Two months in the life of a junior doctor

I've seen people try to commit suicide. I've seen people die. I’ve seen dead bodies. I've seen miscarriages, cancer diagnoses, brain tumours, assault, rape. You know, all the nastiest things in society come through the doors and I’m the doctor that sees and speaks to these people about their horrific life situations… and it just strikes me that we see some real shi**y situations, on the verge of burnout … but there's no active follow up. And when you're tired and feeling near burnout, yes, the onus is on you to seek the help.

From the outside, the rewards of a medical career can seem plentiful - the work is prestigious, it might appear to be reasonably well paid, and, when things go well, it must be incredibly gratifying - you have saved or improved the quality of someone’s life. Even so, few would doubt that being a doctor is tough.  

Today’s NHS doctors have worked through a gruelling global pandemic, dealt with crippling staffing shortages, and continue to juggle high waiting lists. There is no doubt that all of this requires grit, determination, and resilience in bucket loads; and many doctors are saying they have simply had enough.  

In fact, it has recently been announced that junior doctors are overwhelmingly in support of a 72-hour walkout over concerns of poor pay. Just under 78% of those eligible came forward to vote, and 98% supported the strike. 

Junior doctors are arguing that they are under constant and unsustainable pressures, and that the pay just does not compensate their struggles.  

As an F1 [Foundation Year 1 doctor] I don't get paid enough. …I don't get paid enough to have people die on my watch. And, you know, be like verbally or physically assaulted by patients, and I think it's a lot of responsibility. I know there is pay progression as you go up, but I don't think it's enough.

It's that sort of feeling of like “well we don't value you, we don't value to your time, we don't value your night”. You know you need to pay me really well if you want me to work on a weekend when I work full time anyway.

So, what exactly are the working conditions that lead to burnout for junior doctors? And how are these stressors experienced day-to-day?  

Hearing directly from the doctors 

In the first study of its kind, (due to its regional sample, duration, and mixed method approach using both qualitative and quantitative data) colleagues and I set out to answer these questions in research supported by Health Education England and the UK Foundation Programme. We asked 58 junior doctors in their first and second years to keep an audio-diary for two months, making verbal entries of their experiences of stress on the days they experienced them.  

These doctors were based across the UK. They were also interviewed before and after this period. Overall, this meant that 118 interviews were carried out along with 745 audio-diary entries, totalling just under 1.2 million words and 6,400 minutes of audio data. 

The data show overwhelmingly that junior doctors faced high levels of stress across the period of the study – 81% of the sample reported experiencing days that they would describe as “very” or “extremely stressful”. This was true across specialities, ranging from accident and emergency, and geriatrics, to general practitioner.  

Despite anecdotal tales of “you’ll get used to it”, many doctors’ levels of stress persisted over time and often got worse. Alarmingly, negative experiences in the workplace often changed doctors’ internal cognitions (thoughts), which negatively affected the way they made sense of future events that they found stressful. This created a negative spiral of worsened stress over time and sometimes led to severe symptoms (intrusive thoughts, migraines - even hair loss).  

Numerical data also revealed that these sources of stress were chronic, and were consistently experienced across the eight-week period.  

Main causes of stress for junior doctors 

The top four most cited sources of stress amongst junior doctors were: 

1. High workload 

2. Understaffing 

3. Lack of senior support 

4. Interpersonal relationships  

High workload 

There were 339 references to high workload, making this the most common complaint, and something that affected more than half of the doctors in some weeks of the study. The challenges included excessive administrative work, high volumes of patients and long working hours.  

Doctors spoke about how this made them feel panic, despondence, and desperation – in one case, they said the workload for a junior doctor was worse in the UK than it was in their “third world” home country! 

It made me feel very panicked because they were all very ill. And they were close to dying, essentially. There was [sic] four patients that I was trying to handle at the same time, one that I was physically with who was imminently in danger, and three others that I was trying to manage, like over the phone with nurses on the ward. And I just didn't feel like I was, I felt like I was spread way too thin.

Yeah, it's just I shouldn't be showing up for work. I'm too tired. I've now worked 66 hours this week, and I've got another 10 hours at least tomorrow. And that's just ridiculous to be honest… I felt like I spent the whole sort of three and a half hours to be honest, just, just collecting jobs, and I sort of collected, you know, two jobs for every job I did. 

Like I come from a third-world country, right? And I thought that working in a first-world country would be much better than working back home and I don't think that's the case.

Understaffing 

Understaffing received 250 mentions within the audio-diaries. Junior doctors believed this was widespread, and experienced across the health service by nurses and junior doctors, right through to senior consultants: 

It's simply too exhausting to carry on in this department and everyone is aware of staff shortage but nobody can do anything unless the Trust hires new people…I was the only junior doctor and there was only one registrar. I left work late and felt so tired and drained.

In some cases, the recordings were harrowing as they reported how this led to severely compromised patient care. Such cases were clearly distressing to these doctors, who would express feelings of shock, guilt, and panic: 

And there was nobody on the ward, absolutely shocking. There was nobody in the bay… so you know, so this poor man just fell, and I was sat by the window, and I watched him fall, and it just made me feel so awful. His catheter came out. It was a complete mess. There was blood everywhere. One of the other patients who has dementia was trying to look after him, and we're trying to get him back to bed. So pure chaos. And [it] made me feel guilty that I watched it before but it was too far away, I got up and ran to him and shouted everyone… it could so easily be avoided if there was just enough staff. So sad, but that seems typical NHS.

Lack of senior support 

There were 231 separate reports of junior doctors feeling unsupported by more senior colleagues. In some cases, this related to the understaffing concerns, but at other times they found consultants were simply unwilling to help: 

I really felt properly unsupported… We had a patient who had a high potassium that could have been dangerously high and caused a heart attack. And I tried to contact all my seniors for advice, but absolutely no one would call me back or if they did, they didn't want to comment.

Often, this meant juniors were left on their own to make complex clinical decisions that they did not feel capable of making: 

A woman came in maybe having a heart attack, I looked at her ECG and wasn’t sure. Do I treat her as if she’s having one? Do I not? I literally don’t even know…so I just chopped up 300 grams of aspirin and hoped for the best… It’s really scary because if it was my Nan, I wouldn’t want someone who doesn’t know what they are doing look after her. I feel like I’m playing doctor sometimes.

Interpersonal relationships  

Alongside feelings of being unsupported, junior doctors also experienced stress through interpersonal conflict amongst colleagues. There were 202 mentions of confrontation and conflict in the audio diaries, between junior doctors and trainees, registrars, nurses, and consultants, and junior doctors frequently reporting being illtreated, belittled, and undermined: 

So basically, today, I've been shouted at for basically just moving… I basically have to hold something for four hours, I moved, she's not happy, I got shouted at for not moving the blade… We're tiptoeing around her, and it's just the environment is so hostile, it's so awkward and hostile. And it was stressful because I had to deal with that from eight to five, from eight to seven… It was a very, very stressful day. I also have been sprayed in the face with blood and medication because she was a bit angry - she threw a bit of a tantrum and that went on my face. So yeah, I just had to suck it up and I just stood there for the next hour or so. And then I just had to ask someone to basically douse my eyeballs with saline.

In a small number of cases, juniors even felt like they were being actively discriminated against: 

My main source of stress was the fact that my consultant was almost not talking to me, but talking to a male F1. And I, I couldn't understand if he was discriminating me as a female…so it upset me greatly during the job, especially because I'm really keen to learn, and I really want to know what's going on with my patients. The F1 joined us and the moment he joined, the consultant became suddenly very talkative. And so today, it really stressed me out.

The findings overall paint an alarming picture of the plight of today’s junior doctors. They highlight the harsh and unsustainable working conditions that junior doctors face in the UK, and show just how close many are to burnout early in their careers. While the study highlights a need to change structures, funding and working conditions that improve workload, staffing, and support systems, the findings also raise the question as to whether increasing pay alone is enough to alleviate the stress experienced by junior doctors. 

Our findings also show how there are both cyclical and cumulative consequences of experiencing these stressors. They affect how doctors rationalise new situations, and can create vicious cycles, perpetuating feelings of anxiety and despair.  

The benefit of an audio-diary study like this is that it captures how people are feeling in the moment. Using these data, we can begin to shed light on how burnout is actually experienced, and we can use this to inform preventative policy, as well as support packages and treatments that better protect junior doctors from the negative effects of stress.