Also Human Page 4
A month or so into her first job, when Bella was working in A & E, a patient was admitted close to the end of her thirteen-hour shift. Whilst other trainees might have busied themselves with paperwork until the shift was over, Bella started to attend to this patient. She continued treating him until he was stable and all the necessary tests had been organised. Then, exactly as she had been instructed at induction, she went to find her senior in order to ensure a safe ‘handover’ of the patient. Bella went by the rulebook which explicitly stated that she was not to work more than thirteen hours.
The senior, probably stressed with her own workload, reacted with fury, shouting at Bella in front of the whole team, and accused her of being irresponsible. Bella was ordered to stay for as long as it took to continue treating the patient, and ended up working a fifteen-hour shift.
‘What really shocked me was that I worked so hard, and followed all the rules, but I still ended up getting shouted at,’ Bella said.
Feeling too exhausted to drive home, Bella retreated to the toilet, where another colleague found her sobbing in the corner. ‘I couldn’t bear the fact that she found me crying,’ Bella told me. After this incident, she asked to be taken off the night rota, but with her confidence in shreds, an insidious depression spiralled rapidly out of control.
Bella did exactly as she had been instructed to do in medical school – she went and asked her supervising consultant for help. And his response?
‘Of course this is how you feel. You’re an F1. You’re a girl. You’re going to be upset.’
For somebody as proud and determined as Bella, admitting to a senior that she was in difficulty was far from straightforward. ‘It was a huge thing to ask for help,’ she said. ‘And then only to be dismissed …’ Bella’s voice tailed off.
Ten weeks into the job, Bella was so severely depressed that she was signed off sick, and referred to the psychiatrist who later contacted me. As I slowly got to know Bella over the course of the following six months, I gained an increasing respect for her determination, bravery and openness. She was an extraordinarily impressive young woman. I also learnt that, far from being haughty, she actually struggled with an acute lack of self-confidence.
Bella never resumed her career in medicine. As is often the case, although her family were initially disappointed that she wasn’t going to work as a doctor, they were actually far more concerned about her well-being, and accepted her choice. It’s a couple of years now since Bella was first referred to me. Despite the fact that in our initial sessions Bella was convinced that she would never be able to hold down a responsible job, for the last eighteen months she has been employed in a demanding role in the pharmaceutical sector. Judging from our recent telephone conversation, she’s no longer the severely depressed young woman who felt that she had no future and who occupied her time doing 2,000-piece jigsaw puzzles.
But Bella’s case still makes me angry. How is it possible for somebody to slog their way through a six-year medical degree, do brilliantly in finals, and then last just ten weeks in their first job? What does the fact that it is nearly impossible to declare a history of previous psychological difficulties say about medical school culture? Why wasn’t the discrepancy between her academic and situational judgement scores seen to be a potential ‘red flag’ – or her earlier dramatic weight loss, for that matter? Why do the more vulnerable trainees get sent further away from home, thereby increasing the chance that they will end up having a psychological breakdown?
How could a supervising consultant joke about Bella’s obvious distress?
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Bella was certainly not alone in finding that the transition from medical school to junior hospital doctor precipitated depression. What’s more, this is not a new phenomenon; articles about depression and suicide amongst junior doctors have been buried in medical journals for over thirty years13. Then, from time to time, a particular suicide catches the public imagination, and coverage migrates from medical journals to the mainstream press. This happened in early 2016 at the height of the junior doctors’ strike in the UK, when Rose Polge tragically killed herself by walking into the sea. For a couple of days the mental health of junior doctors made the headlines, then shortly afterwards the news moved on, and once again the whole issue got buried.
Little has changed.
In 1983, two junior doctors asked psychologist Jenny Firth-Cozens if something could be done about the stress and depression that they saw all around them14. Two first year doctors in one hospital had killed themselves in the previous month, yet no senior clinicians discussed this within their teams. It was unmentionable. This prompted Firth-Cozens to undertake a series of longitudinal studies of medical students and junior doctors15.
Four years later, in 1987, Firth-Cozens reported the results of a longitudinal study of 170 first year junior doctors in the British Medical Journal (BMJ): 28% of the sample had scores on standardised questionnaires that indicated the presence of a depressive illness and ten individuals reported thoughts of suicide. ‘The incidence of distress is unacceptably high in junior doctors and both they and the hospitals need to deal with the causes of distress,’ Firth-Cozens concluded. Twenty years after starting the first research project, another article by Firth-Cozens in the BMJ lamented that not enough had been done16: ‘What we need is a systematic approach to the problem,’ she wrote.
Roll the clock on another twelve years, and in 2015 following the suicide of two first year residents in New York City, an opinion piece in a leading medical journal listed some of the ways in which medical training increases the risk of mental illness17: ‘Role transition, decreased sleep, relocation resulting in fewer available support systems and feelings of isolation.’
Somewhat surprisingly, the author of this paper doesn’t even comment on the nature of the work that we are asking young doctors to carry out, and how this might contribute to their distress. In the same year a major international review of fifty-four previous studies18, involving over 17,000 physicians in training, was published in the Journal of the American Medical Association. The main finding was that the extent of depressive symptoms in trainee doctors was extraordinarily high; between a quarter and a third of the sample reported experiencing significant symptoms. The authors of the study also emphasised that because the development of depression at one point in time increases the risk of future depressive episodes, their findings may affect the long-term health of these doctors. An accompanying editorial reached the following conclusion: ‘The personal and professional dysfunction, not to mention the suicide rate that may derive from this symptom burden, should be disturbing to the profession; these findings could be easily construed as describing a depression endemic among residents.’19
This wasn’t the hyperbole of a tabloid headline; it was the Journal of the American Medical Association.
The author of the editorial then goes on to suggest that there is a fundamental ‘mismatch’ between the system for training doctors and the current practice of medicine. Specifically, he argues that whilst little has changed in how we train junior doctors over the last fifty or sixty years, the delivery of medical care has altered beyond all recognition. Amongst the changes in medical practice he includes: life-prolonging and life-creating technologies that lead to unsolvable ethical dilemmas; electronic medical records and documentation requirements that encourage inaccurate and sometimes dangerous copy-and-paste shortcuts; malpractice exposure in which a high proportion of residents in some specialties are named in lawsuits before finishing their training; short hospital stays that require protocol-driven procedural care with little opportunity for thinking and learning; online ratings of physician performance; and clinical productivity pressures on faculty members that detract from the formation of strong mentorship relationships with residents. This list is not exhaustive, and some of the changes may apply more in certain healthcare systems than others. But the basic point seems incontrovertible: in many countries, the methods of training doctors no longer mat
ches the delivery of healthcare.
There are a few exceptions, however, where training has undergone radical transformation. In New Zealand for example, since the 1970s medical students have spent their sixth and final year as ‘trainee interns’. The explicit purpose of this year is to provide a more seamless transition between being a medical student and starting to practise as a doctor. In effect, trainee interns are apprentice first year doctors. During the first five years of medical school, students’ clinical knowledge and competence are assessed; in the final year it is workplace-based performance. Crucially, the focus of these posts is educational as opposed to service need. Trainee interns in New Zealand would not find themselves contending with the responsibilities that doctors like Hilary faced on her first day at work. And Bella, in our sessions, described how she wanted somebody to check her work and give her regular feedback, so that she knew she was on the right track – which is exactly what happens with the trainee interns in New Zealand.
An article published in the mid-1990s in the BMJ suggested that the New Zealand model might have ‘much to offer’ the UK training system20. The system might well have helped doctors like Bella. But sadly the suggestion in the article seems to have fallen on deaf ears. The fact that trainee interns are paid 60% of the salary of a first year junior doctor whilst final year medical students in the UK are not paid a penny cannot have helped – particularly with the current pressure on healthcare budgets.
Does it work? One survey reported that at the end of the trainee intern year 92% of students felt prepared to be a doctor. The authors of the survey point out that this figure is substantially higher than the proportion of final year medical students who felt ready to work as junior doctors in the UK and in the US. Even more importantly21, another study in New Zealand found that the first year doctors’ scores were in the normal range for measures of depression, anxiety and burnout22. Admittedly this was a small-scale study but the contrast with the ‘depression endemic’ noted in studies from the UK and US is striking.
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Improving medical education often reminds me of solving a Rubik’s cube. If you twist the cube one way in order to align the colours on the top surface, all sorts of untoward changes are probably happening on the five other sides that remain hidden from view. The controversy over junior doctors’ working hours is a classic example of this Rubik’s cube principle. Undoubtedly over-tired doctors are problematic, for their patients, colleagues and also, of course, for themselves. But placing restrictions on junior doctors’ hours turns out not to be the perfect solution. When working hours are shortened, even though there are some obvious advantages, other sides of the medical education cube such as opportunities for training or the solidarity of the team get twisted out of shape.
In the UK, the European Working Time Directive restricts the average length of the working week to forty-eight hours. The directive was first applied to senior doctors in 1998 and applied fully to junior doctors in 2009. Five years later in 2014, a review of the available evidence concluded that limiting doctors’ working hours reduced both needle-stick injuries (i.e. doctors inadvertently pricking themselves when giving an injection to a patient) and road traffic accidents caused by exhausted doctors driving home after a very long shift23.
As I read about the reduction of road traffic accidents, I thought of a delightful F1 doctor who had been knocked down outside the hospital early one morning, following a long night shift. Tragically he sustained significant head injuries. Following a year in rehab, and returning to work part-time, with considerable difficulty he managed to finish his foundation training. But his training programme director confided in me that she couldn’t see him passing any postgraduate exams due to his poor concentration and short-term memory. In reality, his medical career was probably over.
Any measure that reduces the risk of fatigue-related injuries should be welcomed. However, evidence on the link between the reduction of working hours and depression was much more mixed, and overall the authors of the 2014 review concluded that such a link remained unproven. What this suggests is that reducing working hours per se isn’t enough to protect junior doctors from depression. In fact, reducing working hours doesn’t even eliminate fatigue24 – a finding that emerged from a telephone survey of trainees carried out in 2014. As one trainee commented: ‘There’s no continuity in terms of predictability … you run an eight cycle rota so you’ve got eight weeks to get through and none of those eight weeks are the same at all … I think that from my side is what creates fatigue.’
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The 2017 Nobel Prize in Physiology or Medicine was awarded to Jeffrey Hall, Michael Rosbash and Michael Young. In an opinion piece published in the BMJ, Michael Farquhar, a London-based sleep medicine specialist, celebrated the achievement of these prizewinning researchers25:
Hall, Rosbash and Young have beautifully demonstrated how fundamental our circadian drive is to how our bodies and brains function. We owe it to all those who work at night, for their own health and for the quality of work they do, to recognise that working against that drive is difficult.
Farquhar doesn’t only write articles – he’s also spearheaded an initiative in his own hospital group that is gaining momentum in other hospitals across the capital. Working with the medical director and the chief nurse, Farquhar has successfully introduced teaching on basic sleep physiology and simple strategies for improving sleep as part of mandatory induction training. Some of the strategies are extremely simple – wearing sunglasses and avoiding phones and computers when one finishes a night shift, in order to maximise the chance of falling asleep when one gets home. Others are perhaps more counter-intuitive; working at night, if one wants to drink caffeine one should do it just before one takes a 15–20 minute nap – not after the nap. Caffeine takes 15–20 minutes to take effect, so if you take it before the nap, the effect will just be kicking in at the point one wakes from the nap.
Alongside this mandatory training for individuals, working with the hospital board, Farquhar is leading a culture change across the organisation as a whole. The HALT campaign (Hungry, Angry, Late, Tired) promotes the message that breaks are an essential part of effective workforce planning26. Managers are tasked with leading by example; encouraging a team-based approach so that staff don’t work longer than five hours at a stretch without a 15–20-minute break, identifying suitable rest areas and promoting a ‘take a break’ culture within the team.
One of the strands of the HALT campaign is effective rota planning – minimising frequent changes between day and night shifts. And in Farquhar’s induction teaching he advises junior doctors to try, wherever possible, to minimise changes day on day as to when one goes to sleep and when one gets up. The trainee in that 2014 survey who commented on the lack of predictability of the eight-week cycle is a case in point. Rotas of this nature are precisely what sleep experts advise should be avoided. And Farquhar’s campaign is a rare example of an evidence-based training intervention; knowledge gained from his clinical role as a specialist in sleep medicine is applied not just to patients, but also to the doctors and nurses who are tasked with treating these patients.
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Of course reducing the hours that each trainee is allowed to work and campaigning that staff have regular breaks doesn’t magically reduce the actual clinical tasks that need to be completed. There is still the same number of sick patients on the ward or waiting in A & E. Often working-hour restrictions exist on paper rather than in reality; the 2016 annual trainee survey carried out by the GMC found that more than 50% of doctors in training worked beyond their rostered hours on a weekly basis27. This is exactly what happened to Bella. On paper she shouldn’t have been working for fifteen hours on the day that it all became unbearable. But she couldn’t complete all the tasks that had been allocated to her, so she just kept on going.
Not only do patients’ needs stay the same, irrespective of government rulings on working hours – but juniors also have to reach the same standards of p
roficiency without any increase in the length of training. Particularly with the so-called ‘craft’ specialties such as surgery, where hands-on procedures take time to be mastered, it can be problematic to squeeze the same amount of learning into a significantly curtailed time frame.
In Britain, a government review commissioned by the Secretary of State for Health attempted to look at this very issue28. But in an ironic twist that verges on the absurd – the scope of the review itself was limited by its own short time frame. (The review reported in 2010, a year on from the full implementation of the 48-hour limit on junior doctors’ hours. Given that specialty training takes at least eight years after leaving medical school, the review couldn’t draw conclusions about the impact of reduced training hours on the future competency of consultants, one year after the working hours directive was implemented.29)
What the review did find, however, was that the working hours’ restrictions meant that trainees were often called in at short notice to fill gaps in the rota, particularly in evening and night shifts. During these time periods consultants are frequently not on-site, and therefore the learning opportunities are reduced. In addition, trainees often felt poorly supported at night – which is exactly what Bella, and Hilary, and a hundred other trainees have told me. The review concluded that if consultants were more directly involved in out-of-hours work, it would be possible to maintain high-quality training during the compressed timescale. But that’s a big ‘if’.
There’s some evidence that more recent groups of trainees welcome the working hours’ restrictions, and that female trainees are more positive than their male counterparts30. But what is absolutely clear is that reducing the working hours hasn’t solved the problem of fatigue, depression and burnout amongst junior doctors. And it might even have inadvertently compromised training in some specialties as well.