Training in the '90s: solutions for new stresses
In addition to sleep deprivation and grueling workloads, housestaff today must cope with corporate shakeups
From the July/August 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.
By Phyllis Maguire
When the ophthalmology and otolaryngology residents at the Manhattan Eye, Ear and Throat Hospital began hearing rumors this spring that the 130-year-old hospital was going up for sale, they became worried. By the time department chairs finally verified the rumors, the residents already knew the worst from media coverage of the proposed sale: They might have to find new training programs.
The stress of wondering where they will end up has taken its toll on the hospital's residents. "If I'm going to be relocated and forced to work with new attendings and hospital staff with whom I have no personal relationship, my education is going to be severely affected," said Isaac Namdar, MD, a fifth-year otolaryngology resident whose chief residency was scheduled to begin July 1.
For today's residents, the threat of a teaching hospital being sold—or closed—raises the level of stress they already experience due to long hours and grueling workloads. As a result, some educators say that now more than ever, it is important to help housestaff learn how to handle stress.
At a workshop on resident stress held at Annual Session this spring in New Orleans, Faith T. Fitzgerald, MACP, professor of internal medicine and program director for internal medicine at University of California, Davis, Health Systems, explained that the chaotic practice environment that awaits residents may prove to be "residency in perpetuum."
Dr. Fitzgerald, who also serves as the College's Governor for the Northern California Chapter, asked the 30 or so residents attending the session to compile a list of stress factors. While that list grew to include more than two dozen items, an alternate list of stress relievers—such as exercising, keeping a diary and organizing support groups among residents—remained much smaller.
The old and the new
Many sources of stress cited by residents at the session have long been hallmarks of medical training: sleep deprivation, problems balancing work with personal life, the pervasive fear of making mistakes, the sense that one will never know enough, the difficulty of delivering bad news to distraught families, and the emotional impact of dealing with death and disease. International medical graduates also claimed that for them, stress arises from visa status and cultural differences.
But residents today are also coping with sources of stress unheard of in years past. Housestaff at the workshop noted that the change in the pace of medicine is now much faster than at any time before, compelling them to keep up with the explosive growth of diagnostic technologies and therapeutic procedures. They must also grapple with an environment increasingly dominated by documentation and regulation.
In addition, residents at the meeting said that patient turnover happens so fast that they do not get to know their patients and often cannot gauge the effectiveness of their treatments. That uncertainty fuels their anxiety that they don't know enough to make complex medical decisions. "We don't get to see the evolution of disease," one resident said, claiming that the lack of patient interaction affected her sense of personal satisfaction.
While such new stress factors make the need for mentors even more acute, most residents said that faculty involvement has become more scarce. As faculty members scramble to secure research grants or to make time for medical practice, they have less opportunity to focus on residents. Sometimes, residents claimed, senior faculty are so out of touch that they don't appreciate how stressed out residents are, or, more often, faculty simply don't have the time to address residents' non-clinical needs.
Looking for relief
Some training programs are looking for solutions. At UC Davis, for example, volunteer faculty distribute short biographies to give residents an opportunity to seek out senior clinicians who are not full-time faculty members. But few residents, perhaps because most were too busy, actually contacted those volunteers, Dr. Fitzgerald reported.
"I think the major support for house-staff is other housestaff," Dr. Fitzgerald said in a telephone interview after the workshop. "The important thing is that they all agree, either by choice or by cultural decision at the beginning of the year, that they are not in competition but in colleagueship. They have to look after each other, and they do."
Part of the problem, she said, is that residents' personalities make them prone to stress. Medical schools typically choose candidates who exhibit an overextended work ethic and "a compulsion to be perfect." Stress in residency may also be heightened by what Dr. Fitzgerald called the prevalent "culture of no whining" in teaching hospitals, an environment that discourages the expression of personal doubts or concerns.
A number of training programs are working to foster collegiality and offer resources to help residents. Here are some suggestions from residents and educators around the country who have learned to reduce the level of resident stress:
Hold frequent get-togethers. Socializing away from the hospital between housestaff and faculty can be a real stress reliever, according to Lazaros A. Nikolaidis, ACP-ASIM Associate, a third-year cardiology fellow at Pittsburgh's Western Pennsylvania Hospital and a former member of the College's Council of Associates.
His residency program at York Hospital in York, Pa., held a number of extracurricular get-togethers. Some were medically oriented, like a monthly journal club that rotated among different attendings' homes, while other events were purely social. Dr. Nikolaidis said that such functions allowed residents to get to know faculty better and improved their chances of finding mentors. Getting housestaff together with each other and with faculty also provided opportunities to note which residents might actually be struggling.
Use retreats to build bonds. At Cedars-Sinai Medical Center in Los Angeles, residents and faculty leave the hospital for an annual retreat, according to chief resident Angela M. Park, ACP-ASIM Associate. "Camaraderie is definitely important, so we spend three days together, just to take a vacation and talk about ways to improve the program," she said.
Establish a forum for discussion. During Dr. Nikolaidis's residency, chief residents held weekly no-holds-barred sessions where residents could voice complaints. The chiefs then took those concerns to the faculty and to the program director within a week. Dr. Nikolaidis said that as the administration proved that it would act on residents' issues, like intervening with a particularly demanding senior physician, the level of resident stress noticeably declined.
The residency program at Thomas Jefferson University in Philadelphia holds a series of stress-management sessions each year where residents meet with university educators to discuss their problems and learn about resources for financial and psychological support. The confidential sessions are conducted without physician supervisors, giving residents an opportunity to speak more freely.
"Residents realize they are not alone in the stresses they experience," said Gregory C. Kane, FACP, assistant professor of medicine and Jefferson's internal medicine program director. "They realize that their colleagues are dealing with the same things, like having patients die."
Publicize ways to get emergency help. Cedars-Sinai has instituted a help program for residents in conjunction with its department of psychiatry. Residents can use the program for telephone therapy or to receive counseling sessions. "It's completely anonymous and available 24 hours a day," Dr. Park reported. "Residents are told about it their first day and reminded of it throughout the program."
In relieving stress, experts say, the emphasis should be on finding methods that can become lifelong habits. They point out that stress in medical practice—while it may be more manageable than in residency—will remain a constant. Managing stress is essential for both personal satisfaction and professional accomplishment, in residency and beyond.
"If relieving stress ultimately leads to better patient care," Dr. Fitzgerald said, speaking at the Annual Session workshop, "then it's a form of being a better physician."
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