Transcript

MIC CAVAZZINI:               Welcome to Pomegranate Health, a podcast about the culture of medicine. And tēnā koe, David Beaumont.

DAVID BEAUMONT:        Hi there, Mic, lovely to be here. And yeah, great to be involved.

MIC CAVAZZINI:               So, I'm Mic Cavazzini, producer for the Royal Australasian College of Physicians. Can you tell us a bit more about who you are and what you do, David?

DAVID BEAUMONT:        Yeah, sure. David Beaumont. I’m an Occupational and Environmental physician based on South Island, New Zealand. And also a member of the Health and Wellbeing Committee for the College and have a particular interest in people's wellbeing. But within that healthcare professionals as well.

MIC CAVAZZINI: And your interest in professional wellbeing came about from your own “hero's journey”, let's call it. What was the experience that got that fire under you?

DAVID BEAUMONT:        Yeah, that's a great question—a great way of phrasing the question as well. And my journey started with adversity. And it was the 4th of November 2003, a date forever etched on my mind and my family's mind. Because I had a heart attack at the age of 42, out of the blue with no risk factors. And boy, that helped me realize my mortality. And I was put on all the usual cocktail of preventative meds and secondary prevention. And, of course, dutifully took them and realized, looking back, that I actually did little or nothing else. Because my belief in the power of medicine and drugs meant that I was doing everything that was asked of me.

And it was only actually ten years later, in 2013, when I reflected that I was still middle-aged, overweight and unfit. But there was an added factor that I was also unhappy and struggling with my relationships, particularly my marriage, which, on reflection was failing, and so was my mental health. And my doctor said, “You're depressed. You go on antidepressants, you halve your workload, or I'm going to need to report you to the Medical Council”. And that was a real shock for me. And, of course, even more of a shock when my marriage did collapse, and break down.

And I realized that I had no meaning and purpose in my life to fall back on, having spent my life as a devout atheist. I actually had no belief system to underpin this, what it was effectively, an existential crisis happening in my life. So, I started on my journey in earnest of looking at ancient philosophies and also indigenous wisdom. We have to see that health is more than the absence of disease. Not only is health more than physical, but it's also more than psychological, and it's also more than emotional. And of course, that’s when I started practising to this model as well, and it changed the relationship between me and my patients completely, and also changed their outcomes completely.

MIC CAVAZZINI:               You talked about this epiphany at the College’s annual Congress in May. And how it sent you off to understand health as a complex homeostatic system. This conception does challenge some ways in which we deliver healthcare today, and we’ll come back to that at the end of this podcast. But I want to start with a raw take on mental health in the sector that came from the opening plenary at Congress. This was delivered by Professor Neil Greenberg, an occupational psychiatrist with more than 23 years in the UK Armed Forces, including tours in Afghanistan and Iraq. He is Professor of Defence Mental Health at King’s College, London and President Elect of the Society of Occupational Medicine. Neil Greenberg also led development of the World Psychiatric Organisation’s position statement on mental health in the workplace. His presentation was a crisp overview of everything he has learned through rigorous observational and interventional research. I’ve edited this down for our listeners out there. You’re not missing much without the slideshow but you can find a link to every paper that gets mentioned embedded in the transcript. Just go to racp.edu.au/podcast and click on this episode. Here’s Professor Neil Greenberg.

NEIL GREENBERG:            So, if you work in a healthcare setting, you're exposed to lots of very predictable stresses, you're going to see trauma, at least in most places—maybe not if you do dermatology too much—but most places in healthcare settings, trauma comes up and grabs us. Workload pressures, I don't need to tell you about that. It's a busy difficulty working in a healthcare setting.

But particularly since COVID, there has been a focus on what's called moral injury. Moral injury describes the intense emotional reactions that we get when we're put in situations that clash with our moral or ethical code. So, a classic COVID example of that might have been for an intensive care nurse who is used to delivering really good care to one very sick patient. But then during COVID, they had six patients to deal with. So, when an alarm goes off, which patient do you go to if there's two alarms. And at the heart of a morally injurious event is this feeling that, “I should never have been there, this should never have happened, I should never have been asked to do those sorts of things”. And that's true.

But as we all know, sometimes we are put in positions, which are incredibly difficult. Moral injury can occur in different ways, through acts of commission. These are things that I or other people did that really were wrong. Acts of omission in things I just stood by and let things happen. And then acts of betrayal. And that's feeling of being betrayed by people who we feel should have been looking out for us. We did a big review on looking at moral injury, linked to mental health problems. And although moral injury is not a diagnosis—you won't find it in the DSM or the ICD—it's linked strongly with post-traumatic stress disorder, depression, and also suicidality.

I'm one of the lead investigators on a large study we have in the UK of about 25,000, health care staff. It's called NHS check. And this is not just clinicians, this is everybody working in secondary health care settings in the UK, so you know, hospital based. And what you can see here is four different ways that we've measured mental health. There's depression, anxiety, general mental health and trauma there. But we asked the respondents in this study also tell us about their exposure to what we call ‘potentially morally injurious events’. So these are situations that they would have said, “we should never have been asked”. And you can see we've categorized it in low, middle and high exposure. And it's the high exposure group that, by a long way, report poorer mental health. So, there's people in your workplaces who are saying, you know, “this should never happen, I should never have been asked”, they are substantially increased risk of suffering with mental health difficulties.

And when we look in health care workers, what the biggest reason for suffering moral injury? It's betrayal. And actually, we've done some in depth studies of this, because we thought that most of the betrayal would come from my immediate supervisor, you know, “why did my boss asked me to do it?”. But certainly, in the UK, we actually found that wasn't the case. The betrayal felt was at a much higher level. So, it might be the chief executive or the government, or the head of department. And people feel really let down by the whole experience of being in healthcare, by not being able to deliver the care that they really want to do.

And this is, I think, quite important. I'm sure it's similar in Australia as it is in the UK, that there's lots of lots of surveys that often get reported in the media; “97 percent of first year medical students are describing that they’re—”  and they’re always alarming statistics. The ones that say that only 5 percent were disgruntled, I guess, just never make it into the media. They're not interested. And so, you see a lot of this alarmingly high rates of supposed mental ill health. And you can see here in our study, where we've used mental health screening, we've done it professionally, and you can still see pretty high rates; 25 percent nearly, suffering with post-traumatic stress disorder. And if that really was the case, then our health service and yours would have fallen apart because PTSD is quite a significant diagnosis.

So, what we did here is we did a very careful study where we selected people who appear to have these disorders from our sample. And then we did a very careful clinical interview with them to see if they really had the disorders. The way we did it, we used two particular measures, the CIS-R and the CAPS. You don’t need to know about them in detail, but these are gold standard assessment tools administered by a research psychologist in a careful way.

And why this is important? Because you can see here on the screening tool side, you know, 52.8 percent appear to have common mental health disorders. In fact, it's about one in five. So it's less than half when you interview them—less than half. And before you think one in five still sounds like a lot, that's pretty similar to you'd find in the general population as well, healthcare staff are only a representation of the general population. And for post-traumatic stress disorder, the rate is about 8 percent, which is just under double the rate that you would see in the general population. And again, perhaps not surprising, given the sort of work that healthcare workers do. So, I'm not trying to minimize the importance of potentially one in five health care workers having depression or anxiety, but we need to be careful not to get sucked into these media lines of, “Everyone's falling apart.”

We did a study looking at our sample looking at suicidality . And we used very standard measures that we would use in our Office of National Statistics, so these are very comparable with the rates you find in the populations. And what we found is that at baseline, roughly 10 percent of people said that they had thought about taking their life and about 3 percent said that at some point over the last two months they had made an attempt to end their life—these are health care workers—and then we followed them up about six months later. And of those who have said, “I was completely fine, I've never tried to harm myself and the like”, about 4 percent of them had tried to take their own life in the in the last two months. So, you know, those figures are quite small. But I think if 4 percent of our working population are making efforts to end their own life, we should be concerned about that.

And when you looked at the reasons why they were doing this, actually, the biggest reasons that they felt let down, not being able to deliver the care that they wanted to do. So, it's right back to that moral injury is, “How could I have been put in this situation,” and for them when they got hopeless, a suicidal act was what they tried to do. So, I think it's important that we keep in mind about the impact that poor mental health can have on staff.

And actually, the biggest impact in terms of people's mental health at work is the relationship that they have with their immediate supervisor. So, it's not talking about the chief executive or the head of department—that's important from a moral injury point of view, but it's the person who day to day is giving them their duties is telling them what to do and it's instructing them about what they can do in terms of their work pattern.

And the little graphic over here is military personnel in Afghanistan. At this this study we carried out back when I was in the military some years ago and we surveyed troops whilst they were deployed, so they were in difficult environments. And we found in that particular study that around 3 percent of them probably have PTSD, which is not surprising because they're in a war zone. But you can see the lower group there are people who felt their immediate supervisor was supportive. And the higher group, which is 10 times aims higher, were the people who said, “my immediate supervisor wasn't looking out for me”. Now, for those of you interested in numbers, you will hopefully say, “But that's association that's not causation”. And you'd be entirely right. But you find those similar sorts of figures and lots of other samples. And we found very similarly in our healthcare samples as well.

The other paper here is actually a study that went on in New South Wales, where they trained up fire station managers to have psychologically focused conversation with firefighters and they did a randomized control trial. And so, in some of the fire stations, they trained up managers and others they didn't. And the outcome measure they used was looking at sickness absence. And because they published it in The Lancet, it was in pounds and not dollars that the figures were reported. And they found for every pound spent on that training program. For managers, it saved 10 pounds in sickness absence in the following six months. And that was a randomized control trial, pretty small, but again, showing the really important impact of a supervisor, being able to have what we call a psychologically savvy conversation with their staff.

[So, when COVID kicked off in the UK, I was asked to set up a strategy for mental health in what was going to be our London major, big, huge hospital that was going to have thousands of patients. And thankfully, it didn't quite happen that way. But what we needed to do very quickly was to make sure that healthcare staff could also talk to their team members in a similar way. So, we developed this intervention called REACT. And REACT stands for Recognize; Engage; Actively listen, Check for risk and Talk about a specific plan. Basically, it was a one hour training package—because as you remember, everyone was incredibly busy—which gave a bit of information, and then got people practicing how to have a conversation about mental health.

We did a smallish evaluation of that, which we published in Occupational Medicine. And we found that before they went on this training course, over half of the supervisors didn't feel competent to identify, speak with and support a colleague who had mental health problems. One month later, nearly 85 percent felt confident. So, this was a really bite-sized intervention—eventually ended up being delivered over Zoom for all the reasons that you'll know. So when you think, “Oh, we haven't got time to train up all our supervisors to do these sort of conversations”, this is not very much for what is likely to be a useful impact down the line.]

This is important because of what we call type 1 and type 2 traumas. So, the type 1 trauma is the major incident, you know, a shooting at a shopping mall, for instance, or the fire or a terrorist incident. Those type 1 traumas take someone who was functioning pretty well and then within a few days, a few weeks afterwards, they're not functioning very well at all.

But healthcare particularly is much more likely to expose staff to what we call Type 2 traumas, which are these chronic exposure to trauma as part of their day-to-day situation. So, if you work in the emergency department, if you work in maternity, if you work intensive care, trauma is what you do on a day-to-day basis. And what happens is, over time, people take on a huge dose of trauma. And I know that sounds a bit strange, but that's what happens, and they go gradually downhill. And so, six months after Neil started in this department, he was a happy go lucky total person. Someone says, “Right Neil, we're going to move your chair from over there to over there”. And Neil goes, “Right, that's it. I'm out of here!” And everyone goes, “That's a bit strange. We're only going to move his chair.”

But Neil has been going gradually downhill for a while now. And every time someone said to Neil, “How are you doing?” What's he said? “I'm fine”. And you will know what fine stands for, which is “Fucked up. Insecure. Neurotic and Emotional”. So, Neil was trying to tell you, but you just weren't listening. The reason I say that is when we do a check on staff, when we have a conversation and someone says they're fine, you haven't done a mental health check. You've passed the time of day, that's all you've done.

So, what can you do to make things better? The key thing that managers can do in the short term is to apply what we call the PIES principles. Basic common-sense principles that a supervisor, a shop floor supervisor, can use in the aftermath of someone going through a tough time and reacting. They were developed in military settings back, a years or more ago now. And the Israeli military did a study after the first Lebanon War in 1982. They had lots of stress casualties on the battlefield at the time, and they applied the PIES principles—I'll run through them in a second—and they did a 20 year follow up study—and you don't get many 20 year follow up studies, as you'll be aware. And they found that the more the PIES principles were applied at the time that someone was acutely distressed, the better the outcome was 20 years later on. So, these are good, general principles.

So, the first principle is the principle of Proximity. So don't just send people who are stressed home. People who get sent home, think that everyone's talking about them and they think people don't trust them. And of course, who knows what their home situation is like? So proximity means keep them close to you. Reassign their duties if they're, you know—don't let them do safety-critical work, if they're not ready for that, and try and give them some more support. And most people will get better, and they'll get better pretty quickly. I stands for Immediacy, and immediacy means that if you've got people who are gradually going downhill, don't just have one of those “fine” conversations. Get beyond fine, have a proper conversation with them, find out what the problem is, and see if you can fix it.

Expectancy says that, actually, people who go through traumatic situations should expect to develop some symptoms, it is completely normal, as we said, and most of those symptoms will get better. But the other bit of expectancy is if those symptoms don't improve, then we will make sure that you get to the right sort of help. And the last principle of Simplicity means that if you've got people who are acutely distressed and, say they're desperate, and they can't do a particular procedure, and they're very stressed and they’re anxious, because they've got to be asked to do the procedure again, tomorrow, those anxious people don't need 12 sessions of cognitive behavioural therapy for anxiety, they need to learn how to do procedure properly. So simple things make a huge difference. The American military have got a great phrase, which is “three hots and a cot”. That basically means if you take someone who's acutely distressed, and you give them three good meals, and a good night's sleep, they often wake up thinking, “Gosh, I feel a lot better”. So, the simple interventions like that can make a really big difference.

For those of you who scuba dive, you will know that when you scuba dive you buddy people up, you do it for safety. We work in a challenging, risky environment, we should buddy people up in the same way. This is data from military peacekeepers who were coming back from deployments to horrible places some years ago. I use this for my MD thesis many, many moons ago. And we asked them who did you speak to about your experiences. And 97 percent said, “I spoke to people like me. I spoke to my buddies, that's who I talked to. Only 8 percent went to health or welfare services, and our military has a pretty reasonable health and welfare set up. So we know that most people seek support from those around them. And it's important, therefore, that we keep in mind, we need to create opportunities for them to seek that support. I suggest that if you have a team that's doing really challenging stuff, one of the things that you should be trying to do is to provide forced opportunities to buddy up. So, “Sandra. Bill. Today, you're obviously going to do your shift, but actually part of your job should be, every hour, you should check in with each other. I know you're busy, you got lots of things to do”, but actually by buddying people up, you may force opportunities for people to have conversations.

And so, one program that aims to do this, and I will say, I'm conflicted here because I was one of the designers this program and I promote it, is the TRIM program. And this is not the only example of peer support, there are plenty of other peer support programs around. And the idea of TRIM is that you take people in the workplace, who are people doing the doing, and you give them over a couple of days the skills and competence to have a psychologically informed conversation with their colleagues, particularly those in Type 2 rich environments where there's lots of trauma. And what they're able to do then is to is to use this these 10 risk factors.

Now, these risk factors, we know from the evidence base, are all indicators that someone might have a long-term difficulty there. They're not diagnostic, you're not trying to train people over two days to become a sort of mental health clinician. But if people are scoring on lots of these risk factors, and they stay persistently scoring on them, then the indication is they are likely to go on and develop a formal mental health problem. And so, what you do on the TRIM courses, you get to practice having these roleplay sort of conversations. And so that means that when they're coming to do it for real, they’ve practiced the skills. This is not kind of a pink and fluffy approach, it's very much about someone who's a bit like you, sitting down with you, and having a structured conversation, to try and identify if you've got difficulties.

And if you have, the first thing you do is let's try and manage them. Let's try and make the workplace a bit less stressful for you temporarily, let's try and find some ways of getting you more support, don't leave you in the room working by yourself. And often those simple things will make a difference, and we'll come back to that. And the evidence for peer support is pretty good. We've now published about 16 papers on TRIM, academic papers. We've got a randomized control trial in there, which was the use of TRIM in a hospital setting in the UK. And there's now about 70 NHS Trusts that use TTIM in some form or another. And overall, peer support is not penicillin for trauma, it won't prevent everyone from coming unwell, but it seems to help people access social support, it seems to help with health-seeking. And importantly, it does seem to make an impact on sickness absence as well.

But one thing we shouldn't be doing, absolutely shouldn't be doing, is the use of what's called psychological debriefing. The idea many, many moons ago was that if you had a very trauma rich environment that you want lots of people like me hanging around to talk to staff about you know how terrible it is, and tell me what the worst bit is. So, when there's a major disaster, certainly in the UK, the media often say, “and trained counsellors are now in attendance”. And they you can see why there is this sort of concept that having a mental health professional might somehow make things better.

But this comes from our NICE guidelines. And NICE specifically say do not do psychological debriefing. And NICE, very rarely say don't do something. I was part of the NICE guidance development group, and we had some papers about the use of dolphin therapy for PTSD. So, dolphin therapy involves going swimming with dolphins if you've got PTSD, and the claim is that it might make people better. The evidence was a bit shaky. To be fair, I would quite like to go swimming with dolphins, but I don't think it probably gets people better from PTSD. NICE does not say, “Don't do dolphin therapy”. NICE just doesn't really mention dolphin therapy at all, because it's not something that NICE has got any evidence on. The reason NICE say don't do it, and your Australian guidelines also say don't do it, is that when you take two groups of people, one who get debriefed psychologically, and one who don't, the people who get debriefed psychologically do worse. So that's why they say don't do it. In a military sense, you want to keep us away from the troops to start off with who may have symptoms, but they're normal symptoms. If you go through a terribly traumatic situation, and you're not sleeping well for a few days, and you had the odd nightmare. That is perfectly normal in most cases, and in most people in those situations get better without the need for any professional intervention.

So, what NICE say you should do instead is to actively monitor people, keep an eye on them, check in with them, or about a month after a trauma. And then if they happen to be unwell, there are evidence-based talking therapies, trauma-focused cognitive behavioural therapy, and EMDR, which stands for eye movement desensitization and reprocessing. Both of these are evidence-based talking therapies, 8 to 12 sessions is usually effective for people who will well before a traumatic incident. And they work. The big problem with them is that people don't get access to the treatment and they don't come forward and get it. And by the time they do come forward, they've often become depressed, they become a bit thirsty with the alcohol, they've told their boss what they think of them, which may not be the best thing, their spouse has left them and their self-esteem is in the floor. So, you can get rid of their trauma symptoms, but you can't replace all those things, the things that we call secondary losses.

And then moving forward is we're trying to think not just about avoiding people becoming ill. But actually, we're trying to foster this concept of what's called Post Traumatic Growth. Now, this is kind of summed up back in the Nietzsche phrase of, “Anything that doesn't kill you makes you stronger.” I don't fully subscribe to that, but the basic idea here, and this absolutely comes out of our NHS-Check study, is the vast majority of people who worked during that really difficult time actually, when they look back on it, and they use some scales, they say they feel rather proud about what they've done. And they feel that, actually, they can cope with that, they can probably cope with things that are pretty tough. This doesn't get talked about by the media either, because it's obviously far too positive. But what you should be aiming to do in a workplace is not just to avoid illness, but to try and foster psychologically more resilient individuals and more resilient teams.

So how can you do this? Well, one thing as you can do is to say, “thank you”, and not a very difficult intervention. But you will be surprised at the number of times that when staff fill out our surveys, they say, “no one even gives me any appreciation, or that's what they feel anyway”. So, a proper meaningful, “thank you” makes a difference. Another thing you can do is to make sure people take their time off. If they're coming back to work, or if they're—if they've just finished a really busy shift, or you've gone through a particular crisis, people need time to recover. And again, none of this stuff is rocket science. But the evidence is really strong, that people who take the right amount of breaks actually are more likely to sustain themselves.

And then back to this concept of moral injury we talked about. And the key thing about moral injury is people develop narratives, they develop stories where, “it's all my fault”, or “it's all someone else's fault”. And that leads them to have these festering negative emotions and thoughts. And what that basically means is that we need to have meetings and groups, reflective practice, that don't just talk about what went wrong, how do we fix it, but talk about the impact. So, if you've got a group of midwives and they're that unfortunately babies die, as we know, and that's tough—there's no way you can not make that tough. And we need to make sure staff are briefed on that in advance. I don't know if you have the same resuscitation training here, but we will have a Resusci-Annie doll. Do you have a Resusci-Annie? But Resusci-Annie is the doll that you do your practice on. And I feel bad about saying this, but Resusci-Annie needs to die sometimes. Because every time you do the training, you do it and they go, “That's really good. They survived”. Well, you know better than I do, if you're an out of hospital cardiac arrest, I think you have a 10 percent chance of getting people to come round. But yet, we always train for success. And sometimes we also need to train for the realism that, actually, even when you do the right thing, bad things can still happen. So, we need to prepare people to talk about the impact of what the work that we do, and not to try and live in a rosy world, which pre-disposes us to then think there's something wrong and it shouldn't have happened. And so that's what reflective practice in terms of moral injury, talking about the impact, about how hard these things are.

What we don't need, though, is more screening. So, I'm not going to go on to this at length, because there's a talk in itself, but there is sometimes a feeling amongst trauma-exposed populations that what you need to do is to have mental health screening. You know, “we could screen people, we could select them out and find them”. There’s no evidence this works. This is an editorial that I wrote with David Forbes, who heads up your Phoenix Centre for Trauma in Melbourne, published just recently. Although it's really attractive, the bottom line is mental health screening within organizations just doesn't work. And it's not a good idea. It seems like it should be a bit but trust me, it's not. What is useful, though, is to allow people to have opportunities for them to identify themselves. If they might have difficulties, they can do that confidentially. no one's going to know. And it's their choice, then, whether they want to access help.

And then the last piece that I'll leave you on, is where you do get people to get mental health care, you want to make sure that mental health care is occupationally focused. And by that I mean that the key thing is the clinician needs not just to say, “Well, my job is to deal with symptoms”; the clinician needs to say, “my job is to get you back to work or keep you at work”. The evidence is really strong that if you have clinicians who have keeping people at work as a treatment outcome, guess what, people are much more likely to stay at work. So, we need to make sure that keeping people at work is absolutely something that clinicians should be aiming for.

So, putting it all together, we need not to over-medicalize normal distress in the occupation that we do. There are inevitably going to be some hard situations and they will happen. However, what we really do need is to nip things in the bud. If you can have psychologically-focused conversations with a supervisor or with a peer, you can spot something early, often you can solve things before they then become festering and cause you to have frank mental health difficulties. And certainly, in our health care setup, the term resilience now is turning into a bit of a word that people don't like because staff feel they're being told that they need to be more resilient. And so, we need to stop thinking about resilience at an individual level, we need to think about it at a team level. So, we need to foster psychologically resilient teams. And this is a cheesy phrase, but resilience often doesn't lie in individuals, it lies in the bonds between them. So, the more that you can do to have peer support, to have supervisors to have those conversations, to buddy people up stuff; that actually isn't complicated. You will end up with a group of people who when something really bad comes to them and they face it, they'll be all able to do it in a much more psychologically resilient fashion together, rather than individuals. So, thank you very much indeed for listening.

MIC CAVAZZINI:               Well, David. We heard from Professor Greenberg some very specific interventions to build resilience in the workplace. You’re on the College’s Member Health and Wellbeing Committee, which recently launched a new wellbeing framework. What level does that document operate on? And what did you make of Professor Greenberg's lecture?

DAVID BEAUMONT:        I have to say, the opening plenary was the highlight of Congress for me and for a lot of people I spoke to. Really clear about what healthcare organizations can do for their doctors and other health care professionals in the workplace. Our personal health is as, as doctors, as members of our College, is dependent on multiple levels of the system. And interestingly, when we originally set up the Member Wellbeing Committee in September 22…

MIC CAVAZZINI:               Not that long ago.

DAVID BEAUMONT:        No, no, no, we've not been going long. And it's taken us until this year, really, to work out what our role is. When we first started, and we started to canvass opinion from membership, we got some quite vehement responses to the idea of wellbeing for the College members. Things like, “Don't tell me what to do about my health and wellbeing, sort out what my hospital does and what the College does”. And we kind of scratched our heads and thought, “Well, it’s a fair point”. But of course, it's not either-or, it's both-and. So, it became a matter of looking at roles and responsibilities. And the role of the Member Wellbeing Committee, we've realized, is to help individuals to take control to take to become empowered to manage their own health and wellbeing.

Whose responsibility is the hospital setting? Well, that's the hospital's responsibility. And a key role for the College is advocacy. We can advocate for what they need to do. And the first thing they need to do is all hospital administrators need to listen to Neil Greenberg's plenary lecture because it's all in there. It’s totally all in there. And what does the College need to do? Well, absolutely, the College needs to take responsibility for its role in in looking after the membership and, as the Wellbeing Committee, we can advocate for that to happen within our College and help our members take responsibility for the bit they can control, absolutely, which is their own health and wellbeing.

MIC CAVAZZINI:               The analogy that came to my mind was, reducing the carbon footprint of your house during a cold winter. You can sign up to a green power plan, which sources its energy from renewables. But that's very hands-off, top-level stuff. Maybe that's the government policy or the College's frameworks. At the level of the workplace, let's say, out in our allegorical building, you want to install double glazed windows and better roof installation. But then there's the personal level of responsibility which you've described. That’s the equivalent of putting on a jumper and turning the TV off when you're not watching it. So, every little bit makes an incremental contribution.

DAVID BEAUMONT:        Yeah, absolutely. And I was disappointed and saddened to see that only 8 percent of doctors will approach health and welfare services. And that's borne out exactly in the College's own experience. We have the support services that every member has free access to and it is very rarely used. I'm going to say that I've used it, I've used it on a couple of occasions and found it excellent. And there is a misconception that you only use support services when you're in crisis, which is a total misconception. The idea of support services is to stop you going into crisis.

MIC CAVAZZINI:               So going back to your own presentation to Congress, it was a little more personal and more philosophical. You cited an article in the Disability Health Journal 2021, where Gloria Krahn and colleagues went through the various ways health has been defined over the years. They start with the World Health Organization’s 1948 definition that health is “a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity”. And while that definition did broaden the concept of health beyond the body, the authors say “use of the phrase “not merely” also implied that having a disease or infirmity would preclude good health”. So, yeah, sometimes you find illness in the absence of objective disease or subjective health in the presence of disease. And apparently Australia’s National Health survey of 1983 reported that two thirds of people over 85 rather their health as good despite having a number of comorbidities. So, say a little bit more about that.

DAVID BEAUMONT:        Yeah, absolutely. I mean, even the WHO definition of health, “a state of complete, physical, psychological—”, I mean, it actually precludes even having a disability or having a disability from birth. Because, yes, absolutely, you can have an illness, you can have a disease, you can have a disability and still experience health in your life, health and wellbeing. I particularly like Felicia Huppert’s definition of wellbeing as being the combination of feeling good and functioning well. So healing in that respect is about getting the most out of life and fulfilling your potential as much as possible despite illness, disease, infirmity, disability.

MIC CAVAZZINI:               And there’s an outline of this systems theory in the March 2019 edition of Frontiers in Medicine, co-authored by no less than 16 academics from around the world. Lead author Associate Professor Joachim Sturmberg, a GP academic at the University of Newcastle. One example that Dr Sturmberg and colleagues go into for this systems theory is mitochondrial dysfunction. Yes, it can come about through genetics and development. It’s associated with oxidative stress and bad diet too. But psychological stress can also create these conditions via the hypothalamic-pituitary-adrenal axis and autonomic nervous system. Is it fair to say that Western medicine ignores this sort of holistic picture? I've always been lucky to find clinicians who did ask the right questions. They might not have an hour to talk through the emotional stressors, but they can usually refer me to someone that does.

DAVID BEAUMONT:        I, personally, don't use the expression holistic, because I think it's become tainted by a certain movement. In itself, I don't disagree with that movement but actually, I think that we need to reclaim a more whole person view of health within medicine. So, in the 1970s, Aaron Antonovsky put forward what was then a revolutionary idea, the salutogenic theory of health. Rather than the pathogenic, which is the origin of disease, salutogenesis means the origin of health. But what he said was that the events in our lives, lead us through the mechanism and the stress, to a state of dis-ease. And that dis-ease can result either in illness without obvious pathology or can result in pathological disease. This is now well captured in life course theory, in these studies on adverse childhood experiences, and we know it to be a fact.

So, there is one mechanism that underpins all of this, that might actually start to tie it together. And that is mitochondrial dysfunction. And what the research is now showing us is that—I mean, particularly easily if we look at the metabolic disorders like insulin resistance, obesity, prediabetes, diabetes, the mitochondria are sick. But they are also in cancer, and they are also in Alzheimer’s and other neurodegenerative disorders. And what we're doing is overwhelming the mitochondria either with stress hormones, or with too much food, too much energy, and we’re throwing out homeostasis. So, this is systems within systems within systems. What happens within our lives, influences our organs and systems, influences our cells, influence our intracellular organelles, particularly the mitochondria. So, I actually talk about creating life homeostasis. Not too much, not too little, keep it within parameters and find homeostasis.

MIC CAVAZZINI:               Yeah, that's a good way to bring it all together. It ties into again, another quote from this paper that Western healthcare has focused on, as you say, non-health and disease and therefore is seen as a repair shop. But the authors of that paper add that “Managing diseases, mostly regarded as the essence of medical care, ought to be guided by the patient's goals and aspirations—not all of a person's diseases need every available biomedical intervention, and some interventions required to achieve a person's goals and aspirations will be out of the scope of the traditional medical model of patient care… pragmatically, asking: “What are your goals for your care, and how can I help you?” Is it all about expectation management?

DAVID BEAUMONT:        Yes, it is about expectation setting at the start. My first question of my clients, my patients is, “What is the greatest hope for your health?” And I work very much on a partnership model with my patients, I don't take responsibility for their health, because there is usually so much more that they can do for their health than I can by the prescribing, that I don't do anymore. Can I throw in a wee anecdote here? And that is, I saw a young woman, she was probably late twenties. And she’d injured her back, nothing serious, but she got a bit of chronic pain. And she was well known for being an awkward patient. And I had a session with her and she was obstructive in in the consultation. And at one point, I just put my pen down. And I just said, “What is it that you want out of this?” And she said, “I just want to be able to ride my horse again”. And I said, “Oh, okay, well, that's great. There is nothing that I have found out about you or reading your notes have found from your imaging that says that you won't be able to do that. Why don't we have that as the as the focus for your rehabilitation, not your return to work, because if you can get your on your horse and ride your horse, then of course, you can get back to work as well”. Completely different consultation from then on.

MIC CAVAZZINI:               And then you're eliciting more meaningful feedback from the patient.

DAVID BEAUMONT:        Well, you're also seeing the patient as another person, not just another patient. And that's the risk. And obviously, the more patients you see in a day, the more likely you are to treat them as just another patient. And one of the things that comes out of burnout, you become cynical about patients. And if you're seeing 70 patients a day, how can you not get burnt out? So, there's a there's a whole system's discussion about health care systems to fit in that and who should do what, and the delegation of tasks away from doctors to people like health coaches, for instance. Another conversation for another day.

MIC CAVAZZINI:               That was David Beaumont ending this episode of Pomegranate Health. If you want to read more from him, at our website I’ve provided a link to his book, titled Positive Medicine. Thanks also to Professor Neil Greenberg, for allowing me to share his lecture with you. Again, there’s a transcript embedded with all the research citations at racp.edu.au/podcast. You’ll also find musical credits, and the names of all the College members who generously provided feedback on early drafts of this podcast. 

At the web page racp.edu.au/fellows/wellbeing is information on how to provide support for a colleague in difficulty, and an eLearning course on caring for trainees under your supervision. There are also details for the College’s Employee Assistance Program with partners TELUS Health. They offer phone support 24 hours a day to all College members who need it. The number in Australia is 1300 361 008 and in Aotearoa-New Zealand it’s 0800 155 318. And if you need crisis support right now, please don’t hesitate to call Lifeline. Their number in Australia is 13 11 14 and in Aotearoa-NZ it’s 0800 54 33 54.

I’m always happy to hear feedback and story ideas through the email address podcast@racp.edu.au and. Please get your peers to subscribe by searching for Pomegranate Health in Apple Podcasts, Spotify, Castbox, or any other podcast aggregator. The RACP founded on the country of the Gadigal clan of the Eora mob. I pay respect to the generations of healers and storytellers that have come before us. I’m Mic Cavazzini. Thanks for listening.