the perfect storm for burnout in junior doctors in Singapore + pandemic fatigue + we don’t need #STcovidheroes we just need a break

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This is part of an ongoing monthly series capturing the highs, low (and everything in between) in my working life as a doctor in Singapore. If you’re interested in finding more about medical/non-medical job options or getting answers to doctoring-related questions you’ve always wanted to ask, check out my brand new Chasing Careers series!

The past few months have passed by in a fog of hard work, exhaustion and the feeling like we’ll never quite be able to escape COVID (both in the news and at work). The COVID fatigue is real for all of us, the healthcare community and civilians alike, and it doesn’t feel like healthcare workers are going to get a respite from it anytime soon.

Earlier this month, when PM Lee announced more VTLs (vaccinated travel lanes) and the gradual resumption of international travel, my friend excitedly texted me and jio-ed/invited me on a trip to Korea, because we’d promised to make a pilgrimage there together once borders reopened. But I knew better than to get my hopes up that I’d be able to travel anytime soon.

Earlier that week, all doctors in the public sector had received a circular email that dealt a crushing blow to any illusions of ✨freedom & happiness✨ that we might have held.

I’m not sure if I’m legally allowed to copy-paste the exact wording in that email since it’s not for external circulation, but I’ll take the creative liberty to paraphrase it in Oprah’s words: “You get to travel! You get to travel! Everybody gets to travel, EXCEPT HEALTHCARE WORKERS (who are currently not allowed to apply for leave for overseas travel)!”

19/10 update: In a lovely and unexpected turn of events, MOHH has just lifted the suspension on application for overseas travel leave for healthcare workers! Whether we’ll actually be allowed to travel remains to be seen, but hallelujah anyway!!

Was I surprised? No. Was I disappointed? Again, no.

Ever since stepping into House Elf-ship (because House Officers are slaves just like house elves), I’ve learnt to set my expectations real low so nothing can hurt me, or maybe my soul caught COVID and died long ago.

Obligatory legal disclaimer: This is a personal blog. Any views or opinions represented in this blog are personal and belong solely to the blog owner and do not represent those of people, institutions or organizations that the owner may or may not be associated with in professional or personal capacity. Any views or opinions are not intended to malign any religion, ethnic group, club, organization, company, or individual.

Pandemic fatigue – it’s a real thing

The whole damn world must be tired of hearing the word COVID by now. It’s changed all our lives irreversibly, and all just in a span of under 2 years. I can’t imagine being a news anchor who has had to report a constant onslaught of COVID-related news day in and day out for the past 20-odd months. I can’t imagine being a teacher pulling ridiculous hours trying to optimise all my students’ learning via Zoom and having new administrative duties like contact-tracing (which I’ve heard about from my teacher-friend). I can’t imagine how my close friend working in a government agency works so tirelessly to establish new VTLs/vaccinated travel lanes for everyone else’s enjoyment, while she can’t even get a day off work.

Everyone is tired. Maybe the final nail in the coffin won’t be the virus itself, but the mental fatigue of being cooped up in this tiny island and being bombarded with a seemingly never-ending flood of ‘COVID this, COVID that’.

I’ve only been in the workforce for 6 months, so the extent to which COVID has affected me pales in comparison to more seniors doctors & healthcare workers who’ve been hit by tidal wave after tidal wave of exhaustion, constant flip-flopping policies, and restrictions on annual leave (or leave encashment in lieu of taking annual leave) which they’ve had to bear the full brunt of.

My close friend, a Medical Officer, was sharing how just 2 weeks ago, when our daily COVID numbers surpassed the 4-digit mark, her hospital suddenly opened up multiple new COVID wards to cope with the sudden spike in cases. Wards which had been empty just the day before were suddenly flooded with 20 new patients, the A&E was flooded with hundreds of patients(some with COVID, some without) waiting for beds.

And when I say the ward was empty the day prior, it doesn’t mean that there were doctors/nurses sitting around in an empty ward slacking off and waiting for patients to come in. The opening of new wards means that manpower across the hospital had to be readjusted (and stretched more thinly) just to cope with the sudden opening of extra wards. The doctor/nurse-to-patient ratio worsened significantly, meaning that her entire team had to work longer hours (an increase from the usual 12-hour days) and cope with caring for more patients. And shuffling manpower has a domino effect on other teams as well, because moving one doctor from their previous team into a newly-created team means their previous team has to takeover all the patients that doctor was taking care of.

This pandemic sucks for everyone, some more so than others.

the perfect storm for burnout in junior doctors in Singapore

As someone who still experiences work-related burnout (although my situation is already far better in my current workplace), I can tell you with confidence that most of my circle of friends and colleagues are also suffering from varying extents of burnout. Having many patients to care for, working long hours, facing constant exhaustion and pressure is a recipe for burnout.

If it were temporary, we’d probably be alright, but COVID has been dragging out for the past 20-odd months and it’s pushing healthcare workers to their breaking points. I’m not surprised that more nurses are quitting/leaving to work in the private sector, and to be honest, I’m sure a lot of doctors would quit too if we had the chance (but we’re bonded for 5 years, excluding Housemanship).

I can’t say that I’m speaking for the entire healthcare community, but among my circle of friends/fellow doctors, our main sources of burnout and stress (even pre-pandemic) stem from:

  1. Long & dangerous hours. As I’ve mentioned in pretty much all my previous posts, House Officers work ~80-100 hours at work every week and do calls (overnight/30-hour stints at work) at least 1-2 times a week. To put things into perspective, we’re consistently working more than double of the regular 40-hour work week, with only 21 days of annual leave. Going to work before the sun rises and leaving after the sun sets is something familiar to almost all junior doctors, and that’s probably why we have Vitamin D deficiencies. Apart from A&E/Emergency doctors who have relatively protected hours due to shift work, the rest of us do not have the privilege of working in shifts, and instead just show up at work as early as 5.30am and leave at 8pm. The hours vary greatly between specialties and hospitals; surgical postings have far longer hours than medical ones (15-hour days vs 10-12-hour days). And when we’re on call, we complete a regular work day, then continue working through the night until the next afternoon when we get to go home and sleep. Most of us are working in excess of the ’80 hours a week or 24 consecutive hours’ recommended by the Medical Council in the USA (ACGME). I know we’re not in the USA so these regulations unfortunately don’t apply to us, but do we really have to wait for a Libby Zion-esque case (in which a fatigued doctor accidentally caused the death of a patient) for things to change?
  2. Overstretched manpower. Poor manpower has been a long-standing issue in the public healthcare sector way before COVID hit (that’s a can of worms for another day), but it’s been exacerbated with the surge in COVID cases and increase in hospital beds (including the A&E extension in TTSH’s carpark which you may have seen on the news). Even if the number of doctors remained the same, the tsunami of patients means each doctor is in charge of more patients, which is detrimental towards both patient safety and the welfare of healthcare workers.
  3. Constant shuffling of manpower. Pre-COVID, doctors generally rotated to different teams on a monthly basis, but with the current manpower crunch, teams can be shuffled and manpower rearranged far more frequently. Earlier this year when 2-week Quarantine Orders were still a thing, I heard of entire teams (~6-8 doctors of varying levels of seniority) being whisked away to serve Quarantine Orders, meaning doctors had to be taken from other teams to cover that team’s wards/patients. It’s disruptive and suboptimal for continuity of patient care, although it’s unavoidable with all the mess that COVID is creating. (Case in point: I was switched to a new team the day after first publishing this piece)
  4. Psychological burden: In a job where you’re expected to care for all your patients, be accountable to their families, and continuously make decisions in their best interests, on top of having to report back to your bosses, doctors are like candles being burnt from both ends, and it’s not psychologically healthy or sustainable.
  5. Poor remuneration. For our first 5-6 years as junior doctors, we’re paid approximately $8-10/h for 300-400 hours of work a month (*this is just a ballpark figure for House Officers). We’re more than capable of working long hours, and we’re willing to work hard for the sake of our patients, but unlike our peers in the finance/legal sectors who pull similar hours for $7k-$20k++ monthly (my friend in investment banking earned my entire year’s salary in a month), we’re not remunerated fairly. Being $125k in student debt and bonded for $500k+ isn’t ideal. I get it, healthcare workers are supposed to be altruistic and receive payment in claps, but that doesn’t pay off our debt.
  6. Not having adequate days off from work + annual leave issues. My current hospital has relatively good manpower and doesn’t face this issue, but I’ve seen a lot of grousing online/from my friends about how they’ve worked 21+ days with no days off (the most I’ve ever done was 19 days straight thankfully), with some being made to take leave on weekends in order to get a day off, and others having to encash their leave. And no, the concepts of weekends are foreign to doctors/nurses, so if you’re a prospective med/nursing student reading this, please think twice before eagerly signing your twenties away.
  7. Restrictions on taking leave/staycations/travelling. VTLs have been opening and international travel is slowly resuming for the general public, but not for us. Applications for overseas travel have been suspended for all doctors in the public sector, with some hospitals going as far as to temporarily restrict staff from even going on staycations or cruises to nowhere (source)…we’re basically overworked caged birds at this point, and I hope that in the next few months, regulations ease and we’ll be able to find some compromise that allows our exhausted workforce to finally enjoy life or travel again. <19/10 edit: THE TRAVEL BAN HAS BEEN LIFTED!!>
  8. Inability to unionise. House Officers/Medical Officers are under contract with MOH Holdings Pte Ltd, a private company (not the public institution Ministry of Health), which means we’re unable to form a union to safeguard our safety, rights and wages. We’ll just have to keep our heads down and continue working 30-hour calls/shifts which is hazardous to our own health and possibly compromises patient safety, because we signed the right to unionise away when we signed our employment contract. You can read up on the benefits of worker unions here.

This is by no means an exhaustive list, and doesn’t even address the systemic issues that have created all these problems, but this is just an overview so you/the general public can have a rough idea of what we’re going through.

holding our workplaces accountable for burnout

In an op-ed penned by the co-editors of the Burnout Research e-journal, they explain that:

Highly stressful workplaces are often poorly designed, socially toxic, and exploitative environments. Why should such workplaces be given a free pass, when they are the sources of stress, while their inhabitants are being told that burnout is their own personal problem and responsibility?

Instead of letting such bad job settings off the hook, we should also be focusing on how to improve the workplace environment. Burnout is a signal that things are not going well in the relationship between people and their workplaces, and as with any relationship, both sides need to be part of the solution.

op-ed: “Burnout” is not only a personal problem, it’s a workplace problem

Behind the scenes, we’re tired and frustrated at our lack of rights, but far from giving up, we’re instead trying to find ways to effect real change…which is easier said than done. Focus groups (with Health Minister Mr Ong Ye Kung, who has been doing a good job and working tirelessly alongside us) have been organised by junior doctors to speak up about our concerns and desire for concrete change, and a taskforce has purportedly been established to investigate how our working conditions can be improved, so there’s still hope (?) that things might get better in the future.

Even if changes are eventually rolled out, they won’t benefit us/current junior doctors, because policy changes have 101 layers of bureaucratic red tape, but if it can benefit our future generations of healthcare workers, it’s the good fight.

#stoptheplatitudes

I’m sure everyone living in Singapore (and not under a rock) has heard of the various initiatives to show appreciation to healthcare workers, a.k.a. the ‘fRoNtLiNeRs’ and ‘hEr0eS’. Don’t get me wrong, I appreciate the sentiment behind organising such campaigns, and the sincerity behind the public’s well wishes & words of encouragement. And to be fair, there’s not much the public can do except express their support in this way, because they haven’t been given a behind-the-scenes look of the policies & restrictions that healthcare workers have been and are currently being subjected to.

#STcovidheroes was yet another well-intentioned platitude doled out by the government and local media to show support to the healthcare community during these insanely challenging and downright exhausting times, on top of last year’s round of applause and flypast, but from the sheer number of memes I’ve seen about it, it seems to have been the straw that broke the camel’s back.

I shall leave you to read the well-written post by fellow-doctor/meme creator @pyrexic_memes below, which is fairly representative of the sentiment on the ground. It spawned a Reddit thread as well, which I’ve linked here.

It remains to be seen whether things will start looking up for public healthcare workers/doctors in the short-run, but there’s nothing we can do except continue our endless routine of ‘wake up, go to work, sleep, wake up, work 30h straight on call, crawl home to sleep’. And so we’ll carry on.

I’ll continue sharing my journey as a House Officer/junior doctor and wherever life takes me after Housemanship year, so be sure to follow my Insta or Facebook page to stay up to date with my latest posts and life updates!

xoxo,
Faith

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