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Reform, not resilience, is the key to changing the narrative and culture of the medical profession and will save doctors’ lives, write Dr Emma Hodge and Dr Elise Witter.
The rampant prevalence of poor mental health of doctors in training is a silent epidemic within the health care sector.
The studies show we are more likely to be anxious, depressed and report higher than average levels of distress compared with other doctors or the general population.
Most shockingly, despite having lower all-cause mortality compared with the general population, doctors die by suicide at two to four times the rate of the general population, and have one of the highest rates among professional groups.
The medical workforce holds the particularly dubious honour of female doctors dying by suicide at twice the rate of male doctors, in contrast to a national trend of increased completed suicides in men.
In addition to women, doctors of minority background and doctors in training are particularly vulnerable to distress, poor mental health, and suicide.
Sadly, this is an issue not solely for the medical profession. Nurses also endure lengthy hours and poor working environments, with moderate to high levels of psychological distress seen across a wide range of health care workers since the coronavirus disease 2019 (COVID-19) pandemic.
If this were seen in other occupations, there would likely be a national inquiry. These are damning statistics speak to the problematic culture and weight of stigma and shame surrounding mental illness within our medical workforce.
The individual and institutional responses
These statistics have sparked an individual and institutional response that tends to adopt one of three perspectives.
Firstly, the “back in my day” narrative, insisting doctors these days should be grateful for working only 20 hours of overtime instead of the 40–50 hours of overtime expected earlier in their careers.
This is further compounded by limited recognition of the increasing bottleneck for prevocational doctors aiming to be accepted into specialty training, with now far greater competition and resulting pressure to commit to additional study or extracurricular roles on top of already exhausting full-time jobs.
Most doctors in training would be familiar with this attitude. It is perpetuated in everyday practice by assertions by some senior clinicians that they should not claim overtime as this labels them inefficient and a culture of “teaching by humiliation” that begins in medical school and continues throughout their training, accompanied by anecdotes of how much harder it used to be. Instead, younger doctors are often expected to count their blessings for the progress that has been made, despite reports that bullying by medical colleagues, patients and nurses and perceived workload have actually increased in recent years. As if somehow doctors are superhuman and despite committing our lives to improving the health of others, our own health is a more trivial matter.
There are also nascent attempts to foster greater wellbeing, with online modules which aim to de-mystify and normalise occupational stress and fatigue and wellbeing action plans that exist on paper but are yet to translate into practice. Although health services are to be applauded for an increased recognition of the importance of employee wellbeing and efforts in this space, the myopic focus on individuals limits the impact of these well intended initiatives.
Of course, there is also the resilience narrative. The idea that doctors of today must simply embark on more yoga and mindfulness practice, foster their resilience, and will thereby be able to overcome any number of challenges thrown their way. And that doctors who eschew complaint must just have greater perseverance and tolerance for hard work.
This is a particularly insidious narrative. It erroneously implies wellbeing is entirely dependent on ample coping strategies and those doctors who struggle to cope with the demands of working in health care are simply not resilient enough. The implicit conclusion is that a sufficient level of resilience will inure one to all challenges, and that those we have lost to suicide or who succumb to mental illness must therefore have some kind of deficit that rendered them vulnerable, weak, unable to cope, deficient in the aptitude and fortitude required to become a doctor.
The resilience myth
Despite the pervasiveness of this blame game, several studies reveal the resilience myth is empathically false and likely perpetuated by a government attempting to improve health care with a dearth of resources. Even the most resilient doctors are not immune to burnout. The factors which contribute to the greatest to physician burnout and poor mental health are not individual but institutional – excessive workload and fatigue, inadequate resourcing, moral injury, bullying and harassment, limited career control, and endless banal administrative tasks detracting from patient care.
Self-care can provide some protection, but it is largely inadequate to confront the challenges of working within the health care sector, such as the daily confrontation with trauma, whether it is the brutal death of a patient in a resuscitation bay in the emergency department or the slow decline of a young person with terminal cancer. There is the expectation that one will stare down death, despair and distress every day, be expected to deliver more care with less resources, and work more than 12 hours per day at the expense of their own basic needs, relationships and aspirations, yet somehow overcome this with a free coffee or yoga session. It is a convenient deceit to consider individuals entirely responsible for their own wellbeing; it mitigates any critical problem solving or investment from organisations to change the untenable status quo.
With sustained advocacy, however, there has been increased recognition that these systemic factors have a greater role to play in shaping the wellbeing and sustainability of the workforce. The new National Occupational Health and Safety Code of Practice (2022) identifies that workplaces are responsible for managing the psychosocial hazards of their employees. In Queensland, the Hospital and Health Boards Act 2011 was amended in early 2023 to provide a rigorous legislative framework holding employees responsible for the psychosocial wellbeing of their employees. Along with South Australia, Queensland is one of only two states to enshrine this change into law. We applaud this first step towards improving the health care workforce experience and welcome this implementation across all states in Australia.
Critically, this now places the onus of supporting wellbeing onto the hospital and health services in these states. While we hope systemic changes in the health care working environment will ensue, only time will tell how this crucial opportunity will unfold. The recognition that systems factors have an essential role in employee wellbeing is an important first step; however, a nationally consistent approach with legislative change across the country is urgently required to support systems change.
Taking real action
The Committee of Doctors in Training have identified a series of key action areas, both immediate and long term, that could be implemented to improve the wellbeing of doctors in training. These range from simple environmental factors such as better lighting and security guard support when accessing ones’ parked car after night shift, to greater flexibility and improvements in rostering practices that reflect occupational health and safety principles.
Consultation of the workforce with positions in governance and leadership committees, more rigorous and transparent responses to bullying and harassment, and implementation of dedicated wellbeing champions and specialist mental health clinicians within the service are further suggestions proposed to improve employee wellbeing.
Recognising the prevalence of stress and burnout among doctors is also vital, with accompanying collegial support and avenues for support. This is exemplified through the Regional Medical Pathway, which offers a novel approach to wellbeing, with workforce nurturing central to the end-to-end training program, including the first medical education and wellbeing position in Queensland which has enabled integration of evidence-based wellbeing support into the clinical environment.
Such changes will likely benefit the entire health workforce, who are subject to similar stressors and challenges in the workplace. Reform, not resilience, is the key to changing the narrative, culture and adverse mental health outcomes for doctors.
Dr Emma Hodge is a Medical Education and Wellbeing Principal House Officer at Wide Bay Hospital and Health Service.
Dr Elise Witter is Psychiatry Registrar at Cairns Base Hospital and Health Service.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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RIP Dr James Dang
It’s been really difficult struggling silently.
I’ve lied about ‘my grandparents dying’, or pretending to be physically sick or all sorts of bizarre excuses- somehow all of these seem much safer than telling the truth- I am burnt out and need to take some days off.
Thank you for writing this and for everyone who commented, I feel less alone.
I love the new generation. They go for their rights. As a FACEM and a doctor for 20 years it’s not unusual for me not to have recognised my rights for years! It’s interesting that everyone has their own prospective of what the problem in healthcare is ! Almost 80% of very depressing and anxiety provoking issues normally stays “upstairs “ with senior clinicians and for the wellbeing of trainees, never are transferred to them . For example imagine if all of these rough organisational targets and often fails and blames are transferred to trainees on hourly basis! This example was the most civilised one so I would leave the risk for you imagination. In general , should we say that Administration is not happy since their budget and aims are not met with needs, Senior doctors are not happy because… junior doctors are not happy because… nurses are not happy because… at the end patients are not happy because they did not receive a high quality care and so on ! If you get my point you realise that a much bigger health reform is needed ! We as FACEMs have raised this through our college president many many times ! I guess a collaborative measure with the federal and local governments is what we need as a starter ! Change is not easy and painful but it appears to be vital now!
Thank you Elise and Emma for a well written and accurate picture of the medical workplace in hospitals.
Our young doctors in training need much better psychological support and protection from fatigue and burnout secondary to the long hours , endless shift work and the emotional strain of dealing with death and complex severe illness .
I thought the hospital workplace and conditions for trainees had changed since my training in the 1980s ,but I see from the young doctors I know ,that the same conditions , long hours and poor support at times of crisis and anxiety still persist.
There must be change.
Warmest congratulations on this important article which is a clarion call for senior doctors to advocate for psychologically safer working conditions for early career doctors in the wake of a pandemic which has thrown our health system into chaos. Reform, not resilience. As Emma and Elise point out its time for the medical profession to change its culture to save doctors’ lives.
I graduated 40 years ago and worked those crazy hours for no pay. But the patients were different, and the treatments were different. No arterial lines, no long lines, no subcutaneous ports, no infusion pumps, gasses took an hour to come back, Xrays overnight we had to go and see the film in the department, no CT or MRI at all. We didn’t know as much about the various diseases, metabolic diseases were in their infancy, no ammonia or lactate measurements, Patients weren’t as complex because they died before they got to multi-organ impairment. We ran at 85% occupancy so there were always beds available.
We had free serviced accommodation in the hospital grounds, some hospitals provided hot meals both at lunch and in the evening. We led different lives. We were our own peer support group living in the hospital and socialising with each other. Marriage before finishing the junior years was rare.
Was it better? No, it was different. Yet we try to maintain the same way of treating and managing patients as we did then. The volume of patients and the complexity of patients is much higher, and we should step back to evaluate how we manage these numbers, we need to change how we do things, just as the technical and medical treatments have changed the system for looking after these patients needs to change too. Multiple summits and conferences discuss but then attempts to implement new ways often fail at the funding hurdle. Demonstration of value cannot always be delivered in 6-12 months, sometimes we have to seed fund for five to ten years to show the population improvement and benefit of doing something differently. For example, what if instead of spending a $billion on the next big hospital we spend that money on community services? Maybe then the old hospital would suffice.
As a trainee, FACEM and DMS I agree there is a problem. Not just in junior doctors. Senior doctors, nurses and others too. For those of us trying to change the system from within it’s not as simple as just more doctors and less hours each. The whole system needs a total overhaul to make it sustainable for the people in it.
There will always be an element of unpredictability and after hours and on call in health – it’s about how we make it reasonable. For a start the poor behavior in medicine needs to stop.
I agree with the tone of this discussion, and I’m pleased to see the responses it has generated.
Providing “resilience training” has always smelt to me like the health system blaming the victim. There is little doubt that fatigue is the the great moral hazard of our time, mostly in high-pressure or high impact jobs, which medical training is both.
Although kindness, consideration and courtesy cannot be legislated, the lack of these qualities is a driver of the toxic cultures we see develop in some centres. When present, they suffuse the entire system, with very few trainees developing dysfunctional responses.
Reform is the key; fatigue management the tool.
There are lots of reasons why doctors are burnt out. Attending conferences and courses are inspiring and help make doctors better doctors but the cost is often prohibitive for junior doctors. Especially if you add registration, college fees, exam fees, moving every year etc. I would love to see more of the cost of this fall on employers to make it more accessible. After all we all want doctors who are up to date and feel passionate about their jobs.
Thank you for a timely article . As the authors highlight , the focus on individual resilience unfairly shifts responsibility away from cultural and systemic factors . If doctors were falling over regularly at work and breaking their legs we would be stepping in with overhauling the environment in which they work to improve safety . We need to think of psychological safety the same way .Reduce the stigma , throw out the “in my day “ narrative and bring in changes especially around work hours and support which in turn allow doctors to flourish . And it is not just doctors who suffer . Tired and burnt out doctors are more likely to make mistakes . It is extraordinary to think with all the evidence presented in the article that so little is being done .
After making the grade for medical school, surviving to graduation and completing internship, we must be among the most resilient people in society!
Australia suffers from the UK syndrome of abusing the time of public hospital junior doctors.
I worked in Emergency Medicine in Canada back in 1990, and gained many valuable insights into making hospital work more efficient. When I returned and ran my own department, I worked hard to eliminate redundant and inefficient tasks, including phone calls and paging calls, but the gains were hard-won because our system does not value the labour of junior doctors (nor, to a large extent, also many senior hospital clinicians).
It would be great if the additional cost of previously-unclaimed overtime drove some improvement to work-practices.
Excellent article
Administrators and senior clinicians have systematically exploited the altruism and insecurity of junior staff, also senior staff, for years
It makes them look efficient, as budget is kept low and they get to go home at 5. After 3-5 years in the job they bank the brownie points accumulated and broker them into a bigger job, in which they get to exploit more people. Rinse and repeat
EAPs and suchlike may be helpful at the individual level and we ALL need to have a self-care plan, of whatever nature, but they are mostly a way for admin to pretend to care, while shifting blame for any disaster onto the individual.
The core issues are systematic underfunding and a hierarchical, bullying structure. This has been so forever and will not change unless the focus is shifted squarely on to these issues, avoiding distractions such as „ resilience“, which has a place but is not the core issue
https://insightplus.mja.com.au/2017/31/the-resilience-myth-in-medicine/
I completely agree
A piece from 2017 we need to keep pushing
GT
Having trained in NSW Public hospitals and worked largely in public hospitals in NSW [and one in the ACT as am Emergency Physician mostly as Head of Department doing 12 hour plus shifts then attending hospital meetings after-hours, call-back (unpaid) then DMS where I routinely worked 60-70 hours or more (unpaid “overtime”) and permanent on-call as I was the only DMS] for close to 40 years nothing has changed in relation to the work conditions in Public Hospitals except improved though grossly inadequate medical staffing.
Following my graduation I regularly worked 48 hour and much longer [over Public Holiday Long Weekends and other holiday periods [Easter the shift commenced on the Thursday at 0800 hours (or earlier) and finished Tuesday afternoon around 1800 hours]
100 hour weeks were not uncommon [most of it unpaid]
Most of my “overtime” was unpaid!
I was regularly the only doctor on duty after-hours [overnhight] in the Emergency Department [including in teaching hospitals (and entire hospital in rural and peripheral hospitals)]
An an Aneasthetic trainee I was required to be at the hospital no later than 0600 hours and frequently did not leave the hospital until 2000 hours.
During my O&G anaesthetiv training we did 48 hours on 48 hours off but frequently had to work unpaid on our off hours as therte were only two of us doing O&G Anaesthetics
I could go on and on in relation to the other issues.
The generations that followed my generation [graduated in 1978] were much less resilient, more reluctant to do additional work and stay back to complete the required work and dare I say less well trained and experienced as a result
Despite improvememnts in medical staffing of Emergency Departments [I was director of two Emergency Departments in Sydney as the only Emergency Physician for over 2 years at each of them, no Registrars at one and only 2 registrars at the other
Thank you Elise and Emma for a very timely reminder that Doctors need support and are provided less resources due to the nature of our profession and attitude of “Physician Heal Thyself”.
Doctors like the general public suicide for various reasons including financial, marital disharmony, family stresses etc. However the common denominator in the majority of cases is an AHPRA/ regulatory complaint. Doesnt this require greater attention/ scrutiny? The words “protecting the public” has been taken to great extremes by regulators and put our colleagues at high risk of harm from organisations we fund by our annual fees. It can only get worse unless drastic steps are taken to curb the powers and increase accountability of big brother to the profession and public at large. I agree whole heartedly with Dr M Haikerwall, the former AMA President – that AHPRA needs a Royal Commission to look into its role and accountability, why isnt the federal AMA backing this cry from the medical fraternity?
When the atmosphere in the coalmine is toxic and kills the canary, the solution is to clear the toxic environment, not create a stronger canary.
—These damning statistics speak to the problematic culture and weight of stigma and shame surrounding mental illness within our medical workforce.
You say “there is” stigma and shame to mental health issues. I say we are taught to say there is. The outcomes, uniformly negative, do not deter us from continuing the teaching.
Harold A Maio