One small reckless act, one giant blow to my career: how can coaching help a doctor in this situation?
Member of the FMLM Coaching network
It is universally accepted that working in the NHS is now more stressful and difficult than ever. Even before the Covid-19 pandemic, the impact of work pressures was highlighted by the GMC at their 2019 conference, which looked at the crucial importance of good leadership in preventing and mitigating these pressures. A report by Suzanne Shale (2019)[1] has highlighted the prevalence of toxic working cultures in which unacceptable behaviours from senior doctors persist unchallenged, often due to the culture of fear that they engender. Initiatives to bring such matters firmly into the centre-stage of medical leadership are to be welcomed. Indeed, GMC President, Dame Clare Marx, has emphasised that hospitals where good leadership exists are safer for patients[2].
Occasionally – perhaps more often than we like to think – a doctor may become so overwhelmed that they start behaving in ways that are highly disruptive, unprofessional, perhaps even potentially dangerous. A moment of weakness, which may be highly uncharacteristic, can threaten to destroy their professional reputation and career. Until that moment, such doctors may have had exemplary careers, high-status roles, unblemished national and international reputations, and received awards. Now, that all hangs in the balance as they find themselves facing a formal investigation, referral to the GMC, and perhaps a medical tribunal to ascertain their fitness to practice. Whilst it may be the case that some doctors under investigation may have little or no insight into their actions and impact, the doctors I see in these situations are keenly aware that they have acted unprofessionally. They realise they are entering a nightmare of uncertainty, shame and anxiety about their future through a morass of legal and regulatory processes and are mortified and remorseful.
Confidential, emotional and psychological support
Once under formal investigation, talking to friends and colleagues becomes almost impossible; confiding in family can be excruciatingly difficult: if a doctor is facing the end of their career, they may wish to protect their family from financial worry and will be deeply ashamed of having succumbed to provocation and unprofessional behaviour.
There are few individuals in whom such doctors can confide. These may include human resource managers handling their case, their medical defence organisation, and their lawyer. However, while these parties will manage the legalities and the process issues involved in investigations and tribunals, by virtue of their roles, they cannot necessarily provide the emotional and psychological support that the doctor desperately needs.
As an executive coach, my perspective is that of someone who has become involved in supporting individual doctors in the type of situation I have described. The following testimony came to me from a doctor who had faced the end of his career, sought coaching, and had started to rebuild:
“I felt adrift, … washed along by powerful, probably malign forces over which I had no control. After the (coaching) sessions … each time I felt the situation to be more manageable and I came out with a plan of things I could or should do. It made me feel better and I think I functioned much better through that year than I would have done.”
What can a coach offer to a doctor in such a scenario? First and foremost, listening without judgement. The opportunity for the doctor simply to narrate their story, uninterrupted initially, and to know that their coach is probably one of the few (if not the only) individual who will not judge , feel disappointed or let down by them, and whose prime purpose is to support them to the point that they can look at their future again with some hope and renewed self-respect. In this scenario, doctors can bring their complete set of emotions to the coaching sessions and rehearse the approach they will take when finally telling their family what has happened. Typically, then, the goal of the coaching is to help them to plan for different career and personal scenarios depending on the outcome of their investigation or tribunal.
Developing insight, recognising warning signals
Second, the coach can support the doctor to recognise and accept that their previous level of working has now become unsustainable. Third, coaching can explore and generate greater insight into what led the doctor to make such an error of judgement in their behaviour. Fourth, armed with those insights, the doctor can work with the coach to identify practical strategies for managing their way through the difficulty and then to prevent a recurrence. Learning to recognise warning signs early and acting accordingly can be an important first step – not easy in a profession that has been trained from an early stage to ignore personal strain and stress and to plough on, simply because there was often little alternative.
There are potential pitfalls in such a coaching relationship. Ultimately, it is a business relationship and maintaining professional distance, while also remaining empathic, can be challenging for the coach. The doctor’s story may be compelling and their distress real. A coach may inadvertently over-identify with the doctor’s distress particularly if the coach him/herself is a doctor. The coach may become increasingly drawn into the coachee’s story and their predicament, regarding the coachee as a victim and others as their persecutor, thus feeling more compassion and concern for them than may be helpful. It may also be tempting to accept wholesale the coachee’s version of events, thus denying them an opportunity to consider a different perspective, or to examine their own contribution. While there are often genuine pressures on a doctor that can drive them to the brink, particularly in the current environment of the pandemic, extreme fatigue, fear, illness and other personal stress factors can push doctors into uncharacteristic behaviour. Doctors who are driven and ambitious or unable to say ‘no’, become consumed with and overwhelmed by work. They lose perspective, ignore or do not recognise their internal warning signals, until they are provoked beyond endurance. While patient safety must remain paramount and good medical practice adhered to, censure without support can pitch an already vulnerable doctor into utter despair.
Coaching is a process that can help to identify persistent patterns of behaviour that may have benefits (eg success, fame, research grants, status, etc) but which, when overdone, can derail that individual – diligence becomes obsessionality, confidence turns to arrogance, resilience masks underlying physical symptoms and may prompt denial of any weakness. Most doctors in such a situation will be anxious to prevent any recurrence of the behaviour that has led to their potential downfall, particularly if they have been allowed to continue to practice but with a warning or conditions attached to their practice. They will want to know how to avoid jeopardising their future a second time, since then it will be clear that there would be no way back. Helping them to maximise their strengths while preventing these from being overplayed, will be an important coaching goal.
Building strategies for effective self-management
Coaches occupy a particularly privileged role as often sole confidant(e) to the doctor, but managing boundaries is always important in a coaching relationship. I have often found myself saddened and surprised when I discover that a doctor has felt the need to conceal their difficulties from everyone close to them, including their spouse or partner. Some gentle reality testing can be helpful, encouraging the doctor to consider what possible scenarios might follow from sharing their predicament with their family. This usually provides the breakthrough, giving the permission they need to confide in their family. The relief when they have done so, knowing that they are still loved and respected, can be a significant step forward in their ability to cope with the coming months.
Unlike many other professions, a doctor’s job forms a core part of their personal and professional identity. To find this threatened is therefore deeply destabilising and distressing particularly if it happens towards the end of an otherwise exemplary career. I believe that we could do much more to help prevent doctors from getting into this situation in the first place, by supporting them to build strategies for effective self-management under pressure and encouraging the development of mindfulness and the ability to notice feelings of stress and fatigue. The recent Covid-19 pandemic has highlighted more than ever how vital self-care is to physical and psychological survival, and by extension, to patient safety. Dr Clare Gerada, Director of the Practitioner Health Programme, in a recent interview with the Royal Society of Medicine, emphasised the crucial importance of providing opportunities for doctors to talk about their feelings and reactions, in a safe space.
If you think the FMLM coaching network could help you or a colleague, do get in touch coaching [at] fmlm.ac.uk
[1]Dr Suzanne Shale (2019) How doctors in senior leadership roles establish and maintain a positive patient-centred culture. A research report for the General Medical Council.
[2] Dame Clare Marx conference speech: https://www.youtube.com/watch?v=5uWVh2aQu4E