Medicine training is like an abusive relationship

For those who go through the trials of getting into medicine training, they are aware that the relationship they have entered deserves their respect. But what they don’t realise is that it is still hampered by inequalities that make it impossible to emerge from unscathed. Just like domestically violent relationships, there is a sense of personal shame if you are unable to tolerate the structural abuse and lack of ability to control your working life.

It starts with the expectation that medicine is now your life. Sure, there is lip service to work/life balance but the public health system is structured to disadvantaging those who want to work part time, as they miss out on overtime rates till they do full time hours but still do overtime at regular pay rates. Because the system is underfunded, there are staff shortages that can’t be filled if a trainee takes time off, so often they work to help their colleagues, to the point of personal detriment. This sets up a martyr situation from the beginning.

Then there is this expectation of being a leader because you are a doctor; however, really you are the newest member to the group so you rate the lowest in the pecking order. You are a trainee and only have 3-6 month rotations, whereas the team are all in permanent positions and have an established culture. This creates a strange tension whereby the teams are exhausted, having to deal with each trainee who doesn’t know what they are doing but are trying to establish their position in the group. This leads to pandering by the trainee and coercion by members in the team in order to extract the required conformity to the current group culture. Sometimes this is intentional. Sometimes you are lucky and get a supportive team but each rotation poses the challenge. The consultant doctors often expect trainees to be a clinical lead but can also never give trainees any responsibility because the final decision and medico-legal accountability lies with them. Or to make up for their own decade of study handicap, they take a public health job but have three others consecutively, and can’t be bothered with juniors or don’t have time to train them.

The education that trainees are required to complete, on top of full-time work, is often sold to the highest bidder and privatised so that thousands (even tens of thousands) are spent on getting through the education program. Then each state pays junior doctors at a rate they have established in their award, making it impossible for the doctor’s union to negotiate for fairness or equality. It’s like the parent deciding what pocket money to pay each child but giving different amounts based on where each child lives.

Time and cost are dedicated to assessment hurdles that often require resits because the pass rate is so stringent. These are put up by the respective specialty colleges and serve as revenue for their coffers. All the while, if you are lucky enough to have a partner and family, they never see you, or, if you are single, you need support from parents or friends.

Trainees are assured that strict requirements for specialty attainment are necessary, but there is a lack of transparency around how these are assessed. Often the training time needs extending beyond its minimum in order to complete all the tick boxes. If trainees question the validity of assessments, as recently occurred with the psychiatry body in Australia and New Zealand, then more layers of bureaucracy are added to deal with the issue and further assurances of dedication to problem solving are given, while time drags on and nothing changes. It could be likened to a parent saying ‘We’ll see’ or ‘maybe’ in order to not make a decision on a child’s request.

The pandemic has brought these issues to light by a string of failures for trainees to progress which have been revealed to be gross inadequacies and bungles, particularly by the college of psychiatrists. In an effort to prove that we are ‘real doctors’, additional layers of scrutiny have been added to the point that the official body, ACER (Australian Council for Educational Research), made multiple recommendations to address the issues, most of which have been blatantly ignored or, at best, not yet implemented, while the college acts in denial of its own functional failings.

Meanwhile, junior doctors are still underpaid, overworked, often dealing with toxic work environments, and told to be resilient, and suffer further by ‘sucking it up’ in order to get through for some sense of achievement and freedom. While there are some managers that encourage individuals to speak out, they are often labelled as trouble makers. If they make more than one complaint, then the fault clearly lies with the individual, rather than the culture. There have often been multiple predecessor trainees, who felt unable to defend themselves, and have inadvertently helped to maintain the victim status for the role.

This extends further to female doctors who are not afforded the same level of instant respect or authority that a male counterpart would and can be judged for not being a nurse because of their gender. The number of times it has been assumed I am a social worker or allied health such as occupational therapist is astounding and doctors are still assumed to be male. Have you ever noticed when a question is asked and both a male and female doctor answer with differing responses, more than likely it will be assumed the male is correct? This is engendered discrimination that is still entrenched in medicine and often undermines self esteem, much like abusive relationships.

By the time junior doctors achieve their fellowship, there is little wonder that the relationship has soured and newly trained specialists are disillusioned and despairing, so then leave the public health system, scarred, if not traumatised.

At least the private sector affords the possibility of a little self-respect in your working life and to be a clinical lead. That is the hope, at least.