Author: Duncan Campbell
Reviewer: Leena O’Brien
A personal perspective
In January of this year, I was undeniably stressed. On rotation away from my parent hospital, I found myself working an extremely busy ward job where I was responsible for upwards of 25 seriously unwell patients, and with very little senior supervision and support. At the end of each day I was exhausted, both physically as well as emotionally. I felt ready to collapse in a heap, but was compelled to do whatever study I could to prepare for looming college exams. Any time spent either not working or studying, and I was overcome with a sickening feeling of guilt. I put my social life on hold. I became miserable and short-tempered. I was burnt out.
During all of this, I heard the tragic news that one of my friends from medical school had died by suicide. Although we worked at different hospitals, she and I were enrolled in the same training program, and had been preparing to sit the same exams in February. When I heard the news of her suicide, I was shocked. Not just because she was young, intelligent and incredibly passionate about the work she did, but also because I had always thought of her as an unstoppable force. She had a strong passion for social justice, and dedicated so much of her time to standing up for what she believed in. She created a voice for those who had none. I couldn’t help but wonder what had happened in the years since we finished medical school. The most obvious thing was that we had commenced full time work.
I can clearly remember how excited I was to start as a new intern. Finally I could put years of study into practice, and be financially rewarded for it! Without a doubt, I can say that my internship was one of my most enjoyable years. Although it wasn’t an easy transition from medical student to junior doctor, I always felt well-supported, and every working day reiterated that it was the right career path for me. I was excited to progress through my training, gaining increasing skills and responsibilities. But before long, and almost without noticing, work took over my life. As recently as two years ago, I was actively involved in music, amateur theatre, debating and community radio. On weekends I loved to cook, host dinner parties, and go on road trips with my partner, but as work had become busier – and with a changeable roster that included evenings, nights and weekends – all of these things had fallen by the wayside. Talking to my colleagues, it didn’t take long to discover that they had all had similar experiences. As one of them put it, we had become ‘boring people’. I found the whole thing depressing; it was no wonder that I was burnt out.
The modern day pandemic
Every junior doctor will be familiar with the burnout pandemic rapidly spreading across the medical profession. Whilst burnout affects doctors at all stages of their careers, it appears that junior doctors are more vulnerable. A national survey conducted by the Australian Medical Association Council of Doctors in Training revealed that 69% of junior doctors met criteria for burnout. We are either burnt our ourselves, or work with colleagues who are. But why has burnout suddenly become such a hot issue? Surely it’s not something new; generations of doctors must have endured it before us. Is it because we are burning out at a faster rate than we used to, or are we just more willing to recognise it? And if we are, why is this the case?
One term that is frequently bandied around is resilience. Are we less resilient than our predecessors? Whenever you talk to senior colleagues about working hours and job stress, you too often hear a response along the lines of, ‘Back in my day, we worked from Friday morning to Monday night and we were lucky to get any sleep at all!’ Not only is this type of response unhelpful because it fails to validate the genuine stress and exhaustion that you currently feel, but it also makes no attempt to understand your particular situation, and how things may have changed in decades gone by.
Modern day health care and our hospital systems contributing to burnout
Over the past century, there have been incredible advances in medicine and technology, and these are continuing at an exponential rate. Thanks to new investigations, medications and interventions, we are now equipped to treat diseases that as recently as 10 years ago were a death sentence. But along with these new capabilities, we have increasingly high expectations of ourselves to make the correct diagnosis, intervene within the required time frame, and escalate care as required. And society expects this of us too.
It is genuinely pleasing to see that health literacy in Australia is improving. One part of this is due to improved levels of education across the board, but another part is due to the increased societal interest in health and medicine. This can be witnessed as the rising popularity of dieting, exercise programs and reality TV, and specifically the subgenre of medical docudramas. Additionally smart phones allow any member of the public to access an encyclopaedia of medical knowledge at any place and any time. Dr Google poses a whole new challenge to the patient-doctor relationship: doctors are no longer considered keepers of secret and specialised information. Instead when patients come to see you, they often bring with them a list of differential diagnoses and investigations they want performed. And if they don’t, their loved ones probably will! The evolution of medical practice has now found itself centred around principles of collaborative decision-making and informed consent, necessitating often lengthy discussions with patients and their loved ones about life and death.
Integral to this is managing expectations. We have all found ourselves in situations where families expect absolutely everything possible to be done to prolong the life of a sick relative. After all, if you’ve just seen someone brought back to life on ‘24 hours in Emergency’, why shouldn’t the team of doctors and nurses caring for your mother be able to do the same thing for her? Don’t forget, ‘she is a good person!’ Conversations about goals of care have had to become more nuanced. It’s no longer a question of ‘can it be done?’, but rather ‘is it the right thing to do?’
Weighing up the costs and benefits of treatment requires not only consideration of the individual, but also resource availability. As our population grows and ages, hospitals are increasingly operating at capacity. During the winter months, medical ward lists often exceed 30 inpatients, with additional patients waiting in the emergency department until a bed becomes available on the ward. The practical implication is that it becomes increasingly difficult to deliver required care to critically unwell patients. Earlier this year, I attempted to transfer a patient with a gastrointestinal bleed from a suburban hospital to a tertiary centre so that she could receive care from a collaborating team of gastroenterology, surgical and intensive care units. After six hours spent on the phone to seven different hospitals across Melbourne, we were deflated to hear that there were no beds available, and that the transfer was not possible. 36 hours later and as she continued to deteriorate, we had no other option than to arrange an ambulance to take her to the emergency department of our nearest tertiary centre. She died 48 hours later. I can’t help but wonder what might have happened had she been able to receive the required care earlier.
These examples illustrate new and increasing pressures placed on doctors that did not exist to the same extent even a decade ago. Although these pressures affect all doctors, they particularly affect those with the greatest patient and family contact: interns, residents and registrars. These young doctors in training are also subjected to other pressures, including preparing for and passing competitive exams, and re-applying for jobs every year, not to mention the same life stressors as everyone else.
Although it is important to recognise burnout and the various factors that contribute to it, the next step is to make changes to address these factors and improve doctors’ mental health. In part 2 of this blog, I will draw on my own personal experiences to provide some tips on how to cope with burnout.
- Markwell AL, Wainer Z. The health and wellbeing of junior doctors: insights from a national survey. Med J Aust. 2009. Oct 19; 191(8):441-4. Abstract available from PubMed: https://www.ncbi.nlm.nih.gov/pubmed/19835538