Do doctors have post-traumatic stress from their training?

I woke early this morning, thinking about an article written by a young female surgeon (1) I had read recently, and I could not go back to sleep. I had first read the article a few days previously, after circling around it in a most uncharacteristic way for a few days. It really disturbed me on first reading and has stayed with me ever since. This morning I realised that the disturbance was due to all the uncomfortable feelings and memories the article brought up about my own days as a junior doctor … which I had been trying to suppress … and this has me wondering: do all doctors have post-traumatic stress from their training?

Medicine is a very stressful career, and we are exposed to a great deal of shock and trauma during the course of it. Unless we are completely impervious to human misery and suffering, or completely able to lovingly detach and take none of it on, many if not all of us take some of this trauma on, and it can cause stress in our minds, bodies and beings.

It may be too much of a leap for some to say that all doctors have experienced PTSD, which is a specific syndrome, but I certainly feel that I did in my younger days and I know I am not alone in this.

What is post-traumatic stress disorder (PTSD)?

Post-traumatic stress disorder (PTSD) is a particular set of reactions that can develop in people who have been through a traumatic event which threatened their life or safety, or that of others around them. This could be a car or other serious accident, physical or sexual assault, war or torture, or disasters such as bushfires or floods. As a result, the person experiences feelings of intense fear, helplessness or horror. (2)

People with PTSD often experience feelings of panic or extreme fear, similar to the fear they felt during the traumatic event. A person with PTSD experiences four main types of difficulties:

Re-living the traumatic event – The person relives the event through unwanted and recurring memories, often in the form of vivid images and nightmares. There may be intense emotional or physical reactions, such as sweating, heart palpitations or panic when reminded of the event.
Being overly alert or wound up – The person experiences sleeping difficulties, irritability and lack of concentration, becoming easily startled and constantly on the lookout for signs of danger.
Avoiding reminders of the event – The person deliberately avoids activities, places, people, thoughts or feelings associated with the event because they bring back painful memories.
Feeling emotionally numb – The person loses interest in day-to-day activities, feels cut off and detached from friends and family, or feels emotionally flat and numb. (2)

It’s not unusual for people with PTSD to experience other mental health problems at the same time. These additional problems, most commonly depression, anxiety, and alcohol or drug use, are more likely to occur if PTSD has persisted for a long time. (2)

I know that for myself, I experienced all of these difficulties during the early years of my training, and it is only recently that I have been able to sleep more easily whilst on call and even now, I am still more anxious and startle when the phone rings during that on-call week.

Medicine is such a wonderful career, but it can be very intense, from day one of our training. We are placed in confronting situations with little support to ‘toughen us up’, ‘make us resilient’, see if we ‘have what it takes’ and are fit to do the job … but this treatment can be incredibly stressful. Does it truly make us better doctors? And what does it do to us as people?

We are told that to be great doctors, we have to work long hours to get the experience we need and to be willing to work day and night, and sacrifice everything else in life, if that is what is called for. Old school doctors decry the ‘softness’ of their younger colleagues, who want sleep, time off and a life like ‘normal’ people. Why is this so wrong?

The vulnerability of unaccredited trainees

The article I read (1) was written by a young female doctor who was working as an unaccredited surgical registrar in a Sydney hospital, a position which is not protected by the relevant surgical college. Her working conditions were brutal and they took their toll, resulting in her working largely unsupported until she became exhausted, burnt out and finally quit the job, even though she knew that by so doing she would never get another job in the speciality she loved. This is an indictment of our profession and a great waste of a career. Thankfully she left before it became yet another tragic loss of a young doctor’s life.

Unaccredited registrars and other young trainee doctors are in a very vulnerable position. Their career progression is dependent on the goodwill of their superiors and no matter what hours they are technically rostered to work, or what medical administration says they should or should not work, they have to do what they are asked to do by their seniors, if they want to keep working in that field.

This can lead to them regularly working unpaid overtime, coming in early, staying back late after they are rostered off, and generally going the extra mile like this young woman did, to prove their commitment to the job.

Take what we give you to show you have what it takes

Not only do our trainees have to work exceedingly hard, which is actually abuse of one kind, they sometimes have to put up with more flagrant abuse.

Especially as a young female surgeon, you may have to put up with being ‘put up with’, as many surgeons would frankly prefer to work with male trainees, and you generally have to be ‘better than the boys’ to gain any respect. Women are treated differently, being subjected to snide remarks, innuendo, sexualised comments and sometimes frank propositions and even physical and sexual abuse (3). If they stand up to it or speak out about it, they are blacklisted and their careers affected, as was the case with a neurosurgical trainee in Australia. (4)

Will the tide ever turn?

There has been a lot of talk lately about changing the culture of medicine, and especially the abusive culture of surgery, but is it all lip service to placate our concerns with no real impulse for true change?

It is distressing to read stories such as these and to hear of yet more young doctors committing suicide, often when they cannot take the pressures of the job any more. (5)

And these terrible stories are but the tip of the iceberg … many doctors are living lives of “quiet desperation” as the song says, (6) just getting through each day, getting by in life, and not living with the true joy and vitality that is everyone’s birthright.

Many of us are still suffering from the effects of our training … beaten down by years of being put down, abused, expected to work beyond what is humanly possible, never being good enough, eternally in fear of making a mistake or failing an exam … endlessly replaying in our minds scenarios where we have been less than perfect … traumatised by care-less comments or active abuse from our superiors … devastated when we did not get into training programmes we had our heart set on … heartbroken when a patient we have cared for dies … stunned and shocked by the endless waves of human misery and suffering we are confronted with on a daily basis … there are so many ways in which young doctors can be stressed, and there are few to no systems in place to deal with these stresses.

Medicine is a stressful career, and our early training in particular is extremely stressful, when we are not yet competent, confident and established in the practice of our art and our careers. Our young doctors deserve all the support in the world … they are wonderful human beings who desperately want to become good doctors so they can support their patients to recover from illness, disease and the other stresses of life … and should they stumble and fall along the way, they too need a helping hand. Doctors have very self-critical personalities as a rule … we already give ourselves a hard time if we are less than perfect and we don’t need the belief that we are not good enough to be cemented in by our supervisors.

Currently, the inherent stresses of being a doctor are compounded by inhumane working conditions, unrealistic expectations, physical, mental, emotional and occasionally sexual abuse, and lack of support when things go wrong, as they inevitably do. Individual doctors are scapegoated to avoid dealing with the shortcomings of the medical system which are the real core of the problem … no wonder we have post-traumatic stress!

What is the treatment of post-traumatic stress?

Let’s say that doctors do experience post-traumatic stress – what is the recommended treatment?

In general, many people experience symptoms of PTSD in the first couple of weeks after a traumatic event, but most recover on their own or with the help of family and friends. It is important during those first few days and weeks to get whatever help is needed. Support from family and friends is very important for most people. Trying, as far as possible, to minimise other stressful life experiences allows the person to focus more on his/her recovery. If a person feels very distressed at any time after a traumatic event, he/she should talk to a doctor or other health professional. They may recommend starting treatment for PTSD, which in general consists of psychological treatment (talking therapy) and medication if needed. (2)

It is clear that this support is not available to young doctors. There are currently no avenues that allow us time to debrief if we have experienced a traumatic event, to take time off if we are stressed, to spend much needed time with family and friends to recover from the trauma we have experienced. We are expected to just get on with working in an inherently stressful environment and traumatic experiences are stacked one on top of another, with no space for true healing.

We need and deserve a medical system that cares for everyone; that regards the care of our doctors and other staff as equally important as the care of our patients. We need a system that supports our trainees, that mentors and looks out for them and offers them realistic working conditions, as would be afforded any other professional person, so that they are adequately fed, watered and rested, as a bare minimum, and able to care for themselves, each other and all their patients. If in the exercise of their duty of care they become traumatised or stressed, they need even more support. And we need to weed out all forms of abuse, both the overt abuse that can be experienced from other doctors and staff and from patients, and the covert abuse of a system that demands the impossible of us.

A true health care system cares for all of us, including our young doctors.

References:

This article was first published on 25 February 2019 on To Medicine with Love

Anne Malatt on Life

Medicine, Religion, Philosophy & Science