Mental health of doctors-in-training: a reflection

IT has been 8 months since Dr Yumiko Kadota’s blog post on her experience as a plastic surgery unaccredited registrar at Bankstown Hospital in New South Wales. She described hundreds of hours of overtime and on-call work, the lack of supervision and support, and her subsequent burnout. While there was a huge outcry and a complete condemnation of the department that led to her experience, there was a sense of familiarity and painful resignation among doctors-in-training across the nation.

Two years prior to Dr Kadota’s blog post, NSW Health released a Junior Medical Officer Wellbeing and Support Plan in response to junior doctor suicides in 2017. Safe working hours were a priority. In our home state of Queensland, the Australian Medical Association Queensland (AMAQ) has been surveying this for a number of years. The 2019 Resident Hospital Health Check, results from which will be published shortly, found that 46% of respondents had been concerned that fatigue due to long hours may cause clinical error.

Dr Kadota’s experience is not uncommon and is symptomatic of an unsafe culture within the profession. The profession’s cultural norm is to stay at work until the job is done. We fail to recognise that the work (especially administrative work) rolls downhill and our juniors are spending hours and hours in the evenings finishing discharge summaries, clinic notes, letters and endless forms and paperwork. Gruelling work is worn as a self-sacrificial badge of honour, and claiming overtime is seen as incompetent. As we progress through our training, we have more responsibility for patient care, and in Dr Kadota’s case, operating late into the evenings despite the full day’s clinical load. It is common to work over 80 hours a week. This is unsafe for our doctors-in-training and unsafe for our patients.

Bullying and harassment is prevalent, and yet fear of retribution and how it would affect career progression disempowers us from speaking up. The Socratic teaching method is powerful and normative from medical school to fellowship exams; however, it can be eroded by denigrative comments or victimisation. Our profession has a well documented and unacceptable history of bullying. Cultural change is key to preventing this. Some colleges are leading the way with professionalism and teaching skills for hospital-based consultants (and here). Hopefully the next generation of clinical leaders will break the cycle of bullying and harassment in our hospitals. Embedding this through accreditation (the “stick and carrot” approach) is essential for eradication of bullying.

What hasn’t been addressed is who is looking out for the non-accredited registrars? Who will fill the rota gaps while the registrars are removed for their wellbeing? There is no excuse for moving the burden of hours to a more vulnerable set of shoulders.

Finally, where do doctors-in-training turn for help?

When these systematic factors (work hours, bullying and harassment) take their inexorable toll, many barriers prevent doctors from seeking support. The profession’s “hero-culture”, the hierarchal nature of medicine, fear of reprisal, and the need for supervisor references to secure yearly employment all create barriers. Beyond these, fear of mandatory reporting can prevent recognition of stress-related health problems being addressed early. Mandatory notifications have increased in recent years and doctors-in-training are understandably nervous that a notification early in their career could be career-ending. While the bar for notification is high, the obtuse rules are often misinterpreted.

Earlier this year, AMAQ wrote to members of the Queensland Parliament, asking for the legislation to be amended so doctors and medical students could have the confidence and support to seek help when they are unwell. These recommendations were rejected. Between 2017 and 2018, at least four Queensland doctors took their own lives. In 2016, 26% of junior doctors reported suicidal ideation. Our colleagues are suffering and are afraid to seek help in their own state.

Doctors are vulnerable to mental health problems and progress is being made to shift the associated stigma.

Crazysocks4docs started by Dr Geoff Toogood raises awareness and helps start a conversation about mental health, challenging the word “crazy” as well as the culture of silence. The AMAQ’s Resilience on the Run program provides resilience and mindfulness techniques to interns in Queensland, as well as increasing awareness of when to seek external support and to identify ways to better support colleagues. Doctors’ health advisory services in every state have been funded to offer colleague-to-colleague support recognising the unique challenges that a career in medicine can have on our personal health. The Queensland Doctors’ Health Program is the service arm of the Doctors’ Health Advisory Service Queensland and has 40 volunteer GPs taking calls from distressed doctors.

Between July 2017 and June 2019, over 650 calls were received for acute and chronic stress, mental and physical health issues, severe fatigue, and bullying. Over 50% of calls in the last year were from junior doctors.

Good work is being done, but it’s not enough. Actionable changes to work hours, to support doctors-in-training including unaccredited registrars, and to reduce barriers to seeking help are needed. Picking up the pieces after doctors-in-training burn out or leave medicine is an ineffective strategy.

Our patients share with us their health stories daily, and we pick out risk factors, investigate and diagnose and treat the problems. We know the risk factors for burnout for doctors-in-training. We know the diagnosis. Junior doctors are overdue for leadership at a hospital, state and national level, to treat this problem.

Dr Emily Shao is a medical registrar working in Brisbane. She is on the committee of the Doctors’ Health Advisory Service Queensland.

Dr Kate Engelke is a junior doctor currently working at the Townsville Hospital in North Queensland. She graduated Bsc/MBBS from the University of Queensland in 2015. Kate has been involved in promoting the health and wellbeing of doctors and medical students since medical school, serving on the Doctors’ Health Advisory Service (QLD) Management Committee and more recently on the Board of the Queensland Doctors’ Health Programme (QDHP).

 Dr Margaret Kay is a Senior Lecturer at UQ and is a GP in Brisbane. She is the Medical Director of the Queensland Doctors’ Health Programme.

If this article has highlighted difficulties that you are experiencing, please call your state Doctors’ Health Advisory Service for confidential support and advice. In Queensland, confidential support and advice can be found on 07 3833 4352, while other states’ phone numbers can be found at www.dhas.org.au.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.