They might hold a mock multidisciplinary team meeting to diagnose a senior consultant with psychopathic, grandiose or narcissistic personality traits. Because it’s more comforting to believe your supervisor is mentally unhinged than accept a perfectly sane superior just threw a patient’s chart at your head. Sonia Henry, a junior doctor studying to be a GP. Credit:Dean Sewell This is the dead-pan reality of working as a junior doctor in Australia’s hospitals, and an effective coping strategy, up to a point. But it’s harder to joke about the suicides. Two junior doctors working at NSW hospitals killed themselves within the past few weeks. At the request of their families and on the advice of the NSW Chief psychiatrist no further details will be made public.

There wasn’t much to laugh about when a third Sydney hospital unit was stripped of its trainee doctors amid bullying allegations and concerns for their welfare last week. The College of Intensive Care Medicine took the extreme step of withdrawing training accreditation from St George Hospital’s ICU amid allegations of bullying and dysfunction among senior staff. Westmead Hospital was stripped of its intensive-care trainees. Credit:AAP The College has also stripped Westmead Hospital of its intensive care trainees, and College of Surgeons banned the Royal Prince Alfred Hospital’s cardiothoracic surgery department from training its registrars in 2019 over similar allegations of bullying, harassment and dysfunction. These humourless, deeply tragic and alarming events are symptomatic of a fundamentally flawed healthcare system that trains future doctors by breaking them.

It’s a system where humiliation is a teaching technique and too often senior specialists perpetuate the same bullying tactics they endured as junior doctors, because why should the next generation have it any easier? Loading The 2018 NSW Health "Your Training and Wellbeing Matters" survey found 54 per cent of junior doctors had witnessed bullying at work in the previous 12 months and 30 per cent were subjected to bullying. When asked who were the most serious perpetrators, 42 per cent said a senior doctor. Of more than 2,000 survey respondents (24 per cent of the trainee workforce) 57 per cent said their hospital had a culture that did not effectively deal with discrimination, bullying and sexual harassment. It’s a bitter prescription for the doctor, the healthcare system and their patients.

Exhausted pilots versus sleep-deprived doctors The comparisons between the healthcare system and aviation are frequent and obvious. They’re both complex ecosystems with multiple layers of checks and fail-safes responsible for millions of lives every year. Dr Sonia Henry hadn't thought too deeply about the parallels until she was a passenger on a plane that had been taxi-ing on an airport tarmac for over an hour. Eventually the pilot made an announcement: he had exceeded his on-duty hours and the plane would be grounded until a back-up pilot could take his place. The junior doctor was incredulous. “That would never happen in a hospital,” Dr Henry said.

“We won’t let an exhausted pilot fly a plane, but we’ll let doctors make important medical decisions for patients at the end of yet another consecutive 14, 16, 18-hour shift? "What patient wants a sleep-deprived surgeon operating on them?" Dr Henry said. More than two-thirds of trainees worried they would make clinical errors because they were overworked and overtired, according to the 2018 NSW Australian Medical Association and the Australian Salaried Medical Officer Federation’s Hospital Health Check survey. The government’s own JMO survey found more than half believed their fatigue was substantially affecting their work performance. “It’s getting pretty tiring hearing that we’re somehow impervious to pain and illness, that we can’t show weakness and we have endless reserves of resilience,” Dr Henry said.

There’s danger in attempting to perpetuate these myths. In the year she completed her training, three junior doctors in Dr Henry’s cohort killed themselves. “I remember this sense of inevitability … like we knew someone under this kind of pressure would suicide” Dr Henry said. NSW Health Minister Brad Hazzard. Credit:Nick Moir Their deaths (over 2016 and 2017) drew intense public outcry and prompted NSW Health Minister Brad Hazzard to launch a Junior Medical Officer (JMO) Wellbeing forum to explore strategies to redress the mental anguish among junior and senior colleagues. By November 2017 NSW Health launched its $3 million JMO Wellbeing and Support Plan.

The AMA NSW's Doctor-In-Training committee wants a national register of doctor suicides to accurately track the extent of the tragedies. “None of us went into medicine thinking it was going to be easy," Dr Henry said. "But we’re doing a hard job that is made even harder by the conditions,” said the author of a fictional account of life as a junior doctor in Sydney called “Going Under” out in September. The book exposes the hidden curriculum in medicine that pushes junior doctors to work harder, stay back later, never say no, to the great detriment of their sense of self-worth, identity and mental stability. Many doctors are perfectionists, competitive, type A personalities who push themselves beyond breaking point within a system that attracts and encourages these traits.

“Where does that leave us?” Dr Henry said. “We need a system that will enforce strong boundaries that will keep us safe.” Invisible overtime The AMA NSW has repeatedly warned of the dangers of burned-out, sleep-deprived trainees expected to work untenable hours who were actively discouraged from claiming their overtime. “I know of neurology and geriatric registrars doing patient consults through to midnight, then coming back at 7 or 8am the next morning and they’re not claiming any of that overtime, Dr James Lawler, co-chair of AMA NSW and the Australian Salaried Medical Officers Federation of NSW's Doctor-in-Training Committee, said. “Then we have some hospitals cracking down on [trainees] who try to take a nap during quiet periods overnight when nothing urgent is going on ... It’s just madness,” he said.

More than 42 per cent reported working from ten to over 25 hours of un-rostered overtime a fortnight, according to latest Hospital Health Check survey. Another 31 per cent reported 5 to10 hours un-rostered overtime. NSW Health's own survey found 50 per cent never claimed their overtime. The perception that they couldn’t manage their role stopped 35 per cent from claiming overtime, and 27 per cent believed it would impact their career opportunities. Trainees who do claim overtime can “stick out like a sore thumb” when in reality they timesheet accurately reflects the requirements of their job, Dr Lawler said. NSW Health safe work standards introduced in 2018 dictate Junior Medical Officers should not be rostered for more than 14-hour shifts and must have a 10-hour break between shifts. Dr Lawler said in the past six months there has been a 25 per cent reduction in violations of the rule, but the figure did not capture unclaimed hours.

When the vast majority of junior doctors don’t claim their unrostered overtime, management don’t realise their units are under-resourced. “If hospitals are efficient it’s because junior doctors are only being paid for half the time they work." The trainees in no-mans' land There are 60 NSW public hospitals accredited by the NSW Health Education and Training Institute (HETI) to supervise doctors during their first three years of basic physician training. Within these hospitals, there are 500 departments that have accredited training programs with limited training positions for the thousands who want them. Competition is fierce among junior doctors vying for a coveted training position on the most sought-after programs, including several surgical subspecialties.

Then there are the unaccredited junior doctors who don't - or haven't yet - made it onto an accredited program. Without the protection and guidance of a specialist College they are the most vulnerable to exploitation. Many doctors have praised the Colleges for withdrawing accreditation, but the group most disadvantaged by the loss of training positions is the trainees themselves. St George Hospital had training accreditation withdrawn from its ICU. Credit:AAP "I've spoken to a number of trainees who wish this hadn't happened," Dr Lawler said, following the latest accreditation withdrawal at St George's ICU. Unaccredited junior doctors will likely fill the void left by the accredited registrars, without the oversight of a College holding the hospital to safe standards.

These unaccredited trainees are often trusted to supervise units overnight, to intubate and resuscitate patients and perform surgeries, but they can spend months with little or no contact with supervisors whose references could be the difference between securing a vaunted training position. In extreme cases, they can spend several years exclusively on night shifts, missing out on round-after-round of training positions, missing their families and friends, perhaps the chance to pursue a relationship, not to mention a regular hit of melatonin. The harrowing case of unaccredited trainee Dr Yumiko Kadota ignited a firestorm of outrage in February. The aspiring plastic and reconstructive surgeon was hospitalised for over six weeks, physically and mentally broken, after working up to 70 hours a week, 24 days in a row, over 100 hours of overtime a month, on-call for 180 continuous hours at Bankstown Hospital. Her case prompted health minister Brad Hazzard to launch an investigation into unaccredited trainee working conditions. The review is expected to report back by early 2020.

Mr Hazzard has also invited all national specialist colleges to a roundtable in September to discuss the withdrawal of accreditation issues, and their shared responsibility to protect junior doctors from senior specialists who are inflicting the same “tough love” regimens they endured on their subordinates. “Often these older specialists are at the top of their game and it’s very hard for hospital management to have the clout to affect the cultural change needed without the support of the Colleges,” Mr Hazzard said. There are vocal crusaders among senior doctor ranks. Dr Geoff Toogood is among a growing number of veteran specialists privately counselling and publicly advocating for their junior doctor colleagues. He became an unlikely public advocate for doctor mental health after the self-described “conservative” cardiologist started wearing mismatched and brightly-colour socks to work.

There was a simple explanation: they cheered him up after a dark period of mental illness, and his new puppy had a predilection for chewing-up his sock collection, leaving him few matching pairs. But to his sniggering colleagues, Dr Toogood’s odd socks were a sign that he’d “gone crazy again”, the senior consultant said. And so he founded the CrazySocks4Docs movement to combat the stigma of mental illness in medicine. Search social media for #CrazySocks4Docs and you’ll find countless images of doctors across 20 countries sharing images of their multi-coloured feet and words of solidarity with their colleagues doing it tough. Dr Toogood’s public profile means he is regularly invited to seminars and workshops aimed at teaching junior doctors to ‘be more resilient”. “I got one a few days ago, and I could feel the steam coming out my ears,” he said.

This cult of resilience was more hindrance than help, he explained. “There is far too much focus on the individual doctor’s failings rather than the systemic failings … and it really is a national problem.” “Junior doctors are up against the same old cultural problems: the bullying, the sexism, doctors being afraid to speak out about awful conditions because it’ll affect their career progression,” Dr Toogood said. “Some older doctors would disagree, but I do think that current junior doctors are working longer hours, at greater speeds and with greater complexities.” The competition for training positions is “way beyond what we had to deal with 25 years ago,” the cardiologist said.

“These days they’ve all got to what they call ‘CV-buffing’: extra training courses, getting research papers published just to try to get on a training program. “Remember, these are young people trying to live a normal life, maybe start a family or a relationship, which of course is going to take a big hit,” he said. The next generation of aspiring doctors was paying close attention. Medical students have just finished applying for the latest round of hospital internships this month. They’re making their decisions based on the culture of the hospitals as much as the prestige of their departments. “If a hospital is overworking its interns, or not supporting their junior staff, I don’t want to go there,” president of the Australian Medical Student Association Jessica Yang said.

“We want to be able to train safely and maintain our mental wellbeing to become the best doctors we can be,” she said. Jessica Yang, President of the Australian Medical Students Association. Credit:Dean Sewell But medical students were already exposed to the unwritten curriculum of teaching-by-humiliation. “I’ve seen a supervisor pour water over an intern’s head for taking a break,” Ms Yang said. But the most common technique involved senior consultants “drilling” a single intern with a series of technical questions beyond their level of education and training in front of their peers, Ms Yang said.

“The purpose is clearly not to teach but to make you look like an idiot,” Ms Yang said. When Health Minister Brad Hazzard held the first Junior Medical Officer forum in 2017, Dr Bethan Richards was already documenting the rising levels of stress, anxiety and depression among their trainees at Royal Prince Alfred Hospital. Royal Prince Alfred Hospital was banned from training certain registrars. Credit:AAP A 2013 Beyondblue survey found almost 50 per cent of junior doctors were burn-out. Dr Richard’s more recent data suggests its now closer to 65 per cent. “Something has amplified over the last few years,” Dr Richards, appointed the first Chief Wellness Officer in a NSW hospital in February.

“Their high-stakes exams are one part of the equation. Their [work] hours are another,” Dr Richards said. “They’re working in a system that is incredibly stressful and they don’t feel they have any control of autonomy. There’s a feeling of futility; that they can’t change anything,” she said. “Then we saw a spike [in anxiety and depression] after the exams when they had a sudden realisation that the exam wasn’t the end of this treadmill they were on, she said Senior doctors were also burning-out, and with little in reserve to support their junior colleagues, their own mental fragility was manifesting in “humiliation-at-the-bedside” teaching. “They’re also modelling the behaviour they were taught,” Dr Richards said.

“I’ve got senior doctors afraid to give any feedback [to junior doctors] because they’re afraid that whatever they say it won’t be right.” In February RPA launched its wellbeing program MDOK, based on a successful pilot program and a Stanford University model shown to lower burn our rates among doctors. “If we’re truly going to change the system and shift the culture, it needs to come from above,” Dr Richards said. “We’re trying to change that rule they’re taught from day one of medical school that patients always come first and you are a very distant last,” she said. “We sign up to look after others, but we’re incredibly bad at looking after themselves.” There’s exercise programs, an on-site nutritionist, meditation sessions, and stress and burn-out avoidance workshops.

They’re introducing “protected lunch breaks” across the hospital, in which staff take an hour to eat, relax and can only be paged in an emergency. “It’s crazy this doesn’t already occur,” Dr Richards said. “We know that if you stop for lunch you’ll perform better in the afternoon.” There’s also concerted push to encourage junior doctors to claim overtime, and Dr Kadota’s case prompted the RPA team to consider a real time electronic monitoring system to track overtime, and trialing sleep pods for staff to take short naps during low-activity periods. Unaccredited doctors can access a mentoring program, which became particularly vital when the cardiothoracic surgery department had its trainees removed after a junior doctor alleged serious bullying and harassment. They’re also rolling out ‘clinical supervision’ sessions, in which small groups meet regularly with a psychologist in a supportive environment to debrief.

Both trainees and senior consultants are involved in the program’s design. They tell Dr Richards’ team what they need, and the team does its best to make it happen. Supervisors requested training to teach them constructive ways to have difficult conversations with trainees: for to counsel a junior doctor in distress, or a trainee they feel is not suited to their current training program, or what language to use to comfort a trainee who has failed an exam. The difficulty has been was implementing initiatives without eating into more time that could be spent away from the hospital with their families and friends. The MDOK program is one of several funded by the JMO Wellbeing and Support Plan, which has allocated $4 million to fund 10 practical initiatives to improve conditions for junior doctors. A dedicated JMO Support line offering specialised confidential support to trainees who experience unacceptable behaviour, and a ‘Performing Under Pressure’ course for JMOs is to come.