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This second opinion piece in the three-part series is a call for further action by a united medical profession to address the enormous scale of work-related burnout and mental injury in doctors who work in psychologically unsafe health care workplaces. There are solutions.
When a 24-year-old labourer’s apprentice used a chainsaw without training, they sustained a jagged laceration through their left quadriceps. When I saw them 12 months later in my general practice, their laceration was well healed. However, they remained unemployed because their untreated post-traumatic stress disorder (PTSD) was aggravated on their return to work when their boss put a chain saw in their hands to help them “toughen up and get over it”.
Clearly, the apprentice’s severe mental injury was contributed to by the failure of his employer to provide adequate training and support. The young man’s surgeons carefully attended to his physical injury, but underestimated his mental illness when they certified him fit for pre-injury duties in an unsafe workplace.
There are striking parallels in this case with the way the medical profession sometimes underestimates acute and repetitive work-related mental injury in doctors who work in psychologically unsafe health care workplaces, particularly in its own apprentices.
In recent times, major global and national issues have plunged our health system into chaos and resulted in a major mental health crisis in our communities, and our health workers, including the medical profession. And yet, in the wake of a pandemic and other multiple disaster exposures (here), there seems to be a tendency in medicine to “just want to put it all behind us”. Have we considered that responses such as “I don’t want to talk about it”, “it’s just part of the job” or “toughen up, get over it” may be symptoms of unhealthy avoidance following multiple traumatic experiences?
Work-related mental injury is under-recognised and undertreated
The medical profession must reconsider some fundamental questions if we are to effectively address the current “doctor burnout crisis”.
As a profession, are we recognising the difference between burnout and more severe forms of mental injury?
According to the International Classification of Diseases, 11th revision (ICD-11), “burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterised by three dimensions: 1) feelings of energy depletion or exhaustion; 2) increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and 3) a sense of ineffectiveness and lack of accomplishment”.
Work-related mental injury may include a range of different mental illnesses in addition to PTSD and complex PTSD, such as adjustment disorder, major depression, anxiety disorder, and panic disorder, each with diagnostic criteria requiring a comprehensive mental health assessment and specific evidence-based psychological treatment and/or pharmaceutical management.
When burnout does not respond to rest, self-help strategies and reduction of work stress, we must consider the possibility this is more likely to be a more serious work-related mental injury, as this hospital medical officer (HMO) described to me.
“I am haunted by traumatic losses of patients, family members and friends during the pandemic. When I was expected to cover other doctors’ sick leave at short notice and take on enormous patient caseloads, I couldn’t cope and I still feel like a failure. Although lockdowns are over, I continue to withdraw from people outside of work. I’m exhausted, but can’t sleep due to bad dreams …”.
How can the medical profession better support doctors like this young HMO?
It is important to remember that, sometimes, simple actions rather than formal psychiatric interventions are effective. This may include being listened to, receiving informal emotional support from colleagues, confronting and discussing fears, finding a new meaning or purpose in life and work through adversity, and having senior role models who are willing to share their vulnerabilities “having been there and recovered”. Unfortunately, these sorts of supportive interventions are lacking in medicine.
Every doctor can benefit from prioritising advanced approaches to psychological protection just as we prioritise physical protection. We can also seek professional support from a GP for routine mental health screening as part of an annual comprehensive preventive health check.
Unfortunately, there is a persisting negative stigma and shame surrounding psychological problems in medicine which prevent doctors from seeking interventions for mental health problems.
Why have we been unable to shift the entrenched attitudinal barriers that deter the access of the doctors to optimal mental health care, including fears about confidentiality and mandatory reporting? Having a trusted, independent GP (who is not a friend or work colleague) for routine health care allows a doctor to take time off work for stress and mental health issues confidentially and also overcomes any risk of an inappropriate mandatory report to the medical board.
Do doctors know where to access early specialised psychological therapies and, if needed, pharmaceutical treatment for the specific psychiatric conditions listed above? Or where to access online cognitive behavioural therapy programs, websites and resources, specialised online treatments for insomnia, and regular consultations with an experienced therapist face to face or via telehealth, particularly for isolated rural doctors?
Many of the answers to helping doctors recover from work-related mental injury are documented in evidence-based guidelines for psychiatric conditions. As one example, Phoenix Australia has published specific guidelines for PTSD or complex PTSD, which should be read by every doctor given the extent of trauma exposure in our communities and ourselves.
Work-related mental injury is aggravated by an unsupportive culture in a psychologically unsafe workplace
The mutual support of colleagues through shared challenges is one of the great joys of a medical career. Through adversity, we develop strong connections and lifelong friendships which sustain us. Unfortunately, during the prolonged isolation imposed by the coronavirus disease 2019 (COVID-19) pandemic, these supportive relationships have been lacking and many doctors were let down by other colleagues in vulnerable times in the past few years.
In a medical career, when we are routinely confronted with many stressful and traumatic experiences; suffering is a natural human response, not a mental weakness. In this situation, it is unfathomable that doctors continue to report being bullied, ostracised or overlooked by colleagues or employers after temporarily being unable to “pull their weight” due to a work-related mental or physical illness. After years of dedicated service to patient care, the words “toughen up” and “get over it” are deeply painful when a doctor is unwell.
A clarion call for a new approach to work-related mental injury in medicine
The intractable nature of mental health problems in doctors has a long history, which suggests that something must dramatically change in the future.
The medical profession has undertaken a concerted effort on doctors’ mental health since the 2013 Beyond Blue survey of 14 000 Australian doctors and medical students. Some of the shocking statistics in the survey included “thoughts of suicide are significantly higher in doctors compared to the general population and other professionals (24.8% vs. 13.3% vs 12.8%), [and] approximately 2% of doctors reported that they had attempted suicide”.
In response, many dedicated doctors through DRS4DRS, Doctors’ Health Alliance; a number of colleges including the Royal Australian College of General Practitioners (RACGP), the Royal Australian and New Zealand College of Psychiatrists and the Australian College for Emergency Medicine; the Black Dog Institute; Beyond Blue and others have implemented programs, services, websites, resources, forums and conferences with a lot of good will and in kind support.
In addition, the Australian Medical Association recently launched an initiative to encourage all doctors to have a GP. The RACGP GP Support Program offers free, confidential psychological services to their members to help cope with professional and personal stressors affecting areas such as mental health and wellbeing, work performance and personal relationships (here). The Every Doctor, Every Setting National Framework has also been developed by Everymind and the Black Dog Institute in partnership with the medical profession and mental health leaders in Australia and funded by the Australian Government to tackle mental ill-health in doctors and medical students.
Despite these major initiatives, unacceptably high levels of mental health problems persist in the medical profession for complex reasons. Notably, many doctors have been subjected to abnormally demanding and unsafe work environments, long hours, high stress, and traumatic situations in the past few years, and are currently at increased risk of mental health problems than they were ten years ago.
It’s time to for a united medical profession to re-evaluate and scale up its efforts in relation to high levels of work-related burnout and mental injury in doctors who work in psychologically unsafe health care workplaces. I will further unpack the recovery options and solutions in part 3 of this series next week.
Next week, the final part in this three-part series discusses ways every doctor can cocreate a psychologically safe health workplace.
If this opinion piece has triggered any discomfort, please make a long consultation with your independent and trusted general practitioner, the DRS4DRS program, or the Doctors’ Health Alliance to talk about recovery from burnout and work-related mental injury.
Clinical Professor Leanne Rowe AM is a rural GP and co-author of the 2nd edition of Every Doctor: healthier doctors = healthier patients. Her Doctor of Medicine thesis is on the topic of GP mental health training, and she was a past Chairman of the Royal Australian College of General Practitioners and Deputy Chancellor of Monash University.
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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Thankyou Leanne, this is an important article and even though there is nothing new here – it needs to be said repeatedly and loudly to gain any momentum.
However there are two points I want to raise.
1. As with all other coversations about doctors wellbeing there is a call for strong compassionate leadership. But there is no mechanism to produce this or ensure it. Leaders are chosen by poor leaders, politicians and systems with no vested interest in change. Leaders are not trained in compassionate leadedship, they are not monitored supported or managed. There have been countless calls for good leadership but there is no way of achieving this when it is the politicians and entrenched public servants – neither of whom have a long term and vested interest in change, who select and neglect the leaders.
2 For all that is wrong with the world. The go to answer is ‘see your GP’. The poorest paid, most drowning in bureaucracy, most controlled by a government completely hostile to the profession, most time poor and overloaded of the specialties.
Dont go and see your GP. How on earth will your GP effect any sort of improvement in this epidemic of cultural and moral harm. There arent enough of us to sort this problem, we are burnt out too and few junior doctors are chosing this specialty so we arent being replaced.
Go and see your politician, go and see your hospital administrator and your dean of medicine and talk to them about the system and culture that is the cause of this psychological, moral, spiritual and physical injury.
I don’t agree that every doctor can heal from work place trauma
I think the effects of trauma in itself, can be long lasting, despite therapy, time off from work, or change of work
I have and am currently undergoing workplace trauma
For the last two years
I likely have complex PTSD as a result
I have changed in my personality and character
I am not as trustful of others
I have become harder internally
I do not share as much as I used to
I have become cynical about the job and people in general
Because people in my workplace have caused such trauma
These people are doctors who did this to me
And as a junior, there is a power imbalance
I went to all the right places for help and was told no one could help
It is difficult to say how such trauma can leak into other avenues of life in the future, including relationships and work
It is a sweeping overgeneralisation that all workplace trauma can go
I believe, even five years from now, if I had to think about what I have and am currently enduring, it will still bring a tear to my eye, and it will still hurt very much indeed
So much has been taken away from my life by senior doctors in positions of power
So many words said to my face that will never be erased
Trauma in itself across the world, whether it be war related, or an abusive relationship, has been shown to last for some people a lifetime.
I realise my series of 3 opinion pieces on our collective responsibility to provide greater advocacy and support on our work and training conditions can be deeply triggering for many reasons. The enormous extent of unrecognised, unreported and untreated mental injury in doctors due to unsafe work and training conditions and the negative stigma of mental illness is currently underestimated, and it is manifesting in acute on chronic medical workforce shortages.
To summarise the main points in the 3 part series:
• Unfortunately, early career doctors can sustain career damage if they speak up about unsafe work and training conditions, uncivil behaviours, and unlawful bullying, sexual harassment, discrimination and racism. Senior medical leaders/senior doctors therefore have a responsibility to effect change.
• A united medical profession has more influence than it currently realises to reform the culture and safety of health care workplaces. There are solutions if the leadership of our many medical organisations and hospitals health services and practices advocate and support doctors together.
• In this environment, senior medical leaders/senior doctors must understand they are responsible and liable for work related mental injury in doctors working in psychologically unsafe workplaces under HR laws.
I am calling these issues out in Part 3 every doctor can co-create psychologically safe health care workplaces on Monday Oct 2 in MJA Insight Plus. I hope you will consider supporting this call for united action to support our colleagues.
Thanks Leanne, excellent and important series. Your writing as always giving great insight and reflective your long term experience and expertise.
Part 1 and 2 of this 3 part series are confronting and I very much appreciate all the feedback and comments. It is clear from recent opinions expressed in MJA insight Plus and other publications that early career doctors are encountering major challenges in their work(1) and training conditions(2), which require greater advocacy and support by senior doctors to change the system.
At an individual level, every doctor can enlist the support of a trusted independent GP – who can provide informal debriefing, support, and if required, time off work after excessive work stress and trauma (with a generic certificate not disclosing a mental health problem to an employer). A GP with mental health training can also provide early evidence based psychological (and if required pharmaceutical) therapies and/or specialist referral. Treating GPs will not make an inappropriate (3) report to the medical board if they are made aware of the correct criteria for mandatory reporting(4). If there is a risk that patient care may be compromised in any way when a doctor/patient has a physical or mental illness, a GP will assist them take time off work. A medical condition is never disclosed to an employer on a sick leave certificate for any patient, including a doctor/patient – this would be a serious breach of privacy.
If doctors find it difficult to access GP care, please call the DRS4DRS(5) program, or the Doctors’ Health Alliance(6) to talk about recovery from burnout and work-related mental injury.
For more information, please refer to Part 3: Every doctor can cocreate a psychologically safe health workplace – to be published in MJA Insight Plus on next Monday 2 October 2023.
1. https://insightplus.mja.com.au/2023/32/doctors-in-training-need-system-reform-not-more-resilience/
2. https://insightplus.mja.com.au/2023/34/failure-in-medicine-these-exams-need-to-change/
3. Think you know when to make a mandatory notification? Read this | InSight+ (mja.com.au)
4. Dispelling myths: doctors CAN disclose mental illness without fear | InSight+ (mja.com.au)
5. DRS4DRS – Help doctors stay healthy
6. Doctors’ Health Alliance (doctorshealthalliance.org.au)
I don’t feel that what you have said is true, for me. I was bullied and harassed in my last job, which affected me mental and physical health (chronic migraines) to the point where even my GP told me to leave. I have had only minimal support from the AMATas, which has reduced my fees, which helps because I am now on Jobseeker payments. The doctors I previously worked with harmoniously, have not replied from my request for a referee. So I am essentially unemployable. Did I have a history of mental health issues? Yes, from various traumas I have complex PTSD and depression, and was then ,surprisingly, diagnosed with ADHD 2 years ago by my psychiatrist. I disclosed my history of depression to the DMS of the NW region. Following this, I experience a distinct change, an increased level of scrutiny over relatively minor issues like arriving to work late, even though I stayed much later at work than all of my colleagues. Various issues related to my frequent sick days, mainly because I also have chronic migraines. They made me report myself to AHPRA, it was really terrifying and humiliating. And AHPRA cleared me. Despite that the Clinical Lead,]then reported me to AHPRA, which lead to several more months of stress until AHPRA, once again cleared me. I was then reported to the Depth Health Tas, and they also cleared me of any wrongdoing. But still the scrutiny and pressure continued. My credentialling was changed to “nonclinical”, without my knowledge or any consultation with me. I am a passionate clinician, my strengths are with helping people and working with an interdisciplinary team, it was my passion. And then, I had to work in a small room, away from my team, without any connection and limited contact with people. I was given limited instructions at first of what I was supposed to do, and then was told to attend meetings with the clinical lead once a fortnight to discuss what I had achieved. I have ADHD. Sticking me in front of a computer all day is never going to work. I feel they knew that. I also feel I targeted, probably because I disclosed my mental health history to the DMS. And then the other physicians working there, including the DMS were well renowned for leaving early, according to the many junior doctors I spoke with. Or they would take an hour or two off to take their junior doctors off to a local restaurant or send them out to get coffee. I never did any of that because I felt it was inappropriate, but yeah, I was the one, the only female physician, I was the one targeted, because I had mental health issues, which were then exacerbated by how I was treated in the THS. I am a specialist in a field that is really in an area that needs my help. I am on Jobseeker because none of the physicians I worked with would give a reference, I assume because of the mental health stigma. So good luck trying to change that, it is a multi-generational, core belief system amongst physicians: if you have a mental health condition, you must be crazy, unreliable and poison. It is a disgrace really, but when you forced down into the gutter, you really have no way out
Wow! Great article which addresses the real issues and particularly the psychological safety that is vulnerable to the workplace, administrators, and AHPRA!
In the short term, recovery can only start when the trauma ceases.
In the medium term, a lot has been done to allow the calling out of bullying behaviour by other doctors but more is required.
In the long term, something has to be done to stop administrators and AHPRA living off the fear of doctors.
Neither are able to be held accountable because of the powers they have been given to harm doctors!
Congratulations Dr Rowe. I am not knocking your methods, but I have never discussed my probs with anyone, so in case there are others of similar bent, what has helped me is 1: Jog or swim for 1/2 t 1 hour 3 or 7 times / week. Sporting tricks like shaking my fist at the void (always out of sight) always surprise by their helpfulness. Singing, alone or in company.
I so agree with you, Leanne. I think we talk a lot about prevention, but as a GP who started my career in heavy industry in the 1970s, I know what it took to keep heavy industry safe. I remember as a child passing signs on the road saying “x number of days since our last fatality”. I’m not suggesting we repeat that strategy, but that’s what it took to get people to wear safety boots, use safety equipment and manage forklifts.
I think in medicine, one of the things we don’t do well is the aftermath. There is often a long tail of trauma, and returning to work is so hard. We also don’t do a root cause analysis. We would if a patient is harmed, why not a doctor? I also think it’s time to curb the workcover insurers who cause more trauma in many ways.
Thank you for this excellent article. I always appreciate the work you do.
As always insightful powerful piece
Says it clearly from some one who indeed can speak with authority
GT
Have you considered applying this to war veterans? Would your opinion change if for ever time you said “doctor” you said “soldier”? Do we tell them that their PTSD is curable and therefore they will be able to return to the battlefield in time? Do they not have a certain degree of irreversibility to their condition once it has reached a certain severity? In all my years of practice working with veterans with PTSD I cannot say I’ve seen many get to the point of return to work. What about us then? Perhaps not everyone can, even with intensive therapy, make a recovery.
A heavy but important topic