Participants included nine women and three men, aged 24–35 years of age (mean age = 28.9 years), employed across six hospitals. The participant group was spread across the early stages of medical training, comprising three interns (in initial stage of clinical training following graduation), five residents (with between one to 2 years of training) and four registrars (a position held after at least 3 years of clinical training). A range of specialties were represented, when disclosed. The majority of participants had received their medical degree at an Australian university. Over three-quarters had undertaken rural and or regional placements as part of their training. During the course of the interviews, four participants self-disclosed that they had sought professional help for mental health problems.
Summary of themes
There were four main themes identified across the interviews, namely: i) professional hierarchies; ii) workplace stress; iii) emotional labour, and iv) taking distress home. The term ‘professional hierarchies’ refers to the structural dimensions of social relationships between people employed at various levels in organisations such as hospitals and other healthcare institutions. These aspects were central in the JMOs’ accounts of workplace experiences; both positive and negative. Two professional relationships that were embedded within the training hierarchy and frequently mentioned by the JMOs were the relationship between supervisor and junior doctor, and the relationships between fellow junior doctors. Key sources of workplace stress were a highly demanding workplace and adverse working conditions, time demands and lack of control over shifts and rostering, high expectations of JMOs and the continual transitions JMOs navigate. Responses to workplace stress included a fear of making mistakes, insecurity, feeling ‘trapped’ in medicine and exhaustion. The third main theme is that of ‘emotional labour’: the demands on JMOs to conform to emotion rules that involved both providing care to others and expectations to control their feelings so as to be seen as behaving professionally and competently in the workplace. The fourth main and novel theme is ‘taking distress home’, which highlights how JMOs’ experiences of feeling overwhelmed and anxious knows no boundaries.
These themes are intertwined, so that professional hierarchies contribute to, or in some cases, mitigate workplace stress, while emotional labour is central to managing the stress created by non-supportive hierarchies. Stress permeates home and work and affects relations within these spaces. The transitional nature of the training program, with term-to-term placements and rotations through teams and specialties, creates a cyclic dynamic of upheaval and uncertainty. This exacerbates some of the anxiety-laden responses and accentuates the need for stable supportive professional mentorship and peer cohesion to engender a sense of belonging and shared understanding.
Theme 1: professional hierarchies
Professional hierarchies were enacted through relationships between different levels of the hierarchical structure of medicine and the hospital. These levels included the administration, senior consultants and clinicians, supervisors throughout JMO placements, teams within wards, and fellow medical JMOs. Crucially, these relationships could be negative or positive in nature, and could impact on JMOs’ well-being for better or worse. Chief actors in these relationships were senior clinicians, supervisors of JMOs, colleagues and fellow JMOs, as well as the broader professional structure of medicine.
Negative professional hierarchies could be characterised by an imbalance of power, absence of personal connection or scarcity of availability. Several JMOs described unsupportive or distant senior doctors. Charlie noted, for example, that ‘my clinical supervisor I haven’t seen in like a year, and lots of the consultants, you don’t really see them’. Some described a power hierarchy between supervisors and JMOs, and instances of bullying and dismissive interactions from time-poor consultants who ‘defended their time aggressively’ (Sam). Within a stressful working environment, relational disconnection from colleagues generated a sense of de-valuation and low self-esteem for some JMOs: ‘I felt like my bosses didn’t really value me, or my other registrars didn’t really value me in the workplace’ (Alex). There was a common theme of insecurity around professional competence and some JMOs expressed a fear of others’ negative evaluation. With most JMOs on one-year contracts, an additional recurrent source of stress was that of annual job applications, a process that for some JMOs, fostered this insecurity around professional competence.
Professional relationships could be positive and enhance JMO well-being if they were supportive, consistent, available, and dedicated to developing better doctors and delivering better healthcare. Supervisors occupied a position within the medical hierarchy that rendered them able to provide clinical advice, and professional and personal support to the JMOs. When supervisors fulfilled their support responsibilities, the performance and coping of junior doctors was constructively addressed. These relational connections promoted a sense of being valued, both as a person and a JMO doctor, and being respected as a learner. JMOs described different contexts and spaces in which supervisors could provide mentorship and support to JMOs both formally and informally. These examples included proactive supervisors undertaking regular check-ins and teaching on the wards, informal catch-ups and advice over on-call consultation at the bedside, where supervisors co-navigated the care of patients with JMOs, and in turn, showed care for their supervisees. Scheduling mid and end-of-placement check-ins and formalising regular mentorship times within training programs could set aside formal spaces for mentorship and supervision to occur more frequently.
The importance of developing this respect and feelings of greater confidence was evident in many accounts, where JMOs described a process of trust, learning, and the development of mastery and competence in clinical skills: ‘as you go on, you realise even those little mistakes. .. you can learn from them’ (Alex). For some JMOs, training generated an affective atmosphere of stimulation and intellectual challenge. They experienced this time as an opportunity to develop competence and mastery: ‘the best part of being a JMO was actually reinforcing all the things that you’ve learnt and putting them into practice on daily basis and feeling like you’re progressing as someone in the medical field’ (Robin). These findings demonstrate how a supportive supervisory relationship can help JMOs manage their fear of making mistakes and to learn how to deal with workplace stressors more effectively, and how opportunities for face-to-face teaching on the ward can positively influence JMO self-esteem and professional development.
Peer relationships and feelings of team belonging were important facilitators of JMO well-being. Many participants identified that a key source of support for a JMO was their fellow junior doctors. These were crucial relationships of shared experience and understanding that were largely positive and formed a consistent base for JMOs in the face of the regular transitions as they moved through their training program. Long hours at work meant that the majority of JMOs spent their time together in shared spaces as they participated in the training program together. In experiencing the same fears, stressors and dilemmas, the cohort of junior doctors provided shared understanding, common humanity and a sense of comradery that was evident in many spaces and formats. Many JMOs described instances of positive, plentiful support, and a sense of altruism and dedication to helping out fellow JMOs: ‘as an intern you know like, everyone wanted to work hard, be the best, go have coffee together and then help their mates if they finished their job early’ (Alex). This sense of team cohesion, of being valued and supported by colleagues, particularly fellow JMOs, was an important factor in generating motivation, professional identity and shared purpose.
Theme 2: workplace stress
Several of our interviewees had previously worked in other professions, and one commented that medicine was ‘the hardest job I’ve ever done’ (Jamie). JMOs described working under intense time pressure and described cognitive and emotional strain from multiple demands on their attention. Adverse working conditions were described as a visceral source of stress for many JMOs. These included long hours, high patient loads, infrequent breaks, high job demands and low job control. There did appear to be individual differences between the participants in the degree to which they reported experiencing distressing affective responses to working as a JMO and in the coping strategies they adopted. Some JMOs reported that their affective responses can change over time as a result of experience and changes in location.
For many participants, being stretched in terms of time was a prominent source of stress that left them vulnerable and exhausted. When combined with a high patient load and understaffing, study and training demands contributed to a sense of endless pressure, over which JMOs had little control. Even the most basic requirements for their physical well-being were commonly lacking on hospital premises, such as no quiet spaces on the wards. Working without lunch breaks, and not being able to go to the bathroom, were commonly reported.
It was not only a matter of working hours (per se), but the lack of control the JMOs had over determining those hours, and of having too much to do within those rostered hours. More broadly, it was the lack of power over these aspects of their work that was described as most problematic for their mental health. Regardless of how hard they worked, JMOs were at the mercy of the organisational factors such as understaffing and unrealistic patient loads and carried their pagers at all times. Ultimately, top-down administrative pressures prevented JMOs from maintaining a healthy work-life balance during and after work hours. Procedural barriers and administrative difficulties in rostering were practical obstacles for some JMOs in applying for holiday or sick leave or attending appointments. Improvements in workplace staffing and shift scheduling would provide more human resources and material support to assist doctors.
Workplace stress associated with the external factors discussed above was at times exacerbated by internal factors, such as JMOs’ own interpretations, personality traits, self-stigma or internalised expectations of the medical profession. Insightfully, one JMO identified a process of normalisation of extremely high standards in medicine, where: ‘everyone has pretty high standards of themselves. .. And it’s hard because when you’re around that environment that becomes normal’ (Alex). This tendency was identified in some JMO accounts when describing themselves and their cohort as ‘Type A medical people’ (Alex). Upon reflection, Alex noted that regardless of one’s personality, the extraordinary demands of the job would make anyone stressed. The skewed baseline for comparison meant JMOs only compared their performance to a very high-achieving successful cohort of fellow peers. For some JMOs, this was a source of feelings of low worth.
The high stakes nature of the role, where ‘everything is a lot more serious because it’s people’s lives’ (Jamie), generated a highly stressful affective atmosphere amongst JMOs. All participants reported a fear of making mistakes, particularly in the first intern year. For example, Alex described ‘thinking that everything, every mistake you could make could be potentially cataclysmic and result in death because, you know, you work in health in a hospital and you’re a doctor’. Alex went on to observe that this fear was compounded by feelings of uncertainty, anxiety and unpreparedness: ‘that responsibility was somewhat frightening, and I felt like we weren’t really prepared that well in terms of everyday tasks’.
This fear of making mistakes and feeling unprepared was exacerbated regularly due to the rotational nature of the JMO training program. Each term required placements at different locations and adaptation to new teams and new environments, accompanied by upheaval and self-doubt. This anxiety was exacerbated for some JMOs by a perceived lack of clinical support and advice when required, leaving them feeling unsupported, in what was described as a ‘sink or swim’ training process. The relational connections for support and learning JMOs needed in these anxiety-provoking clinical situations were often not available or offered to them. Further, the wider context of medical practice generated extra anxiety for most JMOs. Anxiety about clinical decisions was exacerbated by the broader litigious culture of medicine in which doctors: ‘practice really defensively because you’re aware that the current climate we’re in is quite sort of litigious’ (Charlie).
Several JMOs pointed to the gap between their expectations of training and the reality of living these experiences. One participant observed that JMOs were most vulnerable to mental and physical ill-health when there was a pronounced mismatch between their expectations and demands at and outside work. Relatedly, participants referred to the relentless training and career progression of a doctor as offering little opportunity to reflect realistically and self-compassionately on whether they were suited to the profession, and if it was sustainable for long-term well-being. Constant focus on study and examinations was required for career progression and entry into competitive specialist training programs. After lengthy study and intense sacrifice to the demands of work and exams, some JMOs described feeling trapped: ‘lots of people feel that they can’t leave and it would be like a failure if they left medicine, even if they’re hating it and not well suited to it’ (Charlie). For some, leaving the training pathway from clinical medicine was considered ‘unachievable’ (Charlie). Education on career alternatives was identified by some participants as a necessity during training.
Interviewees felt that their time was devalued by management via administrative errors around leave and payment and inflexibility around rostering, and through procedural barriers and administrative difficulties that they encountered when applying for leave, particularly sick leave. These obstacles were further complicated by stigmatised attitudes towards illness within the workplace culture: ‘The logistics [were a problem] because then I would have to reveal that I was going to a medical appointment or a psychologist’s appointment’ (Jamie). Similarly, workplace stressors of understaffing and under-resourcing created a culture of guilt around taking leave, which was viewed as harmful to the team.
Theme 3: emotional labour
Several prominent forms/acts of emotion rules and related emotional labour emerged from the interviews, which had largely harmful impacts. The tension between an expectation for outward displays of clinical competence and confidence, despite lack of experience, was a key source of anxiety that was recurrent throughout training stages. For example, Alex observed a cycle of waves of anxiety throughout their training. These feelings emerged at the commencement of a new hospital, a new term/speciality, in a new team, or annually at the commencement of a new role, and were continually recurring due to the rotating nature of their training and identity formation from medical student to competent doctor. Alex described: ‘this spike of apprehension again which is a bit less so than before, but you suddenly realise okay, well now everybody expects me to perform at this next level and what if I don’t perform at this next level?. .. when people expect you to like have this whole new year’s worth of experience.’ (Alex). Given the daily experience of anxiety and distress, it was concerning that a number of JMOs expressed self-stigma and shame around their mental health because the emotion rules of their workplace demanded that medical staff should not display these feelings. For some, this was another barrier to help-seeking. Charlie described feeling ‘embarrassed to go to anyone about my work anxieties’, even a GP. Robin reflected that seeking professional support ‘would be a pretty big step for me to take. And. .. it would take, I think, a fair bit of nudging from a friend or a family member to get me to go there’. Several participants reported that they did not have a regular GP. Charlie’s observation that ‘I feel like anxiety’s much easier to hide and manage’, suggests an underlying inherent pressure for JMOs to hide their mental distress. An underlying stigma was also hinted at in some accounts, where a mask of humour, ‘camaraderie and banter’ (Pat), was employed as a coping strategy to broach serious issues such as mental health problems within peer cohorts with a sense of distance and detachment: ‘Like jokingly say, “I want to kill myself.” Things like that. Or, just like in a joking manner say, like, “If this happens, I’m going to shoot myself”’ (Pat).
These sentiments and behaviours among JMOs, and among senior doctors, could be interpreted as a response to the enduring professional and cultural norms and expectations of a doctor as ‘invincible’, a provider of care to others, always placing patients first. Some participants reported feeling a sense of failure or weakness in the face of the silent expectation of a doctors’ ‘invincibility’, an idea also expressed by Mexican physicians-in-training . In these Australian accounts there was a tendency for JMOs to downplay their worth as patients, reflecting that this was a barrier to help-seeking. One participant reflected: ‘it’s not really like confidentiality. It’s more, and I guess like, the judgment from those health care professionals. We’re all dealing with that every day. You can manage this yourself. You’re kind of wasting their time.’ (Charlie).
Professional stigma was at times modelled by senior colleagues, with some JMOs describing a reluctance to openly discuss mental health issues within the workplace—for example extremely dismissive interactions with managerial staff around mental health sick leave and a failure to check-in regularly with JMOs about basic well-being. Additionally, the insularity of the ‘medical’ world also interfered with help-seeking via professional pathways. A lack of confidentiality within the profession was described as a barrier to JMOs accessing medical treatment, and for some, contributed to a sense of isolation and an unmet need for shared understanding. Furthermore, the closed nature of the profession meant that often a supervisor or senior could also be the individual tasked with deciding entry into specialty training programs. This situation complicated disclosure of mental health issues to senior staff.
To address these issues, Jamie suggested that JMOs require ‘a confidential sort of means for JMOs to talk to someone who sort of understood what they were going through’. When help was sought, JMOs described a preference to seek help outside the local hospital system in which they worked to maintain confidentiality. A confidential specialist healthcare service for doctors, run by doctors, with appointments available that suit doctors’ rosters was called for, as was allocated time in rosters for appointments and check-ups that could be applied for easily and confidentially. A dedicated, independent medical service for doctors and streamlining the administrative processes for leave for appointments were suggested by JMOs. These changes would provide the material space and the organisational sanctioning for JMOs to receive medical or psychological care themselves.
One participant highlighted that deep systemic changes were required at an organisational and policy level to change the impact of workplace culture towards staff mental health. Expectations of ‘invincibility’ and structural and practical impediments to help-seeking and to a healthy work-life balance, generated a sense among some JMOs that their own needs were being de-valued by the organisation and the profession. These affects were perpetuated by the daily realities of excessive workloads and understaffing. Normalisation of these workplace demands, and of a devaluation of the participants’ basic needs and a lack of agency to assert these within the structures of administration and hierarchy (such as taking meal breaks), generated a collective silence among many JMOs. Some JMOs felt unable to voice their experiences with peers, other colleagues or supervisors, whilst others turned to other JMOs for understanding and support. There was anger expressed due to the perception that JMOs were being blamed for a lack of resilience, with one participant describing initiatives to improve resilience amongst JMOs as ‘tokenistic offering [s]’ (Robin). One JMO stated: ‘yes, I kind of feel there needs to be some accountability from people higher up because there was a lot of focus on the JMOs being more resilient and it’s kind of insulting’ (Jamie).
Theme 4: taking distress home
Critically, these distressing feelings were not confined to working hours or to hospital grounds. Some JMOs described an affective atmosphere of worry and rumination that continued at home, after hours. One JMO described this feeling as physiological arousal akin to them being on the ward in a time of critical medical context. Charlie noted that: ‘I feel like you’re stressed for 12 hours that you’re at home about what the result was and what’s happened’ and described the resulting physiological hyperarousal at home as ‘not being able to switch off, like you’re [still] at work’. In this situation, JMOs have no space in which they can feel they can escape the pressures of work, and therefore, no chance for relief from these feelings even when they are off-site. Long working hours was a huge problem for some JMOs, resulting in sleep deprivation, isolation from family and friends, work-life imbalance and a limited capacity for healthy behaviours. Time spent in recreation or rest was minimal. The only space and pursuit in which JMOs were present was work-related. JMOs described temporal and physical dedication to being on site for extremely long working hours. They described a life phase in which previous strategies to promote well-being, such as socialising and exercise, were frequently abandoned to meet the demands of overtime and workload.
Many JMO accounts revealed a split or distinction, between ‘medical’ and ‘non-medical’ people and social relationships. This could be observed in the accounts, for example, in explicitly identifying a partner as ‘non-medical’ or implicitly referring to a collective ‘us’ when mentioning the JMO cohort. Their position within or outside this context, engenders a distinct professional, social and personal identity for the JMO themselves, and their relationships. On a practical level, long hours and overtime prevented JMOs from fostering non-medical connections and spending time with family and friends or on holiday. Some JMOs described feeling distant emotionally, physically and temporally from their friends and family, of having no common ground, spending no downtime at home after all day at work. Overtime and shift work upended routines of sleep, meal times and weekends. Many JMOs expressed feeling torn and sometimes guilt-ridden as they negotiated the tension between the demands of the medical world, and their non-medical interests and connections. One participant described their feelings using the metaphor of emptiness and a hollowing out of selfhood: ‘I felt like I was burning-out, and a bit of a shell of myself’ (Alex).
Separation and isolation were also evident at a relational level. Those ‘non-medical’ individuals, such as family or friends who do not have awareness of the affective realities of the medical world, of the daily exhaustion and pressure of the hospital, were viewed by the participants as not connected to the JMOs’ experiences. The implicit shared understanding that being a fellow ‘medic’ brings, and the lack of understanding with those outside the ‘medical’ sphere, can either open or close relational connections and opportunities for support and validation for JMOs amongst their social networks. Alex described feeling not understood by friends and family, and an inability to foster such understanding in these relationships. This generated an affective atmosphere of loneliness and social isolation outside of work.