Trainee stress: treat the cause not the symptoms

IS IT just me? I’m constantly bumping into warning signs. I’ve never slipped on a wet floor, but I keep walking into those signs that say “Warning – wet floor”. Sometimes, the treatment is worse than the disease.

This is the way I sometimes think about current risk-management culture.

Much has been said recently about the stress on young doctors in training, including tragic suicides. While the discussion continues to focus on workload and working hours, and issues related to the trainee-supervisor relationship, we must look more deeply at what specific features in the workplace culture cause distress among our colleagues.

A workplace with a risk-averse, error-intolerant management culture may present a toxic environment for young trainees, already suffering from a surfeit of self-judgement. We select trainees for their diligence, attention to detail and drive to do well. We give them a job that includes unavoidable uncertainty and conditions that can make them error-prone. Then, we watch them like a hawk, swooping down when perceived imperfections are found in their work. It is ironic that some of the solutions proposed to mitigate risk and error stand a greater chance of causing error.

This brings me back to my problem with warning signs. No doubt, wet floors are seen as an occupational safety hazard. But what if the solution – the unpredictably-placed warning sign, sitting below gaze-level – causes more injuries than it prevents?

What if a significant proportion of errors are caused by an overcrowded task list, excessive interruptions and multiple conflicting demands? And what if the proposed solution is more checking and reporting – more checklists, more forms to complete and more frequent interruptions in order to complete the checks? Could it be that the solution worsens the problem?

We now have the perfect storm: a group of self-critical high-achievers, already terrified of making a mistake, already time-poor and task-burdened, being given more and more tasks as a way of “managing risk”, and more and more scrutiny, lest they trip.

Perhaps it’s time to get rid of the warning signs and just concentrate on the slippery floor. Is the floor being washed too often, with the wrong cleaning products? Could we change the floor material, change the cleaning times, or re-engineer the cleaning process in some other way? Do we need more cleaners, or cleaners with different skills?

While cleanliness is important in hospitals, a healthy and competent workforce is essential. Our community spends decades educating and training young people who will eventually become our doctors. We want them to be meticulous, motivated and caring. We can’t afford to destroy their confidence in a cloud of risk-aversion, or drown them in an unending avalanche of tasks. If we continue to do that, tragedies will continue to occur.

Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She is an executive member of Friends of Science in Medicine.

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