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The health and wellbeing of junior doctors: insights from a national survey

Alexandra L Markwell and Zoe Wainer
Med J Aust 2009; 191 (8): 441-444.
Published online: 19 October 2009

The health status of doctors is better than average; like other higher socioeconomic groups, they are less likely than the general population to suffer lifestyle-related illnesses, such as heart and smoking-related disease.1-3 However, they are at greater risk of mental illness and stress-related problems and are more susceptible to the “3 Ds” — depression (including suicide), drink and drugs.4,5

Junior doctors (interns through to completion of training) are a subgroup of the medical profession who may be at greater risk of poorer health. They face specific pressures related to their professional stage and development, including coping with the demands of each new clinical placement, furthering their medical career, and maintaining social and personal networks. Junior doctors do not prioritise their own health care and feel pressured not to miss shifts because of ill health.6 They can be unwilling to admit illness or accept that they are not coping with the demands of their career. This can lead to a failure to recognise, acknowledge and act on the early warning signs of illness.

Recent data on the attitudes of junior doctors to work–life balance suggest that they now are less willing to accept the personal costs traditionally associated with a career in medicine. In response, recent initiatives have endeavoured to improve the support available to junior doctors.7 Medical colleges are providing wellbeing programs for trainees and Fellows, and medical schools increasingly include self-care programs in their curricula.8

Despite these innovations, the Australian Medical Association (AMA) Council of Doctors in Training remains concerned about the state of junior doctors’ health, and in 2008 undertook a survey to raise awareness and record baseline data on the health and wellbeing of junior doctors in Australia and New Zealand.

Survey methods

The AMA’s junior doctor health survey was adapted from the 2007 Junior Medical Officer Welfare Study (developed by Dr Daniel Heredia, Dr Suzanne English and Ms Sheree Keech, and funded by the Postgraduate Medical Council of Western Australia).9 The 96-item confidential, online, self-reporting survey was conducted between 6 February and 20 April 2008. Junior doctors in postgraduate year 2 and above participated.

The survey was hosted on the AMA Federal Secretariat’s website, and the link was distributed electronically by the AMA and the New Zealand Medical Association to about 3820 and 290 junior doctor members, respectively. Participation was voluntary. Formal ethics approval was not sought, but participants were provided with information on the intended use of the de-identified data. Respondents were provided with a list of support resources on the survey website.

The survey assessed several areas related to junior doctors’ health and wellbeing, including:

  • intention to continue to practise medicine;

  • perceptions of morale and wellbeing;

  • career satisfaction;

  • workload and the working environment;

  • coping strategies when faced with work-related stress; and

  • self-care and work–life balance.

The open-source Professional Quality of Life (ProQOL) scale was included in the survey.10 This instrument uses three discrete psychometric scales to determine the prevalence of secondary trauma (compassion fatigue) and burnout, and job satisfaction levels.

Survey results
Profile of respondents

There were 914 completed surveys, representing an approximate response rate of 22% for both Australian and New Zealand junior doctors. A majority of respondents (71%) were aged between 26 and 35 years. Forty-eight per cent identified as resident medical officers, 28% as registrars, 14% as senior registrars and 10% as non-training registrars. There were more female respondents than male (56% v 44%). All specialties, states and territories were represented.

Career satisfaction

Most respondents (98%) indicated they would continue to practise medicine.

The key findings from the questions on morale, job satisfaction, workload and working environment are summarised in Box 1. A majority of respondents (59%) reported spending time with family or friends as their main coping strategy, and 17% used exercise (Box 2).

Based on established ProQOL cut-off points:8

  • 54% of respondents met the criteria for compassion fatigue (59% of female and 48% of male respondents);

  • 69% met the criteria for burnout — characterised by hopelessness and difficulty in performing their job effectively (73% of female and 65% of male respondents); and

  • 71% had lower than average levels of job satisfaction (75% of female and 65% of male respondents).

Self-care and work–life balance

Seventy-one per cent of the junior doctors reported being concerned about their physical or mental health during the previous year. Nearly two-thirds (63%) had been concerned about the health of a colleague. Two-thirds of respondents (66%; 75% female, 46% male respondents) had their own general practitioner for independent medical advice. Fifty-eight per cent of those with a GP (71% female, 43% male respondents) reported having consulted this doctor during the previous year. Five per cent of respondents (60% of whom were women) reported using a doctors’ health advisory or similar service in the previous year.

Thirty-eight per cent (40% female, 35% male respondents) reported that they had self-prescribed or self-medicated during the previous year (antibiotics, 30%; oral contraceptive pill, 25%; and non-opioid analgesics, 21%). In addition, 11% (102 respondents) completed the free-text response: of these, 19% described self-prescription or self-medication of anxiolytics and sleeping tablets, and 10% of antidepressants.

Results from the questions on work–life balance are given in Box 3.

Discussion

The physician who doctors himself has a fool for a patient.

Sir William Osler, 1849–1919

This survey confirms that junior doctors have a high level of career satisfaction; however, it is of concern that 38% of respondents indicated that they were not prepared for life as a doctor, and 17% would not choose medicine as a career if they had their time again. This is consistent with 2006 British Medical Association data, which established that 15% of medical graduates had a low desire to practise medicine.11 The coping strategies nominated by most junior doctors were appropriate, although they relied heavily on the ability to maintain relationships, which could leave junior doctors vulnerable if they became isolated through heavy work and study demands.

The ProQOL prevalence figures for burnout, job satisfaction and compassion fatigue are consistent with those reported in other studies, and comparable with an earlier study using a different instrument.4,12-14

That 71% of respondents were concerned about their own health, and 63% were concerned about the health of a colleague, confirms that junior doctors are aware of their health care needs and require access to independent medical care. That said, the survey found that fewer junior doctors (66%) have their own GP compared with the general population (80%).15 The rates of self-medication and prescription probably reflect that junior doctors have difficulty accessing independent medical care, and that the culture of medicine promotes self-care. No formal data are available on the use of doctors’ health advisory services by junior doctors, so the rate of 5% provides a baseline for future reference.

Junior doctors appear unable to access annual leave in full. This is of concern as taking leave may help protect them against the long-term effects of fatigue. Junior doctors also take relatively small amounts of sick leave and carers’ leave. It is conceivable that this may change as the average age of medical graduates increases, and so too does their need to care for children or elderly parents.

Although adults require between 7 and 9 hours of quality sleep in a 24-hour period, most junior doctors were sleeping 7 hours per night or less.16 Likewise, the Australian National Physical Activity Guidelines recommend that adults do 30 minutes of moderate-intensity physical activity on most days; only about a quarter of survey respondents were able to follow this recommendation.17 As most junior doctors were working up to 60 hours per week (as well as studying), it is not surprising that exercise and sleep are given a low priority.

To address the concerns raised by this survey, the AMA Council of Doctors in Training has put forward a series of recommendations (Box 4) and resolutions (Box 5), which were endorsed by the Federal Council of the AMA in March 2009.18 A poster campaign designed to raise awareness was also launched in October 2008. The full report of the survey is available on the AMA website at <http://www.ama.com.au/node/4217>.

Conclusions

This survey provides a snapshot of the health and wellbeing of junior doctors and an indication of how they are able to balance their personal and professional lives. The results indicate that most junior doctors have a rewarding and satisfying career in medicine, but at a cost to their physical and emotional health. The data also confirm that the medical culture of self-reliance persists, and inappropriate self-care practices develop early in doctors’ careers.

On the basis of this survey, it is clear that the AMA has an ongoing role in

  • improving the support provided to doctors;

  • undertaking further research into the health and wellbeing of junior doctors; and

  • ensuring that systematic problems contributing to doctors’ poor health are rectified and the inherent risks mitigated.

Supporting junior doctors during this challenging phase of their careers is vital to ensure a healthy and sustainable medical workforce.

1 General experience as a doctor

Working as a doctor

  • 38% believed that medical school had not prepared them for life as a doctor; and 17% admitted that, given their time again, they would not have studied medicine

  • 45% felt that working as a doctor was what they had expected it to be

  • 77% enjoyed working as a doctor, and 73% were looking forward to working as a doctor that year

Workload and safety

  • 54% reported their workload had been excessive; 53% believed that an adverse event could occur as a result of their high workload; and 41% believed that their workload compromised patient safety

  • 70% had experienced high levels of stress at work; 56% had been concerned about the welfare of their colleagues because of the working conditions; and 31% believed that they regularly worked unsafe hours

Support received

  • 46% believed that their hospital administration had not been supportive in the past year; however, 74% had found their supervising consultants to be helpful and supportive

2 Main coping strategies of junior doctors


* Alternative coping strategies included: informal debriefing, sleep, meditation or prayer, hobbies, crying, psychiatric therapy, and counselling.

3 Junior doctors’ work–life balance

Working hours

  • 97% worked full-time; of the 3% working part-time, 65% were women

  • 76% worked 41–60 hours per week; half (49% female, 53% male respondents) had worked an average of ≥ 50 hours per week during the previous year

Leave

  • 23% had taken ≤ 1 week and 67% had taken ≤ 4 weeks’ annual leave in the previous year. Reasons cited included lack of cover (20%), more leave not being sought (20%), insufficient leave accrued, or a change in employment

  • 76% had taken < 1 week of personal leave; respondents were more likely to take leave for their own health (84%) than to care for others (35%)

Sleep, exercise and study

  • 84% slept on average ≤ 7 hours per night

  • 27% exercised ≥ 4 hours per week and 15% (13% female, 17% male respondents) reported no exercise in the preceding month

  • 35% of respondents had studied ≥ 6 hours per week and 20% had studied ≥ 10 hours per week in the preceding month

4 Recommendations from the Australian Medical Association (AMA) Council of Doctors in Training18*

Junior doctors should:

  • take responsibility for their own physical and psychological health

  • establish a continuing relationship with a general practitioner they trust

  • incorporate regular leave, good nutrition, exercise, leisure and family time into a healthy and balanced lifestyle

  • recognise there are dangers to others associated with (i) a reluctance to admit illness or failing competence, and (ii) continued or regular self-medication and prescribing

To support junior doctors — hospitals, medical colleges, medical boards and government should:

  • promote good health and the adoption of a healthy lifestyle for junior doctors throughout their medical training and career

  • ensure access to confidential and high-quality medical and health services

  • establish professional debriefing, support and mentorship

  • identify internal and/or external stress factors contributing to, and recognise the warning signs and behaviour patterns of, poor health in junior doctors

  • promote access to early and expert assistance from professional services and providers

  • incorporate skills such as stress and time management into continuing medical education

  • establish clear referral pathways for junior doctors in need of assistance

  • adopt a “no-blame” culture that supports those in difficulty, so that junior doctors are confident that seeking help will not damage their career progression

  • ensure that the training and workplace environment does not adversely affect a doctor’s health, conduct or performance, which in turn could place patients at risk

  • implement and support safe rostering practices and safe working hours


* Adapted from the AMA position statement, The health and wellbeing of medical students and practitioners — 2006.18

 The AMA publication, National code of practice. Hours of work, shiftwork and rostering for hospital doctors, provides guidance on safe rostering practice.19

5 Australian Medical Assocation Federal Council resolutions

That Federal Council calls for and assists state and territory doctors’ health advisory services to obtain funding to establish a research epidemiological database of doctors and medical students at risk of suicide and completed suicide*

That Federal Council supports a forum of doctors’ health advisory services, professional organisations and impaired doctors programs to discuss improvements to the health, wellbeing and pastoral care* of doctors

That Federal Council calls for systematic research on coronial and other reports of completed suicides of doctors and medical students to ensure system failures are identified and rectified


* This information must remain de-identified.

 Pastoral care refers to the psychological health and wellbeing of doctors.

  • Alexandra L Markwell1
  • Zoe Wainer2

  • Australian Medical Association Council of Doctors in Training, Canberra, ACT.


Acknowledgements: 

The survey was funded by the AMA and undertaken with the assistance and support of the AMA Federal Secretariat. We thank the doctors in training who completed the survey, and acknowledge the ongoing support and inspiration of the Council of Doctors in Training. We also thank Professor Tony Brown for his editorial input in the development of this article.

Competing interests:

Alexandra Markwell, as a former board member of the Federal AMA, has received an allowance and travel assistance to attend meetings on behalf of the AMA. Work on this survey was undertaken on behalf of the AMA. She has received travel assistance from the Medical Council of Tasmania to present at their conference, and from Queensland Health to present the survey results at the International Doctors’ Health Conference in London, 2008.

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