Well, wasn’t that a year!
Though much of Australia has been spared the brunt of the COVID-related awfulness, plenty of our colleagues, particularly in Victoria, have been battling it out with rising cases, high workload and an omnipresent fear of falling ill themselves. As politicians and department heads have met to plan and strategise, many junior doctors have continued to show up and work carrying great uncertainty: not knowing the latest updates, limited access to fit-tested PPE, little say in where they will be deployed and, in primary care, not knowing if their job will be there tomorrow.
Junior doctors, a term that refers to those who haven’t yet completed specialty training, are simultaneously the frontline and the engine room of our hospital systems. We are the doctors the patient meets first in the emergency department, we document their progress on the ward round, we make sure important scans and blood tests are ordered, we follow them up in clinic. We perform these tasks while responding to hospital-wide calls for help, teaching junior colleagues, and ensuring the hospital keeps running at night. We keep the cogs turning and the system working in a healthcare machine that relies heavily on our intrinsic motivation and sense of duty to provide patient care.
2020 has frightened us, so we approach 2021 with caution. Yet we continue to show up to work with a smile and some COVID-safe chocolates. We lead by example, caring for patients as best we can, with the resources we have. We take rapid change in our stride, covering gaps in the roster and navigating delays in life-changing exams and college training requirements.
Some of us innovate, by including medical students on the ward round via Zoom, giving talks online or starting new initiatives to support the mental health of clinicians. We support our bosses and care for expat colleagues grappling with survivor guilt (and isolation from their families) as cases rise overseas. I am proud to observe my colleagues stepping up across the country to go above and beyond their job description day after day. We know how much our patients, our colleagues and our hospitals rely on us.
We continue to rise to the occasion, but this is often at the expense of our personal wellbeing. We continue to give everything we have, but it can often feel like the system we work in does not reciprocate.
This pandemic has shone a light on many of the points of stress in our healthcare system, one of the largest being junior doctor wellbeing. This is not a new problem, but an exacerbation of a serious issue that has affected the medical profession for decades.
We’ve all seen the stats from Beyond Blue, demonstrating alarming rates of psychological distress and even suicidality in doctors; we’ve sat through Grand Rounds about #civilitysaveslives; and we’ve participated in other initiatives designed to reduce the negative impact of our work environment on our mental health.
The conversation has value, but much of it so far has centered around individual factors. The fabulous #NotYoga online symposium in December 2020 reflected a sentiment that many of us feel: that no amount of downward dog can overcome the systemic contributors to poor wellbeing. Burnout, moral injury and mental illness rates are expected to rise significantly as a result of COVID, so this issue will remain long after the pandemic has passed.
So, if it’s not yoga, what can be done at a system level to improve wellbeing in our own hospitals and units? The following are my suggested actions that hospitals can take to improve the conditions in which their doctors are working:
- Include junior doctor representatives on councils, boards and important committees. We know more about what is happening on the ground than any heads of department; we have innovative ideas; we know which systems work and which don’t; and we can identify points of stress before they become gaping problems in the health service. We have the energy! We just need a platform from which we can be heard.
- Establish a fair and transparent rostering and leave system. Much of medical rostering and leave approval is a mystery, which leads to frustration, resentment and disillusionment in the process. By involving junior doctors in the rostering and allocations process, and by keeping a transparent record of leave approval and rejection, hospitals can demonstrate a commitment to education and training, and equitable opportunity, that goes beyond plugging gaps in the roster. Doing this will also allow junior doctors to understand the considerations that need to be made in accommodating multiple requests against competing demands.
- Actively audit and pay overtime for your staff. That’s it.
- Review and continue to improve the hospital orientation. How many doctors have shown up to work in a new unit with no swipe card access, no computer logins and no idea where to go for help. This shouldn’t be something we just have to *deal with* every time we rotate to a new institution. It shouldn’t be an unexpected surprise when we turn up on our first day in a new unit. In addition, being compensated for doing 10+ hours of compulsory online training for a workplace should be non-negotiable. The impact of this is magnified for junior doctors rotating through multiple sites for their training.
- Establish a safe common space for junior doctors within the hospital. A large proportion of junior doctors rotate to a new unit every 10 weeks. Having a constant space they can go in order to debrief, meet colleagues and establish social connections is beneficial for the wellbeing of the cohort, and can be a lifeline for those who feel isolated.
- Support or initiate a formal peer mentoring program. While some people find their own mentors, many junior doctors can benefit from having these connections set up in a more formal manner. Such programs (like this one at the Royal Perth Hospital) have a positive impact on stress levels, morale, sense of support, job satisfaction, and psychosocial wellbeing.
- Work to promote and establish a junior doctor society within the hospital. Anecdotally, the places where these networks don’t exist seem to be the places that need them the most. If there is not one, hospitals should identify the barriers and actively work to break them down. Allocate a meeting room, invite them to have a seat at the table (see point 1) and actively support those who express interest. There are passionate, interested individuals on your wards, but they either don’t know how to start, are afraid of retribution or judgement, or exhausted by the prospect of interacting with the system. Invite them in. Enable them to become engaged and lead. You won’t regret it.
- Support and emphasise the wellbeing of your senior medical staff. We talk a lot about junior doctor mental health, but much of this is contributed to by the disastrous effects that medical training and work has had on the generation before us. Those who remain in the profession did not come through unscathed. No senior doctor can adequately support and respond to the needs of their junior staff if they are struggling themselves.
This is by no means an exhaustive list, but it is measurable and achievable. I know this because we implemented each one of these things at my last hospital. The process took several years with a team of passionate junior and senior doctors, the hospital executive, medical education and medical administration staff.
What we are asking for is simple: a seat at the table and some agency. Many of these points can be achieved easily; some take a bit more work, but they make a huge difference to the wellbeing of the group as a whole – and a well group is a productive group that achieves high quality outcomes for patients. (Hall et al., 2016; Shanafelt et al., 2017)
Who knows? With enough support and engagement, junior doctors might even have enough energy left after work for a spot of yoga.
For further information and support, the following services are available for junior doctors:
Drs4Drs 24 hour mental health support – a network of doctors’ health advisory and referral services –
Hand-n-Hand COVID-19 peer support – designed and facilitated by our mental health colleagues
The Essential Network by the Black Dog Institute – an online hub for support of healthcare workers
- Hall LH, Johnson J, Watt I, Tsipa A, O’Connor DB. Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PLoS One. 2016;11(7):e0159015. Published 2016 Jul 8. doi:10.1371/journal.pone.0159015 (online)
- Shanafelt T, Goh J, Sinsky C. The Business Case for Investing in Physician Well-being. JAMA Intern Med. 2017 Dec 1;177(12):1826-1832. doi: 10.1001/jamainternmed.2017.4340. PMID: 28973070. (online)