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Parts 1 and 2 of this three-part series were a call to action to the medical profession to unite and transform its approach to preventing and managing work-related burnout and mental injury in doctors.
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 Unfortunately, remnants of this outdated “get over it or get out” attitude in medicine is continuing to contribute to a psychologically unsafe health care workplace the 21st century.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.
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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Thank you for your thoughtful assessment Leanne. A safe workplace is enshrined in law, activating safe workplaces accordingly is not impossible, it requires intent – will.
As a psychologist coach of doctors I hear these very challenging stories shared in the comments every week. Doctors as a group are motivated intrinsically to do their work, showing up to human suffering often simply because they can. This has been taken advantage of perhaps by the whole community, not just by employers, and by medicine itself.
For expectations to change they need to be named and noticed. Thank you for helping that process. After naming clearly what we have we can take steps towards what we desire – if we know what that is.
Collective, collaborative, systemic action can move the dial if people are willing to build the skills required. That will mean working with people who are non- doctors, including patients and administrators and letting go, unlearning some of our old ways. Painting a vision of the future so we know the hard work of the present is worth the effort. Your writing in this series can help with that too. Congratulations and thank you for helping to synthesise the complex thinking and for helping us see a path forward. We are better together
Such a touching article Professor Leanne Rowe. Thank you!
To this day I still recall unsafe unresolved workplace incidents that occurred during my hospital training years. I wish I had a mentor who could have talked me through it these incidents at the time, or to know it was safe for me to discuss it, and “not harden up”. It’s great that we can discuss these issues openly and accept our vulnerabilities and need for support during the difficult times.
Thank you for your wonderful articles!
I am acutely aware that this 3 part series may be deeply triggering for doctors who are working in unsafe and traumatic environments. It is difficult to adequately cover the complexity of the issues in word limited articles over 3 weeks and my goal is to challenge discussion of the issues in our profession.
I therefore very much appreciate all the comments after Parts 1-3, including those from doctors who have reacted with anger and emotion. Please know that other doctors recognise the gravity of what you are saying and the courage it takes to speak out. Unfortunately, many doctors (including me) resonate with your negative experiences and reactions.
However, disunity, cynicism, hopelessness, lashing out at each other or averting our eyes will not change the status quo. Based on my 43 year medical career, I hold the view that our profession has more influence to change the system than we currently realise – if more senior doctors would support and advocate for younger doctors and call out unacceptable behaviours in their peers as well as the cowardly silence of witnesses of workplace abuse. A safe workplace is a basic human right enshrined in workplace law. What is your view?
The concept is noble, but the execution may be impossible in the real world. “After any traumatic death, I never took time to grieve or debrief because I had to get straight back to work.” The problem is, if you take a day off without notice, whether for physical illness or mental stress, your workload is redistributed to your colleagues, as in the UK case of Dr Bawa-Garba. In a country town, that may mean a double load for the other GP. Or no GP at all.
In a public hospital setting, no hospital can afford to pay a second-on-call ENT surgeon/ENT registrar every Saturday night, in case one team has an exsanguination death on the Friday afternoon. Either the traumatised doctors suck it up and work the next day, or the poor sods who covered last weekend get their weekend off cancelled without notice – neither option is satisfactory. Or some unfortunate parent gets told that their child is going to exsanguinate from a tonsillar haemorrhage, because there is no ENT surgical team available. A hospital is not a ‘safe workplace’ like Qantas, ‘sorry your flight is cancelled, pilot has exceeded safe hours, come back tomorrow’.
For a solo practitioner, which remains the model for many specialists, a disgruntled cancelled patient can complain to regulators, and cause months of additional stress. Even a reasonable explanation like ‘I had to take Friday off after the death of my patient on Thursday’ may not impress the regulators, particularly if an oncologist does not see their sick inpatients or a neurosurgeon cancels a tumour list.
In NSW, public schools struggle to fill staff absences, even with 50 – 100 teachers in a typical school and about 44,000 casuals in the system. In theory a State Government could maintain a casual pool of doctors, particularly ‘interchangeable’ roles like anaesthetists or general residents, but that would be a difficult job in itself – “today you are in Westmead, tomorrow you start 2 weeks in Lismore…”. I don’t know about other states, but in NSW we don’t even have the same cardiac arrest phone number in every public hospital, when you’re really desperate for help. Let alone standardised sets of surgical instruments, or pathology forms.
We can be nice to each other, but often that means working when you are sick/tired/hungry/busting for a toilet break, because if you don’t do the work, someone else adds it to their workload, or patients suffer. Clicking through the links in this article, I did get a laugh out of Safe Work Australia’s risk factor: “Workers have little control over aspects of the work including how or when the job is done.” Compared to Friday night in the trauma centre, (“put your finger in that artery, Mr Jones, I’ll be back in 8 hrs after my mandatory shift break”) preventing “unlawful bullying, sexual harassment, discrimination and racism” is a doddle.
It is vital to recognise AHPRA’s role in the production of an unsafe workplace. As AHPRA has grabbed more and more power to name and shame before any evidence is heard, doctors have more and more reason to fear any vexatious, frivolous, or false allegations made against them.
Perhaps it is time to hold AHPRA accountable for the harm they have directly and indirectly caused to doctors, their families and their patients.
Great article. Thanks Leanne
I was defeated by my attempts to contribute to a psychologically safe workplace. The (hospital) workplace became unsafe for ME, and I had to leave after (at the time) 35 years in hospital medicine. I regret leaving so many more junior doctors struggling to cope within that culture, but I don’t regret my own move in the least.
I now work (in Emergency Telemedicine) with many of the same patients, and many of the same work colleagues, but with a much better employer (a private company) who values my contribution, shows me respect and is proud of the work that I do.
Hospital medicine has become all about compliance and reducing risk for the organisation (more than the patient). It’s brutalising – both for staff and patients.
Psychological trauma doesn’t just occur from seeing many sad events (I have had no shortage of these over a career in emergency medicine). It occurs from the anger and frustration of feeling disempowered, undervalued and being forced to provide a poor service.
In my early years, with much less training and many fewer resources, I felt trusted to do my best with the circumstances I was given. When I left the system, with so much more knowledge and experience, I felt that I was only valued if I was compliant and avoided organisational risk – not if I acted in the best interests of patients and colleagues. I also felt that the “risk management system” was more interested in controlling me than benefitting from my skills and judgement.
Our workplaces reflect societal norms, but public workplaces also contain perverse incentives and multiple layers separating patient and clinician.
I am now in a wonderful headspace, thoroughly enjoy my interactions with patients and other clinicians, and still manage acute risk in a rational way. Large public institutions can only provide these sorts of workplaces if the layers of management are at least as skilled in management as the clinicians are in clinical work, and if the values are aligned.
Thank you Leanne. I have also written, spoken and continue to advocate together with many other colleagues about the topics you have visited across this series[1]. I agree setting tone for psychological safety for our colleagues as senior consultants and clinical managers is essential. A major determinant of an employee’s wellbeing at work is their immediate manager. Team huddles, after-action reviews, small moments of connection all matter in creating the environment where staff feel safe for interpersonal risk taking and speaking up with questions, concerns and ideas. Read any of the research work by Professor Amy Edmondson or more locally my colleague Dr Eve Purdy, emergency physician and anthropologist [1,2]. However senior clinicians are also depleted, poorly supported, and as a generation part of the “suck it up” culture that has been pervasive for decades. The so-called “Era of Distress” persists in many areas of medicine[3]. Co-creating the future needs collaboration and investment across all levels of leadership in healthcare to empower senior clinicians at the critical work-unit level to build a culture of safety, high performance and wellbeing. Wellness-centred leadership has been described as: 1. Respect and care for people always 2. Commitment to building individual and team relationships 3. Inspire Change[4]. This is a framework we can all aspire to. Undoubtedly we have a growing coalition of leadership across Australia working for change and we must learn from the current pockets of excellent practice[5]. I welcome an end to the era of distress and our revolution to make way for “wellbeing 2.0”. The healthcare workplace wellbeing imperative has never been more pressing for the safety and wellbeing of future generations of clinicians and their patients.
[1] https://www.themindfullmedicpodcast.com
[2] Edmondson, Amy C. The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. Hoboken, NJ: John Wiley & Sons, 2018.
[3] Eve Purdy MD, MSc, Laura Borchert MD, Anthony El-Bitar MD, Warwick Isaacson MBBS, Cindy Jones PhD, Lucy Bills BSN, RN, MRes, MNP, Victoria Brazil MBBS, MBA
Psychological safety and emergency department team performance: A mixed-methods study
EMA 2023 June Vol 35;3:456-465
[4] Shanafelt TD. Physician Well-being 2.0: Where Are We and Where Are We Going? Mayo Clin Proc. 2021 Oct;96(10):2682-2693. doi: 10.1016/j.mayocp.2021.06.005. PMID: 34607637.
[5 ] Shanafelt T, Trockel M, Rodriguez A, Logan D. Wellness-Centered Leadership: Equipping Health Care Leaders to Cultivate Physician Well-Being and Professional Fulfillment. Acad Med. 2021 May 1;96(5):641-651. doi: 10.1097/ACM.0000000000003907. PMID: 33394666; PMCID: PMC8078125.
[6] https://beamtree.com.au/our-solutions/workforce-wellbeing/
Thank you for a brilliant article. The subconscious graveyard really resonated. There is so much to be done . As mentioned, the cost of burnout and early exiting is smashing the profession .