Growth Edge Leadership Podcast: Dr. Paul Molyneux
Laurie Baedke:
Well, hello and welcome to another episode of the Growth Edge Leadership Podcast. I am your host, Laurie Baedke, and this is the first episode of the 14th season. Welcome back. Today I am joined by Dr. Paul Molyneux, who is a former neurologist and medical director, turned executive coach in the UK, whose work explores a question that feels increasingly important in medicine and leadership. What happens when what we do becomes too much of who we are? Paul, welcome to the show.
Paul Molyneux:
Thank you, and what a wonderful introduction. I'm absolutely delighted, Laurie, to spend some time talking about something that I think is really important. It's an increasing area that I come into contact with in the coaching that I do, so I'm really grateful for the opportunity to spend some time thinking about it with you.
Laurie Baedke:
Well, I am grateful that you replied to my email. So for the listeners' context, I was recently researching a new talk that I was developing, and I came across an article that you had written and that was published that really talked about and explored this topic of identity. You've spent 35 years in medicine. What made you become interested in this idea of identity, and particularly the way that our professional identity can begin to consume us?
Paul Molyneux:
So it's a really interesting journey because it began almost by serendipity. I went to a conference in America, the American Academy of Neurology, back in 2016, and for the first time there was a discussion about this notion of burnout. I hadn't even heard of the term, and I don't think that any British doctors were familiar with the notion of burnout at all at that stage. I was horrified to discover that 50% or more of US neurologists met the criteria for burnout.
So I took that back over the Atlantic, back home, and started doing my own thinking and research around what this might mean. At that time, in the hospital I was working at, I was encountering an increasing number of doctors who were finding their working lives more challenging. They didn't have words to put to it, but they just felt lost and had lost that sense of meaning and purpose. So the first thing I was interested in was what's going on at an organisational level. What are the drivers of burnout? Why is it that some of the most resilient people on the planet have such high levels of burnout? So I spent a lot of time thinking about the ecology, the environment we work in as doctors, and the factors underneath that create the environment where burnout is so prevalent. My first focus was really upstream on what's causing it.
As I left my clinical neurology job and left a leadership role, I began to work as a coach, and one of the topics that came up time and time again was around that notion of identity fusion. This is what psychologists call it when our role becomes almost fused with who we are. I encountered so many doctors who, often at the point of retirement, or when they were involved in litigation, or what they perceived as an existential threat, found that the potential loss of their doctor identity was just an overwhelming threat to them. So it set me on a journey to thinking about what it is about our identities as doctors that can get in the way of us thriving in our working lives, because fundamental to my work is how we can explore and understand how clinicians of all shapes, but in particular doctors in my world, can begin to thrive in their working lives rather than survive. I think identity says something really important about how we can map that change from surviving into thriving.
Laurie Baedke:
Dig in just a little bit more on that term, identity fusion. I saw that in the article I discovered, and help me understand it from your research and now from your coaching practice as well. How do you identify that? How does it manifest? And then, once someone has become aware that perhaps they have an over-identification, or a problematic identity fusion, what does that continuum look like?
Paul Molyneux:
Having a strong identity as a doctor is a profoundly good thing at its heart. It gives that sense of meaning and purpose, it drives us to perform at our best, and we get a profound sense of fulfilment in our job. The challenge becomes when it begins to dominate all other identities. We can develop that adaptive response to a dominant identity as a doctor, and when things are going well, it can be in service to us. But particularly in times of stress, in times of challenge, or in times of change, when we just have that narrow doctor identity, it can create real problems that we perceive as a fundamental threat to our sense of self and our sense of being.
One of the individuals I found really helpful when I was exploring this was a professor called Henri Nouwen. He was a Catholic priest who then became a professor at the University of Notre Dame, and later held positions at both Yale and Harvard. He spent a whole career and lifetime asking the question, who am I? He came up with this wonderful set of three cognitive traps, or fallacies, that we can fall into. The first he defined was, "I am what I do." In other words, we're defined by what we do rather than who we are. Ask a physician to tell you about themselves at a party, and they'll say, I'm a doctor, I'm a physician, I'm a neurologist, I'm an obstetrician, not I work as a doctor, I work as a physician, I work as a neurologist. I am.
One of the three frames I use in coaching is to change that, and allow people to say, when they're asked about themselves, I work as a doctor. That subtle uncoupling of I am, from what I do, can be profoundly helpful in people's experience. So that's the first fallacy that Henri Nouwen talked about: I am what I do. The second is, I am what I have. I think what he was talking about was not just the material sense of the possessions we have, but possibly, in medicine, the titles we have, the acknowledgement we have, the professional identity that we have. So we lean into I am what I have, and we cherish all of those professional identities because we've worked so hard for them. The third is, I am what people say about me. That's equally important, because we have that sense of affirmation as doctors. We're really proud of the work that we do. So a complaint, litigation, anything that can challenge that sense of what we feel people are saying about us, can get in the way of our identity.
Laurie Baedke:
I am so appreciative of your sharing that, because each one of those really kind of just hit me in my chest. I'm curious, as you first encountered that, what were a couple of your initial insights or aha moments as you thought through that, or perhaps any other relevant, anonymized examples from individuals you've introduced that framing to.
Paul Molyneux:
So I think what's helpful is to think about why doctors are so vulnerable to those three traps. I think there are broadly two reasons underneath this. The first is that we see medicine as a calling, as a vocation, and as a higher purpose. I'm not saying doctors are alone in having that sense of calling, there are many other professions that have that too, but I think doctors in particular are vulnerable because there's a sense of sacrifice underneath that.
The second is the enormous opportunity cost of training to become a doctor. A couple of hours ago, I was just totting up how long it would take someone to qualify as a doctor. Certainly in the UK, it's about 10,000 hours. In the US, it's probably even longer, because you have a different way of training as a doctor. You have to do a degree first, and then to become a consultant, or board certified, or an attending, is probably another 25,000 hours. So cumulatively, we have invested 35,000 hours in our doctor identity. That's 35,000 hours that we haven't spent being other parts of our identity.
Certainly when I look back at my own training, I would have sacrificed anything in order to qualify as a doctor, and in order to pursue my ambition of becoming a neurologist. It was at times all consuming, and that sense of perspective, that being a doctor isn't who we are, it's what we do, and that there are other parts of my identity that are just as important, got lost. I found that there were times when I sacrificed nearly all other elements of my identity: my relationships, my family, the creative side of me, my attention to my health, my wellbeing. Unfortunately, when you have a very strong identity as a doctor, all of those can suffer and get turned down.
Laurie Baedke:
Yeah, undoubtedly. And also when you mention that front loaded commitment of thirty-five thousand hours to become equipped and prepared to enter your career as a physician, and then the pressure that almost every physician I've ever encountered and been in conversation with is seeing this train coming down the tracks, as it were, of unrelenting pressure and volume of workload, specialist shortages or physician shortages and access issues everywhere, certainly prevalent across the US. I presume it's also significant within the UK, although I'm not as conversant with your unique experience. It's understandable why this compression of pressure around identity, and the need, but also comes with a Hippocratic oath that asks individuals who serve as physicians to put others' needs in front of their own. It's a perfect storm.
Paul Molyneux:
It is a perfect storm, and that whole notion of the patient comes first is hardwired. It's a sort of system program we inherit right away from medicine. The difficulty that doctors have is that we lack an off switch. We lack the ability to say that when we're not with the patient, the patient doesn't come first. So we take our work home with us, we ruminate about work. The other thing I think is really interesting and important is the notion of the arrival fallacy: something that I encounter a lot, and it can cause a profound sense of guilt, because alongside that opportunity cost, that recognition of what we have given up, is a belief that if we work hard, we will become successful, and when we're successful, we will be happy. We don't have a very long period of time with that sense of profound happiness before other things begin to get in the way. There's a phrase, hedonic adaptation, where we're happy for the moment when something great happens, but that happiness wears off. When you've given 35,000 hours to adopt that identity, and then you feel that you're not happy, that can invoke some really profound senses of frustration, irritation, but often guilt and shame, because we think, well, I should be happy, I've done all this work, I thought I was going to be happy. It must be me. Other people appear to be happy. What's going on for me?
Laurie Baedke:
And then, as a high-achieving professional, the inclination is to just work harder, achieve more, accumulate more, and look for that thing that is going to let the feeling last. So let me nudge you toward the metaphor of the identity mixing desk. Tell us where that came from and how it works, please.
Paul Molyneux:
Yes, of course. There's a long history of understanding that identity isn't unified, it comes in different parts. The work of William James, right back in the 19th century, began to explore the fact that we have different domains, or parts, of our identity. Bearing this in mind, I was with my daughter in Stockholm, and we visited the ABBA Museum. My daughter and I are avid ABBA fans, we have been for many years. We were so excited to go to the ABBA Museum and have a wander around, and one of the exhibits there was a mixing desk, and the opportunity to make your own ABBA single. The mixing desk had various elements: the bass, the drums, the lead vocals, the keyboards, the backing vocals, and there were a whole series of different dials you could turn up and down in order to make the perfect, authentic sound, as close to the original single as it was possible to produce. It struck me that there's an enormous similarity between those bits of the mixing desk and our own identities. We are made up of not one, but so many identities, and each person will have a different mix of identities, whether it's life partner, parent, a creative identity, a spiritual identity, a physical identity, whatever those different parts are that make us up. That got me thinking: what happens if one of those elements is too high? If you turn the bass up too high, the whole song sounds awful, and not only that, but those other bits of our identity get quietened, or drowned out.
Laurie Baedke:
I love that so much. Just thinking about how singularly focused we can become, it doesn't make for a diverse and lovely song if it's all just the bass drum, or, you know, here's a bit more cowbell. Let's explore that a little bit. If we actually sit down at our own mixing desk, what are some of the identity domains that we should be considering beyond profession?
Paul Molyneux:
So that's another fantastic question. Before I do that, maybe I'll just think about what it means when all those different bits of our identity are in sync and in resonance. I'm going to come back to the word integrity, because we often think of integrity as being an upstanding citizen, or whatever the American equivalent is of that rather staid English terminology. But actually, the word comes from the Greek integer, which means number. So integrity really means wholeness. When I think about those different elements of our identity, what I'm trying to explore is how we can consciously align those different elements to create a whole identity that is our authentic self. So how do we do that? It sounds like a wonderful idea, but how do we actually do it? I think the first thing is to just reflect on what the different parts of our identity are. This may be something people have given some thought to, but in my experience with doctors, often they haven't. They've never really sat down and said, okay, what are the different things that make up who I am? What's important to me? What are the identities that I hold? So the first thing I encourage people to do is just spend some time writing down their identities. That can take a little time, because a week after we've done this work, we suddenly think of another identity that's important to us.
While everyone's is different, there are some common themes. We obviously have our identity as a physician. Then we often have an identity as a life partner, as a parent, those are common to many of us. Often people have a creative identity that has just lain dormant for so many years, because we haven't had the opportunity, with our busy, overwhelming medical lives, to allow that side of our identity to show up. Then there are our identities as a friend, and that's something else we often lose in service to our dominant doctor identity. I also think about a spiritual identity, and I don't mean that we have to be a person of faith in order to have a spiritual identity. It's more about our sense of something more important than us, a higher purpose than us, and that sense of spiritual identity, our place in the world, and what that means to us, is also really important. So what I ask people to do is just write them down, and then give each one a number out of one to ten.
As you think about your life at the moment, where does each element of your identity sit? Then, rather than trying to dial each one up to ten out of ten, which of course is not what we want, we think about what subtle changes we might make just to dial up the volume on that identity, just to let it show up a little bit more, to be a little less quiet. Then I also ask people to think about what happens under stress, and what's incredibly interesting is that under stress, physicians borrow energy from all of our other identities in service to our doctor identity.
I thought for a long time about how it is that, given that 50 or 60% of doctors meet the criteria for burnout, so many doctors appear to be performing at their peak. There's no apparent loss of performance at work. How can that be? I think the answer is that we borrow other identities. We borrow our time, our attention, and our energy from those other identities in order to make sure that our doctor identity can stay stable. Often what I see is not a slow decline into burnout, which is what you might predict, but actually what a colleague of mine, a psychiatrist in the UK, Richard Duggins, calls the burnout cliff. What he means is that there's one often tiny and seemingly insignificant event that can tip someone over, from seemingly able to function at their best, into a profound level of burnout, which can take weeks or months to recover from. I think underneath that is the fact that when our identity is so narrow, and all those other bits of identity have been crowded out into that one dominant physician identity, we can't tolerate any threat to that doctor identity, and one thing tips us over the edge.
A good way of thinking about this is that burnout often isn't just about doing too much. Often it's about being too little of everything else.
Laurie Baedke:
I had that jotted in my notes, because that was exactly where I was going to nudge you next. And again, that reality that burnout is not about doing too much. In fact, physicians and healthcare professionals have consistently been rated as some of the most resilient and most deeply connected to service and purpose of all professions, and so arguably the most capable of handling enormous stress, enormous complexity, enormous risk. Maybe talk for a moment about the adaptive need to approach this differently, because life is dynamic, and for each of us, through every season or phase of life or career, our identity changes a little bit. Maybe we were not a parent, and then we become a parent, and there are so many different roles that shift. So how about life phases, and any advice for the listener on how to make sure that the way you approach this evolves as your life evolves?
Paul Molyneux:
I love that question, and there's a really interesting extension to the metaphor, because if you are, and I am, not a sound recordist, you'll think about the mix and the phase, and what works for one song is not going to work for the next song. It's not going to work for the whole album. Being attuned to the fact that our identity necessarily changes over the long span of our career is incredibly important. I noticed at certain times in my career, particularly when I was combining a clinical role with a medical leadership role, that my medical identity was significantly dominant, and it took me some time to reflect on that, and to understand the impact it was having, not just on me, but on the people I loved around me. That was a real wake-up call for me, when I came to appreciate that I was living and breathing medicine in a way that wasn't helpful.
Some people come to that view early, and create that adaptive response, which is thinking about what else is important in my life, what else gives me meaning, what would I like my legacy to be. It's not for me to say what someone else's unique identity should be, or where each dial should be turned. It's a really personal decision that depends on the uniqueness of each of us as human beings.
There's another metaphor that may be helpful to briefly mention. I recently read a book by a US physician called Dike Drummond, and he's written a book called Physicians Unchained, which speaks to that whole idea of identity fusion, identity shift, and what can happen around retirement. The metaphor he uses is that you've got this huge box of Lego. You put the pieces together and you create the physician you. But what's left in that box are other pieces of Lego that you haven't used when you created that physician you. When you come to retirement, or you step away, you can deconstruct the physician you, and recreate one that uses some of those pieces you didn't use the first time, almost like a medical metamorphosis into something different.
Laurie Baedke:
I agree, and that makes me think about an article I encountered from Dr. Herminia Ibarra, who's a professor at the London Business School. She, in fact, talks about working identity, and her encouragement, I'm not going to state the quote perfectly, but essentially her exhortation is to think about that identity reconstruction while we're still standing tall, while we're still in a full and robust season of life, while we still have network and social capital to rely on, and we still have some of that identity. That becomes a challenge, because when you're at the top of your game, it's extraordinarily challenging to have any margin to do so. But it's a prudent investment of our time, because then we actually move into that next season of our career, or the next season of life post our working career, and we in fact have a head start, or a little bit of that foundation, that we can continue to advance from.
Paul Molyneux:
So, I mean, I completely agree. I think, certainly when I'm coaching doctors coming to the end of their career, planning for retirement is so much more than the financial planning and all those other elements, getting a sort of life hygiene in order, as it were. It's challenging, because in that whirlwind of overwhelm, our working lives seem to get busier and busier as we approach retirement, and it can create even less space to do the thinking we need to do around what becomes increasingly important. But creating that space for thinking and coaching is a great way of doing that, and it can be absolutely transformational in allowing people to see that transition from our working life into our life beyond work as a really positive thing. I love that whole idea of not retiring from, but retiring into. That's another reframe, because we're not just retiring from it. People say, I've stopped being a doctor. But actually, what we're thinking about is retiring into a new and exciting identity that may not have been an important part of ourselves for so many years.
Laurie Baedke:
Yes, I love that so much. Last question, because our time is running so short. If a listener, or anyone, whether they're a physician or another high-achieving professional, could remember just one thing about the relationship between excellence and identity, what would you want it to be?
Paul Molyneux:
I think I would fall back on the wonderful words of Henri Nouwen, and I would say, I am more than what I do.
Laurie Baedke:
So beautiful. Thank you so much, Paul. This has been a delight, and I already fair warned you before we started recording that I'm probably going to coerce you to come back for another episode, or maybe more, in the future. So thank you for sharing your wisdom, you've dropped so much insight and wisdom today, and I look forward to the listeners being in touch with you. I'll share links in the show notes for reaching out and connecting with your work.
Paul Molyneux:
Thank you so much, I really enjoyed it.
