The ecology of survival for new medical graduates

The most effective strategies for preparing young doctors will operate outside the closed public hospital system

This issue of the MJA includes a report by Chanchlani and colleagues about a study of the value of peer mentoring for the psychosocial wellbeing of junior doctors; the authors conclude that the program employed in their randomised interventional study was valued by participants.1 The authors detail the negative aspects of the public hospital environment for interns, including navigating the complexity of the health care system, being required to regularly develop and implement new clinical skills, and a pervasive anxiety about future career advancement. Any program that achieves better outcomes for young doctors is praiseworthy, but it is disappointing that little has changed in the past 20 years in either descriptions of the work environment or the levels of anxiety, stress and burnout reported by junior doctors. Bullying and harassment are said to be endemic in our hospitals.

The term “mentor” is derived from the story of Mentor, the old friend whom Odysseus entrusted with the responsibility of looking after his son during his protracted absence, and has come to mean a wise and trusted counsellor and an influential sponsor or supporter. The medical interns in the study by Chanchlani and her co-authors were mentored by peers only marginally more advanced than themselves in the traditional public hospital model of early postgraduate employment and training. It is hard to see how these mentors could fulfil the role without having yet attained the maturity and authority of a traditional mentor, and arguably lacking the external environmental perspective that a mentor should have, while themselves being subject to the same pressures as their mentees.

A more apt analogy than mentoring might be that of a newly incarcerated inmate receiving survival tips from the more established lags. Social psychologist and criminologist Hans Toch applied the term “the ecology of survival” in his studies of the American penal system,2 and his descriptions of the effects of incarceration and institutionalisation bear an uncomfortable resemblance to contemporary descriptions of life for Australian junior doctors.

This is not to devalue either the intent or the outcome of the study by Chanchlani and colleagues, a useful contribution to the literature on this topic. However, given that so little has changed in either descriptions of the work environment or measures of the anxiety, stress and burnout reported by junior doctors, we need to examine the premises upon which current interventions are based and to search for alternative solutions.

Firstly, public hospitals in 2018 are short stay, high acuity units for patients whose more chronic and complex health care needs cannot be effectively evaluated or managed during the brief window of a hospital admission. Opportunities for interns to develop a broad suite of skills, as well as opportunities for empathising and bonding with patients, are limited. Hospital-based apprenticeships are not preparing recent graduates with the skills that will be required later in their careers.

Secondly, the career anxiety experienced by junior doctors is disproportionate to the relative security of new medical graduates compared with people of similar age entering other professions. The digital revolution, characterised by disrupted service delivery models, means that the public hospital and vocational training environments are premised on old and failing paradigms. We need to define where and how new graduates can best develop the skills and resilience needed for adapting to shifting environments. Demanding better access to the pathways of an outdated career model is misguided. Our young doctors need assistance to envision their new potential futures.

Finally, each generation of doctors reports anecdotes of mistreatment. Few doctors are inherently bullies, but some are caught in an intergenerational and self-perpetuating cycle of behaviour, similar to that of domestic violence. Bullying and harassment are frequently manifestations of intergenerational burnout and post-traumatic stress. As with other forms of intergenerational abuse, effective solutions are complex, but must include active rejection by the victim of earlier dysfunctional behavioural paradigms.

Some doctors-in-training have recently criticised any advocacy of the need to develop resilience as a cop-out that avoids the need for significant system change. While system change is needed for a range of reasons distinct from those that specifically affect interns, the most effective strategies for preparing young doctors for their future lives and careers will operate outside the closed and self-perpetuating public hospital system. Mentoring by peers is only likely to have longer term positive effects if all young doctors (including the peer mentors) receive better support for grappling with life- and career-related problems from a broader perspective. This requires an expanded range of work environments, a commitment by colleges and other training bodies to greater flexibility and integrated training models, and ultimately the liberating acceptance by young doctors that their futures require their understanding and interacting with the wider world.