Public hospital leadership must eliminate workplace abuse of doctors in training, not perpetuate it

Two weeks ago, a public hospital human resources officer’s email referring to doctors in training as “a workforce of clinical marshmellows [sic]” lit a firestorm in social and national media. The insult was described as “a very common attitude amongst public hospital HR/admin towards JMOs [junior medical officers]”, and couldn’t have been more ill-timed.  

In November, the government legislated Work Health and Safety (Managing Psychosocial Hazards at Work) Code of Practice 2024  was announced to support changes to work health and safety laws (WHS). It is now in force across the Commonwealth, but it provides guidance to all jurisdictions on how to prevent harm from psychosocial hazards at work.

Of course, public hospitals are not exempt from WHS laws in their jurisdictions, and directors and officers (board members, chief executive officers, and human resources managers) may face significant penalties for breaching them.

To add injury to insult,  it appears that some public hospitals have not heeded the outcry following the December 2024 release of the well-publicised  Medical Training Survey (MTS) of over 24 000 doctors in training. The surveys performed by the Medical Board over the last 6 years present irrefutable evidence of unsafe working conditions and high levels of intractable bullying, harassment, discrimination and racism, aggression and violence in public hospitals— a period coinciding with many doctors risking their lives on the frontline during the pandemic.

In the 2024 MTS, one-third of trainees (33%) reported having experienced and/or witnessed bullying, discrimination, harassment, sexual harassment and/or racism, spiking to 54% of Aboriginal and Torres Strait Islander trainees and 44% of interns. Sixty-nine percent of doctors in training reported that these experiences had severely impacted their career progression. The 2024 MTS also revealed that 47% of all trainees described their workload as “heavy” or “very heavy”, with 21% working unrostered overtime that significantly detracted from their training. Eighteen percent of trainees reported being forced to work unpaid overtime, which is another red flag given the successful class action in relation to wage theft by doctors in training resulting in settlements of hundreds of millions of dollars by public hospitals.

There were also positive statistics in the MTS, but public hospitals will be concerned at a time of medical workforce shortage that nearly one in five doctors in training are contemplating a future outside of medicine mainly due to their negative experiences.

Following the release of the 2024 MTS in December, the immediate past Medical Board of Australia Chair, Dr Anne Tonkin AO, said (paraphrased): “There is no place for bullying, discrimination, racism, sexual harassment or other forms of harassment in medicine or in any civil society. …. There was no excuse for the lack of professionalism and respect reported by trainees ……I am appalled by what Aboriginal and Torres Strait Islander trainees report”.

The Australian Medical Association (AMA), the Australian Salaried Medical Officers Federation (ASMOF) and others have advocated tirelessly for workplace rights, and for more action on work-related mental health problems and suicide in doctors in training. AMA states (here, here) also advocate and monitor the sentiments of doctors in training annually, and this data supports the negative findings of the MTS survey.

In the past, this long term advocacy on chronic work health and safety (WHS) issues has not always been acted on in public hospitals because of competing priorities for limited resources. No-one would argue that public hospitals must prioritise the reform of intergovernmental health funding to provide equitable, high quality patient care first and foremost.

But as Dr Anne Tonkin AO said in early 2024, with the release of the MTS results based on gender: “the established link between poor culture and increased risk to both patient safety and doctors’ wellbeing requires urgent attention”.

Public hospital directors and officers could face substantial fines, criminal charges and imprisonment for serious WHS breaches

All directors and officers require up to date expert WHS legal advice to fully understand the regulatory environment, their responsibilities, and potential penalties in their jurisdictions because WHS in Australia is changing.

Safe Work Australia developed a single set of laws known as the ‘model’ laws, but the government legislated amendments to the model WHS Act do not automatically apply unless they have been implemented in a jurisdiction. Despite the concerted efforts of Australian governments to put in place laws to help harmonise occupational health and safety laws as part of national reform,  a complicated interplay continues between the Fair Work Commission, Safe Work Australia, the Office of the Fair Work Ombudsman, the Australian Human Rights Commission, and the 11 workers' compensation schemes.

To summarise, if WHS breaches result in serious harm — whether psychological or physical — the consequences for directors and officers may include substantial fines for individuals and organisations (sometimes not covered by insurance), criminal charges, imprisonment and disqualification from managing any other company or organisation. The insurance premiums for directors and officers are soaring because of costly WHS litigation.

Mitigating WHS risks requires a proactive approach by public hospital directors and officers, as they may not be fully aware of WHS non-compliance in their own public hospital. Findings from the 2024 MTS indicate that doctors in competitive specialist training programs with limited tenure are often reluctant to report incidents of workplace abuse for fear of punitive career repercussions. However, such under-reporting is not a defence for directors and officers in WorkSafe investigations and enforcement proceedings, given the MTS and AMA survey findings over the last 6 years.

Public hospital directors and officers can reduce their legal liability by promoting safer work environments for all employees, including doctors in training

As public hospitals are hazardous environments that require occupational health and safety management of the highest standard, directors and officers also require specialised advice to protect them from legal liabilities.

However, it is important to note that legal protection can be built by directors and officers through a range of positive practical measures that would benefit doctors in training, including preventing and managing WHS hazards through the implementation of clear and contemporary policies and procedures, visible support from senior management and supervisors, and monitoring of anonymous independent surveys or other tools to gauge work culture and manage potential WHS issues early, as well as appropriate follow-up after WHS incident reporting.  

Directors and officers can also establish fair, confidential complaint processes including whistleblower protections for complainants, ongoing staff training on accountability, and regular HR and other management performance appraisals. Heads of departments and other senior doctors can also be enlisted to play major roles in creating physically and psychologically safe workplaces.

It is recognised that public hospitals must set an example to other Australian workplaces in reducing work-related physical and mental injury. There is a myriad of information about ways to prevent and manage WHS hazards on government and other websites, a snapshot of which is provided below:

1. The right to fair, safe working conditions

The Fair Work Ombudsman has set out clear advice on basic workplace rights including fair rosters and patient loads, breaks, leave, flexible working conditions and cover for leave requirements.  

Common well known psychosocial hazards predisposing employees (including doctors in training) to work-related mental injury include: excessive job demands causing fatigue, which endangers safety, particularly in remote or isolated work; low job control, job insecurity and poor support especially after exposure to traumatic events.

2. Bullying, discrimination and racism

All workers have the right to a workplace free from unlawful bullying, discrimination and racism.

The Fair Work Commission deals with applications to stop bullying at work under the Fair Work Act. The Australian Human Rights Commission also has responsibilities to respond to discrimination and racism at work. 

3. Amendment to the Sex Discrimination Act

In December 2023, following legislative amendments to the Sex Discrimination Act 1985 (Cwlth), the Australian Human Rights Commission was formally granted new powers to investigate and enforce an employer’s “positive duty” to take reasonable and proportionate measures to eliminate certain types of unlawful conduct. All workplaces, including public hospitals, must now address hostile work environments and eliminate unlawful behaviours, such as direct or indirect sex discrimination, sexual harassment, sex-based harassment and victimisation of complainants or witnesses.

4. Aggression and violence

Under WHS laws, organisations and employers must manage the health and safety risks of workplace violence and aggression, and this is particularly relevant to the rising threat of violence by patients against doctors, especially those in training (here, here).

Directors and officers face severe fines and criminal charges for industrial manslaughter if it is found that their failure to address known workplace hazards led to the death of an employee or contractor due to unsafe working conditions, including assault, accident or suicide.

Conclusion

In this opinion piece, I have simply summarised some well-known WHS laws, standards and rights.

However, the application of WHS laws to the working conditions of doctors in training is not simple because of the need to balance the needs of patients and personal safety. But one thing is clear. There is an urgent need for stronger advocacy: more government funding to help public hospitals comply with government-legislated work health and safety laws, and greater accountability by public hospital directors and officers.

Unfortunately, one human resources officer’s insulting “marshmellows” comment sparked national outrage about the injustice of intractable workplace abuses of doctors in training in some public hospitals.

An apology from the hospital that ridiculed doctors in training is not enough.

In the context of changing WHS laws, all public hospital directors and officers must now confront an important question: Can we afford not to prevent and manage the intractable workplace abuse of a significant cohort of doctors in training?

Clinical Professor Leanne Rowe AM is a GP who has also served as a non-executive director in the health care system for nearly 30 years. She is past Chair of the RACGP and co-author of the book “Healthier doctors = healthier patients”, published internationally by Taylor and Francis. In the past, she has written on WHS issues for Insight+, including bullying, suicide and wage theft.

If this article has raised issues for you, help is available at:

Doctors’ Health Advisory Service:
NSW and ACT: 02 9437 6552
NT and SA: 08 8366 0250
Queensland: 07 3833 4352
Tasmania and Victoria: 03 9495 6011
WA: 08 9321 3098
New Zealand: 0800 471 2654

Medical Benevolent Society

AMA lists of GPs willing to see junior doctors

Lifeline on 13 11 14
Beyondblue on 1300 224 636
Beyondblue Doctors’ health website