Unique stressors on hospital doctors

Unique stressors on hospital doctors

Burnout is rife across the profession, but the everyday stressors differ depending on your role. The NSW Doctor looks at the unique burdens that hospital doctors bear.

ALL DOCTORS shoulder the incredible responsibility of caring for patients. Whether you work as a general practitioner in a rural town or neurosurgeon at a major metropolitan hospital – you are required to make life and death decisions on a regular basis.

While there are significant commonalities, there are also unique differences in the sources of stress that impact doctors. The pressures facing general practice (payroll tax, pharmacy prescribing, the impact of the Medicare freeze) are particular to that specialty. Consequently, we are covering these issues in a separate article.

This feature focuses on hospital doctors, which upon further reflection, is about as specific as looking at doctors with belly buttons. Your specialty, whether you are still training, and your location will have an incredible impact on your day to day – so to this end, we’ve tried to encapsulate the unique stressors hospital doctors face and break those down further based on location, experience, and specialty. We also spoke to a wide variety of doctors to get a sense of what challenges they face.

This is by no means an exhaustive categorisation. There are many lenses from which to examine stressors, including gender, sexuality, race, age and more. Unfortunately, there isn’t space in this edition to adequately examine these characteristics in greater detail, but we invite readers to submit comments and letters (news@amansw.com.au) to drive further discourse on this important topic area.

COMMON STRESSORS

Workforce shortages

Findings from Deloitte’s White Paper “Medical Workforce Pressures in NSW” reveals an increase in demand from a growing and ageing population. Over the past 10 years, growth in service volumes (Hospital Separations 2.2% on average per annum) have significantly exceeded population growth (1.3% on average per annum). Pressure on the system is further documented by the Bureau of Health Information’s Quarterly Reports, which reveal a steady increase in emergency department presentations and a corresponding decrease in the health system’s ability to meet the performance targets set by the State. Comments from an open letter written by the NSW Medical Staff Executive Council encapsulated how this pressure is impacting on doctors: “Public hospital staff were working at an incredible pace prior to the pandemic, and this has continued to escalate without abatement despite moving to COVID-normal. … It is exhausting. And while there is management pressure to take leave and allotted days off, we feel burdened by the realisation that there is not enough fat in the system to absorb the extra work this creates for our colleagues. There is chronic understaffing in all areas.”

According to ENT registrar Dr Jacqueline Ho, doctors-in-training are at the pointy end of the resourcing pinch.

“Doctors-in-training are the forefront of hospital system and see day to day the systemic shortcomings in trying to provide the best care for our patients. They work in an underfunded, under-resourced health system – repeatedly apologising in response to the brunt of patient criticisms about hospital inefficiencies, bed block, long clinic wait times, cancellations and surgical waitlists.”

Radiology registrar Dr Sanjay Hettige said bed-block is more the norm than the exception and junior doctors are under enormous pressure to get patients out of hospitals as soon as possible.

“This means that they are often multitasking, making sure all the tests, investigations, and appointments are sorted for their patients while trying to take adequate notes for a ward round, communicate adequately with patients, answer questions from their consultants, sorting out discharge summaries, answering emergency calls and pages all while trying to find some time to eat and maybe go to the toilet.”

According to Dr Hettige the pandemic laid bare workforce issues that were previously simmering in the background.

“This includes a severe shortage of JMO workforce in our metropolitan hospitals. Unfortunately, as workloads build and working conditions get worse, doctors-in-training are leaving the NSW hospital system in large numbers which adds even more pressure to those left behind, exacerbating the problem.”

Outdated agreements

Another source of frustration for hospital doctors are the award conditions and the wages cap. The outdated Staff Specialist Award and the wages cap has resulted in many hours of unpaid work. The NSW Staff Specialist Award was written prior to the establishment of team-based, 21st Century medicine and is well behind updated Victorian and Queensland Awards. The VMO arrangements have also not been meaningfully updated for many years. The VMO Determinations were last the subject of a major review in 2007. Since that time advances in technology, societal expectations regarding work/life balance, an ageing population and complexity of patient presentations to hospitals, and significant workforce challenges demand a review of current arrangements including what is a reasonable on-call commitment and the need to address the fact that many can and do provide services from locations other than the hospital for which they are not remunerated.

Clinician engagement

AMA (NSW) conducted a survey of senior doctors in 2021 that revealed senior clinicians felt unsupported by key decision-makers. The Senior Doctor Pulse Check found 63% of senior doctors did not think their LHD/network enabled strong medical leadership and cross-organisation participation in decision-making. In addition, almost half (47%) did not think they could openly and honestly discuss workplace problems or issues with their hospital/LHD. Meanwhile two in three senior doctors did not believe senior management at their hospital/LHD could be trusted to tell things the way they are. Two-thirds of respondents (69%) did not feel valued by their hospital. Deloitte, in conjunction with AMA (NSW) conducted a similar survey in 2022 which found only 34% of senior doctors reported feeling valued in their roles. Reasons for feeling undervalued included feeling replaceable, lack of support from management (including a sole focus on KPIs and an inability to respond to improvement requests).

Lack of resources

According to the 2021 Senior Doctor Pulse Check, eight in 10 doctors reported experiencing workplace stress, with the majority citing excessive workloads (60%) and lack of resources (69%). In 2022, three quarters of survey respondents in the Deloitte/AMA (NSW) survey found their work settings were under-resourced.

Geriatrician and general physician, Dr Alison Semmonds said there is a strong perception that hospitals have more competition for resources now than previous years.

“One of the issues I’ve found in the public sector is that because so many people are competing for the health dollar, there has been a withdrawal of support that was expected and traditional for doctors.”

She explained that with limited funding, doctors are being bogged down with administrative tasks such as typing clinic letters and arranging clinic appointments.

“They don’t recognise the importance of supporting specialists, so we can look after patients, keep them out of hospital and manage them effectively as outpatients. That would have never happened years ago.”

According to Dr Semmonds, there is greater support in the private sector.

“There are fewer barriers. If you see something that needs to be done it’s more, ‘how can we help you?’.”

Complaints

Medical complaints are intensely distressing to all doctors. Even when matters are resolved in favour of the doctor, many describe a medico-legal complaint as one of the most traumatic experiences in their lives.

Dr Semmonds said the prospect of a medical complaint is something that “is with me every day, but not with me with every patient.

“It does influence what I do a lot. You know that even though you can do a wonderful job, there is so much emotion in health that it doesn’t take a lot for there to be a misunderstanding and then there is distress and anger and it can turn into a complaint.”

Doctors who face medical complaints will be forced to question their competence, decision-making, and conduct. This can have significant ramifications on a medical professional’s wellbeing. A BMJ study published in 2015 of 8000 doctors in the UK found those who experienced professional complaints had a higher risk of anxiety and depression. Doctors were 3.78 times more likely to report suicidal thoughts while going through a complaints process. Unfortunately, given the rise in complaints to AHPRA, it is increasingly likely that more medical professionals will experience at least one complaint in their professional career. AHPRA received 10,803 complaints about 8380 practitioners in 2021/22 – a 6.5% increase over the previous year. The AMA identified the need for AHPRA to address vexatious complaints – those complaints made for vexatious reasons, including using the complaints process as a tool for bullying and harassment, including by other health practitioners. Following detailed consultation with the AMA in the second half of 2020, AHPRA released its new framework to support the identification and management of vexatious notifications.

Public perception

Recent media reporting on Medicare rorts has had a significant impact on the mental health of medical professionals. Whilst the extent of rorting was greatly exaggerated and an independent review has revealed that many incidents of incorrect claiming are a result of system confusion, the perception that a significant number of doctors are intentionally frauding the system has left many feeling scarred and their reputations unfairly tarnished.

Dr Semmonds said the negative reporting was heartbreaking.

“When I think about that, it actually makes me want to stop working as a doctor full stop.

“People who end up being doctors generally have worked and worked and studied and studied. When you give so much of your life to this career and you do the right thing, and then you read these reports and think, ‘oh, what does that person think of me?’” She added that she is grateful she is at the end of her career and that many of her colleagues are now actively discouraging their children from doing medicine.

UNIQUE STRESSORS

Whilst the above provides a few examples of stressors that affect doctors working in public hospitals, we wanted to examine a few of the differences that exist depending on a doctor’s role, locality, and specialty. These are broad brush strokes and do not fully cover the differences that exist within the health system.

BY LOCATION

Regional and rural

NSW The rural health inquiry exposed many of the stressors associated with rural and regional healthcare. Despite having a greater need for medical services and practitioners, there is a disparity between the number of specialists in major cities (143.5 FTE per 100,000 in 2020) compared to the remote areas (61.7 FTE per 100,000 ). Without a ‘critical mass’ (multiple doctors with the same speciality in a popular location) there is greater professional isolation. Regional and rural areas often lack appropriate infrastructure, including availability of long-term certainty of theatres and lists, diagnostic services, access to specialist drugs, specialist nurses and staff, access to private hospitals as well as connection to metropolitan colleagues.

Oncology, palliative care, neurology, cardiology and stroke services can be limited in regional and rural areas and have been identified as needing greater investment.

Outer metro hospital

Areas such as South Western Sydney and Western Sydney are unique in their demographic and socio-economic status. They cater to diverse populations.

The South Western Sydney LHD is one of the fastest growing areas in the State – from 2016-2036, population growth is expected to be 45%, which is almost double the average for NSW of 28%. There is a changing age profile that will result in significant growth in the number of elderly people over the next 20 years. In addition, the proportion of people with profound or severe disability is higher than the NSW average. More than half (51%) of residents speak a language other than English at home. There is high socio-economic disadvantage, unemployment, low levels of English proficiency, and high concentration of social housing. There is also low private health insurance coverage. ]

For example, Bankstown is a culturally and linguistically diverse suburb, with one in three residents from a Culturally and Linguistically Diverse (CALD) background. This presents challenges for health delivery in terms of health literacy, diagnostic accuracy, engagement with health services, and adherence to treatment protocols. Funding should address the need to improve interpreter services and address these unique challenges.

The parliamentary inquiry report into current and future provision of health services in the South-West Sydney Growth Region, found there has been a history of underfunding in South-West Sydney in proportion to population and need. Funding is provided through Activity Based Funding (ABF) and block funding where ABF is not appropriate. This model does not adequately address the healthcare needs for patients who need to leave the area for treatment.

According to Dr Fred Betros, a general surgeon who works in Western Sydney, the growing population of the region has a significant impact on hospitals.

“Without a doubt, the most challenging part of working in Western Sydney Hospitals is finding a way to cope with the sheer volume of disease burden related to such a large population. Our patients live in a geographical area that contains some of the most densely populated Local Government Areas in Australia. Compounding this issue, is also the fact these same LGAs have some of the highest incidence of lifestyle comorbidities found anywhere in the country. Our health resources in these facilities are stretched to the limit – sometimes beyond the limit– and this definitely includes our medical staff. The mental energy required to manage our patients safely in this environment cannot be overstated. I believe that for many of our hospital doctors, this type of sustained pressure in the workplace significantly contributes to burnout and mental health issues.”

DOCTORS-IN-TRAINING (DITS)

Working conditions

AMA (NSW) conducts an annual Hospital Health Check (HHC) survey of doctors-in-training across NSW to find out about working conditions in their hospitals. DITs report on areas such as rostering, access to leave, overtime, bullying & harassment, and hospital facilities. There have been notable improvements in a number of areas since AMA (NSW) started surveying DITs in 2017. These include a significant increase in the number of DITs claiming and getting paid for overtime, in part due to AMA (NSW) advocacy to make it easier for DITs to claim their overtime.

There has been a slight dip in the last two years in the number of DITs who reported ‘feeling valued’ by their hospital – from 63% in 2021 down to 46% in 2022.

Most recently, the HHC has uncovered growing concern from DITs about their facilities. Comments from DITs regularly point to a need for safe parking, access to fresh food, and adequate spaces for rest and relaxation. AMA (NSW) has made facilities a focus for its 2023 HHC and will be delving into the areas of greatest need across the State to find out how and where the association can assist.

Dr Ho remarked that the uncertainty of training adds another dimension to the overall stress doctors-in-training are feeling.

“As a doctor-in-training, you are faced with jumping multiple hurdles to get towards fellowship and being a consultant. It is more than just turning up at 7am and leaving at 4pm and doing your job – there’s the unrostered overtime, on call, self-directed learning, studying for exams, putting together research, supervising juniors, audits and departmental presentations. It’s impossible not to take our work home with us. This is often juggled with spending time with family, maintaining wellbeing and trying to avoid burnout.”

SPECIALTY CONCERNS

Each specialty comes with its own unique stressors. Child psychiatrist Dr Sandy Jusuf has had the unique experience of working as an ED trainee before moving across to psychiatry.

“They are almost exact polar opposites,” she explained, adding that different personality types tend to be attracted to the different specialties.

In her experience, ED was more hierarchical than psychiatry, and the doctors tended to be more Alpha dominant. In addition, there was a different expectation when it came to putting up with aggressive patients. She recalls that during her pregnancy, there was expectation to just get on with the job and ignore patient abuse. However, her psychiatry colleagues expressed greater concern for her safety and welfare.

According to Dr Semmonds, in the field of geriatrics, the stressors tend to be related to resourcing.

“There are no KPIs for what are seen as less urgent specialties. For emergency departments there are wait times. There are bed turnovers in the ICU, there are waiting lists for angiograms – there are clearer things that funding can be tied to with those specialties. But in geriatrics there is not. So the stresses have been that a lot of the hospital system and even in the general community, there is this feeling that older people are a problem and a bother and are taking up hospital beds. Therefore, there is always a lot of pressure on resources. It’s difficult for administrators to tie that to KPIs and performance and to understand what all the geriatricians and all the allied health team are trying to do.”

Meanwhile, according to Anaesthetist and Prehospital and Retrieval Medicine Specialist, Dr Simon Martel, anaesthetists face unique stressors in part because of their dependence on, or regular contact with, other doctors.

“Surgeons, to a large extent, control our access to patients and income,” he said. “Work, on the whole, is on the basis of a surgeon requesting our services. This obviously puts a lot of importance on the surgeon-anaesthetist relationship and creates an unequal power dynamic.

“In the private sector, and to a lesser extent the public, anaesthetists are seen as secondary providers and of less importance. We don’t bring patients, or work, to the hospital, which can put us in a weaker position.

He added, “Whilst it works well most of the time, it does leave open the potential for abuse and stress. Annoy your surgeon at your peril, which can lead to anaesthetists doing things that may not be their first choice.

“The likelihood of this being an issue for an individual anaesthetist would depend on their vulnerability. Many factors could potentially affect this vulnerability. New consultants are more susceptible. People who avoid conflict may be more likely to be bullied. Financial pressures and the dependence on a particular relationship for income may contribute.

“Personally, as a VMO working in many hospitals, in both the public and private sector, with many different surgeons, I have the luxury of not being dependent on one person or one hospital for my livelihood. I have also prioritised relationships that I value, and discarded those that I don’t, so that I now have a roster that I am happy with,” Dr Martel said.

Conclusion

While the stressors are unique, the solutions tend to be the same. Doctors, whatever their specialty, location, or training level are encouraged to ensure they have their own treating doctor, and focus on eating well, sleeping well and participating in relationships and activities outside of work that give them joy.

For more support, contact Doctors’ Health NSW on 02 9437 6552. This is an independent and confidential service for doctors and medical students.