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More than resilience: why we need to shift the conversation around doctors’ wellbeing

 

You’re a keen, first-year medical student. Today, you’re practising breaking bad news to patients – actors of course, but boy does it feel like the real deal. Before you begin, the whole room stops. You all close your eyes, and practice mindfulness – just for three minutes – but as you return to the room, you find you’re truly present and ready to take on this consult. You each have your turn breaking bad news. You have to tell a father that his six year old daughter has died. You fumble through the conversation. You almost cry with him. You collect your things and leave, once all your colleagues have had a turn, but you return to that workshop later that evening through your reflective journal. What did you learn about this skill? More importantly, what did you learn about yourself? And how, when you’re faced with this in future, are you going to do better, or differently?

Medical school equipped me with a skill set in addition to that of clinical medicine. The extras included how to manage difficult relationships in the workplace, dealing with emotionally challenging experiences, how to be vigilant of my own health and wellbeing, and simple practices I can employ throughout my practice and life to make myself the best doctor I can be. These skills were reinforced in my intern education sessions and at multiple conferences. I’m now a junior doctor – an occasionally very stressed, often very busy, and at times burnt-out junior doctor.

We know doctors have high rates of emotional distress and mental health issues. But our conversation around this is fixated around teaching more personal resilience skills at medical school. I’ve been taught these skills, and many medical schools have a similar emphasis to mine. Why, then, does this continue to be the centre of our conversation on doctors’ wellbeing? Yes, we should continue to pressure medical schools, teaching hospitals and training colleges into fostering these skills in their trainees. But we urgently need to broaden the conversation.

Junior doctors are often put in positions where we are stretched to our limits both personally and professionally, with immense workloads, long hours, having to adapt to a new department, system or even hospital every five to ten weeks. On top of this, we need to remain competitive and employable by doing research, extra degrees and study for training programs. We exhaust all our energies and wellbeing strategies managing these challenges, leaving us with little to give when faced with a difficult case, complex scenario, or personal challenge.

The daisy in the desert

A daisy won’t grow in a desert. We’ve made enormous strides in teaching doctors resilience: now need to broaden our focus to the system itself. We work in an environment where the bar is set close to perfection. We rarely forgive ourselves for our mistakes. We work ourselves harder than we could have imagined, to ensure the very best for our patients. We work unpaid overtime, we skip meal breaks. Honestly, there are days when I wonder if my own creatinine isn’t higher than my patients’.

So let’s do some primary prevention. Let’s work on the things further upstream that affect our wellbeing. Perhaps we need to start with the simple things: making sure we take a lunch break. Or even just a water break, so we’re not so dehydrated we don’t even need to go to the bathroom. We need supportive and positive feedback, not only highlighting what could have been done better. We need leaders who encourage and support us in these endeavours. Find the issues causing your colleagues to burn out, and find a way to create change. We need to look at the bigger picture and see how we can alter the desert, not the daisy.

This conversational shift comes with a risk. Let’s go back to some high school physics – bear with me, I promise it’s worth it. Force = pressure x area. We’ve been focussing on one part of the conversation – a small area. So a little bit of pressure, and we get a reasonable force. If we broaden the conversation without the extra pressure, we risk reducing our impact. The challenge is to not get lost in the vastness of this problem – find the next, impactful step and take it, and remember the endpoint. The goal should not be more resilient doctors. It should be doctors working in environments that allow and encourage them to be healthier, happier people. That allow us to use our resilience skills to tackle challenging scenarios, not the everyday.

With all this in mind, my challenge to you is this. Find one small change to make, that will make you happier and healthier at the end of the day. Find it, and make it happen. Let’s share our simple step with a colleague from a different practice or hospital, find what they have changed and swap ideas. Let’s encourage leaders to support this, and advocate for changes that need to occur. Let’s create a subtle creep of wellbeing that isn’t taught in a lecture theatre. And then, let’s tackle the desert.

Dr Nicola Campbell is a resident medical officer currently working in regional Queensland. She studied medicine at Griffith University and aspires to be a rural GP with an advanced skill in mental health.

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

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

What are we training medical students for?

 

When young people go to medical school they are called medical students. They know that they are to learn about medicine. Everything about medical school is about learning about medicine. In fact, every waking moment is about learning about medicine.

We learn about anatomy, physiology, statistics, how to read a research paper, how to do a research project, we learn about diseases, pathology, histology, how to examine patients. We learn the right questions to ask in the right way to get the information that is needed.

We endlessly learn about rare diseases, treatment protocols and how to do various procedures and operations. Our whole lives are consumed with medical information.

But is this all that there is to medical school?

Of what value is all the medical knowledge in the world if the person holding that knowledge is miserable and unwell themselves, struggling to work and struggling to cope with people?

Students graduate at the age of 24 (at least) after the most intensive periods of their lives where literally every moment is dedicated to learning as much information as possible.

It has even been said that medical school is a prolonged period of adolescence where life skills are not learned, but one simply has to learn what other people tell you.

There is no time to notice anything else about life. Finances, relationships, property, politics, community engagement……sleep….. everything comes a distant seventh to medical school and learning. Life itself is an afterthought, something that one attends to only if one has to.

Our medical students are not taught about how to conduct or engage themselves in an empowered way in day to day life. They are taught how to recall information, pattern recognise and survive ward rounds.

But how to be in all aspects of life determines how well we are in life, not how much we know about facts.

Our statistics tell us how unwell our medical students and doctors are.

Medical students and junior doctors are not taught how to take care of their own health and well-being, and in fact the very nature of the setup of medical training encourages and fosters them to ignore their own health and well-being.

Our high rates of mental ill health, suicide and physical ill health are a painful reflection of these low standards of self-care in medicine.

  • Medical students are not taught how to take care of finances.
  • They are not taught how to be empowered and to run a business.
  • They are not taught the basic skills of marketing and business administration that people in engineering or even beauty school are taught, even though finally after a prolonged period of education and working they will be working in businesses in the community.
  • They are not taught how to have relationships with people that are equal, loving and caring that go beyond the arrangement of role of doctor and patient.
  • They are not taught about the importance of caring for their physical bodies, and indeed much of medical culture in fact promotes the stressing of the human body and mind, asking it to go beyond its limits without care for how it needs to be literally cared for.
  • They are not taught how to take care of their mental health, with instead judgement and criticism, condemnation and the drive for unattainable perfection being the daily ingrained forms of communication in medicine, none of these building self-esteem or self-worth.

The health and well-being of us doctors is poor. We are not happy; over 50% of us are burnt out. Our suicide rates are at least 2 times higher than the general public, with some studies pointing to 5.7 times higher, and these are only the suicides that we know of. We have higher rates of anxiety and high psychological distress than the general public.

The pressures on us doctors are very real and put simply, in the health care profession we are barely surviving, and most certainly not thriving.

We know medical facts, but we do not know how to take care of ourselves and keep ourselves well in life.

Doctors are disempowered as people and do not consider themselves as human beings with equal human rights, and instead in the role of ‘doctor’ in training learn to simply accept and put up with the circumstances that they find themselves in.

They agree to working arrangements that would not be accepted anywhere else in the corporate world, with many of them seeing bullying as so normal that they don’t even realise that they are being bullied, or that they are engaging in bullying.

Working relationships in hospitals are toxic between doctors and between doctors and other health care professionals. And let’s not even begin with the relationships that doctors have with administration!! This is accepted as ‘normal’ and something to ‘survive’.

Toxic relationships build bad teams and are bad for our mental health and well-being. This has a knock on effect on patient care.

We know that there are multiple determinants of health and well-being. We need to address all of these in our lives to build health and well-being

  • How are we in relationships? Are we loving and caring?
  • How are we with food? Is it for indulgence and coping with life, or nourishing the body?
  • How do we take care of our bodies?
  • How are we with our finances?
  • How are we with taking care of ourselves, valuing and empowering ourselves?
  • How are we with sleep?
  • How are we with our self-talk, our emotional and mental health?
  • Do we know how to be who we truly are in all aspects of life? Or are we boxing ourselves in, acting in different ‘roles’ in different circumstances?

As health care professionals we need to be the ones to lead the way in the health and well-being stakes to inspire our patients.

Instead at present as a whole we are more anxious, stressed and suicidal than the general public. Something is wrong here.

There are many reasons that our doctors are not thriving.

Rather than focussing on developing doctors who are simply minimally ‘resilient’ to the current stresses and strains, I propose that as part of our care and responsibility for those we train, that we prepare people to be well in life as a whole, in both medical school and in doctor training in hospitals.

If we don’t prepare our students to be well, then we are leaving them vulnerable with an incomplete education in the world. And thus far the statistics are speaking for themselves.

We need to prepare our students to be well. And we need to design our systems to support our doctors to be healthy and well and not simply ask them to put up with systems the way that they are when they are not honouring of dignity, decency or respect of general human rights.

Care for people is the foundation of health care. To move forward as an institution that leads the way in health care we need to place care for all people firmly at the foundation of our training and our work ethos, beginning with our medical students.

As part of that care, it is important for us to design programs that not only teach students about the nitty-gritties of medical knowledge and information but arm them with the tools to thrive and to live well in all areas of life; how to take care of themselves, value themselves and empower themselves in all areas of life.

Our educational processes and health care systems themselves need to empower our doctors and our students.

Only then will we have a profession that is healthy, well and able to consistently care for others in all avenues of life.

Dr Maxine Szramka (pictured above) is a Sydney-based consultant rheumatologist. She blogs regularly at Dr Maxine Speaks.

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

Seven survival tips for doctors in training

 

You’ve completed your studies, done your internship and are finally qualified to practise. You might think the worst is behind you, but research is increasingly showing that junior doctors in training are one of the most vulnerable groups in medicine.

According to a 2008 AMA survey, junior doctors routinely work up to 60 hours a week, with most sleeping less than seven hours and only a quarter finding the time to exercise regularly.

But it’s not just the long hours that can be deleterious, it’s also the lack of autonomy that goes with the job, with junior doctors having little say over how and where they spend those long hours.

The hours, coupled with uncertainty over placements, can take a heavy toll on personal relationships and family life. Days off are few and far between, and the temptation can be to use any spare time to do work-related activities rather than enjoy proper down time.

The workplace itself can add to a junior doctor’s stress. Doctors may be uncertain about their future, suffer inflexible work conditions and may be exposed to abuse from patients as well as bullying from senior colleagues. It can be a bewildering minefield for a doctor fresh out of internship to navigate.

Here are some tips for staying healthy and keeping your sanity during the training years:

  • Research as much as possible the demands of each specialty, including hours and placements. That way you’ll have a clearer idea of whether it fits in with your idea of an appropriate and healthy lifestyle.
  • Adopt a mentor: many hospitals have mentorship programs, and having a senior consultant with whom you can discuss clinical, professional and career-related issues on a one-on-one basis can be an enormous help.
  • Keep close relations with your peers. It’s good to find colleagues with whom you can socialise outside shift hours: that way, you’ll be able to debrief each other and also lean on each other through the tough times.
  • Make your own health your priority: you can’t manage other people’s health if you can’t manage your own. Find a GP before you need one, particularly if you’re moving to a new area. And resist the pressure to turn up for work when you’re sick: it’s not good for you, your patients or your colleagues.
  • Find time for physical exercise: it’s not only good for your health, it’s essential for combating inevitable work fatigue and potential burnout.
  • Work at maintaining family relationships and friendships: they are your outside support network, giving you perspective and helping you manage day-to-day stress.
  • Maintain or develop outside interests. Whether it’s sport, playing music or going to the movies, non-medical interests will help you find some work-life balance and can be an important de-stressor.

Source: Avant

The Australian Medical Association has a wide range of online resources for doctors in training on their website.

For more information about health issues for doctors, access a range of online resources from Doctors’ Health Services Pty Ltd.

Study quantifies junior doctor distress

 

Australian junior medical officers (JMOs) suffer from dangerously high levels of psychological stress that are considerably greater than in the general population, according to new research published in the Internal Medicine Journal.

The study of over 1,000 JMOs surveyed between 2014 and 2016 assessed distress according to the commonly used Kessler Psychological Distress Scale (K10). The average score was 18.1, compared with 13 in the general Australian population shown in previous studies.

Unsurprisingly, increasing hours of work correlated with higher distress, with every extra hour worked per week increasing the odds of a high K10 score by 3%.

Smoking and drinking alcohol as ways of relieving stress were correlated with higher levels of distress, as was taking illicit drugs, which 7.7% of those surveyed admitted to doing.

Feeling ill-equipped during internship and workplace bullying were also associated with higher distress levels.

On the other hand, spending time with friends or family correlated to lower levels of distress.

Only 17% of those surveyed had resorted to professional help for their psychological distress. GPs were most commonly the first port of call, followed by private psychologists or psychiatrists.

Worryingly, nearly 20% of JMOs said that if they had their time over again, they wouldn’t choose to do medicine.

The researchers from Sydney’s Nepean Hospital said that theirs was the first study to measure psychological distress in Australian JMOs over a three-year period. The bulk of existing literature relies on data from overseas, they noted, and even that literature was skewed towards senior clinicians rather than junior doctors.

They wrote that although long hours correlated with increased distress, one of the issues was the difficulty of accurately monitoring how many hours JMOs worked, due to a culture of unpaid overtime.

They said their work demonstrated the need for a more focused approach to JMO support and education, encompassing increased administrative support, education on coping strategies and action around bullying behaviour.

You can read the study here.

The Australian Medical Association has a wide range of online resources for junior medical officers on its website.

For more information about health issues for doctors, access online resources from Doctors’ Health Services Pty Ltd.

Doctors’ health: the wrap

 

All this month at doctorportal we’ve been highlighting the critical issue of doctors’ health and wellbeing.

The doctorportal website hosts the online resources of Doctors’ Health Services Pty Ltd, an organisation funded by the Medical Board of Australia and coordinated by the Australian Medical Association. Its aim is to ensure doctors and medical students, no matter where they live in Australia, have access to consistent and readily available services, including advice, referral and health-related triage.

Here’s a roundup of doctors’ health stories we’ve covered at doctorportal this June:

For more information about health issues for doctors, access a range of online resources from Doctors’ Health Services Pty Ltd.

Or phone:

NSW and ACT … 02 9437 6552

NT and SA … 08 8366 0250

Queensland … 07 3833 4352

Tasmania and Victoria … 03 9495 6011

WA … 08 9321 3098

New Zealand … 0800 471 2654

Lifeline on 13 11 14

beyondblue on 1300 224 636

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.