I remember the first patient that died in my presence. I had been a doctor less than a year and was working in a national colorectal surgical centre. Before the change of shift, my colleague had told me about a woman that had been admitted. She had been reviewed by a more senior doctor but they were still unsure what the problem was. My memories of the presentation are vague; I think she had recently had surgery, had been in another hospital, and had developed non-specific abdominal pain post-operatively so was returned back to the centre where she had had her procedure. I was at least fourteen hours into a 12-hour shift when I was called by the nursing staff to say that this patient was distressed. When I arrived she was delirious (an acute confusional state that can be precipitated by any number of things – hypoxia, infection, medications, etc). She was calling for her husband and gasping for breath. She was obviously extremely unwell and deteriorating. I started auscultating her chest to listen for signs of acute respiratory distress, and listen to her heart.
I cannot say for certain now – our memories are fickle and play tricks on us – but I think her heart stopped beating whilst I was listening. She went into cardiac arrest. I immediately lowered her bed down (as she had been sitting up), pressed the emergency buzzer, and started CPR on her. The whole situation feels so surreal now. I felt incredibly helpless. The week of on-calls were seven 12-hour shifts, which each easily became fifteen hours, and on day 8 was a half day on which you were supposed to hand over care to the oncoming team. Two junior doctors managed all the acute patients being admitted, and on the weekend, were also managing all the patients of the three or four other teams; well over a hundred patients altogether. The registrars were either in theatre or admitting people in emergency. Consultants would do breakneck speed ward rounds before spending long days operating. It was an awful experience, especially for someone who likes to be in control and have an overview of my work situation. It felt chaotic and haphazard.
The crash team arrived and people sprang into action, following the prompts of the defibrillator. After a while it became apparent that resuscitation would be unsuccessful and the process was stopped. I remember the two medical registrars running the resuscitation comforting one another and affirming that they could have done no better. I was halfway between stunned and completely detached from the situation. I stood there observing. And then my pager went and I was off to the next task.
Looking back I feel sorry for my younger self. I didn’t realise how stressful I found my first two years working as a doctor until much later. I had been high-performing and high-achieving in my studies. It was painful going from being an excellent student to being a doctor where life and death were handled on a daily basis with nonchalance, and treatments were instigated with varying degrees of success and what seemed like blind hope at the outcome, mostly. My first job was in the gastroenterology and hepatology ward at a national liver transplant unit in a country with some of the highest alcohol abuse rates in Europe. Many of our patients had end-stage liver failure. One of the results of liver failure is the inability of the body to produce blood-clotting factors. Chronic alcohol abuse can also reduce the platelets in the blood, another essential component of the early blood clotting cascade. In addition, people with cirrhosis have a few major points in their body which are areas of engorged blood vessels due to back-pressure from their cirrhosed livers. They are sitting blood bombs just waiting to burst. I remember my third or fourth shift as a doctor, being the only doctor there from 5 until 9.30pm. The weight of the sense of responsibility for these incredibly unwell people was overwhelming at times. I remember having to call an anaesthetist because a patient had developed a nose bleed which was not stopping. People in this state hose blood when they start. He was shouting at me to get a catheter to insert in the patient’s nose to place pressure on the arterial blood. I was covered in blood, was trying to hand this slippery rubber catheter with a syringe attached to the anaesthetist, and I couldn’t inflate it. I’m not surprised I had diarrhoea with associated stomach cramps for my first couple of months of work there.
As a doctor develops more experience there is an improvement in knowing better how to handle a sick patient, how to recognise a deteriorating patient, and how to pre-emptively get help when this happens. But then other things come in: working shifts whilst having young children at home; studying for postgraduate exams whilst having young children at home and working shifts; dealing with major family illness whilst working, having young children at home, and ideally studying for postgraduate exams. Whilst working shifts. Getting divorced. Getting assaulted by an aggressive patient. Losing a parent or a sibling. Throw into this that the daily job is constantly dealing with human misery, pain, and trauma (in some specialties more than other), in health systems which are over-burdened and stretched, in societies where health provision is a powerful political and economic signpost, within a culture which is harsh and unforgiving with high rates of bullying and harassment, especially for women. It can be rather brutal.
In Australia, a few days ago there was a technical hitch with the RACP basic physician trainee exam. This resulted in the $1800 exam, which doctors will have studied for months for, whilst working full-time in most cases, which will have required loss of time spent with children, partners, family, and friends, to be deemed null and void. For the pleasure of sitting the exam, it will have required bartering with roster planners to ensure that the examinee was not on night shift the night before the exam, but may have gone onto night shift the day of or day after the exam. It will have involved careful negotiating to try and access professional development leave (which is part of doctors’ contracts) to have some uninterrupted time to study. It will have involved negotiating with clinical teams if you had more than one doctor needing to take the exam at that time. Some will have used annual leave to study and attend revision courses (which themselves can cost thousands of dollars). Holidays will have been delayed.
And now, these trainees’ exams are void due to the technical glitch. They need to sit it again in two weeks.
Peter Donkersley, a medical student at the University of Tasmania, took his life earlier this year. He is, sadly, one of the many of our colleagues: Dr Andrew Bryant, a consultant gastroenterologist in Brisbane; Dr Chloe Abbott, one of three NSW doctors in the space of a few months. And there were three psychiatry doctors in Victoria in 2016, where details were withheld. These are just some of the known ones. There are many whose causes of death will remain unknown or kept private.
In The Medical Journal of Australia we are encouraged to have the ‘courage to act on burnout,’ and these problems are not isolated to Australia. In the US, the Medscape National Physician Burnout and Depression Report 2018 emphasised the extent of the problem. The survey of over 15,000 physicians revealed that 42% of them were ‘burned out.’ An article in the British Medical Journal in 2017 stated that ‘medicine must change its culture to tackle the toxic aspects of medicine that cause and sustain burnout.’ It also quoted a Canadian study which ‘estimates that early retirement and reduced clinical hours from burnout will cost the health system $C213m (£130m; €146m; $167m) in lost future service.’ The findings are echoed in China and New Zealand.
So what can we do?
A 2016 The Lancet systematic review and meta-analysis on interventions to prevent and reduce physician burnout showed that interventions DO work. Fifteen randomised trials including 716 physicians, and 37 cohort studies including 2914 physicians demonstrated that ‘both individual-focused and structural or organisational strategies can result in clinically meaningful reductions in burnout among physicians,’ which can equate to a 10 percentage point drop in rates of burnout, from 54 to 44%. Good…but not brilliant.
Over the last month I have been in the process of laying the groundwork to develop a tool which can be used by individual medical students and doctors to improve stress and burnout, and which can also be used by hospitals and health services to partake in improving wellness. The task is large, and there are multiple barriers. We cannot change centuries of culture and dogma within the profession. We cannot instantly change the systemic and organisational issues that plague all healthcare workers.
What we can do is start prioritising looking after ourselves, and health services, their staff.
To encourage this, I want to employ the use of the tenets of the pursuit of wellbeing as described by Professor Martin Seligman at the University of Pennsylvania in the Department of Psychology. Following the mnemonic, PERMA:
- Positive affect (or emotion) – how do we make space for positive feeling at work amongst the trauma and distress and pain? We can rely on our morbid sense of humour for so long, but what happens when you go home and there is an emptiness because of the emotional and mental outlay that your job requires?
- Engagement – doing things which get us into a state of flow, both at work and personally
- Relationship – ensuring that we have personal relationships which are healthy and remind us of the much bigger world beyond medicine, but improving the authenticity and openness within our professional relationships. Only doctors know what doctors go through; the help we can offer one another is massive
- Meaning – there is an expectation that being a doctor is an inherently ‘meaningful’ job. It can be – but the meaning is very easily lost amongst electronic health records, HR departments, KPIs, technical glitches, and the hierarchical, punitive structure. How do we imbue our jobs and personal lives with meaning?
- Accomplishment – it’s easy to accomplish in medicine. But what happens when you’ve accomplished everything that there is to accomplish? What happens when, perhaps, you have not accomplished in your family life, or interests, or health, or hobbies, or psychological health? What happens when you reach your peak professionally? We need to ensure our lives are not empty beyond the practice or hospital walls.
I look forward to sharing more in the weeks to come. In the meantime, please reach out if you are struggling. I’m happy to be contacted here personally, or go to The Doctors Health Advisory Service, or reach out to a trusted colleague.
We’re in this together.