16 November 2018

Fatigue is a junior doctor’s greatest fear

Hospitals Mental Health

The loss of training credentials at two top-flight Sydney hospitals over alleged bullying could be taken as a portent that junior doctors are rebelling at mistreatment and aren’t going to take it any more.

But independent surveys of medical trainees – pioneered by the AMA in Western Australia in 2015 – indicate that bullying remains likely to go unreported and overwork is a growing concern.

The 2018 report card for NSW was released in October, soon after shocking revelations that Westmead Hospital’s intensive care unit and RPA Hospital’s cardiothoracic unit had been stripped of training responsibilities because of alleged bullying.

In the category of trainee well-being, Westmead scored an F, making it the only hospital, apart from Wollongong, to receive the lowest rating.  Across all categories, however, the major western Sydney teaching hospital was around average for the state.

Of the 1350 NSW trainees surveyed across the state’s public hospitals, 42% reported they had suffered bullying and harassment, and 66% said they feared consequences from reporting inappropriate workplace behaviour.

But the big issue appeared to be overwork. The survey found 71% feared making clinical errors due to fatigue caused by their working hours. Nearly as many, 68%, worried about the impact on their personal health.

Nearly nine out of 10 NSW trainees said they worked unpaid, unrostered overtime, and 82% said their rosters did not represent the number of hours they were expected to work.

Dr James Lawler, co-chair of the AMA NSW Council of Doctors in Training, said junior doctors were very concerned about high rates of fatigue affecting them in the workplace.

“I think what is changing is that there seems to be more work to do and less acceptance by the junior doctors that they will do that work for free, not getting paid,” he said.

“There seems to be a real culture in most hospitals now that you will work from nine to five and keep working after that. What that does is put the responsibility on the individual to get all the work done nine to five – it’s not on the hospital to create more efficient systems to provide quality care.

“They have power to adopt new processes that junior doctors have to follow, without accepting any consequence about what it does to the workload.  I think that’s a big factor creating fatigue.”

In the past year, AMA Queensland ran a campaign to encourage junior doctors to claim overtime. In a mark of progress, it reported, the number of trainees  surveyed who said their overtime claims had been denied edged down from 31% to 24%.

But the latest Queensland survey also found more than a quarter of respondents felt unsafe at work and almost half worried about making fatigue-induced clinical errors. Nearly 40% had experienced bullying, and 77% had witnessed it.

Dr Bav Manoharan, a director of the Queensland AMA’s DIT council, said junior doctors had jumped at the opportunity to assess hospital workplaces without fear of reprisals.

“In 2016 and 2017, we certainly noticed a trend. About one-third of our doctors were working overtime and not getting paid for it,” he said.

The  AMA campaign encouraged junior doctors to think differently – not only about being paid to provide a service, but also about medico-legal complications.

Dr Manohara said the primary aims of the survey, borrowed from the WA model, were to give junior doctors going to a new hospital an idea of the strengths and failings they could expect in a new workplace and to encourage hospitals to improve by example.

“It was never intended to say, ‘you got Ds and Es, you’re terrible’, but to show employers what their employees were telling us,” he said.

“We’ve found the reception among junior doctors was quite amazing; they actually started waiting for the survey to come out and we’d get a lot of feedback.  A lot of hospitals tried to dismiss the results, but the data is absolutely statistically significant at state level.”

Dr David Oldham, director of the Doctors Health Advisory Service in WA, said hospitals that scored well in the medical trainee surveys tended to pay overtime and allow leave for professional development.

“In my experience, the best indicator of the respect a hospital or a department gives a doctor is whether they pay unrostered overtime,” he said.

But hospitals that rated badly tended to say the results were skewed or only reflected the views of the disaffected.

“The first results were very bad, with most hospitals getting fails or D ratings on most counts. You would expect any employer confronted by those results to take action, but unfortunately, the reaction in WA was one of disbelief,” he said.

“A few private hospitals did well, getting As and Bs in some categories; I’m sure their managers weren’t saying the survey was biased.”

Dr Oldham said this year’s WA junior doctor health check results showed little improvement, leading some hospitals to do their own surveys.  “I am told they haven’t released them because the results are so bad,” he said.

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