Talk to colleagues.

– Formal support. Many paediatric departments will have a debriefing session following upsetting events (such as child protection cases, prolonged resuscitation or the death of a child) in order for those involved to process what has happened. Some units also run regular meetings for trainees to discuss issues which they have found troubling or upsetting. Normally these are facilitated by someone impartial (such as a CAMHS doctor) or involve trainees only. This can be a useful opportunity to talk openly with your peers and it can be reassuring to find that other people are struggling with the same issues.

– Informal support. Finding a few moments to sit and talk with colleagues can help, particularly those who have been involved in whatever has happened. If a child who has been known to members of the team for a long time dies, some people find it helpful to attend the funeral service or to arrange an informal gathering with colleagues away from the hospital to remember the life of that child and share memories and stories about time spent with them.

  Be prepared. One of the hardest things to deal with can be the breaking of bad news to families and your response to their grief. Managing this well can have an enormous impact for these families but also for helping you to cope with the situation. For advice on breaking bad news see Chapter 3 – Communication with Children and Their Parents.

  Don’t be afraid to cry about it. This is something which doctors are often terrified of doing as they fear being perceived as weak or unprofessional. In fact, families do not perceive this as weakness but as a sign of how much you cared for their child; a survey of bereaved parents found that professionals delivering bad news with genuine empathy for their grief were perceived as much better than those who were ‘business-like’ (Finlay and Dallimore 1991). Obviously, it is important that your reactions are proportionate and that you maintain composure but sometimes it is all right to shed a few tears with families who are grieving. Finding a quiet place where you will not be disturbed for 5 min to go and cry on your own can allow you to continue much more effectively with the rest of your shift rather than swallowing back your emotions and ending up dwelling on it all day.

  Take a few minutes to be by yourself. Go for a short walk around the outside of the hospital, go for a cup of tea, sit quietly in the hospital chapel or listen to some music. Whatever it is you choose, give yourself 5 min to take a few deep breaths and feel calmer before getting back to work.

  Humour. Doctors often use humour to help them cope with difficult emotional situations. This can be useful for some people but be aware of your impact on others. Colleagues may assume that you are callous or uncaring if they don’t realise that this is your way of coping so be sensitive to this. Similarly, overhearing laughter (even about something entirely unrelated) will feel devastating to families who are grieving.

  Sometimes you may not feel anything. Experiencing no emotional response at all can be even more alarming than feeling upset. There is no ‘right’ way to respond to a situation and your reaction may differ from that of your colleagues or between different patients and scenarios. This initial detachment may be followed by emotions later on once you have had time to process what has happened. If you find that you are feeling numb and detached from patients and their families quite frequently then this could be a sign of burnout (see Box 10.1 for signs and symptoms of burnout).

Box 10.1 Some symptoms of Burnout (Kearney et al. 2009)

  Poor decision making and increase in errors

  Perfectionism and an inflexible approach

  Physical and emotional exhaustion that doesn’t improve following time off

  Cynical, detached approach to patients

  Irritability and frequent arguments with colleagues

  Apathy and low motivation

  Insomnia and fatigue

  Social withdrawal and isolation

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  Your feelings may change over time. Your emotional response to an event may alter as time passes. This is a frequent bereavement reaction and sometimes following the death of a patient you have worked with closely, you may experience bereavement in the same way as you would if a friend or family member died. See Box 10.2 for the five stages involved in coming to terms with death.

Long-term coping mechanisms

Stress is the immediate reaction to a difficult situation, but burnout happens after this has continued for a long time. Everyone has days that leave them feeling stressed or tired but burnout is when, even after time off between shifts, you don’t recover. Burnout is actually a recognised and defined problem but one which is rarely talked about. Symptoms of prolonged stress and burnout are very common amongst doctors and this has implications for the quality of patient care, not just the quality of those doctors’ lives (Firth-Cozens 2003). See Box 10.1 for symptoms of burnout.

Recognising symptoms of stress in yourself and others is one thing, but how do you go about alleviating it? Some of the protective factors against burnout are to do with the environment in which you work but there are also ways in which you can control your own behaviours. There is evidence from randomised trials to suggest that practising mindful meditation and reflective writing can be helpful in preventing burnout (Kearney et al. 2009); other interventions such as work-based programmes are still being studied. Many of the other things listed below have little evidence base in reference specifically to doctors but are part of the widespread advice we give to patients about handling stress so perhaps we ought to pay more heed to ourselves.

  Meditation. Time and time again when talking to doctors who don’t seem stressed, despite busy schedules and demanding jobs, I find that they practise meditation. There is also some evidence to suggest that this can make doctors more self-aware and better at listening to their patients (Beckman et al. 2012). In fact, several medical schools have even incorporated mindfulness into their curriculum (Hutchinson and Dobkin 2009).

  Reflective writing. Keeping a reflective log is often thought of as another hurdle to jump in a long list of tedious work-based assessments, but if you use it well it can be enormously helpful. Using a structured way of reflecting (see Box 10.3), can help you work through what happened, and why, and to come up with constructive solutions for what you will change if you come across a similar situation in future. This is a powerful way of improving your practice and can help you to take something positive away from a bad situation and move on rather than dwelling on what happened. Reflective writing forms a key part of the GMC revalidation process, which all doctors must now undergo every 5 years. It is all right (and only human) to make mistakes but the important thing is that you can show that you are capable of reflecting on what happened in order to learn from it and improve your practice. Sometimes, writing a formal reflective piece, which others may read, may not be appropriate immediately, but you may find it helpful to write in a diary. This can allow you to write freely and fully acknowledge your emotional response to the situation. You may find that it is later useful to complete a formal reflection on the same subject once you have had time to distance yourself from your immediate emotional responses. Alternatively, you can write it formally but keep the page locked (i.e. with a password) and then you might want to unlock it later on or share it only with one other person.

  Hobbies. Remember how when you were applying for medical school you had a personal statement crammed full of all the extracurricular things you did? Many of those previous hobbies may seem like a distant memory now but they are more important than ever once you start working. The whole point of selecting medical students who have a wide range of interests is so that once they are doctors, they will have constructive ways of relaxing that don’t always involve getting drunk! Make time for these previous hobbies or try something totally new and different. Whatever it is, make sure that you prioritise time for enjoying yourself. At times, it may feel that all you do is work, eat and sleep but even having one thing to look forward to each week or each fortnight can be enough to keep you going through the worst.

  Exercise. Find some form of physical activity that you enjoy, or at the very least work it into your daily routine so that it becomes habit (taking the stairs instead of the lift, cycling to work). It shouldn’t become another chore or it defeats the point; find what it is that you enjoy and make time for it. Taking exercise to relieve stress is something we advise our patients to do; the key is finding a way to take your own advice.

  Friends and family. Talking things over with someone you care about can help enormously as can having someone around to cheer you up and distract you. Do your best to keep in touch with friends and family even when you’re working a busy rota. It can sometimes feel like you’re too exhausted to see anyone at all, but this can be the very time that you most need to make the effort to get out and see people. Putting in a small amount of effort to go and meet up with someone you care about can leave you feeling far more energised than an extra hour in bed.

  Coaching and mentoring. Coaching sessions can be a very useful way of working through specific challenges by helping you to find answers for yourself. There are coaching and mentoring schemes available in some deaneries, often provided by a medical professional trained in coaching but from a different specialty (so that they will never be someone to whom you answer for clinical work). Look at the Support4Doctors website (www.support4doctors.org) under ‘Search for organisations that can help’ for a list of available coaching and mentoring services. Alternatively, if there is not one available in your area you could consider paying for private coaching sessions or try to set up a scheme at your deanery. The London Deanery coaching and mentoring scheme is well established and would be a good place to start for advice about setting up your own (http://mentoring.londondeanery.ac.uk).

Bullying and harassment

Stressful and upsetting situations at work are not just confined to our interactions with patients; relationships with colleagues can sometimes be difficult to manage too. Getting on badly with some of your colleagues or being around colleagues who don’t get on with one another can be very stressful. Witnessing or being subject to bullying is also very distressing. Most trusts will have their own antibullying or equality and diversity guidelines. The BMA also has a useful guide on its website. Some key points to consider if you are witnessing or experiencing bullying include the following.

  Talk to a supervisor or senior colleague whom you trust to raise your concerns.

  Consult your trust’s antibullying policy.

  Keep a diary of incidents to refer back to.

  Consider contacting the human resources department at your hospital for advice.

  Check your deanery or local education trust board website – there may be local advice and support available.

  If you are a student, raise the issue with your medical school who should have a dedicated member of staff who deals with pastoral issues.

Practising paediatrics when you have your own children

Fulfilling dual roles of being a doctor and a parent can be very challenging at times. Working out the practicalities of childcare and shift work can be a tricky balancing act and combining the two roles can sometimes involve situations which trigger strong emotions. But being a parent also has the potential to make you a better doctor and many families will be heartened by paediatricians who have their own children.

Below are some of the challenges doctors who are parents sometimes face, along with possible solutions and how these challenges can help you develop skills which make you a better doctor.

Emotional impact

  The challenge. Sometimes the most upsetting situations can be those involving people who remind us of our own family members. This can be particularly hard if you are looking after a sick child who is a similar age to your own. Witnessing the grief of parents or the suffering of a child can be much more painful for some people once they have children of their own.

  How this can be a strength. Having children of your own can deepen your understanding of what families and parents are going through. Knowing first hand some of the challenges parents face can make it easier to anticipate their questions and properly address their concerns. This certainly does not mean that your experiences of parenting will be the same as everyone else’s but it will give you a useful starting point. Having your own children can also give you a much better feel for the range of what is normal.

  Potential solutions. You may find it helpful to talk to colleagues who have children of their own. This doesn’t just have to be other doctors; it can be useful to talk to nursing colleagues and other members of the multidisciplinary team as well.

Not enough hours in the day

  The challenge. Being a parent and being a doctor are both very time-consuming roles and parents can end up feeling guilty about having to compromise either on time with their children or time spent at work. Childcare arrangements can sometimes be very restrictive, meaning that you have to leave work at a fixed time, which can occasionally cause resentment from colleagues.

  How this can be a strength. These added time pressures can help you to develop excellent time management skills and you may find that you become much more efficient at work as a result. Splitting your time between childcare and work also adds variety to your life and may allow you to approach both with a greater enthusiasm than if you were solely doing one or the other.

  Potential solutions. Investing in decent childcare can put your mind at rest and help with some of the time restraints. If you are expecting a baby, look into this before they are born as there are often waiting lists for good childcare facilities. For advice on how to find good childcare services, see the less than full-time training page on the RCPCH website and for information on the financial support available for childcare go to www.gov.uk. Sometimes it may be difficult to leave on time, particularly if your colleagues are not very sympathetic, but don’t be afraid to be assertive. If you need to pick your child up from childcare then you do need to go so don’t feel guilty about it. If you find that colleagues are becoming resentful, you can offer to help them out in other ways – try to swap shifts if you can or offer to take on some of the boring jobs that day if you know you will need to leave early. You may wish to train less than full time for a while in order to free up more time to spend with your children. For more information on less than full-time training see Chapter 11 – Developing Your Career.