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The junior doctor in distress: the role of a medical education officer at the individual level

Karen Grace
Med J Aust 2002; 177 (1): S22. || doi: 10.5694/j.1326-5377.2002.tb04625.x
Published online: 1 July 2002

Despite our best efforts to create systems and organisational supports to facilitate optimal development for all junior medical officers (JMOs), some will continue to perform suboptimally and experience distress. It then becomes necessary to take an individualised approach to these JMOs. It must be emphasised that there is a clear distinction between distress and impairment. Distress does not imply impairment, although prolonged and unalleviated distress may eventually lead to impairment.

North Western Adelaide Health Service (NWAHS) allocates about 50 interns (mainly from Adelaide University Medical School and from the graduate-entry program at Flinders University School of Medicine) between two main public teaching hospitals — The Queen Elizabeth Hospital, which serves a predominantly ageing multicultural population in Adelaide's western suburbs, and the Lyell McEwen Health Service, with an expanding, younger client base in the north. These two hospitals are 25 km apart and together serve some of the poorest socioeconomic areas in Adelaide. This, together with the politically uncertain future of The Queen Elizabeth Hospital, puts NWAHS low on the list of preferred placements for newly graduating medical students. (For the Year 2001 intake, only one of the top 90 graduates indicated NWAHS as first preference.) This means that NWAHS, an already stressed system, may receive a disproportionate share of JMOs at risk of poor performance.

Here, I present a step-by-step overview of the processes and insights gained since the medical education officer (MEO) role was introduced at NWAHS in June 1999.

Establishing the drivers of distress

Following an alert, a wider context needs to be established. There is a need not only to check the information, but also to look beyond the obvious (eg, a seeming inability of the JMO to prioritise may disguise an avoidance issue and a host of other factors). Fact finding may involve talking with other members of the unit, or being aware of a particular unit's history with JMOs, and/or the "track record" of the person who initiated the alert, and of the JMO concerned. Of course, there is a need for discretion, whether enquiries are made directly or at a more casual level. Usually, an informal interview is conducted with the JMO to detail the issues raised and note any additional pertinent information. Once the facts are established and a picture begins to emerge, the underlying issues can be more clearly identified, and then decisions can be made and actions taken. The key drivers of JMO distress that have emerged at NWAHS are listed in Box 2.

Stressors may be external (ie, to do with the outer environment), or internal (ie, to do with inner processes at a personal level). An example of an important external stressor that is crucial to a JMO's experience is the quality and continuity of registrar presence on a unit. For example, how organised is the registrar? Does the registrar involve the JMO in patient management decisions? How willing is the registrar to teach and extend the JMO? How willing is the registrar to assist and support the JMO during busy periods? And, finally, how available is the registrar when needed? In this regard, the lead-up to physicians' examinations is a particularly stressful time for JMOs.

Other external stressors of note include bullying and harassment, particularly the way in which nursing staff can undermine a JMO (or a student). Once covert, these issues are now beginning to be more openly discussed. Having a supportive medical administration, too, can make a big difference to JMOs' sense of wellbeing. This has been clearly documented by end-of-year intern surveys conducted at NWAHS in 1999 and 2000. Highlighted issues included perceived unfair rostering and leave allocation, general unhelpfulness and discourtesy, and bullying and harassment issues.

One of the internal stressors listed, professional ethics, has emerged from interviews and end-of-year surveys of JMOs. Issues related to the constant pressure for early — sometimes perceived as too-early — discharge of patients; how "not for resuscitation" orders are interpreted by nursing staff on some wards; and, more generally, the way patients are routinely treated by some health professionals. By the end of the year, some JMOs report disillusionment with a system which they perceive is forced to practise "conveyor belt" medicine. Given that many JMOs entered medicine for altruistic reasons, these ethical issues are a source of distress.

Tailoring individual interventions

These assessments will influence decisions on how to tailor individual interventions to best manage each situation. Listed below are some of the strategies that have been implemented at NWAHS.

Clinical learning contract (Box 3)

When a JMO's difficulties are related to personal performance, it is most important that this is identified within the first month of an attachment. This allows time for the problems to be discussed by all concerned, a plan of remediation to be constructed, and a performance review to take place before the final assessment. Those involved include the supervising consultant and unit registrar, together with the JMO, and, at times, the MEO or DCT acting in a facilitating and supportive role. The clinical learning contract forms the basis for this process and serves as a simple, documented record of the JMO's progress.

First-line counselling strategies

Some of the first-line counselling strategies are listed in Box 4. The first few relate to general skills that are available to most mature and reasonably sensitive people willing to spend time with another person in distress. The second group applies to people trained in counselling.

Conclusion

Integral to the whole process, and the real strength of MEOs, is their independence from medical power structures and from direct involvement in JMOs' evaluation. The MEO, however, should be able to "network" and access hospital and medical authorities. To this extent, the trust placed in MEOs by all concerned (junior doctors, registrars, senior clinicians, and administrators), and the need for confidentiality and discretion, are complex and crucial factors. Professional integrity on the part of the MEO is paramount.

The Conference has focused on students and junior doctors in distress. However, it is artificial to consider the problems of students and JMOs in isolation from senior practising clinicians. To what extent are senior clinicians' performances and sense of wellbeing also affected by varying levels of distress; and of course this begs the question — does their distress have an impact on medical students' and junior doctors' wellbeing? We need answers to these questions.

  • Karen Grace1

  • North Western Adelaide Health Service, Adelaide, SA.


Correspondence: graces@picknowl.com.au

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