Sick of being a doctor: Over-worked hospital medics pushed towards the brink
IN the last six years, Donal*, a hospital doctor in his early 30s, has worked in nine different hospitals, in Ireland and abroad.
Since 2012, he has also lived in a different county each year, as part of his specialist training.
His position seems enviable — as a highly paid specialist registrar, he has just a few years to go before becoming a consultant, the pinnacle of his profession.
But Donal is not only frustrated and stressed, but also depressed by the emotional, financial, and social toll of his working conditions.
“The moving around is the most stressful part of my work and training,” he says.
“I own my own house, but I have to rent accommodation wherever I’m sent, which is financially stressful.”
Socially, he says, the temporary work — he has no control over where his training scheme sends him — leaves him isolated.
“I am away from my family and girlfriend on a constant basis,” he says, adding that the unpredictability of his placements and his long working hours constitute significant stressors.
“There’s no stability. You’re living out of a suitcase for years. Sometimes, people only find out where their next place of work is to be weeks before they’re expected to start, and that’s very stressful”.
He regularly works every second weekend and has a lot of on-call hours.
“I do a lot of on-call work. Over the next two weeks, I am doing four 24-hour shifts, plus I have an assignment due for a course I’m doing.
“You don’t really get time for normal life things,” he says.
While his superiors are “quite supportive,” in that “they back you up and it’s a good training scheme,” the system is very isolating.
Once he finishes his training, he says, he will emigrate to Canada or Australia.
“There are better working conditions, a better quality of life, and better pay, plus the freedom to choose what you want to do and where you want to work.”
I make a joke about how, in just a few years’ time, he’ll be living in a prestigious penthouse, overlooking the sunlit waves of Bondi Beach.
“But maybe not as a doctor,” he says. He’s not sure if he can keep going, he says grimly. And, no, he’s not joking.
One in three Irish hospital doctors are close to burnout, delegates were told at last weekend’s Irish Medical Organisation’s annual conference in Killarney.
Leo Kearns, chief executive of the Royal College of Physicians of Ireland, drew a comparison with airline pilots, and the likely impact pilot burnout would have on the airline sector.
“How safe would people feel about getting on the plane? You just wouldn’t. Yet people think it is OK for doctors. And what are the implications for patients?”
In Caroline Elton’s shocking new book on the medical profession, Also Human: The Inner Lives of Doctors.
It’s a graphic exposé of the exhaustion, depression, and stress among doctors and it has sent shock waves across the health services.
Elton highlights unrelenting problems in Britain’s NHS, such as massive under-staffing, hideously long hours, and pressure on junior doctors to carry out clinical tasks for which they feel they’re not adequately trained.
She references a study of nearly 500 junior doctors by the Royal College of Physicians in Britain, which reported that 70% worked on a rota that was permanently under-staffed: four times a month, doctors completed a full day or night shift without having time to eat; 18% had to carry out clinical tasks for which they had not been adequately trained; 80% felt their work sometimes or often caused them excessive stress; 25% felt their work had a serious impact on their mental health.
The stress, and their fears for the impact their poor morale and heavy work-load may be having on patient safety, is stark.
But this is not just a problem for the NHS and the HSE. In 2015, a major international study, published in the Journal of the American Medical Association, showed that the level of depressive symptoms in trainee doctors was extraordinarily high — between a quarter and a third experienced significant symptoms.
“Their training can equip them for dealing with the demands of day-to-day clinical work that one would expect to happen in a well-functioning healthcare system,” says Elton. “But it’s not equipping them to cope in a system which is under as much pressure as this.
“Rotas are understaffed, people are being asked to carry out clinical duties that they are not trained to do ... There are long hours, lack of a support, and a denial that this can be emotionally demanding work, which can push doctors toward the brink.”
We have lost sight, she says, of the psychological demands of medical work and the need to support doctors.
None of this came as any surprise to several Irish doctors who spoke to Feelgood about working conditions within the Irish health service.
“On-call is probably the hardest, because of the late-night work,” says one former hospital doctor, who is now training as a GP.
“During the day, you’re on a hospital-based team, with a consultant in charge and there’s more direct support, but when you’re on-call, you’re much more autonomous.
“If you’re very junior, there will be a more senior doctor over you, like a registrar, but the registrars are junior enough themselves, yet they’re responsible for whatever happens, and that’s huge pressure.
“There’s a lot of responsibility, and even though there is senior support, it can be remote.
“The long hours and the frequency of on-call work is very debilitating — when I was on medical on-call, 24-hour call was standard.
“It takes a few days to recover from being awake for 24 hours and you’re often going flat-out for that 24 hours, because it’s really busy.”
But it’s not just in hospitals — GP practices are under growing pressure, according to Kieran*, who worked for some years in the hospital system, before joining a GP trainee scheme.
“The stress in the GP sector is in the workload you carry, while, in hospitals, the stress levels are high in terms of the long hours.
“Many hospital doctors work 12-hour days and then they’ll do an on-call on top of that.”
As a result, he adds, doctors are “being driven out of hospital medicine into the GP system, because the GP service is the only speciality where you can have a work-life balance and a family — it is structured and very few of us do nights.”
However, although it is a more predictable working day, a modern GP practice is often extremely stressful — GPs are routinely expected to diagnose a patient, take a history, and come up with a treatment plan in 10 minutes.
“On top of that, we have no access to diagnostics, not even a basic chest x-ray, and this is a huge stressor,” he says.
“And there’s no back-up from the hospital system.”
It’s no surprise, then, that so many young GPs are emigrating: a survey published by the Irish College of General Practitioners, in late 2017, showed that almost one in five of recently graduated GPs had already emigrated, while one in three of those currently in training were considering working abroad.
“There is plenty of work for GPs in Ireland, but a lot of my counterparts have decided to emigrate, because the workload is becoming increasingly difficult,” says Kieran, adding that the 38% cut in the income stream from medical-card patients is another major disincentive for doctors considering a community-based medical career.
In contrast, he says, in Australia or Canada, GPs “can get all the back-up and diagnostics you want, plus the pay is better — a career as a GP is now a very unattractive profession in Ireland.”
Another GP trainee, who did not wish to be identified, says “As a GP, you know that a person needs to see a certain specialist or get a certain investigation, but you also know that that investigation or that access to a consultant could take a year or so down the line.
“That’s a source of stress, because when this kind of thing is routine, you end up with a whole cohort of people whom you know need further investigation or specialist review, but the access to these facilities is not timely — for example, in the case of hip replacements or cataract surgery.
“There’s a huge gap between what is needed and available resources.”
Because of the ever-dwindling number of GPs — the National Association of GPs has warned that the number of GPs in the country has fallen far below international best practice — patients are now experiencing increasing difficulty in even getting a GP appointment, he says. And when they do get to see a doctor, they have less time in the consultation than previously, because of the pressure of numbers.
There is a “huge” issue with burnout among doctors, warns Dr Mark Rowe, a GP of 23 years, lifestyle medicine expert, and author of A Prescription for Happiness.
He points to research in the Journal of the American Medical Association, which shows that about 50% of physicians were experiencing symptoms of burnout, he says.
“Caring is wearing and if you ask any doctor about burnout, they’ll ask you which burnout story do you want to hear,” says Waterford-based Rowe.
“You are dealing with increasingly complex cases — you could have people on up to 20 different tablets daily.”
Then, there’s the long hours, and the rise in litigation, which is another stressor for over-worked doctors.
“Systems are far from perfect and mistakes happen, but there’s now a culture of ‘hang the doctor out to dry’, rather than looking at the system around something. This puts a lot of pressure on doctors — the fear of being sued.
“The lack of resources and lack of access to central services is a major issue.
“It’s not acceptable that people in Ireland have to wait so long to get basic tests. This frustration for patients affects the doctors,” says Dr Rowe.
“A lot of GPs are going to Australia and Canada — they’re moving there because of money, but the reason a lot of them are staying is because the systems are much better. In Australia, if someone has a problem, they can have their scans done on the same day and the GP will have the results back that evening and get a specialist to see the patient the day after,” he says.
Doctors in Ireland work extremely hard and in very difficult conditions, adds Dr Rowe.
“A doctor can find himself or herself working all the time and neglecting health and key relationships,” he warns.
“At a fundamental level health needs to be valued as a resource rather than as a cost and the people who provide healthcare need to be valued as resources and not just seen as a cost.”
