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From Luke’s Journal Nov 2024 | Vol.29 No.3 | Mental Health II

The first part of this paper was initially published under the title, “Holiday-Deficient Doctors” in the Queensland AMA magazine, Dr Q. Autumn 2024.

PART ONE

I have to confess, my medical career has been holiday deficient. I am not saying I don’t like getting away, relaxing, and enjoying a refreshing change from work. Rather, I sheepishly put up my hand and say the words, “I should have taken more holidays.” The mantra, ‘work-life-balance’ is very fuzzy at the edges. Apart from a good dose of ‘workaholism’, yes, I love my job.

I am interested in reflecting here on why doctors are often on the wrong side of a sensible holiday ledger. There is some published literature encouraging adequate holidays:

1. Workforce retention¹ In the promised land of amazing technology, work demands never seem to fade. This is particularly true in rural and remote areas, but very few contexts seem exempt from seemingly insatiable demands. Locum services and other schemes can provide the backup needed, but cost, available workforce, and professional goodwill just don’t add up much of the time. The acute and chronic nature of this reality keeps the fire of ‘burnout’ going. Taking appropriate leave helps retain our workforce.²
2. Presenteeism³ This word captures the phenomenon of doctors struggling on with an ever-present sense of duty, even when we are sick or exhausted. While ‘responsibility’ is a shrinking violet across the board, somehow doctors not only role model responsibility, but take it to another level. It can be viewed as a structural blind spot for administrators and politicians and so doesn’t factor into workforce planning. Genuine productivity declines rapidly because of the personal consequences of presenteeism. Mature practice should guide us all to take adequate, timely leave for our wellbeing and productive professional service. Regular exercise, regular good-quality sleep, and modest alcohol use are associated useful interventions. Loss of these capacities should be a red flag for a holiday.
3. Job satisfaction The MABEL⁴ longitudinal study identifies that most of us have good job satisfaction. Correlations include a good support network, a patient base who have realistic awareness of their medical needs, and few hurdles for holiday leave time out. These characteristics span all sectors of the profession. Losing job satisfaction is a red flag for needing a holiday.⁵
4. Access to General Practice care It has long been recognised that doctors need their own General Practitioner (GP).⁶ Reliance on self-assessment and self-prescribing is fraught with danger. The external set of eyes and ears of a seasoned GP can help semi burnt out doctors understand that a holiday is imperative. Access is not always easy. GP booking schedules are tight and not all are prepared to serve a colleague. Doctor’s Health in Queensland (dhq.org.au) can be contacted for advice around ‘docs for docs’ locations near you. The DHQ helpline is covered by trained, experienced GPs who can provide confidential crisis support. This service depends on all doctors establishing their own GP links.
5. Doctors as patients A flipside to access to care is the willingness of all doctors to enter into a partnership with a colleague for our own health’s sake. None of us like to fail, yet it is a fallacy to imagine our roles exempt us from health challenges. We have fears, we bleed, we lose confidence in our capacities. Exaggerated pride and an inflated sense of resilience can distort our perceived need for the genuine refreshment of a holiday.⁷
6. Structural barriers There are times when the systems within which we work become obstacles to holiday leave. Our administrators, our medical leaders, our political bureaucrats and decision makers need to be vigilant to the needs of the health workforce for leave, and the wellbeing of a holiday. Holiday rosters need to be responsive, team-orientated instruments to empower their workforce. Poor structural decisions can aggravate demands on a medical workforce in ways that cut across good leave rhythms. In the medical context, working more than fifty hours/week is linked to suicidality.⁸

“All work and no play” is an aphorism that makes intuitive sense. Holiday deficiency is never a good measurement for a healthy medical workforce.

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PART TWO

The idea of a holiday doesn’t seem to translate readily into a Biblical world reality. This may be a little surprising, considering the creation story in Genesis records God as ‘resting’ on the seventh day. Indeed, the value of timeout and leisure can be seen when we also discover God ‘strolling’ in the garden with Adam and Eve in the ‘cool of the day’. We catch a sense of mutual value in this garden glory perambulation for God and his image bearers.

But pleasurable leisure is soon brought crashing to the ground as sin enters the narrative. So in time, God calls a ‘wandering Aramean’ to build a people He will choose to bless.

One of the blessings now is the gift of ‘sabbath’. Sabbath connects the God who rests with the value of rest for humanity. We receive the blessing of the Sabbath through the Ten Commandments. The account of Sabbath-keeping in Exodus links this practice to the role model of rest set by God. It was a day to enjoy the natural creation; to set aside business and focus on the worship of God. In the book of Deuteronomy, we find Moses sketching out God’s hope – God’s vision for Israel on the brink of the Promised Land. In this new context, there needs to be a Sabbath reset; now social justice, justice in the memory of delivery from slavery, and the memory of four hundred holiday-less years is to characterise Sabbath.

Every human person is “created in God’s image”. Every human being is given the dignity and respect of Sabbath in Moses’ reimagining. Rest, leisure, and relief from the burden of work is a human right imagined and spelt out here. Israel was to be the torch-bearer for ‘holiday’ in the world.

The tragedy of evil, self-interest, and anxiety-driven wealth creation threatens the dignity of the Sabbath.

The prophets repeatedly call out self-interest, and speak against flagrant violations of Sabbath. Isaiah issues a Sabbath clarion call in chapter 58, verses 1 to 15. His passion for Sabbath and justice flows like a river: “On your fast day [the perverse twisting of Sabbath rest into a day of fasting to display so-called holiness], you do whatever you want, and oppress your workers. You quarrel and brawl…” and then, “Isn’t this the fast I choose; releasing wicked restraints… Isn’t it sharing your bread with the hungry and bringing the homeless poor into your house…”.

The prophet Amos also focuses on the process of Sabbath injustice, “I will tear down the Winter house as well as the Summer house… says the Lord” (Amos 3:15). Sabbath is community-connected holiday and worship time.

Jesus continues to run the prophetic Sabbath race. He is scathing of religion which oppresses people, and calls it out: “The Sabbath was created for humans,” (Mark 2:27). As the one who brings in God’s Kingdom, who is the Lord of the Sabbath, Jesus not only binds the strong-man of anti-Sabbath, but offers the pastoral hope of God with us (Emmanuel). “Come to me, all you who are struggling hard and carrying heavy loads, and I will give you rest,” (Matthew 12:28). In the gospels, we find Jesus not only reasserting the safe dignity of Sabbath, but He also models this for His discipleship class. When ministry is busy, He takes time out to meditate and pray (Mark 1:35-37; 6:45-46). He took his disciples to the beach holiday city of Tyre (7:24) and then embarked on a two-to-three week hike with them (7:31). The Saviour of the world needed time out as much as anyone.

The writer of Hebrews reflects on the idea of rest.  A gentle warning is issued: “Since the promise of rest is still open, let’s be careful so that none of you will appear to miss it.” (4:1). The writer recognises that Sabbath blessing is a gift that keeps on giving, so encouragement flows like this: “Keep loving each other like a family. Don’t neglect to open up your homes to guests (we could add, “especially holiday-makers”) because by doing this, some have been hosts to angels without knowing it.” (Hebrews 13:1).

The narrative arc of the Bible lands in what we could describe as ‘eternal’ Sabbath: a forever holiday of dignity and worship of God. We hear the promise in Revelation 21:3-4; “Look, God’s dwelling is here with humankind. He will dwell with them, and they will be His peoples. God Himself will be with them as their God. He will wipe away every tear from their eyes. Death will be no more. There will be no mourning, crying or pain anymore, for the former things have passed away.”

My case for taking holidays comes from the metanarrative of the Bible. The contemporary research I have cited, is a modern echo of  Scripture.

“To travel is to feed the mind, humanise the soul, and rub off the rust of circumstances… who would not travel at a penny a mile?” These words penned in 1854 by Thomas Cook carry the ‘rest’ of holidays. Thomas was born in a small town called Melbourne in the UK and later established himself in the city of Leicester. From a young age, he exhibited not only an entrepreneurial spirit but also lived by his evangelical Baptist faith in the Victorian era where the average person worked six days a week. Cook committed six years of his young adult life as a village evangelist. He retained a lifelong passion for preaching.

The excesses of alcohol misuse in English community life confirmed Cook as a teetotaller, and in 1841 he arranged a special train trip and outing to a temperance league event. He supplied food and a band to entertain. Cook built on this experience and by 1855 was arranging package tours to Europe; and later, in 1969, a trip to Egypt and Palestine. These later trips became very popular. In 1872, Cook was emboldened to create a 222 day around-the-world package tour.  Cook’s holiday packages enabled low-income families to travel and also provided a safe context for single women to enjoy a holiday. As a Christian, Cook embraced a Christian vision of rest and holiday. In his imagination, these tours offered evangelical possibilities for ‘gossiping the gospel’.

While Cook experienced both personal and family suffering, he never let the dream die, working with his son to develop the company’s ‘portfolio’. The slogan, “Don’t just book it… Thomas Cook it,” was associated with the global business identity until 2019 when it was sold under financial duress. Along the way, profits from the business were returned to the community in the form of low-cost housing for needy people. A trust continues to manage these Sabbath justice-oriented facilities.

A good holiday gathers many of the concerns I have shared in this paper. In 2024, we need to factor in climate change and new social justice consequences of holiday choices. While Sabbath informs push-back against the relentless rush of modern life, some in our day are trapped in restless holiday consumerism, where ‘bucket lists’ replace the true rest of God. I am writing from the trenches of the modern rat race. Isn’t it time for change? Let us renew an embrace of the holiness of time, as we plan our next holiday!

Discover more insights into REST from Dr Brioney Keats. Catch her interview now with Dr Eleasa Sieh on Youtube or Spotify or Apple Podcasts.

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References

1. Wieland, L., Ayton, J., & Abernethy, G. (2021). Retention of general practitioners in remote areas of Canada and Australia: A meta‐aggregation of qualitative research. Australian Journal of Rural Health, 29(5), 656–669. https://doi.org/10.1111/ajr.12762
2. Russell, D. J., McGrail, M. R., & Humphreys, J. S. (2016). Determinants of rural Australian Primary Health Care Worker Retention: A synthesis of key evidence and implications for policymaking. Australian Journal of Rural Health, 25(1), 5–14. https://doi.org/10.1111/ajr.12294
3. Christie, C., Bidwell, S., Copeland, A., & Hudson, B. (2017). Self-care of Canterbury General Practitioners, nurse practitioners, practice nurses and community pharmacists. Journal of Primary Health Care, 9(4), 286. https://doi.org/10.1071/hc17034
4. Joyce, C. M., Schurer, S., Scott, A., Humphreys, J., & Kalb, G. (2011). Australian doctors’ satisfaction with their work: Results from the Mabel Longitudinal Survey of Doctors. Medical Journal of Australia, 194(1), 30–33. https://doi.org/10.5694/j.1326-5377.2011.tb04142.x
5. Shrestha, D., & Joyce, C. M. (2011). Aspects of work – life balance of Australian General Practitioners: Determinants and possible consequences. Australian Journal of Primary Health, 17(1), 40. https://doi.org/10.1071/py10056
6. Shrestha, D., & Joyce, C. M. (2011). Aspects of work – life balance of Australian General Practitioners: Determinants and possible consequences. Australian Journal of Primary Health, 17(1), 40. https://doi.org/10.1071/py10056
7. Forsythe, M., Calnan, M., & Wall, B. (1999). Doctors as patients: Postal Survey examining consultants and general practitioners adherence to guidelines. BMJ, 319(7210), 605–608. https://doi.org/10.1136/bmj.319.7210.605
8. Petrie, K., Crawford, J., LaMontagne, A. D., Milner, A., Dean, J., Veness, B. G., Christensen, H., & Harvey, S. B. (2021). Working Hours, common mental disorder and suicidal ideation among junior doctors in Australia: A cross-sectional survey. BMJ Open, 10(1). https://doi.org/10.1136/bmjopen-2019-033525
   
   All biblical quotes are from the Common English Bible © 2011