A total of 13 individual interviews were completed after one participant withdrew from the study before the interview. Each interview lasted an average of one hour. There were five male and eight female participants who were between 26 and 38 years of age. They were in their postgraduate years (PGY) of three to eight. Three main themes were elicited from the data collected and further elaborated with subthemes (see Fig. 1).
1. Nature of palliative care.
The nature of palliative care was described in terms of the type of patients and how care was provided for them, the culture experienced within the working and learning environment, and the existence of staff support activities. Often, these aspects contrasted with their previous rotations.
a. Patient characteristics.
Palliative patients were identified as having complex medical and psycho-emotional needs with profound uncertainties about treatment responses. Therapeutic approaches were individualised and included emotional and psychosocial support. Aspects like spiritual care distress may be unfamiliar to the participants (P14, PGY5), but resulted in a sense of connection and closeness to the patients when provided. When patients deteriorated or died, there were strong emotions like a sense of failure and also sadness.
“…it's quite hard to not feel… that loss especially when you have had built a relationship with…your patients or family and some of the conversations can be quite emotional so I think for me… I would say I struggle with the most during the posting.” (P11, PGY 3)
b. The culture.
The junior doctors appreciated a positive culture of fairness, empathy, and support. (P7, PGY6). They felt that this was because of innate personalities of their consultants who appeared to be self-selected into the discipline. Similar values that guided clinical practice reinforced these values.
“I think that it’s innate but it’s also learned… palliative care draws a kind of character. People who are genuinely more intentional in caring… so I guess it is innate to some extent...” (P6, PGY3)
c. The working and learning environment.
A high level of competency was expected in communications but was often learned through opportunistic observations and role-modelling. This led to anxiety and low confidence (P2, PGY8). There were consultants who demonstrated professional values like patience, persistence, and genuine care. These observations of positive role-modelling were inspiring and left a deep impression on the junior doctors.
“…irrespective of how difficult the communication… or how much time it would take, they would invest that effort… a lot of dedication to that craft and being there… It is inspiring to see someone who has been in this field for very long and still able to do something with so much passion and… a lot of us commonly ask whether we’re able to last that long or whether we are able to keep this up and do this for many years on as a career.” (P11, PGY3)
d. Staff wellness
There were formal staff support sessions and informal practices that promoted self-care, including art-making programs,30,31 and free drinks and food from consultants respectively. These layers of support signalled that staff wellness was important. This message was reinforced when seniors engaged in the formal programs themselves (P4, PGY3). There were also numerous unspoken “rituals” like “pre-rounding” that were passed down from predecessors, like reviewing patients before their consultants came for ward rounds. These practices were valued for improving work efficiency and promoting a sense of accomplishment (P6, PGY3).
2. Stressors as a junior doctor
a. Professional identity as junior doctors.
Despite an open culture and a sense of support, the junior doctors remained hesitant to receive such support whole-heartedly. Based on their past experiences, hierarchical concerns remained, and the junior doctors saw themselves at the bottom of the hierarchy. Their priority was to preserve the status quo in each new rotation by “maintaining collegiality”. This resulted in actions like withholding feedback, and under-reporting working hours (P4, PGY3). There was a persistent sense of resignation mixed with cautious optimism.
“… we are too junior to make any sort of like meaningful change… I have to do what is within my means… just have to… flowing with it...” (P11, PGY3)
b. Challenges with frequent rotations.
As junior doctors, the participants had to rotate across different disciplines regularly. This resulted in the need for prompt skill mastery, adaptation to varying cultures, and uncertainty about schedules and time off (P13, PGY3). Often, the junior doctors took it upon themselves to adhere to departmental culture to avoid offending the existing permanent staff. It was unclear if such perceptions were justified.
“…every time you transition to a new place… I have to be temporarily at a heightened alert because I’m the guest… visitor, whereas they are the home team. They have different culture(s), different expectation(s), different people… different combination of personalities and they will expect the visitor to get to know them and to kind of integrate into that culture… it’s very difficult… inadvertent that you’re going to step on someone’s toes… who often bears the blame… is usually the visitor or the guest or the MO (medical officer) because from the department’s point of view, “We’ve always been like this… It’s he (who) doesn’t know us…” (P8, PGY3)
3. Tensions encountered.
a. Service requirements vs philosophy of care.
The junior doctors appreciated the high standards of care provided and advocated for by their seniors. However, the high clinical workloads cast doubts on how these standards could be met. This in turn affected their sense of agency in how they could pursue and achieve these standards.
“…it becomes a lot… work-focused… getting the job done than actually like really… assessing the patient from genuine place of care… Get the job done you know which your boss expects...” (P6, PGY 3)
b. Service vs culture.
The consultants supported the junior doctors through behaviours like assisting with the clinical workload, soliciting feedback, and putting in frequent reminders to finish work on time. However, these practices felt inadequate and sometimes counterproductive. For example, soliciting feedback when change was not possible and approving leave when manpower was limited led to frustration and a sense of injustice (P12, PGY6).
“But we all know that’s impossible… Who are we kidding… ‘guys try not to—can you try not to bring work home...’ I do think that kind of adds to burnout because it’s just so much work to be done in the day you don’t really have a choice. You have to…” (P5, PGY5)
c. Staff support programs.
The junior doctors were hesitant to participate in staff support programs as it meant that they had less time to finish their work. Some of them were also hesitant to engage in activities that they were not familiar with although they could see the relevance of these programs. Eventually they felt obliged to participate despite the reservations they had, suggesting an implicit sense of coercion and loss of autonomy.
“…actually quite stressful because implicit(ly)… you need to participate actively… you are just tired and you’re just like, ‘why am I even here’ and ‘I don’t really feel it you know and I’m not very good at art’… I think the intentionality and the heart behind it is there… honestly… we have to get the work done, we want to go home.” (P6, PGY 3)