Stress, burnout, and parenting: a qualitative study of general practice registrars
Rebekah Hoffman
A * , Judy Mullan A , Christine Metusela A and Andrew Bonney A
A University of Wollongong, Northfields Avenue, Wollongong, NSW, Australia.
Australian Journal of Primary Health 29(5) 537-546 https://doi.org/10.1071/PY23013
Submitted: 1 February 2023 Accepted: 3 May 2023 Published: 6 June 2023
Abstract
Early career medical professionals experience stress and burnout at higher levels than the wider community. Burnout can arise with competing demands of life and career, which is evident in early career development, where family planning can coincide with specialty training. General practice may be seen as a family friendly career option; however, few studies examine the experience of general practice trainees with stress and burnout and the impact that parenting has on their experience. This study aims to explore the experience of stress and burnout in general practice registrars and the exacerbating and protective factors, with a focus on the experiences of two groups of registrars, those that have children, and those that do not.
A qualitative study was conducted with 14 participants, who were interviewed with questions exploring experiences of stress and burnout. Participants were grouped into those with children and those without children. The transcripts were thematically analysed.
Themes were identified as those that contributed to stress and burnout (such as time, financial concerns and isolation) and those factors that reduced stress and burnout (such as support from others and being respected and valued within the workplace). Parenting was identified as both a factor that could contribute to and reduce stress and burnout.
Stress and burnout are important foci for future research and policy to ensure the sustainability of general practice. System based and individual focused policies, including individualising training to support parenting, are required to ensure that registrars are supported through their training years and beyond.
Keywords: burnout, family health, HEALTH education, mental health, parenting, primary health care, stress, wellbeing, workforce.
Introduction
Australia is experiencing a workforce shortage in general practice. There are several factors that contribute to this, including burnout (RACGP 2021; Karuna et al. 2022), a decline in attracting new registrars, difficulty retaining new to mid-career fellows and an ageing workforce (RACGP 2021). At the inflow of training, there is a reduction of numbers of junior doctors wanting to apply to complete a fellowship in the specialty of general practice. In Australia, the Royal Australian College of General Practitioners (RACGP) has had 20% fewer registrar applicants over the last 5 years (Smith 2019). With end career general practitioners (GPs) there is an increased number leaving or contemplating leaving the profession, with 13% of GPs being over 65 years of age, and 18% of all GPs planning to retire in the next 5 years (RACGP 2021). Accordingly, there is an urgency to plan for the succession of the general practice workforce across all career phases.
A challenge to this succession planning is that early career medical professionals experience stress and burnout at disproportionate levels compared to the wider community (Rotenstein et al. 2018; Beyondblue 2019; Clough et al. 2019). The risk factors for stress and burnout in this population include an imbalance of expectations and outcomes within the workplace and a lack of selfcare (Hoffman and Bonney 2018; Cohidon et al. 2020). This dynamic can lead to compounding stress and, if left unchecked and unsupported, may lead to burnout (Cheshire et al. 2017; Hoffman and Bonney 2018). With new fellow to mid-career GPs, a recent systematic review has shown a moderate to high rate of burnout in this population worldwide, leading to reduction of working hours, or leaving general practice to look at alternate careers (Karuna et al. 2022). There is a lack of evidence examining burnout experience in early career GPs, and with this current knowledge gap, there is inadequate evidence to determine the cause and protective factors, and the impact of stress and burnout, in this population (Prentice et al. 2023).
Burnout is also dependant on competing demands at life and career stages, which is particularly evident in early career planning. Often family planning coincides with the time registrars undertake specialty training (Morris et al. 2018; Hill et al. 2019). Many doctors plan to complete training before parenting (Estryn-Behar et al. 2011; Lambert et al. 2017; Bering et al. 2018), or choose training programs or training locations that are perceived to be more flexible and family friendly (Farahat 2009; Champion et al. 2015; Lachish et al. 2016; Lambert et al. 2017). However, the research in this area is conflicting, with recent data suggesting parenthood may be associated with reduced burnout in some groups of medical trainees (Hoffman et al. 2023).
General practice training has been perceived to be a family friendly career choice for junior doctors internationally (Le Floch et al. 2019). However, in Australia, the current Australian General Practice Training (AGPT) policies do not provide paid maternity or paternity leave, and have relatively inflexible training conditions, suggesting this is a less family friendly training environment than perceived (Hoffman et al. 2022). At the time of our data collection, Australian general practice training was under the auspices of AGPT to deliver training through a regional training organisation (RTO) model. Since 1 February 2023, it has returned to the RACGP and Australian College Rural and Remote Medicine (ACRRM). The same structural issues, where there is no government funding for maternity or paternity leave with AGPT, remain in place for the RACGP and ACRRM. However, registrars may be eligible to apply for the government basic wage maternity scheme, which is means tested, if they meet the federal requirements. The dynamic between being family friendly and job longevity is controversial, with conflicting opinions on the link between having a family, general practice training and burnout prevention (Nomura et al. 2015; Shiner et al. 2020).
There is a paucity of evidence characterising the burnout experience for early career GPs (Prentice et al. 2023). This is despite the acknowledged high prevalence within this group (Davis et al. 2021; Karuna et al. 2022) and the complexity in proposing mechanisms for change (Prentice et al. 2023). This study aims to explore the experience of stress and burnout in general practice registrars and the exacerbating and protective factors, with a focus on the experiences of two groups of registrars, those that have children, and those that do not.
Methods
This study adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al. 2007).
Recruitment
This qualitative study was undertaken by completing semi-structured interviews with eligible participants who were general practice registrars (term 1–4) and new fellows (within 5 years of fellowship), across Australia. The inclusion of new fellows gave the study greater potential to recruit participants while still obtaining reasonably contemporary data. New fellows were asked to reflect and respond to the interview questions based on their time as a registrar. Participants with and without children were recruited. General practice registrars and new fellows who required an interpreter (English language) were ineligible to participate in the study.
Participants were recruited from private social media Facebook groups, such as GPs Down Under and Medical Mums and Mums to be Australia/NZ. These private Facebook groups only allow Australian and New Zealand doctors to be members. Snowball sampling also took place, to help improve recruitment and to ensure eligible participants from a variety of demographics. Permission was obtained from the administration team for each social media page prior to advertising.
Prior to interview, participants were sent an information sheet and scheduled an interview time. At the time of interview, verbal consent was obtained and recorded prior to the interview starting.
Data collection
Semi-structured interviews were conducted between April and July 2022, via an online video-conferencing platform or in person. Interviews were conducted by RH and CM. As part of the interviews, participants were asked basic demographic questions prior to being asked broad open-ended questions about their experiences of stress and burnout. Box 1 outlines a sample of questions asked during the interviews. All interviews were audio recorded and transcribed verbatim. Interview durations ranged between 31 and 68 min.
| Box 1.Interview guide questions. |
| Part A: stress |
| Stress is defined as a physical, emotional, or psychological strain, where one feels overloaded, wound-up, tense and worried. It occurs when we face a situation that we feel we can’t cope with. |
| Can you please describe if you have experienced stress (feeling overloaded, wound-up, tense or worried) as a general practice registrar? |
| When you experienced stress as a general practice registrar, were there any stress supports that you used at home or at work? When you experienced stress as a general practice registrar, in your view were there any barriers, which may have impacted on your stress levels at home or at work? |
| Part B: burnout |
| Burnout is defined as a state of physical or emotional exhaustion that also involves a sense of reduced accomplishment and loss of personal identity. |
| As part of your general practice training can you describe ever experiencing burnout? |
| When you experienced burnout as a general practice registrar, were there any supports that you used at home or at work? |
| Part C: opportunities |
| In your view are there any stress or burnout prevention opportunities/resources that should be offered to support trainees who are completing their general practice fellowship? |
Data analysis
A pragmatic qualitative approach (Thompson et al. 2022) was undertaken to describe and understand the experiences of stress and burnout among general practice registrars who were parents and those who were not. We analysed the data using a reflexive thematic analysis approach as described by Braun and Clarke (Braun and Clarke 2019), where three of the authors (RH, CM and JM) familiarised themselves with the data, then individually worked through the dataset to identify patterns and meaning in the transcribed interviews. The themes interpreted individually were brought back to the group to reach consensus (Braun and Clarke 2019). After analysis had been undertaken of the 14 interviews, the researchers deemed that data saturation had been achieved, as no new themes emerged from the qualitative interviews (Braun and Clarke 2021). RH individually coded all 14 of the transcripts, and JM and CM coded seven transcripts each. The researchers engaged reflexively throughout the research process and were aware that their professional experience as researchers, and their professional and personal background, could influence their interpretation of the data.
Results
Fourteen participants completed the interviews as part of the study, seven who had children, and seven who did not have children. There were 12 females and two males, working across five states or territories in Australia (NSW (n = 10), Tasmania (n = 1), Victoria (n = 1), NT (n = 1), and ACT (n = 1)). Most (n = 10, 71%) were on the RACGP traditional pathway, with three participants working towards Australian College of Rural and Remote Medicine (ACRRM) fellowships and one was working on the Practice Experience Pathway (PEP) with the RACGP. Just over a third of the participants (36%) were rural based in their training and most (65%) undertook training on a fulltime basis. See Table 1 for further information.
| Participant | Training term | Hours worked | Training location | Training provider | |
|---|---|---|---|---|---|
Participants with children | Term 1 (n = 1) Term 2 (n = 2) Term 3 (n = 1) Term 4 (n = 0) New fellow (n = 3) | Part time (n = 4) Full time (n = 3) | Rural (n = 2) Urban (n = 5) | PEP (n = 1) ACCRM (n = 1) RACGP (n = 5) | |
Participants with no children | Term 1 (n = 0) Term 2 (n = 1) Term 3 (n = 1) Term 4 (n = 1) New fellow (n = 4) | Part time (n = 1) Full time (n = 6) | Rural (n = 3) Urban (n = 4) | RACGP (n = 5), ACRRM (n = 2) |
All of the participants reported having experienced a period or situation that they could describe as burnout, and all of the participants related their burnout to being related to work.
Two key themes emerged from the data. These were identified as ‘Factors that contribute to stress and burnout’ and ‘Factors that help reduce stress and burnout’. The participant quotes below are differentiated by participants with children (A) and those with no children (B) and the participant number (e.g. A1 refers to participant 1 with children and B2 refers to participant 2 with no children).
Theme 1: factors that contribute to stress and burnout
There were several factors that were perceived by the participants to contribute to stress and burnout. These factors included pressures (such as time and financial), isolation (from usual supports and within the workforce), lack of support, and worry (around making a patient error or worry and guilt around letting someone down).
Of the key pressures that study participants considered contributed to stress and burnout, time pressures were often perceived to be a contributing factor, due to factors surrounding juggling workplace and training requirements, such as minimum training hours and studying for exams. These pressures were perceived to have been exacerbated by the limited availability of leave due to policies around training requirements.
The fellowship training program was seen as prohibitively rigid due to time constraints and competing demands of exam study.
I know it’s difficult because it’s a short time, but I feel … that general practice training is quite narrow and rigid. (A1)
The concerns around limitations for leave were not isolated to the lack of study leave, but extended to the lack of flexible leave options for burnout prevention.
Because if you’re burnt-out you just need time off. Like that’s the answer to burnout. (B2)
And so that time I went to full time work in order to pass exams and that was probably one of the things that sort of tipped me over a little bit, and then that’s what tipped me over to making a couple of mistakes during your burnout time, which everybody does. (A2)
Financial pressures echoed this, with the exams being a costly expense, with no paid study leave available to supplement annual leave. This burden of participants working and studying for exams was a commonly reported concern. Leave requirements, where participants have minimum training times to be eligible to sit exams, also meant that participants felt they were unable to take additional unpaid time off to help prevent burnout. The impact of the Covid-19 pandemic was also recognised by one participant, with reducing patient numbers meaning a reduced income, and increased financial pressures.
Just don’t have enough leave to allow an actual break as well as study, we’ve got just enough that you could do some great study leave …. But there’s not enough time to actually take non-study based leave as well. (B1)
That was a financial thing, because we did not have patients coming through the door in the first wave in a bulk billing practice, so that was not so great for me, that put stress on me paying for exams, because I was saving up for exams at that point. (B4)
The pay drop between a hospital junior doctor position and a general practice registrar was identified as a financial pressure for some, while other study participants took on second jobs or sought help from family and friends to support them financially.
The pay rate for a term 1 general practice registrar is less than a hospital resident, so you take a big pay cut coming to general practice. (B2)
Financial stresses of being [paid] significantly less than my hospital colleagues. Hence needing to take on a second job to support myself as a single person. (B3)
In addition to experiencing the same time pressures as participants who were not parents, participants who were parents reported additional time and financial pressures, including a lack of leave flexibility due to complexities of juggling multiple roles at work and at home.
And as a parent, I couldn’t rely on my evenings and weekends to be able to study without significantly burdening my partner with the bulk of the childcare. (A1)
Yeah, and then when you get home it’s homework, baths, dinner, bed and by the time the oldest one’s finally gone to sleep …. I’m wrecked, especially if you’ve been at work all day, and then can you really sit down and study and remember it? (A3)
Just being with a newborn … with the teething, the feeding and the solids … and your training and trying to learn and trying to clear exams and knowing that you have no leave, you work when you’re sick, I thought that was really tough …. (A4)
For some parents this financial pressure led to perceived challenges around planning for families and leave.
That’s very stressful, because general practice training, as a registrar, financially it’s pretty tough; it’s tight anyway. And then if you’re doing general practice training in your fertile years, you’re going to have to go on maternity leave if you want to have a family, and it’s unpaid. (A5)
I think proper maternity leave would be great, so that people don’t feel … the pressure to come back so quickly because it is financial pressures. (A5)
Isolation was another factor that contributed to stress and burnout for many of the study participants. For some, the isolation from support networks, especially in a rural area, were seen as an important contributing factor to stress and burnout.
The isolation, having such little connection with other trainees or GPs that I felt got it or could sort of hold space for that, this was really difficult. (A6)
I’m the only reg there now, it can be quite isolating … especially rurally. (A5)
Rural, lots of driving, isolation from my new husband, family and friends, I didn’t know anybody down there when I went down. (B7)
For other participants, the isolation arising from working independently, with isolation from a team of colleagues within the workplace, was perceived as a factor that contributed to stress and burnout.
Now at least I can talk to the other registrar …. I was so alone at the other place. (B2)
The isolation, having such little connection with other trainees or GPs … was really difficult. (A1)
And it was very hard, because GPs – it’s completely different to hospital. Especially when you’re a junior registrar there’s always someone that you will check, ‘I did this, is that okay?’ So, I did feel quite isolated. (A6)
Exacerbating the feeling of isolation as contributing to their stress and burnout, was the feeling among the participants of a lack of support from those that were expected to be helpful. Individual supervisors and training practices were seen by some participants as a factor that could increase stress and burnout.
The teaching was close to absent. The feedback loop of how I was progressing, that was also absent …. In terms of patient support, that was probably one of the most stressful things was when I asked for help, help would arrive up to 60 minutes later. (B5)
The regional training organization (RTO), that co-ordinates the placement and training for general practice registrars, was sometimes also perceived as a contributing factor to stress and burnout among participants who felt unsupported.
I felt completely unsupported by my first training practice and ended up escalating that through the (RTO) ranks, and nothing was actioned. So besides feeling unsupported by the practice, I was completely unsupported by the higher ranks of the training organisation, as well. So that was extremely stressful. (B5)
In addition to the above factors experienced by all participants, those who were parents suggested that a workplace that was not supportive in terms of flexibility, patient appointment scheduling and urgent childcare demands contributed to increased stress with juggling family priorities.
Because they don’t factor that in; they’re just trying to get through the day. I don’t know how I’m going to go back to work and (use a breast) pump. Just like, can you imagine running 30 minutes behind and having to pump for 30 minutes? (A3)
I remember feeling quite unsupported that I did have to go to pick up my kid …. But knowing that other people felt that way in the practice made me feel like if I had to call in sick, that I was doing something wrong. (A6)
Another factor that was perceived to contribute to the participants’ stress and burnout was that of worry. Worry and concern was experienced by the participants in a number of ways. Some participants suggested that they were afraid of making the wrong clinical diagnosis or making a patient error.
Knowing you’re there then and just there by yourself with the patient. I think patients can be stressful because of generally their expectations of what they want completing and solving, versus your, what you perceive as what is possible to be done safely in order to prevent misdiagnosing and glancing over symptoms that probably need a bit more time and attention. (B3)
Being in a situation where you’re not sure if you’ve made the right decision, or if you are missing something and not being quite sure how to address that straightaway. (B6)
But it’s a completely different kind of stress, where the buck stops with you. (B4)
The worry and guilt of letting someone else down was another factor that was perceived to contribute to stress and burnout, especially among participants with children. These participants felt they were not fully supporting the needs of their children or family as well as their requirements in the workplace.
Yeah, I feel like I’m failing. Certainly, at the end of pregnancy, I felt like I’m drowning, I can’t do anything above just getting work done, getting patients through, which I hate. (A3)
Probably returning from maternity leave, I found that very stressful. How I was going to juggle … juggle day care …. I did my exams when [name of child] turned one. So, I found it really difficult. I felt guilty when I had to study and be away from him and he just wanted to play. He didn’t understand. (A5)
Surviving winter in general practice with a small snotty child … cancelling a day of patients to accommodate a sick child … definitely increased my stress … it was, well, simultaneously difficult to meet the needs of my patients and my family, and particularly my child. (A1)
Theme 2: factors that help reduce stress and burnout
Participants perceived that there were several factors that could help protect them from experiencing stress and burnout. The first of these protective factors was that of support, which included support from family and friends, workplace colleagues and other healthcare professionals such as their GP or psychologist. The second was that of being respected and valued within the workplace, and the final factor was having a balance between the juggle of work, study and other life commitments.
Family and friends were reported by many participants as being able to provide emotional assistance, and it was seen by many as the key protective factor that prevented stress and burnout.
My family and friends, I mean I lived on my own at that time, rented alone. But yeah, probably my biggest support was my mum and my closest friends and the other registrar. (B5)
Having a stable, emotional, psychological, healthy family situation … is crucial, because I think, if you don’t have that, you pretty much can’t function already. (A4)
Participants who had partners in the medical field, felt there was an additional emotional support benefit of understanding when debriefing, and this was appreciated.
It’s good to debrief; I have a medical partner, so he understands. (B2)
My sister’s a paramedic, so I talk to her sometimes just stuff happens that you can’t really talk about with non-medical people, but you need someone who’s not work related. (B6)
My wife and I were on our own … we had each other, I guess it’s a double edged sword, isn’t it when you have a medico as a partner, they understand, you support each other, but it’s also very difficult to get away because they are also on the same track. (A4)
I was – I’m lucky that he’s in the same field, so he understood. But I don’t know if anybody else would be so understanding. (A5)
For participants with children, having a supportive partner meant that, as well as the emotional support, there was physical support that allowed the distribution of child and care requirements.
Because it’s after dinner and bath; I’m lucky to have someone I live with so he can do the bedtime while I do my meetings, and he’d come home early if I had a meeting, he’d make sure he wasn’t still at work late. (A3)
Participants also suggested that workplace colleagues and supervisors were another support that could help to reduce stress and burnout.
Look, I’m really lucky, I suppose I’ve got a very supportive practice, my supervisor. (B1)
The culture and values of the practice were also viewed as factors that could help to reduce stress and burnout.
So, the culture around support within the GP practices that I’ve worked at is very good. Then the culture around, I guess more alliance with my ethics of providing quality patient care and also accountability, and support from colleagues as well. (A7)
In my first practice, the whole practice was very cohesive actually, everyone would meet together at lunch every day, there was dedicated teaching time. (A4)
Furthermore, participants suggested that feeling respected and valued as a team member helped to reduce stress and burnout.
I didn’t expect to be respected as a senior colleague but just respected as a person who’s learning … he treated me as a person who had some knowledge and who was deserving of his time, and there was never any barrier to asking him anything. His door was always open, he always had time for me, and I was a priority for him. (B5)
I feel like my supervisor is very good to debrief without judgement, and make an action plan that doesn’t shame (what were) not the best choices on my behalf sometimes. (B2)
Participants also suggested that they benefited from utilising other healthcare professionals for support, such as having their own GP.
I just walked into a random GP in Sydney, and they happened to be someone who had a very similar experience …. To know that it’s totally okay to need help and … talk to you as a doctor … would have been really helpful much earlier on. (B6)
And then I also saw my GP and just discussed a few of these things. I suppose also they were a person to debrief with and/or normalise a lot of the feelings that I was having. (B7)
Some participants suggested professional debriefing with a psychologist may be an ideal opportunity to reduce stress and burnout across the profession.
But most of what you see on a day-to-day basis can be quite distressing, patients and all of it. So just like they have in most other healthcare settings, compulsory psychology or debrief sessions, I think that would definitely help. (B3)
Prioritising work life balance was viewed by the participants as an important strategy to help reduce stress and burnout.
I just had to put general practice training first as a priority and be strict with my time, just learn to say no. (B3)
And that if you say yes to something, it means no to something else, and so … having to realise that there was only so much that I could do at work and still be able to sort of function as I wanted to at home, and vice versa I think. (A1)
Some participants who were parents identified that it was easier to prioritise work life balance, and say no, as they were prioritising for their family, not just themselves.
But as a parent, you also feel bolder and braver and more protective …. I do feel older and braver as a parent in decision-making because there’s more than one person involved. (A5)
So, I’m returning to work in September, and I’ve booked time off at Christmas, which I don’t think I’ve ever done before because I suddenly realised, well, hey, I have a child to spend Christmas with, so I don’t feel guilty asking for Christmas off. (A1)
I’d say, compared to before I feel like work was never as important anymore since she was born, it gives you perspective …. (A4)
Discussion
In this study, we aimed to explore the experience of stress and burnout in general practice registrars, with a comparison between two groups, those that have children, and those that do not, making this a unique focus compared to other studies. This paper is consistent with previous findings where many general practice registrars are experiencing stress and burnout (Cohidon et al. 2020; Prentice et al. 2023). This paper expands on this research, reporting on the participants experience, and the factors that they perceived to exacerbate or contribute to stress and burnout, as well as factors that they suggested helped to protect and reduce stress and burnout.
Our findings suggest that stress and burnout was experienced by all study participants, irrespective of having children or not. The key factors that contributed to stress were financial and time pressures, isolation, a lack of support in the workplace and worry about letting others down, such as their patients, themselves or even their family and friends. The key factors that were deemed to help prevent and/or reduce stress and burnout included family support, workplace support, feeling respected and valued and a balanced work and life dynamic. In addition to these key factors experienced by all the study participants, those with children suggested that a lack of flexibility in the workplace and no maternity leave financial assistance contributed to their stress levels. Interestingly, however, they also suggested that having children provided them with the confidence to say no to additional work-related requests, which helped to improve their work life balance. Of note, the interviews for this study were undertaken during the Covid-19 pandemic, a time that was universally met with crisis and burnout, and with a diverse range of experiences reported for general practice registrars (White et al. 2022), yet only one participant from this study commented on the impact that the Covid-19 pandemic had on their stress and burnout. This participant reflected on how it impacted on the financial viability of being a registrar, specifically when having to output a significant portion of income for training examinations.
Time pressures have been highlighted as a significant stressor within this study. Flexible leave policies and working arrangements were highlighted as highly desired and helpful to reduce stress and burnout. The impact of leave and flexibility demands were increased through the combination of family demands, workplace demands and study demands. This is reflected in the literature, where training programs that offered flexible arrangements, including childcare facilities, breastfeeding facilities, job share and flexible working hours were more attractive training positions (Purdy 2017; Piotrowski et al. 2018). In Australia, general practice registrars are the only doctors-in-training who do not work within an award that provides paid maternity leave (Hoffman et al. 2022). This was seen as a key stressor and may contribute to general practice training being less attractive as a training pathway. Leave and flexible arrangement policies are a key area in which there are opportunities that could work to improve the desirability of general practice and improve registrar retention and reduce burnout. There are several current options being trialled, to allow flexibility with paid leave, such as the single employer model of general practice training in Tasmania, Australia (AMA 2023).
Isolation from family and friends, as well as working alone without the support of workplace colleagues and networks, contributed to the stress and burnout of the study participants. General practice registrars work in a field of medicine that is complex, unpredictable and often ambiguous (Malterud et al. 2017). This can be a daunting and intimidating experience (Sturman et al. 2021), especially for trainees who are lonely and more likely to experience stress and burnout (Ofei-Dodoo et al. 2021). A greater awareness, and action at a practice level, may go some way to addressing this issue. Actions such as developing or utilising a community of practice, including virtual communities of practice (Barnett et al. 2016), especially during times of crisis, such as the Covid-19 pandemic (Mullan et al. 2022), have the potential to improve collegiality and teamwork. This simple approach could help to reduce the registrars’ sense of loneliness and isolation, which in turn could help to reduce stress and burnout.
Having the skills to work through an ambiguous case, such as medically unexplained symptoms, or a poor outcome, is a challenging process only developed over time. Workplaces need to ensure they are able to provide a safe space for the registrar, to be able to develop the skills to work independently and make the complex decisions that are necessary to grow in their clinical practice. Other professions require compulsory clinical supervision to accommodate and allow for this growth and a safe space to discuss and debrief, such as clinical supervision for psychologists (American Psychological Association 2015). This may be an opportunity for registrars, or all GPs, to improve resilience or reduce the element of isolation by being supported by others in the healthcare profession.
Participants’ experiences reflect previous Australian studies (Hoffman and Bonney 2018; Prentice et al. 2023) demonstrating that stress and burnout are a common experience among junior doctors. This is supported by a review of previous research, where Hoffman et al. (2020) identified that parenting and medicine had structural and individual barriers to successfully negotiating both roles simultaneously, with parenting slowing career progression, and medical careers leading to delayed family planning (Hoffman et al. 2020). This current qualitative study also provided data that assist in understanding the seemingly paradoxical findings of recent research that demonstrated an association between parenting and reduced burnout in general practice trainees (Hoffman et al. 2023). This study contributes to the literature by identifying the impact of parenting on both contributing to, and potentially alleviating, stress and burnout. This study further emphasises the importance of research into registrar stress and burnout, and the need to allocate support for all registrars in an individualised way. This study also highlights the importance of ensuring that policies are put in place to support isolated registrars and investigate options for potential financial supports and flexibility around time constraints and paid leave arrangements. Addressing these issues will help to attract and retain junior doctors to the general practice profession. Table 2 summarises these recommendations.
| Recommendation | Summary | |
|---|---|---|
| Flexible leave policies and working arrangements | Policies implemented by training organisations (ACRRM and RCAGP), in consultation with registrars | |
| Enable registrars to balance work and study with competing demands | ||
| Structural change to allow maternity/paternity leave and study leave | Enable registrars to take a paid leave break, to allow them to be a primary career for their children. | |
| Due to the nature of the training programs, where registrars rotate every 6 months, and the funding of their training position being largely by the small business they are working in, this is not a simple solution. | ||
| Current options being trialled such as the single employer model of GP training in Tasmania, Australia (AMA 2023). | ||
| Developing and utilising a community of practice to reduce the isolation of General practice | A virtual community of practice, would enable an ongoing source of support for registrars, even as they move away from home support networks. | |
| Starting this in a supported environment, early in GP training would encourage a stronger network and bond prior to registrars rural rotations. | ||
| Clinical supervision (akin to current requirements for psychologists) | Clinical supervision and formal debriefing allow registrars, and experienced doctors to discuss challenging patient interactions in a safe environment. | |
| Advocating for participation in clinical supervision throughout the medical career would normalise seeking assistance for these situations. |
Limitations
The findings of this study should be interpreted in light of its limitations. There were a relatively small number of participants, who were recruited through social media advertising and snowballing, resulting in the majority of participants being female (12/14) and from the same Australian state (10/14). It should also be noted that there was a potential for responder bias, with participants who had experienced stress and burnout more likely to volunteer to participate.
Conclusion
This study has demonstrated the experience of stress and burnout in general practice registrars, with all of our participants having experienced stress and burnout. Parenting is complex and attributed to both increasing and reducing the pressures that lead to burnout and stress. This study provides actionable ways to improve the attraction of general practice as a speciality and reduce stress and burnout in registrars and early career GPs. It also highlights the need to provide structural systems-based support to ensure registrars are able to access leave entitlements provided to other specialisations of doctors. The authors are watching with interest the outcomes of initiatives to address some of the barriers identified in this study, e.g. the single employer model of general practice training in Tasmania, Australia (AMA 2023). Individual approaches are required to intervene to ensure registrars are using several strategies, both in their personal and professional lives, to help minimise their risk of experiencing stress and burnout.
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