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I’ve been struggling for inspiration and time for this blog over recent weeks due to efforts to organize the Wellington Intensive Care Medicine course, perform my SOT role and balance the demands of home with an acute shortage of non-clinical time at work.  

However, with the next exam sitting fast approaching, I thought I might re-post a response I gave last year to one of Todd’s blogs on the demands associated with the exam. It certainly doesn’t hurt to highlight welfare issues for our trainees again and this may be timely for some, so here goes:

Intensive care asks much of its trainees. The stressors described in “Zen and the art of the Fellowship exam” are very common. 

Trainees are a mobile population which often means not only the stress of moving location and workplaces but also away from usual supports. 

It is also a time of life where there is often additional relationship pressure. For the single trainee, there is no opportunity to develop new relationships which are sought for companionship, security and support. For those in new relationships, time is demanded, but not easily available. And for those in established relationships, often new families are starting or the pressure of postponement of such life goals builds and the increasing demands for support take their toll. Every moment seems to have high opportunity cost, yet there does not seem an end in sight.

Within the workplace, we work in a high stress environment. Often highly traumatic situations are dealt with for the first time, and alone. We are frequently asked to deal with death and dying, we see the full emotional spectrum, and the variety which draws us all to the specialty adds academic and cognitive demands. The pressure of responsibility as we make high pressure decisions increases with training.

Trainees work highly unsociable hours. Rotating shift rosters confuse body clocks and fatigue builds as the trainee tries to fit in as much as possible to keep up.

Add onto this the FCICM exam, an exit exam which prides itself on its degree of difficulty, which over recent years has a pass rate of less than 50%, and the obstacles can certainly seem overwhelming.

What are the costs of such a training scheme? 

I'm sure all of us have seen them:

- failed exams and lost time

- broken marriages or relationships

- loss of friendships

- alcohol or drug abuse

- mood disorders

- loss of self-identity, hobbies and the feeling of being uni-dimensional

- burnout, cynicism and emotional apathy

- loss of child-bearing opportunities

- in extreme cases, suicide and death. 

Some walk away to find friendlier environments, but many of us have fallen in love with Intensive Care and continue this rite of passage. We are a strange bunch who like to be surrounded by stress and such demands get normalised. We are surrounded by suffering via patients, families and fellow colleagues, such that our own difficulties are often marginalised or seem unimportant.

I have had the good fortune to get to the other side. As a new consultant, I hope I can reassure that life is much better. There are a whole new bunch of stressors to deal with but that exquisite pressure I felt as a trainee is no longer omnipresent. I have reestablished hobbies, been able to better prioritise family, friends and my long-suffering and enormously supportive wife, and feel more in control of my work patterns. I even have a routine now that I am free of the registrar shift work. I love my job and the clouds have largely lifted.

However, I suffered through some very dark times to get here and were it not for my wife Maria (who put her own medical training on hold, partly to raise our 3 children and partly to avoid the double-specialist training nightmare) and plenty of luck along the way, I feel that I could have had deeper wounds instead of the minor scars that I bear. 

I think that the system is setting a decent proportion up for failure on some level. We are able to quantify the exam failures, but have little data for the other negative consequences mentioned above. 

My impression is that the prevailing attitude is that this is a rite of passage with limited consequences which will pass in time and should just be tolerated. An attitude of "If it was ok for me, and I'm ok, then you will be too". One must prove one’s worth to be considered ready for the job.

There is no doubt that hard work and sacrifice are required in order to do the job. But is it okay, in a profession which is about looking after the wellbeing of people, to recognise these stressors and risks and not act to try to reduce them? Particularly when we strive so hard for improvement in all other areas of practice?

So what can be done to help trainee welfare?

1. Recognition of the problem. This will require a culture change within Intensive Care. Blogs like this are a start but the dialogue needs to be broad and open. Data may need to be collected to confirm the size and nature of the problem and to convince those that can only be convinced by scientific evidence. 
2. Senior support. Mentoring is crucial to help navigate the training scheme. Sometimes just as a listening post, sometimes to share wisdom, sometimes to redirect, sometimes to intervene. SOTs have a vital role in not only ticking college boxes, but in supporting trainees through their training including a recognition of welfare issues. 
3. Collegial support and friendship. Study groups have been mentioned and are invaluable as a source of shared knowledge, experience and strength through adversity. Face to face groups are great, but online support through study groups/blogs/discussions is a growing area to utilise as necessary. As a trainee, your colleagues are likely the people you see most of and who have the best understanding of your current context so seeking and providing support is really useful.
4. Personal attention to health and stress. Know yourself well (and listen to those who know you well). Figure out a strategy for debrief and to unwind. Don’t be afraid to say no or ask for help. Know your priorities and be prepared to advocate for them. If you’re not very assertive, try to find allies who are. Have a GP and look after your relationships outside of work - they will be the ones who pick up the pieces if it all goes wrong. Decide which aspects of your life you are not willing to compromise on, and find a way of ringfencing them; if you don’t protect them, they can easily be eroded away. 

And where does the college fit in?

1. Welfare SIG +/- officers. ANZCA has a Welfare SIG (special interest group) to discuss matters of member welfare among like-minded individuals. Some departments have welfare officers. Should this be more a part of CICM?
2. Trainee representation. Your trainee rep is your conduit to the college. Choose them wisely and ensure that they are supported to speak up about trainee stresses and concerns.
3. Part 2 exam. This is a whole different topic. However, I wonder whether the exam is doing trainees justice in its quest to turn out better and better intensivists. Is it appropriate for an exit exam to have a 38% pass rate? Does that mean a problem with the training or with the exam? I wonder whether a different exam process mightn’t significantly reduce the stress on senior trainees.

Anyway, I’m interested in others’ views. Todd’s final advice from his earlier blog is perhaps the easiest and best to institute:

Look after one another, we’re all in it together.