In times of stress, remember who is behind the mask


As clinicians, we often forget or become desensitized to the image that society has of medicine and doctors. Alongside teachers and scientists, we are seen to be among the most trustworthy of professionals, yet our morale is low, with almost 50 percent describing it as “low” or “very low.” You can imagine, then, why I often describe medicine as a forest: beautiful, scenic and picturesque from afar but potentially hostile, and even lethal, inside. From a distance, the forest is amazing to behold, but inside, from time to time, its inhabitants — and we all know this feeling far too well — grow tired of being chased by wild beasts. Despite the distance we are made to run, medicine remains a revered and noble profession, one in which we are fortunate to be able to work in, but there are fatiguing stresses which we regularly endure and stress does strange things to people.

When nice people are subjected to intense pressure, the stress they endure may make them behave in not-so-nice ways. When left on a ward with confused patients and angry relatives, without realising, our courtesy can sometimes abandon us. In some ways this is unsurprising: we work in a tense environment. The sound of your beeper, the incessant ringing of a telephone, the screaming of an agitated patient, and the smell of an incontinent one, are not easy to get used to. In isolation, these things tend not to trouble us, but together they act like fuel to a fire, causing flames to grow and our temperature to rise until the smallest of things makes us boil over.

With that said, and with us already simmering, it is unsurprising then that when your beeper goes off at 4 p.m. on a Friday and you speak to an anxious, scared, but well-meaning, junior doctor who informs you that, “Mr. Smith (note: a fictional name) has pulled out his suprapubic catheter again,” you snap. You have an unwell patient to review; you have a stack of paperwork with your name on it, and you have commitments outside of your job to attend to. Those words are the last you wanted to hear at the end of a long day.

By the way, those same words are the last that the junior doctor wanted to utter at the end of their own long day. With experience, you have managed to organize yourself in such a way that you usually leave work on time; the junior doctor, on the other hand, is new to the job, inexperienced, and has managed to leave on time on only a handful of occasions. The two of you have a lot in common: like you, the junior doctor has his own patients to review, he too has paperwork to complete and he also has commitments outside of his job, but before he can sheepishly finish his sentence, you snap at him.

The pressure becomes too much and unfortunately for him, but maybe fortunately for you, he becomes the outlet for your frustration to thunder down on. You make it clear how unacceptable it is that he has left it until now to tell you about this issue: “When was it pulled out?” “Why didn’t you tell me this sooner?” “Didn’t anybody see him in the morning after it happened?” “You don’t leave it until 4 p.m. on a Friday to tell me this, OK?” As you take a moment to breathe, the unthinkable happens: He also snaps.

“I didn’t leave it until now to tell you,” he answers back. “Why would I intentionally wait until now to make mention of this?” he cannot help but think. Stunned silence and an unfamiliar whiff of confusion fill the air. For better or worse, he does not see the benefit or reasoning in taking the blame for something that he has little to do with. He is not looking for a fight; he just wants to clarify the situation, and he did not call to fluster or frustrate you; he called you for advice. He has also had a long, stressful day and in the same way that his words tipped you over the edge, your words pushed him over the edge too. He became tired of running.

In some ways, it is strange. The junior doctors do not usually say a word when spoken to like this. You yourself, as a registrar, do not even say a word when the tables are turned, and your own senior takes their frustration out on you. You sit there, grit your teeth, take a verbal beating and then speak about it during lunch with your colleagues. If you sit silently during such moments, then this junior doctor should also not utter a word because that is just the way it is. You went through it, you still go through it, so the junior doctors should do likewise. The unsettling thing about this view is that something being the norm does not make it right.

The junior doctor has done the right thing by approaching you for advice. He realizes you are more knowledgeable than he is and it is good that he recognizes the need for your help. If you respond by humiliating him, it is no surprise that next time he will be less keen to approach you for help. There is a real problem when our juniors are fearful of approaching us for advice. It is remarkable that, through fear, conversations along the lines of, “You call him [the registrar],” followed by, “No, you call him,” happen between junior doctors in hospitals up and down the country.  Irrespective of our apprehensions, we should not shy away from seeking advice and potentially hindering our development out of fear of getting bruised, just as we should not shy away from advising others in fear of upsetting them.

If an improvement is there to be made, we need to be able to communicate with each other in the best manner to promote our continued learning and development as clinicians and therefore ensure the best for our patients. Conversations touching on these topics should take place, but they should be tactful. In addition, in the same way that we should give advice in the best way, we should try to receive and respond to it likewise. Giving advice in the wrong way, on the other hand, can have serious side effects, so when we feel ourselves reaching boiling point, we should try to find a way to deal with such stress, and think about the effect our words will have on the person we are speaking to.

Our aim is not to demean or speak down to others, but help develop them. Our seniority does not give us a right to bruise and batter the confidence and self-esteem of others. It may, unintentionally, help relieve our frustration, but it comes at a hefty price. Such a transaction is not worth it. We should not forget that the only thing that separates us from our juniors is seniority: they can be exactly where we are; they can reach even further than we have reached, but the difference is that they at an earlier stage in training than us.

When things go awry, we should remember that none of us are infallible. Words and looks can go a long way and when we roll our eyes, smirk and respond sarcastically when asked a question, it usually does not encourage juniors to become better doctors; it may just build hatred in their hearts for us. Being known to have a reputation for behaving in this manner is not something to be proud of.

We should ask ourselves who, or what, lies behind the mask. We can masquerade as a lion when dealing with our juniors but there is always somebody more experienced and knowledgeable around, and when we are in their midst, it is unsurprising when the lion’s mask falls off to reveal a kitten; his limitations having become more obvious to him. It begs the question of why we sometimes feel the need to exert our dominance in such a negative way. Some may do it out of tradition, others to stamp their ground, some for entertainment and others may genuinely see it as a means of trying to help, perhaps considering it “tough love” but it does little to build healthy working relationships. Behaving this way, or “ribbing,” others in the workplace should not be seen as a rite of passage.

With seniority and experience, our burden of responsibility to act as role models grows. We should be the ones to lead by example but when statistics such as the fact that almost one in 10 doctors feel bullied exist, they serve as a continual reminder that we are falling short of our responsibility. Hierarchy is a concept that transcends professions but we should not use it as an excuse to speak down to others, nor should it make us feel obliged to instil fear in those who are lower down in the food chain than us.

The transition from student to working life can be hard, particularly in science and medicine, where we spend so many years studying. Some may be surprised to learn, however, that it is not the daily tasks themselves that we may initially struggle within the first months of the job, for our years of education prepared us reasonably well for these. Rather, it is the personalities and egos that we may find hard to placate. A working environment is made not by the walls enclosing it, but the people who reside within those walls. We make our jobs harder for our own selves when we viciously set upon each other. If only we reminded ourselves of how we felt when we first started and how we continue to feel today when stalked by the lion of our workplace: perhaps these thoughts could motivate us to transform the, sometimes hostile, forest we work into the scenic place it seems from afar.

A key feature of working life is being part of a team and we work as teams to try and reach a common goal. In medicine, for example, we work in teams to try and do what is best for our patients. We will work better as a team if we learn to respect one another even in moments of extreme stress. It is not easy but it is something to be conscious of and when we keep it in mind, perhaps it will be easier to achieve. Our job is not to humiliate, but to nurture and sincerely advise.

Artaza Gilani is a physician in the United Kingdom.

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