Two South Asian doctors share their stressful experiences being on the frontline and comment on whether new app Karva Health can tackle burnout.
"I'm wearing all the PPE you see on TV, and I'm doing all the things," says Michelle to quickly evoke the vague image of hospital pandemonium and perhaps save herself from detailing the daily grind that left her physically and emotionally exhausted.
Michelle was in the thick of it - a medical registrar in the COVID in-patient ward. She managed treatments and gave care to COVID patients, all while immunocompromised and under the perpetual threat of catching the disease.
The pandemic brought a higher workload, the daily whiplash of changing protocols, and most painfully, the moral injury of having to turn families away from their loved one's while they were dying.
It eventually left her burnt out.
"You feel like you're not in control yourself and you're having to exert this control over other people," says Michelle. "Lots of mornings, especially after COVID Ward night shifts, I'd sit in my car and just cry for half an hour before I could compose myself to drive home. I thought lots of times about quitting my job and just walking away."
Michelle is one of many doctors who were pushed to the brink in 2020. In May, the UNs cautionary report, “Action on Mental Health”, highlighted healthcare works as "being under exceptional stress,” having to face “extreme workloads, difficult decisions, risks of becoming infected" and "witnessing deaths of patients."
In the midst of the alarming prognosis, the mental health crisis has attracted innovation, like in Karva Health, a wellness app being developed in Melbourne that tracks burnout and offers mini-therapies intended to restore rest and motivation. But while the app may seem like the right idea for promoting self-care, putting the solution in the hands of doctors might be missing the point altogether - systemic and cultural issues have been burning out doctors well before COVID struck.
Burnout is a psychological syndrome caused by chronic stress. People with burnout are often tired, in pain, feel ineffective and can lose empathy and meaining in their jobs.
For the better part of a decade, a national survey by Beyond Blue has been making the rounds in universities and hospitals after it found that Australian doctors had higher rates of stress and more suicide attempts than the general population. The survey also found that almost 50% of junior doctors were experiencing high levels of emotional exhaustion and cynicism.
These mental health problems have been compounded by the pandemic. A 2020 survey of 10 000 healthcare workers found that 58% had burnout, 61% had anxiety and 28% had depression.
In 2020, Michelle became exhausted, started having migraines, and found herself losing motivation.
"I'd always been described as the kind of person who was really happy to be at work, who gets along really well with the interns and residents. I realised one day at work I was snapping at people, I was grumpy, I didn't want to be there and I was finding it harder and harder to get out of bed in the morning."
Burnout and self care
Once burnout starts it can lead to depression, absenteeism, medical errors, substance abuse, and the loss of a doctor's values and spirit.
A 2018 study of general practice registrars and hospital doctors found junior doctors will burn out when they fail to be supported by others, are working beyond their perceived abilities and are not engaging in self-care.
That third factor, self care, is what Karva Health, an app by Melbourne-based duo Atharva Gajendragadkar and Astika Saxena hopes to target.
In the app, doctors respond to ten questions that have been adapted from the Copenhagen Burnout Inventory, a questionnaire that measures personal burnout, work-related burnout and client-related burnout. Questions include:
How often are you physically exhausted?
Are you exhausted in the morning at the thought of another day at work?
Do you feel that every working hour is tiring for you?
Do you feel that you give more than you get back when you work with patients?
A doctor's burnout percentage is then calculated and the app prescribes daily “worktamins” - bite-sized audio therapies that comprise CBT and mindfulness exercises the user can listen to throughout the day.
Co-founder Atharva Gajendragadkar, a biomedical engineer based in Melbourne, says that the main goal is to remind doctors to "just take a breath, relax for at least two minutes and gather themselves, before they go again.
Doctors perspectives on burnout and apps
But is the solution as simple as taking a break? And could the app be taking the spotlight off systemic problems?
General Practitioner Lakshmi (name changed) believes that the app has potential to be powerful. "If you are able to recognise your stress and go, "Okay, I'm feeling very overwhelmed, I'm going to open the app and I'm going to do a two minute exercise," that could be really valuable because you can work better for the rest of the day."
Lakshmi was pregnant for the majority of 2020 and says the possibilty of contracting the disease gave her stress. It was especially bad, she says, when patients lied to receptionists about having no respiratory symptoms but then told her in her office they had a sore throat.
She says that doctors would benefit from a reminder to unwind because they tend to be perfectionists that are always trying to meet the expectations of their patients, themselves and their senior doctors.
Lakshmi says that forcing herself to take days off, even though there was nowhere to go during lockdown, saved her from burnout. But she says that she was extremely lucky to have a supportive clinic and manager, unlike many of her friends in the industry.
MIchelle, the registrar who worked on the COVID ward, believes the app will be ineffective at reducing burnout in hospitals because of the impracticality of taking breaks.
"Frequently people don't take toilet breaks and don't take meal breaks. I can't imagine that they would prioritise an app over those basic things."
While she believes the app is well-intentioned, she has "a real problem with putting the onus on the people who are suffering from burnout to fix the problem."
In a national survey, some healthcare workers said they used apps to help with their self-care, however, there was a greater desire for organisational solutions that didn't rely on creating a resilient workforce. The focus on resilience training in hospitals is seen by some doctors as a performative solution used to brush past organisational issues and shift responsibility.
Research has identified a number of organisational factors that lead to burnout, including excessive patient loads, long working hours and difficult rostering requirements.
Image source: Australian Journal of General Practice
A culture of working hard, suffering in silence and education by humiliation is often considered a rite of passage to build resilience in junior doctors.
Lakshmi says that senior doctors may be underestimating the added complexity of the job today.
"Doctors thirty years ago could just tell people what to do," says Lakshmi, about the role of a GP. "Now we're expected to give patients all the information, have good bedside manner, and give patients autonomy in their choice."
The difficult situation junior doctors find themselves in was typified in 2019 by the story of Dr Yumiko Kadota, a top university student who abandoned her dream of being a reconstructive surgeon after being "spiritually broken" by long hours, stress, and being ignored by senior colleagues. During a period of sleep deprivation, she crashed her car and was hospitalised. She was later told by staff, "If you can't handle the hours, maybe this isn't for you."
Michelle says that doctors should take a page out of their nursing colleagues’ book. “They enforce their breaks, they enforce nursing ratios, and they seem much more empowered, at least in my experience, to take their breaks without interruption. It's not the case in medical culture. We don't hand over our pages, we don't hand over the phone when we have lunch. We just either don't eat lunch, or we try and scoff it down as quickly as we can."
Beyond Blue's national survey also suggests a stigma around mental health distress and a culture of victim-blaming. 40% of doctors felt medical professionals with a history of mental health disorders were seen as less competent. Furthermore, the three leading barriers to doctors seeking treatment were a lack of privacy, embarrassment and impact on the right to practice.
“There has to be a shift in the way we write rosters, in the way we share around the burden of dangerous jobs, and the way we treat our staff a bit more humanely,” says Michelle.
A systematic review by The Black Dog Institute into potential interventions that would reduce mental health disorders in doctors concluded organisational interventions were largely unstudied and research was "urgently needed." One of the researchers said at a 2019 summit that there were zero published controlled studies trying to solve organisational issues such as working hours.
In the same review, CBT and mindfulness were found to be beneficial, indicating the promise of apps like Karva Health at the individual level. The Black Dog Institute has also developed an app, "Shift", specifically for junior doctors working in New South Wales, which focuses on teaching mental health skills and managing the demands of the profession.
The developers of Karva Health have plans to turn the app into a social media space; a digital clinic for doctors to anonymously talk about their workplace problems.
"I think it would reduce a lot of the stigma," says Lakshmi. "It was never acknowledged that you could be too stressed or burnt out,"
"It took me many years to actually realize, "Oh okay, this actually isn't how I'm supposed to be. This is actually stress and probably will turn into anxiety or burn out if I let it go any further."
If you are a doctor and would like to participate in pilot testing for Karva Health, visit https://www.karvahealth.com.
Chenturan Aran is a playwright and journalist from Melbourne. He's a member of SAARI's Editorial Team and you can reach him at Chenturan@SAARICollective.com.au.