s wrong when operations which were a breeze become insurmountable obstacles, and you hate a job you once loved because it gets in the way. That day was the day things caved in. I couldn’t see a way out. I was so mortified that I refused to go back to work and I was lucky I wasn’t reported to the GMC, given my actions in the run up to that day of reckoning. In the next month, my wife left me, taking our children with her, and I descended into 24-hour drinking binge. I remember little of that time, and to this day I’m still unsure as to how I ended up – still retching, sweating and vomiting – at PHP about 4 months later.
My recovery was not straightforward. It was another 2 years before I truly began to feel I had broken the back of my addiction. PHP, without a doubt, saved both my life and my career. I needed 3 separate stays in residential drug and alcohol rehabilitation unit to learn to beat my demons. Further down the line, I referred myself to the GMC on the advice from PHP and, whilst never a pleasurable experience, I at least felt honest, something unfamiliar for an addict! The team at PHP were fantastic; never judgmental, always supportive, wise, humorous and positive. The odds were in my favour. Medics do well, when they finally put up their hands and ask for help. Just make sure that hand doesn’t go up too late. You may be worse than me, have lost more, or you may have lost nothing – yet. The right time to put up that hand is now, this minute, not tomorrow or next week.
Six and a bit years down the line from my last drink, my life is great. I’m re-married to a beautiful, insightful, patient woman who clearly saw some potential from the mess! I have a lovely house, a busy and challenging job, a driving licence, no debt, good health, a great relationship with all my children; I even have a swimming pool – which is more expensive than drinking, but healthier! All in a few sober years.
Most importantly, I’m still a doctor, and that is what defines me. I’m an alcoholic – that defines me too – but because I put up my hands to PHP, it hasn’t destroyed me.
A Depressed Dentist
I began working in general dental practice in 1998. In 2002 I attempted suicide having never sought help. I quit practice and it would be 3 years before I found my way back into part-time clinical work for a London PCT. In 2009 I got a clinical academic post in a dental school.
Back in hospital in 2002, I was visited by a psychologist. The psychologist said there wasn’t anything wrong with me. Partly because of this, I never sought medical help for my ongoing depression and suicidal ideation.
I spent several years attempting to self-manage my depression but I continued to get regular and deep episodes. Finally, in December 2015, my depression interfered significantly with my work and my line manager told me I needed to see a GP. The GP I saw was very supportive. As well as prescribing medication, he recommended the Practitioner Health Programme. One of the team patiently listened to me, discussed options PHP could offer as help and ultimately organised for me to see a therapist for CBT as well as seeing me regularly himself. I remember the huge sense of relief that there were others supporting me.
Independently, I began using online guided mindfulness sessions in August 2016. In December 2016 I was weaned off my medication. I am aware of how depression can suddenly take me by surprise but the last 12 months have been some of the psychologically calmest of my adult life.
How a Complaint Nearly Destroyed Me
My PHP journey began with a letter from a patient.
Slowly and imperceptibly, my enjoyment of life in general, and work in particular, had been diminishing. The burden of professional life weighed down almost intolerably on my shoulders: my colleagues around me and my patients began to suffer the fall-out from this downward spiral. I will be forever grateful to the patient who took the time to write to me following a consultation saying “…you made me feel as if you were in a hurry, that I was your last consideration, and that you basically wanted me out of your room as quickly as possible…”.
To say that I was shattered by this is an understatement – I had gone from someone whose pigeonhole frequently contained cards and gifts from grateful patients to someone who radiated antipathy towards the very people I was supposed to be caring for. This hand-written letter, sent to me personally, and not to the Complaints Department, was the catalyst for me to take action. My sister did some research and found out about PHP, and within a week of contacting them I was assessed and commenced on a programme combining pharmacological and talking therapy (CBT).
The relief was overwhelming. I will feel forever grateful for the compassionate response I received. This allowed me to regain control, enjoyment and effectiveness at work, and without taking any time off, or feeling stigmatised for having sought help. Perhaps most of all I have appreciated the opportunity to develop personal resilience, and to acquire tools to combat stress when I have encountered it subsequent to my PHP experience. It is beyond doubt that PHP has helped me to manage my well-being on an on-going basis, and I now take every opportunity to share the work of this organisation with colleagues who find themselves in difficulty. I am a passionate advocate of well-being at work, and in some small way I strive to repay the enormous kindness I received at a very dark time in my life.
I Stopped Caring: a Tale of Burn-Out
Going to Practitioner’s Health Programme (PHP) last year was a scary but defining experience. Being heard, understood and supported is, sadly, a rare and special experience. At that time, January 2016, I was a partner in a 7-handed, 11,000-patient Practice wondering if “burn-out” is a terminal, irrevocable diagnosis. Am I fixable, or bound for the scrap heap of old toasters and used-up GPs?
Although it had been building for several years, my Burn-Out Story really begins in 2015, after a fortnight’s holiday and two years after a house move. I had let a fortnight’s leave become a rarity for me. By now the norm was dread of seeing patients during evening surgery and a large glass of Merlot on getting home, with exercise a rare afterthought. All partners were taking holiday to catch up on learning for our appraisals. Two of us were still in surgery at 9pm, others of us logging-in from home. Holiday-times became dicey: difficult priorities for visits and urgent paperwork sometimes slipping through the net.
This August, we were holidaying in North Yorkshire. Coming home on the motorway we were clipped by a car, hit the central barrier, spun across the carriageways, and finally rolling into the ditch after hitting a small tree. The airbag forced the dog from my lap into my forehead, causing bruising to both and the seat belt fractured my rib. My husband had his pelvis broken. I went back to work the next day. On the second day, I picked up my husband from hospital but didn’t make it back for evening surgery. On the third day, my step-son-in-law gave me a surprised look when I flew off the handle – the penny dropped, I had concussion. I couldn’t remember the accident itself because I had been knocked-out. I had a head injury, I couldn’t think straight or react properly and I shouldn’t drive or go to work.
I got sick notes for a month or so, speaking to a FY2 once and seeing a registrar once. My GP spoke to me on the phone and suggested I return to work for admin only. I eventually saw a different registrar face to face who thought I should be off sick but, as I was already back at work, my Practice Manager asked me to get it changed back to light duties. I did, with my doctor, over the phone.
“Admin-only” was impossible. Before the end of morning surgery, the reception manager was so desperate for appointments she couldn’t see why I shouldn’t just see a couple of my regulars. Ditto my colleagues with visits. I thought I was coping brilliantly, given I couldn’t think or remember. Organisation and sequencing were impossible; my memory gone. I had to look through the BNF to remember a drug name and those lists of differentials had fled my brain. I knew there were some things that had to be done for a given presentation but I couldn’t remember what they were.
In October, I started doing duty days. I made errors. These were noted and fed back to me. I went on working my usual surgeries. I used leave in November to keep up with letters. I failed to obtain a delay for my appraisal. For the first time since appraisals began, I had done no learning throughout the year. (As well as the growing tsunami of tasks, there had been family illness during the Spring.) That December the CCG sent us all an offer of PHP appointments for anyone with “burn-out”. Well I was going to give that a go! So by the time of my appraisal in mid-January I had my appointment with Clare G fixed up for February.
My appraisal day was in early Jan.. My tough talking, down to earth, “say it as it is” appraiser started by saying I shouldn’t be a GP, at least not a partner. I was shocked and stunned. We agreed I needed to feedback to my colleagues (and my GP) that I had gone back to work too soon. Foolishly, the very next day I broached this with a partner. Another partner joined us and started yelling at me. I was speechless, literally. I slunk out of surgery and over that weekend I struggled to speak to or face anyone. Sadly, my second mother-in-law was dying and I would have liked to be more help.
I went sick again, this time for eight weeks. I wasn’t depressed or anxious, I just couldn’t do anything. I had lost all my resilience, all motivation, all energy. My GP spent six weeks increasing my antidepressents. Then, switching medication, I was better by Easter. The practice had no locums, so I went back to work. I still had slight memory, organisation and cognitive difficulties which gradually faded over the summer. The month I returned to work, three partners handed in resignations including me. It was a torrid time. We needed mediation to agree leave dates. I left the partnership at the end of October 2016 and I have not looked back.
PHP was an important plank of support to help me re-frame my life. The PHP clinician I saw understood exactly what I was going through and made me feel fully supported. He named my difficulties and gave me useful pointers to help make sense of my situation. It was bread and butter to him and that in itself was reassuring. I found my own counsellor, whom I am still seeing. This, for me, is a vital piece of support and vehicle for change. I took up the NHS offer of “life coach”, which was also helpful, offering useful strategies.
I moved to a salaried job with fewer sessions and less money; admin but no tsunami; hoping to get back my drive and enthusiasm for primary care. I found a lovely practice with good values and a friendly culture. While I enjoy seeing patients and bask in the ease and experience of managing consultations and making decisions, the everyday stresses of multiple strands of work with insufficient consultation, learning and results time really bugs me.
Exploring my options, “out of hours” work turns out to be a winner. Appropriate units of time with reasonably-sized bits of work. No build-up of letters and tasks. There are a manageable number of interactions in any shift. Each slot is a new patient with a fresh, straightforward problem. Seeing people once is all I am ready for now – although knowledge of people’s lives, complaints and illnesses used to be my satisfaction.
Primary care is in my blood but can no longer take centre stage in my life. My light has gone out. There is still some healing and catch-up ahead of me. Although I plan to work in medicine for another decade, it won’t be within general practice.
Coming Out of Darkness: Message from a “Good” Doctor
From what I have read, doctors with burnout are unrealistic, oversensitive perfectionists, too frail for the real world. Organisations wipe their hands of responsibility by providing that recent invention, ‘resilience training’, reinforcing the belief that the individual is the problem. My own defence organisation in a recent BMJ article characterised burnt-out doctors as shouting at patients.
In fact, research shows that burnt-out doctors do equally well in patient satisfaction surveys. I believe it is the ‘good’ doctors who burn out, the ones who try to extract their patients from the avoidable messes caused by the failings of the NHS: abysmal communication, lack of resources, unrealistic targets. These are the doctors who keep on top of the excessive workload. For a while: eventually they break. And let’s face it, we’re all ‘good’ doctors. So we all break. It’s not a question of ‘if’, it’s a question of ‘when’.
Stop publishing articles on how to work smarter. It’s insulting. I didn’t work a 13 hour day because I was inefficient. Start facing the equation in the room – workload = not humanly possible. As the workload increases more doctors reduce hours, leave or burn out, leaving fewer to do the work.
The price of NHS underfunding:
Presentation: Sudden onset of overwhelming mental and physical exhaustion. Telephone CBT for burnout within 48 hours of triage by the BMA helpline.
Two months in: can drive my car. End of BMA CBT: recommend urgent face-to-face CBT. GP refers me to IAPT.
Three months in: colleagues unsupportive. Nightmares about work. Telephone call from a ‘support technician’ who reads out the HADS questionnaire.
Seven months in: feelings of anger and grief. Telephone assessment by assistant well-being practitioner. Burn-out not recognised by professionals. My worry that we might lose our home because we can’t pay the mortgage is hypothetical as it hasn’t happened yet. I should ignore hypothetical worries. I fantasise about holding a gun to her head and seeing how well she does at ignoring it. I am discharged. I have exhausted local options so can apply to CCG to attend PHP.
Ten months in: I have difficulty booking train to London. Can’t estimate timings and arrive two hours early for 1st appointment at PHP. Diagnosis: severe burnout due to excessive workload. Recommendation: 12 sessions of specialist CBT.
Eighteen months in: manage to drive past my former practice. Last appointment PHP. Unlikely to return to work as burnout too longstanding by the time appropriate help was accessed.
Depression and Burn-Out Can Get Better
Allison, a medic
Having qualified from Newcastle University, after graduation I found myself moving to London to live and work. This was a huge change for me and one that I did not realise had such a profound effect on me until I was nearly 2 years in. I suffered stress, anxiety, weight gain and weight loss, all until I unfortunately reached that “burn-out” stage, without truly realising it. Throughout this time I had been trying to reach out for help via my local GMP and council services, to no avail. I spent hours searching websites looking for help and through simple googling I came across PHP. I contacted them directly, spoke to a member of the team within 24 hours and a week later had been given a face-to-face appointment.
For the last 2 years PHP has supported me more than I could have imagined: through talking sessions, general support and CBT. I have made really amazing progress in my personal and work-life and am continuing to do so thanks to the help of PHP. I really am grateful for all that has been done for me and for the treatment I have been able to access. All that remains is to say that I wish there were more services like this to support healthcare professionals.