The Stanford marshmallow
test has always fascinated me. Led by psychologist Walter Mischel at Stanford
University in the 1960s, the series of studies looked at a young child’s
ability to delay gratification. If they could wait and not eat the marshmallow
in front of them until the adult returned, they would be rewarded with a second
one. It was found that those who were able to exhibit this type of self-control
were more likely to succeed in life1. For me, the long road of
medical training is like asking you to forgo eating a large number of
accumulating marshmallows for a very, very long time. The promise of a future
reward is constantly dangled in front of you but it often feels like the
obstacles along the way are so great, you’ll never get there. One of the
biggest obstacles I faced was surviving the junior hospital years – so here is
I started my medical career working in a highly regarded major
tertiary referral hospital, fresh faced and excited to learn. I was looking
forward to making new friends and I had a strong desire to put years of study
into practice. Like most interns, I quickly began to live and breathe work.
Even in my free time, I often spent it with my peers as we mutually celebrated
our new financial freedom and working life. I felt like I was part of
something, I was part of a team. I always helped the other resident on my ward,
making sure I pulled my weight. I became known by the nurses as “the nice one”,
always approachable and responsive to any request. Full of empathy and
compassion, I willingly spent extra hours at the end of my shift with patients
and their families explaining their care. I looked up to my experienced
registrars, and diligently accepted my responsibilities. In essence, I was
thriving by having a new sense of purpose. I’m not going to lie, there were
frequent moments of anxiety due to a high level of self–doubt and fear of
making a mistake. However, I managed to bounce back from these moments and was
slowly gaining confidence in my skills.
Fast forward to two years later.
My morning as a junior doctor began like every other day. I met up with my
fellow resident and we prepared for the ward round, taking the opportunity to
guzzle some coffee to open our weary eyes. It felt like I hadn’t slept, it felt
like ground hog day. I grumbled negatively to my friend “Here we go again”. I
didn’t feel like myself anymore. I was increasingly bitter, quick to anger and
uncharacteristically bothered by the typical nursing staff requests. I wanted
to sneak into the ward unseen, so I could get in and get out, cross off my
tasks and go home. When a patient became ill, instead of feeling my usual sense
of compassion and duty, I was frustrated. This meant I’d be home late again. I
felt bone crushingly exhausted despite a decent nights rest. There was no time
for “me” outside of this 80 hour 6-7 day a week job. My family and friends
never saw me. I had missed countless weddings, baby showers, and birthday
celebrations, and worked almost every public holiday including Christmas, New
Years and Easter. The hospital had allocated my five-week block of annual
leave, and unfortunately this meant it had been 18 months since I’d had a
holiday. “Just keep going, you are almost there” I’d tell myself on a daily
basis. I had one week to go but it felt like a lifetime. I had begun to have
frequent thoughts of wishing I’d done something else with my life, and felt
overwhelmed at the prospect of having to spend another few years doing the same
thing, over and over until I had specialised. I found myself feeling envious of
others who had 9-5 low-stress jobs. I knew I was struggling, however, many of
my peers felt the same way. We were all battlers, in it together, bound by the
system, and for many months I had found some comfort in that thought.
the end of yet another long shift as I was packing up to leave, a nurse asked
me to put an intravenous cannula in a patient that wasn’t my responsibility, as
their resident had failed to respond to multiple pages. So I paged him myself.
After not hearing back, I grumpily agreed to do it this time, as I knew the
patient would suffer without it. Forty-five minutes later, after four failed
attempts, I found myself in the storeroom furious and frustrated that I was
missing another dinner with my friends after taking on a responsibility that
wasn’t mine. To top it off, I had failed at a task I thought I had mastered. I
stopped caring about the patient. I angrily (and dangerously) threw the needles
into the bin, swearing out loud, just as the nurse walked in. Feeling
incredibly inadequate, hopeless and overwhelmed, I immediately burst into
tears. I’d reached my limit.
So how did I become a person who I barely
recognised? Over time the demands placed upon me had taken its toll. I realised
I had become a victim of “Doctor Burnout”. It’s a term to describe the physical
and emotional changes that occur with chronic unrelieved stress. Burnout and
doctor suicide is gaining more and more awareness in the media and so it
should. It’s real. Beyond Blue’s National Mental Health Survey in 2013
suggested that almost 50% of younger doctors were experiencing symptoms of
burnout2. The key triad consists of emotional and physical fatigue,
a sense of depersonalisation and cynicism, and a reduced sense of achievement
or contribution due to a low professional efficacy3. These symptoms
develop gradually as you become increasingly unable to recover between insults,
and they tend to peak when it begins to affect your quality of life and
relationships outside of work3. It’s easy to see how this spiral can
lead to doctors questioning their career decision and feeling as though they
want to quit medicine all together.
There are many burnout risk
factors, both at an individual level, and an environmental level.
Interestingly, a recent MJA insight article highlighted that while burnout
certainly occurs in male doctors, single young female doctors who possess a
strong work ethic, and high levels of empathy and self-criticism are most at
risk4. This combination leads them to take on more than they can
emotionally and physically handle4. I certainly feel I fit this
In terms of environmental influences, a key risk factor is
a highly demanding job with a low level of autonomy3. As junior
doctor, on call and extra weekend shifts are routinely rostered, leading to
very long working weeks. At all times during your shift there are high
expectations on your level of performance and organisation. Often, the list of
tasks placed upon you to achieve in a day is impossible. You are expected to
run all major decisions by your senior registrar or consultant, yet they are
often so overworked themselves that the support system fails. You are
subsequently forced to take on responsibilities above your experience level.
There are no sheltered morning tea or lunch breaks – it is viewed as a luxury.
A “good day” for me was when I managed to make it to the hospital cafe for a
cappuccino and a proper lunch instead of surviving on ward snacks at my desk.
Clearly this is not the making of a healthy lifestyle.
To survive the
onslaught over the first few years, I learnt the skill of leaving work at work,
which is difficult when faced with distressing situations and an endless list
of chores. Detachment and compartmentalisation requires conscious practice.
Another important buffer was the sense of comradery I felt with my fellow
junior doctors and the ability to debrief with others who understood my plight.
I think that was probably what finally broke me that day – I felt that one of
my own teammates let me down.
So the following day, I decided to put
aside my work ethic guilt and made an appointment with my GP, who promptly
handed me a medical certificate. I instantly felt a burden lift from my
shoulders. Relieved, I took what felt like my first breath in months. Over the
following week I focused on myself completely. I avoided social media and
emails and unnecessary chores. I just rested, read, ate well and made sure I
got outside in the sunshine and exercised every day. It was the beginning of my
Although in hindsight I should have sought assistance sooner
and prevented burnout taking hold, the silver lining was that I recognised my
unhealthy pattern before I made a mistake, quit, suffered significant
relationship difficulties or dived head first into a depression spiral.
Unfortunately, not everyone is able to avoid such consequences. A lack of
self-awareness, lack of perceived control, or a fear of seeking help due to
possible workplace repercussions leads some down a very dark lonely path. I was
eventually able to push past the guilt that comes with feeling indispensable
and put my needs first. So there I was, forcing myself to step outside of
life’s pressures to focus on myself again. In this moment, I had paused, and
given myself permission to eat one or two of my marshmallows. And although this
allowed me to recover in a physical sense, it turned out to be much more than
that. It marked the beginning of a change in direction for me, and ultimately
led to a major career decision.
This blog was originally published on
www.onthwards.org on 31 July 2017. Read the original article at Eating
your marshmallows – part one: the slippery slope to burnout.
Read part two: Eating
your marshmallows – Surviving burnout and cultivating a new work-life balance
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Avant and onthewards partnership
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a free open access medical education website dedicated to creating resources
for the doctors of today and tomorrow. onthewards was developed to address the
gap in formal education specifically designed for, and aimed at, medical
students and junior doctors. Educational topics are selected by junior doctors
for junior doctors.
What started as podcasts for junior doctors at
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increasing interest from doctors across different hospitals expressed their
interest. Avant and onthewards have
committed to working more closely together to develop risk management content
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The article has been republished with
the permission of onthewards. The views expressed do not necessarily represent
the views of Avant. Avant is not responsible for the accuracy of any
information contained in the article.
1.Mischel W, Shoda Y, Rodriquez ML. Delay of Gratification in Children.
Science. 1989; 244(4907): 933-938. DOI: 10.1126/science.2658056. Abstract
2.National Mental Health Survey of doctors and Medical Students. Beyond Blue.
Oct 2013. Available from:
(accessed July 2017).
3.Thomas NK, Resident Burnout. JAMA. 2004;
292(23): 2880-2889. DOI:10.1001/jama.292.23.2880. Available from:
4.Corke C. Have
the courage the act on burnout. MJA InSight (Issue 7). 2017 Feb 27. Available
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