Grace Under Pressure – Medicine in the Spotlight

Last night, together with our students and some staff we read the play Grace under Pressure. This is a powerful verbatim theatre work by David Williams and Paul Dwyer, developed from extensive dialogue with working doctors and nurses of different specialties and stages in their careers. It is a “no holds barred, at the coal face” exploration of the working life of young doctors and nurses, their experiences and their thoughts.

First produced and directed in Sydney by David Williams it was enthusiastically received.

Keith Gallasch of Real Time said:

“Williams and Dwyer have structured their expert cut-and-paste of the recorded interviews to move broadly from short utterances, recollections and observations to longer anecdotes, exchanges between speakers, intensely private revelations about suicidal impulses and finishing with a conversation about the final moments of life. The first words come from nurses, then a variety of interns, doctors and surgeons, whether in large hospitals or a small, under-resourced rural one, but in a cumulative weave so that there’s always a sense of many voices and roles, intricately but often problematically connected.”

Gallasch called his review “Grace under Pressure – a call for mutual understanding”.

Indeed, our patients, in their own distress, may have little insight into our working lives. Doctors portrayed in the many television series set in hospitals tend not to have an inner life, even a life beyond the hospital. Perhaps this is in part our own construct – we have painted ourselves as indestructible and omnipotent and have even come to believe it of ourselves.

Grace Under Pressure asks us to face the reality of the overwork, exhaustion, bullying, sexual harassment, burnout, anxiety and overwhelm sometimes experienced in our workplaces, and how we may be really affected by this down to the depths of depression, despair and suicidal ideation. For me it raised the opportunity for truthful conversation, a conversation which could be a catalyst for change.

Some say there is no hope for Medicine, it is too far gone, but I believe there is a beauty there, a joy, a kernel of truth that with nurturing can evolve into something special – the Medicine that we as physicians want, the Medicine our communities need. It may not come in my lifetime, but I have worked with students and young doctors who have recently joined the workforce who have the inner strength and the belief in Medicine to bring about change. Our role as the elders in the profession is to nourish and support them to do this.

Ours was not a theatre production, and I have no doubt professional actors would bring out the pain and rawness in it more effectively. The Medical Humanities Department of Sydney University is supporting us to put out a production here in the Northern Rivers later in the year. The power in our reading was that collectively, students, nurses and doctors, we had a lived experience of the medical workforce.

My part was that of any older doctor passing on knowledge and reflecting on her time as a junior. It could have been written for me – my character even described going down a coal mine as we did as students in Cardiff, bringing back memories of the narrow tunnels of the older mine, the dank and cold, the black faced hard-hatted men going down for what seemed miles in the seemingly battered and creaking lift.

Later they were the men on the leukaemia ward I worked on, the men with pneumoconiosis. I had gained a small understanding of their lives, these men I came to love as I delivered their twice daily IV chemotherapy. My character, as I had done later, worked in a small rural hospital. I had been older and more experienced than she, but also dreaded the crash victims coming in from the highway, felt out of my depth in those emergencies when I was ‘it” and the throngs of staff responding to the crash call in “ER” simply never arrived.

I too had been sexually harassed by not only senior staff but by patients, asked innumerable times, because I was a woman, when the doctor was going to arrive and experienced a low level of bullying. In retrospect, I feel I was fortunate in choosing to specialise in Paediatrics where women were accepted more graciously and there is not a hierarchical culture of abuse of juniors. Children are very levelling and it is hard to hold onto any vestige of ego and pomposity when being peed on. Though some of that was unpleasant at the time, somehow as one of a gender minority we accepted such behaviour – for far too long I now realise, as we are only bringing honesty to the culture of medicine forty years later.

The reading generated some interesting discussion. While the play ends on a very positive note portraying the humanity in Medicine, the joy of connection, I feel that it is important for students that they are “alerted but not alarmed”, that they should not feel they will be eaten alive as junior doctors; rather that through starting the conversation we can support them to encourage zero tolerance of bad behaviours.

It is difficult for junior staff, needing good references to further their careers, to challenge senior staff and this power differential needs addressing. In part, this involves encouraging more senior doctors to examine their own behaviour and that of their colleagues and the deleterious impact this can have on junior staff.

At one part in the play a comment is made that by stopping bullying we may have less suicides but will risk having less competent doctors. This is an attitude to teaching and role modelling that went out with the Ark in parenting, so why do we persist in believing that it will work in Medicine?

In most situations, not only in Medicine, staff perform better if they are respected and valued and if they themselves have a deep respect for their mentors and supervisors. So perhaps we can encourage not only junior staff but senior staff to see this play and join in this conversation. It is only by working together that we can bring about true change.