The first time you wake in the night sweating over a decision made in the day

Make sure your peer group is a safe space where you can share your uncertainties and develop reflective practice

The story we tell ourselves about our­selves is critical. Through it, we are constantly commenting on our own performance. We don’t hold back on ourselves – our reviews are usually very negative – and the impact on us of the story we tell is extremely important to the way we behave.

In his book The Untethered Soul (untetheredsoul.com), Michael Singer describes the difference be­tween who we are and the person we may think we are, as represented by the internal voice telling us this story.

If you do not know this voice, take a few deep breaths in a quiet room and listen to your thoughts. If you do not “hear” that internal voice, contact me and tell me to increase my medication.

Singer points out that “we” are not the voice; our “self” is the person who hears the voice and listens to the story that voice is telling.

Psychologist Carl Rogers (1902–1987) described the “real self” as who we actually are, and the “ideal self” as who we want to be. He identi­fied that as incongruence between the two increases, people become more distressed.

Our internal narrative spends much of the time speculating about the dif­ference between the ideal of how we would like to be seen and the reality of how we behave. It is worth noting that none of this internal narrative helps us understand how we are seen by others; we only find out what others think of us through the observation and reflection of people we trust.

Waking in the night in a cold sweat about the potential prob­lems arising from decisions you made the day before is a common experience of doctors. As a “junior”, we are hope­fully protected by our supervisors and colleagues from being solely responsible for any decisions. As a “senior”, we are more isolated but have learnt the benefits of shared deci­sion-making and careful communication. We safety net and, through experience, know that probability is a real science that we can rely on to protect ourselves.

But, in the middle of the night, when we wake from our unconscious dream world to the loud and persistent critical narra­tive, we are alone with the story we are telling.

The role of the doctor is full of critical decisions. We are trained to deal with uncertainty, to carry the risks of each of those decisions, and to hold ultimate responsibility for the care of the people we deal with. However, only the superhu­man could always contain the critical internal narrative of the self that carries this burden.

Despite appearances, I am not superhu­man. I doubt any doctor who claims they never wake in the night sweating over a decision they made in the day.

So, how do you cope?

Avoid the problem.

Understanding the world view of the per­son presenting to you is vital. This extends beyond taking a history. It means under­standing who they are and what they think is going on.

Whanaungatanga – getting to know others and sharing something about yourself is fundamental to connection. After sharing your pepeha, or telling something of your back­ground, ask your patient to “tell me something about your­self”. For a familiar patient, ask them to “tell me something I may not know about you”.

Explore this person’s fears and anxieties, and their con­cerns about what they are experiencing. It is not hard to ask these sorts of questions in a consultation: “What do you think is happening?” “Is there something you are worried might be underlying all this?” “What is worrying you?”

Understand what they are expecting from the consultation by simply asking, “What were you hoping to achieve today?” It is surprising how often the answer is about understanding their problem, as opposed to finding a cure.

Apply John Murtagh’s probability framework to differential diagnoses by asking yourself the following:¹

• What is the most likely thing happening here?
• What are the things I must not miss?
• What else might be going on?
• Could this be one of the seven great masquerades (anae­mia, depression, diabetes, drugs, spinal dysfunction, thyroid disorders, urine infection)?

Outside the consultation, seek mentors, source a coach or professional supervisor, and make sure your peer group is a safe space where you can share your uncertainties and de­velop reflective practice.

But first, you save yourself. Share the decision-making with your patients.

In his book The Inner Consultation: How to Develop an Effective and Intuitive Consulting Style, Roger Neighbour describes in detail the process of “handing over” to the patient your own findings and thoughts about what might be happening, based on the story you have been told and the examination you have undertaken.

He talks about checking that the patient agrees with, or at least understands, what you are thinking by asking, “What do you think?” “Does that sound sensible to you?”

Yes, people will sometimes retort, “Well, you are the doc­tor, what do you think?” To which I usually explicitly say that it is important to me that we are in this together.

I add that they should understand what’s going on, so that if I’ve missed something, they can correct me, or if things don’t go to plan, they know they can come back and let me know.

I will sometimes say, “It’s important you know the uncer­tainty and various possibilities here, because we need you to watch out for anything new that might give us more clues, and then you should come back to see me.”

If none of this works, you could always follow the advice of my boys’ school priest Father Pete: “If, son, you wake in the night all hot and sweaty, just roll over, say an Our Father, and it will all be gone in the morning.”

Jo Scott-Jones is medical director for Pinnacle Midlands Health Network, has a GP practice in Ōpōtiki and works as a GP across the Midlands region

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