Interview: young doctors at breaking point

A string of scandals over the last 12 months has exposed a toxic culture of exploitation and abuse in Australian hospitals. Gruelling workloads and hours, dangerously low levels of support and supervision and high levels of discrimination, bullying and sexual harassment have shattered the lives of many trainee doctors and appear to be building to a breaking point in the hospital system. Red Flag’s Adam Bottomley spoke with one resident doctor based in Victoria for the view from inside the hospital wards.

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What are the issues for trainee doctors in hospitals?

First, every trainee doctor needs to reapply yearly for their job. You rely on senior doctors for references, so job security depends on your seniors being willing to rehire you. This creates a few issues. Unpaid overtime is a huge problem and is largely due to this job insecurity – if the work isn’t getting done, you won’t be rehired. Because the hospital is so understaffed, this means a lot of work being done outside shift hours.

In my hospital, you’re expected to have teaching time as well, because it’s a training hospital. You are meant to be trained in a broad selection of skills. But the hospital allocates doctors according to where they’re needed to cover gaps, rather than according to where they need training. So doctors are forced to learn a lot of mandatory skills in their own time.

Understaffing is the overarching issue. Being put into roles you’re not ready for is common. They’ll try to find a trained doctor, but often they can’t, so they use a junior doctor. For example, being placed in a critical care role without intubation skills [being able to pass a tube into a patient’s airway to assist breathing]. Seniors are stretched, consultants are not available and, as a junior doctor, you’re not confident to say no. But often you’re not able to perform the necessary tasks. The consultant will be unhappy and berate the junior.

There’s so much pressure around not having children, and not taking time off for family responsibilities. At a doctors’ conference recently, there was a session called “Myrena [a hormonal contraceptive] before membership?” It was a facetious title, but it reflects a real issue of whether family is a barrier to admission to specific roles.

And then there’s the general bullying, sexual harassment and that sort of thing. Registrars, unaccredited registrars, are the most vulnerable. If they’re not progressing to accreditation with one of the colleges, then they’re even more reliant on the good will of their seniors for references and jobs, which makes them ripe for abuse.

What’s the longest shift you’ve worked?

There’s no standard shift length. You’re not meant to be rostered for more than 14 hours straight, after which you’re meant to have a 10-hour break. But that doesn’t take into account overtime. People often don’t claim overtime, partly because there’s not a clocking-off procedure. I’ve never claimed overtime in my whole career. Sometimes a consultant will say “You should claim overtime” – for instance, if you’ve been doing CPR on a patient. Even then the normal response is “No, it’s fine”. That’s the expectation. Overtime costs the department, and you need to get rehired again.

Can you explain the structure of the doctor workforce in Victoria?

There are consultants – they’re like the bosses of the clinical teams – often working across a mix of public and private, only working during business hours and often not on site even during the day. So the hospitals are generally run by junior doctors on a salary and only employed by public hospitals.

Interns are doctors in their first year out of medical school. From the second year, you’re a registrar. Registrars are employed by the hospital but under the protection of the colleges, which are external to the hospital and manage the training of doctors. Then there are unaccredited registrars. They’re employed by the hospital and employed to do the job of a registrar but are not protected by the colleges. They are overseen by the hospital.

Above consultants, there is management and the heads of department. Locums are freelance doctors, employed by an external agency. They’re called in for shortages and are expensive. Many rural hospitals are effectively run by locums due to shortages. Having so few regular staff creates problems; things can get missed.

How do overwork and abuse impact on doctors?

The mental health of doctors is horrific. There are a lot of factors that play into it. The work is extremely high stress, and the overwork takes away all your reserves. When you are working upwards of 60 hours a week, you are not able to do the basic things that sustain mental health – seeing family, partners, exercising, sleeping well. Every year of my career, I’ve heard of a colleague taking their own life. Many of my colleagues have fallen asleep at the wheel going home from a shift. It’s common for off-shift doctors to call the hospital at all hours because they’ve remembered something important that could be life or death for a patient. A lot of the time, if no one is dying, it’s just luck.

As a junior doctor, you can also be sent to rural areas away from connections and support. I’ve never heard of a doctor avoiding being transferred to a rural area. You have no control over which hospital you’re placed in, nor your hours, which is to the detriment of the doctor. The response from management is, “Maybe this isn’t the job for you”.

What is the impact of overwork on the public?

The time allocated and the mental space is not enough to catch the things that need to be caught. Waiting time for patients is one thing, but your mental faculties and your ability to have empathy and compassion is pushed to the brink because the easiest time that you can wrench out of the day is explaining a new diagnosis to a patient or talking with a family. Which is bad because the most common complaint from patients is that they don’t have enough explained – diagnosis, prognosis, reassurance, that sort of thing.

Doctors in Australia are at the top of the hierarchy in hospitals and don’t have much of a history at all of organising industrially, or of showing solidarity with other groups of workers. Why has nothing happened up until now, and what could be done to fix the situation?

There’s this sense that these problems are just the price you have to pay for the life you are going to have as a consultant – high pay with a degree of autonomy. But it’s reaching a crisis point; it’s no longer sustainable. The population is growing and so are the health needs of our patients. Hospitals are not growing to match these needs, and overworked junior doctors are providing the buffer. We’re getting to the point where we have nothing more to give.

Sadly, many of the people speaking out already have nothing to lose. In the United Kingdom recently, a junior doctor, Dr Baba Garba, on her first day back from maternity leave, was covering multiple wards as well as the patient load of another registrar on leave. Unfortunately, a series of medical, nursing and technical errors occurred and a child under her care died. There was no consultant on site for most of the day. Although he attended for a verbal summary, he did not see any of the patients. The junior doctor was convicted of manslaughter and struck off the medical register.

There was a huge uproar among doctors in the UK and across the world, with numerous solidarity actions and fundraisers to pay for her appeal. Every single junior doctor has been placed in that position and understands the terror of not being able to keep their patients safe. Understaffing and inadequate support is an endemic problem and it’s taking a toll on people’s lives, doctors and patients alike.

I think there’s a reason why doctors are starting to question the situation. We can see that the other workers around us – well-unionised nurses and other health workers – are speaking out. They are showing solidarity and standing up for themselves, and the doctors are taking notice.