The path to sustainable working conditions for doctors



    Doctors' working conditions have received significant attention this summer. The Norwegian Medical Association and employee representatives are continuously working on this topic. However, we are still a long way from being able to ensure a healthy and safe working environment, a culture of professional and emotional support and openness, as well as equipping individuals to fulfil the responsibilities of a doctor.

    The death of a young, overworked colleague has triggered fierce engagement among doctors. In June, the interest group '#legermåleve' (doctors must live) was formed, and a media campaign with the same name is highly visible in national, local and social media. The stories shared under #legermåleve clearly show that many doctors have challenging working conditions (1). Even before the campaign, doctors were sending distress signals from the frontline (2–4), covering broader issues than just a lack of toilet breaks (5).

    A total of 2700 doctors and medical students are currently members of the Facebook interest group #legermåleve. The subject is engaging doctors in all stages of life, regardless of gender, age, specialty, workplace and political affiliation. The doctors who share their experiences tell of their love for their job, but also of their despair, desperation, powerlessness and shame. The idealists have become disillusioned, the empathetic are becoming indifferent.

    Doctors themselves report that there is a connection between their well-being and their ability to provide optimal patient care (6). We need doctors who are thriving at work and who can stay in the profession for the long haul. The Norwegian Medical Association has referred to its support programme for colleagues and Villa Sana (7). However, there are strong indications that these support programmes are still not enough.

    The average age of those seeking help from Villa Sana has decreased in recent years (8).

    Tough working conditions and moral injury

    Tough working conditions and moral injury

    There is no doubt that many doctors experience tough working days and nights in our hospitals, medical practices and emergency clinics. Media coverage has been dominated by the organisational aspects of doctors' working conditions. The Working Environment Act also applies to doctors (9). Its purpose is 'to ensure a working environment that provides a basis for health-promoting and meaningful working conditions, and ensures complete protection from physical and mental harm' (10). Doctors are admittedly exempt from some of the provisions on working hours, but the provisions that were intended to ensure good working conditions despite these exemptions are not sufficiently upheld. This responsibility lies with the employer. The stories from #legermåleve suggest that the framework is being challenged (11).

    It has been suggested that we stop talking about burnout among doctors, and instead discuss moral injury

    This is not just about the number of excess hours spent at work with demanding tasks; the content itself is contributing to the disempowerment that many clinicians experience. The stories about burnt-out doctors, many of which were told under the #legermåleve tag, reveal a systemic problem within the health service.

    It has been suggested that we stop talking about burnout among doctors, and instead discuss moral injury (12, 13). Moral injury occurs when someone has to disregard their own professional and ethical values over time in a way that causes a mental burden. By replacing burnout with moral injury, we redefine the problem and therefore also how the problem should be approached. Burnout implies that the problem is individual and that the solution is also therefore individual. Moral injury is a consequence of systemic failures, where the solution is systemic change.

    From patient focus to profit focus

    From patient focus to profit focus

    One of the major systemic failures is the disconnect that we doctors experience between what should be the professional content of our job and the framework in which we have to execute it. Doctors find themselves working in systems that counteract their professional engagement, with managers who are detached and do not listen. Meanwhile, as the number of tasks and their complexity grows and patient influx increases, hospital doctors in particular have less control over their own work domain. This issue was put on the agenda of the health service action group Helsetjenesteaksjonen as far back as 2013 (14).

    Hospitals' focus has shifted from doctors' professionalism and good clinical practice to hospitals' profitability, with an increased utilisation of doctors as mere producers of health care, based on the notion that 'efficiency improvements lead to quality improvements' (15). The desire to be thorough in their work is challenged when the primary concern is the speed of service delivery.

    In my specialty, radiology, it is easy to determine that the requirements for quality and efficiency are often at odds with each other. As diagnostic complexity grows, so does the expectation to work faster, whilst the resources remain the same. Mechanisms within the organisation of health services that might underlie excessive diagnostic activity were well described by Wyller earlier this year (16). Driving forces are pushing for shorter observation times, broader assessments earlier in the course of illness, quicker clarification and also faster discharge of patients. Guidelines are used as algorithms, and there is no room for reflection on resource use and the benefit to the individual patient. Rushing through assessments leads to a flood of examinations that could safely be done at a later time, masking what is truly urgent.

    Rushing through assessments leads to a flood of examinations that could safely be done at a later time, masking what is truly urgent

    Working under conditions where good clinical practice is not given sufficient space within the framework, and where staff feel pressured into compromising on quality, is taking its toll on us. The combination of increased pace, heavier workloads and diminished professional influence leads to overload and moral injury. Doctors need to be able to influence their own working day.

    Life is more than work

    Life is more than work

    The doctor is no longer a man with a stay-at-home wife. The expectation that life should encompass more than just work has also changed in recent decades for both male and female doctors. There needs to be scope to be more than just a doctor. Doctors also want leisure time, time for other relationships, or to care for children or ageing family members. Time constraints do not only impact on doctors, but their effects are particularly felt when working hours are too impractical or long to enable a work-life balance. Some doctors struggle with their own health problems. Flexibility would allow more doctors to sustain their roles. During challenging life phases, doctors must be given more choice in their workload, in line with the employer's obligation to accommodate employees' needs (17).



    Doctors, as a group, are conscientious to the point of self-effacement and have a tendency to blame themselves for perceived inadequacies (18). We can be perfectionistic and conscientious, putting our own needs aside to provide good patient care. When the workload becomes overwhelming, we try to increase our own work capacity. These qualities can be strengths, but the diminished ability for self-care creates a vulnerability that can increase the risk of mental health problems. The consequences can be serious if our identity is rooted in mastery and control. Guilt and shame for not measuring up add an extra burden. The perception of doctors as superhuman is likely something we as a group have inadvertently cultivated. Disdain for our own weakness and fear of showing vulnerability can also affect the way we interact with patients (19).

    Villa Sana is a high-quality resource. Its content is well tested and is beneficial for weary doctors. Knowledge from the professional community around Villa Sana should be utilised more extensively for prevention and to enable medical students and doctors to recognise the mechanisms of burnout and increase their knowledge of self-care.

    Social support acts as a buffer against the strain of high demands and little control. The #legermåleve stories unfortunately suggest that not everyone receives this support from their colleagues and managers. The doctor culture has major potential for improvement, providing an opportunity to reflect on our own practices.

    The Health Personnel Commission states in its report that 'a manageable workload, well-being, motivation and professional development are important for recruiting and retaining employees' (20). This is an essential realisation that must be taken seriously. Well-being is about how we get on with each other, how we communicate and how we support each other. Strong relationships require work.

    Doctors are particularly vulnerable in the early stages of their career. Throughout history, junior doctors have been told that 'things were worse back in the day'. In many hospitals, it is still socially accepted that junior doctors are reprimanded in front of other people. In some places, junior doctors are even afraid to contact the doctor on call, which compromises patient safety. Insecurity creates a poor learning environment (21).

    Doctor colleagues should aim to be a resource for each other and share their experiences. Everyone has a responsibility to look out for colleagues and help create a culture of effective communication; however, older doctors should feel a special responsibility. Junior doctors need care, a safe environment, adequate training and professional support.

    Investing in the working environment

    Investing in the working environment

    With continuously increasing demands on the scope and content of medical services, a significant focus would be expected on retaining expertise within public hospitals. When employees are not listened to, the employer risks depleting departments of skilled professionals. Private operators often offer more leisure time, more autonomy and better pay. Public hospitals and medical practices must be attractive and competitive if they are to retain their doctors.

    When employees are not listened to, the employer risks depleting departments of skilled professionals

    Highlighting doctors' working conditions can hopefully accelerate the necessary change processes. #legermåleve has heightened visibility of issues that are already being addressed but have not yet been fully resolved. The campaign has also made a valuable contribution to the culture of openness, which in itself can be a source of support for individuals.

    It will be interesting to observe how trade unions, local union representatives, central health policymakers and employers will contribute to improving conditions. We have a shared responsibility to be good colleagues to each other. Sustainable working conditions for doctors are essential, not just for the doctors themselves, but for maintaining good-quality health care for the benefit of society and patient safety.

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