Authors

1. Costi, Jennifer Dip T (Sec), MEd Studs, Grad Cert Ed
2. Pearson, Alan AM, RN, ONC, Dip N Ed, DANS, MSc, PhD, FCN (NSW), FAAG, FRCN

Abstract

Review question/objective: What are the causes of stress and what is their impact on individual work performance among Junior Medical Officers working in tertiary care settings?

Background: The initial experiences in full time work as a medical practitioner have often been described as stressful.

In Australia, although the Junior Medical Officer may have met the requirements for the MBBS degree or similar by completing their undergraduate or graduate program at a university, they still have to obtain employment at a teaching hospital in an accredited training program in order to satisfactorily complete an intern year. During the first year of employment, the Junior Medical Officer is often and usually referred to as an intern. During this intern year, the Junior Medical Officer is granted 'provisional registration' by the Australian Health Practitioner Registration Authority (AHPRA). At the end of that year, the intern usually progresses to 'full registration' when details of satisfactory completion of the intern have been supplied by the employing hospital to AHPRA. Criteria for satisfactory completion of the intern year include 48 weeks of satisfactory service and a determination by the supervising Consultant of satisfactory completion of three core terms of 10 weeks duration. The core terms are in the broad subject domains of medicine, surgery and emergency.

The first year of employment as a Junior Medical Officer has a formal component of assessment included to meet the requirements of AHPRA. Lack of success experienced during this year will have direct ramifications on employment opportunities in the subsequent year. These requirements are layered onto the first year of full-time professional work.

Firth-Cozens described levels of stress in Junior House Officers in the UK as higher than other reported occupational groups and estimates the prevalence of emotional disturbance at 50%, with 28% of the subjects showing evidence of depression.1

Willcock et al., describe junior medical staff as having high rates of psychological and psychiatric morbidity.2 Brown and Arnold suggest that the need to "debrief and reflect on the stresses that confront them" is important and also looks at the Australian Curriculum Framework for Junior doctors for structures to "provide proper feedback, supervision and caring for our next generation of doctors".3^(p501)

Combined with this is an understanding expressed by Jenkins in the Medical Journal of Australia (MJA) that doctors may have susceptible personalities that cause them to become stressed or psychiatrically unwell.4 He further suggests that it is imperative that the stresses of the job and the workplace are recognized and that efforts are made to reduce them.

Markwell and Wainer in exploring the need for a healthy medical work force for the future, look at how this relates to junior medical officers minimizing their own health issues and failing "to recognize, acknowledge or act on the early warning signs of illness".5^(p441) The pressure to perform to a satisfactory standard at the very least is often done at the expense of self-care. The Australian Medical Association (AMA) too through their 'Doctors in Training' group (2006) has made recommendations regarding debriefing, support and stress management.

At the extreme end of stress and distress, Tyssen et al., found that suicidal ideation was high in medical students and young doctors.6 While suicide attempts were lower by comparison, Tyssen et al., concluded that clinical implications should address coping with stress and the provision of mental health services for young doctors.

Reviews related to these issues have been conducted by Shapiro et al., in "Stress Management in Medical Education: A Review of the Literature".7

Another review by Tyssen and Vaglum looked at the previous 20 years of data.8

While there exists a body of knowledge about stress and related morbidities in relation to Junior Medical Officers, the drawing together and review of this data has not been undertaken for some years. It is obvious that as time progresses, certain stressors such as working hours will be ameliorated by the introduction of reduced working hours under industrial awards and legislation. Other stressors may be exacerbated by the expectations of colleges for Junior Medical Officers to have research experience prior to, or concurrent with, application for admission to the college program. Other stressors may not be apparent, such as changes in the IT environment which may need further and hidden effort. Combined with this, the domestic and professional dynamic has evolved over the last 35 years since Firth-Cozens first wrote about emotional stress in Junior House Officers. There are also stressors that are specific to subsets of the cohort, such as communication issues for International Medical Graduates (IMGs) who also have to travel the path from limited to full registration under the AHPRA guidelines.9