What pushes doctors to the edge? How our health system works against our own self-care.

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Photo by Adrian Swancar on Unsplash

“We never know what pushes doctors over the edge but having gone through this and feeling this way, I can see that our system is certainly a contributor.

Sincerely
Jonathan

This is how I recently signed off an email to a medical administrator.

I was frustrated and feeling worse for wear.

I was glad that I had organised a week off to coincide with my birthday many months earlier.

I needed the space to rest — I was at my limit.

More than that I needed time to process what had just happened to me and to be to able re-engage at work.

What pushed me to this point was that I’d briefly been caught up in an administrative and system misunderstanding which escalated rapidly to the highest level without warning.

I thought that it was something that was amenable to be fixed with a conversation or phone call and a follow-up email, but it wasn’t.

It was blown out of proportion.

As I sought to resolve and bring reason to the situation, I found myself in a reflective state and thus signed off my email accordingly.

See, two things had happened that made me stop and think about what pushes doctors to their limits.

Firstly a senior nursing colleague had called and asked me if I was okay? She’d noticed that I hadn’t been myself lately and wanted to know if there was anything she could do — she was worried about me. I told her that I was sadly distracted by things outside of work and dealing with a few administrative issues which were taking their toll on me. I appreciated her encouragement and took her concern as mine too — other people noticing that you aren’t okay is not a good sign!

And secondly, and most concerning to me was that I was still feeling the aftershocks of the suicide of a colleague of mine. His death was a surprise to all who knew him and had sent shockwaves through that state and country. In listening to his wife give his eulogy I learned that he had been struggling privately with the fatigue, despair and discontent which can closely accompany any type of medical work.

All of this made it clear that the forces working against doctors can certainly take their toll and we can never be certain as to what pushes a doctor too far.

From my own experience of being burnout and struggling with the fatigue associated with doctoring, I realise that we all have a limit. And as we approach these limits, we experience symptoms that are unique to us. For me, it is a tiredness and stomach pains that aren’t helped by sleep, intentional rest and world-class self-care — I simply need a mental break from medicine. For others, it may be a pervasive sadness or crankiness or even a somatic symptom such as neck pain, headaches or stomach issues. But whatever it is, they serve as a warning sign that danger lies ahead — a loving wake-up call from our body to us.

And so we know that we need to take time to care for ourselves and get the necessary help that we need. We also need to enquire into our inner world to see what is troubling us. This is not new and forms the basis of a great body of work around Doctor well-being and self-care.

But I couldn’t help but recognise the large role that the administrative systems in our hospitals and our health culture play in pushing doctors towards their limits. This is much harder to control and can be the source of great pain and distress in a doctor’s life.

Most recently, the Weekend Australian published 450 words that I submitted about being a burnout doctor and my recovery in their “this life”, column — entitled “this (burnout) life’, published on March 26-27th.

In one of the many conversations that followed this article being published, a well-respected and hardworking hospital specialist commended me on my article. But his tone changed as he shared his concerns about how the system can adversely impact a doctor’s well-being. His point was that whilst caring for ourselves was central and our professional responsibility, working with an uncaring, belligerent and bureaucratically minded administration was a major thorn in a doctor’s life.

He then shared a story to reinforce his point. My friend said that only a few years ago when his wife and he were both registrars in training with two young children at home when a simple rostering request was blown out of proportion and pushed him to his limits.

He had sent a polite email to his new place of work requesting that his wife and he not be rostered on night shift together because of their young children at home. To his surprise, this was met with a generic, terse and negative reply. When my friend again said that he could not work the shifts allocated to him, it was quickly escalated up the managerial chain and that resulted in an ultimatum that threatened his speciality training — “do your allocated shifts or find another job”.

“Jonathan, they couldn’t understand why my wife and I couldn’t work night shifts together, we had children at home! No amount of exercise, meditation, debriefing and regular rest was going to change the fact that my career was being threatened. I was so depressed that I came close to quitting. They just weren’t listening. I’ve never felt so victimised and threatened before!”.

We shared an uncomfortable silence as we both reflected on his story. Gone were the exhortations and good vibes from writing a brilliant article. My friend had a point. A big glaring unmistakable point! And with my recent bureaucratic experience fresh in mind, it was clear to me that our health care system is a large contributor to what pushes a doctor to their limit.

The stresses and strains of being a doctor

Being a doctor is a full-contact occupation. This means that the stresses and strains that a doctor incurs during their work can have an effect on their entire being. It is quite unlikely that doctors will finish their careers without medicine having a significant impact on their lives and more importantly their spirit.

Specifically, the contributors to burnout and stress in doctors relate to (1) The doctor’s health (Their psychological, physical, emotional and spiritual well-being) and (2) The Doctor-Patient relationship and finally (3) Healthcare and Hospital System issues (West et al 2018).

This is no surprise as these issues relate directly to the flow of our work. But in understanding what these specific issues are, Professor Geoff Riley’s timeless article entitled “Understanding the stresses and strains of being a doctor” provides a glimpse into the subjective stressors that doctors face each day.

Subjective Stressors

  • The intensity of demand on doctors, conflicting demands and time pressure
  • The gravity, emotional intensity and responsibility entailed in the job
  • Insufficient resources provided in the public sector
  • Constraints and demands (“interference”) of various government agencies
  • Requirements for accreditation and continuing professional development
  • Medicolegal threats and unreasonable expectations and demands of patients
  • Demanding, hostile and emotionally difficult patients and even actual violence
  • Maintaining amicable relationships with colleagues and staff within the work environment
  • Managing the demands of small business, finance and accounting
  • Loss of the traditional status of doctors, and negative media representation
  • After-hours and on-call work
  • Interference with family life
  • Poor remuneration (compared with expended effort)
  • Lack of appreciation

(Riley 2004)

This 2018 article published in the Internal Medical Journal is both sobering and important to us to read as doctors as it brings all these factors together. It explains that high levels of burnout, work stress, compassion fatigue and a lack of job satisfaction, all contribute to the development of mental health problems in doctors. And this article too highlights that medical students and junior and female doctors (at all levels) are the doctors most at risk.

Whilst this list and summary are extensive, I can certainly say that none of these is ever at the front of my mind when I am engaged at work. As an eternal optimist, there is a sense of flow and rhythm and a gentle headwind that I would describe as my “doctor life”. This is because I love what I do! For me, it is a well-paid extension of medical school.

But it is only when I encounter certain roadblocks both in my internal world, challenging patients and difficulties in my healthcare environment, that medicine starts to feel like hard work and becomes a hazard to my health and wellbeing. These roadblocks as I’ve learned, are clear derangements of human behaviour, health bureaucratic nonsense and challenging patients and families and finally, adverse outcomes.

See after my friend committed suicide, it re-ignited a theory that I had been thinking and working on over the last year. It is about the importance of the moments that lie between our clinical practice — the invisible parts of medicine.

As Pulitzer Prize winner, author and Oncologist Dr Siddhartha Mukherjee
puts it, “my medical education had taught me plenty of facts, but little about the spaces that live between the facts”. This is because the space that lives between the facts and our clinical encounters are moments that matter most in medical practice.

My observation was that the moments that lie between our practice of medicine are where the real impact of clinical work is felt. And it is how we care for ourselves in these moments that determine the quality of our lives as doctors.

For example, after a less than ideal encounter with a health administrator or after experiencing an adverse outcome or simply being overwhelmed with the workload and the suffering of our patients — all this takes a toll on our entire being. These things slowly accumulate and can lead us to be physically tired, psychologically exhausted, emotionally numb and spiritually depleted, with little joy or hope for the future. And how we care (or not) for ourselves between the moments of clinical engagement determines our trajectory and fate in this medical life.

This is no exaggeration as this is the other side of a doctor’s life. The one that predisposes to depression, anxiety and suicide at rates significantly higher than the general population (National Mental Health Survey of Doctors and Medical Students 2013 & 2019). And more than that, certain personality and cognitive traits that we love and admire most in our doctors are ones that predispose us to poor mental health. These are conscientiousness, commitment, and obsessiveness which are in turn associated with perfectionism, self-criticism and an inability to relax (Bailey et al 2018). My doctor friend, don’t these sound familiar? It does to me!

So, therefore, how we care for ourselves and reflect on our practice between our moments of clinical practice, doesn’t simply matter for our clinical life, but rather for our entire existence. It is imperative that we as doctors care for ourselves well in our moments between medicine and that we get the help that we need — something that we often struggle to do (Forbes et al 2019) & Garelick 2018).

Our moments between medicine matter.

And more often than not, the doctors who thrive are those who build routines around their own self-care and learn to recognise the signs when they may need help or more importantly a break. And help isn’t always for psychological and emotional distress, it may be help needed to negotiate with an emotionally unintelligent and uncaring system or help to deal with a bully or unwanted harassment.

But whilst we understand that a doctor’s health is important, how do system factors contribute to causing distress and impacting a doctor’s well-being?

See it wasn’t a medical decision to roster my friend and his wife both on the night shift, it was a mindless administrative one, free from insight and logic. But common sense prevailed when the Australian Medical Association and my friend’s mentors became involved. But why did this have to happen? Where was the compassion? Where was the emotional intelligence? Where was the understanding that doctors do not simply face internal battles but also are impacted by administrative and system failures of kindness?

A recent study on what predisposes junior doctors to burnout found that it was often an overlap of key factors that led to their distress. Those key factors were a lack of personal self-care, unclear expectations from themselves and unfair expectations from their environment (both from people and hospital and health system issues) (Hoffman & Bonney AJGP 2018)

This brilliantly reflects the point that solely focusing on doctor-wellbeing, building resilience in doctors, and promoting physician self-care is useless if there isn’t a reciprocal focus on improving system issues. This means health workers’ well-being and doctor self-care should inform the entire healthcare system and be taught to the people working with them.

Please do not talk about resilience training unless non-medical, executive and managerial staff are receiving the same training and specific education that pertains to working with doctors in understanding the stresses and strains that are particular to them.

As I reflect on what happened to me, it could have all been resolved with a considerate phone call or judgement-free email. Instead, it received an instant email escalation up the chain with sweeping statements, mild threats and several unnecessary people copied into the message. As easy-going and affable of a person that I am, it floored me. It made me sad to realise that even as a senior doctor I wasn’t trusted nor respected in the process. It meant nothing and that hurt.

These are failures of the system to understand the stressors and strains that doctors face. And it is clear to me that these are only but a few small examples of the system and administrative issues that contribute to pushing doctors over the edge. We haven’t even begun to talk about bullying or harassment, which stands as a hidden stain and deep threat to medical training and workplace culture.

The current urgency of healthcare system issues

Recently, Dr Nikki Stamp’s brilliant and confronting article in the Australian Magazine highlighted the issue of sexual harassment that exists in medical training and within the surgical profession. And sadly too Professor John Wilson, the president of the Royal Australian College of Physicians resigned due to failures within the Victorian Health system to listen and head calls about staff burnout and exhaustion.

This is a tweet from another respected Victorian clinician about taking time off to care for himself highlights the strain being felt within the profession.

But the stories that hurt the most are the suicides of my colleagues both near and far. Dr Tash Port took her life, isolated and stressed with her mental health deteriorating about the bottleneck of getting into speciality training. And my mate Jono who took his own life a few months ago deserves a separate article to commemorate his life — his death was felt personally by me and many others. He was simply brilliant and the news of his death was devastating.

Here are a few sobering tweets — I do not post these lightly as we are ALL vulnerable at the moment and I acknowledge that these are only but a handful of beautiful souls lost around our country.

Doctor suicide can no longer be treated lightly. It needs the full attention of our country. This is because we need an entire healthcare approach to improving the well-being of our health workers and addressing mental health issues. We need our legislators, policy-makers and those tasked with running our health service to listen and act.

This is fresh and our health system across Australia is in crisis. This isn’t because patients are at risk but rather our health workers are at breaking point. It may have been the pandemic but our statistics predate this. The COVID-19 pandemic was simply a stress test which broke the already weakened links.

I strongly suspect that within the next year or two, we will experience the effect of the exodus of healthcare professionals from our Australian system, mimicking what is already occurring in the United States as seen below.

How to tackle burnout among healthcare workers — Grattan Institute


Why is this happening and what can we do?

It has always been my belief that good health worker well-being translates to good patient outcomes, even very good ones.

This is common sense and there is evidence to demonstrate this. Health workers who are burnt out, make mistakes. This systematic review found significant associations between health-worker well-being and medical errors (88.9% of studies) and health-worker burnout and errors (83.3%) (Hall et al 2016).

And specifically in medicine, this meta-analysis and systematic review found that burnt-out doctors were:

Twice as likely to be involved in patient-safety incidents 
Twice as likely to deliver suboptimal care 
Three times as likely to receive low satisfaction ratings from patients.

(Panagiotti et al, 2018)

Likewise, as brilliant and unshakeable as our surgeons are, this study showed that being burnout doubled the odds of surgeons making a major medical mistake (Shanafelt et al 2010).

Stressed and burnout doctors do not perform well — this common sense has to inform policy and legislation.

Measuring health-worker well-being and satisfaction, trust and psychological safety is far more valuable to indicate a healthcare system that is thriving. Because in the end, it is the people that do the “health-caring” not favourable and politically charged numbers.

As a doctor, I do not focus on bulk-billing rates, emergency department wait times, elective surgery wait lists, ambulance ramp times or the number of outstanding discharge summaries. This demonstrates a system whose punitive focus is solely on worker output or their lack thereof. Where is the reciprocal concern about health workers and doctors well-being and psychological safety as our performance indicators?

This article is not about inciting a riot or adding to the noise but rather bringing awareness to every single person who works in healthcare (medical, nursing and non-medical) to understand and take responsibility for their own and each other’s wellbeing by being kinder to themselves and others – this is where the change starts.

Health care works when you are kind to yourself, kind to those in your craft group and kind to those who support you.

Simply because a doctor carries the medical and thus legal responsibility for patient care and outcomes, this doesn’t mean that the psychological, emotional and spiritual burdens are inert and without consequence. They have a significant impact too, especially when working against strong and uncaring bureaucratic headwinds.

If our legislators, administrators, managers and health executives are not mindful of the system’s impact on a doctor’s health and wellbeing, the psychological statistics will not lie.

So instead of counting and focusing on the number of patients who have been bulk-billed or seen in the emergency department under four hours or the number of patients on the elective surgery waiting list, our legislators and administrators will need to start counting and reporting on more sobering yearly statistics.

How about counting the number of doctors who have lodged bullying or sexual harassment complaint against another doctor or health administration? Or the number of doctors who have taken stress leave or the number of doctors who are burnout and are leaving the profession? 
And the big one here is suicide — how many doctors have committed suicide this year? These numbers should be public and published widely too.

What a grand privilege it is to be a doctor, or have a child or grandchild who is a doctor. But stop for a moment and realise that doctors are more likely to suffer mentally and commit suicide than the general population. It isn’t so grand anymore to have a sense that the stresses and strains that a doctor encounters could cost them their livelihood or life. These statistics need to be more widely known and pursuing a career in medicine needs to come with a warning.

Four per cent of medical students and two per cent of doctors have made a suicide attempt at some point in their career (Bailey et al 2018). Our sadness at this triggers a flurry of activity — meaningful social media posts, heartfelt articles (such as this one), campaigns such as “Are you okay” and “Crazy Socks for Docs” and public pleas by medical and non-medical families for change, but tell me, what have we meaningfully done? Where are the new policies? Where is the national legislation? Where are our new psychological and well-being performance indicators? And more importantly where does the responsibility lie?

(Read Dr Steve Robson’s powerful story about silence, suicide & speaking out)

I would contend, that whilst individual self-care is a professional responsibility of every healthcare worker, our healthcare system needs to reciprocate by placing healthcare workers’ well-being at the forefront of policy, spending, education and strategy — it cannot be one-sided anymore.

Health care only works when an equal focus is given to both patient care and staff care.

I wonder if the stigma of stress and mental health issues would be lessened if we had a caring and health-worker focussed system?

When it is heavily weighted and scrutinised against patient outcomes at all costs, healthcare workers pay the physical and mental costs. And this translates to worsened patient outcomes.

These are NOT simply a handful of stories of burnout, stress, bullying, harassment and doctors pushed to their limit but thousands of stories across Australia. This is a worrying pattern and we need a renewed focus and a new strategy. Doctor wellbeing and mental health are not simply a good idea and a “nice touch” anymore. It has to be at the bottom line of every healthcare strategy and thus budget.

As Dr Stephen Duckett and Dr Edward Meehan from the Grattan Institute discussed in a recent article on healthcare worker burnout:

If there was a training course that could halve healthcare workers’ odds of harming patients, it would be made mandatory. Prevention of burnout should be treated with the same urgency by governments and all health sector employers

The strange and sad thing is that the evidence is here already. Perhaps we are too ingrained in the old ways that we’ve confused it with fact and believe that this is all there is.

This article is a piece of hope and a reflection on the system and administrative issues that I believe are amenable to change. It is part of a two-article series with the next piece focusing on the issues at hand and ways we can improve doctor and health-worker wellbeing.

They may be radical in nature, but I am not going anywhere. This is because, in the end, we all became doctors as there was something intrinsically valuable to serving another person in their distress — this shouldn’t be made hard to do and certainly shouldn’t cost a doctor their well-being or their life.

Stay tuned for part two in the next week where I will discuss harassment, bullying, minding your words, mandatory training that matters, changing how we accredit hospitals and simple ways we can start to improve our system today.

Thank you.

Live intentionally.
Love relentlessly. 
Enjoy your health. 

Dr. Jonathan Ramachenderan
@drjonathanrama

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