Lunch times eaten?

At a recent regional meeting of consultant psychiatrists I did something rather irregular. I admitted I frequently take a lunch break. It felt like a confession having just heard dedicated colleague after colleague describe forgoing their lunch breaks in order to pack more and more into their overloaded days. Afterwards at the bar someone asked me if I felt guilty. My immediate response was “no”. After all I have been brought up to believe that the hallmark of a civilised professional life is having time to think. However the question intrigued me — should I feel guilty? Or, more to the point, maybe I had revealed too much by making my psychopathy apparent especially as I often follow lunch with a stroll by the sea.

My explanation for my abnormal behaviour is that I am trying to get some respite from the Fellini film I've been living in for the past few years — since the attempts to run the NHS like Tesco's in the shadow of a law court. It was when we were encouraged to make our child and mental health service more accessible that I first realised I had entered a surreal world, for instead of being offered another branch to cope with the increased demand, we were threatened with being fined if our waiting times continued to rise. This has continued in a kaleidoscope of surreal images. Bills started flying between former friends, and managers bidded for fictional development money. Services have changed their names to give the illusion of progress and been required to devise logos (the best our service could come up with was “always look on the bright side of life”). We had to start paying for the privilege of parking at work. Alongside all the pressure to fulfil contracts and continually make efficiency savings by giving that 1% more is the anxiety created by the increasingly litigious climate. The scape-goating inquiries can push experienced psychiatrists to feel responsible for everything their patients do. On top of this we hear about the unprecedented number of suspensions.

So, perhaps it's hardly surprising that so many colleagues have decided to knuckle down and work harder. The new anxious workaholic culture we've created seems well suited to our nature. I recently heard of a consultant who managed to finish work at 6pm but was so embarrassed to be seen going home that he crept out of the hospital the back way. Yet few of us seem to enjoy being workaholics — many describe feeling oppressed, trapped and undervalued.

Does working through lunchtime actually lead to increased efficiency? I agree with industry in thinking not. Many of us are exceeding our elastic limits and losing any time for healthy reflection. The price of colluding with the ever increasing performance ethic is low morale as described in every issue of Hospital Doctor I pick up. We hear of psychiatrists queuing up to retire early. General practitioners also have high level of discontent and burnout (Roberts, 1997). As Roberts points out, medicine is itself sick.

So why do we do it? It is the myth of medical omnipotence which snares so many of us into believing we should be able to do more and more. Doctors of my generation were brought up in a macho culture where we were somehow expected to be above having feelings, problems, or fatigue. Bosses would typically boast “in my day as a houseman I was lucky to get half a day off a week” which made it difficult to complain and ask for help even though we were working ridiculously unsafe hours. Now society demands that we worship the ideology of ever increasing performance. What better candidates than doctors?

Various superficial strategies to cope with the stress are around. Consultants changing jobs is on the up, as is counting the days to retirement. But few look to the simple measure of recapturing their lunch breaks from the enemy. If we're not careful they could even try to take our toilet breaks as well (perhaps we'll all be supplied with incontinence pads in the name of efficiency).

What do we need to do at a radical level? In our region concern about burn-out has resulted in a proposal for a mentoring scheme for new psychiatrists. At a seminar to discuss setting this up we concluded, ironically, it is often the older consultants who need the mentoring. Younger colleagues, trained how to play the new culture, often seem better at setting limits and working to contract than us older ones.

However, most importantly we need to examine our beliefs about our professional selves in order to develop a more balanced philosophy. So as not to get sucked into the anxiety and psychosis rife in the NHS we need to decide what we can be professionally responsible for and what we cannot. This means accepting we are not superhuman and responsible for everything. Some while ago my own medical omnipotence was leading me to lie awake at night worrying about the waiting times in my service. Then, as on the road to Damascus, the revelation struck — our strategy should be to get managers waking in the night to do the worrying. Likewise, recently when I saw a patient who had set a fire I had to remind myself it was he who lit the fire, not me. As psychiatrists we cannot be held responsible for all the misbehaviours of our patients as though these are all due to their disorder. Alongside all this it is vital to develop a culture among consultants that it is not failure to reveal problems and ask for help. How ironic that as psychiatrists we spend so much time encouraging others to do this. A frequent cause of medicine's illness is emotional constipation.

Getting back in control of our professional lives also means losing the arrogance which denies the human being in each of us that needs looking after (many of us would not treat our cars the way we treat ourselves — at least they get regular servicing and time off the road). Actually, the time has never been better for regaining control. Modern job plans and contracts are much clearer and more specific, defining limits and abolishing the open-endedness about consultant roles, which maintained omnipotence and made it difficult to say no.

So I shall continue taking lunch breaks without guilt. My post-prandial stroll, now often taken with a colleague, helps me wind down from the morning's work. Fortunately, the prevailing wind usually obliges and carries the expletives out to sea.