Caution! High tension

Tuva Stranger Mjønes About the author

I, and my friends with me, do not want to work ourselves to death. Are the health services ready for the new generation of doctors?

In a study by Fimland and colleagues, published in this issue of the Journal of the Norwegian Medical Association, students describe a discrepancy between what they consider important and what is expected of them in the workplace (1). The focus-group interviews indicate that the medical students’ motivation and need to be clever make them vulnerable to accepting difficult working conditions.

The fact that the interviewees are worried that in the future they will have to compromise on their own needs, should raise concern. Since there is still a great number of applicants for every place in medical training programmes every year (2), the reader (and politicians as well!) may have difficulty seeing the problem. We who apply to study medicine have an intrinsic motivation that has not yet been noticeably affected by unfavourable working conditions and the expectations that we will face in our future workplaces. Moreover, young doctors tend to be conflict-averse and perhaps also their own worst enemies (3): competing for positions which entail an expectation of productivity on the part of the employer makes it harder for them to express discontent that may arise.

Although the study by Fimland and colleagues is small, it may seem that it unfortunately describes a reality that will be widely recognisable, although not of recent origin. In 2016, during the doctors’ strike, the Dagens Medisin journal wrote that similar concerns were common among medical students (4). The doctors’ strike came about because of disagreement between The Employers’ Association Spekter and The Federation of Norwegian Professional Associations regarding the regulation of the doctors’ work rosters (1). Mutual trust between the parties had deteriorated, and the strike was brought to a halt by compulsory arbitration (5).

We let society believe that it is okay to work excessively long hours, too often and under pressure

Whereas it is common practice in many professions to ‘clock’ in and out when working overtime, the study from the University of Bergen describes a self-reinforcing vicious circle among employees in the healthcare services. Overtime is not reported because of a strong feeling of responsibility towards the next doctor to come on shift, and the workload to be done (6). Conscientiousness and a desire to avoid conflict take precedence over the values and attitudes that the doctors initially brought with them into their working life. It is a pity that this is the case in an occupation that is so much about showing empathy and seeing the needs of others. As future doctors, we need to be skilled in seeing what the patients need, understanding difficult life situations and respecting them. We have to show the same level of care in regards to ourselves.

By having excessive expectations regarding overtime and the pace of work, we ‘shoot ourselves in the foot’, in the words of one interviewee (1). I am not a financial controller, but if I were, I would be unable to guess that more doctors are needed if those who are there continuously overstretch themselves. As a result, we let society believe that it is okay to work excessively long hours, too often and under pressure – we allow everyone to believe that those five or ten extra hours do not exist. Consequently, we are not provided with more colleagues, and the pressure on our time persists.

The tension between intrinsic motivation and external conditions can be explained by a theory of motivation called self-determination theory (SDT) (1). This theory describes how cognitive dissonance and psychological discomfort arise when personal values and attitudes are in conflict with the environment. In 2017, the Young Doctors’ Association conducted a survey among its members, and the results revealed that one in every ten had fallen asleep involuntarily on a shift, and that four out of ten have insufficient time to rest between shifts and do not feel rested when returning to work (7). One in every five junior doctors works more than 60 hours per week. That is a good recipe for cognitive dissonance, if you ask me.

One in every five young doctors works more than 60 hours per week. That is a good recipe for cognitive dissonance

The medical students’ uneasiness are a clear sign that something needs to be done. The Norwegian Medical Students Association’s working life committee has long sought to improve the working culture in healthcare institutions. For example, they conducted the #kollektivtvern campaign, which addressed disorderly recruitment practices (8). Are the medical students of today, who want to take care of themselves as well as others, ready for the labour market that awaits them? As is so often the case, the answer is most likely both yes and no. Yes, because the students’ intrinsic motivation to help people and the desire to work in an interesting field are just as great as before. No, because there are far too many old habits that die hard.

We must dare to disagree with each other, without regard for rank and seniority. I will have the courage to defend my boundaries, and I hope that you who are listening will hear me. Moreover, I will take care of myself, so that I can take care of others.

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