In this Special Feature conversation, retired doctor and public health professional Dr. Hilary Guite discusses her experience of working as a newly qualified doctor with her friend, who is 2 years out of medical school.
Hilary: “There are only 168 hours in a week, and my worst [week] was 135 hours. My best were 93. How many hours do you do on average now?”
Fred: “Quite a bit less: I work about 40 hours a week of standard non-on-call shifts and then about 8 hours on call on top of that, which averages out to about 48 hours a week. About half the average when you started.”
I am talking to a friend of mine who qualified as a doctor nearly 40 years after I did. We are comparing our working conditions as junior doctors —the years after qualifying as a doctor and before becoming a consultant or attending physician.
In the course of our conversation, we explored how and why changes in working conditions might have impacted on work-life balance, burnout, and suicides among doctors.
While our experiences are very different, high levels of burnout among doctors continue to be a significant problem.
Find the accompanying podcast here:
‘Once, I fell asleep on a patient’
Fred: “What was it like in the 1980s doing on-call for 3 out of 5 weekdays and weekends?”
Hilary: “[We would work] a full week, with at least one night on call. So the on-call started at 9 in the morning and went all the way through the night; you would work all the next day as if you hadn’t worked through.
[T]hen you would finish when the patients were sorted. And then you would go home and start again at 9.
So having done all that Monday to Friday, you would start again at 9 on Friday morning and go all the way through to Monday evening, when the patients were sorted. I would probably get 3 or 4 hours [of] sleep a night.
Once, I fell asleep on a patient. I was just doing a cardiac examination. I put my stethoscope on his heart — it’s very peaceful listening to it, so I just snuggled in.”
Fred: “For a little nap?”
Hilary: “Yes, a little nap. He just left me there. He was so nice.”
Fred: “I’ve never fallen asleep on a patient yet, but there is still time. I think the most tired I’ve been is after a run of 12-hour shifts — that’s still with a 12-hour break to go home and sleep in between.
But even then, when I’m getting to the end of a run of five or six of those, I can feel my performance flagging, and I can feel it’s taking me longer to do things and longer to think about things.”
Physical exhaustion can be lethal. In the 1980s, there were reports of doctors falling asleep during operations, and going back to sleep after being called at night.
In one case, this led to a stillbirth as the exhausted doctor went back to sleep after being called to the delivery ward. There were also reports of doctors falling asleep while driving home after working continuously for more than 24 hours.
A series of reforms in the United Kingdom reduced the working hours of junior doctors first to 90 hours a week in the late 1980s, and then to 56 hours in 1991.
In 1998, the European Working Time Directive reduced the average working times for consultants to 48 hours per week.
It took another 11 years until this was enacted for doctors at all levels of their career.
‘There’s no bed?’
For Fred, only 1 week in every 9 was a standard 40-hour working week; the other weeks all included at least one 12-hour shift in addition to his 9–5 working pattern.
Even on days he was not on call, he would regularly stay past 5 p.m. to finish up on jobs. His working week ranged from 40 to nearly 80 hours, averaging out over a 6-month period to just under 48 hours per week.
Doctors may not be falling asleep during operations or failing to respond to bleeps now, but they continue to add to the toll of road traffic accidents, as exhausted doctors return home after night shifts.
Just over half of all U.K. trainee anesthetists reported in 2017 that they had had an accident or near miss getting home at night after a night shift.
For most doctors starting their first year on the wards, night shifts are a daunting prospect due to the relative lack of staff compared with day shifts.
Fred explained the realities of working on-call shifts overnight.
Hilary: “When you are awake on a shift, are you awake the whole night?”
Fred: “So, normally, I’ll try and stay up the whole night. You can maybe get away with a couple of hours [of] sleep, but I try to just go straight through the night.”
Hilary: “You have a room?”
Fred: “At the hospital I am working at, there is a doctors’ mess. It’s not particularly well equipped. There are kind of sofas you can sleep on. There’s tea and coffee.”
Hilary: “There’s no bed?”
Fred: “No, not as far as I know, there is no bed available. Some people would find a comfy chair but not often. Some would just curl up on the sofa and have a bit of a nap at least until their bleep went off again.”
Work-life balance and burnout
Work-life balance for a junior doctor can be difficult to achieve, but in a review of the topic, Dr. Siva Raja from Cleveland Clinic and Dr. Sharon L. Stein from University Hospital Case Medical Center in Cleveland, OH, found that poor work-life balance was linked to a wide range of problems.
These included poor physical health and self-care, higher divorce rates, poor mental health, low efficiency at work, and lower patient satisfaction.
Fred: “I made quite an active decision for my first year that I was just there to get through it, to get experience and find out what it’s like to work on the wards. I wasn’t there to do any extra research or pick up any extra shifts.
I tried to make sure that in the time outside work, I was seeing friends, swimming, going running. I even started a pottery class, until COVID put an end to that — it was a lot of fun.”
Hilary: “I would go out and see friends, and I’d fall asleep.
They would say, Oh, that person on the cushion, that’s a junior doctor. Everyone knew about it. There were questions being asked in the Houses of Parliament about it.”
There is an association between long working hours and both poor work-life balance and burnout, and between higher rates of burnout and suicidal thoughts.
Burnout has traditionally been measured by the Maslach Burnout Inventory. This defines burnout as having three potential dimensions:
- Emotional exhaustion: This refers to a feeling of emotional and physical depletion, to feeling “used up”.
- Depersonalization: This manifests as seeing patients as objects rather than human beings. It also means having compassion fatigue and feeling cynicism and “switched” off from the job.
- A low sense of personal accomplishment: This refers to a lack of efficacy, or doubting the quality or meaning of one’s work as a physician.
In addition to organizational and cultural factors that increase the risk of burnout, such as level of autonomy when responding to patients’ needs, there are also individual character traits and behaviors that increase the risk of burnout. These include perfectionism and responding to problems by working harder.
In the U.K., concern about the impact of working conditions on junior doctors led to persistent political pressure for improvement.
Over 40 years, there were 584 questions and debates on the issue in the Houses of Parliament, eventually leading to the hours being roughly halved from when I started working as a junior doctor in 1981.
We might therefore expect burnout and suicide rates among doctors to have improved over the last 40 years.
High levels of suicide prevail
Making direct comparisons over time is difficult. Earlier studies relied on face-to-face interviews or postal surveys. More recent studies have used online surveys but have seen lower response rates.
Comparison with other professional groups provides one way to benchmark changes. Across the decades, doctors have reported levels of burnout and suicide rates that are up to double the rates of comparable professional groups.
A 1987 study of doctors in their first year found that 50% had emotional distress compared with 34–36% among executive civil servants. Just over a quarter of junior doctors recorded symptoms that suggest depression.
According to a 1999 study, around one in two psychiatrists at a hospital in the U.K. had signs of burnout.
Interestingly, the level of burnout fell with more senior grades. For example, one in three senior registrars had high emotional exhaustion scores, falling to one in four for consultants.
A review of physician suicides and undetermined deaths between 1979 and 1995 in England and Wales found the rates to be 19.2 per 100,000 for male doctors, and 18.2 per 100,000 for female doctors.
However, among the general population, males have higher suicide rates than females.
In comparison with their non-medical counterparts, male doctors were about one-third less likely to die from suicide, while female doctors were twice as likely.
The latest findings from the 2020 U.K. national survey of junior doctors used an updated burnout scale — the Copenhagen Burnout Inventory. It reported that to a high or very high degree:
- just over 50% did not have enough energy for family and friends during leisure time
- just over 20% felt burned out by their jobs
The high levels of suicides among doctors remain a considerable concern.
In the U.K., there were between 13 and 20 deaths per year among doctors from suicide and underdetermined intent in 2011–2019. Last year, there were 19 deaths. This is the highest number since 2014.
Do fewer working hours impact patient safety?
One of the arguments against reducing the standard working hours for junior doctors was over concerns for patient safety. If doctors moved to a shift system, would there be a loss of continuity of care?
A 2011 review concluded that capping doctor’s working hours at 80 per week had no adverse impact on safety.
Later studies, which looked at a further reduction to 48 hours per week, were of poor quality and had conflicting results.
Fred: “[W]hen you were doing these sort of mega long weekends on call and extra long shifts, [d]id you feel that it was unsafe? Or was it just how the system was and what was expected of you?”
Hilary: “I think it was so much debated at the time, it was really hard to show that we were unsafe, because we were [all] so exhausted.
In terms of how I felt, there was so much adrenaline when there was something really, really important, like when a patient crashed.
[Some situations were] so adrenaline fueled. I think those bits worked OK.
I did feel unsafe, though, because at a very young age, like in my second year, I was the most senior doctor left in an accident emergency department.”
Fred: “[I]f you felt things were getting out of hand and you needed support, did you feel that your seniors were approachable? Did you feel like you could ask them for help?”
Hilary: “It was almost a badge of honor not to call in your registrar [who would be on call at home in bed].”
There were two reasons for this. The first was that you worked long hours in your first few years. When you became a registrar, you were on call but did not expect to come into the hospital.
The second was that the consultant also did not expect to attend the hospital out of hours. The “good” young doctor would not bother them.
Being careful not to upset senior doctors who gave you a reference for your next job was part of the culture.
Fred: “From what I understand, that’s one of the massive changes. There’s more supervision.
We were told to never be afraid to speak to your consultant or your registrar if you’re concerned, because they’d rather you spoken about it then, than try and deal with it by yourself and get things wrong.
And, usually, there’s at least one or two more senior doctors on the ward at all time who are actually physically present and awake.”
Highs and lows
As well as working patterns undergoing dramatic alterations, the day-to-day frustrations of junior doctors have completely changed over the past 40 years.
In the United States, having insufficient time for documenting care on the the Electronic Health Record is associated with higher levels of burnout.
In the U.K., simple access to computers can be the source of a lot of frustration.
Fred: “Part of the issue is with the supply of computers in the hospital.
There’ll be some days where there would be three or four computers between a team of six or seven doctors and about 10 nurses, all trying to get onto those few computers.
So you can’t prescribe anything, you can’t order any tests or check any tests. It’s really frustrating.”
Aside from the changes that our conversation highlighted, we found one important aspect that continues to play a big role in helping doctors cope with the demands of their work.
A 2015 editorial in the International Journal of Health Policy and Management described how compassionate healthcare was good for both patients and doctors. It can speed recovery for patients and improve doctors’ resilience.
Hilary: “We also got a sense of satisfaction. Particularly when you were part of team that was compassionate, the nurses and the consultants were compassionate toward the patients. And then you felt you were doing a really good job. That got you through it.”
Fred: “You’re right to say that. Loss of compassion is a massive part of burnout — when you’ve forgotten why it is that you want to do the job, and the central aspect of the job, which is looking after patients.”
For Fred, a sense of powerlessness is one of the factors that he puts at the heart of burnout. He explained that being a junior doctor can, at times, feel like being merely a service provider.
The change in working hours does not lend itself to building up a deeper connection with patients, and there is often a loss of continuity of care when doctors hand over their patients at the end of their shift.
Looking to the future
Fred pointed to a recent report by Health Education England as an example of how organizations are looking to tailor medical degrees to equip future doctors for the demands of the job.
Fred: “If we don’t have meaningful changes to the physical nature of the job, to the provisions that we get, [and] if we don’t have meaningful changes to the level of support that we get, particularly psychological support, following this pandemic, then these sort[s] of reports into what it’s going to be like in the future are just going to remain buzzwords. I think we need actual change on the ground.”
Hilary: “There is nothing that prepares for being the person that helps save someone’s life or is part of someone losing their life.
Nothing can prepare you for that when you are so young. We’ve both seen more death than anyone else in their 20s will see.”
Reflecting back on my career, I see patient-focused care as the key to having happier doctors. A system that works well for patients also works well for doctors.
* This is not the contributor’s real name. We have used a pseudonym to protect his identity and to avoid identifying colleagues or particular hospitals.
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