Why we need to talk about medicine's 'shameful secret'.

I really do enjoy my job. I love that I am able to spend my work days making a meaningful difference in other people’s lives and that I am constantly challenged. However, I feel it is timely to add my voice to those speaking out about how the conditions under which many junior doctors are working are contributing to an awful epidemic of suicide and distress. This week the Royal Australian College of Physicians released a statement on the issue which suggested that junior doctors should have a GP and ask for help when they need it. This is completely missing the point. Prevention is better than cure and this response completely ignores the underlying causes. We need to actually understand and talk about the why so many doctors are feeling this way in the first place.

Medicine’s “shameful secret”, the horrifyingly frequent suicides of young doctors, has recently been splashed across national newspapers, featured on TV news and become the subject of countless blogs and opinion pieces. A large scale discussion on such a devastating problem is well overdue and I hope that some change will come from getting these issues out in the open. But I remain skeptical, because the problems with our health system and medicine as a profession run deep, much deeper than a few awareness campaigns and newspaper articles are able to fix in a hurry.

Junior doctors work under immense pressure - pressure placed by seniors, by medical admin, by patients and by ourselves. In my first year of medical school, a lecturer spoke about how the majority of medical students have ‘type A’ personalities - that is, they are perfectionists, ambitious, sensitive, have high trait anxiety, are competitive and are compelled to avoid inefficiency. The further I am reaching into my training, the more this seems to ring true.  These aren’t necessarily bad traits - they are what make doctors thorough in their examination and investigation of patients' problems and drive us to achieve the best outcomes for those in our care. On the flip side, these are the traits that can be our downfall. Perfectionism can stop us from admitting when we are struggling and compels us to work ourselves into the ground because we want to be as hardworking and committed as we see our colleagues to be. Medical training further ingrains these qualities and sets us up for a whole career-worth of feeling like we must portray that we are coping, whether or not we actually are.

Universities are pumping out record numbers of medical graduates as the government proclaims they have funded “X more doctors for Australia” but the problem remains that there simply are not funded training positions for all these newly qualified doctors to complete internship and move into a specialty training pathway. There is a hugely constricting bottleneck in training which results in huge numbers of junior doctors vying for training positions (i.e. competing to be fully qualified) so the cut-throat process of applying to specialist training is amplified. I am not discounting the reality that training colleges (responsible for selecting which junior doctors can join the ranks as a surgical/physician/obstetrics etc trainee) want only the best applicants to enter their specialty. However, flooding the market with thousands of medical graduates who will spend years floating in the system before they are able to begin training in a speciality only worsens the strain. Junior doctors pay thousands of dollars to sit college entrance exams which have forced fail rates of around 30%, regardless of the score these candidates achieve. Doctors who have gone through their schooling and university as academically successful high achievers often face their real first prospect of ‘failure’ no matter how many hundreds of hours they spend studying on top of their already stressful and difficult job. Couple this with those type A traits I mentioned and it is little wonder these cohorts suffer such high levels of psychological distress.

I may have only been a doctor for a short time, but I spent half a decade as a nurse, and have seen some pretty heinous treatment of junior doctors by their seniors and by the ‘powers that be’ in medical admin. The former is often justified by “you have it much better than when I was an intern and had to work XX hours per day” or by the thinking that juniors will only learn if publicly humiliated. It is clearly unacceptable for a boss to bully an intern on a ward round, as it is for a registrar to hang up on a phone consult or a surgeon to force a medical student to re-scrub while the entire theatre of staff critique their technique. And yet I have seen all of these things happen so regularly that none seem as shocking or disturbing as they actually are. While it is easy to say we just need to be more patient and kind to each other, in a health system under pressure it is the staff who are first to crack and their colleagues sit in the firing line. I have had a few horrible experiences, including being the recipient of sexist and completely inappropiate comments from a consultant surgeon in front of a theatre full of staff, and yet the last thing I have ever thought of doing is reporting these incidents. Those who we can report to are often close colleagues of those behaving badly or are also the people who are responsible for re-hiring us the next year, and no boss wants to deal with a whinger, do they?

Doctors are of course not the only profession to work long hours and have stressful workloads, but the difference between myself and a finance consultant or a manager is that my work has immediate and significant effects on another person’s wellbeing. Every single decision I make in the course of my work day, from prescribing medications to replacing electrolytes to deciding whether that patient’s symptom needs investigation or not, has the potential to cause harm if not thoroughly considered. That thought alone is enough to make me feel anxious about the responsibility that being a doctor involves. Pile this up over hours, days and weeks with little reprieve and it is pretty easy to see how those junior doctors who don’t feel supported could crumble under the pressure. We are not robots, we do care for and are concerned about the outcomes of our patients. We cannot be expected to provide high quality, thorough and evidence-based care without being emotionally affected by the trauma, death and tragic illness to which we are exposed. This has been known for generations and yet young doctors often feel as though they should keep their worries to themselves and not admit when things start to become too much. 

Few professions are open to such widespread and critical judgement by the government, the media and the wider public. News stories are published almost weekly about “doctors wasting money on tests” and then “doctors miss life-vs-death diagnosis”, or “surgical waiting lists longest on record” unsurprisingly due to “health budget facing further cuts”. Being an industry relying on government funding, we don’t always have the freedom to provide the care that we think is right. Young woman traumatised as she miscarries in ED? Sorry, your 4 hours is up and the hospital funding is based on the ED meeting this ridiculous timed target. Elderly lady struggling to cope living alone but now medically cleared? Sorry, admin are pushing for your discharge because we need the bed and your length of stay is creeping up. Middle-aged man with a heart attack needing stenting? Sorry, can’t use the kind of stent I’d like because you aren’t privately insured. Despite being somewhat of a middle-man/woman between the health budget and the patient, we are judged as if we are operating in a world where we have complete freedom to treat as we see fit, but where it is scandalous to order that CT-scan that costs the system a few hundred dollars even though it could save thousands in early detection (or in litigation in years to come). We are very often bemoaned for our failings and shortcomings, yet rarely thanked by those same detractors for the good outcomes and successes we continue to achieve.

We are working for the government in delivering their health policy, but when we are struggling to cope with the ageing population and more complex patients, we are not supported by them at all. The government essentially runs our hospitals and employs those who deny leave at the last minute, decide outcomes on which our performance will be judged, employ us under contracts that last for just a year at a time, pressure us to not claim pay for the hundreds and hundreds of hours of overtime we do to ensure patients receive quality care, and often turn a blind eye to the horrendous and appalling conditions under which many junior doctors work. Above all, those who run our hospitals and decide many of these things have no clinical training and have no idea just why we can’t squeeze our workload into the 8 hours a day we are actually paid for. How on earth can we feel valued and supported as staff members when we are being held to unachievable and irrelevant KPIs? 

Whether or not increased conversation around doctors’ mental health and the pressures placed upon them will make any real difference remains to be seen, but how are we supposed to care for our patients when we aren’t able to care for ourselves? All discussion and awareness is useful and the more we as doctors admit that there are issues, the more likely it is that systemic change can one day occur. I’d love to see drastic changes within the time of my career and that is really only going to happen if we stand together as a profession and let those who run our health system know that enough is enough. We must look out for each other and be the change we want to see, but for cultural change to be enacted we need the support of policy makers, admin and the Ministry of Health; all of whom need a monumental push from doctors as well as the wider community to show that this is an important issue and that we will not stand to see our colleagues suffer.

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