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.Extreme consequence
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.