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A POWERFUL lesson for Dr Caroline Johnson came from a senior partner early in her first month on the job in general practice.
Dr Johnson had had to deal with a traumatic emergency situation in the morning, and her senior colleague then asked her to join him and his wife for lunch at a restaurant nearby the practice.
Dr Johnson, who is now a member of the Royal Australian College of General Practitioners Expert Committee – Quality Care, with an interest in mental health care, said that the lunch started with the partner saying “well, that was a crappy morning, wasn’t it?”
“I was made to feel welcome to talk about it and in an environment where I was removed from that pressure. It was a very powerful experience for me.”
Dr Johnson’s comments come as experts write in the MJA of the importance of senior doctors in “leading action” to help prevent burnout in their younger colleagues.
In a Perspective, Professor Michael Baigent, Professor of Psychiatry at Flinders University, and Dr Ruth Baigent, GP and part-time medical educator at the University of South Australia (UniSA), wrote that burnout was highly prevalent among doctors and was a risk factor for mental illness. While they said there had been some state responses, and several medical colleges had made efforts to deal with the issue, there had been no effective national response.
The authors pointed to a 2013 beyondblue national mental health survey of doctors and medical students that found that young doctors aged under 30 years were at greatest risk of burnout. These young doctors were most likely to report high exhaustion (48%) and high cynicism (46%). Exhaustion, cynicism (role negativity, feeling callous and detached) and professional efficacy (self-evaluation of competence and achievement) were the three main factors that constitute burnout, the authors said.
“Avoiding burnout is a shared responsibility: it is too easy to blame the system and, likewise, for the system to blame the doctor,” they wrote. “A certain amount of work hardening and experience is necessary, but perhaps older doctors look back on their pressurised junior years through rose-coloured glasses and see it as a rite of passage.
“Is it not time for senior, influential and experienced doctors to lead action on behalf of our young apprentices?”
Professor Maureen Dollard, Professor of Work and Organisational Psychology at UniSA, however, said that the responsibility for increasing burnout among young doctors lay squarely with the health system.
“The overarching impression of the work in the medical profession is that it is too much of a burden for a single person,” she said. “There are so many factors that are impressing on a person that it’s just really no wonder that people are becoming distressed, burning out and sometimes [dying by] suicide.”
Professor Dollard said that capitalism had a lot to answer for in regards to increasing workplace pressures.
“If you’re not providing enough resources, it can lead to exactly all these problems that are [explored in the MJA article],” she said. “It’s not because people are not working hard enough; if there is excessive and unrewarded paperwork, then where is that coming from? These are organisational problems and this is both a societal and public health issue.”
Professor Dollard said that attention should be paid to how the system can be modified to provide an environment where medical professionals can work effectively and sustainably.
“There is no time for care,” she said, noting that the nursing profession had expressed the same concerns. “For community doctors, with a 6-minute timeframe to consult with a patient, it’s just not really long enough to understand their psychosocial needs.”
Associate Professor Charlie Corke, senior intensive care specialist at University Hospital Geelong, said that there was growing recognition of the severity of burnout among younger doctors, but warned that the prevalence of burnout was likely to increase.
“The significant overproduction of young doctors will make the competitive side of things … worse,” Professor Corke told MJA InSight. “There will be a profound amount of competition for jobs, and I think there will be more reluctance to talk about burnout in the future or to show any sign of weakness.”
A further issue, said Professor Corke, was a lack of recognition of patient death as a normal part of the medical process.
Professor Corke said that he appeared on the SBS television program Insight in 2017 alongside young doctors discussing young doctors’ wellbeing and was concerned to hear young doctors blame themselves for what appeared to be natural, inevitable deaths.
“The doctors blamed themselves and felt that had they stayed on later, had they been cleverer … the patient wouldn’t have died at that time. They took it as their personal responsibility to prevent death,” said Professor Corke, who is also President of the College of Intensive Care Medicine of Australia and New Zealand.
He said that perhaps young doctors were not taught about the inevitability of death, and the acceptance of death as part of medicine.
“We don’t teach doctors to recognise dying and to make it as pleasant and natural as possible when the time comes,” he said. “They are left just feeling responsible, and feeling they have failed.”
Speaking in an MJA InSight podcast, coauthor Professor Michael Baigent, who is also on the board of directors of beyondblue, said that one of the critical factors that can contribute to burnout was a “misalignment” of goals.
He said that junior doctors began their careers with goals of helping patients.
“They go into internship and their resident medical officer and registrar years, and because of the high work demands, that gets beaten out of them,” he said. “They are not able to maintain a focus on what’s the best outcome for the patient.”
Professor Baigent said that senior doctors who had negotiated the “hard times” in their earlier days of practice had a lot to offer junior doctors.
“There is some merit in developing ‘grit’ … but it has to be supervised and supported,” he said.
Dr Johnson said that a major challenge in addressing the problem of burnout among doctors was the tension between the responsibility of the individual and the responsibility of the system.
“My pragmatic approach as a GP is to say we have to develop the personal skills we need to be resilient, but we also need to advocate for a system that’s healthy and supportive,” she said, adding that system reform may be easier to achieve in the small business model of general practice, than it is in the more complex hospital setting.
Dr Johnson agreed that senior doctors could play a beneficial role in modelling more healthy approaches to work.
“As older doctors, we can role model ways of thinking and ways of doing things that support the enjoyment and satisfaction in the job,” she said.
If this article has raised issues for you, help is available at:
Doctors’ Health Advisory Service:
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NT and SA … 08 8366 0250
Queensland … 07 3833 4352
Tasmania and Victoria … 03 9495 6011
WA … 08 9321 3098
New Zealand … 0800 471 2654
AMA lists of GPs willing to see junior doctors
Lifeline on 13 11 14
beyondblue on 1300 224 636
beyondblue Doctors’ health website:
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Interesting comments so far…
We seem to be stuck with this fee for service medical care model, both in general and private practice, even though in the USA, there is good evidence that the quality of care suffers (especially for complex or elderly patients) and the rate of unnecessary investigations rises. However, although my experience as a salaried staff specialist physician sees improvements on these fronts and potential to mentor and teach, there are still pressures due to workload (there is still just as much work) and there are always some “bad pennies” who don’t contribute their share.
Sleep is definitely important, not only quantity but also quality (ie disruption) and circadian phase misalignment. There is no doubt that new rostering regulations have improved the sleep quantity issue (potential time available for sleeping). However, I haven’t seen any recognition of sleep disruption (usually a problem affecting more senior doctors and young parents) or incorporation of knowledge of circadian rhythms into rostering strategy. My own hospital rosters the registrars in a pattern that is circadian averse (from days to nights to evenings and back to days. I live in hope that the time will come!
There are all sorts of platitudes to describe the causes of low moral in General Practice. My experience tells me it relates to systemic issues such as the inequality of incomes between specialties, denigration of the difficulties of undifferentiated presentations GPS face, and community expectations that quality care can be done for free as a bulk billed interaction. I have been in GP for 40 years and I consider it’s more difficult than when I started – greater complexity with an older patient cohort and community expectations that all I’ll Health is remediable. Government interaction with the freeze and inadequate funding has been the final insult. Take care of our younger colleagues they deserve and need it.
Unfortunately medicine is not the high status career that it once was. It is a job and like any job, people are over worked. The system and doctors feed into each other. The aging population will only make it harder. I do not see it as under paid, probably because it is not a glamorous job. In fact, medical staff get paid a lot compared to other professions with similar amounts of training. And we all know that people do not work just to earn the dosh. But I think juniors need to pay for quality mentoring even offered via Skype to get the expertise needed to develop in their years. I don’t think quality mentoring comes free.
About sleep deprivation: there was a projection in the state of Massachusetts sometime in the 90s costing what it would take to run a health system with no sleep deprivation in the workers . . Unsurprisingly, it ran to billions over budget. Let’s face it: we work in a sphere that has to operate faultlessly with life & death 24/7/365 (!) Thus there is a justifiable medico-legal scrutiny.
Working on call 168 hours straight each second week for 12 years, and asked to attend emergencies when up to 50 hours without sleep at one extreme, I found myself asking a barrister at a medico-legal conference: “After how many hours on call is it legitimate to use sleep deprivation as an excuse not to attend an emergency?” The answer: “Never! But if something goes wrong, we may consider mitigating the sentence” !!!!!
Junior doctors may develop burnout due to learning new skills while under high pressure, feeling unsupported by their seniors. They are also highly likely to be sleep deprived and fatigued, at least in O&G (1). Senior O&G doctors, such as gynaecological oncologists, may be burnt out due to work overload, a high stress job, and fatigue (2). Sleep deprivation affects the emotional functioning of the brain (3) and the doctor is less likely to communicate empathically with their patient (4) or their colleague.
Facilitated peer support and case discussion sessions can help reduce burnout (5) as can proactive work-life balancing (6). But we’ve got to address sleep deprivation of doctors, and all shift workers, as a priority.
1. Tucker, P. E., Cohen, P. A., Bulsara, M. K., & Acton, J. (2017). Fatigue and training of obstetrics and gynaecology trainees in Australia and New Zealand. Australian and New Zealand Journal of Obstetrics and Gynaecology, 57(5), 502-507.
2. Stafford, L., & Judd, F. (2010). Mental health and occupational wellbeing of Australian gynaecologic oncologists. Gynecologic oncology, 116(3), 526-532.
3. Goldstein, A. N., & Walker, M. P. (2014). The role of sleep in emotional brain function. Annual review of clinical psychology, 10, 679-708.
4. Passalacqua, S. A., & Segrin, C. (2012). The effect of resident physician stress, burnout, and empathy on patient-centered communication during the long-call shift. Health communication, 27(5), 449-456.
5. Allen, R., Watt, F., Jansen, B., Coghlan, E., & Nathan, E. A. (2017). Minimising compassion fatigue in obstetrics/gynaecology doctors: exploring an intervention for an occupational hazard. Australasian Psychiatry, 25(4), 403-406.
6. Zwack, J., & Schweitzer, J. (2013). If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Academic Medicine, 88(3), 382-389.
Where to start? As a consultant Paediatrician subject to labour ward calls in a big country town (private + public hospitals), I was ALWAYS more sleep-deprived than my junior resident or registrar. It was very difficult to support them on top of my load. Latterly, I have been prejudicially considered an ignorant member of some old white male patriarchy, with no sympathy for minor aging problems (e.g. having it noised abroad that I was “bullying” if I apologised and leant forward to hear a quietly spoken female med student or RMO). Female RMOs from certain Med schools in particular
(For some reason ANU+ Monash), arrive in the workforce with girded loins and banners flying, ready to battle the “toxic” male patriarchy, and read every comment delivered under stress through the lens of this false narrative. (I couldn’t understand initially, why inviting an RMO in to a discussion about another RMO’s performance, whom I had bent over backwards to support, against great opposition, was reported in writing that I ordered her to remain in the room by exercising my hierarchical power – crikey! – she could have spoken up & left any time!)
This introduces a second inhibition to “supporting” junior staff – if I’m not dealing with colleagues any more, but potential litigants (!!) ( For whom the last thing one gets is the courtesy of a conversation about an incident), why the hell do they see it as a senior’s role to guide them?
By the way, I recall a few times as a registrar when I offered to take over some of the stress of a consultant when extra problems arose – e.g. sudden death of a family member. The workplace works best when we all feel part of a team. I could elaborate so much more, but will leave those few thoughts . .
I’ve been a GP for 40 years with another profession prior to that . GP practice in the main today and certainly in capital and regional centres is easier by far , compared with what we were required and expected to do .A good percentage of these young doctors need to “toughen up ” somewhat and appreciate that they are in a very priveleged position in a very well respected profession with all the associated benefits .
I agree that there is a huge issue with GPs not being able to receive the support that they need. I provide mentorship for several doctors in my practice, including 2 registrars. This is a time-consuming process and cuts down my income substantially. This, along with my longer consultations (often around 17-19 minutes: the best way to make a pittance as a GP), means that my income is very much on the low side for a GP.
GPs are often under pressure to see more patients, with all non-patient contact time being unpaid and seemingly hard to justify.
We need a system where GPs are funded to provide mentorship, support and opportunities to debrief. This would help to prevent burnout.
I have worked much of my 40 year professional life as a GP, and a substantial part in hospital ED setting. I have consistently found GP an unsupported environment. When there is an emergency or critical incident, the pressure of waiting room numbers makes debrief or support effectively impossible, especially while the fee for sevice model prevails. Apart from managing irate patients experiencing consequent long waits, there is the additional problem of lost income for doctors who take time to mentor. By contrast, the public ED environment, although stressful, is able to offer collegial support.
Can someone tell Prof Dollard that in Australia, 6 minute consultations are legislated against ( 80/20 rule, if there are 10 consults per hour in a 10 hour day, you are in trouble).
Couldn’t agree more that sleep deprivation a major issue.
As an anaesthetist, I chose not to work the morning after a night on-call and structured my daytime work to support what I could manage physically, supported, fortunately by my local system. Constant pressure by surgeons to “squeeze” ten hours of work into eight or less. The private system especially allowing such practices. Easy, let a more “hungry” colleague pick up the work !!
The big elephant in the room in health care and other social systems is the poor quality and inadequate duration of sleep – sleep problems correlate with medical errors, lack of empathy towards patients and colleagues and is increasingly linked with a wide range of poor mental and physical health outcomes, including what we call burnout. The shift work rosters are also a significant contributor to this problem.
What part of the problem we attend to influences the interpretations we make and thus the interventions we provide
Older and more senior doctors also often skimp on sleep so it can’t only just rely on the system and the older more senior doctors
Early intervention and mentoring is the key to fostering the well-rounded clinician.
On entry to the medical course, the intensive bridging program is an opportunity to begin the process.
Using a framework which enables medical students to envision their future medical roles, to determine their strengths and weaknesses, and to accept the imperative to become the best they can be across all the domains of the well-rounded clinician is not only achievable, but ought to be an integral part of the curriculum.
As a GP teacher (UNSW.Monash.Deakin,UniMelb) for 3 decades, I have a clear view of what is needed, and I teach the concepts at every opportunity.
I look forward to the time when this teaching is integrated longitudinally from first year and beyond the medical school.