Shevonne Matheiken (SM): The Psychiatric Trainees’ Committee of the Royal College of Psychiatrists is proud to present You Are Not Alone, a podcast series covering a range of topics on factors affecting the wellbeing of healthcare professionals.
There is a lot more talk about mental health and wellbeing since the pandemic began. However, wellbeing is complex, dynamic and personal. It is not always something that can be solved with just resilience training, or mindfulness. Both those things have its place, but concepts like intersectionality explain why there is so much more to consider regarding the well being of healthcare professionals. This is what we hope to do through our conversations. Episode Two - Shielding Doctors.
Hello everyone, and welcome to this episode on shielding doctors. I'm Shevonne Matheiken, your host for today and I am doing specialty training in dual old age and adult psychiatry in East of England and vice chair of the Psychiatric Trainees’ Committee. It's my absolute pleasure to introduce you to our guests today, my fellow trainees and colleagues, Dr Leanne Tozer, who is an ST6 higher trainee in general adult psychiatry in Livewell Southwest, working in Plymouth, and Dr Raka Maitra, an ST5 higher trainee in child and adolescent mental health services at Tavistock and Portman NHS Foundation Trust in London. Welcome to you both.
Shielding is a new term for us all since the pandemic, a word we previously probably associated only with a battlefield. Some deaneries have also used the words COVID-displaced trainees to refer to this group of trainees affected because of being more vulnerable. Can you tell us a little about how this shielding journey started for you in the first wave of the pandemic? I'll start with you, Leanne.
Leanne Tozer (LT): For me, I was an ST5 doctor working in a general hospital in liaison psychiatry in February 2020. I've just rotated. So the team were aware that I was immunocompromised. I'm immunocompromised because I'm on biologic therapy for ankylosing spondylitis. But I'm still relatively new to general hospital work, which was relatively anxiety provoking in itself because of not having the ability to fight infection effectively even before the pandemic came along.
The team were really supportive and they actually sent me home before shielding officially began as per government guidance. However, when that letter arrived from the government, it was the first time since my diagnosis that I felt really disabled and vulnerable, I suppose, mortal as well. I felt a lot of guilt and shame for not being able to step up when the NHS needed me most.
Thankfully, I was redeployed to community mental health. I was rapidly set up with virtual clinics, my project work began again and I was able to offer to support my colleagues across the organisation. I had a brilliant team and a brilliant educational supervisor. In a way that actually felt more safe because I could just avoid everyone, whether that was for COVID, or for other infection purposes.
I suppose my worries then were more about normality, finding fresh food, work equipment. I never thought I'd be the sort of person who would work from home effectively. But thankfully, I surprised myself and with support from educational supervisor, and actually a wonderful medical secretary, made it happen. I was able to manage a full outpatient caseload with virtual clinics, as well as doing all the other things that I really enjoy.
I remained working from home for 15 months and I'm just getting back to some hybrid working this week. So it's all still very new. The shift back to hybrid working was partially due to vaccination, but also because I rotated into my ST6 year and started working in a secure inpatient setting. Whilst the team are still wonderful, they still include me in everything. It became much harder to build a rapport with patients and I started to feel less clinically effective when working remotely, so I'm happy to be taking that next step now.
SM: Thanks, Leanne. It was absolutely inspiring to listen to that journey. And I'm sure it wasn't easy at the start, because I got reminded of the early days where we had so much information yet it wasn't clear who needs to shield and who doesn't need to. I was working with juniors who had health problems and it was very difficult time, so I'm really happy to hear the good bits of that and about the support you had too. Raka, would you like to tell us a little about your shielding journey.
Raka Maitra (RM): So, I guess now it's quite known that, you know, I have a son who has a medical condition that makes him quite immunocompromised. And so the moment the pandemic had begun, even before the official lockdown, I had requested to work from home, which my team had kindly facilitated. And within days, the official lockdown began. And my supervisor was surprised that I was able to take this decision beforehand. So in a way, you know, being able to anticipate and negotiate working arrangements helped to, you know, create that safety.
Now, the thing was our entire team of community CAMHS at Tavistock immediately shifted to working remotely. So it was a big shift for everyone and some really good practice was put in place. We had short reflective check-ins before team meetings and also devoted time to address remote working, good practice in remote working, challenges in remote working and everybody was feeling those challenges, so not just people who were shielding, as part of service delivery discussions during our weekly team business meetings. And our CEO also had remote meetings with all staff to talk through working arrangements and the difficulties.
So it was quite a shared experience in the beginning, and our teams worked supporting each other. And even before the government had published the list of clinically extremely vulnerable people, the team members had identified fellow colleagues who might be at risk because of age and other factors, and requested our team manager not to assign face-to-face on-call duties to them. Among trainees, we were three trainees who were shielding, one was pregnant, the other was shielding by proxy. And I was shielding as clinically, extremely vulnerable myself and also shielding by proxy because of my son.
So the trainees were very supportive and came up with a plan of hybrid on-calls where the shielding trainees would take all on-calls, and only for face-to-face was really needed, like maybe a 136 assessment or something, or something very complicated where an assessment by your co-trainee or a paediatrician wasn't enough, then someone would go in, and so we were paired with a non-shielding trainee who went in. So all this was great learning points regarding how an organisation and its different parts come together for a positive action. It felt like a shared experience. And in the early days, it felt that all of us, whether shielding or not, shared the same responsibilities and same challenges and had an equal voice in shaping how we work safely.
SM: Thank you, Raka, I think there was so much there which felt really positive and I can only hope that the wider group of shielding trainees, doctors, other healthcare professionals also got that kind of support, in terms of the shared experience, psychologically, as well as practical changes in terms of what you described as hybrid on-calls and sounds like that definitely was helpful and supportive.
We've all probably felt and talked about the impact of this relentless uncertainty during the pandemic. I guess it got worse at some times, but there was always some degree of uncertainty and still is. And I can only imagine that for shielding people it would have been another level of uncertainty. Were there any particular things that you found helpful to cope with that? And I'll start with Leanne again.
LT: For me, shielding probably actually resulted in a reduction of uncertainty in a lot of ways. Everything out of the home was risky and needed to be avoided. So it was all rather pleasantly black and white for me at the beginning. I think that experience was probably my reality, though, due to the actions of my colleagues; they still engaged me, they took me up on my offers of support, and were delegating things to me. So I felt useful. They weren't adopting an out of sight, out of mind attitude, which was great. That meant then that my uncertainty around completing my PDP, getting my workplace-based assessments done was really reduced. So I felt confident about progression with my ARCP, which I know had been a real problem for a lot of my colleagues who were shielding.
So I think in summary, coping for me was about being useful, keeping busy. It helped having a designated office space so work was still vaguely separate from home. And also having a routine. It probably says something about my personality that I quite stuck to a strict routine throughout the pandemic. That was useful in maintaining that healthy lifestyle around work as well as during work hours and maintaining my mental health too.
SM: Thanks, Leanne, that's very helpful to hear that perspective. I'm guessing from the bits I know that it might have been slightly different for Raka, having to go into hospital and in terms of uncertainty so I'm keen to hear your perspective as well, Raka.
RM: I would say the team support, the clinical supervisors’ support and fellow trainees’ support were crucial. At the beginning during first lockdown, we had three urgent visits to the hospital for my son, one of them for an urgent procedure and all these were very stressful. None of us got the virus despite visiting hospital who were catering to COVID patients at the time. Hence, that was a relief and also showed how carefully hospitals were segregating COVID patients versus non COVID patients. I was worried about my fellow trainees who had to go into A&Es during on-calls, PPEs were an issue, but they were arranged fairly promptly. I know not all things everywhere had this advantage.
I knew personally both from the treating teams of my son and also from other colleagues that some healthcare professionals, instead of shielding by proxy, had actually moved out of their houses separating themselves from their vulnerable family members, including children and staying on their own in order to continue to work for the NHS. This was both heartbreaking and admirable. Such inspiring stories, support from my colleagues, being part of an active shielding group that was initiated by some anaesthetist trainees and anaesthetists all contributed to my feeling that I am supported, and I'm doing the best I can.
SM: Thank you Raka and I'm sure your colleagues agree that you absolutely did do that and a crucial part of the team during that and really good to hear about the support network as well. My next question is probably slightly linked to you again, Raka, I mean, I know you as an incredibly resilient person who I look up to, but I still can't imagine that the isolation the fear and just never-ending-ness of it all… was there an impact on mental health?
RM: So I would say Shevonne that, you know, the main worries during shielding as a trainee was about how Health Education England would respond to what's happening and the progression of training and what the arrangement would be, so it was really helpful that our College immediately made plans regarding ARCPs and progression of training and, you know, the information was available on the College website and stuff. Health Education England was a bit slow to respond but a group of trainees especially focused on return to work and supported returned to training formed a shielding panel at Health Education England and organised many activities including very helpful webinars with invited Occupational Health professionals and other people to actively discuss the practical issues we're all facing: what are the different solutions across NHS trusts and across specialties and how can we come up with something that is helpful for most.
Then, you know, many people wrote articles about it highlighting all of that to create that awareness, informal shielding social media networks were formed some purely for doctors and some where it included other healthcare professionals too, so you know, all of them kind of made you feel not so isolated. You felt that, you know, there is support, that you are part of conversations of how things can be improved. All this helped immensely in remaining grounded to reality and planning realistically, which helped.
Now it was clear that irrespective of your specialty, there were common experiences among shielding. At the same time different specialties were differently capable of accommodating remote working, and hence some shielding trainees were left with no option of continuing clinical work. That was a major stressor. There are some anecdotal stories about not enough support, and I'm not too sure if whether GMC or HEE trainee service capture the challenges of the shielding trainees, and especially those of shielding by proxy trainees adequately, even the PTC survey has overlooked this area.
But we need to recognise that those with medical conditions or with challenging responsibilities are our colleagues whose challenges are invisible to most of us. So therefore, it's not a surprise that the surveys did not address the questions as much as was needed to actually have an in-depth understanding of the needs and what needs to be provided. Hence, suddenly being visible also presented its own challenges. But these informal networks helped foster connection despite different trajectories of trainees in different specialties.
And also Shevonne, I just wanted to refer to, during our work of supporting stranded doctors, we found that getting connected was something that really helped in feeling that, you know, you're being looked after and something will be done and you will not be forgotten. And it was a similar feeling to be part of a shielding group of healthcare professionals.
You know, the other thing I do want to mention, which kind of talks about more support is that the term shielding by proxy arose informally, it was not part of official documentation initially. And it then exposed another huge issue of unpaid carers within the NHS. And building on that, the NHS is now committed to support unpaid carers, and HEE has launched e-learning modules on how to support unpaid carers in their professional journeys. So you know, some positives have come, some supports have come, which then, you know, contribute to your wellbeing, and reduce the stress despite the uncertainty.
SM: I totally agree. And that's why we definitely wanted to have this episode on this topic, about this very unique group of people and hear both your voices hopefully representing the wider group. I guess, in some ways, we are luckier in psychiatry, in terms of what you were saying about how much we can be flexible to switch to remote working as compared to maybe like a surgical specialty and things like that. So thank you for that.
And Leanne, I'm also aware that you'd also done lots of useful webinars on shielding in various conferences, our training conference and different platforms to sort of make people more aware and support those in similar situations, to feel less alone and more connected and grounded. And I wondered, based on those experiences, I wondered if you had any thoughts on the social impact. And in terms of your reflections on how the people around you coped with changes in routines and roles?
LT: I think the social impact was really difficult. And thinking about the question that you asked Raka, I think the social impact probably had more of an impact on my health than anything work related, actually. For me, there were very different periods where my mood dipped. And that was particularly in the context of my wider social situation, because that was around not being able to go out the house follow my usual exercise physio regimes that kept me well. So actually, the social dynamic of increasing disease progression and disability was actually the biggest fear that I had at the time.
Being cut off from friends and family was very reminiscent of previous periods of disability related to my condition. And at those times, my husband had to take a step back from his own work in order to care for me. And then during the pandemic, he was once again limited because he was shielding by proxy to keep me safe as well. My mother in particular was extremely anxious about my immune status during the pandemic, as mums are. And I feel awful about how that must have affected her own experience of the pandemic, of not being able to be near her grown up baby, as it were, at such a vulnerable time.
I was really lucky though, that I have a great group of very tech savvy friends, so we were still able to do virtual coffee breaks and pub quizzes and even girly nights in watching films in different locations. So there were some plus sides as well.
SM: That's lovely to hear, Leanne, and I guess it was nice to mention about mums. Raka mentioned earlier about the mum’s intuition to start shielding early and also about unpaid carers and things. So it was lovely to hear that. And good to know that there was some positive memories that you can think back now looking back despite the difficulties involved. Let's really hope and pray that won't be another wave. But say there is one in the future. With the wisdom of hindsight, would you do anything differently? And would you want your employers to do anything differently?
RM: I was just thinking that you know, I feel very fortunate to have received the vaccination. It was very helpful that my husband also was offered vaccination because he's obviously living with two clinically extremely vulnerable members of the family. I'm also aware that many in the shielding group are not having as strong an immunity response to the vaccination as one would hope for so we still need to identify who may need further booster doses in future or not.
I know some shielding trainees have returned to face-to-face work and are really enjoying that, while others who have returned to face-to-face work are facing quite unrealistic expectations from their colleagues and teams. So vaccination may improve immunity but it does not take away the chronic conditions shielding trainees have to juggle with or the unpaid carer roles that the shielding by proxy trainees have to juggle with.
So hopefully we won't be returning to a normal that we knew but create a new normal, where wellbeing of staff is at the heart of the service, and training delivery and hybrid models of remote and face-to-face ways of working coexist to ensure that we remain inclusive working training organisations.
SM: Thanks, Raka. And I definitely agree that we should definitely not lose the momentum that they've got during the pandemic with regard to flexible working and thinking out of the box, I guess, in a way in terms of how we work. Did you have any thoughts on that? Leanne?
LT: Isn't hindsight a wonderful thing? What would I do differently? For me, I think I'd speak up about difficulties, simple difficulties, sooner, things like sourcing fresh vegetables. When I did, my educational supervisor of all people actually sent me the information for a local farm who delivered. I was so worried about feeling beholden to putting people out as we lived off tinned veg for weeks when we didn't really need to.
In terms of work, I think it would be about scheduling breaks. There were long days of back to back virtual meetings. And those breaks in between came to be incredibly important, not only to pop to the loo and grab a cup of coffee, but also to process and reflect on the content of those meetings, those conversations, put together an action plan, and also undertake any of the urgent phone calls and email responses that come into us all when we're in those sorts of events. And previously, we would have done that when we were travelling between meetings. And when you're working from home, you don't have those same luxuries of in between time. And I know I used to moan about travelling beforehand. So it's put a different light on that for me.
In terms of my employer, I think they've been absolutely amazing and I couldn't ask for much more. The only thing that I probably would have liked to have seen was on the initial risk assessment paperwork, where they were grading everybody by gender, social class, ethnicity, the group that was missing was shielding trainees. So I actually came out in the lowest group risk group, even though I was clinically extremely vulnerable. So I think it would have been the early recognition by employers that shielding trainees needed to be accounted for.
SM: Thank you, Leanne. And that brings us on to a very important point about how support needs to be personalised if at all this ever happens in the future, and maybe there would be different situations where that lesson can be taken forward. So the pandemic clearly has highlighted that we may all be in the same storm, but definitely not in the same boats, for example, new international medical graduates with very limited social and professional support networks, or ethnic minority doctors with we've seen unfortunately, disproportionately higher mortality from COVID-19 as clearly shown in the data.
So these examples also highlight how the group is very non-homogenous, the shielding doctors or healthcare professionals group with very different needs, depending on the different conditions that they may be shielding for. So I'll come to you, Raka, on this one. Do you think this made it harder for employees to offer personalised and meaningful support?
RM: So that's a great question, Shevonne, because it brings up so many things. And I think it helps that there was some early research that captured high risk to the black, Asian and minority communities. Our College responded immediately by coming up with a risk assessment plan which could be easily accessed on the website. What this highlighted is that shielding was an official term from the government and referred only to those who had been identified as clinically extremely vulnerable, such as me, such as Leanne, such as my son, but there were others who did not necessarily fall into the clinical extremely vulnerable criteria, but were high risk. The support to this latter group was quite variable really.
The important thing to consider is that identification of the clinically extremely vulnerable was through GP records, so those international medical graduates who may have recently arrived may not have had a GP and may have missed out on being identified as clinically extremely vulnerable. It is also possible that owing to unfamiliarity of the system, the new international medical graduates may or may not have sought Occupational Health assessments or declared their conditions that could put them at high risk. Help seeking is known to be an issue among new international medical graduates so anyone arriving in the country new. Firstly, because as you said, they don't have social networks when they arrive in a new country and secondly, because some may come from cultures where such an openness about personal struggles is not encouraged.
Even in the e-learning modules from HEE about shielding, they highlight that although it is up to the trainee to organise an Occupational Health assessment, the supervisors need to at least discuss that point, just to ensure that trainees are aware. This brings us to the wider question of how aware are fellow colleagues and line managers about the different logistical hurdles that new international medical graduates face and how to help them with acculturation and access [to] help when needed. So yes, intersectionality certainly plays an important role. And this whole experience of the pandemic chaos, the shielding, has brought out many important aspects that as a society, we need to be more mindful of.
SM: Thank you, Raka, really powerful thoughts there and two of the concepts that we're trying to bring and [are] often coming up in most of the episodes are about intersectionality and about allyship. So I am truly hoping that the listeners to the podcast would not just be people affected by the topics that we're discussing, because that wasn't the point. It's also that colleagues and seniors and people making decisions listen to this.
We talk about learning from lived experience of patients. There's also lots to learn about lived experience of different kinds of our own colleagues. And that's what we're hoping these conversations through the podcast would do. Is there any particular positive reflection that you've felt as a result of this whole experience of shielding? I'm hoping you're both coming towards the end of this experience that we are talking about for good. But looking back, Leanne, are there some light moments or anything that particularly stands out?
LT: I think, for me, my most positive reflection is the amount of variety of opportunities that have been made available to me. The shielded trainee springboard scheme by our local deanery has allowed me to undertake a postgraduate certificate in healthcare leadership management and innovation. I've had the time and the support from my trust to undertake a service development project via the Royal College’s Leadership and Management Fellowship Scheme. That really helped me with building connections with the College, with the PTC, with the wider psychiatric training community, which was lovely.
I also managed to develop relationships, again, with the medical school, with third sector organisations locally, which really allowed me these opportunities and working from home provided me with the resources to grasp them. And the new technologically supported ways of working have really facilitated that and I hope we can take that forward.
SM: Thanks, Leanne. That's lovely to hear, you’ve achieved quite a lot, haven’t you, while shielding as well, and Leadership and Management Fellowship Scheme’s great, so happy to hear that you're on that as well. Raka, what were your reflections about any positives?
RM: So I was thinking that, you know, my most memorable experience of during the shielding, and that was mainly because of remote working and that I had more time was the stuff we did together in supporting the 250 international doctors stranded in the country. And I don't know if at any other point, I would have had the time and resources to be able to do that. It obviously meant a lot that because my family was protected, that I felt safe enough, and suddenly had a burst of energy to be able to do all of that and it was a great experience with you.
For me, it always comes back to the point about unpaid carers really, and people with children or family members with complex needs and how flexible models of working can encourage them to retain their professional identities and allow them to continue to contribute in meaningful ways. I was both a healthcare professional as well as a service user during the pandemic and I feel that this blended way of remote working and face-to-face working and training would go a long way in serving the needs of our society and establishing necessary nurturing connections.
So overall, I think that, you know, I'm really amazed by the resilience shown by my colleagues, the incredible way the medical teams have worked looking after my son. The incredibly supportive ways the teams have facilitated my being able to work remotely and carry on with clinical work as long as I was able to. So all of this just shows that, you know, we are all capable of thinking flexibly, thinking compassionately, supporting, coming up with creative ways of making things more meaningful for all of us.
SM: Thank you, Raka. And I can only agree with that 100%. And also not to forget to give a shout out to your brave little man as well, while we're talking about all this. So, coming to the end and looking into the future. With the hope of immunity with the vaccination, I guess I want to ask, do you feel safe enough and ready to go into the new normal imminently?
LT: I think that's a really difficult question. I think for a lot of people who've been shielding the future is actually much more uncertain and anxiety-provoking than the last 12 months have been. The government shielding scheme, as it were, has officially ended. A lot of the practical support that came with that has ended. And unfortunately for a lot of people, the empathy of their employers has also ended with the end of the official scheme.
We're still awaiting evidence of the vaccine being efficacious in those with immunosuppression. But yet those of us who have been shielding are emerging into a world where there's reduced caution, and people feel secure in the general public. I'm often hearing “Don’t worry, I've been vaccinated.”
Having said that, I am really keen to enter the new normal and particularly going back to hybrid working. I'll continue to take the precautions that have become normal to everyone else, while I've been shielding away from society. I'll be sensible. The rules and societal norms have changed what I've locked myself away. And I'm starting to appreciate the experience of our patients when they're discharged after a lengthy inpatient admission, coming out to a brave new world.
SM: Thank you, Leanne. That was a very poignant note to end on, when we're able to connect with our patients in a different way, as part of our own experience, isn't it? And Raka, I wonder what your thoughts were about the new normal.
RM: So I think Leanne has really captured almost every thought in my mind regarding this question. And I think that, you know, moving forward that lots of things were put in place where, you know, the discussion was unilateral, really. And I think that now in workplaces, especially since the NHS is now looking into, you know, caring roles, and we already have things in place for people with disabling conditions and stuff, that these voices need to be part of active planning. And I think this is something that needs to be in focus.
And I think, last year other than [the] pandemic, you know, the atrocity of what happened with George Floyd and all the communication regarding race and diversity kind of has brought out a lot of things that, you know, in our work, we really need to have a much more inclusive mindset to be able to adapt to the different needs that are there, and to recognise those needs and to facilitate them. So I think it's lots of things have, therefore emerged. And I would completely agree with all the great points that Leanne made for a new normal with the more creative ways of working.
SM: Thank you, Raka. And I think that's definitely true. And hopefully all these various voices will be taken into account as decisions are being made. We've done the disability podcast and the same views are made that some good has come out of breaking barriers in terms of the digital momentum and remote working, which were very difficult before the pandemic. So I really hope that decision makers would take on all these points based on the lived experience of our own colleagues.
Thank you Raka and Leanne for sharing your story through our podcast today. I'm positive that it's going to help many other shielding or ex-shielding healthcare professionals to see the shared experiences, both the good ones and the not so good ones, and know that they're not alone. I also hope that it’ll help colleagues and supervisors to have this inspiring group of clinicians to reflect on how to be better allies and how they can help to break barriers of thriving at work despite setbacks posed by the pandemic.
And thank you to our listeners. And we hope that you'll join us for the other episodes in the You Are Not Alone Wellbeing series. We will have more related resources on the links to the podcasts and the RCPsych website when they come out. Thank you.
RM: Thank you very much for this opportunity, Shevonne.
LT: Thank you, Shevonne, and thank you to all of our colleagues who have made it possible for us to shield during the pandemic.