Working cultures, mental health and suicide among junior doctors

We will employ in-depth interviews to explore doctors’ experiences of work related distress and other contributing factors. We will also invite doctors to complete an online survey to measure stress and distress associated with working conditions, cultures and environments. The study has received research governance and ethical approval from the University of Birmingham.

 Dr Ruth Riley

Ruth is an applied social scientist and qualitative methodologist as applied to health.  Her main research interest focuses on the health and wellbeing of healthcare professionals. Ruth's research explores sources of stress, distress, mental ill health and burnout in the workplace and approaches to prevention and improving access to support.  Relatedly, her research also explores discrimination in the workplace, exploring how individuals perceive, internalise, manage and resist discriminatory practices, including racism, sexism and homophobia.

Dr Kevin Teoh

Kevin is a Chartered Psychologist and Lecturer in Organisational Psychology at Birkbeck, University of London who is interested in the relationship between work and health.

Dr Anna Taylor

Anna recently finished her academic foundation programme and is spending this year working as a clinical teaching fellow before taking up an academic clinical fellowship in psychiatry. Research interests are focused around workforce wellbeing and psychological medicine.

Anya Gopfert

Anya is currently a public health registrar at Oxford University. Anya, previously worked as the Health Foundation’s National Medical Director’s Clinical Leadership Fellow, where she worked on projects on improving the health and wellbeing of NHS staff. Anya studied Medicine at the University of Newcastle and undertook Academic Foundation training in Bristol.

James Martin

James Martin is a Lecturer in Medical Statistics in the Institute of Applied Health Research. He is a member of the Biostatistics, Evidence Synthesis, and Test Evaluation (BESaTE) research group.

Professor Carolyn Chew-Graham

Carolyn is a GP Principal in Central Manchester, Professor of General Practice Research at Keele University, Honorary Professor of Primary Care Mental Health at Midlands Partnership Foundation Trust and Honorary Professor of Primary Care, University of Manchester. 

Maria van Hove

Maria van Hove is a junior doctor, currently doing an MSc in Public Health. She has previously worked for NICE as a Medical Director’s Clinical Fellow and prior to that worked as a foundation doctor in Bristol, where she was also a BMA representative and worked hard to improve working conditions for junior doctors. Maria studied medicine in Vienna.

Dr Marta Buszewicz

Marta Buszewicz trained and qualified in both general practice and psychiatry. She works part-time as a GP in north London and holds an honorary position at University College London having recently retired from her academic post there. Her main research and teaching interests are in the field of primary care mental health.

Publications:

Riley R, Buszewicz M, Kokab F, et al. Sources of work-related psychological distress experienced by UK-wide foundation and junior doctors: a qualitative study. BMJ Open 2021;11:e043521. doi: 10.1136/bmjopen-2020-043521

Riley R, Kokab F, Buszewicz M, et al. Protective factors and sources of support in the workplace as experienced by UK foundation and junior doctors: a qualitative study. BMJ Open 2021;11:e045588. doi: 10.1136/bmjopen-2020-045588

Blog:

Junior doctor’s wellbeing: A call to action

The distress of junior doctors in the UK is an issue that has been widely reported. In 2017, two-thirds of Junior Doctors reported that their mental health was being damaged by the severe pressures within the NHS placing them under unbearable strain¹. The General Medical Council’s (GMC) 2016 report outlined dangerous levels of low morale, distress and alienation among junior doctors, concluding: ‘the system cannot simply go on as before’². These concerns have been amplified by the concerning reports of suicide among junior doctors, including the widely publicised death of Rose Polge in 2016, whose mother directly linked her suicide to her working conditions³.

Our research group set out to explore the recent experiences of junior doctors. Through our studies, we identified sources of psychological distress as well as the relationship between working conditions and cultures, junior doctors’ mental health and levels of suicidality. These findings paint a familiar picture of demanding workloads, poor working conditions, toxic cultures, lack of support and mental health stigma⁴. In line with our findings, the 2021 GMC trainee survey found four main factors which predicted satisfaction for junior doctors: workload, access to supervision, feedback and being in a supportive environment⁵. Our findings echo what has been evident in doctors’ experiences for the past 30 years, placing further emphasis on the requirement for clear actions to change the situation.

As part of our project, we ran a key stakeholders’ event (KSE) to start a ‘call for action’. Attendees included junior doctors, key policymakers and researchers as well as representatives from Health Education England, NHS England, occupational medicine, medical and foundation schools. We presented our findings and asked attendees to discuss what they or their organisation could do to make a difference in the working lives of junior doctors. Below, we present the key points which emerged:

Where does the problem begin?

Multiple contributing factors to the high levels of psychological distress were identified among junior doctors. The stakeholders described these problems as beginning within the selection processes for medical school. One specific concern identified as contributing significantly to junior doctors’ distress was the culture of ‘bullying by Datix’. Datix reporting is encouraged within the NHS; however, this drive to find a person to blame where an error or near miss occurs places further pressure on the individual, removing the ability to learn from mistakes or the acknowledgement that most failures are systemic rather than individual.

Factors that were seen as essential for junior doctor wellbeing included appropriate beds for on-call, doctors’ messes, a ‘safe space’ to talk or debrief after a hard shift, the importance of team working as well as compassionate and supportive leadership.

The impact of COVID-19

The pandemic placed further pressure on a healthcare system already struggling to cope. COVID-19 had significant consequences for junior doctors’ training, clinical practice and wellbeing. However, junior doctor participants also reported positive impacts from the pandemic which were explored at the KSE.

One of the positives to emerge from COVID-19, identified by stakeholders and backed up by our research, was the opportunity to work in consistent teams for longer. As rotations were paused, junior doctors stayed in the same teams, creating a sense of belonging while offering much-needed support.

Authors of a recent survey found that the demands of working in the pandemic could be mitigated through the creation of novel training opportunities and that all redeployed junior doctors benefitted from direct, consultant-led supervision⁷. This supports our findings and the discussion at the KSE that supportive leadership is key for junior doctors’ wellbeing, particularly at demanding times.

Several changes made in response to the demands of COVID-19 – including consistent teams, reduced red tape and new wellbeing supportive measures – appeared to make a difference to junior doctors’ experience. Sadly, many trusts now have returned to pre-pandemic ‘normality’, leaving one of the KSE attendees to reflect: ‘we know the problems and we know the solutions, but we are not doing anything to retain ways of solving the problems’.

What can be done?

Despite the funding and staffing demands within the current healthcare context, there are pockets of good practice. Furthermore, the research conducted by our team also identified protective factors ⁸ which should be utilised to support junior doctors’ wellbeing. In line with the discussion at the KSE, several suggestions were made to support junior doctors:

• The positive improvements that were made within the pandemic should be maintained. Stakeholders emphasised the importance of longer rotation periods to support consistent teams and supportive leadership.
• Working environments are in desperate need of upgrading. Some of the KSE attendees felt that Trusts expect junior doctors will put up with poor physical work and rest environments, which fosters a culture of ‘not caring’ about junior doctors.
• Good practise should be recognised and junior doctors appreciated. One example of good practice used within some Trusts as a response to the blame culture and issues found with ‘Datix’ was ‘Greatix’⁹. ‘Greatix’ documents positive feedback from patients which are reviewed alongside the ‘Datix’ within risk meetings. Considering these together can shift the focus from a culture of blame to a more positive and supportive learning environment.

The call to action

The key stakeholders committed to taking the information discussed in the meeting back to their organisations. Following this, stakeholders and commentators will be asked to reflect on the changes which have been implemented to improve the working conditions and cultures of junior doctors and improve access to support following the event.

For further information about our research, and updates on our publications from this project:

Follow us on Twitter: @WellbeingNhs

Or contact our Principal Investigator: Dr Ruth Riley r.riley@bham.ac.uk

References:

¹ Campbell D. Two-thirds of young hospital doctors under serious stress, survey reveals. Guardian 2017 Feb 11. www.theguardian.com/uk-news/2017/feb/11/stressed-out-doctorsanaesthetists-survey-nhs

² General Medical Council. The state of medical education and practice in the UK. GMC, 2016.

³ Ross A. Junior doctor who killed herself “talked about leaving medicine.” Guardian 2016 Dec 19. www.theguardian.com/uk-news/2016/dec/19/junior-doctor-rose-polge-killedherself-over-worries-about-staying-in-medicine.

⁴ Riley, R., Buszewicz, M., Kokab, F., Teoh, K., Gopfert, A., Taylor, A. K., Van Hove, M., Martin, J., Appleby, L. & Chew-Graham, C. (2021). Sources of work-related psychological distress experienced by UK-wide foundation and junior doctors: a qualitative study. BMJ open, 11(6), e043521.

⁵ General Medical Council. Summary Report 2021. GMC, 2021.

⁶ Baverstock, A., & Finlay, F. (2021). A good enough doctor. Archives of Disease in Childhood-Education and Practice, 106(1), 64-64.

⁷ Dekker, A., Lavender, D., Clarke, D., & Tambe, A. (2020). How has the COVID-19 pandemic affected junior doctor training? A survey analysis. The Transient Journal of Trauma, Orthopaedics and the Coronavirus.

⁸ Riley, R., Kokab, F., Buszewicz, M., Gopfert, A., Van Hove, M., Taylor, A. K., ... & Chew-Graham, C. (2021). Protective factors and sources of support in the workplace as experienced by UK foundation and junior doctors: a qualitative study. BMJ open, 11(6), e045588.

⁹Learning from Excellence. 2021 July 21. https://learningfromexcellence.com/