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Career focus: Reducing stress among junior doctors Carole Luck listened to more than 400 junior doctors in her hospital trust, then implemented a series of measures to improve their lot More is asked of our junior doctors than ever before: training is shorter, the career ladder is steeper, work is more intense, and public expectations are higher. Stress is inherent in a medical career, but excessive stress leads to poor performance and affects health care.1,2 What are the causes of unnecessary stress, and what can be done to limit them? Over five years as a district clinical tutor in a large district general hospital, I discussed a variety of problems with over 400 junior doctors, mainly preregistration and senior house officers. The purpose of the interviews was to analyse the sources of stress in order to contain and reduce them.
Career choice A quarter of the junior doctors found career indecision a considerable cause of stress. In one case a senior house officer had always wanted to follow her father as a general physician. She failed the MRCP twice and hated nights on call. She had difficulty organising her time and felt that work pressures were too intense.3 Sleep deprivation meant she was too tired to study for exams and could not balance her work and home life.4 She was unwilling to discuss her fears with her specialty tutor, believing this could prejudice her references. She benefited from one to one discussions, in which we examined her strengths and analysed her aspirations. A network of consultants and general practitioners willing to talk about their various specialties had been created, and the senior house officer took advantage of this, shadowing a local general practitioner. She decided on a career in general practice and has since obtained a general practitioner registrar post and is enjoying her career. Various problems were voiced by her colleagues, including anxiety about the lack of expansion of the consultant grade, the enormous competition for specialist registrar posts, and a distaste for being resident on call as a consultant. This emphasised the need for frequent publication of national data on trends in vacant specialist registrar and consultant posts. The advisory network and factual career advice from clinical and specialty tutors have become extremely valuable. Repetitive tasks The difficulties encountered by the doctor mentioned above highlighted a problem of repetitive tasks in the day and unnecessary tasks at night.5,6 With the encouragement of the regional postgraduate dean, the hospital trust appointed phlebotomists and nurse practitioners to take blood, resite intravenous cannulas, certify expected death at night, manage beds, etc. This reduced the number of doctors perceiving problems from 10% to 1%. Hours of work and rotas Some trainees suffered more than others because of work intensity, difficulty with rotas, and sleep deprivation.7 Discussions were held with the dean, the task force, and hospital management. To comply with the government's "New Deal," preregistration house officers in intensive specialties went to bed at midnight, and an extra tier of non-consultant career grade doctors was appointed. East Berkshire serves a population of 430 000, and its two acute hospitals are 14 miles apart. In some specialties - such as obstetrics and gynaecology, orthopaedics, paediatrics, and general surgery - Wexham Park (Slough) became "hot" and Heatherwood (Ascot) became "cold." This focused emergency services on one site, eliminating travelling and creating a more acceptable lifestyle and training package for junior doctors. Medical assessment wards were created on both sites, allowing direct access for general practitioners' patients, thus bypassing the accident and emergency department. This gave trainee physicians first hand experience of medical emergencies. Housekeeping A junior doctor arrived on his first day in his first job to find no heating in his room and no hot food available on his first night on call. He felt undervalued by his employers. Good living accommodation and availability of adequate food throughout 24 hours is essential to the wellbeing of junior doctors. Discussion with hospital managers ensued. A housekeeper was employed in the doctors' mess. Freezers, fridges, and microwaves were stocked. Land in the hospital grounds was sold freehold to a local housing association. This resulted in high quality, affordable, and well managed accommodation for medical staff. Overseas doctors A doctor on four years' permit-free training had considerable difficulty understanding the freedom of women in this country. He was tempted by an offer of a drink with a female patient who was originally admitted with a drug overdose. His wife spoke no English and did not drive. Because they were unfamiliar with the locality their 9 year old son did not attend school for six months. The doctor's self esteem became low, and he had difficulty relating to patients. Another problem highlighted in discussions was regret that some form of certification was not available to overseas doctors. They perceived a need for written evidence that they had worked in this country. Several doctors have experienced hostile situations in other trusts, leading to waves of misery, homesickness, and resentment. A longer induction period for new overseas doctors is essential. The staff of the medical staffing department and the postgraduate medical centre now undertake to familiarise such doctors with local travel, banks, schools, domestic arrangements, etc. Teaching A large majority of junior doctors identified a need for more "on the job" teach- ing by consultants while acknowledging the huge pressures on consultant time. For efficient training, it is essential that fixed sessions for teaching be a part of relevant consultant contracts, supported by professional development and appraisal as educationalists. We have not yet achieved this, but the trust has funded secretarial support for specialty tutors, relieving a small part of the pressure on their time. All junior doctors appreciated feedback on their performance. Appraisal by educational supervisors now occurs two or three times in every six months for all junior doctors. Lack of generic teaching was highlighted by the postgraduate dean. This was remedied in part by using the guidelines laid down in the The New Doctor8 and The Early Years.9 Some of this teaching came from paramedical staff, managers, information technology staff, etc. A weekly "houseman's hour" to discuss specific topics, and an annual junior doctors' presentation prize (12 clinical presentations of 10 minutes each, a trophy, and a cheque) were very popular. A small number of junior doctors struggled academically. In all cases it was revealed that problems had been identified by their medical schools, but we had not been alerted because of confidentiality issues. Prior knowledge would have enabled extra support and appropriate job placement. This situation is as yet unchanged. Stress A junior doctor was spending longer and longer on the wards, her case presentations were disorganised and not always logical, and she was often "too busy to eat" and was losing weight. She was clinically depressed. Of those I interviewed, 8% of senior house officers and 4% of preregistration house officers had reached the point where stress was affecting their work. Some suffered from relationship problems, including perceived bullying, and others had problems at home. Some suffered from stress inherent in medicine - such as after major trauma or unexpected death. Doctors find it difficult to acknowledge stress, feeling that they should be able cope because they are doctors.10 Some were already flirting with alcohol and drug misuse. The need for help for stress in health professionals is now widely recognised.11-13 A confidential support service available to all junior doctors in every trust is essential, both to isolate problems and to offer wider support. In the Oxford deanery we are inaugurating "Medic Support." This is a three tier support service. Tier 1 consists of three or four named empathic individuals (doctors, nurses, priests, or paramedics) who are trained in basic counselling and understand the problems of junior medical staff. They are also aware of local and national support organisations such as Relate and Mind. Tier 2 consists of named clinical psychologists in the region. They are available for a limited number of sessions funded by the deanery. Tier 3 is accessed via tier 2 and involves psychiatric referral.
Conclusion Virtually all the junior doctors interviewed were enthusiastic and motivated. Preregistration house officers and overseas doctors are increasingly vulnerable in an organisation that is undergoing huge change. If we are to retain our doctors more attention must be paid to their welfare and career choices.14 Many of the current batch of poorly performing doctors may well have become disillusioned because of early lack of support and advice. Carole Luck consultant radiologist Heatherwood and Wexham Park Hospitals, Ascot SL5 8AA
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