Fatigue vs. resilience.
A survey by McClelland et al. published in Anaesthesia in 2017 suggested that a lack of support mechanisms for anaesthetic trainees in the UK has increased the reported incidence of fatigue-related health risks 1. This survey mainly examined the effects of out-of-hours work, lack of rest facilities and the risks to trainee anaesthetists who drive after night shifts. The survey highlighted the effects on physical health, psychological well-being and personal relationships. Another survey by the Association of Anaesthetists and the Royal College of Surgeons 2 produced similarly worrying results, and provided recommendations for action that included: more focus on a listening culture; improved rest facilities for doctors on-call; and work patterns that better reflect the need for personal and professional development. This stress that trainees are under is further highlighted by quantitative and qualitative reports from a new survey published in this issue 3, 4. This survey again highlighted workplace stressors that are perceived to have an impact on health and well-being in anaesthetic trainees, and in some cases have resulted in depression and burnout. It is difficult to try and pick apart each of the factors that have led to this general dissatisfaction but since many trainees cite on-call work as a major stressor, it is reasonable to first consider the amount and type of on-call work that is being undertaken by anaesthetic trainees. Before the introduction of the European Working Time Directive, trainee anaesthetists typically worked more hours of on-call work, but the ready availability of rest facilities may have, to some extent, reduced the perception of fatigue. Despite implementation of the European Working Time Directive, it is also clear that there is pressure on trainees to fill rota gaps during on-call shifts, and this may have also exacerbated the problems with trainee fatigue. Recruitment and retention seems to be becoming an increasing problem in many medical specialities, and the effects of Brexit and Government policies on immigration have almost certainly exacerbated this. It also seems that out-of-hours work is becoming more intense in comparison with previous cohorts of anaesthetic trainees. There has been an increasing burden of emergency admissions, due in part not only to the fact that the UK hospital population is older and has more comorbidities but also due to an increased focus on surgical standards 5. There is more timely treatment and less tolerance of delays in emergency surgery in order to improve outcomes, promoted by initiatives such as the National Emergency Laparotomy Audit 6. Trainee anaesthetists are often called on to resuscitate and manage these patients when they arrive in Emergency Departments, and this also adds to their work-load. Against this backdrop of increasing out-of-hours work-load, the removal of simple support mechanisms for trainees such as availability of rest facilities and hot food after office hours seems mean-spirited and short-sighted. It has contributed to an impression of a healthcare system that is being cut to the bone, with trainees who work out-of-hours bearing the brunt of poor managerial decisions to save money that in turn disproportionately affect their work patterns and morale. Although all acute hospital specialities are being stretched and similar problems are being reported in other hospital specialities, anaesthesia is one of the more stressful careers in medicine, and the challenges that junior anaesthetists face during training are well known 7, 8. It has been reported that the speciality as a whole has a high incidence of suicide in comparison with other specialities 9 and that anaesthetists tend to die at an earlier age. Given the intense nature of speciality training in anaesthetics, it is likely that the experiences of trainees represent an early indicator of trouble ahead for all postgraduate trainees working in a hospital environment. If we assume that all surveys are, to some extent, prone to reporting bias and may emphasise some of the more dramatic problems in training, we are still left with consistently reported issues that most anaesthetic trainees are able to identify within the training environment. Some of these problems will inevitably have local factors that need to be addressed, but there also seems to be a large amount of uniformity in the reports that suggest nothing less than a national problem. Probably, the most worrying aspect of the surveys is the suggestion that trainer fatigue is leading to risks for patients when trainees are unable to obtain the support that they need. The Bawa–Garba case in the UK (where a trainee doctor was charged with gross misconduct) highlighted many systemic problems in lack of support for junior doctors. Although trainees are always managed under the supervision of a specialist, help may not be immediately available and they work in a complex clinical environment where there are often conflicting priorities. The recently published independent review of the Bawa–Garba case 10 recommended that "Where a doctor is being investigated for gross negligence manslaughter or culpable homicide, the appropriate external authority should scrutinise the systems within the department where the doctor worked. Where the doctor is a trainee, this should include scrutiny of the education and training environment by bodies responsible for education and training" (Recommendation 10). This seems a sensible principle to apply not only to errors when they have occurred but also to situations where trainees highlight potential patient risks in a system that is leading to stress and burnout. It is clear that fatigue and stress are major problems for anaesthetic trainees 7, and surveys such as these give clear accounts of the consequences of this workplace stress. It is also clear that this sense of dissatisfaction with medical training starts almost from the time potential doctors enter undergraduate education, and this affects not only the UK but has been seen in medical school undergraduates in many developed countries. In 2016, the Journal of the American Medical Association reported an incidence of depressive illness of 27.2% in undergraduate medical students, with 11% reporting suicidal ideation 11. Similar problems have also been identified in postgraduate training. It has been reported that a third of junior doctors have mental health disorders 12, and the suicide incidence amongst junior doctors as a whole seems to have increased in frequency over the last few years. There is overwhelming evidence that medical trainees are vulnerable to stress and healthcare problems. There is also evidence that medical students are apprehensive that the medical role has changed beyond what was expected on entry into medical school 13. What may have started as initial enthusiasm for medicine as a profession in many cases does not survive early experiences in the workplace, giving way to disenchantment and despair. According to a survey of medical students' finances by the British Medical Association in 2018 14, the average total debt of medical students in the UK is now £43,700, a figure that has substantially increased since the last survey in 2013. It seems likely that this has also added to the burden of stress experienced by medical students and junior trainees in the recent years. Data from the 2018 General Medical Council report "The State of Medical Education and Practice in the UK" 15 suggests that the proportion of UK graduate doctors under 30 leaving the workforce has increased from 1.5% in 2012 to 2.7% in 2017, with a similar increase in international medical graduates (3.1–5.7%). These figures may indicate doctors leaving the UK or leaving the medical profession. Either way, it is a worrying trend that is likely to get worse over the next few years with the uncertainty effect of Brexit and other challenges to provision of medical services. There is a suspicion that many doctors who leave the service may have been behaving sub-optimally for some time, and it is likely that stress plays some part in this 16. It is clear that stress and fatigue are currently major problems for trainees, and similar problems have been identified in many countries with different cultures and challenges. What is not so clear is how these problems can be addressed in ways that support both individuals and the system in which doctors work. Much of the focus on the last few years has been on promoting resilience among undergraduate and postgraduate trainees. Resilience can be regarded as the ability to respond positively to challenging experiences, and this in turn seems to be dependent on medical knowledge, stamina, good health 17 and the ability to identify individual limits of competence and health 18. It is often interpreted in simplistic terms as 'mental toughness', but it is more useful to think of it in dynamic terms, as an interaction between individuals and their environment – "the ability to succeed, to live, and to develop in a positive way… despite the stress or adversity that would normally involve the real possibility of a negative outcome" 19. This type of definition is important. If resilience is perceived to be an immutable character trait, it may engender a sense of failure and isolation amongst those who cannot cope with the workplace and have reached a breaking point. In the UK, the General Medical Council, in its latest guidance on good medical practice for medical students, focuses on promoting resilience among doctors 20. As a result of this focus, resilience may be a factor that is considered in interviews during medical school admission processes and is consistently highlighted as one of the factors that needs to be taken into account when assessing trainees. Validated assessment tools to measure resilience do exist 21, but any quantitative measure can only be a 'snapshot' of an individual's development, and may or may not predict a resilient response when exposed to a wide variety of stressors in the clinical environment. In assessing resilience, the environment that produces the stressful response also needs to be taken into account. It is not yet clear if assessment of resilience at interview is able to successfully predict future performance in challenging clinical situations. Using these concepts of resilience to understand the reporting of fatigue amongst trainee anaesthetists, it seems likely that individual trainee circumstances are interacting with an environment that is overwhelming their ability to succeed in personal terms. Externally, they may appear able to perform their clinical role in an adequate way, but only at the expense of personal fatigue and what they sometimes regard as personal failure. The tragedy is that trainees have already succeeded in navigating an increasingly competitive and stressful environment as undergraduates and in foundation posts, but seem to be reaching a crisis point during their speciality postgraduate training. Decreasing on-call requirements may reduce stress, but this should not be at the expense of losing training time 22; deliberate supervised practice is also necessary to develop resilience. To some extent, training can be regarded as an incremental process of exposure to increasingly stressful and challenging situations. It has been suggested that coping strategies may develop during anaesthetic training 23, and that this process may help trainees manage stress and develop resilience as increasing responsibilities are encouraged during progression towards speciality accreditation. The presence of good role models also helps during this development 24, and learning from others who are able to cope well with clinical challenges probably plays a large part in personal development of resilience during training. Much of this training is overseen by clinical and educational supervisors who are trained to assess development of knowledge, skills and attitudes; but a worrying aspect is that stress and fatigue reported from surveys have occurred during supervised training that from an educational perspective was regarded as a success. If resilience is learned at all during current training, recognition and development of this process by trainers seems to be largely informal and may currently be regarded as less of a priority than other educational markers of attainment such as completion of workplace-based assessments. Changes are probably needed at many levels. The recommendations produced by the Association of Anaesthetists and the Royal College of Anaesthetists are an excellent start 2. Degradation of support mechanisms for trainees in hospital needs to be reversed, and basic rest facilities should be available for all trainees covering on-call shifts. Rotas need to be reconfigured to take into account the intensity of work-load experienced by trainees, and the hospital environment in which medical trainees work needs to be reconsidered in terms of workforce sustainability. Maintaining an on-call rota by using trainees to work extra shifts is unacceptable and potentially dangerous. This should only ever be considered in the short term, and only then when trainees are able to get adequate rest and preserve their clinical training time. Even if these recommendations are accepted in principle, there will inevitably be delays in implementation due to ongoing staff shortages. It is likely that, at least in the short term, the priority of hospitals will be to maintain service throughput rather than addressing the concerns of junior trainees. At a local level, junior doctors' concerns will need to achieve a much higher priority than previously experienced, and there will need to be strong support from consultants, managers and deaneries. While we are waiting for this to happen, we need to better understand how resilience can be developed in undergraduate and postgraduate training. There is widespread agreement that this is what is needed in order to build a sustainable workforce, but at present it is unclear how it can be best achieved. Resilience can only develop in trainees when exposure to challenges is incremental and there is deliberate practice; uncontrolled exposure of trainees to stressful situations when supervisors are not immediately available and fatigue is already present is likely to be counter-productive. The current problem of chronic fatigue and threat of burnout in trainees needs to be addressed before the longer-term solution of developing resilience as an explicit outcome of training can be successfully achieved. We have known there is a problem with fatigue and burnout in trainees for some time. We currently have a working environment that many trainees regard as toxic to their health and well-being. We need to introduce significant changes into the ways in which we develop the skills of trainees and create a workplace that does not prioritise throughput over development of resilience. If nothing changes, most of the data we have suggests that trainees will continue to leave the profession or emigrate. As the whole of the NHS comes under increasing pressure from a relative lack of staff and increased patient demand, we cannot risk the next generation of trainees by repeating the mistakes of the past. BJ is an Editor of Anaesthesia. No other competing interests declared.
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