Working cultures, mental health and suicide among junior doctors

A mixed method study to identify working conditions and work cultures associated with psychological distress and suicidality among junior doctors working in the NHS. This research project has been developed in collaboration with junior doctors.

Working Cultures, Conditions, Mental Health and Suicidality among Junior Doctors

There are currently 55,000 junior doctors working in the NHS. This film presents a personal account from one junior doctor, Charlotte Hall, with input from Chief Investigator Dr Ruth Riley and Dr Anya Göpfert, a junior doctor collaborator.

Junior doctor Charlotte Hall talks about her experience working in the NHS.

Transcript

Charlotte Hall: You feel unsupported because you are unsupported. You're working in a system that has too few people.

My name is Charlotte and I'm currently a junior doctor specialising in anaesthetics.

The commute home, I'm often just quite tired. In the run-up to leaving work, there's the job of finding the appropriate person to hand over to. That's been a real hurdle for me to get over: feeling responsible for the decisions that other people made about patients that I had perhaps handed over.

Dr Ruth Riley: The study was interested in looking at working conditions and cultures, and their impacts on the mental health of junior doctors working in the NHS.

Charlotte: I would come home maybe from an 11 o'clock or midnight finish. What I knew was going to happen was I was going to get into bed, and I was going to try to fall asleep and not going to be able to fall asleep. Or, in my dreams, I would be transported straight back to work.

I had a discussion with a senior colleague, and I just broke down. (So, this is a blanket that I crocheted whilst I was on sick leave.) It was her who made me see that, actually, I wasn't well, and I kind of didn't believe her because I talked to so many people who felt similar things to me. (What I normally like to do to save me from just constantly checking my phone is to do something with my hands, which usually involves something like crocheting.)

Ruth: Junior doctors were telling us that the main causes of stress and distress were around toxic work cultures, poor working conditions, high workloads, lack of support, and a culture of invulnerability.

Charlotte: I just thought, “well, this is normal and I'm just not coping with it,” but then at the back of my mind, I was thinking, “if this is normal and everyone goes through this, but this is how I'm reacting, how am I ever going to get through this?”

Ruth: Evidence suggests that doctors who work over 55 hours are twice as likely to develop a mental health problem and are more likely to make a medical error.

Dr Anya Göpfert: My role in the study has been to provide a junior doctor perspective.

Ruth: The survey reported that 70% of doctors experienced extreme or severely extreme levels of stress, anxiety, and depression, and over half of those had experienced suicidal thoughts, feelings. Some had self-harm[ed] or had made, sadly, suicide attempts.

Anya: I had a friend who was a doctor and who committed suicide. It was not purely due to work, but there were definitely aspects at work which contributed towards her feelings of anxiety and distress that she was struggling with—being very worried about whether she'd done the right thing or made the right decisions—and that can then spill over from work into home, and just really make it difficult to leave your work at work.

Charlotte: I much prefer Yorkshire Tea. Sometimes the frustration at myself would just get so much I would just dig my fingernails into my palms.

Ruth: So, the impetus from the study was interested in exploring and understanding why there were slightly elevated rates of suicide amongst female doctors.

Charlotte: It would be naive to suggest there isn't a difference between the ways that male and female junior doctors are treated. I do think that there is more of an expectation when you are a female doctor, in the more sort of caring aspects of the job.

Ruth: Interestingly, three quarters of the participants in the qualitative study and the survey were female doctors. And again, is that because women are more likely to come forward and talk about their mental health compared to men, or does it reflect increased levels of mental illness amongst women?

Charlotte: And I have friends who left the country. The stress on junior doctors will cause there to be fewer junior doctors, and that will result in poorer care.

These are a couple of the journals that I started keeping as part of seeking treatment for my mental health. I have had very good support from my own GP, and then also a GP I was able to talk to through the Practitioner Health Programme. I've had support from occupational health.

Ruth: I think shame is a big issue in medicine and it starts at medical school—the internalisation of that shame and that perceived inability to cope, it prevents help seeking.

Anya: The NHS is a national, kind of government-led system, which has a limited budget and limited resources. Then there are significant workforce gaps in the NHS, at all kinds of professions and all staff at all levels.

Ruth: In terms of addressing the culture of invulnerability, I think it needs to start at medical school, and there's currently, I think there's an over focus on individual resilience.

Charlotte: I just hope that everyone in the healthcare system are all able to offer each other some more compassion.

Anya: [It’s] really important that senior doctors do not lose their compassion that they do have, because of the pressures that the system is putting on them.

Charlotte: It's about systemic changes. We all want to help people, but we can't do that at the expense of our own lives.

Aims of the project

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.

Meet the team

Dr Ruth Riley

Dr Ruth Riley 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

Dr Kevin Teoh 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

Dr Anna Taylor 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.

Dr Anya Göpfert

Dr Anya Göpfert 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

Professor Carolyn Chew-Graham 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

Dr 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.

Dissemination

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:

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.

⁴Riley, 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.

⁵General 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/

Contact

X/Twitter: @WellbeingNhs