During an orientation session for junior doctors in Adelaide recently, staff were asked to put up their hand if they had ever seen or experienced bullying or harassment in the workplace.
"The majority of hands went up," said Hannah Szewczyk, a trainee obstetrician and gynaecologist.
"It's really common … but it's often hard to get people to speak about their own experience because so many trainees are worried how it will impact their training or progression."
As chair of the Australian Medical Association's (AMA) Council of Doctors in Training, Dr Szewczyk said problems with heavy workloads were even more widespread.
"I'm just starting my eighth year as a doctor and it seems to be getting worse."
Systemic cultural problems and burnout in Australia's medical education and training system have been well documented in recent years. But it seems increased awareness and calls for reform are yet to translate into meaningful change.
The latest annual survey of Australia's doctors in training has found an increase in trainee workloads since 2021, and a rise in the number of trainees considering a future outside of medicine.
More than half of the 22,000 doctors surveyed described their workload as heavy or very heavy, with two-thirds reporting they work more than 40 hours on average per week, including one in 10 who work more than 60 hours on average per week.
The survey, published last week by the Medical Board of Australia, found one in five junior doctors — and one in four Aboriginal and Torres Strait Islander junior doctors — are now thinking about a different career.
AMA president Steve Robson said the findings of the survey highlighted the impact of a health system "under crisis".
"The fact that 20 per cent of those who responded to the survey are considering a career outside of medicine should be a wake-up call for governments across the country, particularly as these are doctors in training who have spent years investing in their education and training," Professor Robson said.
Bullying and harassment rife in medical sector
The survey, which was completed by more than half of Australia's junior doctors, found 34 per cent of trainees had experienced and/or witnessed bullying, harassment, discrimination and/or racism at work in the previous 12 months.
Among Aboriginal and Torres Strait Islander trainees, that figure was 55 per cent.
Of those who experienced or witnessed such behaviour, the most common source was senior medical staff.
"This is an issue that has been going on within the medical workforce training pipeline for a very long time," said Australian Medical Students' Association (AMSA) president Tish Sivagnanan.
"The hierarchical nature of medicine … along with a health system that's under pressure inherently facilitates a lot of the structures that uphold negative cultural practices."
Dr Szewczyk agreed, and said in some instances, poor workplace behaviour reflected the difficult conditions healthcare staff were working under.
"There's certainly some unacceptable behaviour that should have repercussions," she said.
"But it's worthwhile looking at the causes: is it just that person and some action needs to be taken? Or is it a symptom of something in the system — they're understaffed, overworked, not getting enough sleep, not getting support themselves?"
The survey found patients and/or their family members or carers were also responsible for the bullying, harassment, discrimination and/or racism experienced or witnessed by two in five junior doctors.
Of those who had experienced unacceptable behaviour, 70 per cent did not report it. Asked why, 55 per cent said they were concerned about the repercussions, and 51 per cent said nothing would be done if they did make a report.
Dr Szewczyk said junior doctors were often reluctant to speak up because of how it might affect their career prospects.
"Medicine is so competitive … and in order to get into training programs, you have to have great assessments from your supervisors," she said.
"If bullying or harassment comes from your consultants, these might be the doctors doing your assessments or sitting on your interview panel."
Bringing more humanity into medicine
Sydney-based junior doctor Ben Bravery, who is a vocal advocate for health system change, said the findings of the survey were disappointing but not surprising.
"I think [workplace culture] is slow to change because it's been like this for so long."
Dr Bravery agreed that a "strict and entrenched" medical hierarchy was contributing to high rates of bullying and harassment, but added that it was also the result of medical education neglecting "the human side of medicine".
Skills like communication, empathy, and teamwork — "the kinds of things that would help stamp out unacceptable behaviour" — were often overlooked at the expense of focusing on technical competence above all else, he said.
"We could be teaching these skills at medical school in a much more robust way, and elevating them to be as important as the technical knowledge," he said.
"Then once you pump these students out into hospitals, you've again got to reward those behaviours."
Dr Bravery said it was "ridiculous" that doctors were expected to heal people while emotionally and physically "breaking" themselves in the process.
"It doesn't make any sense that we accept a lot of our trainees are negatively impacted and at times broken by the job and the culture and training demands, and yet we expect them to heal other people."
Importantly, he added, heavy workloads and toxic work environments also compromised the quality of patient care.
"If [patients] see bad behaviour directly, they might lose trust in their doctors … Indirectly, poor culture affects communication and approachability," he said.
"It can prevent junior doctors raising concerns with senior staff, and it means that people in a team are less likely to be working as one in order to solve problems and ensure a person receives the best care possible."
Calls for greater accountability
Medical Board of Australia Chair Anne Tonkin said although the survey findings indicated there was "still a lot going well in medical training", the culture of training and education remained a concern.
"The culture of medical training needs attention," Dr Tonkin said.
"It is totally unacceptable that 55 per cent of Aboriginal and Torres Strait Islander trainees have experienced and/or witnessed bullying, harassment, discrimination and racism, and inexcusable that 34 per cent of all trainees did.
"We all owe it to trainees to act."
AMSA president Tish Sivagnanan said "active monitoring" was required to ensure the reporting systems and processes put in place in hospitals and health services to address professional misconduct were robust.
"It's not enough to just have a [reporting system] set up and say, 'We've addressed it'. Because it's obviously not working," she said.
Dr Bravery agreed, and said more needed to be done to "make it safe" for junior doctors to call out unacceptable behaviour.
"Unless you look at underlying power structures, and the tension junior doctors face, they will never be empowered to call this kind of behaviour out … and medicine will continue to lag."
Chair of the AMA Council of Doctors in Training Hannah Szewczyk said to retain trainee doctors, legislative changes were necessary to improve working conditions in hospitals across the country.
"What I'd love to see is wellbeing and psychosocial safety in the workplace being embedded in our National Safety and Quality Health Service Standards," she said.
"We have these standards that all hospitals have to meet, such as management of blood products, hand hygiene — things that keep patients safe. But we know that a healthy workforce keeps patients safe."
Dr Szewczyk said South Australia and Queensland have already made legislative changes to ensure hospitals are accountable for providing a safe psychosocial work environment.
"Change is happening, but it's taking time to trickle down, and as we can see [in the survey], we don't have a lot of time.
"With more doctors wanting to leave the system, it needs to happen more quickly."
