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Exploring newly qualified doctors' workplace stressors: an interview study from Australia

Purpose Postgraduate year 1 (PGY1) doctors suffer from high levels of psychological distress, yet the contributory factors are poorly understood. This study used an existing model of workplace stress to explore the elements most pertinent to PGY1 doctors. In turn, the data were used to amend and refine the conceptual model to better reflect the unique experiences of PGY1 doctors. Method Focus groups were undertaken with PGY1 doctors working at four different health services in Victoria, Australia. Transcripts were coded using Michie's model of workplace stress as the initial coding template. Remaining text was coded inductively and the supplementary codes were used to modify and amplify Michie's framework. Results There were 37 participants in total. Key themes included stressors intrinsic to the job, such as work overload and long hours, as well as those related to the context of work such as lack of role clarity and relationships with colleagues. The main modification to Michie's framework was the addition of the theme of uncertainty. This concept related to most of the pre-existing themes in complex ways, culminating in an overall sense of anxiety. Conclusions Michie's model of workplace stress can be effectively used to explore the stressors experienced by PGY1 doctors. Pervasive uncertainty may help to explain the high levels of psychological morbidity in this group. While some uncertainty will always remain, the medical education community must seek ways to improve role clarity and promote mutual respect.


GENERAL COMMENTS
This is a paper which addresses a common problem i.e. workplace stressors of newly qualified doctors. It is a neglected topic which demands much further research. The strength of this manuscript is its inclusion of a conceptual model. However, as it is, the paper adds little knowledge to the topic and it is therefore difficult to justify its publication. The authors may like to review if they had collected data on the solutions to the problem, from the views of these newly qualified doctors. It may then provide additional contents to turn this paper into a very interesting one. Alternatively, how would their Australian findings compared to similar work in the UK/ Canada or even between those who undertook graduate entry vs undergraduate entry medical studies in Australia.
Specific comments: Abstract: The results section provides minimal information on the findings and this can be improved. The results also do not quite justify some points in the conclusions e.g. job security.
Introduction: PGY1maybe a commonly used term in the UK but is much less so for Australia. As stated by the authors, these newly qualified doctors are generally known as "Interns" in Australia.
Also pointed out by the authors, it is well known that Interns/Housemen suffer from high levels of psychological distress but much work on the contributory factors has also been done. Many publications are available on the topic, some are qualitative while others are mixed methods or survey (Liu & Tang, 2016, Abdulghani et al, 2014, Lam et al 2010.

Methods:
It is stated that a purposive sampling was used but it does not give details how this was done. It would be helpful to state the interview schedule of the focus groups. One focus group was conducted at each of the four sites, it is possible that the participants knew each other well which might have an impact on the conduct of the focus groups. Also pointed by the authors in the limitations section, the addition of individual interviews might have offered an alternative mode of data collection for those participants who preferred it. The number of participants ranged from 7-14 per group. This reviewer has done many focus group studies with doctors and anything more than 8 is likely to make it difficult for a focus group to be conducted effectively. In addition, 46 to 65 minutes is hardly sufficient for focus groups of this size i.e. less than 5 minutes on average.

Results:
The findings or lack of them is a major deficiency of this paper. Many of the findings are already known facts. A google search of the topic would easily come up with much of the similar information. An example is the one by the Medical Protection Society https://www.medicalprotection.org/southafrica/junior-doctor/volume-4-issue-1/stress-and-burnout-the-intern-years. The papers listed above also covered most of the "findings". This reviewer also has reservation of having refinement of the conceptual model in this section.

Discussion:
As it is, this paper does not yield additional insights into the problem of workplace stress for PGY1 doctors, contrary to what the authors claim. The authors highlighted the point of uncertainty, both within and outside clinical practice. These were to major extent also covered by earlier publications listed above. Limitations As a long time qualitative researcher, this reviewer would disagree with the authors" point that the conclusions were limited by the small sample size. Small sample size is intrinsic to qualitative research examining a topic in an in-depth manner that quantitative methods do not offer. If sample size was an issue, a different methodology should have been adopted.

Tables:
The two tables are very busy but do not offer much additional contents to what has already been described in the text.
Introduction -the beginning of the introduction seems under-referenced. I was surprised not to see more reference to Lotte Dyrbye's work, and would have liked a more comprehensible opening, one which set out more clearly where the gap in knowledge/the literature is, and how the authors set out to address this. Is the gap theoretical conceptualisation? And this is why they used Michie's framework? More clarity as to why they did what they did, rather than just describing it would have been useful.
Reply: Dr Dyrbye"s work on burnout has certainly added a great deal to the field, but is somewhat separate from this study. She has developed several self-assessment tools for identification of burnout, including the Physician Well-Being Index, Medical Student Well-Being Index and the general Well-Being Index. This study is not about interns" abilities to self-assess, but about the causative factors and contributors to psychological distress. However, we acknowledge that the clarity of the introduction could be improved, including a clearer statement relating to the aim of the study. This has now been included within the introduction with the addition of the sentence: "This study therefore aimed to address the gap in the literature: the exploration of the factors contributing to psychological distress of PGY1 doctors using a robust conceptual framework to provide theoretical insight and improved understanding." Methods -I would have liked to see some explanation as to the value and acceptability of using an "a priori" approach to data collection and analysis in qualitative research ie it is scarcely surprising that they conclude the model can be utilised given it was the basis of the focus group questions. Big focus groups but no reflection on this. How did they manage to get so many junior drs together at the same time -was this labelled as a CPD session or similar? Analysis section is a bit thin. Is there no more detail to include?
Reply: Justification of the "a priori" approach to data collection and analysis is important and has now been included with the addition of the following sentences in the "data collection" section: "The use of an "a priori" approach to data collection and analysis explicitly allowed pre-existing theory to inform the data. However, participants were encouraged to reflect on their own experiences and discussion progressed to being free-flowing and unstructured. At that stage, deeper exploration of topics was encouraged by the facilitator through the identification of inconsistencies between participants and requests for clarification and examples.14,15 Through the process of free-flowing conversation, the data collected and analysed could, in turn, be used to inform pre-exiting theory." There has also been clarification of the "analysis" section with the addition of more detail.
Reply: Attendance at all sessions was entirely voluntary, this has been clarified in the manuscript. The high level of attendance (better than expected) was attributed to the strength of feeling relating to the topic being discussed. Reflection on the size of the focus groups has now been included in the limitations section with the addition of the following "…it is likely that this forum limited the willingness of PGY1 doctors to discuss either individual personality traits that may predispose to stress, or its impact on their personal lives. This limitation may have been exaggerated by the size of the groups (between seven and 14 participants). Such personal reflections may be more effectively elicited using individual interviews or audio diaries." Discussion again, a bit thin. What are the implications of what they did? Utility of the model/modified model for future research? The conclusion lacks "punch" Reply: Some parts of the discussion and conclusion have been re-written in stronger language and with the addition of implications and suggestions relating to the utility of the modified model. The following sentences have been added to the conclusion "Future work might usefully focus on exploring ways to reduce stress at each of these levels, and in particular reducing the uncertainties faced by PGY1 doctors on a daily basis. The modified version of Michie"s framework presented within this paper may provide a springboard for further research into uncertainty and stress across all grades of doctors. It could also be used by policy makers when considering the impact of decisions on the psychological distress of the medical workforce." Reviewer: 2 Reviewer Name: Ian Fletcher Institution and Country: Lancaster University, UK Competing Interests: None declared This was a well written paper that highlights a salient issue for medical educators.
Reply: Many thanks for these positive comments.
Reviewer: 3 Reviewer Name: Professor Tai Pong Lam Institution and Country: The University of Hong Kong, Hong Kong, China Competing Interests: None declared This is a paper which addresses a common problem i.e. workplace stressors of newly qualified doctors. It is a neglected topic which demands much further research. The strength of this manuscript is its inclusion of a conceptual model. However, as it is, the paper adds little knowledge to the topic and it is therefore difficult to justify its publication. The authors may like to review if they had collected data on the solutions to the problem, from the views of these newly qualified doctors. It may then provide additional contents to turn this paper into a very interesting one. Alternatively, how would their Australian findings compared to similar work in the UK/ Canada or even between those who undertook graduate entry vs undergraduate entry medical studies in Australia.
Reply: The aim of this study was to examine the factors contributing to psychological distress in PGY1 doctors, not to explore potential solutions. We felt strongly that any proposed solutions should be based on a sound understanding of the component parts of the problem, explored using the knowledge that has been generated in other fields. Comparison between groups of students, or between countries, would be extremely interesting but would require different methodology, perhaps even originating from a different theoretical standpoint (if statistically significant differences were sought).
Specific comments: Abstract: The results section provides minimal information on the findings and this can be improved. The results also do not quite justify some points in the conclusions e.g. job security.
Reply: More detail has been added to the results section of the abstract and the reference to job security has been removed.
Introduction: PGY1maybe a commonly used term in the UK but is much less so for Australia. As stated by the authors, these newly qualified doctors are generally known as "Interns" in Australia. Also pointed out by the authors, it is well known that Interns/Housemen suffer from high levels of psychological distress but much work on the contributory factors has also been done. Many publications are available on the topic, some are qualitative while others are mixed methods or survey (Liu & Tang, 2016, Abdulghani et al, 2014, Lam et al 2010. Reply: The term "intern" is introduced to the reader in the "setting" section of methods which seems appropriate. The studies mentioned have been reviewed as part of the prior literature review (reference 9 in this manuscript) which concluded that although some studies looking into causative factors had been done, there was a plethora of questionnaire-based studies and a lack of studies with a robust theoretical basis.

Methods:
It is stated that a purposive sampling was used but it does not give details how this was done. It would be helpful to state the interview schedule of the focus groups. One focus group was conducted at each of the four sites, it is possible that the participants knew each other well which might have an impact on the conduct of the focus groups. Also pointed by the authors in the limitations section, the addition of individual interviews might have offered an alternative mode of data collection for those participants who preferred it. The number of participants ranged from 7-14 per group. This reviewer has done many focus group studies with doctors and anything more than 8 is likely to make it difficult for a focus group to be conducted effectively. In addition, 46 to 65 minutes is hardly sufficient for focus groups of this size i.e. less than 5 minutes on average.
Reply: More detail relating to the purposive sampling technique has been added with the addition of the following sentence: "The purposive sampling technique included selection of both metropolitan and regional hospitals as well as academic and non-academic centres." More detail relating to the focus group schedule has also been added to the "data collecion" section of methods. The points relating to the limitations of focus groups have been added to the limitations section, with the addition of the sentence "…it is likely that this forum limited the willingness of PGY1 doctors to discuss either individual personality traits that may predispose to stress, or its impact on their personal lives. This limitation may have been exaggerated by the size of the groups (between seven and 14 participants) and the fact that group participants were likely to have known each other."

Results:
The findings or lack of them is a major deficiency of this paper. Many of the findings are already known facts. A google search of the topic would easily come up with much of the similar information. An example is the one by the Medical Protection Society https://www.medicalprotection.org/southafrica/junior-doctor/volume-4-issue-1/stress-and-burnout-the-intern-years. The papers listed above also covered most of the "findings". This reviewer also has reservation of having refinement of the conceptual model in this section.
Reply: Many thanks for the link to Dr Govender"s article on stress and burnout in interns, we are delighted that this important topic is gaining attention and generating discussion. Whilst the authors are sure that many of the factors contributing to psychological distress in interns have been identified previously, we are unable to find any research-derived findings that give the comprehensive oversight that we have been able to provide by using a pre-existing model of work-related stress. In addition, the identification of pervasive uncertainty (not limited to diagnostic uncertainty) as a major contributor to stress is novel and has important implications. Refinement of the conceptual model is an important part of the results, the result of the part of the study whereby the data is used to inform the theory (rather than just the opposite). The theory is strengthened and contextualised as a result.

Discussion:
As it is, this paper does not yield additional insights into the problem of workplace stress for PGY1 doctors, contrary to what the authors claim. The authors highlighted the point of uncertainty, both within and outside clinical practice. These were to major extent also covered by earlier publications listed above.
Reply: There is existing literature on diagnostic uncertainty, and the stress induced by it. There is, however, very little on the uncertainty generated in other waysrole ambiguity, uncertainty relating to extent of responsibilities, career uncertainty, inconsistency between the expectations of different consultants, perceived unpredictability of colleagues" responsesto name just a few. This is a novel finding and will change the emphasis of interventions which, to date, have been largely unsuccessful in reducing the extent of the problem of intern psychological distress.

Limitations
As a long time qualitative researcher, this reviewer would disagree with the authors" point that the conclusions were limited by the small sample size. Small sample size is intrinsic to qualitative research examining a topic in an in-depth manner that quantitative methods do not offer. If sample size was an issue, a different methodology should have been adopted.
Reply: We agree that sample size in this type of research is irrelevant and have therefore removed the reference to it in the limitations section.

Tables:
The two tables are very busy but do not offer much additional contents to what has already been described in the text.
Reply: Both tables contain additional detail that we feel will be of interest to readers who wish to see more example quotes or read in more detail about one particular facet of interest. We are therefore keen that the tables remain part of this manuscript, although acknowledge that the text can also stand alone.

REVIEWER
TAI PONG LAM THE UNIVERSITY OF HONG KONG REVIEW RETURNED 06-May-2017