Stepping into Choices

What is it about choice? Why can it feel hard to make choices, or even to recognise that a choice exists? And to recognise that not making a choice is, in fact, a choice in itself. And that is fine if you're happy with how things are but, if you're not, what is stopping you? And what is the impact?

And what can you do about it?

Firstly, an acknowledgement of decision fatigue. Along with the many other curveballs thrown into the pandemic mix, healthcare professionals have been faced with constant decision-making. Particularly near the beginning, decisions were being made with no evidence or experience upon which to base them, yet with potentially far-reaching consequences. The nature of the decisions has constantly changed, yet not the quantity, and so there is a veil of decision fatigue which has not yet totally lifted.

We also know that a substantial proportion of healthcare professionals report symptoms of burnout, and the recent systematic review and meta-analysis reported in the BMJ (BMJ 2022; 378:e070442) found that burnout was associated with a significant increase in the odds of job dissatisfaction and regrets about career choice, significantly lower productivity, and doubled odds of patient safety incidents. The personal costs of burnout have been well-recognised for some time (including physical and mental health repercussions, breakdown of relationships, lack of self-care and addictions), and this study adds to the increasing evidence of the associated risk to patient safety, with implications for both patients and professionals.

Knowing this, how can it not be a good time to direct some of your decision-making capacity towards your own wellbeing? To make choices that enable you to move forwards with positive anticipation rather than a lurking feeling of dread?

An awareness of some of the following common obstacles to making choices can help get you unstuck:

• control
• why?
• what?
• how?
• fear

Control

In your life, there will be some things that concern you, and other things that don't even come on your radar. For example, you may be concerned about your health, your children, the new Prime Minister. Equally there will be other things in which you have no particular mental or emotional involvement.

You can then break this down even further: within that circle of concern, there will be some things you can influence, and others that you can’t. For example, you have some influence over your health, but the vast majority of us had no direct say in the recent election of a new Prime Minister (I will not even go there with regards to which circle the children fit into...). If you spend your time in the outer circle of concern, you become very reactive – it is essentially an energy dump. The focus is on things that you can’t influence or control; by maintaining your focus here, you can unwittingly empower the things within it to control you. Stephen Covey described and illustrated this principle as below.

Choosing to spend your time in the inner circle of influence allows you to be proactive – you work on things within your control. You get what you focus on, so by drawing your attention to those things that you can influence, the positive energy gained serves only to expand this circle.

Why?

Often when faced with choices, we skip this important step. Why is this decision important to me?

This is for choices big and small. It links into your own unique values. If you don't know your why, or what making this choice will give you, how can you know that it aligns with what is important to you at your core? How will you keep yourself motivated?

Small changes can make a big difference and it is still important to connect to your 'why'. What will carving out time for yourself give you? What are the benefits?

For example, just over a month ago, I started running a mile first thing in the morning. My 'why' was twofold: I was looking for the sense of freedom that I get from being physically fit and this seemed a good start, but also I wanted to feel more energised.

What?

Sometimes you may know that you want things to change, and you may know what you don't want (usually the current status quo), but you don't necessarily know what you want instead. When you don't know what you want, it's difficult to even be sure which choices to be focusing on, and so the temptation is not to start at all. In my example above, my 'what' was physical fitness and a positive start to my day. They weren't 'should' things - I knew why I wanted them and that this was what I could do to achieve them.

How?

Sometimes you can't see the wood for the trees - you know where you want to go, but can't see how to get yourself out of the starting blocks. With the caveat that this may be procrastination masking fear (more of that later), it may be a genuine need to explore your options more fully, and/or to break this down into bite-sized chunks to make it feel realistic and achievable.

My 'how' was to go for a run outdoors first thing in the morning as, for me, the combination of getting my heart rate up, in the midst of green stuff and fresh air, felt the best route to my 'what'. I started with a mile a day rather than 10 miles a day - that would have been too much of a mental and physical hurdle, and I just wouldn't have started. Running gear by the side of the bed so I have a choice in the morning of either tripping over it or putting it on.

On the flip side, sometimes you may feel you have too many options - 'analysis paralysis' kicks in and you do nothing. . There was a famous jam study done in America: a store displayed 6 specialty jams (interesting combos like strawberry & lavender - each to their own) and watched how shoppers behaved – 40% of shoppers stopped to look, and 13% bought one. They then repeated this with 24 jams – 60% of shoppers stopped, only 3% bought one. Too much choice - that's also why my log cabin has only received an undercoat of paint - have you seen how many colour options there are out there?! I will just pick one as soon as I finish this article....

Fear

This underpins everything, and is an article in itself; my aim for today is to raise your awareness of its existence. We can get stuck at any of the stages I mentioned above by fear. Rather like clinical presentations in the young and the elderly, it can show up in a myriad of ways, though the most common is procrastination. Frequently-seen fears include:

• failure - medics are often not very used to failure - to have got to your current position will have required you to be successful in navigating multiple hurdles, not least of all numerous exams. It can also be easy to allow the fear of making mistakes in clinical practice to permeate into your life outside of medicine; the acronym 'First Attempt In Learning' can sound rather hollow when you are used to working in an environment in which mistakes have significant consequences. Even if you recognise the fear, your mind may stop at the word 'failure' without exploring this further - what is it that you're actually afraid of? What is your definition of 'failure'? What is the impact of feeling the fear and going with it? What is the impact of feeling the fear and doing nothing?

• success - may sound counter-intuitive but can hold people back. It's more a fear of change and the associated connotations of that. Your mind monkeys can go into over-drive: am I up to it? If I make the change and it works out, what will people think? Who am I then? What will my life be like? How will I sustain it? What if it goes wrong later down the line? Even some of the positive 'what if' questions can take on a negative hue.

• making the wrong decision - particularly if you feel your current position is as a result of what you would describe, with the benefit of the retrospectoscope, as a 'wrong decision'.

• judgement - of others, or your own judgement of yourself. On a larger scale - if your job as a doctor has morphed into your identity along the way (which is very common) - it can feel very challenging to move beyond your perception of who you are based on your job title. On a smaller scale, who hasn't given a presentation and feared the judgement of others? My natural inclination when starting my running venture was to keep it quiet so that the more exercise-inclined members of my household wouldn't have the opportunity to pass judgement (though I'm delighted to report that I moved beyond this fairly quickly and actually chose the route of shouting it from the rooftops in what I suspect was a somewhat nauseating manner).

In summary, you do have choices. Every day, and in all shapes and sizes. Not making a choice is a choice in itself. Focus your time and energy on what is currently within your power to influence. Think about your why, your what and your how. And if you want to make a change but are shying away from making a choice, get curious - why might that be? And, last but not least, change doesn't happen without action.

I help doctors who are feeling overwhelmed and stuck to design a life and career that they enjoy - get in touch if that is you.