The Hidden Curriculum – Funambulism

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As supervisor for the newly qualified clutch of interns swimming through our emergency department I get to nurture them straight out of medical school, before the cynicism of the ward service sets in. It’s never the medicine that is a challenge, but the hidden curriculum that they are not taught in medical school. This is a companion piece to the one I wrote on getting more time for online activities.

As a thought exercise I decided to log my week and figure out just where the minutes disappear.  Now, understand that I am in the privileged position of having made it through my training and out the other side into the land of the consultant so my weekly roster is lighter than those of you still undergoing training. To compensate for that I work two jobs.

There are some things that I have to do every day – eating, drinking, sleeping, and what my father would call the 4S’s (sh!t, shower, shave and shampoo). I sleep roughly six to seven hours a night depending on what the children are up to. Once those vital activities are dealt with, and I take out work, I have about 69  hours for myself and all of my other needs.

Most of us have heard of Maslow’s hierarchy of needs*. Even if you didn’t know the name you would have seen his pyramid. He’s also got a really interesting Wikipedia entry that is worth taking a gander at. His basic premise was that human beings want to realize their full potential, that we want to become better people. Rather than Freud and Jung’s more pathological approach to personal psychology, Maslow epitomized the burgeoning positive psychology movement. To me this sounds a lot like the premise of the #FOAMed movement. He felt that once people surmounted their ‘deficiency needs‘ they were able to move on to ‘growth‘ or ‘being needs‘. They would then journey towards a state of self-actualization, in which people are fulfilled and have achieved everything they are capable of. The cynics out there will think this is an impossible ask. That does not mean that one shouldn’t strive for it. And that is where the doctor becomes a funambulist – a tight-rope walker – trying to achieve balance whilst moving forward.

I am not just a doctor, or a father, or a husband, though. I am a combination of all three. And each aspect of my life has it’s own competing hierarchy. Is it truly possible to achieve a state of balance or am I just going to lurch, lopsidedly and flat-footedly from peak to peak to peak? Let’s break down the steps of Maslow’s pyramid and look at how they may differ in my different roles…

 

Physiological

You might think that these basic pre-requisites are easy to achieve but how often do we go through a shift at work having made it through a shift surviving on the life sustaining calories of a charity box Freddo Frog? How many times have you gone to the toilet at the end of a busy work day and absentmindedly wondered to yourself what your renal function was like? I know I am not the only one. Doctors and nurses are notoriously bad at looking after themselves at work. It would be impossible to reach that state of self-actualization nirvana if we don’t do the basics right.

Bottom line: It’s hard to have good judgment if you are ‘hangry‘ – take something (healthy) to nibble on during your shift. I’ve normally got an apple in my bag and some almonds in my pocket. My wife also knows that if I am not making sense or being downright unreasonable she should forcibly shove food into my face.

 

Safety

It is easy for me to feel safe at work – I am a six foot three white male. But anyone can be a victim of bullying. The Australasian College for Emergency Medicine have set up a working party to look into discrimination, bullying and sexual harassment in the workplace and a number of other colleges have set up similar initiatives.  If you feel as if you are being bullied, or witness such improper behaviour then please speak out.

Work safety also encompasses work stability, free from worries of where you are going to work.

Bottom line: Look out for each other, not just yourself.

 

Belonging

Having dealt with the biological necessities it is time to move to the more challenging stage of the climb towards self-actualization, where competing, and often contrasting, interests are at play. It is great to feel a part of the team – not just the small team looking after one patient but the larger team of the department as a whole.  How can one achieve that? I think (and it is only personal opinion, not backed by rigorous scientific evidence) that you can start by learning and using peoples names. I might get my three children’s names muddled up at times but I know the names of the orderlies, the cleaners, the radiographers and clerks. The department I work in is like a family. When things have been at their worst they have rallied around, providing meals and emotional support.

But does this mean my real family misses out? Though I may only spend 40 hours a week at work I am sure that I spend a lot more additional time thinking about it and other work related projects.  It is easy to be distracted by constant push notifications so every day I try to be more mindful of how I come across. Every time I feel the fear that I am not getting stuff done I think about what is truly important at that exact moment in time.  I’ve done my weekly audit, I know I have so much more free time than I think, and that being present, baking Anzac biscuits or watching Frozen for the fiftieth time is much more important than answering an e-mail or reading a journal article.

It is one thing to be a part of a family but to maintain a loving relationship with a spouse despite the pressures of work can be really tough. I’ve chosen a speciality that will rely on me working shifts until the day I retire and so it is vital that myself and my partner communicate around our needs. We share Google calendars so we each know what is going on at a glance. I used to pride myself in keeping my work and home lives separate but over time have come to realise that is more harmful than helpful.  An honest answer to “How was your day?” is much better than trotting out a clichéd reply.

Bottom line:  Be truly present, whether that is at work or at home.

 

Self-esteem

What exactly is it? Maslow would have it that self esteem is an external construct based on recognition and respect. If you believe this then you are setting yourself up for failure. Any psychologist would suggest the importance of developing an internal, rather than external, locus of control. You cannot control what people think, or how they behave towards you but you can control how you respond to them. That gap between stimulus and response is increased by self-esteem.  Sure, we all like to be rewarded for a job well done. But I’m not going to be an obedient Labrador, gazing up at my master, waiting for a ‘Good boy!” and a ruffle behind my ears if I’ve done a good job, got that cannula in the chubby 2 year old.

Something I’ve struggled with for years is that my own sense of identity is intrinsically linked with what I do.  It is, to some, ‘just a job’ after all.

Bottom line: You cannot control how other people feel but you can develop control over how you feel.

 

Self-actualization

And so it would come to this, the summit of Mount Maslow, where only the most experienced climbers and their sherpas may tread. Here one may plant the flag of #FOAMed and nurture others. Fulfilment and self-actualization comes, not just from helping yourself be better (whatever that means), but also from helping others become better. People who have reached a stage of self-actualization do so through exposure to what Maslow would call ‘peak experiences‘ – a perfect date, that bacon sandwich after a heavy night out, a state of flow in a once chaotic resus bay.

Towards the end of his career Maslow tried to determine how self-actualized individuals behave differently from the rest of us, by examining the lives of a number of key figures. He selected twelve particular characteristics :-

  1. They embrace the unknown
  2. They accept themselves, complete with all their own flaws
  3. They enjoy the journey, not just the destination
  4. They may be unconventional but they don’t set out to shock
  5. They are motivated by growth not satisfying needs
  6. They have purpose
  7. They don’t sweat the small stuff but focus on the bigger picture
  8. They are grateful
  9. They share deep relationships with a few
  10. They are humble
  11. They make up their own minds
  12. They are not perfect

Does any of this sound like someone you know?

Bottom line: It is not just about you

 

I began writing this post as an exercise in dealing with work-life balance. As I have explored some of the challenges involved I have realised that, rather than walking the tightrope between the peaks of family and work, that to achieve true balance those pyramids need to become more closely aligned

 

It’s also worth exploring Nikki Abela’s take on Maslow in the workplace over on the RCEM FOAMed network.

 

* There is a lot to criticise about the simplicity of the this mountain with many modern psychologists arguing that there is fluidity at the higher altitudes.

References

Maslow AH. A theory of human motivation. Psychological review. 1943 Jul;50(4):370.
Solomon AW, Kirwan CJ, Alexander ND, Nimako K, Jurukov A, Forth RJ, Rahman TM. Urine output on an intensive care unit: case-control study. BMJ. 2010 Dec 14;341:c6761.
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About 

An Emergency Physician with a special interest in education and lifelong learning. When not drinking coffee and reading Batman comics he is playing with his children.

@andrewjtagg | + Andrew Tagg | Andrew's DFTB posts