Dr Matthew Roycroft, a specialty registrar in geriatric medicine working in Yorkshire and the Humber, discusses the potential mental health trigger points for trainee physicians.
Mental illness is brought about by a complex interplay between biology, social factors and circumstances (1). Even if we assume that medical trainees are no more predisposed or vulnerable to mental health issues than any other population group (and this is by no means definite (2)), those undertaking postgraduate medical training frequently experience loss of protective factors coupled with many acute stressor events – a recipe for developing work-related stress and mental illness.
While the nature of the working and training environment is frequently a difficult one, work must not be seen in isolation – trainees, commonly aged in their 20s and 30s, are going through a time of significant flux in their lives, often with loss of previously created stability. It’s easy to see where the loss of protective factors, particularly social ones, comes from: friendship groups, often established over years at university, undergo rapid change as people frequently move about the country (or further afield), and the nature of relationships changes as people reach different points in life at different times with major events like marriage and children fundamentally altering previously stable social dynamics and often leading to loss of support structures. These changes are even more significant for doctors moving to a new country as it’s commonly coupled with distancing of family and an alien social environment. At the same time, as support groups change, major life events, well recognised as major mental health stressors, become increasingly common: close family members age and major health issues occur; and key relationships undergo more change in this group than any other with the rates of both marriage and divorce higher peaking.
The working life of a junior doctor in the UK in 2020 is dominated by a story of instability, a lack of belonging and loss of control – all major obstacles to wellbeing (3) with superimposed regular stressor events. Professional identity rapidly changes especially in early postgraduate years and trainees slowly realise what being a junior doctor is really like and the difficulties this can create with many personality types that coped well with it at university. Short rotations and the loss of the old firm structure has led to fewer opportunities to develop friendships. This is especially true in higher specialty training when people often rotate in isolation and there’s no guarantee of geographic stability from one post to another with doctors having to move house or commute long distances even when not changing deanery.
The major work-related stressors are focused in four key areas:
- critical incidents/events (actual or, just as significantly, perceived)
- examinations – which are stressful in themselves but also have a high failure rate – something that’s dealt with very badly by many junior doctors who often haven’t failed at much in their lives
- job applications – again a stressor in itself from the preparation through to finding out the outcome (including whether one has to move about the country) and again coupled with possibility of failure
- annual assessments of progression with the continuous assessment that this creates.
Finally, there are areas more indirectly related to the job: long hours leading to difficulty pursuing hobbies and seeing friends and maladaptive behaviours we commonly see in junior doctors: excessive alcohol consumption and lack of prioritisation in sleep.
The prevalence of mental health problems and disorders is always going to be high among junior doctors but the realisation of just how common they are, the normalisation of them and the de-stigmatisation is something only now starting to happen. It’s only this increasing recognition that allows something to be done about it from both an individual but also a system-wide perspective.
- Kinderman P, Schwannauer M, Pontin E, Tai S. Psychological processes mediate the impact of familial risk, social circumstances and life events on mental health. PLoS ONE 2013;8(10).
- Cantopher T. Depressive illness – The curse of the strong. Third edition. London: Sheldon Press, 2012
- General Medical Council. Caring for doctors, caring for patients. GMC, 2019.
Find out more
The RCP’s Mental health and wellbeing resource aims to support physicians to stay well and seek help when needed by opening up the conversation about mental health issues and their impact.