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Want us to be doctors? Get out of the way.

I have a confession to make. I don’t understand the concept of burnout. I mean, I get the idea. Medicine is, at least when you are the kind of doctor who deals with life and death, inherently stressful. And I feel the stress. It’s as if someone applied a vice grip to my insides in the middle of medical school, and it has never let up since. The pressure is unrelenting, progressive, and downright painful. It has got worse with every successive career milestone.

Brutal. It’s brutal. I knew it would be after a few weeks of rotations on the medical wards. The more responsibility I gained, the worse it got. And I guess I entered the profession knowing this. There was no expectation of reprieve. No belief that I would be let off the hook. I assumed that it was my cross to bear, my burden to shoulder. As the burden became heavier, I learned how to amble through hospital halls with a stooped posture.

I just don’t know if it could be any other way. I can think of no relief from the burden of making life and death decisions. What we do. What we do matters. A wrong turn, a flip on the ideological scale, can have devastating consequences for those we care for. There is no escaping this responsibility. No blunting the effect. You can’t go half way. You can’t stand in the middle of the road. You either make definitive decisions with definitive consequences, or you get out of the business. There is no such thing as sleeping peacefully for a physician.

So why are doctors committing suicide? Why are doctors leaving medicine in droves? It’s not burnout. A small part of the reason is wrong career choice. A young doctor realizes quickly that they didn’t know what they were signing up for.

For the rest, it’s external. It’s not the stress of caring for people or even making life and death decisions. This is part of our genetic makeup. Part of our training.

It’s everything else. It’s the paperwork. It’s the meaningless paperwork. It’s the droves of administrators and clerical staff thwarting us at every turn. It’s the government and endless regulations, and rules, and threats. It’s the loss of respect, loss of standing, and loss of confidence that we feel every day from our community. It’s economic distress.

We won’t fix this by training our young people about burnout or haranguing them with some odd belief in resilience. They made it through medical school; they already are resilient.

You want doctors to be doctors again? You want us to love our jobs again?

Simple. Get out of the way.

And let us do what we were trained to do.

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion. 

What needs to happen to build resilience and improve mental health among junior doctors

Doctors experience higher levels of suicide and mental distress than their non-medical peers. A review of studies in the area found male doctors had a 26% higher risk of suicide, while female doctors had a 146% higher risk (more than double) than the general population.

And a recent survey, conducted by the mental health foundation beyondblue, confirmed there were higher rates of suicidal thoughts and psychological distress among doctors and medical students than in the general community.

But beyond the numbers are tragic stories of young individuals who lost their lives to suicide. In recent months, the suicide of four junior doctors in New South Wales has prompted the state government to investigate the issue. News reports have suggested at least 20 doctors took their own lives between 2007 and 2016 in NSW.

Family members have pointed to stress, “brutal expectations” and working hours as having had an impact on the doctors’ decisions to end their lives.

Are our medical students and junior doctors overworking? Can we identify underlying causes of mental distress and suicidal thoughts, as well as the warning signs? Can medical schools, hospital employers, supervisors, professional organisations and peers do more to prevent further tragedies?

A host of factors

Various inquiries and reviews have considered the above questions, in Australia and overseas. The conclusion is that it’s complex. Behind the phenomenon are a number of interacting factors.

There’s a legacy professional culture that can still view any admission of psychological distress as weakness or incompetence.

Doctors face long work hours in a pressured work environment. They experience anxiety about making mistakes that can have serious consequences.

Workplace bullying and harassment can also contribute. While this has most recently been highlighted among trainee surgeons, it probably extends well beyond surgical training.

And of course doctors have technical knowledge and access to the means to end life.

A lot has already been done to try to improve doctors’ mental health. For instance, progress has been made to reduce working hours. Prolonged shifts and continuous on-call rosters have been discontinued in most, if not all, health service rosters. This was at least in part in response to pressure from the Australian Medical Association (AMA) Safe Hours campaign, which outlined the risks to patients and practitioners of excessive hours worked and the need for breaks between shifts.

These recommendations have been incorporated into industrial agreements for hospital medical staff. These stipulate maximum working hours and mandatory periods of time off. However, 14-hour shifts and rosters that include one in three or four weekends without any reduction in weekday hours are not uncommon. There is considerable anecdotal evidence that some junior doctors are working more hours than they are rostered for.

Progress has been made in other areas too. Polices for better orientation of junior doctors in hospitals to explain supervision and avenues for support have been implemented. Other measures adopted include: education and mentoring programs in hospitals; supervisor training; blame-free reporting; assessment by external accreditors of health services’ and specialty colleges’ reporting and support arrangements; mental health first aid training for students; medical student guides; and confidential doctors’ health services.

But introduction of these initiatives has been patchy. The levels of support available in different hospitals are variable, and too often dependent on a few enthusiastic individuals. A systematic national approach would have much greater impact.

Medical graduates

One source of increasing stress for recent graduates, anecdotally, is the intense competition to get a job that will be their pathway to a specialist qualification. This pressure has its genesis in the dramatic boost to medical graduate numbers over the past 15 years.

Training beyond medical school is an intense period of four to nine years of work, on-the-job learning, study and examinations. By doubling the number of medical schools and almost tripling the number of medical graduates, Australia has severely increased competition in capital-city teaching hospitals (where, unfortunately, most of the training jobs for medical graduates remain based).

Ironically, the main reason for the boost in graduate numbers was the shortage of doctors in regional areas. An increasing number of young doctors (including those who trained in rural clinical schools or regional medical schools) feel that they have little choice but to apply for accredited metropolitan training posts.

They would be better off working and training from a home base in regional Australia, if only the specialist training pathways existed. Australia desperately needs to re-align this phase of medical training to better serve both regional communities and graduates.

Building resilience

There are core professional capabilities that should be taught and modelled throughout medical training. These include managing one’s own health needs, dealing with stress and fatigue, recognising and assisting distressed colleagues, and reporting bullying and harassment.

Medical schools and hospital employers could do better in finding ways to communicate with one other to protect more vulnerable graduates as they transition into the workforce.

We should also critically review our approaches to selecting students into medical school. Selection policies that promote greater diversity, place more emphasis on humanistic qualities (qualities that define who we are as human beings such as honesty, integrity, courage, self-awareness and wholeheartedness) rather than examination marks, and that include people with a positive orientation to risk and innovation may help to take the steam out of the pressure cooker. These approaches could also improve workforce outcomes in rural and under-served communities.

Beyond “resilience building”, there are important system challenges in how the nature of healthcare needs to be transformed into something that is more integrated, person-centred and community-based. This has particular implications for our larger institutions.

It turns out that finding “joy and meaning” in healthcare work is not only good for doctor well-being, it’s also safer for our patients. Teamwork, fun and personal fulfilment in caring for others are the essence of the joy of medicine.


The ConversationIf this article has raised issues for you or if you’re concerned about someone you know, call Lifeline on 13 11 44.

Doctorportal hosts a dedicated doctors’ health service providing support in the medical community.

Richard Murray, Dean of Medicine & Dentistry, James Cook University and Brendan Crotty, Professor & Executive Dean, Faculty of Health, Deakin University

This article was originally published on The Conversation. Read the original article.

Doctor burnout: a worldwide epidemic

Burnout is the modern day pandemic affecting the medical profession. It is a condition which leaves many of us in denial. After all, it can’t be seen on a biopsy result or under an electron microscope, so how real can it be?

Very real.

Up to 59% of doctors are burnt out, according to a 2017 Medscape report. Some studies report burnout rates of up to 65% in some specialty groups, and the rates of burnout have increased over the last 10 years. It would be unlikely to consider that this is simply because there is greater awareness of the condition.

50% of medical students and 70% of junior doctors are burnt out.

This is staggering, and these results are across the board globally. Not just the USA and not just UK. These are overall global professional rates of burnout and the rates are deeply alarming.

Even if we had 30% of the profession suffering from burnout, this would still be a pandemic, yet there is not the global attention to this matter that it deserves.

If there was an outbreak of influenza or a critical disease globally that was wiping out even 5% of people and removing them from the work force, there would be a worldwide inquiry.

Yet here we have matters where there are up to 65% rates of burnout, over half of the entire medical profession, including students, and there is no worldwide inquiry into what is going on in medicine.

Certainly there is no vaccine likely to be available, but the matter is critical.

Ought not the World Health Organisation be taking a key interest in this matter?

The WHO has released a report stating that there is a worldwide epidemic of chronic non communicable diseases, yet there is no report stating that there is a worldwide epidemic of high level dysfunction in our doctors, the very people who are caring for those with illness and disease.

The health of our global population is clearly in crisis with increasing rates of illness and disease to the extent that the WHO has said there is a worldwide epidemic of chronic non-communicable diseases.

We need healthy health care providers to lead the way

If our health care providers are in a state of ill health, which is what burnout is, then we have an even bigger crisis on our hands.

These rates of burnout show that the medical profession is in crisis, and with it our global future health care is in crisis, at a time when we need healthy healthcare providers more than ever.

Burnout is not a simple matter of being a little bit tired. It is associated with higher rates of:

  • Depression
  • Anxiety
  • Fatigue – both physical and emotional
  • Increased risk of medical errors
  • Decreased rates of patient satisfaction,
  • Causes people to leave the medical profession
  • Higher rates of suicidal thoughts and increased risk of suicide (in a profession where the rate of suicide is already at least 2 times higher than the general population with some studies reporting up to 5.7 times higher rates)
  • Higher rates of cardiovascular disease and musculoskeletal pain
  • Deep professional unhappiness and cynicism
  • De-personalisation and decreased understanding and compassion

Neither of which are features desirable or sustainable in someone who is dealing with people in situations that are incredibly trying.

Burnout is not something that is random affecting a few ‘sensitive’ people with ‘poor coping skills’. It quite specifically affects over half of the medical profession, people who specifically enter a profession because they are dedicated to caring for others.

We need to stop and ask not only why, but how.

Are we to blame the ‘nature of the person’ choosing to do medicine, and blame them for simply ‘not coping’? Or perhaps rather is it time to take a wider look at the global culture of medicine that fails to nurture the people that do medicine?

Being in a war zone and in the armed forces is highly stressful, as I am sure that we would all agree and understand. Yet people who have been in the army and in a war zone report that medicine is far more stressful. This does not make sense given that we say that we are a caring profession that values and cares for people.

I have heard people formerly in the army say they were more cared for as people in the army and given greater respect and compassion as people than they have been in medicine.

It is clear that there is a big issue here.

Doctors are people too. If we are to be true to medicine and its foundations of care for all people, then we must equally care for the health and well-being of those who are doing their best to care for others, those within the profession.

Literally over half of our medical profession is burnt out. This is not simply a matter of a few people being a bit tired from too much work to be decried for ‘not coping’. This is an institutionalised issue, a worldwide crisis and one that global attention needs to be paid to.

Dr Maxine Szramka is a Sydney-based rheumatologist and Clinical Senior Lecturer at the University of Wollongong. She blogs regularly at Dr Maxine Speaks.

Doctorportal hosts a dedicated doctors’ health service providing support in the medical community.

For further support and information, call Lifeline on 13 11 14