Transcript

MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast about the culture of medicine. I’m Mic Cavazzini for the Royal Australasian College of Physicians. We’ve known for decade that around half of Australian and kiwi doctors meet the criteria for burnout, and the figure is around 70 percent among trainees.

Back in episode 82, Melbourne surgeon and academic, Eric Levi explained how this sense of emotional exhaustion, depersonalisation and loss of purpose should be considered an occupational hazard rather than a mental disorder. Nevertheless, burnout is often accompanied by clinical depression and Australian doctors have thoughts of suicide at twice the rate of other professionals. 

Over the last decade there has been greater attention on wellbeing of healthcare staff but organisations have been left to come up with their own solutions. The result is that many just end up offering interventions like guided yoga or meditation, which are really just band aids for the symptoms of a broken system.

The New Zealand Health Department, Te Whatu Ora, has recognised that unforgiving work conditions pose a problem for both recruitment and retention of staff to the health workforce. It’s forecast that within ten years supply of doctors, pharmacists and nurses will fall short of demand by 14 to 18 percent. In response a national Health Charter has been established which states the values and standards that organisations are expected to demonstrate to keep staff safe and engaged.

Australia is one step behind, but in early September I attended a leadership conference aimed at developing a similar national workforce wellbeing strategy. The forum was hosted by Beamtree, a data consultancy that manages Health Roundtable. If you’re not familiar with it, Health Roundtable helps services collect and compare metrics on patient flow, readmissions, hospital acquired complications and so on.

Beamtree is bringing the same systematic record-keeping to physician wellbeing and they invited Professor Tait Shanafelt to give a keynote presentation on his research in this field. He spent many years with Mayo Clinic developing not just the metrics but also the organisational responses to addressing physician burnout which clearly distinguish the influence of personal resilience, professional culture and basic administrative headaches. Professor Shanafelt is now employed as the Chief Wellness Officer for Stanford Health and coaches clinical leaders from around the world. I spoke to several attendees at the conference who are driving change in different Australasian health jurisdictions, and I began by asking them to share a fact or experience that had galvanised their commitment to this project.

GEORGE ESKANDER:       Hi, I'm Dr George Eskander. I am the North Metropolitan Health Service Group Chief Medical Officer and Director of Clinical Services. We are at a quaternary hospital-based group in WA and I got into this space because we had to. We had a very severe doctor shortage, and on talking to our doctors, they told us that they're exhausted, they're burnt out, they were done. And so, by default, here we are really well in our journey. And it's been such a wonderful journey.

MIC CAVAZZINI:                Bethan?

BETHAN RICHARDS: Hi, my name is Dr Bethan Richards. I’m the Chief Medical Wellness officer at Sydney Local Health District. I'm a rheumatologist by training and the Deputy Director for the Institute for musculoskeletal health. I got into this space, seeing the increasing levels of distress in colleagues and trainees that I was looking. So we had four basic physician suicides in a four month period back in 2017. That really got a powerful conversation started and people were more prepared to listen and to throw some funding at pilot projects to address it.

MIC CAVAZZINI:                                Tragic. Joanna, who are you and what are you doing here?

JOANNA SINCLAIR:          My name is Dr Jo Sinclair, I'm an anaesthetist at Counties Manukau in Auckland, and I'm also currently the Interim National Lead for Employee Wellbeing with Te Whatu Ora Health New Zealand. So I'm currently in a national role, but it's very much at the beginning of a journey. I got into this area, and very interested in doctors’ health, through becoming aware of some alarming statistics in my own profession of anaesthesia, particularly around substance abuse and suicide. And I felt that that was not right, that we ended up after investing so much of ourselves in training and healthcare, that we ended up in a situation where we were kind of feeling driven to those kinds of things.

MIC CAVAZZINI:                And finally, our host Victoria.

VICTORIA HIRST:              Hi, I'm Victoria Hirst, Chief of Knowledge Networks at Beamtree and General Manager of Health Roundtable. I'm a social scientist by background but I'm in a really privileged position in that Health Roundtable has over 200 hospitals across Australia and New Zealand who are members who come together to share their data and benchmark activity. So we're really excited to be able to start to develop a dataset for clinician wellbeing across Australia and New Zealand and benchmark those activities and hopefully use it as an evaluation tool to see what's working.

MIC CAVAZZINI:                Thankyou, all for making the time. So the keynote speaker at today’s meeting was Professor Tait Shanafelt of Stanford Health. I’m going to use his model as a framework for this conversation but I really want to elicit some real life examples from your roles. In one very comprehensive explainer in the journal Academic Medicine from 2019 Professor Shanafelt has this pie chart of about 20 different stressors in the workplace, that are then clustered into different domains of responsibility. So, excessive work hours, inflexibility in rostering, and the demands of on-call are sometimes just seen as part of the job. But when it comes down to it, they’re really just administrative problems. George, tell us about the about the situation you found when you took over in your role in Perth?

GEORGE ESKANDER:       Yeah, thank you, Mic. And Tait really touched on some really, really important concepts that we were aware of but weren't quite so aware that it was such a national phenomenon. So, in March last year we found ourselves 92 doctors short on a 600 doctor roster, so we were majorly short. We were spending $5 million a year on locums and that cost was just exponentially increasing. And we found that our productivity levels were going down. People were done, they wanted to leave as quick as they could. They were burnt out, they were exhausted. And so, we knew something had to give, we knew that something had to be different to what it was and how we've done things in the past. And we're really blessed in WA, we have the AMA who are really vocal in the space. And they publish amazing reports where they survey our doctors and they tell us exactly what they think. And when you look at our scorecard for that year, we scored the straight F almost everything.

So had this conversation. We simply asked them, “What is it we need to do? How can we be different”. And the answers that came back were just astoundingly simple. “We want part time. We want to get paid overtime. We want leave like everyone else. We want to feel safe at work. We don't want to be bullied at work. We want you to feel valued. And we want to not have to deal with your admin because your teams can't do the admin.” And so from all of that we gave birth to what we’re calling the North Metro JMO Manifesto, which is our public pledge, our charter to our doctors. What are we going to do that's different. And the results of that have been incredible.

So, nine months since inception, we're now into September, we went live in January, we are now fully staffed. A hundred percent fully recruited with nil vacancies. And on top of that; leave relief. Which means that every single doctor now gets a leave plan. When you join our health service it's a contract that we give you that you must take your leave as a condition of your wellness. So every single doctor now gets a leave approved within five days with a more than 94 percent hit rate. Because this generation an online generation we created an online process with a heat map so you can pick your leave. And so long as it wasn't black, which was exam dates or Christmas, leave got automatically approved.

We created a single online, centralized, streamlined overtime process where your overtime comes in electronically, you do it in the safety of your space, you don't feel that you have to be psychologically threatened begging your senior doctor to sign your form, who might who might affect your training down the track. And so long as it fulfills a number of parameters then it gets approved instantly.

MIC CAVAZZINI:                Another thing that Tait Shanafelt said was that to make the business case to your administrators for this kind of change, it might be a financial business case—and you've said you're spending $5 million dollars on locums and administration as well. But there’s also a moral business case, a moral argument. The idea that there’s psychological harm in the nature of the work itself from seeing people suffer, and then what’s been called “moral injury” when you’re unable to help them. Organisations needs to try and mitigate such harms, but instead we have this slippery slope where the more shortstaffed they are the more moral injury is caused because of lack of resourcing, and the more people get burnt out. Joanna tell us what you have done within your systems to build a sense of community and moral support.

JOANNA SINCLAIR:          In my own organization, so I've been a Clinician Wellbeing lead at Counties Manukau for just over three years. And we were able in 2020, to bring in Schwartz Rounds, which is probably the initiative I'm most proud of bringing into Counties. So Schwartz Rounds come to us via the Schwartz Center for Compassion in Healthcare and that's really what they're about. The important points about them are that they are for all staff. So unlike some of the other rounds that we have Grand Rounds and things like that, which are primarily for clinicians, particularly doctors, I guess, Schwartz Rounds are for everyone. So it really is an opportunity for us to share the impact of working in healthcare with each other and be a bit more open and vulnerable about that.

But it's also an opportunity to kind of look up and out from your own little area of distress. We tend to get quite introverted when we're in deep distress and that's sort of where we all were. And it's an opportunity to start to see other parts of the hospital, the workforce that you don't necessarily think about and understand, actually how they are also impacted from by healthcare by working in healthcare. So, an example being one of our interpreters spoke to the impact of being the person that's actually uttering the words, the bad news, to the person and that they don't get thought of in terms of any kind of debriefing afterwards. Same with the security guards who get called into ED to help with CPR, but nobody explains to them what's going on or follows up with them afterwards. They're not thought about and in that debriefing process so. So yeah, I think that's been really helpful in terms of breaking down some of the silos, creating connection, helping people understand that it's not just their little area, that's having trouble. We're all kind of in this together.

MIC CAVAZZINI:                And for people that are interested in that we did a story on Schwartz rounds back in episode 38 when they were being piloted at Auckland. Another cluster of stressors that Professor Shanafelt identifies include things like role ambiguity and competition with other staff. Again, maybe in the past, this was seen as part of the sink or swim culture of medicine. But these days, it's often read as a sign of poor clinical leadership. Bethan you lead the rheumatology department at RPA. How do you identify and resolve these kinds of friction points between staff?

BETHAN RICHARDS:        So I think identifying it is, you know, as a leader, making sure you're providing time to listen. And not just to listen, to actually hear what your staff are telling you. And there's various ways you do that at a work unit level. So, as a Head of Department, having forums for that whether it's in the context of a business meeting, or whether it's a one on one chat. That's a really important litmus test to see what the temperature on the ground is and what the real underlying drivers of potential distress or conflict are that's occurring. I think when there is job role non-clarity, getting to the bottom of that really quickly, and having clear position descriptions, discussion around whose role, whose accountability, is a really important part of that leadership process. And empowering the managers and the others within your units to have similar conversation. So, I think not feeling as a leader that you have to do this alone.

MIC CAVAZZINI:                It was in 2019 that you became the first Chief Wellness Officer appointed to an Australian health district after training with the Stanford WellMD program. But before that you’d already piloted support programs first for trainees then all doctors across the Sydney Local Health District. To get that off the ground what did it take, for others that want to emulate what you’ve set up?

BETHAN RICHARDS:        Yeah, really great question and something I get asked over and over again. You know, when I look back, timing is everything in many ways and we had a political context and climate at that stage that really put a lens on the wellbeing of junior medical staff. We happened to be well-positioned to obtain some of that funding and very much as a grief reaction, processing that with the trainees, we put together a pilot that we called BPTOK. I think when that went very well, the next pressure was well, how do you take operationalizing a wellbeing program for 60 doctors and do it for all junior doctors across one hospital and then all senior doctors. We learned very quickly that a big influencer of junior medical staff wellbeing was actually senior staff wellbeing. And so it was a pressure sort of deliver program for 3000 people very quickly.

So that's when I went over to Stanford to look at what was the rest of the world doing in this space, there were no other prototypes in Australia at that time to follow. And there was the Chief Wellness Officers course, that really helped provide a framework for how to have that conversation, how to create the business case for this, how to obtain the data, what are the right metrics, what is the language you use to try and engage and educate administration at that stage in funding one of these positions so that you could have dedicated time to look at it.

You know, like most of wellbeing champions at the moment, it's a bit of a side job, they're doing it through passion, they're seeing something. And if you want to do this at scale, for big organizations, you need dedicated time, you need a team of people to do this. And you need to be empowered within the organizational governance structure. And you can't do that unless you've got the engagement of your administration. So we were really lucky, we did have engagement in the topic early on, and then we got financial backing to come back and to take a risk in an area that that was a bit of an unknown.

MIC CAVAZZINI:                I’ll feed that back to Jo, given that you're in a similar role, and we heard about a bit about this this afternoon. Why does that Chief Wellness Officer need to be a clinician? If you want to talk about the mistakes that have been made with previous models.

JOANNA SINCLAIR:          Sure. I think at a lot of the wellbeing outputs in a lot of healthcare organizations come from People and Culture, Organizational Development, HR, that kind of space, Health and Safety maybe as well. And they are, well-meaning, they are from people that have some understanding of things, but they don't necessarily have any understanding of the peculiarities of the clinical side of working in healthcare, in the peculiar way that healthcare workers tick sometimes. And then when clinicians have got all these things that they consider way more important in terms of impacting how they feel about their jobs, to be offered a mindfulness session just feels like it's not even going to touch the sides of things. So it's not that there's not clinicians that are really interested in it, it's just that they put them on at 10 o'clock in the morning, when no clinician can either go to them, or they don't fit in with the way clinicians work, and so they're not accessible to them, even if they did want them.

And I think when you bring clinicians into that role they bring with them their deep understanding of what it's like to work the night shift; how fatiguing a shift can be; even if you're just working the normal daytime shift doesn't mean it's not a fatiguing shift; what it's like to care for people all day, every day in the worst days of their lives; to see people die. You know, all these kinds of things that have really deep impacts on us and peculiar things that we experience that you just can't understand.

And then there's also, the culture in medicine that's embedded itself over centuries, I guess, that has put us in this situation where we've still got older consultants saying, “This is the way we've always done it. Back in my day, I did it much harder than you. What are you complaining about? Yes, you need to come in for an evening ward round presents when I'm back.” Yeah, all those kinds of messaging that should have gone out with the ark but it's still around. And I think people that have come into a health care HR space from businesses outside of the health sector, it blows their mind that we are dealing with some of these really old ideas.

And so yeah, I think it's that the people working in those kind of organizational development roles have a particular set of skills that I don't have. So they complement all the things that I want to do, make anything any initiatives I want to run out so much better than they would have been just with me. And I bring that understanding of, of what clinicians want, what might land better with them, how to bring things to them in a way that they can access them and that kind of thing. So I think it's a nice collaboration but you definitely need that clinician voice in that decision making space.

GEORGE ESKANDER:       I think you raise a really interesting point there. This idea that in the past we have focused on the personal response to feeling stressed at work or to feeling burnt out. But it was the wrong solution to a very complex problem. So to give a practical example, we know from talking to our doctors, they feel incredibly stressed on a night shift whenever doctors don't turn up to work because they're sick. Because post-COVID people now realize they can't come to work sick which is a wonderful change in culture. But it changes the way that we run hospitals. And for us being a really complex service provider, they were particularly struggling with doing procedural things after hours with a lack of support. And so, we knew we had to address that. What they wanted from that was a system where we could bring in additional support urgently without them doing it, because they're all alone by themselves. They need the admin support to help enable additional doctors to come in or other nurses or other professionals. And then wanted a review of the policies that we put in place that looking back now are quite archaic. Things about routine care happening after hours at night when we're most dangerously staffed. And so that's a practical example of changing the workplace to make it less stressful, and to make you feel more supported. And whilst yoga is a wonderful thing, yoga will never address those stresses that you get when you're all by yourself, and you're it.

MIC CAVAZZINI:                I don't know if we've got time to—well, tell me if you think these are worth going into otherwise I'll just summarize them in the narration. We saw some data today about how life-work cohesion is very poor amongst clinicians. And you need to give meaning to the work and communicate the values of the organization. And similarly, feeling voiceless and powerless is another thing he describes as a real stressor. I mean, do any of you have experience with those kinds of meetings that he described at the end there, where you hear out what's going on?

BETHAN RICHARDS:        So in terms of interventions and where to start, when you've got a burnt out, angry, distressed workforce, what the data tells us and what our experience showed us was the number one thing you can try and do right up front is make them feel heard. For our junior doctors we held a forum. And we had our most senior person, we had our chief exec and then a senior clinician, myself at that time. Pay them to come after hours. And we asked them one question, a solution-based approach, which was, “if you could do one thing right now to improve your workplace or training, what would that be?” And that was an incredibly constructive way, I think, to allow that vent and anger which was certainly there and just to have it heard, in their mind, by someone very senior in the organization. And then to try and take that and shift the conversation to a proactive solution base.

And what we were able to do was put a structure within the governance channels of the organization in place to ensure that they continued to have a voice. So that's how we set up our what we call the CE Doctors in Training wellbeing committee. And it met every month the CE was there, I was there, and we had representatives from all the junior medical workforce. And it allowed the ideas, new frustrations to come up, to be aired and for solutions to come about. And so that was a really simple powerful way to take a positive step.

GEORGE ESKANDER:       I think one thing it'd be really good to mention or to make clear is that we always talk of resources as a limiting factor. But lots of these initiatives can be rolled out almost free. It actually takes courage. It takes the ability to set a direction and a vision that something has to change. And then empowering teams to create their solutions themselves. A lot of it is common sense. And don't let resource slow you down.

MIC CAVAZZINI:                Without thinking of it as too much of a stick, there are already laws in some states around workplace safety. Just in December 2022 Western Australia amended its Work Health and Safety Act such that the employers are now required to minimise psychosocial risk “so far as is reasonably practicable. This new duty places psychosocial hazards on the same footing as other significant hazards such as falls or operating machinery.” And this change was prompted in large part by reports of sexual harassment in the mining industry. I guess it means employers can be sued if they don’t live up to that standard. George, could you imagine those laws being used in anger by burnt out staff, or is it the wrong tool?

GEORGE ESKANDER:       Well, look, anything's possible in this line of work, I would never say never.

MIC CAVAZZINI:                Is it appropriate, I mean? Or do we wait for an accreditation standard kind of thing?

GEORGE ESKANDER:       No, I wouldn't think—I think legislative change is the wrong tool to drive change. I think for us, it's the innate desire to want to change that has to come from within. And we need to engage every part of all these very complex organizations, but perhaps, crucially, the executive leadership team. They need to be fully on board of why this is so important, and then as Bethan says, to properly resource it. And if you do it properly, then it becomes an iterative conversation where we hold each other to account with respect in a very proper and appropriate dialogue. And for us, one of the most important things we did, was to place the junior medical body onto our executive. They have a direct decision-making capacity into the heart of our organisation along with senior consultants, who also sit on our exec. And so then why the legislative part is the wrong part, is because the floor is too low for it. It's going after egregious offenses, whereas we actually should be tackling the small local issues that bother people every single day. And we continually work on changing that workplace to make it safer.

MIC CAVAZZINI:                Okay, we've talked about the business case for taking wellbeing seriously creating these Wellness officer roles. And for this business case to stack up in the long term, you do need some metrics. And that's mentioned in the Beamtree discussion paper as well, Victoria, that, “Accountability for wellbeing should be built into existing systems such as key performance indicators and board reports.” I mean, the example that George started with might be an easy one to start with. When you're talking about hiring practices, I guess you've got easy access to measures like staff turnover and sick leave. Are there any other any others that we've missed?

BETHAN RICHARDS:        So I think simple things like ADOs taken—or Allocated Days Off— in New South Wales award. Is your leave taken? I think thinking about the metrics in terms of the model that Professor Shanafelt presented, what are the individual level metrics we should be looking at? And so we can look at that in quite granular detail. But then what are the organizational metrics, as well. So I think that's the power of data is, you've got your CE that'll come to you when you're asking for more resources to say, you know, “Show me the data that we're making a difference. Why should I give you more money?”

You know in Sydney Local Health District we've got three years of data and what we've been able to show, even in very early stages of rolling out the wellbeing program is that we're seeing increasing engagement of our doctors with having a GP. So we saw that as an issue as a really easy, clear outcome to try and make a difference on that we did a pocket of work in. We had very low engagement of medical staff with our employee assistance program. And so we've done a big piece of work with them around trying to shift the culture on that. And we've been able to show sort of a 450 percent increase in in EAP interactions.

And in last year's survey, for the first time, we've been able to show that increasing number of interactions with the MDOK program is associated with reduced levels of burnout, reduced levels of distress, increasing levels of self-compassion, and increasing levels of resilience. So they're just some of the early things, we have also seen improvement in quality and safety metrics. I’m very reticent to say that that's just because of the wellbeing program, we've done a lot of other quality improvement work. But we the evidence out there shows that high levels of burnout correlate with higher levels of medical errors [e.g. the inquiry into patient deaths at the NHS mid-Staffordshire Trust revealing that unsafe care was linked to a burnt out workforce].

MIC CAVAZZINI: Some of those data can be ported straight from the HR department, from the EMR or other databases. But to get a more nuanced reading of psychological wellbeing of staff requires validated survey tools. Victoria can you describe the Wellbeing Index? Is that something created within Beamtree or was that licensed from Professor Shanafelt’s team?

VICTORIA HIRST:              So the Wellbeing Index was created by Professor Shanafelt as part of a team at the Mayo Clinic. The tool measures the level of distress in a health worker across a spectrum that goes from “distressed” to “performing well.” It looks at meaningfulness in work, suicidality. Essentially, it's a seven question questionnaire that's done once a month. And we now have enough data in that tool to have created Australia and New Zealand national norms for a range of disciplines within the healthcare sector. For example, we could look at an emergency department in X hospital if we know that they've implemented a particular intervention.

MIC CAVAZZINI:                And Beamtree curates this database so that any participant of Health Roundtable can compare to that?

VICTORIA HIRST:              So the tool is offered by Beamtree through the Health Roundtable Workforce Wellbeing program, but also as a tool that people who aren't members of Health Roundtable can also access.

MIC CAVAZZINI:                Jo, how easy is it to get staff to complete a wellbeing survey every month.

JOANNA SINCLAIR:          Yeah, I mean, everyone's really busy, there's surveys coming out left, right and centre, so I'm very wary of survey fatigue. And so I'm sort of mindful of that when I when I push things out myself, but the app itself will send reminders every month. I think one of the key things about it is having those clinical champions to help with the rollout and help encourage their colleagues to use it. People from your own workforce speaking to the utility of it for them. It's definitely helpful in terms of a tool for self-reflection. You get to see your own data over time, so you can kind of like—when I first started doing, I noticed that it kept dipping down at the end of the year. And so it's an opportunity to sort of reflect on that, it was end of year evaluation of myself was very hard each year, and needed a holiday as well. And, then there's all the resources on there as well which some people are finding really helpful not just for themselves, but having conversations with other people that they speak to in a peer support kind of role. If they express some distress, there's some things at their fingertips that they can offer up to the colleague.

MIC CAVAZZINI:                 As we’ve heard, the National Workforce Wellbeing Strategy proposed by the participants of Health Roundtable advocates for every provider to have a wellness lead within its executive. And collection of validated metrics of wellbeing is essential for an evidence-based response. Another item on the wish list compiled from previous meetings was that there be a national taskforce at the level of the health department to drive this essential agenda. And finally an accreditation system for workplaces that meet the reporting standards and are able guarantee that staff wellbeing is a top priority.

This is just an idea for the time being bit it’s not unrealistic. Medical Colleges already grant accreditation to hospitals they deem capable of taking on and educating trainees. The standards specify that trainees be orientated properly to different settings and be given work of appropriate complexity and volume. There’s also guidance on how to provide them with suitable supervision and feedback. But there’s a lot less detail on required standards for wellbeing of trainees, beyond vague appeals that there the workplace have policies on this topic, and that staff have access to resources like debriefing and counselling.

We know that burnout occurs at significantly higher rates in doctors under forty than it does in those more established in their careers. That’s not surprising given the burdens and insecurities associated with the early years; long hours, high-stakes exams, imposter syndrome and the fear of making mistakes. Junior doctors are also trying to find their feet in new workplaces, as well as within a College that holds the keys for their professional progression. To understand how the responsibility to trainees is shared between these organisations I spoke to Professor Jenny Martin and Associate Professor Anne Powell.

JENNIFER MARTIN:         I'm Jennifer Martin. I'm a clinical pharmacologist and a general physician in Newcastle. And I'm President-Elect of the Royal Australasian College of Physicians.

ANNE POWELL:                 And I'm Anne Powell. I'm the Director of Physician Education at Alfred health in Melbourne. And I've had a long history of teaching doctors in training.

MIC CAVAZZINI:                So I already talked with some of the other leaders at this forum about workforce capacity issues for health. It's not just about recruitment but also retention. What do we know about the peak stress period in a doctor's career as measured by dropout rates, let's say?

ANNE POWELL: So I'm not sure that dropout rates are the best way of measuring distress or issues in medicine, per se. If you look at the burnout rates in medical school, medical graduates, when they first join, are some of the least burnt out compared to other students in other areas. But by the time they finish medicine that's actually increased. And then an exponentially increases over the first year of being a doctor during an internship with other peaks going through as they do their training. So I would not choose dropout as being the major marker, although we all know that about 10 percent of all doctors in any year would like to leave medicine.

JENNIFER MARTIN:         Yeah, I’d like to echo Anne's point about the dropouts, I mean, we have a lot of presenteeism. So they are burnt up doctors that are coming to work. They're often grumpy, they're not performing at their best. They're not engaging in department activities. They're not doing teaching. They're angry with the university or whoever's making them do extra work even though when you actually ask them, they say, “I love to teach, I wish I could do more”. So they’re people that I think have a lot of energy and resilience but are pretty unwell. And I don't have the numbers on that, but I suspect it's quite a large part of the workforce.

And I think coming back to what are the stressful times. I guess, we do know a lot about our trainees, going through our specialty training program that people are worried about taking a week off because every week counts to getting signed off. And I think if they're feeling tired and burnt out they're just looking to the end and trying to keep their head down and make sure that they make it over the line without having any issues that are picked up by a supervisor, and often won't actually tell their supervisors or people they work with that they're struggling. And it’s difficult with the basic physician trainees as well, because they're sometimes trying to get onto really competitive schemes. So they're working really long hours doing extra projects and things so they look good, and will be selected for one of these highly sought after programs. And really, I'm looking at them thinking, “I can see what you're trying to do and I support it, but I don't I don't think this is good either for the workforce or for the people that were actually giving healthcare to.”

MIC CAVAZZINI:                And actually, Anne, your recent paper in the MJA  maybe shows the impact that burnout has on the quality of training itself, the quality of education. Tell me what you were looking into there?

ANNE POWELL: Look, I suppose my article was really to explain why— because over the years of teaching I'd actually seen that so many of our trainees were struggling with a system that didn't seem to be changing or altering. And I realized that it was important to—as a clinician educator— to start to look at it from a research lens so that we could put in some interventions for change, that was really the aim of the article. When I've raised it there was a lot of negativity in our executive to use terms like burnout, and that was really what my reflective piece was about. Because I think                     sometimes people think that burnout is a negative term, and therefore they don't want to look at it, because they think negativity breeds negativity.

I suppose I like to think of it more as just a system measurement. It's recognized by the World Health Organization. It puts the onus on the organization, not on the individual. We know that all of our doctors in training have very high levels of resilience. This is a system-based error that we're measuring, and I suppose that just like if I'm measuring the rates of infection, or falls in a hospital, you might say that that's a negative thing. But it's really about benchmarking and saying, “Look, this hospital has really low rates of these complications, what are they doing, that's good?” And what are the interventions that work to get the best possible outcomes for health services.

So my reflective piece was also looking at the fact that our educators are starting to drop off as well, and for very much the same reasons. Because unfortunately, if it was just a hurdle of burnout in our doctors in training, that would be one thing to fix. But in fact, our rates of burnout in all of our consultant staff are still sitting around the 50 percent mark, as well.

MIC CAVAZZINI:                And that capacity to train is something that the College has been looking at over years, so there’s stress on both sides. And we know that junior doctors also have additional stress on top of clinical training; imposter syndrome, exam pressures, that worry about choosing the right career path, all coming on at once. Jennifer, how, how much of this can be the responsibility of the College, how much is the responsibility of the workplace, and are there issues that seem to be falling between the cracks?

JENNIFER MARTIN:         Yes, I mean, although a lot of the issues in the workplace are workplace-related, the training requirements and the education requirements are part of that as well. So it can sometimes be difficult to allocate blame or to isolate who's responsible here. If I just start with the workplace I think the key the key areas where the College does have some ability to improve the likelihood of burnout for particular groups is actually with the accreditation. So accreditation is one tool that we do have we do, we can ask about wellbeing plans, we can ask if the roster is changed, or rosters are written in such a way they actually support the sustainability of the trainee workforce, for example. As opposed to having an administrator that just comes and puts the trainees names on a roster shift, even if they're not with their team, or if they're rotating across two different hospitals across different parts of town, all in one week. So we have some funny administrative behaviours that have crept into the workplace that do make it very difficult for our trainees, but I think the accreditation tool is one where we can really step up and actually require that of our workplaces. And I know that our education team has been looking at that with regards to what they're expecting of sites on an accreditation visit.

I think that the way we train our physicians is something that we do own in the College. I mean, there is little evidence, for example, to tell us that we need to have three years of basic physician training. Why not just until someone has accumulated and been approved on achieving certain skills in the workplace, which they may be able to do two years out of graduating and some people might take four or five years.

Then we do this exam system, it's something that's highly practiced for that can be gamed, that certainly where we have good training pathways for the exams, we've always had very high pass rates, but not always. In other areas we have good Trainees, but not necessarily the infrastructure to train our Trainees to pass an exam. So that all comes into question. And I know that people are looking at workplace-based assessments as potential tools, and there's quite a few groups within the College that are looking at that in the exam.

And then there's the advanced training. And again, it's very difficult to know how to approach this because we do have 33 different specialty societies, and they all have expectations in terms of what the graduates in their particular area should be able to do. And it's clear for some of them that you might be able to get through training with not much more than a period of time in the hospital working with severely premorbid patients and have good interpersonal skills and be good clinically. But others need to they do require a significant amount of input into gaining technical competency for a lot of technical skills.

And so I think it is it is complex once you start looking at this, but also, we've got a lot of other opportunities in the college to streamline our administrative processes. And I think there are two things that we could do that actually make it easy for trainees. So someone answers the phone, records somebody's query, gets it to the right person at the right time and gets a timely response. As opposed to an issue that goes around for many months, and people don't actually know if have been signed off or whether their term has finished. And I think that causes a lot of stress. So they sound like little things, tidying up the administration tidying up the it and then maybe looking at our training pathways, but I think looking at the Trainee comments, to various surveys and just direct discussion, it feels as if that would actually relieve a lot of distress.

MIC CAVAZZINI:                And that was that was highlighted in Monday's meeting as well, that the simple workplace efficiency, the admin makes a big difference to the day to day experience. And you know, the straw that breaks the camel's back might be that system you have to log into, and…

ANNE POWELL: I think they call it the hurt by 1000 cuts. Yeah, it's like every little thing seems like a tiny administrative detail. But when you have thousands of them all piled up on the Trainees then it really has a significant impact.

MIC CAVAZZINI:                You mentioned accreditation. And this is something we're familiar with in the context of training. But it was also mentioned in this proposed National Workforce Wellbeing Strategy that that a an accreditation scheme for wellbeing of all doctors would be some sort of stick that could be used to bring organizations up to standard. You know, in recent years studying in 2018, there was a lot of attention on bullying and unsafe training environments. At least a dozen departments around the country lost their accreditation to train. And these were decisions, as you said from the various colleges that the workplace was not a fit training environment. What's the consequence of that been? How many of the those departments have been reaccredited? As a regulatory stick, does it work?

JENNIFER MARTIN:         It's complicated. I'm not actually sure of the numbers because I think only two were within our college and the rest were outside, so I'm not quite sure what happened. But one of them did actually affect the area health district that I work in. And what happened essentially is we took all the Trainees away from Maitland hospital, and that was actually quite distressing for the Trainees because we didn't have alternate training sites. It was very difficult logistically for those Trainees. The underlying issue, once you take Trainees away, you then can't provide a whole lot of service. And so it's actually been really detrimental for the people of that of that area, because suddenly, we're up to using senior house officers often IMGs that do need supervision, but we weren't able to provide that either. And that's meant that that community really missed out.

So I think it's not a great stick. I mean, it is if we have to use it, because we have to protect our Trainees. But looking at the whole health outcome, it's much better if we can actually work with the jurisdiction to find out the issues that are problematic and to try and work with them to fix that issue. That particular issue was around poor supervision for trainees, because there wasn't—consultants were in private and popping in to see patients, but that wasn't the sort of environment that we expect in the College. But when it got to the point that we were actually notified, it wasn't really an option apart from to remove training.

MIC CAVAZZINI:                And the question for a national accreditation of workplace well being is well, what would the what would the penalty be anyway? If you don't get accredited, would it be a market where people just don't want to come to work for you?

ANNE POWELL: So having been through the accreditation cycle recently, I have to say that as a Director of Physician Education, we, despite the paperwork, we actually do love accreditation. Because it is our chance to review our education program and work out where the flaws are, and to really engage our executive for positive change. And the media often only hears the disaster areas have failed accreditation. What they probably don't get to see, most people, is that even in a passed accreditation, there will be areas that are addressed as areas of concern that that need to be remedied during the next accreditation cycle. So it gives the health service a couple of years to fix a few domains where they're not really at the standard that's expected. And you'll find that with health services, when you do fall below the majority of health services pay good attention to that and work with their education teams to get it up to standard.

So, accreditation is a really powerful tool of the college to try and improve things. And incorporating more metrics for wellbeing is another area and another domain that the college can just be so helpful. . We need to be able to see the impact of all of the interventions, and unless we have really nice metrics, and it's a national standard, we're never really going to have the best evidence to make the best health services that we can in this country.

MIC CAVAZZINI: And again, from that discussion paper curated by Beamtree, it highlights the importance of wellbeing education through a health worker’s career. They even mentioned “a wellbeing curriculum at the point of entry into the training environment,” and that workplace need to “make sure supervisors are trained and capable of supporting their staff.” The RACP already requires supervisors with a workshop before taking on trainees- and that seems to be well received. I don’t know how much room in the Trainees’ curriculum to add wellbeing on top of everything else?

ANNE POWELL: Yeah, one of the things in the meeting I found really interesting, and it was from a study, was that your manager has more of an impact on your wellbeing than your GP. And so to me, this burnout, this wellbeing, this is about your workplace and the impact it has on you. We encourage all of our doctors to go and see their GPs, but that's for health maintenance. So I think what we're talking about is that your manager has a much bigger impact on your general burnout, wellbeing in the workplace, than we give it credit for. So giving better training for them on how to address this and an understanding of the impact that they truly have on their staff is really important. Doctors are trained to be doctors, some doctors are trained to be educators. But very few doctors are trained to be managers. And that's the part that we want to put into the curriculum.

MIC CAVAZZINI:                And doctors in their early stages, in their thirties let’s say, they’re likely to be experiencing other big life moments; trying to buy a home, maybe starting a family, maybe having to take time away from training. And flexibility of training pathway has always been a hotly discussed topic and feeds into the conversation about gender equity in the profession too, as we discussed back in episode 16. The College addressed this in January this year with the implementation of its Flexible Training Policy. Jennifer can you take us through some of the key aspects of this? Number one that trainees can take breaks of up to 12 months as long as approval has been granted by the training committee.

JENNIFER MARTIN:         Yep, that’s great hey? So you can you have a break for up to 12 months. So I think that's really, really good. The fact that you can actually train one day a week, as long as you can organize that within your workplace. And my own experience is that trainees actually are pretty good at working together and be very flexible in terms of how they help each other with that. So I think that's the second part that's really important. So, a four year program can actually be completed over 10 years, I think I've just forgotten what the third one is.

MIC CAVAZZINI:                And then, if you if you do take breaks for parental leave, or medical leave, it doesn't add up to your 10 year completion.

JENNIFER MARTIN:         Yes. And I think that is realistic with the fact that people do take time off to have and to raise children and for other carer responsibilities as well. And often if people are experiencing burnout, it does actually give people an opportunity to pursue something else.

MIC CAVAZZINI:                Yeah and just as George Eskander talked about flexible part time arrangements within the workplace, you know, if you're trying to attract people to the medical pipeline, then maybe that kind of flexibility is necessary to keep up with other industries other sectors,

JENNIFER MARTIN:         Yes, well in a way it's bringing it into line with how the rest of the world works, actually.

ANNE POWELL:I have to say that eight years ago, when I was first the director of physician education, I didn't have anyone working part time with families in their training. And now I've got quite a few trainees that are part time or choosing to start their families during basic training, or a few of them have started basic training with young families. So what you see is what you realize might be an option for yourself. So it's it needed to start from the College so that then the hospitals then following through with making more flexible strategies.

MIC CAVAZZINI:                The last time I touched on this topic, more conservative-minded observers were concerned that breaks in training would dilute the quality of the learning too much. I mean, these policies don't upset that balance very much, do they?

ANNE POWELL: There's no evidence for that, that that dilutes their training.

JENNIFER MARTIN:         Yeah, it doesn't matter that you don't do all of your training in one block, actually you're just as good a physician if you break it up into blocks. And I had some issues myself in terms of trying to take time off with the birth of my first baby 22 years ago, right at the end of training, and I couldn't take a certain amount of maternity leave—that was before he even had maternity leave—but if I did, I would interrupt the training and I would have to repeat that the year or the months or whatever. And to be honest, for a long period of time, I believed that, I believed that there would be something wrong with me as a physician, if I took time off to have a baby. And I think that was distressing in itself, just waiting for this endpoint of getting through your exam or whatever. I don't think in other areas of work, people have to think like that and to keep planning when they might be able to start a family.

I think we're also told coming back part time—because I had to come back full time—that if I came back part time, we couldn't work like that within the system. Yet there were people that were part time in the hospital part time and private, but somehow we couldn't cope with a woman being halftime at home with their kids in halftime in the hospital. Again, that was built on vested interests, probably, but certainly no data to say that there was a problematic.

But I think this group of trainees are much more aware of the effect of putting up with that sort of dysfunction in terms of their enjoyment of their career and their engagement with the College as well that they progressed it. I think it did highlight a number of things, I think. It highlighted the fact that people having time out, such as carer duties, such as trying to do a PhD, trying to get to be a better educator, for example, these all made us much better doctors, they keep us in the workforce longer, they keep us really engaged. And then we're really contributing also to the next generation, as Anne has said. So, I feel kind of chuffed that we're sort of getting to this point. But also a bit sad that I think that we were kept under for a long period of time by myths that didn't really exist.

MIC CAVAZZINI:                Yeah, the idea that there's only one kind of doctor and, in fact, the more you nurture all these different capacities that the more diversity of care you get. Do you have anything else to add Anne, about, going back to your MJA paper about the quality of education? We've talked about the wellbeing and the capacity for supervisors and trainees. Any other magic wand?

ANNE POWELL: Yeah, I suppose my take is that we don't give up. I think I think we've all agreed that we can accept the status quo. I think there's enough distressed messages coming from our doctors and training and probably from some of our long-term educators as well that we need to change. And other systems have changed. You look at Canada, they've gone to work-based assessments and not the high-stakes examinations. A lot of other areas are starting to change. And I to me, the positive thing is that everyone's coming to the table and considering change. And that's a huge amount of progress from 10 years ago. So that's really my take home message is that it's sort of a starting block to me. I think it's a positive starting block, but we have so much work to do to make our working environment the caring, compassionate place that it should be.    

MIC CAVAZZINI:                 If you’ve been feeling burnt out or just need someone to talk to, there are several phone services providing support and confidentiality. The Doctor’s Health Advisory Service has different numbers in every jurisdiction of Australia and Aotearoa-NZ, which I’ve listed at the web page. The RACP partners with the 24 hour counsellors at Converge International whose number in Australia is 1300 687 327 and in New Zealand it’s 0800 666 367. But if you’re in need of crisis support, please don’t hesitate to call Lifeline. Their number in Australia is 13 11 14 and in Aotearoa-NZ it’s 0800 54 33 54.

I also want to remind you that through the RACP Online Community there’s a channel for identifying mentors. That’s a valuable support at any stage of your career, as we talked about in episode 83. Many thanks to all the speakers who spared their time for this story. They were George Eskander, Bethan Richards, Joanna Sinclair, Victoria Hirst, Jennifer Martin and Anne Powell. The views expressed are their own and may not reflect those of the Royal Australasian College of Physicians.

At our website, I’ve provided papers by Professor Tait Shanafelt with titles such as Nine Organizational Strategies to Promote Engagement and Reduce Burnout and the Business Case for Investing in Physician Well-being. There’s also a link to a seminar titled On establishing a Chief Wellness Officer. Just go to racp.edu.au/podcast and click on the page for this episode. You can automatically record your time spend listening and reading by clicking on the MyCPD link.

If you’ve got any feedback or ideas for Pomegranate Health you can write to me via podcast@racp.edu.au. This podcast was recorded on the lands of the Gadigal people of the Eora/Yura Nation. I pay respect to the storytellers who came before me. I’m Mic Cavazzini. Thanks for listening.