Transcript | PPP043: Stress and Self Care for Our Junior Doctors with Dr Rebekah Hoffman

Ellen: My guest today is Dr. Rebekah Hoffman who's a GP or general practitioner in regional New South Wales, a university lecturer and PhD candidate at the University of Wollongong. And for reasons that I'm going to ask Rebekah about in a moment, she developed an interest in the factors that contribute to and compromise the wellbeing of junior doctors - those in the first few years of their professional lives.

Elle: As part of her PhD research, Rebekah surveyed junior doctors in New South Wales and Victoria here in Australia to understand the experience of burnout and its causes, and that is what we're going to be talking about today. Welcome Rebekah.

Rebekah: Thank you. Thank you for having me.

Ellen: I'm excited to have this conversation with you. I did have a listener to the podcast who is training to be a psychologist and whose partner is training to be a doctor who contacted me and said, I think this would be a really great topic to cover. And so I was excited to find you and find your research and to have someone here in Australia who is actually looking at this very thing, the wellbeing of doctors in the first few years of their profession. But I'm interested to know, what got you interested in this area?

Rebekah: So it was a bit of a journey and there were a few steps to me actually starting or getting interested in doing research to begin with. So as part of the general practice training, so I'm a fellow of the college of GPs. I had an opportunity to do what's called an extended skills placement where you do something that's not general practice. And I decided I wanted to do that in research.

Rebekah: But doing research in a short timeframe is quite tricky because you need to do something that's short and succinct and achievable in that timeframe. And then I was also lucky enough to be able to choose my own topic. And so that's when I decided I wanted to do something about junior doctors because at the time I was a junior doctor.

Rebekah: And, the topic of burnout itself has always interested me because a few years before that I'd actually become very close to being burnt out when I was working very long hours in a very demanding clinical role in a hospital and actually ended up leaving the role because of their conditions that were associated with it at the time, and was actually the best decision and an unheard of decision for me to do that at the time.

Rebekah: Then took a few years out, well, a little bit of time out to work out what I wanted to do with my life and came back into general practice. But at the time when I was looking at what to do with my life, for once I'd quit my clinical job, there really wasn't any information about what burnt out or stressed out or even just concerned junior doctors do and where they go for help. And I really struggled with the, what information was out their step, and I wanted to really look at what was happening in the Australian environment and go further with that.

Ellen: Hence the research?

Rebekah: Yes.

Ellen: And so can you just for me and for our listeners, because some of us don't have any medical knowledge or training or background, what are the pathways? How do you kind of start your career as a doctor? You go to university and then what happens to them?

Rebekah: So you go to university as either an undergraduate or a postgraduate student. So the undergraduate degrees are becoming less common. That's a six year degree. The postgraduate degrees mean you've already done something else first. So for myself, that was occupational therapy. And then I went into the postgraduate medical degree at University of Wollongong, and that was a four year course.

Rebekah: After that, then you go on to be, what New South Wales is termed a junior doctor, which is your intern and then your resident years for your first two clinical years. Then after that you more or less stream into what type of doctor you would like to be. So you start doing medical terms. So things like cardiology, respiratory, gastroenterology and hospital, you start doing surgical terms, you start doing some critical care.

Rebekah: So ICU, emergency, anesthetics, you just can then start doing GP or you can start doing some other stuff like psych or wherever the world will take you. And there you're nonaccredited years. So there where you're no longer a junior doctor, but you're not yet selected onto your specific training program or specific fellowship program that you'd like to do. The timeframe in which you're in those unaccredited years is hugely variable.

Rebekah: So some people spend no time at all and go straight onto a fellowship training program. Some people will spend 10 years in the non-accredited space before they're accepted onto a fellowship training program. Once you're accepted on to a fellowship training program. So there's an application process where you apply to whichever respective college that you'd like to become a consultant in, which takes a reasonable amount of time.

Rebekah: Then you start training within that training program both towards your fellowship, and that can take anywhere between three and five years. So if I haven't lost you already, by this stage, you finished all of your exams in all of your fellowship training and you're then able to call yourself a consultant or a fellow of whichever college you've followed from.

Ellen: Which is what I guess as the users might call a specialist.

Rebekah: Yes. Exactly. So myself, I have been out of medical school now for 10 years, and I've only been a consultant or a specialist for the past 18 months.

Ellen: So that's out of medical school and prior to that. So you said that it's less common now for people to do an undergraduate medical degree that they tend to do an initial degree I'm guessing most usually in a kind of allied health

Rebekah: Yes.

Ellen: ... [inaudible 00:08:39]

Rebekah: [inaudible 00:08:39] So we had a viticulturalist in our year and we had a lawyer in our year and lots of physios and allied health professionals. But it's absolutely remarkable where people come from.

Ellen: So people could have done say maybe four years of an initial degree, then another four years in the medical training degree. Could be up to well, up to 10 years say in those early, unaccredited. You're still really training. You then go through a process of additional training plus exams, and lots of hoops to jump through before you then become say a specialist in your area, an accredited specialists in your area.

Rebekah: Exactly.

Ellen: It's a long slog.

Rebekah: It is. But it's important. And you are learning the whole way and I really enjoyed my training years.

Ellen: So you said that you started and got close to burnout yourself, and you've since been researching that. But from your understanding, I suppose anecdotally but also as a researcher, to what extent is this a problem in training of this or early career doctors?

Rebekah: So there has been quite a lot of research in specifically with Beyond Blue. So they've done a national mental health survey of doctors and medical students, which really motivated and uncovered a lot of these problems and then really started the process of lots of people having a look at this. Who in their study they said that up to 47% of junior doctors had experienced symptoms of burnout.

Rebekah: So that's almost half of all of your early career doctors having problems or having symptoms or stress not being burnt out, but showing signs and symptoms that they might be heading that way. [crosstalk 00:11:02] in themselves. So lots and lots of actually aren't appreciated at the time. Lots of them acknowledged in hindsight. So the main ones are going to be things like not looking after yourself, not seeing your patient and your colleagues as humans who really depersonalizing yourself from the situations that you're in.

Rebekah: And sometimes that's done as a protective mechanism when you are dealing with quite scary or critical situations anyway as a strategy. But when you're starting to do that regularly that can be a sign of burnout. And then things like risky alcohol use or other drug use, not doing your regular self care activities. They're also different in lots of different people. So then we're talking about things that could possibly be anxiety symptoms like, lack of sleep or diet, remunerating about things that have happened that were out of your control.

Ellen: So yes, the sorts of things, and I know because I do talk about burnout in workplaces the people in usually large organizations but small too and still self employed and all the people who were very committed to what they do. And I can imagine that this is part of a doctor situation as well very committed to what you do. But if you don't find the balance between those self care practice as you mentioned and your work.

Ellen: And it's interesting that you say that sometimes we recognize these things in hindsight. They're sort of subtle, aren't they? They don't actually jump out at you. It's not like you have a sore back or there's an injury or something. It's an accumulated effect,

[inaudible 00:12:51] that's the way you down that you only notice, perhaps when someone else points it out to you or when you've got to a crisis point. Would that be fair?

Rebekah: Yes. And they're often progressive in that you're well and able to cope with certain elements of it. So you might be managing really well with lack of sleep or with not doing your normal yoga or meditation, or not eating as well as you should have. But then when you are doing something that normally you'd cope with really well, but it's quite stressful and you haven't been doing everything else, that there'll be a problem.

Ellen: It gets to a tipping point.

Rebekah: Yes. 

Ellen: And what would the symptoms, if you don't mind me asking, what were the sorts of things that you noticed in yourself? How did you get to a point where you realized that this wasn't working for you [inaudible 00:13:36]

Rebekah: Myself, I actually had a holiday, and then on that holiday had realized how unpleasant I had been before the holiday especially to my partner and to my family. And then I really wasn't who I wanted to be as a human being. And then I got back from the holiday and had quit.

Ellen: So that was, it was just removing yourself from the circumstances and an opportunity to reflect. And I think that's interesting what you say about not feeling like you were the person you wanted to be. Getting to that point of noticing and maybe you do need to remove yourself from the circumstances or have somebody prompt you, but it becomes about having that realization that, this is not who I want to be. This is not how I want to leave. This is possibly not healthy for me.

Rebekah: And I'm not saying that that's wrong for other people and that other people can do it really well, but my threshold for what was my clinical load and hours at work and pressure that I was wanting to work under wasn't at that level that I was functioning.

Ellen: So there's a bit of individual variation in this as well. Different people cope to different extent. So what did your load look like at the time? What were the pressures for you?

Rebekah: It was busy. It was long. It was several years ago now, and they probably wouldn't, things have changed. There are many, many people with a high load than that though. So I was quite regularly working from a 5:00 AM start at the hospital through till the theater at least finishing well past dinner time, plus or minus quite a significant encore load which means, you could be interrupted at any time throughout the night with phone calls or to come in and review the patient.

Rebekah: Plus having a after hours load where you were then having to be at the hospital to review unwell patients in most weekends and most evenings. Plus, so that's just the hour base. And then the amount of staff on the floor was probably not enough in that we were then doing the jobs, which was nice to be doing a job beyond your capabilities because you were trusted to do that work. But that in itself is quite stressful as well. And it was a lot. It was busy. I needed a holiday.

Ellen: So not good opportunities for regular decent sleep, which we know is so important for your wellbeing. I'm guessing a lot of kind of mental load there. You actually kind of keep track of all the patients, all the issues, all the concerns across different domains. So what's going on in hospital during the day, what you might be seeing after, after the end of that very long day. That mental load of kind of not being able to switch off completely if you're on call.

Ellen: So, and this comes on top of already many years of training and university studies. So it's this kind of a, is it a systemic problem? I know you said that things have changed a bit since then, which is great. And I know part of your research or I'm guessing part of your research is how do we make sure that appropriate changes are put in place. Is it a systemic issue or is it just part of what has always been done?

Rebekah: Yes. So I think that's one of the biggest problems actually is that, a lot of it is how it's always been, and it's very hard to change anything. So anyone who working in change management will know that change is very slow, no matter how much it's needed. And the biggest reason or the bigger reason why it's slow in medicine is because everyone before you is done at the same and being fine or being various levels of- 

Ellen: [inaudible 00:17:44]

Rebekah: ... whatever fine looked like for them. And because they got through it, they then perceive that everybody else should get through it without acknowledging that lots of other things have changed in that time, that may have made it either more difficult or harder since then.

Ellen: So it has been sort of ... Rebekah: [inaudible 00:18:06] Ellen: Those social and cultural changes that have occurred in that same period, perhaps the nature of work itself, the nature of technology.

Rebekah: Even just how far medicine has come and what skills and techniques we have for treating things that although are wonderful, they're all vastly more complicated and time consuming, but make the patient experience better and the chances of recovery better, but are incredibly difficult to that capacity to learn and understand and use. But all wonderful.

Ellen: But it's more complex?

Rebekah: It is.

Ellen: And it's interesting because I did have a conversation on the podcast last season with Nadine Hamilton, who's a psychologist who specializes in assisting veterinary professionals. And she said, similarly, one of the issues has been the improvements in technology and the skills and the knowledge, which does make it better for pets.

Ellen: It makes it better for veterinary themselves in some ways in that they have tools at their disposal to help animals that they didn't previously have. But of course there's a lot of extra learning that goes into that. There's a lot of expectation from the vets themselves, but also from their,

[inaudible 00:19:28] not their direct clients maybe

[inaudible 00:19:31] paying the bills, the families of the pets. So I'm imagining that, that might be part of that change process as well as you described.

Rebekah: So my mom is av et, so I know infinitely how difficult that is. Yes. So I think it's actually more difficult for veterinarians because it's across so many different species. We only have the human species to look after.

Ellen: That's true.

Rebekah: And I imagine vet is quite similar to being in pediatrics where it's their baby, it's the baby hence the parents and all of the family associated with the care of that human child or the baby.

[inaudible 00:20:16] more complicated.

Ellen: That's interesting. That's not something I'd really given much thought to the fact that medicine has changed. And again, from a change management perspective, as you were saying, and a change in itself is difficult. Systemic change is very difficult. And if there isn't a recognition of those other factors that, that it's not like we're doing medicine in 2019 in the same way that we did it in 1974 for example. And yet perhaps the training or the expectations of our medical professionals haven't caught up.

Rebekah: I agree. 

Ellen: Interesting. So one of the things that you came up with and I did see in some of the work that you've done is a little kind of Venn diagram and I'll put this sort of describing it with my hands and you know what it looks like and I know what it looks like because our listeners don't. So I will put it in the show notes so people can see, that describes in really simple terms I think. Although I know they're not simple factors, but it's a nice simple way of describing it. The components, these things that you've discovered that are driving some of the or the deterioration or the risk as opposed to doctors, junior doctor's wellbeing. Can you talk us through those factors please?

Rebekah: I'd love too. So I specifically wanted to look at from the junior doctor's perspective of what their experiences were with stress and burnout. So more at an individual personal level rather than a whole pitcher or big picture, because I believe that had been done on a bigger level. And there hadn't been research on the Australian individual perspective, because it is different all around the world with different processes in hospitals systems and training systems.

Rebekah: But specifically having a look at the Australian junior doctor experience. And I was wanting to have a look at both the hospital based trainees and the general practice based trainees to see whether or not there was any difference in what their stress and burnout looks like. And quite surprising to me, I'd identified that there was no difference between general practice or hospital based junior doctors, that they both experienced stress and burnout in the same ways and with similar causative factors.

Rebekah: And that, that then replicated to how they felt in quite similar experiences as well. The Venn diagram that you're talking about and the three components of that, actually is expectations of self. So how the junior doctor has expectations and beliefs of what they should and shouldn't be able to do. The second one is expectations and response from others. So what other people's or other forces expectations on them are, and what happens when they're not quite aligned, and then self care. So I'm happy to talk through each one of those.

Ellen: Let's unpack those a little bit. Let's start with the expectations of self because that's one of my favorite topics in psychology too.

Rebekah: So expectations of self looked like when junior doctors were aware of their skills and aware of their abilities, and they usually, well, you should intuitively know what you're comfortable with and not what you're not comfortable with, or you get a gut feeling of when you're just not comfortable doing something that you've been asked to do.

Rebekah: And then specifically when you go into a situation where you're asked to do something beyond that. So that could be something as simple as discussing with a patient or a family member what the surgery they were about to go through entailed, when you yourself have never done that surgery before.

Ellen: So just feeling out of your depth or out of your comfort zone.

Rebekah: Exactly. Or even putting a cannular in someone. So a device to deliver fluids and take bloods directly into the vein that you haven't done before or you know is a particularly difficult patient to do that in. Huge range for than that of when you might be operating outside of your expectations, but in the medical field, quite often you don't know what you're expected to know or don't know what is coming at you until it arrives.

Rebekah: And it's only then that you really are able to say, yes, I'm comfortable and familiar with this or no, I'm not. And that step of then asking for help or acknowledging that it's not something you're comfortable with is where the stress and the burnout happens.

Ellen: So that's the sticking point. It's not so much that you're expected to do things, it's your own expectations of, I shouldn't have to ask for help for this, or I should know how to do this, or I should feel comfortable.

Rebekah: Yes. And I think so more than that. So then there're the shoulds, which what I'd like that as a word anyway.

Ellen: [inaudible 00:25:33]

Rebekah: But the belief that everybody else knows how to do it and you don't, and therefore you're not as good or as capable as everybody else, which usually is untrue. And then also identifying that there's a gap in your skillset that you may not have been aware was even there before until that had come. And as doctors quite often were perfectionist and want to be able to do everything and want to be good at everything we're doing. And then especially in your junior doctor years to constantly be barraged by things that you can't do and don't know how to do, is very stressful for lots of, new doctors.

Ellen: And I've often thought about this because it's not dissimilar. I think the situations are slightly, well, they are different. But the psychologist as well that I think a lot of people who by the time you've got through your training, you're often people, and I'd say this would be even more enhanced for perhaps doctors because always been good at or your academic stuff, you had to do really well at school to get the degree in the first place.

Ellen: And then you've got a whole lot people who are all have those high expectations of themselves, who go through training together and that kind of amps that all up a bit so that perfectionism, that expectation of yourself that you should be able to do everything that if you're confused or uncertain or thrown into a situation that you don't feel really comfortable with things.

Ellen: It is the unhelpful thinking perhaps that goes around that. But I can imagine that part of it is the system that you kind of grown up in that cohort of people who are all similar. And so it all kind of amps it all up a little more and a little more.

Rebekah: [inaudible 00:27:21] Exactly. You often come from a background where you've been one of the smartest at school and one of the best at your extra curricular activities and excelled in your smaller regional town or even in your capital city and done really well at a school level and then at an undergraduate level and then usually at a medical school level. And then to be starting right back from the bottom again is quite difficult once you've already achieved so much. And yet all of that is then meaningless.

Ellen: It's confronting, I'm guessing.

Rebekah: Yes. You can be.

Ellen: So that's one component is expectation of ourselves. And you talk about the expectations that others have.

Rebekah: So this is more talking about what the junior doctors are expecting when they're going into a term or into a situation, or into any discussion or conversation that they're having. And I guess what the junior doctors is themselves when I interviewed them largely expected or hoped is that they would be safe and well supported and they would be knowledgeable and able to go into an environment and do well and succeed in it.

Rebekah: So whether or not that's a realistic expectation already is something that can be further pulls apart. But they were hoping that even if they did have struggles that there would be someone there that could guide and support them. And that's largely does happen. And largely when you're in a situation that you've not been in before, there'll be a more senior doctor or somebody else that can take you by the hand and say, don't worry, let's do this together.

Rebekah: But that doesn't always happen particularly after hours. And when you're in a poorly staffed area or location and you've got to call someone in from a different location and acknowledged that you're not comfortable and you need them to come in from wherever they are at that time, be at a different hospital or from their home looking after their children to come and help you with a situation you are not comfortable with.

Rebekah: And it's seen that when your expectations are met and when there's been no problems and the response of others has been good, that there's no issues, that everyone does really well and succeeds and learns and moves on together. But when there are issues, so when they don't have that backup support or they make the phone call and whoever they're calling is either doesn't answer or as nonresponsive or is on call or is stuck doing something else themselves, or they're told that they should be able to do a skill that they can't or just try yourself or whatever variation of lack of support they have, that then there's big barriers there. Big Barriers to their stress clearly and then leading rapidly and burnout.

Ellen: So I mean, it's from the sounds of things, it's positive in some regards in that there is usually somebody there who is willing to help, but it's whether they're available. Are there ever situations where people, because I can imagine particularly perhaps the senior doctors like all of us, it's hard to remember what it was like when you were starting at. You kind of forget that not everyone knows everything or that they're comfortable with everything.

Ellen: And I can imagine it would certainly be situations where you might ask for the support or not even feel comfortable asking for the support because you're not, you don't feel safe in that regard. From psychological safety, you just don't know what kind of response you're going to get from that other more senior doctor.

Rebekah: So there is actually a wonderful article written up in the MJA, the Medical Journal of Australia last year looking at that. So calling on seniors to be more of a mentor and a colleague to junior doctors. And because it takes such a long time to go from being a junior doctor to being a senior or a late mid to late career doctor, in 10 years time you've completely forgotten or longer 20 years what it was since when you were there. And you've enormously changed as a human being in that time as well. So what you are able to cope with and manage is vastly different on multiple levels. And it is difficult to remember what you were like as a human, and forgive yourself for what you're like as a human 10 years ago.

Ellen: Yes. Again, all those complicated thinking factors aren't they, that kind of expectation of self, what others expect from you. Can I call them? Should I call them? Do I need to call them? Uncertainty, which we know is just stressful for human beings being placed in a situation of uncertainty.

Rebekah: Yes.

Ellen: So that's self expectation and expectation and response from others or of others. Where does the self care piece fit in? Rebekah: So self care is vastly important for stress and for burnout and is really the protective factor amongst everything else. And as a whole, doctors are actually really good at self care when they're doing well, as well as when they're not doing well. And they were all aware that they needed to have good self care and they understood what that looked like. So it looks like exercising regularly, eating regular meals that have good nutrition in them. And some variation on meditation or time to self or being able to get away from the situation that they were in.

Rebekah: And that specifically an interest of me was that those with family or dependence were actually better at self care and better at prioritizing that life in the work life balance than those without. And so self care really looks like what those protective factors are to be able to deal with the ongoing stresses that you have in your work life.

Ellen: And I know it's and I've been through this myself, but I know a lot [inaudible 00:33:29] sometimes self care we know we should do it. It's a cognitive thing and we know logically we should do it, but the doing of it becomes the issue. We tend to prioritize it last or it takes, there's quite a mindset shift I think, and may be it's interesting you say that about people with dependent or people perhaps who are looking after children.

Ellen: Maybe that's easy to make that mindset shift because you realize that you need to be okay to look after them or it's a change in priorities or change in values. I don't know. I hadn't really thought much about it, but I do know that it's, there is that a shift that we need to go through and perhaps sometimes it gets to when we get to burnout or some kind of crisis point before we realize that this is not just an academic exercise, self care really is the doing of it.

Rebekah: And that's actually interesting you've said that because that's now where my PhD has probably moved more towards is I'm now having a look at motherhood in medicine and the barriers and supports that specifically doctors who are mums have, around juggling the doctor role and the mother role. And I might have to talk to you about that another time.

Ellen: That might be another whole conversation [inaudible 00:34:47] because you are a mother yourself, you have [inaudible 00:34:53]

Rebekah: I do.

Ellen: I could see where that would start to lead you down that path because it is another world. It is another conversation, but it's a whole new perspective on life. Isn't it?

Rebekah: Absolutely.

Ellen: So doctors, and it was interesting that you say that, junior because I was kind of imagining being, well, I try to imagine being a junior doctor. I suppose those early years in any career. I know for me when I finally finished studying after many years and I had a job and I had money and I had a bit more flexibility and freedom, although it sounds like junior doctor there's not whole lot of flexibility or freedom.

Ellen: Are you also you indestructible, you'd think you're indestructible. You're not really paying attention to things like self care. You party and have fun and you probably don't get enough sleep. So do you think, is that part of this as well that the age group perhaps, so we're going through it? Does that compound it?

Rebekah: Not as much as I think it may have previously. And just because so many are postgraduates now. And for the age when you're finishing medicine is often your late 20s early 30s rather than ... Ellen: [inaudible 00:36:08]

Rebekah: Exactly your early 20s. So that probably is a much bigger problem during medical school, then after, and I honestly think that most people don't have enough time to pick up their phone, to call a colleague and ask them to have a drink then to go out socializing. [crosstalk 00:36:29] Which is obviously a problem.

Ellen: Socializing is part of, well it is. Maintaining social connections is really important to our wellbeing. So perhaps that's actually dropping away as a consequences of the working hours and the expectations [inaudible 00:36:43]

Rebekah: And the postgraduate studies in that people at that age want families or have families and are going to be using their supports outside of the hospital system rather than within the hospital system.

Ellen: So these three different components, which are [inaudible 00:37:03], but and I know I did read something that you in one of the press articles around your PhD work that not everybody has these struggles, [inaudible 00:37:13] some people for whom they're still able to not just survive but thrive through these challenges. What makes the difference as far as you know at this stage? Rebekah: So it's probably beyond what I've looked at. I think it comes down to that everybody is different and what everybody does well in and excels in is different for each individual and what their capabilities are is different. And that's not saying that someone who gets burned out isn't capable, it's just that the scenarios around that meant that at that point in time they were struggling.

Rebekah: Whereas another person in that situation, we'll have different skills and different abilities and different life experiences that will mean they actually enjoy that stress that they're put under. But I think that's really nice about what humans are and what colleagues and doctors are is that, we're all different and we all bring unique and different experiences into it. And that's why I guess the medical field is so broad and what we can go into is so variable that we're all in there. We ended up choosing where we fall quite well most of the time.

Ellen: I can help to direct the pathway or the place that is best suited for you.

Rebekah: Hopefully. Yes.

Ellen: As best we can ever know these things still an adventure. So [inaudible 00:38:37] said that about those kind of individual and I can sort of imagine that, there'll be individual factors. They'll also be other life factors that are going on for people. I know when I'm talking about resilience in the workplace is that, the same event can affect so many different people in different ways and even affects the same person in different ways depending on what else is going on in their lives. So there might be personality factors, but they might also be that things are difficult at home or they're managing a whole other set of factors in their life that also impinge on our ability to be resilient [inaudible 00:39:13]

Rebekah: Absolutely.

Ellen: So people are complex and lives are complex and as you say, I mean 47% if that statistic is accurate, it's almost [inaudible 00:39:23] an effective way.

Rebekah: It is. Yes.

Ellen: Interesting. Well, that again, that might be another conversation once you've kind of [inaudible 00:39:33] surviving and thriving or [inaudible 00:39:37] 

Rebekah: It's amazing how much research just asks more questions.

Ellen: It does, doesn't it?

Rebekah: Yes.

Ellen: That's the fun part of it. We need to find out more. Now we need to look at this. Now I need to look at that.

Rebekah: Exactly.

Ellen: So we talked about obviously there's risks to individuals in their situation. We don't want people burning out. We don't want people, and the risk with burnout is that once it gets beyond burnout, we're starting to look at clinical illness, anxiety, depression, probably the most common. So we don't want that happening to anybody. But what are the kind of further risks if we've got doctors who are really operating not at their best because they're stressed?

Rebekah: So further risks are usually split into personal and professional risks. And the personal risks are the ones that you described. So that burnout links to anxiety and depression and then can link to the suicide or suicidal intent specifically in doctors or in all people.

Rebekah: And then the professional group is that, that junior doctors who report or are reported to be burnt out are more likely to be absent for work, more likely to have depression, have self reported medical errors or have made clinical decisions that may not be correct or have made clerical areas that shouldn't have been made, and then are more likely to engage in risky behaviors such as increased alcohol or other drug use.

Ellen: So it extends beyond just the individual to errors in their work, which obviously then potentially puts other people at risk.

Rebekah: Which is why it's so important.

Ellen: Absolutely. So what's being done, I mean your research, you were just fantastic. So you're contributing to knowledge in the field. What else is being done is to what extent you can recognize there's an issue and to what extent are things starting to change perhaps?

Rebekah: So the recognition is really largely been media driven, which has been wonderful. Once the media picks something up, it tends to run with it for quite a while. So there was unfortunately quite a few high profile medical suicides over the past two years that really then had been pushed by their family to try and show how much of a problem this is. Which is very difficult for the family to do. But they've really opened up a lot of conversations about specifically junior doctor burnout.

Rebekah: Which also then once the media is involved means that people who can make decisions, politicians and such hear that this is a problem and are more likely to devote their busy time and lives to making decisions and setting policies. But all of these still takes time. And so there has been some funding at a state level and at a federal level looking at junior doctors and of burnout.

Rebekah: And there have been some specific programs placed in individual hospitals looking at training and education. And specifically last year some sites were deaccredited, which means that they can no longer take trainees at that site because they were deemed as being dangerous for their trainee. And that was specifically due to poor work conditions at that site.

Ellen: So change is starting to happen at multiple levels there. So within organizations, within education and training, within policy and then even socially, I suppose once the media gets involved in. Even the fact that you and I are having this conversation, and that you're doing the research is a sign that there is recognition of the problem, which is always the first step in any kind of change, recognition that there is an issue and then starting to look more proactively at what we can do about it.

Rebekah: Absolutely.

Ellen: Fantastic. Well, that is promising positive news, although I'm guessing from your point of view, there's still probably a long way to go.

Rebekah: Yes.

Ellen: And what about the individuals themselves? What is it that we've got junior doctors listening or people perhaps who are currently studying and looking at a career in medicine. What is it that at the individual level people really need to be doing in order to thrive, not just survive?

Rebekah: So my big one that I talk to medical students or junior doctors about is the asking for help. So acknowledging that it's okay not to be comfortable or familiar in a situation, and really getting rid of that barrier of response from others and what your expectations of self are. And expecting that you're going to be uncomfortable and unable to do things because you are just at the very beginning of a career.

Rebekah: And although your medical schooling is training you to be an expert, they're training you to be an expert in a field that is going to change and you're really not an expert in at any level, and that you really need to be able to and be taught how to ask for help and to have those difficult conversations often with potentially difficult people in challenging situations and be comfortable doing that.

Ellen: So conversations asking for help, which is again I suppose in psychology we refer to as kind of having self efficacy, that kind of belief that I can, that it's okay to ask for help. That it isn't a sign that you're not good enough or you don't know stuff that you should know or that you're, inadvertent commerce failing in some way.

Rebekah: Absolutely.

Ellen: That it's very much part of, this is all brand new. It's like you're starting all over again. That's okay. Everybody knows and understands, and it's up to you to take action for your own wellbeing. And I guess even reframing it, from the point of view of your patients' wellbeing.

Rebekah: And even if it's not brand new and you've done it a thousand times before, there's components or situations about that, that may be challenging in that location that you're under-resourced or you don't have the equipment you're used to, or it's a particularly unwell patient or particularly demanding scenario, and that that's going to put you outside of your comfort zone in something that you're very comfortable with. And that's against what is wonderful about medicine is that it's changing but often quite uncomfortable at the same time.

Ellen: Is it about having recognition of that. And I'm sort of thinking in systems terms around, you're operating in a system that even if you know what you're doing and you've done it a thousand times before that system, that container that you're operating in that you're working within is changing or [crosstalk 00:46:34] two sets of circumstances.

Rebekah: Absolutely.

Ellen: That does make sense. It sounds very challenging but it does make sense in the context of, the importance of understanding those things to get people to then ask for help. What else do the individuals need to be doing?

Rebekah: So I guess the next step that I talked to them about is, seeking a mentor or seeking a colleague, and I'm aware that psychiatrists and psychologists all need to have a clinical supervisor or someone who they debrief with at a regular point in time for their mental health. Whereas ...

Ellen: That much part of the practice.

Rebekah: Yes. The general medical profession don't.

Ellen: Really?

Rebekah: Yes. Which is quite surprising.

Ellen: That is surprising. Because they're very much part of our profession, it's so much part of the norm and I wouldn't have that it should have been that different. I mean, I know that emotional [inaudible 00:47:34] well, not even that. Psychologists deal with some really emotional stuff, but clearly doctors are dealing with really emotional stuff too. [inaudible 00:47:40] I did not know that.

Rebekah: Exactly. I really think that would be a wonderful step to move towards even if, because it's very hard to implement these big grand changes, even if it wasn't at the whole level that everybody needed a clinical supervision person that they had someone they could talk to at a regular basis about difficult things, whether that be a colleague or a mentor or someone more senior than them. Ideally in a clinical supervision role, but before that just having someone that they can bounce feelings and thoughts off and not having to manage it all in their own head is really important.

Ellen: I mean, that's something we talk about even in workplaces in completely non related fields is the importance of having a mentor or having somebody, having a manager say who, you can just debrief with when you've got tricky situations.

Rebekah: Absolutely.

Ellen: That does. I mean, even at an organizational level, I would have thought that would be the kind of thing that could be addressed. Although you might not be able to change it quite yet at a systemic level, at least at an organization you're within clinical teams to say this is now part of our practice that, sit down and debrief whether, as psychologist, we have peer supervision as well as ...

Rebekah: Wonderful.

Ellen: As well as a model of, sort of more mentor or more senior person, more experience person. So even then just using that as an opportunity to just go, I just think it's really difficult situation [inaudible 00:49:12] and this is what I did. And what do you think? And how could I do it differently next time? Or has anyone else even just been in the same situation, it's just a really useful conversation to have.

Rebekah: Yes. And especially about the nonclinical things. So the clinical decisions are often quite black and white, lots of gray. But yes, the correct clinical decision was made or no, we would do something differently next time. But all of the nonclinical, the thoughts and the feelings and the communication that have happened is often what's as equally if not more important to debrief on.

Ellen: Even just be able to say, oh my God, that was a really hard conversation I had to have with a parent or a spouse or patient themselves and to have other people say, you know what, they are really difficult conversations and it does affect you and that's just you're human.

Rebekah: Yes.

Ellen: And reminded that you're human. So supervision as a model or a practice asking for help. Are there any other key things that individuals can do that you feel will help? Rebekah: They're my main two I talk to people about. There's lots of self care that we can talk about as well, but I think that as a whole do that quite well. They probably let it sleep when they should continue doing it. But they do

Ellen: Don't we all.

Rebekah: ... normally do it quite well. But there might be once.

Ellen: And where else could people find out more? I will pop [inaudible 00:50:45] puts in articles about your research, by the academic articles and also some press articles just for people who are interested. You mentioned there was an article in the MJA which is the medical journal of Australia. Is that right? Am I getting that right? Yes. Regarding just that kind of senior doctors looking at the more junior doctors. Are there are any other key resources that you think would be helpful to anyone who's listening and who wants to find out more?

Rebekah: Always. I love resources. So each state based health service and each training college are going to have their own policies and programs around doctor's health and wellbeing. So it's specifically for people in the medical field. If they're unsure or uncertain, that's where I would send them to start. So it's either to their state based health service, the hospital they're working for, or their community practice they're working for, or they're registered college that they're a part of.

Rebekah: Beyond that. So, well for instance, with that at the RACGP, the Royal Australian College of General Practice, the New South Wales branch ran a wellbeing weekend earlier this month, where we actually got together with a group of GPs across their careers and talked about things like identifying personal values and goal setting and how to manage those difficult conversations around end of life care specifically. But then also things like having a hobby and we taught knitting and creative writing and [inaudible 00:52:23]

Ellen: All my favorite things.

Rebekah: Although there's really important things and they're done Australia wide at lots of different colleges at different levels and involvement. But there are some really good opportunities coming through. For nondoctors I think Beyond Blue is a great place to start and they have their survey free and publicly available. And then for anybody who has any worries about stress or burnout in themselves or their loved ones, I usually would get them to talk to their GP about strategies and resources themselves and making sure that all doctors have their own GP. And if they're unable or can't get into say their GP, then lifeline is a really good resource as well.

Ellen: And you can find, we often refer people even in workplaces [inaudible 00:53:14] in any domain of psychologists to GPs because [inaudible 00:53:18] to be able to get then a mental health care plan, which then allows you access to a psychologist under Medicare.

Ellen: So [inaudible 00:53:27] which is very, very helpful to a lot of people. Rebekah, thank you so much. It's been such an interesting conversation and I think we can have another conversation [inaudible 00:53:38]  doctors and motherhood because I think, even if for people who are not doctors are in the medical profession themselves, I can only imagine there'll be very similar themes for professional women who are trying to juggle all the things.

Ellen: And I know that's certainly the case for a lot of our listeners. So we can have that conversation further down the line. But I really appreciate your insights today and all those resources. I will put links in the show notes to, [inaudible 00:54:10] your research, all the things that we've mentioned. And we'll have you back on to [inaudible 00:54:16] again soon maybe.

Rebekah: Thank you so much for having me.

Ellen: No problems at all.