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Rites of passage in medicine

The transition from medical school to a hospital job can be difficult for a junior doctor during their intern year. Studying independently as a medical student to being part of a clinical team and dealing with constant stress and patients, responsibilities, decision-making, and change of rotations can be incredibly demanding.

Dr Aisling Kelly graduated from the University of Limerick Graduate Entry Medical School and is currently interning at Tallaght University Hospital, Dublin, in the hope of potentially specialising in vascular surgery. On her first day, she witnessed first-hand the steep jump from medical school to the hospital. She describes her intern year as “being thrown into the deep end”.

“The first day of my intern year was nerve-wracking. My co-intern and I were literally running around the place… Simple things like ordering a scan for a patient take forever because you don’t know the system yet.”

She recalls: “I went to introduce myself to the consultant in theatre and he welcomed me onto the team and told me to put on a pair of gloves. Then he handed me a gangrenous black toe he had just amputated! The consultant made me feel like a part of the team. I felt comfortable enough to ask questions. By the end of the rotation, I had assisted in several different surgical procedures [such as] below-knee amputations — three times actually. It was an unlucky couple of weeks in terms of vascular reperfusions.

“Nothing can prepare you for the change in role from being a student to doctor. The level of trust, responsibility and independence is completely indescribable. You are immediately put in a major decision-making role where people are relying on you to protect them from harm, help them in their most vulnerable moments and bring them back to health.”

Steep learning curve 

Dr Eoin Kelleher is an anaesthesia trainee. His intern year took place at Beaumont Hospital, Dublin, where he is still based. After graduating from the RCSI in 2014, he spent his four rotations in anaesthesia, orthopaedics, endocrinology and neurology.

“I enjoyed all of my rotations but I enjoyed anaesthesia the most, which is why I’m an anaesthetist. I learned a lot and the doctors were good teachers. I found anaesthesia to be very hands-on and practical. The hardest part is doing your first experience on-call. There is a steep learning curve going from being a medical student — that is, a part of a team during the day with lots of support — to being less supported at night. The thing about intern year is that at the time, it is awful, but it’s awful for a couple of reasons that eventually go away and it seems to be awful because it’s your first time dealing with all these new things all at once. I think that it’s mainly the hours and a lot of stress that come with the job that’s hard.” 

Dr Neasa Conneally is a graduate of University College Dublin and knew from very early on in medical school that general practice was the specialty for her. She found her intern year to be an overall positive experience.

“I remember the first month being very tough,” according to Dr Conneally. “It’s essentially an administration job though, and I’m quite an organised person, so that stood to me. You’re also very supported in intern year by your team and it’s hard to get yourself into too much trouble, as long as you ask for help and advice along the way.”

On opting to train in general practice, she says: “The fact that you can have special interests in various fields and how it’s more flexible than hospital medicine all factored into why I chose general practice; it seems a lot more amenable to having more work-life balance and being able to do other things apart from work. That being said, it’s obvious that general practice is in a state of flux at the moment; I’m very interested to see how new GP contract negotiations pan out, if they even do at all, and I’m quite apprehensive of what kind of career I’ll find myself qualifying into in 2022.”

The stress that comes with medical school is obviously high, with exams and the constant pressure to perform, but when it comes to putting the learning into practice, Dr Kelleher says “the hardest transition is in terms of stress; your day-to-day stress is a lot higher, particularly if your job is very busy”.

“There are other challenges, like going from having to do things theoretically to then practising them on patients,” he adds.

“That comes with its own kind of pressure, but I think most doctors adapt to that. Most of the stress doesn’t come from patients, but from the job itself. ”

Coping with stress

Being an NCHD can be physically and emotionally draining. Dealing with stressful situations can also have an impact on a young doctor’s professional abilities. Dr Conneally believes that when tackling stress, the focus should be on the working environment rather than stress management.

“We shouldn’t have to be taught coping mechanisms from war veterans; working in a hospital shouldn’t be like going to war in the first place. Doctors don’t need mindfulness or yoga classes in the workplace; we need predictable and manageable hours with enough staff support and to be paid for those hours that we work.

“There are days when stress gets to you; when you’re on-call and you’re trying to be in three places at once or there’s a distressing case or an unexpected death and it’s important to be able to talk about those with colleagues or friends and family, or being able to access more help if you need it. As you go, you get better at leaving these things behind you at the door at the end of the day,” she continues.

Work-life balance

Getting the balance between their professional and private life can be difficult for doctors, especially when they are starting out.

“That is generally a huge issue for doctors in Ireland — trying to find that work-life balance,” according to Dr Kelleher.

“It is difficult. The hardest thing is, you start working a lot of nights or weekends and don’t really have enough time to go to the dentist or go food shopping or wash your own clothes, and you’re left squeezing that in the hours left in the evening. For many doctors, it’s hard to do the simple things, like keeping fit. Eating is difficult when you’re working late or weekends; when you come home, it’s very hard not to just eat take-out or binge. There really isn’t any magical solution other than to try and keep to healthy habits.”

Dr Conneally comments: “You become more appreciative of your weekends and evenings. It’s important during times when you’re really busy or when you’re on-call to organise something nice to do afterwards or to plan your annual leave so you have something to look forward to. Down the line, it will become more difficult, as I’ll be trying to juggle studying for exams and long commutes as I’m sent to work in different parts of the country. I’m not at that stage but I don’t know how people with young families manage it. I think there needs to be more account taken of doctors’ family and home lives; people have little say or forewarning over where they’re sent to work, which makes life very difficult.”

Burnout is a common issue faced by doctors and occurs when there is an increase in stress levels, which results in less productivity.

The Medical Independent (MI) asked the NCHDs how they battle physical and emotional fatigue.

“I think it is really important to be able to talk about your day when you go home. Some of the things you encounter during the day are pretty tough going and it’s not always healthy to hold onto them. I find talking about things helps me to let go and move on,” Dr Kelly says.

During Dr Kelly’s first year in medical school, she learned that keeping her body and mind healthy was essential, especially in the lead-up to exams.

“I worked so hard and neglected everything else. I wasn’t exercising, I was eating junk food, my sleep pattern was awful. I felt so burnt-out after those exams that I made a promise I would never do that again. So when the next set of exams came around six months later, I prepared large meals and froze them so that I had a healthy dinner every night. It is unbelievable how much better you can perform when you make time for maintaining balance. So I hope to continue these habits throughout my career.”

Dr Kelleher acknowledges that “fatigue is a huge problem, in anaesthesia in particular, because we do a lot of frequent calls and out-of-hours shifts.

“Often, there is lots of activity at night, emergency operations or someone giving birth and it requires an anaesthetist to be there. It’s important to always get rest on-call when you can; simple things like an eye-mask and earplugs make a difference.”

Dr Conneally says: “One issue that I feel doesn’t get enough airtime is that of doctors and other healthcare staff driving home when very fatigued after long shifts, which obviously puts ourselves and others at great risk. A lot of doctors commute, especially to the peripheral hospitals, and you hear all the time of people having near-misses when driving after night shifts.”

A study conducted by the RCSI revealed that there were high levels of dissatisfaction among NCHDs concerning working conditions, training and career progression opportunities in Ireland.

According to its Doctor Emigration project survey, 55 per cent of participants were not happy with their work-life balance and intended to work abroad. Also, 22 per cent of participants did not see themselves practising medicine in Ireland in the future.

“No job is perfect,” Dr Kelleher says. “I am conscious that doctors do have very stable employment in general in most countries and that the salary isn’t that bad but when circumstances aren’t right or you find yourself in a bad situation, it can be difficult. There are definitely things in medicine that aren’t safe for patients or for staff that do need to be changed and in particular, for mental wellbeing. Mental health requires the biggest change because if nothing else, a lot of doctors are emigrating because of the strenuous conditions. A lot of my college friends are in New Zealand, Australia and the UK. We can’t really afford that to keep happening, and it’s the same for nursing. There are a lot of complicated factors at play.”

GP crisis

The GP crisis in Ireland is deepening, with more recently-qualified GPs leaving Ireland in hope of better working conditions, but Dr Conneally believes that the doctor retention problem is one of a multitude of factors, including the lack of attractive posts, two-tier consultant contracts and the matter of general practice being unfunded and overstretched.

“A large proportion of my graduating year have just headed off to Australia and New Zealand straight after intern year and this has now become a rite of passage, almost like an extended J1, to do a bit of travelling and get some sunshine while they’re young and have fewer career and family commitments. I don’t think that this is in any way a bad thing — it should be welcomed.”

Dr Conneally, however, states that general practice, as it stands, is unappealing for new graduates. This is particularly the case in rural areas, where there is little access to community supports or tertiary care.

“I can’t see myself setting up my own practice after I qualify. I think that significant improvements would need to be made in contract negotiations before myself and many of my colleagues would consider it.”

Incidents of ‘tension’ and ‘bullying’

Under section 88 of the Medical Practitioners Act 2007, the Medical Council is obliged to inspect all sites where intern and specialist training is provided. Two sets of inspection reports were recently published by the Council. The inspections were carried out in nine hospitals across the Saolta University Health Care Group and the South/South West Hospital Group. The Saolta University Health Care Group report revealed that 36 per cent were partially compliant and 64 per cent fully compliant with the standards. The South/South West Hospital Group was 3 per cent non-compliant, 63 per cent partially compliant and 34 per cent fully compliant. Among the findings were interns being asked to perform duties above their grade and trainees being left unsupervised when a consultant was absent for a week.

Although there was a certain level of professionalism noted throughout all the sites inspected, incidents of tension and bullying were found. There were reports at Letterkenny University Hospital (LUH) of signs on the radiology department door saying: ‘No NCHDs’. According to the Council, it was recommended that the signs were to be removed immediately. In Sligo University Hospital, it was felt that nurses did not regard the interns as doctors “but as staff employed to carry out certain tasks”.

Mercy University Hospital (MUH) interns described disrespectful treatment by nursing staff and male interns reported that they received preferential treatment to that of their female colleagues from nursing staff while on-call. The Council encourages people to report bullying incidents and stresses in the reports that “all staff should be made aware that bullying is unacceptable”.

Overall, there were consistent issues found with interns obtaining consent from patients. The Council raised concerns about the frequency with which interns were asked to seek consent on behalf of their senior colleagues.

In MUH, it was noted that interns were asked to take consent for medical procedures that they were not familiar with.

Concerns about intern facilities on hospital grounds frequently came up in the reports. Legionella, a pathogenic group of gram-negative bacteria, had been found in the on-call shower facilities next to the intern residence five days prior to the inspection at Waterford University Hospital. It was revealed that management at LUH had suggested moving some of the rest areas for sleeping, as the “new ward-based rota is designed to offer 12-hour shifts at a time” and convert some of these rooms/areas to management offices, which would mean there could be no rest breaks. WiFi and library standards were another consistent concern across all nine hospitals.

Portiuncula University Hospital (PUH) interns reported that they were not being provided with training in a certain procedure because their trainer did not have the required skills themselves. It was found that trainers had a “lack of willingness to train” the interns.

Similar issues on non-compliance have emerged in both reports across all nine hospitals, especially around the area of protected training time, which is an area of concern for the Council. The reports revealed that there was no protected “bleep-free time” for interns attending educational sessions, resulting in “little time for educational practices”. The Council recommended that the interns have one hour, two days a week, of bleep-free time for study.

The Council has raised concerns regarding access to protected training time for trainers with the HSE’s National Doctors Training and Planning Unit, the Forum of Irish Postgraduate Medical Training Bodies and the Department of Health. In places like PUH, trainers discussed having very little structured support provided to them due to occupational demands and said it is not always possible for them to be released from their clinical duties to attend activities that support them in their training requirements.

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