Resident Stress

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Resident

Stress

Abraham

B. Bergman,

MD

From the Departments of Pediatrics, Harborview Medical Center and UnWersity of

Washington School of Medicine, Seattle

In the absence of confirmatory evidence, one can only sense that the lives of residents have become increasingly stressful since the late 1950s. Certainly residency stress is receiving more attention in the medical lithrature.1 An excellent conference on stress in pediatric housestaff training sponsored by the Study Group on Pediatric Education and Ross Laboratories was held in 1985. Whatever took place in the past, present-day residents carry heavy burdens that materially affect their current per-formance and future lives. Some of these burdens could and should be lightened. The first step is for medical educators to acknowledge that they exist.

It is neither possible nor advisable to eliminate all stress in residency training after all, young physicians are being prepared for a taxing mara-thon race. Attempts should be made, however, to differentiate between useful stress and needless annoyances. Working long hours, behaving effec-tively in emergencies, dealing with death and dying, managing difficult patients, and coping with the uncertainties of diagnosis and treatment are ex-amples ofthe first category. For high achievers used to getting As in school, accepting a less than perfect diagnosis, a disease without a treatment, or a mis-take that kills is frustrating but must be endured. The annoyances will be discussed later.

GLOBAL

CAUSES

Faculty probably can have only limited impact on some ofthe more global causes of resident stress. It is important, however, that they be recognized and, even more important that residents know that they are recognized. First, there are the normal

Received for publication Sept 22, 1987; accepted Jan 26, 1988. Presented, in part, to the Association of Pediatric Program Directors Education Conference, Anaheim, CA, April 27, 1987. Reprint requests to (A.B.B.) Department of Pediatrics ZA-53, Harborview Medical Center, 325 Ninth Aye, Seattle, WA 98104. PEDIATRICS (ISSN 0031 4005). Copyright © 1988 by the American Academy of Pediatrics.

issues of adult development common to young per-sons striving to put their personal and professional lives in order.6 It is difficult to be a 29-year-old trainee whose every minute is scheduled by others, while one’s peers are already considered adult and established. Many developmental tasks must be delayed, such as individuation from one’s parents and the development of autonomy. The push to-ward independence is difficult to accomplish when a person remains financially dependent either on one’s family or, more commonly, on a lending in-stitution. There are moves away from home and, for many, marriage. Having babies during residency in a strange community without a family support system is difficult. Bringing up children during residency both increases the stress of not spending enough time at home and decreases the camaraderie among residents by allowing them less time to spend with each other outside of work. For women residents, whose numbers are steadily increasing, the biologic time clock ticks loudly.

MARRIAGE

TO CAREERS

Boys in White7 remains the single best descrip-tion of medical student culture. It is a classic be-cause, regardless of what school one attended, or when, the authors have captured the essence of the experience. Gerber’s Married to Their Careers8 is of the same order. The book depicts the culture of residents; specifically, it describes their attempts to integrate their personal and professional lives. Ger-ber writes ofthe special manner in which physicians tend to be treated by friends and relatives. Although the special status has undoubted benefits (ie, get-ting out of unwanted social obligations), it can be a burden when the physician asks, “Am I living up to it?”

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SPECIAL ARTICLES

261

The residents’ role models are often “workaholic”

clinicians who are always in the hospital and

aca-demicians

who

exult

at having

five

abstracts

ac-cepted at the research society meetings. It would be useful for residents to learn more about faculty who are successful in integrating their professional and personal lives, but the reserve and desire to main-tam a strong image on the part of mature physicians prevents discussing such private matters.

Gerber emphasizes the importance of dealing with the fantasy of residents that “tomorrow will be better” and “someday we’ll have more time for each other.” That myth is invariably superseded by

the realities of life after training is completed. Priorities have to be established during residency, or even before medical school.

Keeping a “stiffupper lip” is the credo of teaching

hospitals. Last year I helped care for a drowning victim in the emergency room. While the residents participated in the unsuccessful resuscitation at-tempt, I listened to the mother talk about her daughter, who happened to be the same age as my own. After it was over, I spoke briefly with the residents about some technical matters and then went out to my car and wept. I later thought how much more instructive the case would have been

for the residents had they witnessed my crying.

DIFFERENCES

BETWEEN

THEN AND NOW

Nicholas

Nelson

said,

“I never

start

a

conversa-tion with residents with ‘in my day,’ .. .because an

angry response is guaranteed.”9 Be that as it may, many of us cannot resist recounting privations of the past, especially the low or nonexistent pay. The residents are not impressed. Pay notwithstanding, the main difference between past training and the present situation is the patient population.

Most of our patients had acute problems that were readily addressed. Some died, most got better; it was possible to see if our treatment worked.

Children

with

dehydration,

meningitis,

and

pneu-monia were fun to treat. We complained mightily about the “scut work,” but there was something uniquely satisfying about performing a lumbar puncture, examining the spinal fluid in the ward lab, and starting appropriate treatment of a child with meningitis, all within 15 minutes. We did not worry about delays in obtaining laboratory results because of “the computer being down.” The sense of exhilaration in the face of exhaustion

experi-enced by residents at the Boston City Hospital in the 1930s when pneumococcal antiserum became available is eloquently described by Thomas.’#{176}

One pediatrician, interviewed a few years ago about the relevance of his training to his practice,

said that what he enjoyed most about his residency were the evenings in the hospital when he learned how to talk with children. What a quaint thought! Current residents scarcely have the time to talk with their patients, day or night.

Today’s teaching hospitals are strange worlds full of patients with incurable chronic illnesses whose care

is

difficult,

frustrating,

and

never-ending.

There is even a unique language, “Medspeak.” Residents face an infinite variety of moral and ethical issues brought about by our technical capac-ity to maintain bodily basic functions. It is exhaust-ing to attempt to preserve the life of a desperately

ill patient;

it is ennervating when one has to wonder whether the effort is worthwhile.

In the meantime, residents move ever-further from the bedside. Attending rounds increasingly consist of minilectures (“give us the essence of managing seizure disorders, preferably in an IV bolus”). Even ward work rounds at many hospitals tend to take place in conference rooms and consist of reading numbers from papers on clipboards. Stethoscopes draped around the neck serve more

as amulets to ward off evil spirits than as

auscul-tatory devices.

Another impediment to patient contact is the full schedule of conferences. Fearful of missing the one or two bits of knowledge they think will keep them

afloat,

the residents

demand

more rather

than

fewer

didactic sessions. Their anxiety is fueled by faculty, some of whom, needing to validate their own im-portance, imply that, “Ifyou don’t know more about

my specialized field, at best you will be a dumbbell or at worst will kill somebody.” Libraries are viewed more as sites to have current articles photocopied (for attachment to clipboards) than as places to read and think.

ANNOYANCES

Radio pagers first appeared in hospitals for the laudable purpose of summoning rapid assistance in emergencies; their unrestricted use now makes them an unmitigated curse. It is virtually impossi-ble to have an uninterrupted discussion with a patient, let alone to visit a restroom in peace with-out hearing the pager’s insistent summons.

It is not unusual for ourjunior residents to receive 50 pages a day, few of them requiring immediate action. I recently asked two ward interns to keep track of their time. In two 12-hour work days that they described as “easy,” from four to five hours a

day were spent

on paperwork,

scheduling,

and

con-tacting private physicians. On the busier days, they did not have time to keep track of the calls. A large proportion of the calls involved relaying

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tion from one attending or consulting physician to another, trying to schedule laboratory tests or fol-low-up appointments, and determining whether a particular drug was “covered” in the welfare for-mulary. One intern said she spent fully 30 minutes trying to mediate the views of two consultants before she fmally had the temerity to suggest that they talk directly with each other. As McCue’#{176} said

Clerical responsibilities, coordination ofconsultant activ-ities, dictation of complicated discharge summaries, and scheduling of procedures is the ‘scut work’ of the 1980’s. None of these activities yields even the meager

interper-sonal satisfaction that performing laboratory tests, start-hg intravenous lines, drawing blood (the ‘scut work’ of the 1960’s) used to give residents.

PALLIATIVE TREATMENT OF STRESS

The single most important thing that faculty can do is to recognize the problem of stress in pediatric training programs and show the residents that we want to help them deal with it. Residents can endure many inconveniences if they perceive that “the system” supports them. There is insufficient bonding between residents and faculty, especially in large programs; our worlds have grown further apart. That is in large measure due to the difficul-ties that faculty members experience in attempting to integrate their own personal and professional lives in an era of two-career families. Nevertheless, a better job must be done of reaching out to each other.

The position ofresidency director should be made more secure, for example, by backing it with “hard money,” as is done in Canada. In the United States, it sometimes seems that the only persons dragooned into becoming residency directors are soft-hearted souls bent on committing academic suicide. Stand-ards for an adviser-mentor system should be estab-lished and monitored to see that they are main-tamed.

Because they now admit relatively few patients, the role of practicing pediatricians in teaching

hos-pitals

has diminished.

Helping

to nurture residents would be a valuable contribution by practitioners to training programs. Residents should regularly have the opportunity to talk about their feelings with psychiatrists, psychologists, or social workers who play no role in their evaluation. For such sessions to be most effective, the mental health professionals should have some familiarity with the special world were residents work, such as intensive care units and emergency rooms.

INTERN

RETREAT

For the past 10 years, the Department of Pedi-atrics at the University of Washington has

con-ducted a retreat for its pediatric interns, and it has been extraordinarily successful.’2”3 The retreat lasts for five days and evenings and takes place late in September, after the interns have had a chance to become accustomed to their roles in their setting, but before they lose all their idealism. The content of the retreat is less important than the fact that it takes place. Subjects such as death and dying, the ethics of neonatal intensive care, and improving communication skills are interspersed with lighter exercises such as practicing cardiopulmonary resus-citation and playing “show and tell” with interest-ing skin lesions. The “guts” of the retreat, however, are daily sessions during which the interns talk about their feelings with a pediatrician-psychia-trist. By far the most important result ofthe retreat is the bonding of the residents to each other. In addition to that bonding, the educational objectives have been achieved when residents are heard to be comfortable saying “I don’t know,” and “I’m scared.”

Few such retreats have been undertaken else-where, presumably because of the fear that hospi-this could not function without interns for five days. At Children’s Hospital in Seattle, substitute interns are recruited from the ranks of community practi-tioners. Amazingly, some of them actually desire to return to work in an intensive care unit. The intern retreat has become a fixture at the University of Washington because the department chairman thinks it is important and because the senior resi-dents are willing to “go the extra mile” to ensure that their junior colleagues have the special ewe-rience.

SILENCE

THE PAGERS

Some simple steps would reduce the level of stress for residents and might make their educational experience more meaningful, as well as more toler-able. The desirable and satisfying experience of spending more time with patients might be achieved by scheduling fewer conferences. Less emphasis should be placed on teaching, more on learning.

Pagers should be banned or at least silenced. A few residents might carry them to respond to true emergencies, but that duty can be rotated. At the very least, digital pagers that can indicate the prior-ity of the required response, and that vibrate in-stead of beep should be used.

Clerical assistants for the ward and clinic teams should be hired. What medical office could function without clerical help? Why are residents “stuck” with scheduling tests and juggling messages? Cur-rently, alternatives are never even considered. It is just assumed that money is not available to pay for

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REFERENCES

SPECIAL ARTICLES 263

Teaching hospitals boast that they are special, and they are, in large measure because residents work in them. Hospitals somehow find the funds to pay for the latest equipment, for specialized support staff, for departments of marketing, and for ever-increasing numbers of administrators. The added expenses of these items are minute in terms of total hospital operations but mighty in terms of easing the burdens carried by residents.

How will this relief come about? In this era of “bottom-line health care,”’4 it can no longer be assumed that those who run hospitals and the per-sonnel who work in them necessarily share the same objectives. Medical and housestaffs are going to have to work together to present a united front in making demands on hospital administrators and governing boards. Because of their transitory sta-tus, residents lack the clout to represent themselves effectively; they are too easy to “wait out and beat down,” a less likely outcome if faculty not only join with them but act on their behalf. It is time that faculty mentors start caring as much for the bodies and souls of residents as for their minds. Residents in turn might develop a better appetite for learning and have more to offer as physicians in the future.

1. McCue JD: The distress of internship. N Engi J Med

1985;312:449-452

2. Valko R, Clayton P: Depression in the internship. Dis Neru

Syst 1975;36:26-29

3. Berg JK, Garrard J: Psychosocial support in residency. J Med Educ 1980;55:851-857

4. Borenstein D, Cook K: Impairment prevention in the train-ing years. JAMA 1982;247:2700-2703

5. Hoekelman R (ed): Stress in Pediatric House Staff Training.

Columbus, OH, Ross Laboratories, 1985

6. McGuire T: Developmental perspective on stress in resi-dency training, in Hoekelman R (ed): Stress in Pediatric House Staff Training. Columbus, OH, Ross Laboratories, 1985, pp 14-19

7. Becker H, Gerr B, Hughes E, et al: Boys in White. Chicago, University of Chicago Press, 1961

8. Gerber L: Married to Their Careers. New York, Tavistock, 1983

9. Nelson N, cited by Hoekelman, R (ed): Stress in Pediatric

House Staff Training. Columbus, OH, Rose Laboratories, 1985, p49

10. Thomas L: The Youngest Science. New York, Viking, 1983 11. Christy NP: English is our second language. N Engi J Med

1979;33:979-981

12. Bergman A, Rothenberg M, Telzrow R: A retreat for pedi-atric interns. Pediatrics 1979;64:528-532

13. Rothenberg M, Rothenberg J: The omrnpotence-omni-science syndrome: Medical education advances when interns retreat. Resident StaffPhysician 1985;31:81-88

14. Levey 5, Hesee DD: Bottom line health care? N EnglJ Med

1985;312:644-647

Nationally, half of the boys and one-third of the girls in high school have had

intercourse.

The

average

age of first

intercourse

in the United

States is around 16; in some communities, it may be as low as 12.

From the Center for Population Options, press release, Dec 4, 1987.

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1988;82;260

Pediatrics

Abraham B. Bergman

Resident Stress

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