11 October 2017
Doctor burnout: the urgent need for culture change
Hundreds of medical trainees in Western Australia took a new oath this year. It starts with a vow, sworn in the presence of their esteemed colleagues, to look after themselves “in the face of adversity and 80 unfinished discharge summaries”.
Lighthearted it may seem, but these are fighting words. The WA Intern Oath takes aim at deadly serious structural problems which are blamed for doctors young and old falling victim to burnout, mental illness and worse, ground down by an unforgiving professional culture and relentless work and study demands.
Dr David Oldham, a GP and longstanding medical educator, says the approximately 250 interns (from four of his state’s five training institutions) were enthusiastic about reciting the oath at their orientation sessions early in the year.
Six months later, he went back to them with a question.
Who had managed to last half a year without breaking their vows, say, by failing to speak up against bullying and unprofessional behaviour (rule no. 2)?
Or by not asking for help when they were struggling (no. 6)? Or by not feeling guilty about taking their half-day off and claiming hard-earned overtime (no. 8)?
“Not one had kept all of them. Not one,” Dr Oldham, the director of clinical training at Fiona Stanley Hospital, said.
Evidently, the attitudes and expectations that drive many medical professionals to despair take root early and are hard to dislodge. But where is the response from the profession?
In 2013, a beyondblue report showed Australian doctors had substantially higher rates of psychological distress and suicide attempts than other professionals and the general population.
Its survey of more than 40,000 medical professionals, and more than 6000 medical students, found younger doctors and women doctors reported the most acute levels of distress.
What is surprising in the intervening years, however, is the lack of concerted work by the medical profession, the colleges, and the health system, to overturn the work practices at the heart of the problem.
“I’ve seen very little shift in terms of medical culture,” Dr Oldham said, referring to his 20 years in medical education and 10 years of involvement in the WA Doctors Health Advisory Service.
“Doctors’ suicide is just a symptom of the underlying toxic culture,” he told The Medical Republic.
“There has been a little bit of improvement in the hospital system in terms of conditions, with the introduction in Western Australia of safe working hours … Eastern states don’t have safe working hours in their award.”
At Dr Oldham’s suggestion, WA doctors in training, led by GP trainees Dr Ros Forward and Dr Sarah Newman, developed the Intern Oath to send a countervailing message about self-care to trainees at the start of their careers.
“When you are a junior doctor, everyone comes first, before you,” Dr Newman said.
“We know they’re at high risk of burnout, psychological distress and suicide. So if we can get people at the start of their training, and get them to consider these little things to help them maintain their welfare, it might instruct them going forward.”
The oath addresses habits that junior doctors struggle to prioritise. It’s a spin on applying the Hippocratic Oath to self-care.
“Bringing together that ceremony and that dedication can help provide junior doctors with the best ammunition to look after themselves, and their colleagues – and their patients,” Dr Newman said.
“Why don’t we apply the same evidence we apply to our patients to ourselves and our healthcare systems? We do it every day for our patients but, somehow, we never reflect on it for ourselves.”
Dr Newman, co-chair of the AMAWA doctors-in-training welfare subcommittee, said doctors applied a double standard by “stigmatising” medical colleagues who had a mental illness, an attitude they would not take towards patients.
One tactic, counselled by the more advanced doctors’ health movement in the United States, is to encourage doctors and medical students to tell personal stories about overcoming adversity.
Some US medical schools and hospitals also have circles of peer-mentors to encourage troubled doctors to speak up, seek treatment and avoid self-destructive coping behaviours such as alcohol, drug use and overwork.
Dr Newman, who experienced depression that interrupted her training, said she would like to see motivated individuals and groups start banding together to erase the stigma around mental health and engender collegiate support.
“I feel like there’s an acknowledgment that there is a problem and a need to change. It’s going to take years, but we are doctors – we can problem-solve,” she said.
“We can be smart about this and not try to reinvent the wheel. Collegiate communication is something we strive for in general practice and complex management.
“Even if we save one or two people from bad outcomes it’s worth it, but we can all benefit from better welfare. Just because we are not depressed, it doesn’t mean we’re not having a hard time and we don’t have psychological distress.”
In an era of intense competition for training places and chronic underfunding in health, Dr Newman believes hospitals have lost the esprit de corps that sustained previous generations during their time as junior doctors.
“That morale and spirit was a form of reward,” she said.
“If you take that away, you’ve got junior doctors who have increased stressors in their training. They have to jump through hoops, often being rejected year after year, and they’re being pushed through more quickly, streaming down different pathways, maybe before they have full experience of the hospital and feel confident about what they are doing.”
Bullying is no longer acceptable in medical education, and sexual harassment in medicine is starting to be called out like never before. And more Australian hospitals are investing in staff welfare officers.
On the other hand, no hospital administrator in Australia would hear a room full of interns pledging to take half-days and claim overtime without guilt, and vowing to support colleagues to do the same, without also hearing an inner shriek of “they can’t be serious!”.
“The problem at hospital level is that budgets are tight, everyone’s busy, and if no one complains, (the status quo) just goes on,” Dr Oldham said.
“At a department or a team level, everyone is competing to get a job and into a training program, and no one speaks out, so nothing changes.
Also, teams will often say their juniors are expected to work extra hours and not complain or expect any payment.”
The reality is, doctors shrink from admitting to any weakness, especially a mental problem, such as anxiety or depression. Yet, according to the beyondblue survey, 21% of doctors had been diagnosed with depression at some point, and 9% with an anxiety disorder.
“Junior and senior doctors have said they’d rather have a diagnosis of severe cancer than depression. If they had a choice, they’d rather have a cancer diagnosis because having serious cancer has very little stigma attached to it,” Dr Oldham said. “You can go and talk about it and everyone one will come and embrace you, but if you tell anyone you’ve got depression they will run away from you.”
Junior doctors in difficulties make up the bulk of calls to Western Australia’s 24/7 doctors health help line. The other prominent group is international medical graduates feeling isolated in rural parts of the state.
In what might be a positive sign, junior doctors appear to be increasingly ready to push back against onerous work conditions.
“I think they are certainly complaining more,” Dr Oldham said. “The older consultants will say they need to toughen up. They put them down, saying they’re not as resilient as us. What that means is, they don’t just shut up and get on with the job.”
Dissatisfied with the pace of change, however, he says the doctors’ health movement needs to focus on solutions.
In a survey conducted after a recent spate of suicides by young doctors, more than two-thirds of junior doctors in NSW said they feared for their own health and safety owing to overwork, and 71% were anxious about making clinical errors because of fatigue.
The survey, by an alliance of the AMA (NSW) and the state branch of the Australian Salaried Medical Officers Federation, found 90% were not paid for all their overtime and more than half worked more than 90 hours a fortnight. Two-thirds thought there would be negative consequences if they spoke out against bullying.
The NSW Health Minister, Brad Hazzard, at a forum in June, conceded the health system was “not working as well as it should” for doctors in training and unsafe work hours were among the concerns.
Dr Tony Sara, president of ASMOF NSW, said hours remained a key issue, but nothing would improve unless doctors learned more compassion and organised to improve the work environment.
“You have to be an organiser and encourage colleagues, or become senior people who are prepared to draw the lightning bolts from the critics, and make systemic structural changes – or we will be having the same discussion in 30 years,” Dr Sara told The Medical Republic.
“The only way to change these ‘eat our own young’ systems is to change the game,” he said.
“We have to change the profession in a short-to-medium length of time.
“We have to change the industrial arrangements to prevent these things from happening to young doctors.”
Dr Sara said he had been hearing the same arguments since the late 1980s.
“In terms of caring for each other, junior and senior doctors, we have to be kinder. We have to change the culture.”