It might sound odd at a first glance to describe surgeons as vulnerable. After all, a surgeons profile is usually associated with charisma, decisiveness, courage, and resilience. Surgeons generally have strong personality traits compared to the general population.
Observing first hand, as someone who works in the profession in a senior capacity for the last 16 years, I have seen it time and again; the fast-moving unpredictable day at work, the multiloculated job plan, the overall responsibility, management roles, long working hours, enduring long operating procedures, personal /family life and the perceived need to survive/surpass equally determined alpha surgeons (both men and women).
Based on this multitude of roles, surgeons do not have a choice but to design their lives around their working hours which means frequent frictions leading sometimes to igniting fires in their own personal/family life.
Unpredictability brings with it a wave of uncertainty for what is coming next. Although emergency on call is rostered to occur at a particular timed rota, a surgeon’s life can feel like an emergency, on call every day. On call itself is a physical and mental strain, a long list of unwell patients and quick decision-making process in the face of failing healthcare, complicating patients’ management even further. Most complaints come from emergency take. A thank you card feels good for a while before it is wiped out by a complaint. After all a surgeon does not have to write a long reply to a thank you card. Dealing with challenging families and patients is another skill towards “customer care”, where a surgeon must ride the tide even with irrational or outright aggressive exchange. When did we see a surgeon writing a complaint about a patient or next of kin? Only a patient could write a complaint about a surgeon!
Failings in the healthcare system seem to be addressed to surgeons first and foremost. Patients rightly so, know their surgeons, they do not know the management personnel and never meet them. So, when lists are cancelled for different reasons unrelated to the doctor it seems that the doctor is the one who has to apologise about system’s failings. It is not just as simple as apologising; Surgeons are made to feel embarrassed about something they had no wrong hand in.
An unrelenting barrage of emails from all directions needing answers every day provides a very tricky but not widely discussed challenges. Many surgeons ignore most emails as either irrelevant or simply don’t have time for it which could frustrates some and risks surgeons appearing arrogant or disrespectful. Some emails are crucial and possibly inflammatory or even anger provoking. Answering them could be costly if one gets it wrong (personal experience). Whatever the response emails take up the largest space in everyday practice without being too much noted. Perhaps surgeons should discuss in their job plan a tariff on how many emails to answer and when. Personal complications are the worst hits, hitting lions/lionesses right in their pride. Meetings, management roles, appraisal, revalidation, pensions, and deadlines everywhere. And then you want to do something different, something the surgeon’s ego could stand in pride like Mufasa showing the jungle who is king or sort of one. These creative moments or moments that enrich one’s satisfaction with his/her job are rare to come by.
All these issues and countless others put pressure on a finite source of strength and resilience of surgeons however bigger it is than the population average. But with these strong personal traits, associated with surgeons compared to general population, one could envisage why a surgeon would appear and look unscathed despite multiple threats and would not ask for help till late… very late.
Indeed, what comes to mind is a photograph of Saint Sebastian still elegantly standing (and in shape unlike most surgeons) despites the arrows hurling at him from every corner.
When it comes to seeking help, sharing emotions/vulnerability or even outright specialist help “surgeons are a hidden group within a hidden group, even more reluctant to seek help when unwell”. The scarce research into surgeon’s wellbeing only measures end points such as rates of burnout, anxiety, depression and addiction.” It is also hardly surprising, given the long, unpredictable hours and the high-stress work surgeons undertake, that they have some of the highest levels of divorce among all the medical specialties.
Perhaps the greatest irony is that surgeons excel at hiding/silencing their own emotions while at the same time dealing with highly vulnerable, trusting patients where emotions abound and who are themselves looking for someone to empathise with them. It is a bewildering thought to try and comprehend how one would be empathic with others if they are unable to show it for their selves. As per dictionary definition “empathy is the ability to understand and share the feelings of another”. How could one be proficient at sharing the feelings of another and not showing it for themselves? This is just one of a few “unnatural” ways of working that surgeons, and others, face in the workplace and pass unnoticed.
I suspect surgeons, as employees, have been subjected to the same rules applied to all places of work since the industrial revolution whereas one becomes worthy (and probably wealthy) by how much one could show/quantify their work, i.e., outcome measures, sales etc. It follows that all employees would work to achieve an outcome and consequent they get rewarded. A reward would equate to happiness/satisfaction and therefore the more you get, the happier you are expected to be. You do not have to (indeed you must not) show your emotions at work because outcomes measures and more recently happiness economics could indirectly show you how happy or less happy you should be by what you do, not what or how you feel. This “Quantitative fallacy” replaced feelings with numbers. It starts, as a way of example, this way; John/Mufasa is rich, has a nice car, a beautiful wife, and a large house. John/Mufasa must be happy. But John/Mufasa says he is not happy, something we could not reliably measure. So, we conclude that John/Mufasa should be happy! If John then throws himself of a bridge, you’d scratch your head for a few seconds and move on. Another unnatural phenomenon: the desire to measure because one can, even if the resultant figure is meaningless.
All employees (including surgeons) are bound to fail, and it is only the mercy of their employers that keep them in job. You must be pensionably grateful for your employer. Job plans and working arrangements are designed to ensure that mistakes and failures are inevitable however careful or risk averse you are. Therefore, showing employability, not just hard work, is one way to keep your job/pension. One way of showing employability, and hence is a sign of submission for your employer, is doing the same thing consistently for a number of years in the same job.
Thus, we evolved to learn the best way to communicate two pieces of bowel/vessel/never together while in the zest of doing so we have been deconditioned to communicate inwardly with our emotions or sharing it outwardly with others.
The problem seems to be ingrained since we were newly qualified. The GMC guidance provides a series of must dos; for instance, newly, qualified doctors must “manage the personal and emotional challenges of coping with work and workload, uncertainty and change”. This a typical regulatory sentencing; you are solely responsible for your own health and any mistakes arising therein. No other way out is suggested in the guidance to support trainees’ wellbeing other than being encouraged to “register with your GP”
A study titled "emotional challenges of medical students generate feelings of uncertainty".
The study concluded that:
in the process of becoming a physician, students develop their professional identity in constant negotiation with their own perceptions, values, and norms and what they experience in the local clinical context in which they participate during workplace education. The two dimensions that students must resolve during this process concern the questions: Do I have what it takes? Do I want to belong to this medical culture? Until these struggles are resolved, students are likely to experience worry about their future professional role. Ref.
The surgical curriculum has been updated by the ICSP in 2021 to address a criticism related mainly to the assessment process (essentially changing from outcome based to capability-based assessment). The detailed assessment does not provide any tangible mechanism to address surgical trainees’ wellbeing except for a general hint of a suggestion in the roles played by TPD, AES and CS and trainees themselves.
TPD. Ensuring a policy for career management and advice covering the needs of trainees in their placements and programmes. AES, helping trainees with both professional and personal development. CS, keeping the AES informed of any significant problems that may affect training. Also provide verbal and written feedback. The only wellbeing that was mentioned in the document is that “Trainees/learners must place the well-being and safety of patients above all other considerations”
Reflecting this forward onto senior doctors, the two questions on the study on medical students remain valid in senior years; Do I “still” have what it takes? Do I still want to belong to this surgical career? The challenge is that it takes courage and a great deal of self-reflection to know who we really are and what do we really want. Many surgeons might disagree on this point and that would be very expected, why? Because surgeons are smart people and as such, they are plagued with the same problems smart people suffer from. I repeat surgeons are smart people. Smart people are good at thinking, reasoning, and defending their points of view. However, Surgeons, like other smart people, are very poor at rethinking and they don’t know that they don’t know this aspect.
Surgeon as smart employees.
Surgeons are able to assimilate large amount of information in a short space of time; from problem solving both in elective and acute care situations, planning meetings, research, defending their opinions, criticising others’ opinions, audits, food, family, schools and childcare etc. This leads to another downside of being smart; surgeons are poor listeners. You might be lucky of you get a few seconds to penetrate their world and get attention. Most of the time, you seem to take a long time to get to the point and they are already thinking about the answer.
Surgeons substitute thinking with feelings and feelings with thinking. Ask a surgeon what he/she thinks about a particular option - let’s say an operative or non-operative approach he or she are not familiar with or have not tried before. “I won’t feel comfortable with this particular approach because ...” The question about thinking was not only substituted with a feeling but the answer that follows the feeling is a carefully worded and thoughtful justification of the “feeling”.
Surgeons are all or non-personality. We perform at top level for a long time, and we can’t allow this to drop to any significant levels. We deal poorly with failure, deny failure, deny the emotions arising from failure and mitigate failure by gaming the system.
Surgeons tend to work in bubbles; a personal bubble that aims to protect its own gains and fends off any requests to give up some of the privileges they acquired over time. They also work in slightly bigger bubbles containing birds of the same feather. True, wide collaboration is unlikely between alpha surgeons who won’t accept members of other troops. This in my opinion frequently leads to many lost opportunities of patients’ care for instance. An initiative advanced by a different troop member would be unlikely supported, attacked if it threatens one’s own bubble or results in the all too passive aggression i.e. withholding true opinions or criticisms when asked for feedback while waiting to watch projects, that otherwise need their support, collapse.
Studies suggest that students often are left alone with their experiences and feelings. And it seems that this trend continues onwards as we travel further into our medical/surgical career. We are largely left alone to our own experiences and feelings. There is no mechanism described even as a general framework at any level from the GMC to medical colleges to surgical curriculum that addresses students/trainees well-being that serves as a backbone to foster openness and ability to share emotional burden arising from work as trainees progress to independent surgeons responsible for patients’ health and wellbeing.
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