'The situation at my hospital is dismal': lockdown reveals junior doctor burnout
During the lockdown, concerns over inadequate personal protective equipment, conflict with management and extreme fatigue have painted a dismal picture of SA’s public health sector, but young doctors who have faced the worst of this failing system are not about to give up, writes Sean Christie
I work in communications in the medical sector and during the lockdown period it was not uncommon for two or three of the many junior doctor-contacts on my phone to be simultaneously posting WhatsApp status updates while on call. I began to notice some trends — concerns over inadequate personal protective equipment, conflict with management and extreme fatigue.
“Headphones on dancing furiously to psy-trance in a cassava patch only way to process last call,” one doctor breathlessly reported from Mpumalanga, where he is doing community service in a rural facility. As the peak period of the epidemic washed over, updates from one contact in particular — Dr Zolelwa Sifumba — dropped with a frequency that amounted to life narration.
I became absorbed, and quite concerned, and, because there is something voyeuristic about passively reading the updates of people you don’t know that well, I reached out.
“The situation at my hospital is dismal,” she responded. “Constant belittlement of junior staff by seniors and it simply isn’t a safe environment.”
Sifumba has had a rough ride through her relatively short medical career. At medical school in Cape Town she contracted multi-drug-resistant tuberculosis (MDR-TB) while doing clinical rotations in local hospitals. Her future in medicine teetered in the balance through 18 months of harrowing, toxic treatment, which left her depressed and angry.
She maintains that she and fellow students were not adequately warned of the hazards to which they would be exposed. When she spoke out, it led her faculty to radically overhaul its occupational health approach. In July, Sifumba, now employed by the department of health, was fixing to make more noise.
“Covid-19 has exposed a lot of issues in SA’s health system but something that has remained largely in the dark is the deep unhappiness of many junior doctors during this time and in general. This needs to change,” she said.
Junior doctor burnout
What changed, in early September, was the nature of Sifumba’s update messages. Gone was the palpable despair. Instead: song screenshots, family pictures, makeup selfies. We arranged an after-dinner catch-up call, during which she broke off to have a loud isiZulu exchange, repeating “ngenza i-Interview” (I am in an interview) over and over.
“Sorry, I’m currently in this clinic and a nurse wants to know why I’m sitting where I am, talking on the phone.”
I was slow to understand.
“I’m in a mental health clinic, Sean. I’m a whole junior doctor and I’m burnt out already. Like, how?”
After overcoming MDR-TB and completing her studies, Sifumba had begun her three years of compulsory state service — two years of medical internship followed by a year of community service.
Her final year, 2020, had not gone well. There had been a car accident, a period of recovery, and then Covid-19 and the lockdown, at which point her fears and frustrations had begun to ratchet up. In short, she felt that too little was being done to safeguard hospital staff from infection and other risks, and her complaints to management and later the South African Medical Association had brought nothing but interpersonal conflict, fanning her anxiety to the point of debilitation.
“You expect that the system that you’re in is going to protect you, but as somebody told me, health care and the health-care system are two different things,” she said, and after a pause: “I’m done with clinical medicine. I’m leaving because it’s not worth my life.”
Bullying, mistreatment and discrimination
The issues that led Sifumba to this sad moment are the subject of a soon-to-be-released documentary called Behind the Frontline, produced by Dr Adil Khan, which stitches together testimony from junior doctors and experts in occupational health in order to tell how “the underlying bullying, mistreatment and discrimination inherent to the medical profession” are driving many young medical professionals, who already work in high-pressure environments, into states of illness and despair.
'Behind the Frontline' tells how “bullying inherent to the medical profession” is driving young medical professionals into illness
The work is the audiovisual equivalent of a distress flare, and it is distressing — no less so for the fact that the issues have been raised before. In 2019, there were several reports about racism and bullying in two Pietermaritzburg surgery departments, while 2016 — the year intern Ilne Markwat died when she crashed her car on her way home from a long shift at Paarl Hospital – saw a series of films, videos and articles traversing many of the same themes.
In 2014, Maria Phalime published Postmortem: The Doctor Who Walked Away, her moving account of burning out in a broken system, and in fact as far back as the early ’80s a national survey of young doctors flagged issues like long working hours and a lack of formal training and showed how these contributed to a loss of enthusiasm for medicine among interns.
On a lunch break, Khan, who has quit clinical medicine and now works as an advisor in the insurance sector, argued that clinical medicine is stuck in a repetitive cycle of “patriarchy and toxic hierarchy”, where seniors have a sense of authority and a habit of demeaning those below them, and those on the lower rungs then perpetuate this behaviour once they rise in the system. “For years the learning model has been trial by fire, where it is assumed that the consultant will blast the medical officers, and the medical officers will blast the interns, but this runs contrary to what we know about where concrete learning comes from — positive reinforcement, slow teaching, not just instilling fear.”
Breaking the cycle
For Khan, the Covid-19 moment presents an opportunity to break the cycle. “South Africans understood that flattening the curve was everyone’s job, and we are saying let’s expand that idea of collective responsibility for health care a bit further because if we want to truly strengthen the system and ultimately improve patient outcomes, then we need junior doctors to feel supported, get enough sleep and draw satisfaction from their work,” he said.
The documentary builds its argument with anecdotes, with the exception of inputs from Wakithi Mabaso and Stefan van der Walt, two junior doctors who researched the burden of depression and anxiety among medical students at the University of Cape Town.
“We reported a rate of one in four students being diagnosed with depressive disorder and one in five being diagnosed with anxiety disorder, which is much higher than average for this age group,” Mabaso said. And while there is little in the way of equivalent published research on mental health issues among junior doctors in SA, Mabaso said: “We can assume a similar picture. A substantial body of evidence and international research show that doctors are disproportionately at risk of depression and anxiety disorders.”
There has been a tendency among more senior doctors in SA, as elsewhere, to put the uptick in mental health diagnoses down to the frailty of a “snowflake” generation, but for Dr Celeste Jonker, who was recently in charge of one of the Western Cape department of health’s Covid-19 field hospitals, this misses the point.
“I confess I have at times, even as a youngish doctor, felt that the new generation has a different concept of work and what is acceptable and what they’re willing to do, but the fact of the matter is that it is not unreasonable or unrealistic for them to want to be supported.”
There has been a tendency to put the uptick in mental health diagnoses down to the frailty of a “snowflake” generation
Failure to do this will inflict serious harm on the system as a whole, she believes. Of the six interns that Jonker worked with at Victoria Hospital in Wynberg in 2014, four, she has heard, are not in medicine any more.
“Aside from everything else, that’s not a good return on investment after only three years,” she said.
Across the country in Pietermaritzburg, Dr Nhlakanipho Gumede, clinical manager at Edendale Hospital, said the situation for junior doctors had changed since he was an intern.
“A decade ago you could expect an immediate offer of a registered post after completing your three years of compulsory service. Today, young doctors are waiting up to four years for a post. Departmental funding has dropped, so junior doctors are expected to do more work with less supervision. It’s no wonder they’re complaining,” he said.
During the two years of medical internship junior doctors are supposed to have prescribed rotations through a range of medical domains such as obstetrics and gynaecology or paediatrics, in order to inform their thinking about future specialisation.
“I can tell you that this model is not functioning as envisaged in many places and junior doctors are having to decide where it is that they want to take their careers but without adequate exposure to the choices,” said Gumede.
When I last contacted Sifumba, she sounded positive.
“Things are happening. I’ve helped to found an initiative that will provide multifaceted support for junior doctors, the kind of support we actually need, not what others think we need.”
The initiative, under the working title of KZN Intern Mentorship and Support Programme, is the brainchild of and is being championed by professor Ncoza Dlova, the dean of the School of Clinical Medicine at the University of KwaZulu-Natal.
In September, the programme, supported by Investec, launched a series of mentorship seminars that will cover topics suggested by a committee of interns, such as financial management as well as soft skills like self-care and mental wellness.
“Being a mother with natural maternal instincts, I felt that young doctors in their three years of compulsory service are left to fend for themselves, not literally but in terms of guidance and support, and I felt that there is a gap that the universities can fill for those who are doing their compulsory service nearby,” said Dlova, the only female among the country’s 10 medical deans.
What makes the mentorship initiative more than just another seminar series is the opportunity junior doctors will have to further their practical knowledge of medical specialties. Dlova has asked the heads of departments of all 27 disciplines at the medical school as well as keen private sector specialists to attend the seminars and to support any intern or junior doctor wishing to learn more about their particular area of expertise.
“On weekends or on holidays those junior doctors who already know what path they want to pursue would be welcome to sit in on academic meetings, join ward rounds, theatre slates, and participate in departmental research. Some of the interns who attended our first workshop have already partnered with cardiologists and psychiatrists — opportunities that can be difficult for interns to facilitate on their own,” said Dlova.
Role for academies
In numerous published works, professor Steve Reid, who heads the primary health-care directorate at the University of Cape Town, has pointed out that though internship is legally part of professional training in SA, it curiously does not involve universities, whereas in many other countries it does, and the greater involvement of tertiary educational institutions appears to benefit the learning and development of newly qualified doctors.
For Reid, a role for the academy in medical internship makes sense. He has also long called for a clearer picture of what becomes of junior doctors after their years of compulsory service so that interventions at university can be better matched to the external reality
“A national database on health professionals showing where they end up would enable research on what interventions work — other countries have very comprehensive databases for exactly this reason,” he said. However, the Health Professional Council of SA — the only body that can follow practitioners over their lifetime — doesn’t seem interested in doing this.
For Khan, inspired leadership and accountability are needed for necessary value transformation to happen in the health system and he sees the sustained visibility of the issues faced by junior doctors as the start of this.
If there is something missing from the testimony of the young doctors in his documentary it is perhaps some recognition that the flip side of the pain they describe is, inescapably, resilience, which arises from reflection on challenging circumstances and then doing what you can within your own circle of influence to ensure that you get by.
It doesn’t seem too far a stretch to imagine a link between Khan’s documentary, Sifumba’s mentorship initiative and the junior doctor managing a postpartum haemorrhage in a hinterland hospital right now, unsupported and having only been shown the techniques a couple of times.
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