Why are rates of mental illness so high among junior doctors and nurses?
Airdate: 
Tuesday, June 20, 2017 - 20:30
Channel: 
SBS

What is it like being a new medical professional in a hospital? How do you cope with the long days, high stakes, death and trauma?

For many junior doctors like Karla, the stress of the job takes a mental and physical toll. 

“I was having some insomnia which I’d never had before and I started having what I later found out to be anxiety attacks,” she tells Insight’s Jenny Brockie.

Mental health organisation beyondblue surveyed more than 12,000 doctors in 2013 and found those in training were almost twice as likely to cite very high levels of psychological distress compared to senior doctors.

A 2009 survey published in the Medical Journal of Australia also showed 71 per cent of junior doctors were concerned about their physical or mental health.

Coronial records show 20 doctors took their own lives between 2007 and 2016 in New South Wales alone.

Likewise, nurses – particularly female nurses – also have high rates of mental distress. A 2016 study of suicides over 12 years found female nurses and midwives had a suicide rate almost triple that of women in non-health professions.

Hannah, a graduate nurse who has been working in the acute psychiatric ward of her hospital explains the stress she experiences regularly on the job.

“I’ve had threats on my life, threats of rape from numerous people, threats with my family … because you’re not giving [a patient] the extra medication they want.”

While emergency situations are a source of pressure, Lizzy, a GP registrar tells Insight that it’s the exhaustion that comes with long hours and few breaks that causes strain.

“You just have this ingrained fatigue,” she says.

“It wears you down quite a bit to not get enough food into you, not enough water, not enough sleep at night and back there again.”

For Karla, that fatigue affected her ability to empathise with patients.

“When you’re tired and you’re hungry … you start feeling resentment,” she says.

“That’s something that I feel really guilty about and then I have to remind myself, actually, they rely on me. I’m the only doctor for these five wards, I have to keep going.”

This week’s Insight speaks with junior doctors and nurses to ask: how can we provide better care for those who care for us?

If this story is distressing for you, please contact Lifeline on 13 11 14 or the Suicide Call Back Service on 1300 659 467 for crisis support.

 

Credits 

Transcript

JENNY BROCKIE:  Welcome everyone, good to have you here. Lizzy, you're in your first year of GP training, you were originally a nurse. Tell me about the first major emergency that you faced in a hospital? 

LIZZY:  So I was a fourth year nurse and I, on an afternoon shift we were asked to divvy up the patients and there was one gentleman who was quite unwell and I took on his care thinking that I, you know, could try to help him out. Work out what was going on and during the course of my shift I just had a sense that something wasn't quite right. He had a moment where he was spitting some blood at one point and I called the registrar who was on that evening and expressed my concerns and I was told no, he's okay, you know, his temperature is alright, it's all okay.  And I'd pulled a bed pan out from underneath him and noticed dark liquid that was about half the pan worth so a good 5 or 600 ml. 

JENNY BROCKIE:  Of blood? 

LIZZY:  Yes, of blood, once I'd turned the light on I went oh! And it was bang on the handover time, people were kind of going home, there weren't that many staff around because it was coming into night shift and he began to spit some more blood and as I reached for the phone to call for the emergency cardiac arrest and calling out to other friends, he then began to vomit blood and drowned on his own blood. 

JENNY BROCKIE:  And how old would you have been when that happened? 

LIZZY:  Oh, I was, must have been 23. 

JENNY BROCKIE:  How did you react when he died? 

LIZZY:  I felt very much responsible. I felt like it was my fault that I should have or could have done more, I should have been more at the registrar to express my concerns. Over the course of the next few days to weeks I didn't sleep, I had nightmares, I had flashbacks.  I can still see his face and it took a long time before anyone even actually recognised that I wasn't coping.

JENNY BROCKIE:  And you'd just applied to med school at that point? 

LIZZY:  Yeah. 

JENNY BROCKIE:  To be a doctor? 

LIZZY:  Yeah, one week prior I'd applied to med school so I then had this sense of how can I possibly cope as a doctor? I can't keep my patients alive as a nurse, I can't, I can't cope as a doctor. 

JENNY BROCKIE:  But you went ahead? 

LIZZY:  I did. So it was during that year that I'd applied and was successful in gaining entry into med school and over the course of my medical degree I had a lot of counselling and a lot of kind of trying to work through this post-traumatic stress and even went and did rotations at the morgue to try to, doing autopsies to try to desensitise myself.  I deliberately tried to challenge myself on it. 

JENNY BROCKIE:  Karla, you're a fourth year doctor. Tell me what happened a couple of years ago when you stayed back to do your paperwork one night? 

KARLA:  I remember all the urgent jobs had been done so I was in the office on the ward just doing some paperwork and one of the nurses approached me to review a patient on the ward. Um, and they were very apologetic, they said I know you're not supposed to be working right now but can you please see this patient?  We've paged the afterhours person but they haven't come yet. So I went to see this gentleman and he was a patient on our medical team at the time. He'd been doing pretty well. The nurse was quite concerned, um, I'd done quite a lot of surgical rotations. I thought he might have some abdominal pathology, he was looking like he'd had a bowel perforation. He didn't have any reason to have that but that's what I thought at the moment so I panicked and I called the surgeons. 

JENNY BROCKIE:  Because that's a very serious thing to happen? 

KARLA:  Yes, So I tried contacting the surgeons who were still in theatre, they wouldn't answer.  I tried to get ICU, I tried to get a registrar to come and see, but it was really a surgical problem. At that point I was really worried that this gentleman might get sicker and die. So I ended up staying back and in the end the surgeons came around, this gentleman was in his mid-70's, he was deemed not suitable for surgery and he was palliated later that evening. I was really sad because I sort of followed this patient through the whole admission and he was almost ready to go home and then this happened. 

JENNY BROCKIE:  And you'd formed a bit of a relationship with him? 

KARLA:  Yeah, yeah. He was a really, really sweet gentleman who I guess in my mind when someone's getting better I allow myself to sort of feel like they're going to go home and they're going to be okay and suddenly everything changed.  The gentleman ended up passing away a day or two after that. 

JENNY BROCKIE:  Hannah, you're 23, you started your first job in January as a newly qualified nurse in an acute psychiatric unit in a hospital. What weren't you prepared for when you went into that job? 

HANNAH:  Everything pretty much. Um, I guess it's difficult starting your first job once you qualify in a speciality area, there's always going to be challenges with that. But I think they never really quite prepare you for the constant, um, like abuse and violence and the things that, I mean they kind of like to think doesn't happen quite as much. 

JENNY BROCKIE:  Describe the things you mean? 

HANNAH:  I've had threats on my life, threats of rape from numerous people, threats with my family, you know, just people threatening to punch you in the head because you're not giving them the extra medication that they want that's not charted and dealing with someone who is extremely suicidal is definitely a skill that no one can really prepare you for, I guess. So the first time you have a patient who is actively suicidal on the ward it's, um, a very big learning curve. 

JENNY BROCKIE:  What happened to you? 

HANNAH:  I had a patient who was very, very psychotic, very paranoid, actively suicidal and it was just that I managed to build a really good rapport and a really good therapeutic relationship really, really quickly with this lady, and she was looking for sheets and blankets to make a noose and it took a few calls to the team and me having to escalate through the nursing staff, so for my in-charge to be able to get people to really take it seriously. So I think having that confidence, they don't really prepare you for how you interact with treating teams, with the different doctors. 

JENNY BROCKIE:  Where does all that leave you though as a 23 year old going into a job like that?

HANNAH:  Um, you grow up very quickly, I think. So I find that when I finish a shift, especially if it's been quite full on or you've had patients that are really escalated and are quite aggressive, it takes a really long time to be able to really wind down.

JENNY BROCKIE:  Lizzy, tell me what an average day looks like for you now? 

LIZZY:  Now? 

JENNY BROCKIE:  Yeah, or what's an average day like in a hospital? 

LIZZY:  During a surgical turn you tend to start quite early so usually a 7 am ward round with the registrars who are trying to get to theatre for their 8 o'clock start and you need to see about thirty patients in that time. 

JENNY BROCKIE:  In that hour? 

LIZZY:  In that hour to try to get some sort of direction as to who's going home, who needs operations, who's unwell, who needs consults, so that can be a very quick ward round and then trying to give divvy up the jobs. Whereas in a medical ward round takes much longer, there's certainly more medical issues at hand so with a kind of 8 am start, trying to round till about maybe 11 am and then calling for consults. So that you can start getting the ball rolling for, how can we get this person home in the next few days and your afternoon is then taken up with doing discharge summaries and reviewing people who are unwell and this is fingers crossed everything's going well and I can get out of here at 5.30 and then someone gets sick. So you have to then try to manage your time around those who are particularly unwell. 

JENNY BROCKIE:  How often did you get out on time? 

LIZZY:  Rarely, yeah. 

JENNY BROCKIE:  So how many extra hours would you do? 

LIZZY:  I would say most days, I'm quite dedicated so I would stay for a good kind of ten hour day and be paid for the eight or nine, sometimes you might do a twelve hour days.  There are occasions that you're then rostered for a fifteen hour day and even on those occasions if it's an 8 am till 11 pm shift, quite often I would stay till midnight because you're trying to just, if someone's sick bang on 10 o'clock you can't leave them even though you have to go to handover, you have to go back, do your notes, and if you're finishing at kind of 11.30, midnight, getting home and back there for 8 am. 

JENNY BROCKIE:  Hannah, what about you as a nurse, how much overtime do you do? 

HANNAH:  Um, I personally am normally there a little bit late for most of my shifts. I think that comes down to the fact that I am new, but I'm also a detailed person so I'm very thorough with everything I do and I really enjoy spending my shift actually taking the time to talk to my patients and build a really good relationship and you know, get all of the information that we need from them so that we can give them the best treatment possible and that's really, really time consuming on top of everything else that you have to do for someone.

JENNY BROCKIE:  What effect does that have on you, do you think, day on day, if you're doing that, if you're living like that? 

LIZZY:  Just absolute fatigue. It wears you down quite a bit to not getting enough food into you, not enough water, not enough sleep at night and back there again. And you just have to keep going. There is no, oh, not feeling too good today, I might not go because you just think God, the work is going to be double when I get back there the next day so. 

KARLA:  I think not just that but you're not able to having to rely on having activities outside of work.  This year I really tried to get some dance classes booked in and I cancelled about four weeks in a row and then I just gave up because I was supposed to finish at five but reliably was finishing at 6.30, 7, and what's the point? 

LIZZY:  Yeah. 

JENNY BROCKIE:  Does it affect patient care that you're in that state? 

KARLA:  I think it depends on how, where you are and what you're feeling. I think when you're tired and you're hungry and you haven't been to the toilet all day and you're busting, you start feeling resentment. Why, oh, why do you have a headache right now?   Why do you have chest pain right now?   Like I'm so hungry and that's something that I, I feel really guilty about and then I have to remind myself actually, they rely on me, I'm the only doctor for these five wards, I have to keep going, I have to keep going. 

JENNY BROCKIE:   Arghya, you're a third year doctor, are you relating to any of these stories? 

 ARGHYA:  Very much so, but I think in all those situations there are people take different things away from it.  I think that when I've been in these situations I've been in good support. I've had a registrar around or a consultant around and I've been to sort of, given the chance to immediately debrief and I think that's really helped me, you know, settle the score at the time and then go home and not worry about it.

JENNY BROCKIE:  In painting a picture of your lives, I want to ask you if work is over when you leave the hospital, when you go home? 

KARLA:  It depends I think whether you're sitting exams or not. I'm planning to do an exam next February so when I get home I need to study. 

JENNY BROCKIE:  For how long? 

KARLA:  As long as possible. I …

JENNY BROCKIE:  So this will be at the end of a ten hour day sometimes or…?

KARLA:  Yes. 

JENNY BROCKIE:  And how many extra hours would you do studying? 

KARLA:  I try to study an hour or two, my concentration doesn't always allow it, I just usually give up and go to bed. 

JENNY BROCKIE:  Jovan, what about you?  You've just finished training to be an anaesthetist, hard to say, anaesthetist.  How many hours a day have you spent at hospital and studying to get to that point where you are now? 

JOVAN: On average the days would be about ten hours as well. It's all pretty civilised in anaesthetics so we know when to go home luckily. It's about ten to twelve hours and then on top of that two to three hours of study, if you can when you get home.

JENNY BROCKIE:  So you are describing your job as being more containable in anaesthetics? 

JOVAN: Luckily, yes, it's part of why I chose it actually because out of all the specialities it does offer a bit more of a balance.  

JENNY BROCKIE:  You're talking about a ten to twelve hour day and then three hours of study on top of it and that's balance? 

JOVAN: That's right because I see my surgical colleagues in the same room and they have to do a lot more a day and still sit similar exams, so yeah. 

JENNY BROCKIE:  How do you all manage?

LIZZY:  Well, I've escaped, I'm off doing general practice training now so I looked at my colleagues and those that are now doing physician training and thought I don't think I can manage. So I've made a deliberate career choice here to go to general practice where I can have some greater control over the hours that I work, can have some time off. 

JENNY BROCKIE:  Because the hospital wasn't viable?  

LIZZY: No, I know how dedicated I am and the kind of doctor that I wanted to be within the hospital and could see that it would break me eventually. 

 

VIDEO PLAYED.

 

JENNY BROCKIE:  Femy, you're a fifth year medical student, what sort of things were you exposed to when you started your hospital placements when you were at what, 18 when you started?

FEMY: Yes, so started med school at 17.  I think at 18 I'd been on the wards and a woman grabbed my hand and she was like am I going to die? And it was only like six months since leaving high school and I didn't know what to say, I just froze. And then the next year at my rural I was in a GP consult with a woman who had just had a miscarriage at sixteen weeks and she was lactating and she was crying and I'm just trying to hold my tears back and not be emotional because you've got to be professional, you can't like let the emotional guard down and I think it was eight weeks into my placement this year I actually saw someone die. I had like to do CPR and then watch that person die in front of me. So I think as a med student I don't think I was ever mentally prepared to kind of see that. 

JENNY BROCKIE:  So in your fifth year, you know, what's it been like at your lowest for you? 

FEMY:  I think it was, I remember walking on Monday and seeing a patient on ward rounds and he came with cellulitis and he had scabies and I was like oh, this is interesting, I like went in, like talked to him. I walked in Tuesday morning and someone said oh, he died overnight and it took me back and I felt guilty. I felt bad and I went home and cried. I grieved for that patient. He was the first patient I'd lost. 

JENNY BROCKIE:  So you, you went through a real burn out, didn't you, in your third year? 

FEMY:  Yeah. 

JENNY BROCKIE:  Tell us what happened? 

FEMY:  I just didn't feel emotion for about six months, no joy, no like sadness, no stress. I was just emotionally kind of blunted and it got to my third year where I would come home and just cry for hours and nothing would like trigger it off, it would just happen. And it got to stage where I would look in the mirror and I would not recognise the 18 year old who had started medicine and the person I was in third year, I was so different. 

JENNY BROCKIE:  And what did you do? 

FEMY:  It took a lot of courage but I picked the phone and I think I called Headspace. I did it on my own because I knew that the way I was going, I would not want me as my doctor, I knew that, it wasn't going to the right direction so. 

JENNY BROCKIE:  You didn't go to the hospital, you didn't go to any of your colleagues, you didn't talk to anybody around you? 

FEMY:  No. I think, I guess it's a cultural thing within medicine that you can't let your guard down, and if you come out and say oh, I don't think I'm coping well, you're worried that people will judge you for being incompetent.  Like you can't deal with what's in front of you.  So…

JENNY BROCKIE:  Do others feel like that? I mean what's your reaction to Femy's description there? 

LIZZY:  Yeah, I'd say there's also quite a difference between nurses and doctors. As a nurse I certainly had lots of debriefing.  At the end of every shift you know, we all walked out together, you'd say we're all going to the pub, we're going to, you know, talk about it and if you'd had a really crap day, you know, your mates would say tell us about it and you'll all laugh and you'd kind of say we're here with you, we were there and you get a very different perspective. Within medicine you are by yourself a lot of the time and even if you are trying to debrief with others, so often the response is oh you think you had a bad day, I had it worse and competing even with how bad it is. So… 

JENNY BROCKIE:  Hannah is that what happens for you as a nurse? Do you get the debriefs after every shift with the other nurses? 

HANNAH:  Honestly I am yet to have a debrief. And I think that that is a, like a work place culture kind of thing and that's at like any of the facilities that I've been at. Things are just sort of expected now where you work. So I know in mental health I can be like oh, my gosh, can't believe that person just, you know, he just ran at me and he was going to punch me in the head and like yeah, he does that all the time.  So it's just this thing that you just have to get used to the fact that that is something that happens.

JENNY BROCKIE:  What happens after those incidents in terms of support from the hospital? Do you, you know, do you get support? Is there someone you can go to and talk about those things? 

HANNAH:  So the facility that I'm at at the moment has an employee access scheme, so if you want to engage with those services, you can definitely do that. 

JENNY BROCKIE:  Do you? 

HANNAH: I personally choose not to. 

JENNY BROCKIE:  Why? 

HANNAH: I have my own psychologist that I linked up with through Headspace about a year, year and a half ago. 

JENNY BROCKIE:  Why are you going to Headspace?  Why aren't you going to your colleagues? Why aren't you going to seniors around you and the people within the system that you're working in?  Why have you got to go externally for this sort of support? 

FEMY:  I think because it's anonymous, I kind I've feel more comfortable saying look, I don't think I'm on the right track. Whereas talking about it to like to a GP and they know that you're a med student, it automatically like I get worried that someone's going to judge and say she's won't make a good doctor, like she's going to struggle and I think that kind of cloud hangs above you for a while.

JENNY BROCKIE:  Hannah, do you feel supported by other nurses in what you're doing?  

HANNAH:  I think that every workplace is different. I've definitely been in facilities where nurses, if they're young, so…

JENNY BROCKIE:  What do you mean by that? 

HANNAH:  It's still very like the old school mentality of; like the matron style that's going on where we were hospital trained so we have these skills and you're just university trained so that's why you don't know how to do that and so it's trying to get around that can be really challenging sometimes. I mean even with doctors, nurses, gosh, but there's some places that you go there it's still very much the old school thinking that the doctors are here and that the nurses are just there to do whatever they, you know, they're little slaves kind of. Very rarely, not as, like I will say…

JENNY BROCKIE:  Go for it you two. 

HANNAH:  I've only met a few but there has been a couple of times. The one that sticks into my head is when one particular consultant said I can't believe these people actually have degrees to do this stuff. So I think that it definitely has changed a lot but there's still just that little bit there that we need to really just push. 

JENNY BROCKIE:  Jovan, did you feel you were burning out at any stage during your training? 

JOVAN: Yeah, absolutely. 

JENNY BROCKIE:  Describe that for me. 

JOVAN:  So there's two major exams that most specialities have to sit and between those two, after I'd passed the first one about, oh, nearly a year into training after that, I felt what you guys felt so some resentment.

JENNY BROCKIE:  To patients, resentment? 

JOVAN:  Yeah, and obviously I felt really guilty about that and I knew prior to that I had a real good bedside manner and I felt that that was slipping as well and I just put my hand up and said no, sorry, time out. I need to deal with this. 

JENNY BROCKIE:  Was that hard to do or was it easy to do?  

JOVAN: It wasn't easy, it wasn't easy, but there weren't too many roadblocks and I was really thankful for that. I was in a department that was quite supportive, and the thing that helped as well was that ages ago at uni we had a couple of lectures on burn out.  They sort of stuck in my mind about burn out, what is this? Okay, took it in. And around that time when I started feeling these things, I'm like wow, so this is what it is and the consequences are pretty devastating if I don't nip it in the bud.

JENNY BROCKIE: Tell us what happened when you first, when you saw your first death? What did your supervisor say because you did kind of put your hand up then, didn't you? 

JOVAN: That was as an intern and that, that was pretty, that was pretty disappointing in hindsight as well. It was probably a month into working as a doctor and I had patient who came into emergency, looked after her, she had a sort of pretty advanced cancer. She ended up going home from emergency but then she came back the next day basically in comatose and very close to dying and it was the first patient that I'd looked after that actually died in front of me. And afterwards, even though it was a very supportive sort of senior colleague, he could see I was rattled and shaken and even had some tears in my eyes and he said, he tapped me on the shoulder and said but you know, you know how to handle this, don't you? Sort of an expectation and then I was just silent. 

JENNY BROCKIE:  It's not an are you okay kind of question, is it? 

JOVAN: Far from it, yeah, and yeah, that was a pretty long drive home. 

JENNY BROCKIE: Karla, you took a year off from training last year, why?  What happened? 

KARLA:  I was also feeling burn out at the end of my second year as a doctor. I became very worried about some symptoms I was having that were, um, pretty intense. 

JENNY BROCKIE:  What sort of symptoms? 

KARLA:  I think it started with apathy towards patients, a bit of, I guess just not feeling any more. I was having some insomnia which I'd never had before and I started having what I later found out to be anxiety attacks that I'd never had before.

JENNY BROCKIE:  Did you tell anyone at the hospital how you were feeling? 

KARLA:  I did. I decided that I had to because I was concerned for my own performance. I approached a consultant who I respected very much and I still do. I basically just asked to speak with him in his office. I explained what I was going through, that I was exhausted, that I felt like I'd just needed a break, I was too tired and I started crying in his office which was very embarrassing. I think because I'd seen him with so many patients being so compassionate and caring, I, I craved for that response towards me but it was more of an awkward response. Like I didn't feel any message of it will be okay, you just need to rest, you'll recover, it will get better. It was more like he was thinking who do I need to inform? I felt like I was labelled as being damaged. 

I later approached my, my educational supervisor for my training who I was very good friends with, he's an excellent consultant, and I told him I wanted to take a year off. I felt that I wasn't ready to proceed with my training, I felt like I wouldn't be the best kind of doctor.  I was advised not to take the year off first of all. I was told it would be career suicide, that it would be seen very bad, unless I had a legitimate reason such as a PhD. or a masters and…

JENNY BROCKIE:  Was burn out a legitimate reason? I mean was this because you hadn't said that it was burn out do you think or was it…?

KARLA:  I think the advice given to me was for my benefit. It was so that I had something to explain for my absence. I think it was a legitimate reason to take a year off, it was the best decision I made.

JENNY BROCKIE:  Karla, why do you think speaking up is hard when you're struggling as a junior doctor? 

KARLA:  I feel that from day one in medical school you take on this character of this competent person who's confident and has to develop this authority almost. And I think we get really good at pretending like we're okay and I think we start believing it ourselves when we realise oh, dear, something's wrong, it's really difficult to admit that to ourselves and then to get help from anyone that knows us because we're ashamed that we're the one that's struggling.

JENNY BROCKIE:  We spoke to one junior doctor who wanted to stay anonymous about the pressure that she's felt and why she kept it to herself. 

 

VIDEO PLAYED. 

 

JUNIOR DOCTOR: Lowest point for me as a doctor was probably about eighteen months ago I was struggling quite a lot to get into the speciality program of my interest. I started getting like sort of the voices of the registrars that used to tell me different things about oh, why?  Why did you not know enough about this? Why did you not do this? So that reinforcing my incompetence, if you will, those voices that came the negative thoughts that just sort of tipped me over into a spiral.

I remember being quite afraid the first time I thought like what's the point? What are you doing, what's the point? I couldn't bring myself to speak to my family, I couldn't bring myself to make them understand. I couldn't, and I definitely could not tell anybody. 

It's the culture, it's that you suck it up and you deal with whatever goes wrong. You are praised for being able to deal with strife and I wasn't dealing with my strife. It probably took me about four, five months of that before I went to see someone.  So I went to the GP who referred me to a psychologist and with her I actively chose not to mention my thoughts of suicide.

I'm in a much better place now. I got into my speciality program, yes, it definitely still as in some weeks at a one where things go badly I do struggle but I haven't not been able to recover from it alone so I'm doing really well. 

 

JENNY BROCKIE:  That's someone who talks about having suicidal thoughts and didn't feel at the time able to tell anybody about that. You know, and we've heard so much about doctors and suicides lately and I know that you knew a couple of the people who, who suicided, didn't you? 

KARLA:  I did. Two people from my cohort at university committed suicide in January. One of them I knew, I worked with closely.  The other person I sort of just knew by name and face.

JENNY BROCKIE:  How did that affect you Karla? 

KARLA:  Um, in a number of ways.  So when I found out that my colleague had passed away, I just knew that it was suicide. I don't know how, I just had this, this dread and it didn't make sense because he was never someone who struggled. He was academically excellent and so loving as a doctor.

JENNY BROCKIE:  When you say you knew, I mean to just broaden it out a little bit, why did you, why did you feel that you knew? 

KARLA:  There had been other doctor’s suicides in the media, but they're not discussed widely. Even, even when I tried to contact mutual friends who knew that he'd passed away, I said what happened? Do you know what happened? No one would tell me. I think it was common knowledge what had happened. There's a reluctance to discuss the issue. It's not, until recently it's not been covered in the media at all. I'm so glad that we're talking about it because if we don't talk about depression, anxiety and suicide in medicine and in health care, then how are people supposed to feel like they're not the only ones? 

JENNY BROCKIE:  What do the rest of you think about that? 

FEMY:  I've been so fortunate that every single supervisor I've had has gone out of their way to make sure I'm doing fine. But I've also seen a lot of medical students not receive that kind of care that I received and I think there's no talk about self-care at university. It's kind of a thirty minute kind of squeezed in lecture before lunch.

JENNY BROCKIE:  Is it hard to speak out about this stuff now, I mean to do it here? 

FEMY:  Yes, I think right now I'm worried that my colleagues and maybe my supervisors will think she will probably struggle and I'm betting that when I get back to the hospital there will be some doctor who is going to be like are you okay? And I'm worried they're going to judge me for speaking out about it, that I'm not competent and it takes a lot of courage to come out and say it out loud in public. 

JENNY BROCKIE:  Charlie Corke, you're the president of the College of Intensive Care Medicine. What's it like hearing junior doctors telling these stories tonight?

CHARLIE:  Well it's not a surprise I'm afraid. We know that this is happening. It's clearly tragic when people who are so highly performing burn out and struggle and have difficulties. But it's something we recognise and something that we're, you know, our college and a lot of other colleges are very concerned about. 

JENNY BROCKIE:  Is there a culture problem in medicine though? 

CHARLIE:  There are culture problems as well.  The one of suck it up and learn, you know, you need to be tough and get over it is not helpful. But in fact, you do with the things that happen and the evolution of being able to evolve and work out strategies that work for you is really, really important and all of us have been through this in various ways. 

JENNY BROCKIE:  Did you feel like this as a junior doctor? 

CHARLIE:  Oh, absolutely, absolutely and I think you know, years ago when I was training the support was completely absent.

JENNY BROCKIE:  How receptive do you think more senior doctors are to changing things in the system, to provide more support? 

CHARLIE:  Well I'd hope that we're very concerned and distress and suicide in young doctors, I think gets to all of us, it's horrific.

JENNY BROCKIE:   Arghya, what do you think?   

ARGHYA:  There are situations we'll come across which will be difficult where there's death and things like that. But I think when we select for medicine I think we should go into knowing that these things are going to happen. You're going to see dead bodies, you're going to see suffering, it's a lifestyle choice you've made, you're very accomplished, you could do something else at any point in your career if you really put your mind to it.

JENNY BROCKIE:  Okay, comments over here, yes? 

JASON:  So I find as a trainee in a specialist program that a lot of the colleges are very inflexible. If you do need to take time off you have to explain to your supervisor, the college, in writing, your mentors, your workplace, break your contract, it's very, very difficult to take time off. And then there is ingrained bullying, especially in some surgical or surgical trainees.  A recent survey showed 49 percent of trainees are victims of bullying, harassment, vilification on a daily or regular basis. So at the grassroots, the culture needs to change within the medical profession as a whole.  

JENNY BROCKIE:  Is there a difference in the experience for men and women do you think? 

CHARLIE:  Can I answer that?  

JENNY BROCKIE: Yes, sure.  

CHARLIE:  I thought that burn out was something that happened to elderly doctors and made them, elderly male doctors and made them grumpy, but the evidence is that young girls are very vulnerable and they're very vulnerable, we believe, because they're so highly, have such high internal expectations of their, and drive themselves much harder and are disappointed by themselves. 

JENNY BROCKIE:  Is this imperial Charlie or is this…

CHARLIE:  That's from research that has been done.  The issue is for me that you know, I don't have to tell them that they're not doing very well. They are just absolutely fierce on themselves.

JENNY BROCKIE:  Reaction to that? 

CHARLIE:  The ability to be fair to yourself I think is a problem in young high achieving girls. 

LIZZY:  I've certainly noticed that it's, yeah, three women on the panel tonight.  I think we all have our strengths as well as our own self-awareness of our vulnerabilities. Having male colleagues as well I find that they're much more able to say, you know what, I'm take a day off to go to the dentist or I'm take a day off to do this and they're able to just kind of go too bad, I'm not going to work today or I need do this. Whereas myself and my other female colleagues do that sense of greater responsibility or I must stay on.

JENNY BROCKIE:  What do you think Arghya?   

ARGHYA:  Yeah, I think there's definitely some gender bias, it is easier for a guy to take a day or just, you know, sort of get out on time and say okay I'm going now. I've found female colleagues do have to justify themselves a bit more.

JENNY BROCKIE:  When it comes to health practitioners at risk, there's this thing called mandatory reporting. What do you all understand that to be?  What is mandatory reporting? 

KARLA:  As I understand it, it's something that's put in place to, to protect society, I guess, when we feel that another practitioner is at risk of not caring for patients safely, where we have a duty to report that. The exact rules I'm not aware of. 

JENNY BROCKIE:  Hannah? 

HANNAH:  So I had never been briefed on mandatory reporting in a staff context, it was purely just, you know, patients come in.  If there's risk for children, family members, that sort of thing then you mandatory report child safety, those kinds of services. But otherwise I'd never been, that's not something we ever go over, never been taught about.  

JENNY BROCKIE:  What about others, what do you understand it to mean? 

JASON:  If a doctor is at significant harm to the general public in their practice or if they're impaired, then you are obliged to report them to the national authority or the state's health board, were that be medical, nursing or another practitioner's board. However, this has been misinterpreted by a lot of health care professionals and students who fear that if they seek help that they'll automatically be reported if they're in a severe state of distress.

JENNY BROCKIE:  Joanna Flynn you're chair of the Medical Board. Describe for me how this system works, the mandatory reporting system and where the lines are in determining these things like impairment? 

JOANNA:  So mandatory reporting is a feature of the national law governing fourteen health professions in Australia and it places an obligation on any other registered health practitioner or employer who has reason to believe, because of what they've observed or learnt of, that another practitioner is placing the public at serious risk of harm. And there are some subsections so from seriously poor performance or unprofessional conduct, from working while intoxicated as a result of drugs or alcohol, or the more challenging one is about impairment. So the practitioner has an impairment, mental or physical impairment, that would place the public at serious risk of harm if they continue to work. So it's a high threshold, it's about serious risk. 

JENNY BROCKIE:  And do you think it's working in a good way, in the interests of the mental health of health practitioners? 

JOANNA:  So I think we can leave the ones about poor performance or sexual misconduct aside, I think they're clearly in the public interest. The issue about whether it's helpful to report people who have an impairment, particularly in this case we're discussing mental health issues, is much more problematic and when we look at why did the practitioner make a report, most of the actual reports that are made about impairment are in a situation where there is some barrier to the practitioner who is the subject of the report actually taking caring of their own health. Either they're so seriously mentally disturbed that they have no insight in what's going on, or they a record of dishonestly and concealment where they may have been taking drugs or doing something else that they're trying to cover up. So they're the main reasons. So mostly…

JENNY BROCKIE:  So you're saying, you're saying there's a high threshold but is that what the junior doctors understand the situation to be in terms of mandatory reporting? 

JOANNA:  We have a great deal of anecdotal evidence that people perceive this as a barrier in seeking care and to the extent…

JENNY BROCKIE:  So if they're in trouble, if they're burning out, if they're feeling suicidal? 

JOANNA:  Yes, and to the extent that it is a barrier to people seeking care then I think that that's a problem. 

JENNY BROCKIE:  What do the rest of you think? 

FEMY:  I think as a medical student I think I would fear it and I asked a lots of my colleagues about it, I asked if anyone knew what gets reported and no one knew what gets reported and what would happen if you get reported. So everyone was more happy to sit on the sideline and saying I'm not going to seek out help just in case I get reported.

JENNY BROCKIE:  So you actually know of people who have had that conversation? 

FEMY:  Yes. 

JENNY BROCKIE:  Who said I won't put my hand up and say I'm struggling? 

FEMY:  Yes. 

JENNY BROCKIE: Because it might backfire on me? 

FEMY:  Yeah, I've think a lot of students choose to talk amongst themselves and we tend to kind of have a community network within ourselves and that's how a lot of the support comes from, it's never from an external source because we're scared that we will get reported to the board. 

JENNY BROCKIE:  Joanna, if a junior doctor is depressed or suicidal and say tells their GP about it, would that GP be obliged to report it? 

JOANNA:  No, not on the basis of those facts.  It would be somebody who was psychotic who was intending to continue going to work in a situation where they were not actually rational, that would make the threshold. Somebody going and telling their GP they're burnt out, anxious or depressed would not meet the threshold. 

JENNY BROCKIE:  So do you think that it's stopping junior doctors from raising their hands about mental health issues? 

JOANNA:  Well I do have to say that historically doctors have not been good at seeking help in any circumstances and that was the case before mandatory reporting and that goes back to some of the wider cultural things that you've referred to. But I think this perception is a major problem. The Medical Boards actually invests $2 million a year in funding specific services for doctors and medical students in every state and territory, doctor self services to help, to triage and refer people who have any level of health concern.  They're confidential services and they very much understand that the thresholds for mandatory reporting's high but again they're not as widely known as they should be.

JENNY BROCKIE:  Bethan, you used to be the head of Basic Physician Training at Royal Prince Alfred Hospital in Sydney. Now you set up a new program to help junior doctors.  What was the catalyst for that? 

BETHAN:  I saw firsthand, you know, similar stories to what we've heard tonight and I saw the impact that that was having both on the physical and psychological wellbeing of the trainees. I'd see the trainees start to become socially isolated from their support structures, see the undue focus on the exams, see the countless hours of study that they were doing, that they felt they had to do on top of their work hours. I'd see them gain weight throughout that training, I'd see the poor sleep habits, the poor nutritional habits so we were visibly seeing the physical impact.  

JENNY BROCKIE:  So what are you doing, what does the program involve? 

BETHAN:  We're doing things like teaching how to debrief properly because it's actually a skill to get good at and we've heard a lot about that tonight. We're teaching people how to manage traumatic or emotionally challenging events and I know in my medical training I probably got one hour on that and yet that's something that we're expected to do on a day to day basis. We're trying to teach them the knowledge and skill of recognising, we've heard tonight as well, the early symptoms of stress and burn out so that you can actually do something about it. 

JENNY BROCKIE:  How could all this be handled better do you think? 

JOVAN: My biggest thing is, what happens at university because we talk about changing a culture and I think it's really hard to do that with older people particularly, but when people are first starting out I think they're most impressionable and then what they learn there they take with them. So I actually take medical students myself and the university that I teach at doesn't have any sort of education about burn out which is really scary.

JENNY BROCKIE:  Charlie? 

CHARLIE:  I think that we need to recognise that this is an important part of the process of going to medical school to coming out as a doctor and going on to being a specialist, that there is a process that you need to do to understand your expectations and limitations and to be able to cope with the things that happen in medicine. It is tough, it is unforgiving and, you know, it is impossible to go through medicine without making a decision that's going to lead to somebody dying or it's just the way it happens. You can't be right all the time and you have to be able to rationalise that and be fair to yourself and carry on. You've got so much to offer that to be devastated by that, I think is, says something bad about our way of teaching. 

JENNY BROCKIE:  Karla, what do you think could be handled better?

KARLA:  First of all for every young doctor, medical student and registrar and advanced training and consultant not just to try to be a good doctor but to try to be a happy doctor as well and just to reflect on what that means for you. I think as a profession we're not very good at balancing our lives with work. So I think looking in and making that a priority for yourself, number one. And secondly, discuss it with your juniors, discuss wellbeing, discuss fatigue, discuss how you manage your own difficulties because if we do that more we'll start more discussions about and sharing what our experiences are and just realising they are common and they are part of the process. But I think it will help people not feel isolated. 

JENNY BROCKIE:  Hannah, what about for nurses? 

HANNAH:  I think for, especially with the experiences that I've had, having like a bit more of a supportive environment to let people learn resilience because that's something that you can't really teach.  Like you can teach the principles of resilience but you can't make someone come out of university like ready to handle everything.

JENNY BROCKIE:  You haven't chosen yet your speciality Femy, have you? What do you think about? 

FEMY:  I'm thinking of critical care to be honest. 

CHARLIE:  Excellent. 

FEMY:  But yeah…

JENNY BROCKIE:  It's high stress?  

FEMY:  It's high stress. I think I've come to realise the most important thing of being a doctor is being a healthy person. You can't function to look after other people if you don't know how to take care of yourself. So after my third year I've made an active choice every day to exercise, to do something outside of medicine because I know that's the only way I can actually be human is just to accept the fact that I won't cope otherwise and becoming that person took months and months of effort and focus but I feel now I'm a lot more prepared than I was two years ago to deal with what was in front of me. 

JENNY BROCKIE:  Why do you still do it?  Why do you all do it? 

FEMY:  I think for me there's no place in the world I'm so sure of who I am than I'm in a hospital. Like every hospital, whether it's in the middle of nowhere or in the city, walking in that door just makes me so much happier than I'm out anywhere else and I just know exactly who I am and what I'm meant to do on that day, so it just gives me purpose of keep doing it. 

JENNY BROCKIE:  Hannah, give me an example of why you want to be a psych nurse and stay a psych nurse? 

HANNAH:  It's probably the first place that I felt like it was meant to be, which sounds really cheesy but yeah, I had one man that reminded me a lot of my dad so I had a bit of a soft spot for him and you know, in one twenty minute conversation we managed to uncover all of his plans and intents for the multiple different ways that he was going to suicide that he hadn't told anyone yet and that he had concealed from the treating team and the doctors, and we were able to then take that and address it and he was discharged within four days of that with some really intense therapy and I've been able to see him since then when he's come in for check-ups and he's doing fantastic.  And it's things like that where you go oh, that was really cool. So yeah, that's just, it gives you that sense of purpose and like you're really making a big difference for people. 

JENNY BROCKIE:   Jovan, what about you? Why are you doing it?

JOVAN: On my particular area, when you anaesthetise a patient they're handing everything over to you and they're very vulnerable and I really take that so seriously and it's such a privilege to be able to tell them I'm going to take great care of them and make sure they wake up the same way that they went to sleep or better.

JENNY BROCKIE:  Karla, why are you still in there? 

KARLA:  I think it is, it was a calling for me. I, it's such a privilege, I agree, just to, to be part of such significant times in people's lives, to be able to relieve suffering, to be part of the healing and when there's no solution to their disease, to be able to make sure they're comfortable, to make sure families are informed and they feel like everything's been done.  I think we're really lucky to live in a country like this where medicine is accessible for pretty much all of society, I guess with exceptions but I just see it as a massive privilege and I think it's a really beautiful profession. 

JENNY BROCKIE:  Great note to end on. Thank you all so much for joining us tonight and for sharing your stories, I know it hasn't been easy for some of you so we really do appreciate it and that is all we have time for here but let's keep talking on Twitter and on Facebook. Thank so much everyone, thank you.