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TRAINEE wellbeing has been back in the news recently after an anonymous doctor published their experience in the NSW system, detailing registrars’ lack of control over their own lives, insufficient support, and “universal suffering”. It comes off the back of Dr Yumiko Kadota’s expose into surgical training in her book Emotional female.
While these stories don’t reflect the experience of every trainee, it serves as a reminder that trainee wellbeing is necessary for the delivery of high quality care for our patients.
The beginning of a medical career is a demanding and stressful period for junior doctors, who experience high rates of mental illness and burnout. A 2009 survey of 914 junior doctors in Australia and New Zealand found that 69% of respondents met the criteria for burnout and 71% had concerns about their physical or mental health. These figures are alarming and not something for our profession to be proud.
Burnout is an unacceptable risk for any health service. It is associated with higher rates of serious medical error, reduced patient satisfaction and poor staff retention. Experts have hypothesised that burnout may cause more medical errors than a poor safety environment.
As the awareness around doctors’ mental health and trainee wellbeing has grown, interest has turned to designing interventions that address the heart of the issue. A 2019 survey that included 3844 Australian doctors-in-training sought to investigate the drivers of burnout. The most commonly identified factor was the conflict between work, study and personal life. No doubt the COVID-19 pandemic has compounded this challenge for many trainees.
However, there are early signs of progress, with progressive hospitals and departments seeking to improve work–life balance for its trainees. Their leadership has recognised that changing family dynamics and generational shifts mean that trainees are seeking a different work–life balance than that which was acceptable to their predecessors. Institutions achieving this balance will be well regarded and best positioned to attract and retain trainees. Here are some of the interventions showing promise.
Embracing flexible working arrangements
Flexible working arrangements allow trainees to work part-time or job share in order to maintain balance with other aspects of their life. These arrangements have been commonplace for some time in specialties which do shift-work such as emergency, as well as general practice. However, it is promising to see this flexibility extending into the hospital system.
It’s becoming clear that full-time permanent employment is not a model that suits all trainees. In 2017 two doctors job shared their internship over 2 years at St Vincent’s Hospital. Since then the Victorian Medical Women’s Society has created an online job share database to connect doctors seeking flexible working arrangements. It currently has 30 advertisements. In my own hospital I know of doctors in medical and surgical disciplines job sharing in roles that my senior colleagues tell me would have once been unimaginable. Best of all, the departments employing these doctors are reaping the benefits of expanding and diversifying their workforce.
In response to this trend, the Central Adelaide Local Health Network has developed a pathway for trainees to work on short term, part-time or casual contracts. By doing this, trainees remain connected with their employer while stepping away from training to focus on family, research or other aspects of their life. There are obvious benefits associated with full-time and continuing employment, including leave entitlements and job security. However, there are also benefits of casualisation in terms of flexibility and work–life balance. The development of such pathways empowers trainees with specific needs to negotiate an arrangement that suits them.
Modernising rostering practices
Hospitals are also taking a leaf from other industries by embracing electronic rostering. These rostering solutions are easily auditable, which allows periodic monitoring of trainee working hours to ensure they are in line with good rostering practices. This sort of auditing is not easily done on rosters which are essentially written on the “back of an envelope”.
When implemented in UK hospitals, these were reported to improve compliance with mandated breaks between shifts and ensure that rosters were available 6 weeks in advance. However, specific studies on the impact on overall hours worked by trainees are lacking.
An additional benefit of electronic rostering is that it matches staffing levels with trends in clinical demand. This has the potential to improve the efficiency of staffing and hospitals by avoiding workload bottlenecks during peak activity. The electronic nature of these systems also provides a degree of fairness and impartiality that can be challenging when rosters are created by colleagues or individuals with administrative roles.
It is essential that trainees are included in this transition and given a degree of autonomy and ownership over their working arrangements. When there is the perception that those writing rosters are far removed from the coalface, this may lead to resentment. Trainees feel particularly strongly about this topic and have been known to rewrite their own rosters when they have identified an opportunity to improve efficiency. With proper engagement trainees will embrace this transition.
Collaboration with trainees to improve efficiency of health care
Finally, trainees are an important resource to improve the efficiency of clinical care. By the nature of their time spent at the coalface, they recognise the challenges and inefficiencies of clinical pathways. This makes them a resource for leadership to reconcile “work as imagined” with “work as done” in the hospital.
Allowing trainees to use their expertise to improve the workplace will pay dividends for hospitals. Google was long famous for its 20% innovation time, where it gave engineers a proportion of their worktime to focus on a passion project. This resulted in the development of Gmail and Google Ads, which turned into hugely successful and profitable products for Google.
Leadership programs have been developed for trainees to bring their passions into the clinical setting. An example is MediLead, a bespoke leadership course for trainees developed at Medway Maritime Hospital in the UK. This 6-month structured program provides training in clinical leadership and quality improvement methodology culminating in the delivery of a project that is mutually beneficial for trainees and the organisation. Trainees have worked on improving hospital guidelines, optimising revenue from clinical coding and implementing a mentorship program for interns.
Trainee wellbeing is essential for the delivery of high quality patient care. Lack of work–life balance is the primary driver of distress and burnout among trainees. There are opportunities to improve work–life balance by introducing flexible working arrangements, modernising rostering practices and promoting clinical leadership in trainees. These initiatives provide a roadmap for departments and hospitals seeking to improve trainee wellbeing while finding efficiencies in the delivery of care to the communities that we serve.
Dr Joshua Inglis is an advanced trainee in Acute and General Medicine working in Adelaide. He is part of a community of practice of junior doctors working to improve patient care and clinical training in his hospital.
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.
Somewhere deep inside I wish you well Joshua. You’re young, intelligent and service minded, and the profession needs you. I’m retired now. Internship in 1975 was 18 hours on, 18 hours off, in busy hospitals in Sydney. I studied for the membership between the 10pm and 2am breast feeds of twins, with the screamer slung to my neck between me and the books. Due to unusual infertility issues we ended up with 3 boys under 16 months; progressed through advanced training and ‘settled’ into 1 in 2 rostered rural paediatrics working on average 100 hours per week for 30 years.
No one offered mentoring. You landed in the country and established a network of practice using the experience of friends and your wits.
The idea that junior doctors have it tough is true, but not tougher than in the past, and definitely not tougher than some consultants. (I could give you sundry examples, but just one for now: my vascular surgeon working 150% capacity to get through the list of his colleague who’d died young and unexpectedly, so he could support the young widow, just 6 months after his son shot himself dead at Uni . . ). In your freshness Ann’s naïveté you don’t know the half of it!
I have a sister who’s a Professor of Women’s Studies, and the mantra is that women want equality. Sorry, but that really is one of the great lies of feminism. All your well intentioned postulating for roster rearrangements is mostly about how ‘equality’ is the last thing they want: it’s too damned hard!!
There’s a PhD in this somewhere. But pandering to youth suddenly finding out that it’s more hard than they thought is avoiding the whole picture. Just check the suicide statistics of doctors over lifetimes, and you’ll start to appreciate the extent of the problem. And by the way, don’t start suggesting that the ‘government’ should pay for better hours – that’s been costed in a few places, and no state or country can get close to affording it.
By the way, the screamer is now a renowned ophthalmologist, his twin a sought after architect, and the ‘mistake’ made the AYO as a cellist, and is now a successful lawyer. Somehow we made it!
Best of luck!
Yet another piece on trainee wellbeing that doesn’t mention the elephant stampeding in the Emergency Room: bullying.
All aspects raised are noteworthy and should be implemented, yet as long as over 1/3 of doctors are being bullied by their superiors and 2/3 fear reprisals if they speak up about it when they witness it – how can work-culture, safety and doctors’ wellbeing improve?