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Burnout in health care undermines the safety of patients and practitioners alike, and there are growing calls for this genuine health care crisis to be properly addressed.
Burnout remains a serious problem across health care in Australia (here). For people on the frontlines, it would not be surprising to learn that as many as 58% of Australian health care workers report feeling moderate to severe burnout. This number is alarmingly high, but with more being known of burnout as not just an individual illness but as a symptom of broader societal and occupations ills (here), we are forced to consider why this is.
The answer may well be ourselves. Concerningly, the Australian Medical Association (AMA) have once more confirmed that up to 50% of doctors and trainees (not including medical students) have experienced bullying, discrimination, harassment or sexual harassment. In keeping with trends from previous years, the reported incidences remain consistently high and assert an alarming status quo. Given this toxic milieu, it may not be surprising to learn that about one in five junior doctors is seriously considering leaving the profession.
These numbers speak to a health care endemic attitude that demands the commensurate attention and investment needed to combat other crises, such as the recent coronavirus disease 2019 (COVID-19) pandemic.
Although we must acknowledge these behaviours are in no way isolated to health care, the stakes are undoubtedly higher in our profession. In any other industry, when burnt-out staff persist in toxic workplaces for lengthy periods, their workplaces observe high rates of attrition and diminished productivity, with resulting insults to an organisation’s bottom line (as this overseas study shows). It remains the same in the health care industry, with one vital distinction: patient care is jeopardised. For example, a report found doctors who report signs of burnout are twice as likely to have made a medical error in the past three months, three out of five junior doctors report making clinical errors resultant from experiencing severe stress (here), and existing research observes burnt-out doctors frequently made poor decisions concerning patient care (here) and even display hostility towards patients.
It is well known that a major contributor to individual burnout is poor occupational culture (here): one that does not promote psychological safety, nor empower members of a clinical team. In such environments, doctors, nurses and other health staff are more likely to observe unacceptable behaviours such as bullying, harassment, discrimination and abuse, with more common examples including undermining, preferencing and interpersonal microaggressions (here and here).
And although awareness of such workplaces has been anecdotally known about for a long time, it seems that only recently our profession has sufficiently matured to hold a mirror to its conduct.
However, we fear individual appeals to empathy alone may not be enough to sustain the effort that is required to ensure the psychological, social, physical and cultural safety of our workspaces. As the numbers accumulate and the clock tolls, it is simply not enough to consider these as handy accoutrements to an organisation. These should be, in fact, inalienable rights afforded to all health care workers.
Therefore, we consider the financial costs of burnout on individuals, organisations and communities in the hope this encourages hospital administrators and health economists to continue to treat this problem with the attention we on the frontlines feel so passionately that it deserves.
As if the individual costs weren’t enough to prompt action, what are the economic consequences of inaction?
Financial costs of bullying
The financial corollaries of burnout are enormous. Should this epidemic continue unfettered, the cost will be felt not only by clinicians but also by their patients, organisations and the broader community. Corporate data from the United States indicate that employees who encountered workplace misconduct missed an average of six days of work in 2021. This equates to 43 million sick days nationally, at a (conservatively estimated) loss of US$8.54 billion to the American economy.
Similar figures have been seen locally, with an Australian state government-commissioned report citing bullying, harassment and workplace fatigue experienced at South Australian hospitals equating to 20 000 forfeited days of work. This exacts a cost to taxpayers of AU$20 million, placing increased pressure on health care resources already severely depleted in the aftermath of the COVID-19. pandemic
But it’s not just the productivity forfeited by sick days that makes the problem of workplace misconduct so financially pernicious. Workers who are able to persist in spite of these conditions demonstrate presenteeism — the experience of “barely there” functioning underscored by suboptimal work, which also results in similar forfeits in productivity and worker distress.
For some, this is then compounded by the high rates of health care worker attrition observed in the aftermath of the COVID-19 pandemic.
Organisations seen to abet workplace misconduct also invite legal recourse as well as damage to their reputational capital and professional credibility. Established legal protections entitle employees to exercise legal action against their employers owing to a breach of implied duty of trust and confidence, with precedence set in Australia already.
When mapped onto health care, the ramifications are perhaps more profound. Such damaging behaviours also sew broader public mistrust, threaten patient engagement and forces the community to consider how they might hope to be looked after, heard and respected, if their caregivers cannot extend the same courtesies to their own.
For these reasons, the true cost of unsafe health care workplaces may remain difficult to truly quantify.
What is being done?
Efforts are being made to combat these issues. Specialist training colleges and health care organisations in particular have instituted several measures in recent years and should be congratulated for making great strides. These include the Royal Australian College of General Practitioners (RACGP), the Royal Australian and New Zealand College of Psychiatrists and the Australasian College for Emergency Medicine. Although these campaigns vary in their approaches and context, they broadly share a mutual understanding of the scale of the problem, and seek to promote awareness, generate robust support networks and empower members to understand and access their occupational rights.
Some notable examples include the institution of the Australian Orthopaedic Association’s Wellbeing Committee, the British Royal College of Emergency Medicine’s RespectED antibullying campaign, the “Cut It Out” initiative of the Plastic Surgery Trainees Association of the UK, and the #HammerItOut initiative of the British Orthopaedics Trainee Association.
A well publicised test case concerns the efforts of the Royal Australasian College of Surgeons (RACS) that have undertaken several initiatives under the auspices of its “Operate with Respect” campaign. This campaign commenced with an apology to its fellows, members and the broader public in response to the findings handed down by an advisory group into bullying, discrimination and sexual harassment among the surgical workforce.
Since then, the campaign has seen the recognition of culturally safe practice as a tenth surgical competency, overhauled its complaint handling processes, promoted flexible training schemes and forwarded programs to safeguard wellbeing for trainees and Fellows.
The success of these initiatives is generated by motivated memberships recognising the genuine appetite for change, but are all underpinned by substantive investment on the part of the organisation. Given the relative infancy of this work and apparent lack of evidence-based guidance, this continued research is vital.
Likewise, a local rural hospital health district has even reported their first ever deficit reportedly owing to costs allocated to confront workplace bullying, at a cost approximating AU$1 million. Most of this expenditure was allocated to undertaking an independent review examining the scale of the problem in the regional health district, prompted by a spate of allegations of bullying, nepotism and even threats levied against staff who chose to speak up. The wide-ranging review uncovered a corrosive culture that threatened staff and patient safety. This led to the institution of several key initiatives, including an overhaul of the organisational structure, the provision of mandatory occupational and psychological safety training for all staff, and a revision of complaint handling processes, among other measures.
Although the expenditure required by such reviews may sound exorbitant, for these programs to be effective, they must not be reactive but comprehensively proactive. Just like many noxious stimuli, long term exposure can be difficult to detect until it’s too late.
Such activities are both desperately needed and well intentioned, but do not come cheap. However, the efforts involved in motivating genuine cultural change is not small. After all, medicine is confronted with the challenge of untangling decades of harmful historical memory.
We contend these measures are not frivolous, feel-good expenses, but essential investments necessary to promote the workplaces that both ourselves and our patients deserve.
Conclusion
The intervening phenomena of poor workplace culture, burnout and bullying exact immense and perhaps immeasurable costs on individuals, institutions and communities. In health care, the results of these behaviours undermine the safety of patients and practitioners alike. When framed as a genuine health care crisis, one understands the importance of initiatives designed to promote awareness and to challenge damaging behaviours. This investment may not come cheap, but is undoubtedly necessary to safeguard the health of our patients, our colleagues and ourselves. Consequently, we must continue to lobby those in positions of power to reaffirm their commitment to promote an inclusive and psychologically safe culture throughout our profession.
Certainly, many of these problems are unfortunately seen in all sectors of the Australian economy. However, given the harmful health effects and significant costs they incite on patients and our communities, we as doctors and health advocates must take this issue seriously and function as community role models by eradicating workplace misconduct in all its forms. Cultural change requires not just a recognition of the problem but active engagement assisted by targeted interventions with substantive financial support.
Although the financial effort involved with doing so is not insignificant, failing to do so levies a price to pay that cannot be measured.
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.
Further resources
Doctors’ Health in Queensland: https://dhq.org.au/
Doctors’ Health New South Wales: https://doctorshealth.org.au/
Victorian Doctors’ Health Program: https://vdhp.org.au/
Doctors’ Health Advisory Service Western Australia: https://www.dhaswa.com.au/
Doctors’ Health South Australia: https://doctorshealthsa.com.au/
Drs4Drs Tasmania: https://www.ama.com.au/drs4drs/tas
Drs4Drs ACT: https://www.ama.com.au/drs4drs/act
Doctors’ Health Northern Territory: https://doctorshealthnt.com.au/confidential-support
Dr Chris Erian and Dr Michael Erian are twin brothers both currently working as Orthopaedics Principal House Officers at the Sunshine Coast University Hospital and Ipswich Hospitals, respectively. Both share a keen interest in doctors’ wellbeing.
Dr David Bade is a Consultant Orthopaedic Surgeon and Director of Orthopaedic Surgery at the Queensland Children’s Hospital. He also serves as the Chair of the Australian Orthopaedic Association (AOA) Surgeon Wellbeing Group, in addition to his role as AOA Queensland State Chair.
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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If you would like to submit an article for consideration, send a Word version to mjainsight-editor@ampco.com.au.
Culture starts at the top. Consultants under pressure because of the exponentially increasing bureaucratic demands become stressed, time-poor and understandably at times short-tempered or cranky. There appears to be a huge effort going into supporting trainees, but let’s not overlook the more senior members of our profession who undertake the training and supervision of junior doctors. Anyone who has been informed that Medicare has retrospectively changed the interpretation of certain item numbers and that they need to repay thousands of dollars “improperly” claimed, or that they have been “selected” for an audit of their last two years of referrals to check that they were written correctly, would understand what I mean. Most medical organizations, including the AMA and specialist colleges, do not seem interested in supporting their members in private practice over such issues. Then there are the ridiculous changes to CPD from AHPRA to contend with as well.
Habituated human behaviour is very difficult to change without a fundamental realignment of incentives. So long as a specialty or subspecialty jealously guards its hierarchies and the patronage of well-connected supervisors, trainees will continue acting in ways that promote their personal progression through that system, and supervisors will continue to exercise the influence that keeps them feeling influential and relevant.
To change these patterns, trainees need to be rewarded for good interpersonal skills and personal insight as well as knowledge, clinical judgement and procedural skills. They need to be rewarded and praised for maintained work-life balance rather than for staying back later than everyone else. Assessments from co-workers in other specialties and other professions should have real meaning in progress.
Without the desired behaviour being modelled and rewarded by supervisors, trainees will always be motivated to behave in ways that benefit their careers, no matter how good the written policies are.
Perhaps more than anything, the entire medical culture – especially its institutions – must accept that error is inevitable and perfection impossible in life.
in the public health system ( I’m in NSW) low staffing levels particularly post-Covid but often longstanding have made it impossible to conduct reasonable patient workflow. This creates enormous stress within the system to get even the simplest things done, patients wait for ages and become increasingly anxious and often rude, lashing out at frontline staff. . Staff then take more time off on stress leave and we spiral ever downwards .
Adequate staffing of public hospitals would go a long way to alleviating burn out
An excellent article . Thank you . The final statement that these are not feel good frivolities but are essential investments is so true .
In my hospital there is only one SMO out of 15 that is full time.
We have all realised that full time equivalent with strenuous on call rosters is not sustainable.
We now work in avariety of FTE from 0.4 to 0.8 (except our one full timers), which has greatly improved morale at work and reduced burnout.
Having such flexibility in FTE is rare, with poor insight from managers, but has kept us all going!
The intricate link between organisational culture and the psychological safety as well as occupational safety of all members associated with the healthcare organisation has been highlighted very well in this article.
As well all know burnout is a cumulative state encompassing cynicism, exhaustion and depersonalisation which ultimately leads to suboptimal performance amongst the affected medical peers. The suboptimal performance not only result in unwanted clinical errors but can also result in change of behaviour as a secondary consequence.
In my opinion, burnout is not an end result state but a spectrum along which a subject’s professional performance and behaviour diminishes over a period of time.
Proactive approach to early identification of the risk of burnout and prevention of secondary consequences may be able to stop the individual’s progression along the debilitating spectrum of burnout before it reaches the worse end of the spectrum.
While all the initiatives mentioned in the article from the respective colleges and fellow societies provide a good head start to tackle this real threat to the well-being of medical professionals it is also very important for all healthcare employers to keep monitoring the tangible indicators like attrition rate of medical officers, total number of complaints of bullying and harassment, number of sick leaves etc.
The part that AHPRA has played in the burgeoning of disaffection within the medical profession should be analysed and following recognition and quantification remedied where needed.
What about PATIENT burnout ??
Never have I encountered so much rudeness with consultations – both existing patients and new referrals.
Careful. The author quickly jumps from a warning about error-causing burnout, to focusing on a single contributor of that burnout that may or may not even be one of the largest. There are many causes for burnout, one known to be the increased reliance on EMRs with poor useability, another being the ever increasing bureaucratic documentation requirements (what used to be called ‘paperwork’, when we only used paper). And of course, increased workload in busy hospitals and GPs across the country, especially post-pandemic.
Maybe the title of this article should be “bullying as one unquantified cause of burnout leading to clinical errors…”