In the late 1970s, as a medical student in the United Kingdom, I attended a lecture from the then Dean of the medical school, Professor Neil Kessel. I recall him looking around at the 200 students assembled, and informing us that “Four of you will commit suicide”. That was, as I recall, the extent of our education about doctors’ health.

Now, 30 years later, true to Professor Kessel’s foreboding, and despite his writings1 and the contribution of many others to an increasing body of knowledge and education about issues of physician impairment,2 four of my then colleagues have taken their own lives.

Horrific though these mortality statistics may be, we also need to be cognisant of the considerable rates of morbidity among doctors. There have long been arguments about whether it is the stress of the job or the susceptible personalities that we bring with us to the profession that cause doctors to become stressed or psychiatrically unwell, or to develop substance misuse disorders. While we may be able to do little about the personalities of those attracted to careers in medicine, it is imperative that the stresses of the job and workplace are recognised, and that efforts are made to reduce them.

For each cohort of medical students and doctors in training, the stresses of the previous generation may be modified, but they don’t disappear, and new ones are added. In theory, it is no longer permitted for registrars to stay up all night and then work the next day. In 1998, with the belated recognition that a disturbed sleep–wake cycle was good for neither patients nor doctors, and the establishment of the Safe Working Hours campaign,3 such practices are no longer defensible. However, doctors in training are not less stressed than those of previous generations; the stresses are different and often more intense, overlaid with the need for greater accountability, and the increasing militancy and litigiousness of consumers.4

In this issue of the Journal, we welcome two articles and a letter about doctors’ health and wellbeing.

According to Heredia and colleagues, the intern year remains stressful despite reductions in hours and improvements in conditions.5 Self-report showed that 50% of interns thought medical school prepared them well for internship and, for most, internship was what they expected; but structured questionnaires showed that nearly 60% of interns had low levels of job satisfaction and, alarmingly, 18% regretted having studied medicine.5 Likewise, Markwell and Wainer found high rates of low job satisfaction and compassion fatigue among doctors in training, with 17% saying that, if they had their time over again, they would not have chosen medicine as a career.6

In the developmental trajectory of a doctor’s career, each phase brings its own set of challenges, and dissatisfaction with medicine as a career also appears to be significant among more senior doctors. A 2007 survey of what was deemed to be a representative sample of consultants in the British National Health Service found that 18% planned to retire early (before age 55), 32% were estimated to have psychiatric morbidity, and 17% reported drinking hazardous quantities of alcohol.7 The personal toll on doctors who are stressed, suicidal, burnt out or misusing substances must be appreciated; the effects on workforce planning of doctors underperforming or planning to give up medicine are also significant.

Markwell et al found that most doctors in training report that their consultants and hospital administrations are supportive; this is encouraging, especially as it is in contradiction to the clinical experiences of working in a doctors’ health program. Here, some of the worst stresses experienced by doctors during their training (and later in their careers) are not those imposed by the system or training program, but come from the unsympathetic and judgemental attitudes of some more senior colleagues, who still see going through an intensely stressful training program as a rite of passage, or as preparation for tough times to come. Some of this stress is particularly stressful because it is personal and directed at individuals.

It behoves us to treat our more junior colleagues with the same compassion that we show our patients. Postgraduate training for doctors has moved away from the apprenticeship model, making way for competency-based curricula. Trainees are under more scrutiny, and the stress of assessment is continual, with such evaluation tools as 360-degree assessment (multisource assessment with contributions from peers, other health professionals and patients) portfolios and formal evaluations in the workplace. The final exit examination may be less of a hurdle, but this comes at the price of doctors in training frequently being caught in a complex system where training requirements often conflict with workplace demands.

The job is certainly stressful, but, as has been humorously pointed out, we as doctors need to admit the burden that we carry and find appropriate channels to “unload our baggage”.8 Authors of the third article on doctors’ health in this issue, Nash and colleagues, pose — and promise to explore in a future article — the important question of whether psychiatric morbidity is a cause or effect of medicolegal processes. However, they do find that those who work long hours are more likely to be involved in current medicolegal matters.9

Healthy doctors are more likely to have healthy patients. In order to keep doctors healthy, the ongoing challenges include not only continuing research into a changing group of issues, but integrating education programs into both undergraduate curricula and the workplace, and tackling workplace issues that may in part be best considered at the occupational health and safety level.