Episode 21 – Fit notes – Taking time for yourself.



Fit for work website.
The Richmond Fellowship.
Kara Loewentheil. – UFYB Podcast.

Throughout this series I have repeatedly stressed that the work we are doing together is simple, but it’s hard. There are no quick fixes or magic pills. If we want to take control of our own health and happiness, we need to be willing to be uncomfortable. To admit and accept our weaknesses, flaws and pain. To lean in. But leaning in his harder than numbing out. That is why we spend so much time and energy numbing out. We are not stupid.

I have also repeatedly said that all of us have adopted unhealthy or unhelpful coping strategies for dealing with our pain. When we numb out, we get immediate relief from our pain, so it is entirely understandable that we all do it. But it is still an unhelpful coping strategy, because the relief is only temporary. It’s like putting off writing an essay or doing your tax return. In the long run it is inevitably going to catch up with us. If we really want to deal with our pain, we must confront it, allow ourselves to experience it, so that we are able to understand, process and become peaceful with it. We cannot bury pain, or turn away from it, we must hold it, and learn to be comfortable despite being fully present and aware of it.

For this reason, doing this work, embarking on this journey onto a better, clearer path is always going to be challenging. It is going to be painful, and exhausting and frustrating. You are going to fall back into the hole when you have clawed most of the way out. And you will continue to fall into the hole throughout the rest of your life. But by doing this work you can learn to be out much more than you are in. You can learn to see how beautiful the world is, how beautiful humans are, and how beautiful you are. You can learn to see the beauty in all life has to offer, regardless of if it is joyful, sad, frightening, or hilarious.

This journey is the most important thing you can ever do for yourself. But because of how challenging it is going to be you need to be all in. You need to allow yourself the time and space you require to embark on it. As we discussed in episode 5 most of us are leading frantic lives. We have multiple commitments and often prioritise other people and neglect ourselves. But when you are on the aeroplane they always tell you to put your own oxygen mask on before helping others. This is good advice. If you are not looking after yourself properly, you are probably not in the best position to look after anybody else either.

The most common time I encounter this is when it comes to people taking time off work. In my experience most people are extremely reluctant to take time off. There is a perception in society, and very occasionally even amongst some doctors, that people are prone to malingering. To coming to the GP to be “signed off,” out of indolence or self-indulgence, when they are perfectly well and capable of working. I have found the exact opposite to be true. It is extremely rare that I feel that somebody is trying to “swindle” me into signing them off. To the contrary I spend much of my time trying to convince people to give themselves a break, that they will recover faster if they allow themselves to get some rest. This is true across the board, from people taking a few days to get over an infection, to a few weeks to recover from an injury, to several months to recover from more serious mental and physical illness.

This common perception is important because it influences how we think and what we do. We are essentially making sick leave into a moral issue. With all moral issues, as with health issues, the goal is to find the middle ground, to find balance. The right path always lies between two extremes of vice. Vice always represents an excess or deficiency of some trait. We can be too brave, and therefore reckless, but also too timid, and therefore a coward. I didn’t think this up myself – I got it off a guy called Aristotle. Its good stuff. Anyway, the same is true with taking time off work. We may take time off because we have stubbed a toe, and be seen as work-shy or lazy; or conversely, we may go into work despite suffering with Corona Virus and shut down the entire office. The “correct” course lies between these two extremes. The issue with the general perception within our society is that it causes us to miss the mark. We are often terrified of being seen as lazy or weak. We have a strong work ethic drummed into us from a young age by a capitalist system in which those in power tend to profit disproportionately from the hard work of others. We want to hit the middle mark, but we believe we have a tendency to slice to the left, so we deliberately aim right. What this means in practice is that we are far more likely to commit the error of continuing to battle through at work, when we really need to focus on looking after ourselves. We are much more likely to go into work when we should have stayed at home, rather than staying at home when “morally” we should be at work.

I know this to be true because I have personal experience of it. A few years ago I had some time off work myself. This time that I took for myself has had an unimaginable impact on both my personal and professional life. I am not the same person, or the same doctor that I would have been without it. However, at the time I was a long way off having the insight or foresight to realise this. As with most people in our society doctors have a pretty strong work ethic. Because of the nature of the NHS you know that if you don’t show up for your shift, it is highly likely nobody will cover it. This means that your colleagues are going to have to do all of your work as well as their own. The work does not reduce, people will continue to get sick and rock up in A+E whether or not you are there. It can’t wait until Monday. It was not uncommon during my time training in hospital medicine in the UK to be managing the workload of 2 or sometimes even 3 doctors. When you are on the receiving end of this it is horrendous. It is exhausting, its stressful, it’s even frightening at times. If you don’t show up to your shift you know that your colleagues, and above all, the patients, are going to suffer. So, because of this doctors are very reluctant to take time off. I have been to work with pneumonia and high fever, and with migraines with visual disturbance.

I hadn’t taken a single sick day in my first 6 years after qualifying as a doctor. I have a friend who ran an arrest whilst simultaneously vomiting into a bin, because she had developed gastroenteritis during a night shift and there was simply no one to cover her. Since most doctors have similar war stories to tell, it also means that often we are not very sympathetic when other doctors call in sick. Carrying 3 bleeps on your week of nights, despite performing your own appendicectomy on the 4th one, has become a badge of honour, and we have come to love our bragging rights, revelling in a system that is harming us, like some weird kind of Stockholm syndrome. I know that same thing exists in many other professions and walks of life. Kara calls this the “Busy Olympics”.

So, when during my GP training, I started to struggle, it is perhaps not surprising that it never crossed my mind that I might need to actually look after myself. I carried on working far beyond what was reasonable or right. For several months I was in real strife. I had to pull the car over on my drive to work to vomit. I was consulting, seeing a patient, having a cry for a few minutes, and then calling in the next one. In actual fact I didn’t stop going to work until I was told by somebody else that I shouldn’t go, and the only reason I accepted this was because it was suggested that it was a patient safety issue, because I had eventually become unable to focus on my work properly. It is interesting that I was only willing to accept this because of what it meant to other people, rather than the impact it was having on me. So strong was my belief that my duty was always to others, rather than to myself. It is even in the GMC duties of a doctor medics sign up to – “make your patient your first concern.” It was only because I had fantastic support from my supervisor and subsequently the Deanery I was training under that I was able to start looking after myself at all. As it turned out, once I finally did take a day off, I wouldn’t go back for 4 months.

There is a point where the right thing to do is to look after yourself. And this point comes much sooner than you think. There is a reason that we live in a society where most employees are intitled to paid sick leave, and why people that are unable to work, due to ill health or any other reason are looked after. It is because it is right. So, if you are unfortunate enough to find yourself in a situation where you need to take some time to look after yourself you should take it, without hesitation. Actually I am going to rephrase that. Because life is hard. And all of us will inevitably need this time at various points in our lives, and for a whole host of reasons. So, when you find yourself in a situation where you need to put yourself, your family or your friends before your employer, before your clients or before your patients (the duties of the doctor not excepted) take that time. Don’t beat yourself up about it, don’t debate it, don’t feel shame, just take the time. Your duty to yourself, or to your close friends, or to your family trumps the duty you have to your colleagues or your employer.

We live in a society where we look after people because it is the right thing to do. But this is also a blessing and a gift. There are plenty of people in the world who do not have this grace. So, take the time, take it without guilt or remorse, but at once see it for what it is. See it as a gift. And out of respect for that gift, and out of respect for yourself, use your time wisely.

Use this time to do some work, to learn to better understand yourself, to work out which areas of your life might be out of balance, and to restore this balance across all aspects of your life. Use the time to work at strengthening your relationships with your family, friends or partner. Use it to trial and develop new, heathier habits. Use it to reflect on where you’re at, where you want to be, why, and how you are going to get there.

This is not a selfish act. Only by investing time and energy in becoming the best version of you that you can be for yourself can you become the best version of yourself for others. If you take the time to do this work you are not the only one who will benefit. Only by truly loving ourselves can we develop true love and compassion for others. By doing this work you will become more effective and efficient in all areas of your life. You will be better employee, or a better employer; a better friend, better relative, or better parent.

Using this time wisely does not mean that you may not at the same time enjoy yourself. Progress in this work is predicated by hope. Hope is an emotion aligned with joy. It is hard to make progress without hope and joy. We sometimes believe that if we are signed off work sick that we should take to our sick beds. Sometimes people ask me about this straight out – “is it OK to go out to the shops if I am signed off?” they ask. We worry that our boss or colleagues might see us out in town or in the park when we are meant to be “ill”. This is unhelpful. There are a few ailments that require a sick bed – if you have gastroenteritis you probably need to stay at home and rest, preferably close by to the loo. But most of our illnesses do not do well with bedrest. Part of your recovery is getting out and about. You need to exercise, and eat, and socialise and play. Part of your recovery might be going to the gym, reading a book in the park, enjoying a film, taking an art class or even going on holiday and getting some much-needed sunshine. This is OK. And you shouldn’t feel guilty about it. So long as you are being true to yourself, learning new skills and growing as a person all these activities are a legitimate part of your convalescence. For me “Tinder Therapy” played a significant role in my recovery. I might do an episode all about Tinder therapy in the future if its something people are interested in.

In order to restore some balance here, I should point out that whilst these things may have a role to play, they are not enough in themselves. I’m not suggesting that you should ask your GP to sign you off so that you can have a 2-week holiday simply to “recharge”. There must be self-exploration and self-growth. This requires commitment and responsibility. Fundamentally this is about change. If you don’t change the way you think and relate to yourself during this time, you may feel refreshed and temporarily invigorated, but in time your problems will inevitably start to resurface. If we don’t change how we think we will always feel and act in the same way. I would recommend using the time to access some formal psychotherapy or to actively engage with some support groups, agencies, organisations or charities directed at health. The Cambridge Progressive Medicine podcasts might be a good place to start, and if you are listening out of order I would recommend starting at the beginning and doing the homework.

The final thing I would like to say about taking time off work is don’t short-change yourself. If you have finally accepted that things are not really OK, that you need to take charge, take responsibility, and do something about it, make sure you cut yourself enough slack to actually follow through. If you have been suffering with insecurity, low mood, insomnia or anxiety for many months or years it is probably going to take more than a week to get better. In truth all of us will need to continuously work at it throughout the rest of our lives.

Now I’m not saying that, like me, you need to take off 4 months. I am not necessarily saying you need to take any time off at all. We are all different and will have different needs. For some people their work may assist them in their journey, it may give a sense of achievement or purpose, it might provide a break from other struggles or valuable support from colleagues. There is evidence that for many health problems, such as back pain, an early return to work can promote recovery and overall wellbeing. For others financial considerations may make it unviable to have a prolonged period of absence. I am not saying that you must be off work if you want to get better, but I am saying that when making the decision you should make yourself the priority and take the time that is right for you. This may be considerably less than 4 months, or it may even be more. You don’t need to decide this at the beginning. You might want to take a week and then reassess and see where things are at. Also being completely off work is not the only option. You may want to consider altered hours, amended duties or a phased return. These are all things that can be suggested by your GP using the Med-3 or “doctors fit-note” although I should point out that employers are not legally required to follow these recommendations.

Your occupational health department can help to discuss these issues, and I would certainly recommend discussing this with your employer directly. There is also an excellent website called fit for work, which offers free, expert and impartial advice to anyone looking for help with issues around health and work. In addition to this The Richmond Fellowship is a charity that offers employment services both for people who are currently employed, as well as those looking to find employment following a prolonged period of illness. For people who are self-employed, or for advice on the benefits system, Citizens Advice would be the first port of call. These are excellent resources and as always, I will post the links.  

If you have reached a point where you need to take some time for yourself you are not a malingerer, you are not lazy, and you are not weak. You are a human with unmet human needs, who needs time and space to heal and grow. Sometimes it takes more courage to admit that we are not coping than to continue struggling on with the status quo.

So, your homework this week it to take some time to think about your Cambridge Progressive Medicine journey so far. Are you making progress? Are you hopeful? Are you winning? If not, is your work helping or hindering your progress? Is it worth thinking about taking some time for yourself to do this work properly? If the answer is yes you should take the time. You will not regret it. And in the long run neither will your friends, family, colleagues or boss.