Burnt out – how can we support our mental health?
The intern years can be a shock to the system – being aware of the challenges can help to identify, and prevent, burnout, says Professor Jim Lucey
After graduation, the shock of working as an intern can be great. The hours are demanding and the change from largely selfdirected student life to life as a junior doctor working within an organised system requires a vast deal of adaptation.
In addition, the demands placed on interns are very onerous: much of the paperwork and duties of clerkship are relegated to the intern even in these days when more and more systems are becoming computerised. The sudden exposure to real life patient needs can be overwhelming.
There can be a bewildering demand on interns to adapt to the world of work without much recognition of the transition involved. Some interns can feel that they are being asked to go through a trial by ordeal as a first step in a career structure which seems to place more and more demands upon them while offering them less and less in return.
For some, the demand is perfectly reasonable and most doctors bring to the tasks of internship levels of energy and commitment and capacity which are exceptional. However, for others, there is a sudden sense of disillusionment which comes as a real shock and a blow to the original idealised ambitions which originally led the doctor to seek a career in medicine. This disillusionment is particularly toxic when it’s aligned to long hours, exhaustion and unsatisfactory conditions.
What can interns do to prepare themselves for this challenge? The first step is to recognise that denial of these difficulties is not likely to lead to their solution. It is much better to organise and support one another in terms of the professional tasks. Doctors do best when they can progress their individual careers in the context of collective support.
Measures such as the European Working Time Directive (EWTD) need to be enforced and upheld and to achieve this today’s intern and other medical staff need to co-operate with each other in a professional manner. The importance of a professional handover cannot be overestimated in a system which encourages doctors to work shifts.
What can interns do to help their own mental health? The first step is to acknowledge the challenge. Ignorance helps no-one. Once the issue of general health is raised it is surprising how much people can do when they help themselves and when they work together. Try to place general health and mental wellbeing on the agenda for the group working in the hospital.
Interns should have a say in how the balance of work is shared and there should be an attempt to make this equitable
If there is a junior doctor’s residence or leadership committee amongst the interns, there should be an agenda collectively addressing the wellbeing needs of the whole group. Issues like managing the roster and sharing out weekends or nights are as much about professionalism as they are about awareness of the stresses and strains on each of our colleagues’ lives. Interns should have a say in how the balance of work is shared and there should be an attempt to make this equitable.
Each individual needs to look honestly at their own health and the balance of factors contributing to their wellbeing. “All work and no play make Jack a dull boy” is not a new phrase but it is still very true. There are times where prolonged effort and commitment is required, but there must also be time for relaxation and laughter.
It is a mistake to give up your interests in sport or recreation or music in your intern year. It is a mistake to have a life without room for relationships and without communication with friends. It helps to have a dedication to the care of others outside medicine and also to sharing time with people we love.
Look after yourself
There is no doubt that attention to physical health is very important, but young people frequently ignore this.
- Make sure you: get sufficient sleep and remain sober
- take exercise
- eat well.
These simple things are significant benefits to people in times when resilience is required. Exhaustion and intoxication help no-one. The number of people who disregard what they can do for their own contentment is amazing, and this is so even amongst well informed health professionals.
There will be a small but significant number of interns with definable mental health issues and this need to be addressed. In my experience, these issues emerge in the profession at times of great personal stress and particularly at times when demands are placed upon them by onerous work. Issues which could have been contained or may not have been recognised throughout a college career may emerge during the intern year. The best thing to do is to address them confidentially.
It is important to seek help. Most teaching centres which have interns will have a facility for occupational health and this may be an underused resource. It is important to talk about these issues in confidence to someone who can help you address them and genuinely respond with the right kind of focused professional help.
At any one time, 4% of the population will have a depressive disorder of significance. One in five of us will have a depressive disorder in our lifetime in addition to the risks of other issues such as anxiety disorder or substance misuse disorder. The common mental health challenges are no less frequent amongst a body of graduate doctors than they are in the rest of the population. It may be that some of these stress-related issues are even more prominent.
Professionalism involves recognising the duty to maintain one’s own mental health as well as recognising that addressing mental health needs is worthwhile and effective. It is important that we overcome the selfstigmatisation that arises in doctors from the fear of calling for help for our own needs, by speaking up and addressing the mental health needs that exist amongst us.
The good news is that most of these issues are readily responsive to support and, where necessary, specific treatment. Most, if acknowledged early, can be overcome in a way which does not damage careers or interrupt life substantially. Failure to address mental health needs can be devastating.
A number of the techniques can be used. There is increased awareness of the benefits of modalities such as mindfulness as an effective stress management technique. Specific psychotherapy such as cognitive behavioural therapy (CBT) can give remediation for stress-related disorders relatively quickly and this is not hard to access once the issues are acknowledged.
The doctor as superman may find himself or herself prescribing for their own difficulties and self-medicating
A small number of doctors who are clinically ill would be better taking time off and addressing their distress where that is required. Doctors very infrequently declare their own illness and this is something which is problematic. Under reporting arises from concealment and denial of illness, which is made worse by fear and shame. The doctor as superman may find himself or herself prescribing for their own difficulties and self-medicating. This is a road to professional and personal disaster and should never be done. It is important to find a mentor, someone who can be trusted completely, so that the best response within the profession can be made when a crisis is feared or worse, when one strikes.
Each intern (and indeed every doctor) should have their own GP; someone that we can share difficulties with and look to for help. As interns we first experience life as carers for others. The best preparation for a life in medicine includes acknowledgement of our need to care for ourselves.
To find out more, listen to Professor Lucey’s podcast on mental health and burnout, recorded at MPS’s General Practice Conference 2012: Spotlight on Risk, in Dublin.
Professor Jim Lucey is Medical Director of St Patrick’s Mental Health Services and Clinical Professor of Psychiatry at Trinity College, Dublin