Reducing burnout amongst clinicians

Tragically, every three weeks a doctor in the UK commits suicide.  Many more opt either to leave the profession altogether during their training, or to take early retirement. Things seem to be deteriorating rather than improving, and this begs the question: what can we do about it?

Many clinicians in training now feel overworked and under-supported. The increasing prevalence of rota gaps results in stressed and exhausted junior doctors working overtime, and this has a negative impact on the continuity and safety of patient care. The breakdown of the firm structure that once offered stability and pastoral support has been replaced by rotations which range across wide geographical areas. This results in nomadic trainees who find it difficult to either integrate with the existing teams or to establish a settled and stable family life.

The observation that clinicians who experience high levels of job satisfaction have better mental health indicates the crucial importance of work-related factors. As a consequence, there is undoubtedly an argument for allocating a portion of the £20 billion per annum extra funding for the NHS specifically to improve the working lives of its doctors, both in hospitals and in general practice. Obvious areas that require urgent attention include improving unsuitable hospital accommodation, increasing study leave allocation and replacement of the sluggish, outdated computer and other communication technology. In addition, now that Theresa May has declared that ‘austerity is over’, a salary rise would certainly boost morale.

Sir William Osler contrasted doctors ‘whose stability of character and devotion to duty make one proud of our profession’ with those who find it difficult to keep ‘the flame alive, smothered as it is apt to be by the dust and ashes of the daily routine’.  In this respect, team morale is crucial – but was decimated by the junior doctors’ strike and the eventual imposition of the new contract by Jeremy Hunt. This damaging dispute with trainees centred on weekend working arrangements in relation to the Conservatives’ determination to introduce a ‘7 day NHS’- an aspiration that seems to have been conveniently abandoned as the Conservative party has descended into the morass of internecine struggling over Brexit. Rebuilding and maintaining the morale of the medical profession ought to be a top priority for  Matt Hancock, Jeremy Hunt’s successor as Health Secretary, if he truly has the aspiration to reduce burnout amongst clinicians and to keep ‘the flame alive’.  One has to hope that he has – for the sake of the many millions of patients who will be cared for by the NHS throughout 2019, and beyond.

What are your thoughts on these matters? Please do add your comments to this blog.

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Comments (15) Add yours ↓
  1. Antoine Kass-Iliyya ST6 Urology

    Most trainees are under different types of pressures:

    1- Financial: This is exacerbated by changing locations, paying for rent, supporting family , paying for nurseries, child minders, let alone GMC, different membership fees, courses fees, exam fees, etc….
    2- Time: the trainee is often trying to juggle time between his job and family. Long on call days or weekends are time spent away from family that the trainee will never get back.
    3- Commitment: from a surgical career perspective, the trainee is expected to put tremendous amount of hours and effort into becoming the surgeon of tomorrow, this could not be achieved without commitment. The latter needs focus and focus is difficult when all the other mentioned pressures are distracting the trainee.This problem is exacerbated by the lack of any family support which is a likely scenario with the nomadic trainees of today who are often working miles away from family and loved ones.
    4- Caring for patients: medicine is not a 9 to 5 job in any shape or form. It is rare that doctors go home on time. All trainees are conscientious and they wouldn’t leave a sick patient in the middle of assessment because the clock turned 5.
    5- Progressing through career, answering to bosses and being up to date with courses, audits, publications, presentations, assessments, passing ARCPs, passing exit exams etc… as mentioned in the article, courses are expensive and exams are even more so.
    6- Uncertainty and lack of stability: This is a major cause of trainees low moral, trainees often don’t know where is their next job until few months prior which makes planning difficult. (This is hard when a whole family is involved in the process). without settlement and job stability it is very difficult for trainees to achieve their full potential and have a serene state of mind. It is also hard for the family when kids have to change schools for example etc….
    7- shortage of junior doctors: rota gaps are everywhere and in every specialty, this puts tremendous pressure on junior doctors and reduces their job and overall career satisfaction, many of whom are leaving the profession. It is not uncommon nowadays for senior doctors to conduct ward rounds during weekends on their own without any junior support, write in the notes and complete the discharge summaries as well as attending to emergencies etc…

    I think the NHS should have a huge investment into improving the life of doctors. The starting point is to have an open dialogue with doctors and listen to their concerns and suggestions and try and address those. Regular assessment of the wellbeing and workload of junior doctors should be carried out. Financial help is certainly welcome, covering courses, memberships, exam fees are few areas that could be looked into. helping with child care costs is another aspect. compensating doctors for hours worked overtime is another area that needs urgent improvement. (doctors kindness should not be taken for granted)
    Looking into the structure of training and re-visiting the real benefit of changing locations during training and balancing that with the negative financial and family impact. Perhaps give trainees more say into job locations and facilitate interdeanery transfers etc…
    Trying to re-attract junior doctors into working in the NHS by creating a positive working environment and investing more money into creating new training positions to cover rota gaps instead of the millions that are currently spent on locum agencies.

    January 24, 2019 Reply
  2. Roland Morley Consultant Urologist

    Antoine

    Some very useful pointers here and the article is very timely particularly when burnout particularly amongs urologists is high and many trainees leaving surgery early in their careers

    The IST project in Improving Surgical Training will go some way to help provide stability in a region for all their surgical training and the new curriculum will allow all essential courses to be funded separately to help with the financial burden .

    However, I believe the most important aspect to be developed is mentoring for trainees and new consultants .

    ASiT are addressing this at their conference this year but we need to develop a cadre of mentors within BAUS as the expertise is there . Let me know if your interested in a mentoring role and we can take this forward !

    January 26, 2019 Reply
    • Antoine Kass-iliyya ST6 Urology

      Dear Mr Morley, I would love to be a mentor. (antoine.kass-iliyya@nhs.net). I am not sure if I have to be in the same rotation for a year at least to be able to supervise the mentee and meet regularly.

      BTW, I have just met a cardiology FY2 doctor as I went to do an emergency catheter, she is responsible for 30 patients on the cardiology ward on her own. She told me that consultants and registrars never do a ward round as they go straight to the Cath-Lab, she does it on her own and then do all the jobs herself afterwards. She could ask the on-call cardiology registrar for help if she has any queries about the ward patients. She is supposed to have another juniour doctor with her, but there are 2 gaps in the rota and she is therefore left on her own. Rarely the consultant comes unexpectedly and sees his own patients that she had already seen and sorted which doubles her work if anything.

      I think there is a serious issue of feeling unsupported and lonely as a juniour doctor these days. I have to say It’s much better in Urology at least in my current hospital.

      January 26, 2019 Reply
  3. Roger Kirby Professor of Urology

    Despite a relatively rosy outlook at the start of training —medicine remains a popular career choice with a surplus of students applying for a place, and the announcement of five new medical schools in England—there is a worrying exodus that is gaining momentum. In 2017, 57.4% of Foundation Year 2 doctors did not enter higher-training posts and 9000 doctors quit the NHS entirely. In 2011, when career-destination surveys were first conducted, 71.3% of FY2 doctors progressed into higher training-posts. By 2016 this had dropped to 50.4% and last year the rates had plummeted further to 42.6%. This rate of decline is alarming. Furthermore there is a growing culture of quitting both across the specialties and In general practice. Solutions please?

    January 26, 2019 Reply
  4. Matthew Bultitude Consultant Urologist

    Morale is clearly low in the NHS at all grades and all the points above seem relevant. A sensible but significant pay rise would definitely help after all the years of stagnating pay but I just can’t see this government doing that. The issues are much deeper though. The loss of the firm structure has definitely led to the training doctors (note not saying junior) feeling isolated from the team. Rota gaps seem more and more common further damaging the goodwill and morale of those doctors who stay in the NHS.

    Amongst consultants burnout is definitely an issue and continuing full pace for a whole career is very difficult now in the NHS. I suspect we will see more and more people go part-time when they can afford to.

    There is undoubtedly the perception that the DoH / Government just don’t care about all grades of doctors as they limit pay, alter pensions, make rota gaps inevitable with their policies, drive people out of the NHS and then use the media to spin their policies however they wish. Sadly, I suspect too much damage has already been done to reverse this.

    January 27, 2019 Reply
  5. Roger Kirby Professor of Urology

    An excellent blog on the staffing crisis afflicting the NHS by Drs Roycroft and Fitzpatrick. Here is a quote from it: “We must create jobs that provide doctors with the meaning and purpose which first drew them to the profession, and which fit around their lives. Trainees with different circumstances require personalised approaches to supporting them through their training, rather than a one size fits all approach where trainees are just just cogs in a machine. This need for flexibility is finally being recognised, with expansion of the emergency medicine less than full time training pilot and, within medicine, the piloting of flexible portfolio training. However, truly flexible working arrangements are still some way off.

    The single most important priority to improve training is to increase staffing levels, alongside improving the flexibility of work and training to aid retention. This will allow the NHS to deliver excellent patient care, while also providing the space and time to train the doctors of tomorrow“.

    February 2, 2019 Reply
  6. Roger Kirby Professor of Urology

    “Unhealthy perfectionism risks doctors becoming mentally unwell as they blame themselves for the losses and failures that are inevitable in medicine.” See @ClareGerada’s latest column in the BMJ

    February 5, 2019 Reply
  7. Roger Kirby Professor of Urology

    Record numbers of burnt-out NHS staff in England are quitting because they are fed up with spending too much time at work and not enough at home with their family, research has revealed.

    The number of personnel leaving the NHS because of a poor work-life balance has almost trebled in the last seven years, an analysis by the Health Foundation thinktank shows.

    Between June 2010 and June 2011, a total of 3,689 employees cited concerns over long working hours as the reason they had decided to stop working for the NHS in England. But 10,257 did so between June 2017 and June 2018 – an increase of 178%.

    Many of those who left were nurses. The numbers quitting over their work-life balance more than doubled from 1,069 to 2,910 over the seven years studied.

    The 270 doctors who quit for a better work-life balance in 2017-18 represented a 167% increase on the 101 who did so in 2010-11.

    Health unions have been warning for years that NHS personnel are cracking under the strain of heavy workloads, a relentless rise in demand for care and having to work harder as a result of widespread understaffing. Many staff report routinely working beyond their normal hours simply to ensure that they complete all their tasks related to patient care and administration.

    February 16, 2019 Reply
  8. Roger Kirby Professor of Urology

    The Mental Health Foundation has identified Britain’s long-hours culture and employees having too little time for personal priorities as a key driver of the ongoing rise in mental ill-health. “The cumulative effect of increased working hours is having an important effect on the lifestyle of a huge number of people, which is likely to prove damaging to their mental wellbeing,” it said

    About 10m working days a year are lost to work-related stress.

    The NHS long-term plan, the blueprint for the service’s future in England, published last month, highlighted that it would have to offer more staff flexible working in order to tackle its growing workforce crisis.

    It said: “Inflexible and unpredictable working patterns make it harder for people to balance their work and personal life obligations. To make the NHS a consistently great place to work, we will seek to shape a modern employment culture for the NHS [including] promoting flexibility, wellbeing and career development.”

    Sheffield Teaching Hospitals, one of the NHS’s largest trusts, has introduced an array of flexible working schemes in a bid to recruit and retain staff. That includes career breaks, home-working, job-sharing and contracts where personnel only work during term times and take school holidays off, to help families with childcare arrangements.

    Anita Charlesworth, the Health Foundation’s director of research and economics, said: “Retention rates have worsened in recent years, and almost three times as many people are citing work-life balance as a reason for leaving the NHS at the beginning of 2018-19 than in 2011-12.D

    February 16, 2019 Reply
  9. Roger Kirby Professor of Urology

    It looks as though burnout is affecting the teaching profession as well as medicine. Nearly three in five teachers in only their first year in the profession are already not convinced that they will stay in teaching – and rising mental health problems are partly to blame, research finds.

    Half of newly qualified teachers (NQTs) say their job has caused panic attacks or anxiety, while more than a third have been left feeling depressed, a poll shared exclusively with The Independent shows. One teacher turns to alcohol late at night to self-medicate in a bid to cope with the challenges, while others say they plan to quit the profession as soon as possible to improve their wellbeing.

    The survey of more than 275 teachers in their first year of teaching, by a Leeds Beckett University academic, found that only 43 per cent have definite plans to stay in the profession long-term. It found that 29 per cent do not plan to stay in the classroom and 28 per cent were neutral.

    Experts say a growing number of new teachers are experiencing mental health problems. And cuts to mental health services and a relaxation of the government’s teacher recruitment requirements, as well as existing pressures from senior staff and high workload, have contributed to the rise.

    February 18, 2019 Reply
  10. Roger Kirby Professor of Urology

    And it’s not just in the UK! Overworked trainee doctors are also leaving medicine in Australia.

    In recent weeks Dr Yumiko Kadota, resigned from her position as a registrar at a Sydney hospital claiming she did 100 hours overtime in her first month.

    She has been overwhelmed by the response she received after going public with her story about “four months of hell” working at a Sydney hospital.

    In the most recent figures from the Australian Medical Association in New South Wales, 40 per cent of doctors reported working more than 10 hours of overtime a week with nearly 70 percent of those concerned about making a clinical error due to fatigue.

    So, why hasn’t the epidemic of over-worked and underpaid junior doctors been halted? And is a culture of intimidation and bullying of young doctors to blame?

    February 18, 2019 Reply
  11. Roger Kirby Professor Of Urology

    Record numbers of burnt-out NHS staff in England are quitting because they are fed up with spending too much time at work and not enough at home with their family, research has revealed.
    The number of personnel leaving the NHS because of a poor work-life balance has almost trebled in the last seven years, an analysis by the Health Foundation thinktank shows.
    Between June 2010 and June 2011, a total of 3,689 employees cited concerns over long working hours as the reason they had decided to stop working for the NHS in England. But 10,257 did so between June 2017 and June 2018 – an increase of 178%.
    Many of those who left were nurses. The numbers quitting over their work-life balance more than doubled from 1,069 to 2,910 over the seven years studied.

    March 11, 2019 Reply
  12. Roger Kirby Professor of Urology

    We have created a situation where the degree of pressure, and the degree to which doctors feel valued and supported in the workplace, means we risk not being able to hold onto those doctors in whom we have invested” says Charlie Massey CEO of the GMC @gmcuk in @HSJnews #supportingdoctors

    March 13, 2019 Reply
  13. Roger Kirby Professor of Urology

    A recently published study in the Annals of Internal Medicine found that for every hour physicians were seeing patients, they were spending nearly two additional hours on paperwork. Is this really the best use of doctors’ training and ability? Isn’t this another cause of medical burnout?

    April 20, 2019 Reply
  14. Roger Kirby Professor of Urology

    Junior doctors are calling for a change in their contracts to ensure that no one is charged to stay overnight in hospital accommodation, after an investigation found that one in five acute trusts in England asked trainees to pay as much as £65 a night.

    The trainees’ section of the British Association of Urological Surgeons conducted a freedom of information investigation into accommodation charges for doctors working a 24 hour non-resident on-call shift as part of its #DontPayToStay campaign.1

    It sent the request to 213 trusts in England and received responses from 182 (response rate 93%). Of these, 145 had rooms available for non-resident on-calls, and 30 trusts (20%) charged trainees to use them.

    Charges ranged from £65 a night at St George’s University Hospitals NHS Foundation Trust in London to £9.14 at Warrington and Halton Hospitals NHS Foundation Trust.
    Is it a surprise that junior doctors are leaving the NHS?

    April 21, 2019 Reply

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