The below article has been reproduced from a BMJ series to help medical students make the leap to budding doctors. Long working hours, sleep deprivation, and fatigue are just a few examples of the stressors experienced by junior doctors. In this article, Geoffrey Robinson and colleagues give advice on how to overcome these problems.

The transition from medical student to junior doctor is one of the most demanding phases of a medical career. The junior doctor years are associated with a variety of stressors, which can make doctors vulnerable to several important psychological and medical illnesses. This article reviews these conditions and offers suggestions for prevention as well as early detection and treatment.

Emotional and psychological health

Medical students as a group are susceptible to a particular range of health problems, including depression and substance misuse. This may be partly a result of the prevailing culture of medical schools (see below). The social climate engendered by this culture has traditionally normalised heavy alcohol use for male students.¹ More recently, women students have begun to develop this pattern of drinking behaviour. Recreational drug use among medical students is less well studied, but it is known that drug use among university students is not uncommon, and this probably applies to medical students as well.²

The selection process for medical school may favour individuals with perfectionist, obsessive-compulsive, self-critical and altruistic traits, all of which predispose to vulnerability to psychological illness. Psychiatric morbidity, particularly depression, has been found in up to one in three senior medical students.^3,4

Although this background of pre-existing vulnerability needs to be acknowledged, the main focus of this article is the impact on health of the considerable occupational stressors experienced by junior doctors. Historically, this “baptism of fire” has been regarded as a normal and even character-building process on the path to senior doctor status. It is now recognised that the cost of this attitude is a high degree of psychological morbidity in the junior doctor workforce, which has consequences for the doctors concerned, the patients under their care, and the healthcare system as a whole. See below for a list of some of the stressors experienced by junior doctors. These contribute to the high rates of depression and suicide (which may be more prevalent in women doctors), alcohol abuse or dependency, drug abuse and burnout found in junior doctors.^5,6 Burnout refers to the syndrome of emotional exhaustion, depersonalisation, and reduced feelings of personal accomplishment.^4,6

Physical health

Most studies on doctors’ health focus on psychological health problems, perhaps because these conditions are the most recognisable ones. However, some of the physical health issues particularly relevant to doctors merit review. Although doctors have a low standardised mortality rate, this is largely due to a low prevalence of smoking. As with medical students, junior doctors are particularly vulnerable to infectious diseases such as influenza, tuberculosis, hepatitis B and C, and HIV, as a result of occupational exposure.⁷

A major concern is that the management of illness among junior doctors tends to be worse than that in the non-medical population. It would be reasonable to assume that junior doctors have unparalleled access to appropriate medical care, but the reality is different. Paradoxically, there are several barriers to doctors receiving appropriate health care, including embarrassment (one in four doctors reports inhibitions about seeing another doctor), erroneous perceptions that they should be able to manage their own health, or lack of time to see to their own health needs.⁸ Only about half of doctors have their own general practitioner, and less than a quarter have an independent general practitioner.⁹ “Corridor consultations” are common, and many doctors write their own scripts for drugs, ranging from antibiotics to sedatives. While not illegal, this practice has often led to problems and complications for the doctor patient. Such patterns of inappropriate health care and self neglect often develop early in a doctor’s career, and they are not helped by pressure of workload and frequent moves.

Doctors are also surprisingly poor at managing their own preventive health. One study found that a disturbing 30% of female doctors have never had a cervical smear test.⁹ Despite the obvious occupational risks, vaccination rates for hepatitis B may be as low as 50% among junior doctors.⁹

Addressing the situation

Warning signs
A number of warning signs can alert the junior doctor to the development of a health problem. See below for some of these signs, which were compiled from the authors’ experience of working with young doctors.

The signs relate primarily to stress and depression, and to alcohol and drug abuse, any of which may result in absenteeism. We suggest that you read this list with a high degree of self reflection.

The greatest barriers to early detection and resolution of psychological problems are denial of their existence and the perception that they happen only to other people. As a result, look out for the signs in yourself, as well as in your colleagues.

Maintaining health

Below are some tips to help junior doctors protect and maintain their health. We particularly highlight the need for all junior doctors to develop a relationship with a general practitioner. This provides an initial port of call for all health problems as well as a confidential and experienced source of advice and support. Avoid informal “corridor consultations” and do not self-prescribe. Despite the demands of the job, make sure you maintain your outside interests, which may have to be scheduled within your daily practice. It is important to find a mentor at specialist registrar or consultant level and to arrange regular meetings.

Role of hospitals and colleges

Employers and colleges have responsibilities to help junior doctors improve their health.

These include the development of formal support systems for junior doctors, addressing working conditions and hours, and the appointment of accessible junior doctor liaison officers. Hospitals need to provide appropriate orientation and meaningful educational supervision with feedback, to reduce non-medical work such as clerical tasks, and to organise part time or job-sharing work opportunities.

Junior doctors’ organisations have been active in identifying the problems and achieving these changes but would probably agree that there is still room for improvement in these areas.

It is vital that attendance at formal training programmes is maintained to ensure both professional and personal development. This is a right of trainees which must be respected by all team members, including consultants.

Conclusion

The major health issues of junior doctors, which include depression, alcohol and drug abuse, burnout, and suboptimally managed medical conditions, may have been neglected because junior doctors are in some senses a “transient workforce.” The implications of junior doctor ill health can be major, not only for the doctors but also for their patients, and it may result in suboptimal work performance. ¹⁰ For all patients, including the sick doctor, early detection and treatment improves prognosis, and prevention is still better than cure.

Original authors:
Geoffrey Robinson, general physician and chief medical officer, Capital and Coast District Health Board, Wellington, New Zealand
Sharmila Bernau, senior research fellow
Sarah Aldington, senior research fellow, Medical Research Institute of New Zealand, Wellington, New Zealand
Richard Beasley, general physician, Medical Research Institute of New Zealand and Wellington Hospital, Wellington, New Zealand.

We gratefully acknowledge the BMJ for permission to reproduce this article.

References

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