‘We’re very, very expendable’: Why junior doctors are leaving Ireland

Having worked 19 days in a row, a doctor contacts his hospital HR department for support. The department responds by explaining to the doctor that difficult working conditions are “just how medicine is”. This story, which was aired on RTÉ in 2022, resonates with our research on the challenging working conditions that have become accepted as a standard and unremarkable part of being a hospital doctor.

While the popular perception in Ireland is that hospital doctors must enjoy excellent working conditions because they are highly skilled, well-paid workers delivering essential healthcare, this is not always the case. Over the last six years, my research has shown that hospital doctors struggle with long working hours, intense workloads and a job that normalises work-life imbalance.

Junior and senior doctors (NCHDs and consultants) have described to us the challenges of working in a health system in which there is “never enough time to get anything done because of the sheer volume of patients and lack of staff”. Heavy workloads leave doctors feeling overworked and limit the time available to support each other or to improve the workplace. “If you have enough people, then you have enough people to support training and support mentoring. Whereas at the moment, we don’t have enough people.”

Many of the doctors we spoke to felt underappreciated, explaining that they felt “very, very expendable” and “just numbers within the HSE”. Asked about the impact of Covid-19, one said “it’s made me a lot more cynical of the health service. I think it’s highlighted that we’re very, very expendable. . . it has highlighted that the system is bigger than us, and not necessarily in a good way. I think it will throw you aside quite happily anytime.”

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In our latest paper, we build on the work of Prof Michael West who explains that medicine is a “tough job” but one that is made “far harder than it should be by neglecting the simple basics in caring for doctors’ wellbeing.” He suggested three core work needs that should be met to support doctors’ wellbeing at work – autonomy/control, belonging and competence. In our research, we consider them in an Irish context.

Autonomy is about the ability to voice concerns and wield influence in the workplace. Senior and junior doctors who took part in our research felt they had limited power to influence change at work, particularly in relation to influencing staffing levels or workloads. Although doctors noted that “almost every issue I could bring up about hospital dysfunction boils down to inadequate staffing levels”, they found that when seeking additional staff, there were “always competing voices shouting for limited resources.” The HSE recruitment ban adds a further impediment in this regard.

Belonging is about having a supportive work environment and working within effective teams. Doctors spoke positively of the support received from their peers. However, at a hospital level, they encountered silos, disengagement and antagonism. “I don’t get the sense that the hospital values my contribution or that of my colleagues.”

NCHDs spoke about frequently working in hospitals without access to a computer, a place to rest, or anywhere to safely store their belongings while at work, all of which impede their sense of belonging.

[ Junior doctors should have fewer geographical ‘rotations’ and better working conditions, report says ]

Competence is about the ability to deliver high-quality care. It involves having safe and manageable workloads as well as strong supervision and line management. Doctors felt that they regularly had to manage workloads that were neither manageable nor safe, and they worried about the impact on the care delivered, explaining that they were expected “to provide a level of care which simply isn’t possible.” They felt poorly supported at work and we identified the absence of clear line management structures as a particular gap.

Returning to this idea that this is all “just how medicine is”. Although a typical health system response, this is problematic; firstly because it implies that the response to difficult working conditions for Ireland’s hospital doctors is either to endure them or to exit. Ireland’s high rate of doctor emigration indicates that a significant number of doctors opt for exit, which poses a further risk to the future medical workforce.

Secondly it indicates that change is impossible/unnecessary, because challenging working conditions are intrinsic to medicine. In this way, the hospital and health system resist pressure to improve working conditions for hospital doctors. Rather than initiate change, the system pressurises doctors to accept the status quo, ie that challenging working conditions are part of their commitment to medicine.

The challenge is that these ways of working are increasingly unattractive to a new generation of doctors who are committed to medicine, but who also value their wellbeing and work-life balance.

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Regardless of whether they see medicine as a vocation or a job, hospital doctors are also employees and should be entitled to work in workplaces that protect and promote (rather than damage) their health and wellbeing. If we want them to continue to care for us, we must to begin to care for them. To meet our future healthcare needs, Ireland must expand its medical workforce and will need to train more doctors. However, it also needs to retain and protect the wellbeing of the doctors working in the system. My research indicates that improved working conditions are key to doctor retention; they are also an important factor in encouraging the return of emigrant Irish-trained doctors, which is another way to boost the medical workforce.

Doctor retention, therefore, is everyone’s concern. To build a sustainable medical workforce that can meet our future healthcare needs, Ireland must begin to value its medical workforce and strive to meet their core work needs.

Niamh Humphries is a senior lecturer at the Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences. She holds a Health Research Board (HRB) award for the Hospital Doctor Retention and Motivation (HDRM) Project. The latest paper from the HDRM project was published in SSM Qualitative Research in Health. Twitter: @humphries_niamh @HDRM_Project

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