Does stress have a lasting impact on junior doctors?

Junior Doctors in England went on strike last month for the second time this year, following March’s strike action primarily over pay restoration.

The first blog post in this series shed light on the brutal working conditions that junior doctors experience and the main causes of work stress, including a high workload, understaffing, lack of senior support, and interpersonal conflict to name a few.

But do doctors get used to these stressors? Do they become desensitized as time passes?

Our research is in a unique position to answer these questions as we tracked 58 junior doctors from across the UK over two months. These doctors recorded voice notes on their smartphones when they experienced traumatic work incidents, and were also interviewed before and after making the audio diaries to dive deeper into these experiences. After analyzing 745 entries and 118 interviews, we identified three pathways:

Adaptation by experience

Over time, it was found that some junior doctors tended to report less severe stress when the same stressor was repeatedly encountered as they gained more experience of the workplace. One example comes from a doctor who struggled with a high workload early on in their rotation:

“So I actually got so stressed I started crying because I started crying while I was doing the notes. But it's just like it was so overwhelming. And there was so much to do, and there was only me alone. Impossible.”

Three months later, the same doctor reports that significant leaps in learning had taken place which reduced their stress:

“But now I think … well, if I don't finish it, someone's gonna do it. So I'm not even gonna try and kill myself doing this… it's experience. So I think you know, dealing with difficult things. You know that got easier”.

Functional sensemaking

A reduction in stress was also found in doctors who, when faced with a persistent stressor, engaged in a process of making sense of that stressor. Usually, this included the stressor challenging trainees’ views of themselves, others, or the world such that they interpreted new experiences in the context of these (sometimes for the better).

For instance, one junior doctor speaks of a difficult moment with a colleague on day 19 in her diary:

“One of the anaesthesiology assistants is very, I find it very challenging to work with her. Because she, I feel like sometimes she's treats me as if I'm still a medical student. And she would, in front of the patients always give me advice… and I feel like this is very disrespectful, and also sometimes puts me in a bad light in front of the patients because as a patient, I would feel a bit insecure if the, the doctor treating me or performing a procedure on me, was kind of being told off by one of the other healthcare professionals. So that really stressed me out.”

On day 52, however, the doctor appears to be rationalising the same source of stress with newfound beliefs surrounding the situation that developed prior.

“I just feel like my perception has changed. And that enables me to not take things personally, because I've also observed them interacting with others. And then I'm seeing that it's not about me, but it's just a different type of personality, helps me. And so the thing is, I can't change her. I don't feel like I get as heated, and my heart starts pumping, but I feel like I can stay”

Dysfunctional sensemaking

Just as sustained encounters to particular stress sources brought about a pattern of functional thinking over time, the reverse was also found. Some doctors persistently faced the same stressor, making their internal views of themselves or their jobs more negative. Over time, this worsened the stress experienced as individuals drew upon these views as a guiding framework. One doctor’s account shows how this transpired over time:

Day 2: “And there was a scream from a toilet, a cubicle toilet in the corridor…a large female patient was trying to strangle herself with her phone cable. And the door was kind of almost jammed shut. So had to kind of barge my way in, and then help the staff battle to get this phone cable off this lady who was going very purple-faced…and then I had to spend two hours talking to this suicidal, unstable lady. I've seen her five times, five or six times since and every time I see her, it's just this instinctive, tragic reaction.”

Day 47: “The amount of suicide attempts I see. I just have realised this kind of unwanted intrusive thoughts about all the people you see who commit suicide or attempt to commit suicide by paracetamol and the 94 year old who did a real serious job and then slit her wrists as well and it really builds up. I don’t think I’ve actually had the awareness or insight to acknowledge that.”

Day 98: “It triggered a lot of unhappy thoughts as well from all the other previous patients I've seen who are sexually assaulted or who attempted suicide and those kinds of things. And then that suddenly became a really big deal for me. I had no idea…I didn't understand what intrusive thought was until after that patient. Then I literally couldn't control my thoughts about the patients I see at work and that was really horrible. Kind of having all the really dark things that you've seen come back into your mind without being able to control it. And that was really nasty.”

Overall, these findings show that although the strain arising from certain stressors may be adapted to (eg via experience), this is by no means an inevitability. As the data indicates, stressors can alter the way doctors’ internal thought processes play out, leaving them more susceptible to perceiving new situations as threatening. This can perpetuate vicious cycles of stress.

Implications

Much research and treatment focuses on helping doctors once they have already burnt out or have experienced some kind of trauma. The real value of this study lies in the fact that by using the diaries, we were able to collect data in real-time and see how the doctors’ thoughts, behaviours and feelings developed over time. In doing so, we are beginning to understand why and how doctors can experience similar things but for some, the effects are catastrophic (eg developing PTSD or burnout), while for others, they don’t seem to be affected much at all in the longer term.

This means that we can start to change the conversations happening here, by anticipating and intervening earlier to help avoid the severe effects of more complex mental health conditions. Challenging these negative thought patterns early, before they become reinforced, appears to be vitally important in this regard. Recognition by doctors themselves of this negative pathway is also crucial so that doctors can self-refer to minimise the effects of longer-lasting mental health issues.