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Tunisian junior doctors (interns and residents) are exposed constantly to high levels of stress due to multiple factors such as the significant workload and increased medical liability. In fact, the average workload is about 60 hours per week, apart from night shifts, without compensatory rest periods in some wards [1-2]. Tunisia is considered to have the second-highest work hours for junior doctors among 154 countries behind Gabon [3].

Stress itself is not an illness but it can affect well-being and can lead to some mental health issues. Indeed, a large study, done in 2015, including 1700 (out of 2200) Tunisian medical residents, has shown that nearly half met the defined criteria for anxiety and about a third met the criteria for depression [1]. Unfortunately, there is no available data about interns, but it is known that they have higher rates of depression and burnout than the lay public [4].

J.M. and T.R., two third-year residents, and K.L., a previous junior doctor, shared their journeys with stress over their internships and residencies.

T.R. talked about how she first experienced high levels of stress. This was over her first shift in an emergency department which usually lasts from 2 pm to 8 am:

‘My first experience presenting general signs of anxiety (no panic attacks) was halfway through my internship, over my first ER shift in one of Tunisia’s biggest hospitals. I found a lot of left-over charts, neither doctors to ensure a smooth transfer of information about the cases nor nurses to perform blood tests. Patients come for assessments, over 6 people at the same time. I was so confused: what to do?  Whom to examine first? What laboratory exams to order? Patients started to complain and yell so I got nervous and yelled as well. I ended up calling the orthopaedic resident, not able to explain anything on the phone. Luckily, he was supportive and showed up in time.’

K.L. shared the impact of a poor supervisory system on her well-being in the departments where she passed by:

As an intern, I thought it would be awesome because I finally would be responsible for lives and do my best to save them! But the reality was so different. The priority was how to escape all the negative frustrating and devastating attacks from our supervisors during medical rounds. The responsibility you take on as a junior doctor is huge. You sometimes find yourself alone in a night shift in the department dealing with difficult cases. You have no clue on what to do, you need to decide fast and you can’t reach your supervisor on the phone’.

While completely swamped by the work that you need to responsibly accomplish, it is extremely difficult to take a step back and consider any personal mental health difficulty. Indeed, none of our participants mentioned seeking medical help to overcome their psychological distress. K.L talked about some of the reasons that hold her back from that: ‘When I went through a psychiatric department, I was discouraged to ask for help because I discovered there was a lot of stigma towards mental illness and I was not comfortable sharing my deep secrets, fears, and insecurities with some of my colleagues.’  J.M. said, ‘I once thought of seeking help for burn-out but the fact that I have a medical background and some knowledge about mental health helped me to deal with my anxiety, on my own.’

Instead of reaching out, our participants have found some tips to manage these high levels of stress on their own.

T.R. considered using external factors such as ‘taking anxiolytics, beta-blockers to overcome the minor symptoms of anxiety.’ She also added that ‘Smoking and drinking alcohol really help.’

K.L. shared different coping strategies to manage her emotions: ‘The first years were very stressful, I remember I bought chewing gum every day on my way to my training ward. Otherwise, I could not overcome the day without a crying episode’. She also mentioned being more able to handle her emotional distress over the years by ‘keeping busy, trying not to lose the people who are meaningful to me while pursuing my career, taking care of my health by exercising and feeding my soul with music and love’.

J.M. opted for some relaxation methods: ‘to overcome anxiety, I try to take multiple breaks, to disconnect from work as often as I can, and that would not necessarily take too much time, sometimes it only takes 2 hours during which I relax, watch a movie and not stress over all I have in mind.’

From all these statements, it is reasonable to say that just because junior doctors under pressure are not asking for help, it does not mean they are not struggling with stress. Self-care tips may not work for everyone. The dilemma is to recognize when it is crucial to seek help from mental health professionals to prevent any harmful effects of stress such as anxiety, depression, burnout or addictive behaviours.

These levels of stress have undoubtedly increased over the pandemic COVID-19 period. Indeed, some junior doctors have not seen their relatives and children for about two months.

J.M. said ‘I feel quite anxious during the pandemic. Being in the front line, constantly worrying about transmitting the virus to my beloved ones if I ever get the virus, and then there is the anxiety that comes with isolation’.

In contrast, T.R. talked about being ‘less anxious than before because I spend less money, I have less social interaction and most of my deadlines have been postponed… kind of helping to slow down and overcome my previous every-day anxiety’.

Although some seem to be resilient, more efforts should be made to promote mental health among junior doctors over this pandemic period and in general. This is extremely important to consider not only for junior doctor’s well-being but also for a wider societal benefit. In fact, stress and mental health issues could affect decision-making, memory, and attention, and as a consequence could negatively impact safe and high-quality care.

Promoting mental health among junior doctors could be as simple as recognising and being grateful for all the efforts made daily. As a long-term goal, we can follow the models of other countries. In the UK for example, the approach is to suggest some educational interventions for physicians and junior doctors as a part of their continuing professional development [5]. This could include Mindfulness-type interventions, coping, solution-focused therapies, and reflections, which have proven efficacy in preventing harmful effects of stress [5].

It is also essential to shape junior doctor’s attitudes by increasing their awareness and seeking medical help when needed. This will not be possible without reducing the stigma around mental health issues, which could be challenging. One way could be promoting, or including in the academic programme, exposure to senior doctors who openly share their lived experience with mental health illness. This strategy has been demonstrated to have measurable impacts on medical students and junior doctors’ behaviours in seeking help when they struggle and reducing stigma towards psychological distress [4].

NB: Initials have been changed to keep people’s privacy.

References :

[1] Marzouk, M., Ouanes-Besbes, L., Ouanes, I., Hammouda, Z., Dachraoui, F., & Abroug, F. (2018). Prevalence of anxiety and depressive symptoms among medical residents in Tunisia: a cross-sectional survey. BMJ open8(7), e020655.

[2]https://www.businessnews.com.tn/les-medecins-internes-et-residents-cette-main-duvre–qualifiee-et-bon-mare,519,67798,3

[3] https://www.tuniscope.com/article/193542/vie/conseils/medecin-interne-370915

[4] Martin, A., Chilton, J., Gothelf, D., & Amsalem, D. (2020). Physician Self-disclosure of Lived Experience Improves Mental Health Attitudes Among Medical Students: A Randomized Study. Journal of Medical Education and Curricular Development7, 2382120519889352.

[5] Locke, R., & Lees, A. (2020). A literature review of interventions to reduce stress in doctors. Perspectives in public health, 1757913919833088.

Médecin de famille et vice-présidente de la Société de médecins généralistes de Tunisie Junior (SMGT Junior)

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