Every doctor can create a psychologically safe health care workplace

In Part 3, my goal is to begin a positive conversation about the role of senior doctors in cocreating psychologically safe health care workplaces, particularly for early career doctors.

“A doctor must work eighteen hours a day and seven days a week. If you cannot console yourself to this, get out of the profession.”

During the 20th century, these famous words from Dr Martin Henry Fischer (1879–1962) were often quoted to students on their first day of medical school with a veiled threat to “toughen up”. Unfortunately, remnants of this outdated “get over it or get out” attitude in medicine is continuing to contribute to a psychologically unsafe health care workplace the 21st century.

Why are early career doctors more at risk of work-related mental injury?

Most doctors are highly resilient. But for many clinicians, particularly early career doctors, the coronavirus disease 2019 (COVID-19) pandemic was defined by loss. Loss of career progression, exam preparedness and training opportunities. Loss of certainty about the future, growth in friendships and relationships, and formative social and emotional experiences. Loss of patients, family members and colleagues.

Although we would all rather put this in the past and “get over it”, overstretched hospitals and other health services are relying more than ever before on the good will of hospital medical officers (HMOs) and registrars to prop up health system budget deficits and financially unviable practices. In the current environment, early career doctors are being pressured to take on heavy patient caseloads, extra shifts and unpaid on call and after hours, and induction, training, supervision and support are often cut short because of other pressing needs.

Adding to these pressures, bullying, sexual harassment, discrimination and racism persist in medicine despite being unlawful. As a result of witnessing unethical actions or behaviours in health care, moral injury may also have profound consequences for early career doctors.

For as long as anyone can remember, the competitive nature of training programs and the short tenure of HMO and registrar positions and rotations trap young doctors into feeling powerless to influence their work conditions or to admit to having a mental health problem.

To complicate these stressors, most doctors would never consider taking stress leave let alone reporting a work-related mental injury to an employer due to the negative stigma involved and justified fears of jeopardising future career options (see Part 1 of this series for more). Unfortunately, a growing number are quietly reducing workplace participation and exploring alternative careers, further compromising medical workforce shortages.

Doctors-in-training therefore need health system reform, not more resilience.

Why must senior doctors advocate for psychologically safe health care workplaces?

Many senior doctors, who have established careers and do not risk career damage, have recognised their important role in advocating on behalf of junior colleagues to reform the health care system. Why are others resistant to doing so?

Although it may take a seismic shift, it is time for more senior doctors to take leadership and responsibility for implementing contemporary human resources policies and procedures in relation to psychologically safe workplaces, safe hours and fair pay, and the prevention and management of unlawful bullying, sexual harassment, discrimination, and racism for all health workers in all health care workplaces. Unfortunately, it is common to see doctors averting their eyes to uncivil behaviours and breaches of codes of conduct when perpetrated by colleagues. The medical profession can solve these intractable problems if doctors role-model professionalism and adhere to contemporary codes of conduct, Fair Work Commission conditions and human resources law. Notwithstanding the complexity of the issues and the significant penalties for employers when workers are harmed, there would be a significant improvement in our health care workplace cultures if senior doctors would call out unacceptable behaviours as well as the cowardly silence of bystanders.

One of the most personally challenging barriers deterring senior doctors from confronting workplace mental injury is that we must first confront past unresolved repetitive exposure to traumatic incidents (here) and acknowledge the negative impact on ourselves and others, including our families. I discuss workplace mental injuries in more detail in Part 2 of this series. Like many doctors of my generation, I recognised the personal impact of repeated trauma exposure  late in my career:

“As a rural GP, I was a first responder to cardiac arrests and motor vehicle accidents in my community for nearly 30 years. After any traumatic death, I never took time to grieve or debrief because I had to get straight back to work. After I left the practice, I briefly returned to the local cemetery to visit the new grave of a friend. During my search for her headstone, I stumbled across the plots of many of my other deceased patients – those who had died in car accidents, by suicide, in farm accidents, after failed CPR, or from terminal cancer at home. It was as if I opened the locked gates to an abandoned cemetery in my head. The vicarious trauma associated with listening to stories of child abuse, intimate partner violence and other horrific experiences, as well as the direct trauma related to being bullied and assaulted seemed to be buried in the same subconscious graveyard.”

The first step to recovery from mental injury is early recognition

These experiences are so common in health care, many doctors and other emergency services personnel including nurses and ambulance officers may dismiss them as “just part of the job”. Acute horrific incidents faced by police at a murder scene, a State Emergency Services worker in a natural disaster, a journalist in a war zone, or a young apprentice with a severe chain saw injury are easily recognised as significant traumatic events. What non-psychiatrists commonly underestimate is the damaging psychological impact of repetitive retriggering of work-related traumatic events in psychologically unsafe workplaces, particularly when there is no time for time out due to a shortage of health care workers.

In this environment, all health care workers seem to be suffering from chronic burnout and become expert at blocking emotions at and off work. This unhealthy avoidance can be a psychiatric symptom. Confronting unpleasant symptoms of traumatic mental injury, such as suppressed anger, profound sorrow, unwarranted guilt, and mental exhaustion and overwhelm takes courage, particularly when a significant proportion of the medical profession continues to equate the disclosure of a mental health problem with “career suicide”. 

It is time to make peace with ourselves and each other by fully validating and accepting our human experience in medicine. In the wonderful highs and inevitable lows of our medical careers, we gain unique insights into people and life. We share strong bonds with colleagues who have been there and recovered from workplace mental injury too. We can experience joy and an enormous amount of satisfaction, meaning and purpose in our work and our legacies.

I love being a doctor and the only regret of my 43-year medical career is that it took me so long to unlock the metaphorical gates to tend to my subconscious cemetery by talking about it openly. I have learnt the hard way that if we try to patch up the trauma of life’s jagged lacerations with tokenistic bandaids, our open emotional wounds continue to rebleed with future knocks. 

My positive message is that as a united medical profession, we can do so much more to cocreate psychologically safe workplaces and heal work-related mental injury for future generations of doctors — for the health and wellbeing of our patients, our families and ourselves.  

Much more than “get over it or get out”.

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.

This opinion piece was one of a three-part series:

• Part 1: Addressing mental health problems in doctors’ children
• Part 2: Every Doctor can recover from work-related mental injury
• Part 3: Every Doctor can co-create a psychologically safe health workplace

Clinical Professor Leanne Rowe AM is a rural GP and co-author 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.