Auntie Version - MSKMag's Agony Aunt -February 2024

Feeling Good Enough, Asking For Help, Complex Patients, Burnout and More Questions...

Hello! I’m Auntie Version and I am unbelievably excited to be MSKMag’s very own agony aunt. (We’re never going to be able to keep it secret so will immediately reveal that it’s me… Jo Turner 😉)

Oh the arrogance in my assumption that I have any wisdom to impart about your life, and the irony that much of my advice will implore you to resist that clinician’s urge to fix and advise!

Nevertheless, I do hope you’ll find this column informative, thought-provoking, occasionally amusing and that you’ll find some helpful tips amongst my best guesses and opinions.

How can I cope with no admin support to assist with my referral letters and discharges?

AV: This is quite a layered question. The way it’s phrased sounds like you don’t envisage a change in circumstances and I’ll answer with that assumption first. We see frequent debate on the MSK hub about whether or not these tasks should be part of patient contact time. If so, one strategy might be  to use something like a pomodoro timer, set to go off 5-10 minutes before the end indicating that it’s time to end treatment and start your admin tasks. You could also book off longer gaps at regular intervals between clients. 

The question I suspect you may be asking more obliquely however is, “How do I ask my boss for paid additional time or admin support for letters and discharges?” Which feeds into a wider debate about value. Do you have a sense of what is a fair return on your time for these tasks? And with that in mind, how do you feel about the consequent charge to the patient? If there is discomfort in either of these areas, it might be worth sitting with that for a while, perhaps journaling, or discussing it with friends/colleagues. 

How do you feel about presenting a case to your boss? Does it feel easy or uncomfortable? I often use  conversation templates for this kind of thing with coaching clients, broadly based on the following structure,

I’d like to talk to you about X. 

This is what I’m not happy about. 

This is what I’d ideally like. What do you need from me? Or How might we make this work?

If you’re a sole trader, you could even have this conversation with yourself.

I hope that’s helpful.

When is the right time to ask for help when I know that anyone who can help is struggling too? 

AV: At the risk of sounding trite, this is an easy one. The right time to ask for help is when you need help. 

I completely understand your concern at not wanting to add extra burden to people who are also struggling, but I believe asking someone else for help is a gift. It says, I am willing to be vulnerable with you, I trust you, I see qualities in you that could help me. It is also an invitation to the other person to ask for what they need. We may not always get what we need of course, but if we don’t ask, we definitely won’t get it.

Collective martyrdom might be considered admirable and it might be effective at holding failing systems together for a while, but I don’t think it is a long term solution.

I’ll leave you with a Charlie Mackesy quote,

‘Asking for help is the most courageous thing you can do”

How can I better manage the stress associated with complex patients? I’m immersed in the most complex conflict resolution situations several times a day!

AV: This is an interesting question. I can understand the experience of complex patients being angry and sometimes that anger being directed at us as therapists but I’m curious that it feels so often as though you are involved in conflict resolution. As empathic people, we often feel involved in our patient’s experience and I’m wondering how much you are getting drawn in. It makes me think about how difficult it is to treat family members and how frustrated we can get because we care too much or are too invested in the outcome.

How would it feel to create some more space between yourself and your patient? Maybe you could use a breath, or a phrase to yourself just before you enter the treatment room? Something like, “I am here as a small part of this person’s solution, and I can care best by protecting myself with some distance” You could even imagine putting on some kind of cloak to represent that caring, professional space.

I would say also that we often try to do too much and overestimate our capability in one session with such complex patients. A single comment or exercise that lands because you have really heard that patient can go a long way.

And finally, forgive yourself. We are all human. We get triggered by situations involving our patients. We cannot possibly be our best selves all the time. 

I’m burning out again - 3rd time in 5 years. Might just go and work in Costa as they’re advertising similar rates of hourly pay I get now. Am I just being defeatist?

AV: I’m sorry to hear that you are finding yourself in this repeating pattern of burnout. For those reading this who might not be sure on the exact definition of burnout, according to Maslach’s conceptualisation [1], burnout is a response to excessive stress at work which is characterised by feelings of being emotionally drained and lacking emotional resources – Emotional Exhaustion; by  a negative and detached response to other people and loss of idealism; and by a decline in feelings of competence at work.

With this definition, it is easy to see why burnout is common amongst health professionals with a heavy workload of care-giving in often under-resourced organisations. We also know however that burnout is more common in people who show high levels of perfectionism, who hold themselves to very high standards, want to please others, and are more than usually self-critical. 

Without of course knowing anything about you personally, I would say that whilst the idea of a job in Costa might seem objectively more appealing, if you see any of these traits in yourself, then you will very likely be taking them to the new environment. Wanting to make each customer’s day better, taking any negative feedback personally, or perhaps wanting to nail that latte froth heart!

It may be that a change of career or environment is just what you need, but before making any big decisions, I would suggest looking at ways and possibly getting support to better understand and adapt behaviours which might be contributing to this burnout cycle.

I’m a perimenopausal woman working in pelvic health. Navigating the painful path of infertility & childlessness. Much of my caseload is made up of new mums (who come in with their beautiful babies). I’m struggling with deep sadness & helping these mums is of course a privilege but it’s something that is taking a strain on me. Any advice welcome.

AV: Firstly, thank you so much for your question.

I am making an assumption which I hope is correct, that you’ve been working in pelvic health for a while, rather than it being a new area of work. I can imagine that the transitional period of perimenopause might be making things especially hard for you right now. Not just the passing of the theoretically fertile years, but also the emotional rollercoaster that this time can be for women. Sharon Blackie has a new book out called Hagitide which you might find a comfort and inspiration - she draws on her experience as a psychologist and weaves this with myths and legends of the elder woman. You may also feel however that, before you can begin to embrace this ‘second phase’ of life, there is a grieving process to be completed, for the children and fertility that could not be part of your earlier years. It might be that you seek some professional support with this if it’s something you’d like to pursue.

There is a sensitivity and compassion in your writing, which I’m sure makes you an incredible therapist and support for the women you serve at work. As others have said, our profession, and particularly the field of pelvic health requires that we give so much. I hope you might be able to find some protected time away from the needs of others, where you can rest and heal.

I have so many things I could ask….but here is one. In a profession that is constantly striving, and answerable to many regarding its worth…it’s hard to ever feel good enough. How do we define the good enough clinician? (For reference, there is a whole thing on the good enough mother - Paediatrician Donald Winnicott)

AV: What a brilliant question. There are so many elements to this, and I’ll do my best to cover a few.

I think one of the most important things to take away from the good enough mother theory is that perfect mother is a fallacy, as is perfect physio. And I think one of the interesting things is that if asked, I’m not sure we could even describe what perfect physio looks like. This strays perhaps into the systemic identity issues we are all aware of currently in the profession. I am reminded of a card, that a good friend sent me when, at 18yrs, I pulled out of university and voluntarily derailed myself from a path I’d been on as long as I could remember. The card contained the quote “Unhappiness is not knowing what you want, and killing yourself to get it”

I was in a coaching session recently with a client who had been questioning her capability but then described having come to a point of realisation that she was most successful with clients when she adopted a simple policy of being safe, clearing flags, but then relaxing into a state where she could (in her words) ‘allow the patient to fully experience what they are feeling.’ And, as a caveat, we will of course, all miss red flags in the course of our career.

Finally, to your point about being accountable to so many. I hear you, and I know that this year in particular, with the revised HCPC standards, we are perhaps even more aware of the official bodies to which we are accountable, quite apart from the patient as the most important stakeholder. In terms of ‘enough’ however, I believe only we can answer this for ourselves. The good enough mother principle was intended to foster resilience in children through acceptable levels of failing by the mother or parent. This translates in some way to a facilitative rather than teaching approach with patients, allowing them to become resilient through knowledge and experience of success in their own bodies. But I think we can also apply it to ourselves. I believe we can gather such personal strength and resilience by developing a clear sense of what is enough, according to our own best internal barometer (wildly different from the inner critic) I am talking about the most grounded, wise part of ourselves that knows what is truly enough.

It’s a long answer but as I’m old, I’ll leave you with a final reference we talked about in my Mehab Masters group this month. It’s that scene in Love Actually where the best man, tragically in love with the Keira Knightly character has said his piece. He walks away and says quietly, to himself, “Enough now” there is such peace in those two words.

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If you’d like Auntie Version to address something that’s on your mind in the next bi-monthly column, drop her an email at jo@mehab.co.uk. We can’t promise that every question will be featured or responded to directly but we’ll do our best to address common themes. 

If there is something you’d like to explore more deeply through 1:1 coaching (with Jo) please go to www.mehab.co.uk and book a free call.

References

[1] Dall’Ora, C., Ball, J,.  Reinius, M., et al  (2020) Burnout in nursing: a theoretical review. Hum Resour Health18, 41 (2020) https://doi.org/10.1186/s12960-020-00469-9