One of the most distressing parts of my years working for the Association of Salaried Medical Specialists was when there was a member suicide. These tragedies were infrequent and invariably due to a range of factors. But they were a constant reminder to me of the extreme pressures on a highly trained vocational and ethically driven workforce most of whom experience life and death on a daily basis.
Specialists diagnosing or treating make daily decisions that affect whether their patients are harmed or not, cured or not, have a reduced quality of life or not, and often whether they live or die. Further, they have to perform at a level of excellence (this significance is often minimised by the more commonly used word of competency).
As a union advocate I could make mistakes that at worst disadvantaged or inconvenienced others. Specialists don’t have this relative luxury. Their normal routine involves the risk of mistakes no matter how small leading to physical harm or death to others.
But it isn’t just about mistakes. Most avoidable adverse patient outcomes are due to systemic failures including workforce pressures. Whatever the cause of an adverse outcome it can be heart-breaking. It is very difficult to imagine a more potentially stressful occupation.
The Coroner has just reported on the suicide of 47-year old Dr Richard Harding, an anaesthetist and intensivist at Whangarei Hospital on 23 October 2017, a year after coming to New Zealand with his family from the United Kingdom. His suicide was obviously devastating for his family, friends and colleagues. It would also have been devastating for the management (including chief executive) of Northland DHB which employed him.
The Coroner reported that several factors contributed to Dr Harding taking his life. He had suffered depression in the United Kingdom. Moving countries had added to this. But there were also work pressures affecting him.
In my time with ASMS I occasionally came across or heard of specialists recruited from the United Kingdom who struggled with the work pressures in New Zealand. Largely due to the significant difference in population size (critical mass) they found that they worked after-hours more often and with less support because of smaller numbers of specialists and registrars.
This particular pressure on UK recruits was more so in hospitals the size of Whangarei and smaller. It was a struggle to adapt to the relative inferior and less safe working environment. Some then migrated to Australia which had a stronger critical mass advantage.
Dr Harding was clearly aware of his vulnerability. He was being treated by his general practitioner and a psychologist. He was sleeping poorly and working more after-hours (including being on-call) than he was used to. But work pressures received a “somewhat fragmented response”. Eventually he was “overwhelmed with the effects of anxiety and depression”. The Coroner was not critical of Whangarei Hospital but did refer to the tragedy as “a comment on the systemic environment.”
Systemic environment of specialist shortages
The ‘systemic environment’ that Dr Harding and other specialists were working in was one of severe specialist shortages. The Coroner focusses on the stresses of being an anaesthetist and intensivist. While justified, it also applies to other specialists diagnosing and treating hospital patients.
According to ASMS rolling surveys of clinical leaders DHBs have average shortages of around 24% (much higher than the bureaucratically compressed official vacancy rate). Northland DHB’s specialist shortages were as high as 36% in 2019. Shortages of this magnitude lead to an overworked and overstretched specialist workforce because there is no patient demand tap that can be turned off, especially for emergencies, acute admissions and chronic illnesses.
Fatigue is an evitable outcome. So is the more serious outcome of when ongoing fatigue deteriorates to burnout. The only national survey of specialist burnout in DHBs revealed a shocking level of 50% reporting having been burnt out. The response of successive governments has been zero while in DHBs it has been underwhelming.
The practice of medicine should be so professionally and ethically rewarding that job satisfaction should be high. But, in an environment of severe shortages and high burnout, increased job dissatisfaction is instead an outcome and a significant contributor to around 24% of specialists intending to leave DHB employment within a five-year period.
Inaction with aroha is cynical cruelty
It has to be recognised that that usually there is more than one reason behind suicides. A range of factors often contribute including personal and work-related. Workloads and associated consequences such as stress and burnout can be a factor including either the main one or the one that becomes the tipping point.
Specialists involved in the diagnosis and treatment of patients in hospital settings are by their very nature more vulnerable than most other occupations to anxiety and depression because of what is at stake, including risks of patient harm or loss of life. There isn’t much that governments can do about this.
However, governments have a responsibility to ensure that those working in this vulnerable position in the public health system don’t have the additional unjustifiable and untenable pressure of workforce shortages. Governments have a responsible of care.
While much (not all) of the responsibility for specialist shortages rests with the former National led government, responsibility for correcting it rests with the Labour government. It should ensure that shortages, burnout and reduced job dissatisfaction are not the specialist workplace reality and not a contributor to whatever degree to the extreme outcome of suicide.
The Prime Minister has eloquently and repeatedly advocated the need for more kindness in New Zealand. This is commendable. But inaction with aroha to the specialist workforce isn’t kindness; its cynical cruelty.