Originally published in Forum, Vol 14 No 4, September 1993

Rohn S. Friedman, M.D., is Director of the Psychiatric Consultation Service, and Senior Advisor to the Center for Physician Development at Beth Israel Hospital, in Boston, Massachusetts.

"Forty percent of residents report having been so depressed or anxious for four or more weeks during training that their performance was impaired."

"Mood changes during physician training are of concern in terms of both individual distress and patient care."

Successful adaptation to life during the process of becoming a physician involves clinical competence, maturity, integrity, self-control, the ability to communicate, patience, and stamina. Maladaptation in the process of training can interfere with both professional competence and personal contentment, possibly leading to impairment, unhappiness, sub-stance abuse, divorce, and clinical errors. Because physicians encounter these problems throughout their careers, skills training in recognizing and coping with personal and professional stresses needs to be a part of both residency training and continuing medical education.

Stressors

Residency training is widely recognized as a very stressful period. Stressors include personal role transitions (separation from family and friends, establishment of committed relationships, child-bearing), professional role transitions (from student to intern to staff), situational pressures of residency (sleep deprivation, time pressure, excessive workload, burdensome clerical and administrative responsibilities, information overload, fear of contracting illnesses such as HIV, fear of malpractice suits, fear about future job availability), and financial strains (mounting educational debt, decrease in the purchasing power of a resident's salary, and anxiety about future earnings in an uncertain health care environment).

Studies have shown that first year, residents often begin with an initial stage of excitement and eager anticipation which gives way to self-doubt and depression. They then enter a quiet period of un-ending tedium which may lead to further depression by midyear. Anger increases through the winter.

By spring the resident may recognize his or her tangible accomplishments with growing pride and may become elated as the year ends. Subsequent years of training, usually, are viewed as better.

Mood changes may reach levels during physician training that are of concern in terms of both individual distress and interference with patient care.

• Approximately 30 percent of house officers suffer from significant depression during their residency, and a quarter of those have suicidal ideation.
• 11 percent of residents use tranquilizers, 9 percent opiates, and 9 percent cocaine. Many report increasing their use of alcohol, marijuana, or other drugs during residency.
• 40 percent of residents report marital/relationship problems. 72 percent of them were attributed to residency. 17 percent worry that their relationship will not survive the stresses of residency.
• 1.4 percent of first-year residents, and 0.9 percent of all residents take leaves of absence for emotional reasons. Of these, 5 percent attempt suicide, 12 percent are psychiatrically hospitalized, and 2 percent treated for drug/alcohol problems.^1-5

Forty percent of residents report having been so depressed or anxious for four or more weeks during training that their performance was impaired. Impairment may be manifested in negative attitudes toward patients, job dissatisfaction, cynicism, and emotional withdrawal, as well as in overt errors. Thus, leaders of hospitals and training programs seeking to reduce stresses and facilitate residency coping strategies, should regard loss prevention measures as an integral part of that effort.

Interventions

Social supports and role models, as well as concrete improvements in the working conditions, financial pressures, and time off call, have been shown to buffer the stresses of residency, leading to the development of coping skills that may be applied throughout a physician's professional career. A number of intervention programs have proved useful in facilitating this process:

Case conferences (Balint Groups).

At these sessions, psychological issues in patient management are the focus, but the scope of the conferences allows for the discussion of personal feelings and reactions.

Faculty mentors who serve as role models, advisors, advocates, and ombudsmen for residents.

Such mentors should be respected clinicians and teachers who also have the capacity to acknowledge their own feelings, limitations, and errors.

Support groups.

For house staff, these can range widely from "gripe sessions" with a chief resident to discussions with psychiatrists. The gripe sessions usually focus on the concrete problems, such as shortages of ancillary support. Sessions with a psychiatrist are more likely to be focused on the personal and emotional issues of residency.

Retreats away from the hospital.

Various formats have been used, including most of the elements above. The opportunity to get away from the hospital and its pressures, however, greatly facilitates the programs, and further underlines the commitment of the administrative and educational leaders to the importance of this aspect of training.

Formal individual psychiatric consultation and therapy.

These services should be: available, unstigmatized, covered by insurance, and confidential. However, they are the smallest part of a comprehensive program in so far as the focus is on normal stresses and adaptation as well as prevention.

Seminars on matters such as finances, time management, stress management, career choices, and child care.

Provision of these concrete resources and cultivation of these practical skills have proved to be useful in reducing the pressures of training and in communicating the value the administration places on its trainees and on such programs.

Supports after errors, adverse events, litigation, or malpractice claims.

Errors and adverse events are inevitable parts of medical training and practice. In morbidity and mortality conferences, physicians can learn from their mistakes if the atmosphere is one of support rather than accusation, and if respected mentors also acknowledge their errors and uncertainties. Even without litigation, or even clear harm to the patient, residents may be deeply shaken by recognition of their errors and potential to harm. Support groups for physicians facing the legal system may be helpful, but often physicians feel threatened by the sense of self-revelation and exposure in a group setting and prefer one-to-one counseling.

These programs are most effective when perceived as a response to a recognized or felt need on the part of house staff and faculty. Strong support from the head of the hospital, chairmen of departments, and directors of residency training also improves their effectiveness. Such support can be communicated most strongly by the involvement of faculty as facilitators of some of these programs; the provision of time, space, coverage, and money for these activities; and encouragement rather than stigma for residents who utilize these resources.

Notes & References

1. Aach RD, Cooney TG, Girard DE, et al. Stress and impairment during residency training: Strategies for reduction, identification and management. Annals of Internal Medicine. 1988; 109: 154-161.
2. Butterfield PS. The stress of residency: A review of the literature. Archives of Internal Medicine. 1988; 148: 1428-1435.
3. Colford JM and McPhee SJ. The ravelled sleeve of care. Journal of the American Medical Association. 1989; 61: 889-893.
4. McCue JD. The effects of stress on physicians and their medical practice. New England Journal of Medicine. 1982; 306: 458-463.
5. McCue JD. The distress of internship. New England Journal of Medicine. 1985; 312: 449-452.