Mental health services for residents: more important than ever

Resident Mental Health Care: a Timely and Necessary Resource

OBJECTIVE

Residency training is associated with stress and burnout that can contribute to poor mental health, yet many residents do not get the help needed. While some healthcare institutions provide mental health services specifically for residents, literature has documented few examples. The objective of this study was to investigate the utilization and patient characteristics of a resident mental health program.

METHODS

The authors conducted a retrospective records analysis of residents who utilized outpatient mental health services through the Thomas Jefferson University Hospital Emotional Health and Wellness Program for House Staff from 2010 to 2018.

RESULTS

A total of 158 resident patient charts were reviewed. Utilization was highest for females, first years, and general internal medicine residents. Initial help-seeking was most common for summer, winter, and intern year. The most frequent diagnoses were adjustment, depressive, and anxiety disorders. Of residents who completed screening tools, 43% screened positive for moderate to severe depression, 11% screened positive for hazardous alcohol consumption, and 15% endorsed thoughts of death or suicide.

CONCLUSIONS

Resident physicians manifest psychiatric symptoms, mental disorders, and suicidal ideation that require treatment and intervention. Yet, a minority of residents make use of services. This data emphasizes the need to promote help-seeking behaviors among residents and ensure timely access to comprehensive mental health services.

Factors Associated With the Mental Health and Satisfaction of Oral and Maxillofacial Surgery Residents in the United States: A Cross-Sectional Study and Analysis

PURPOSE

Residents in training have reported high levels of stress and anxiety and have a greater risk of mental health problems compared with the general population. Mental health problems among residents have been correlated with decreased professional effectiveness, increased medical errors, emotional exhaustion, and depersonalization and could have significant negative effects on future practitioners. The purpose of the present study was to identify the factors that might be associated with the mental health and satisfaction of oral and maxillofacial surgery (OMS) residents and to determine the associations between these factors and OMS resident satisfaction as a surrogate of resident well-being.

MATERIALS AND METHODS

We designed and implemented an online survey, which was e-mailed to all OMS residents in the 101 accredited training programs in the United States. The survey was designed to determine and assess the factors associated with OMS resident satisfaction. Differences between groups were tested using 1-way analysis of variance for continuous variables and χ² tests for categorical variables. For each factor, we fit a logistic regression model to estimate the odds ratio of resident satisfaction for the factor, adjusting for gender, year in residency, and years of advanced training.

RESULTS

Of the 1181 resident surveys sent out, 300 were completed (25.4% response rate). The satisfied OMS residents tended to be men, further along in their training program, and to have access to mental health resources. Dissatisfaction was associated with greater self-reported stress levels, working a greater number of hours per week, and believing one would be viewed differently for speaking to faculty about mental health.

CONCLUSIONS

OMS resident satisfaction was associated with identifiable and potentially modifiable factors. These factors included workload characteristics, stress and coping ability, and mental health impact and resource availability. Evidence-based strategies for OMS resident well-being could lead to the development of best practice guidelines for promoting and optimizing resident mental health.

Gender differences in the perception of quality of life during internal medicine training: a qualitative and quantitative analysis

BACKGROUND

The higher level of participation by women in medicine may impact this profession's evolution due to gender differences perceived during medical school, after graduation and during residency. Gender differences regarding quality of life are associated with higher states of anxiety and depression among female physicians. We aimed to assess gender differences in the perception of quality of life with quantitative methods and to understand further, from the female residents´ point of view, the reasons that may influence the perception of quality of life using qualitative method. Resilience, empathy and daytime sleepiness were also scored.

METHODS

We performed a cross-sectional study with first-year internal medicine residents to evaluate self-reported quality of life factors specific to medical residents (VERAS-Q), including empathy (Jefferson Scale of Empathy), resilience (Wagnild and Young Brief Resilience Scale) and daytime sleepiness (Epworth Scale). We explored, from the female residents´ view which factors may influence the perception of quality of life using a focus group method.

RESULTS

In our study, one hundred and nine residents completed the survey: 31 (28.4%) were female and 78 (71.6%) were male. Female residents exhibited significantly lower scores than those of male residents for quality of life in the domains of time management (30.3, females vs 41.1, males; p < 0.001), psychology (48.1, females vs 56.7, males; p < 0.01) and physical health (42.8, females vs 53.6, males; p < 0.05). Female residents also scored higher for daytime sleepiness (13.0, females vs 9.0, males; p < 0.001), with pathological scores for daytime sleepiness. No significant gender differences were found in the resilience or empathy scores. The focus group assessment revealed difficulty in concentration and knowledge acquisition, insecurity, feelings of loss, greater critical perception, self-doubt and difficulty in creating effective bonds to support the training period as the main factors involved in the lower perception of quality of life among the women.

CONCLUSIONS

In conclusion, female residents had lower scores for quality of life and higher scores for daytime sleepiness. Measures to improve quality of life among female residents during this critical period of medical training might include investing in mentoring to help them better manage their time and encouraging activities that facilitate relationship development.

Emotional Distress Among Physician Residents and Fellows: An Observational Study of Trainees Seeking Counseling Visits

OBJECTIVE

Emotional distress, burnout, and depression occur frequently among graduate medical education (GME) trainees and may negatively affect patient care, education, and well-being. The authors aimed to characterize the causes and severity of distress among GME trainees seeking on-site counseling services at a large, multi-site, university-based training program in the USA.

METHODS

The authors analyzed visits of all GME trainees seeking counseling from 2009 to 2012 and described trainee characteristics, level of distress, chief and secondary complaints, and initial visit outcomes.

RESULTS

GME trainees (n = 332; 14.1% of total population) attended 2017 counseling visits. Women comprised over half (60.7%) of the clients. Referrals originated from trainees themselves (79.8%), program leadership (16.6%), or partners (1.8%). Mean counselor-assessed distress level at intake was 4.1 (range 1-5). Mental health was the most frequent concern (46.1%), particularly depression (19.3%) or anxiety (11.5%). Other chief complaints included personal relationship (28.6%), career (21.7%), and physical health concerns (2.7%). Counselors referred nearly a quarter (22.7%) of trainees to additional services such as psychiatry, primary care provider, or career mentor. Most trainees (75.3%) returned for ≥1 follow-up counseling visits.

CONCLUSION

GME trainees seen in counseling report significant emotional distress from a broad range of sources. Further research should identify effective preventative and therapeutic interventions to reduce trainee emotional distress.

Availability of Emotional Support and Mental Health Care for Pediatric Residents

OBJECTIVE

Resident mental health (MH) problems can be associated with reduced empathy and increased medical errors. The Accreditation Council for Graduate Medical Education mandates resident MH support services, but it is unknown if these services are accessible and meet resident needs. We sought to describe the prevalence of anxiety and depression in current pediatric residents in New York State (NYS), and their self-reported use of and barriers to support services.

METHODS

We developed an online survey and distributed it to all categorical pediatric residents in 9 NYS programs. Items addressing self-concern for clinical anxiety and depression and use of MH services were pilot tested for content and construct validity. The validated Patient Health Questionnaire-2 (PHQ-2) measured depressive symptoms. Analyses used descriptive and chi-square tests.

RESULTS

Respondents included 227 residents (54% response rate) distributed across training levels and programs. Many reported "often" or "almost always" feeling stress (52%), physical exhaustion (41%), and mental exhaustion (35%); 11% had PHQ-2-defined depressive symptoms. Some thought that their stress levels raised concern for clinical depression (25%) or anxiety (28%); among these, only 44% and 39%, respectively, had sought care. More women reported physical exhaustion (P < .05). Only 45% of residents reported educational offerings on resident MH; 66% wanted to know more about available resources. Barriers to receipt of services included inflexible schedules (82%), guilt about burdening colleagues (65%), fear of confidentiality breach (46%), and difficulty identifying services (44%).

CONCLUSIONS

Pediatric residents frequently experience MH symptoms, but many do not know about or use support services. Programs should enhance MH support by overcoming barriers and increasing resident awareness of services.

Peer counselling for doctors in Norway: A qualitative study of the relationship between support and surveillance

RATIONALE

Peer support can entail collegial responsibility for counselling and support as well as reactions to academic or ethical failure. These considerations can be complementary, but also conflicting.

OBJECTIVE

This article focuses on how the peer support programme in Norway addresses these considerations.

METHODS

Focus group interviews held with Norwegian peer counsellors from August 2011 to June 2012 were analysed by a stepwise deductive-inductive method.

RESULTS

Based on organisational theory, two "ideal types" of counsellors were identified from the data, and these were then used to reanalyse the text. We found that the organisational framework is associated with the peer counsellors' role conception and thereby the relationship between the counsellor and the help-seeking doctor. The relationship between informal frameworks like collegiality, confidence and discretion, and more formalized incentive-driven frameworks, appear to influence the accessibility to peer support, the mandate to provide relevant help and the understanding of what peer support represents.

CONCLUSION

The study showed the need for a continuous awareness of a balance between the informal and the more formalized elements in the framework for peer support. This is of importance for how the service can contribute to better health among doctors and to secure quality and safety in the treatment of patients. The analysis can also be used to demonstrate the consequences of how the peer support program is designed - such as the degree of formalisation and the balance between "hard" and "soft" ways to regulate the interaction between peer counsellors and doctors - for the ability to achieve the stated objectives of the service.

Peer counsellors' views on the collegial support scheme for doctors

BACKGROUND

The health condition and health-related behaviour of doctors are important to the doctors themselves as well as for their treatment of patients. The collegial support scheme is a county-based and easily accessible health and care service for doctors. We therefore wanted to describe the framework and functions of this scheme and examine its utility.

MATERIAL AND METHOD

Fourteen focus-group interviews with a total of 61 peer counsellors from all the counties were conducted. The interviews were recorded, transcribed and analysed with the aid of systematic text condensation.

RESULTS

The framework--easy accessibility, a readily available offer of up to three sessions, a high degree of confidentiality and informal contact--was emphasised as crucial for doctors to make use of the scheme. The peer counsellors described their role as that of a listener and supportive helper. They helped bring clarity and discuss possible needs for further follow-up or treatment of numerous different and frequently complex issues. The peer counsellors highlighted three benefits in particular: the scheme helps raise awareness by legitimising help-seeking behaviour among doctors, it is a contingency scheme, and it eases the burden by lowering the threshold to seeking out further advice and treatment.

INTERPRETATION

A systematic evaluation of the collegial support scheme is important for an understanding of the totality of the collegial health and care services. The collegial support scheme may lower the threshold to seeking help, and encourage some doctors to seek necessary treatment.

Factors associated with mental health status of medical residents: a model-guided study

Residency is a stressful period in a physician's development, characterized by long work hours, time pressure, and excessive work load, that can exert negative effects on residents' mental health. Job burnout and negative work-home interference may play a major role in residents' mental health problems. The present study used the job demands-resources model as a theoretical framework to examine the way in which job demands (e.g., workload, emotional demands) and job resources (e.g., supervisor support, job autonomy) were associated with residents' mental health. From a pool of 290 medical residents, 264 (91 %) completed the questionnaires. Applying structural equation modeling techniques, the results showed that greater emotional exhaustion (β = -.65, SE = .09, p < .001) and more work-home interference (β = -.26, SE = .10, p < .05) were related to poor mental health. Specific job demands (i.e., high workload) and particular job resources (i.e., low opportunities for professional development and low supervisor support) were related to poor mental health not directly but only indirectly, via emotional exhaustion or work-home interference. Thus, through work-related emotional exhaustion, the impact of work conditions might be transmitted to and interfere with non-work related domains such as family life, as well as with domain-unspecific aspects of well-being, such as mental health and psychological distress. Implications of the results and suggestions for future research and practice are outlined.

How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study

OBJECTIVE

Surgical trainees are often subject to the negative consequences of medical error, and it is therefore important to determine how trainees cope with error and to find ways of supporting trainees when catastrophic events occur. This article examines how trainees interpret catastrophic surgical outcomes and ways to provide support for trainees who have experienced catastrophic events.

DESIGN

Totally 23 semistructured interviews were conducted with surgical trainees. Interviews were conducted in English and subjected to modified thematic analysis.

SETTING

A tertiary care hospital in Toronto, Canada.

PARTICIPANTS

Interviews were completed with 23 surgery residents. Potential participants were recruited through communications via the Department of Surgery and volunteered to take part in the study.

RESULTS

Totally 5 themes emerged: (1) catastrophic errors usually represent system deficiencies; (2) catastrophic events provide lessons for future practice; (3) many trainees did not feel comfortable speaking with the surgical staff; (4) counseling services should be offered to help a subset of trainees; and (5) the culture of surgery may act as a barrier to trainees seeking help.

CONCLUSIONS

This study demonstrates the importance of providing support for the emotional needs of surgical trainees who have experienced catastrophic surgical errors and the continued need for mentoring by staff surgeons.

Physician Depression and Suicide: A Shared Responsibility

ISSUE

Although the exact number is often disputed, it has been reported that approximately 300 to 400 physicians in the United States take their own lives annually. Despite calls from key interest groups for prevention and treatment protocols of physician suicide, little systematic change has taken place.

EVIDENCE

Research on suicide risk factors among physicians has expanded. Increasing reports are surfacing that highlight suicidal ideation and depression in medical school, residency training, and later professional practice.

IMPLICATIONS

The purpose of this article is to draw attention to the problem of physician suicide with an emphasis on the role of medical education. Multiple accreditation bodies should be involved to effect a change in physician suicide prevalence. Thirty years have demonstrated that without mandates, large-scale change will not occur. We adapted some of the 2012 National Strategy for Suicide Prevention goals to medical education as a guide.

A Recommendation for Expanding the Definition of Moral Distress Experienced in the Workplace

Despite the importance of moral distress in the nursing scholarship, little attention is paid to the phenomena in the psychological literature as an important occupational stressor. A factor limiting the application of moral distress to other occupational settings is its definitional features. First, a necessary condition of moral distress is the acknowledgment prior to behaviour initiation that behaviour will contravene personal moral ideals. Second, the definition of moral distress specifies that the inability to act in accordance with one's moral framework is driven by institutional constraints (non-autonomous behaviour). This article proposes that moral distress not be limited in these ways, and makes two central contributions to resolve this core problem. We offer a critique and extension of the conceptual definition of moral distress. Fourteen Australian medical doctors participated in a semi-structured interview regarding occupational morally distressing events. Medical doctors were chosen for our interviews because they are an occupational population with considerable decision-making autonomy. Based on the findings, two recommendations are made: (1) that the definition of moral distress is not limited to events where decision-making and behaviour is non-autonomous, and (2) moral distress should not be limited to occasions where the moral conflict is identified prior to decision-making or behaviour. An alternative definition of moral distress is proposed. We conclude that while organisational limitations are an important precipitate of moral distress, they are not a necessary condition for its emergence.

"If you build it, they will come": attitudes of medical residents and fellows about seeking services in a resident wellness program

BACKGROUND

High rates of burnout and distress in resident physicians suggest a significant number would benefit from counseling.

INTERVENTION

A resident wellness program (RWP) was designed to lower known barriers limiting resident access to services.

METHODS

In 2011, medical residents and fellows were surveyed and logistic regression analyses were conducted to identify demographic and training program differences in perceived barriers and willingness to access the RWP.

RESULTS

Of the 88% of trainees who knew about the RWP, 87% indicated they would be very likely or somewhat likely to seek out services. Time remained the biggest barrier for residents to getting help. Being male (odds ratio [OR]  =  0.54, 95% confidence interval [CI] 0.34-0.84) or an ethnic/racial minority (OR  =  0.49, 95% CI 0.28-0.85) was associated with greater unwillingness to seek counseling. Reluctance to access the RWP was associated with concerns about helpfulness, confidentiality, being unable to take a break, and stigma. Women (OR  =  1.60, 95% CI 1.06-2.42) and primary care residents (OR  =  1.58, 95% CI 0.98-2.54) were more likely to be concerned about taking a break. Men were more likely to question the helpfulness of counseling (OR  =  0.55, 95% CI 0.36-0.85).

CONCLUSIONS

The RWP removed barriers of cost and knowledge about counseling services. More educational outreach is needed to address sex and ethnic differences about RWP utilization and attitudes in medical culture about a physician's right to address personal health care needs.

A year in transition: a qualitative study examining the trajectory of first year residents' well-being

BACKGROUND

It is generally understood that trainees experience periods of heightened stress during first year residency, yet there is little information on variations in stress and well-being over the transition period or those factors that contribute to these variations. This qualitative study explored the trajectory of well-being described by first year residents in the context of challenges, supports and adaptations over time.

METHODS

In-depth interviews were conducted face-to-face with 17 first year residents at the University of Toronto. Participants drew a graph of their well-being over the course of their first year and described critical periods of challenge and adaptation. Interviews were audio-taped and transcribed. Results were organized into a thematic analysis using NVivo software.

RESULTS

Residents described a pattern of well-being that varied in accordance with changes in rotations. Well-being increased when residents perceived high levels of team support, felt competent and experienced valued learning opportunities. Well-being decreased with low team support, heavy work demands, few learning opportunities and poor orientations. Anxiety and excitement in the beginning of the year gave way to heightened confidence but increased fatigue and apathy towards the year's end. Residents used a number of cognitive, behavioural and self-care strategies to cope with transitional challenges.

CONCLUSIONS

Residents experienced a pattern of highly fluctuating well-being that coincided with changes in rotations. Residents' well-being varied according to levels of supervisor and colleague support, learning opportunities, and work demands. Residents' well-being may be improved by program interventions that facilitate better team and supervisory supports, maintain optimal service to learning ratios, establish effective fatigue and risk management systems, offer wellness support services and integrate skills based resiliency training into the curriculum.

Psychopathology and Suicide among Quebec Physicians: A Nested Case Control Study

Objective. To describe a psychiatric profile and characteristics of physicians who killed themselves in Quebec between 1992 and 2009. Method. The cases of 36 physicians (7 females and 29 males) and 36 nonphysicians who committed suicide were matched for age and gender and examined in a nested case control design. All subjects were judged as definite suicide by the Quebec Coroner Head Office. Consensus regarding DSM-IV diagnoses was established by two forensic psychiatrists. Results. Rates of all Axis I diagnoses were 83% for physicians and 91% for nonphysicians at the time of suicide. Major depressive disorders were the most frequently observed pathology in both groups (61% and 56%, resp.). Conclusions. Physicians and nonphysicians who committed suicide in Quebec suffered from the same type of psychiatric disorder at the time of killing themselves. The findings advocate strongly for more efficient suicide prevention measures including early detection and treatment of mood disorders for the physicians.

Personal health care of internal medicine residents

Introduction

Medical residents, as part of their job to balance the demands of their work with caring for themselves so as to be mentally, emotionally, and physically sound to stay clinically competent. While regulatory and legislative attempts at limiting medical resident work hours have materialized but have yet to attain passage, there are fairly little data looking into how residents cope up with their demands and yet attend to their own personal health.

Design

Anonymous mailed survey.

Subjects

Three hundred and thirty-seven residents from all internal medicine residency programs within United States.

Methods

We conducted a survey in the form of a questionnaire that was sent by e-mail to the program directors of various internal medicine residency programs within the United States, and responses were collected between May 19 and June 21, 2009. Response was well appreciated with total number of participants of 337 with even demographical distribution in gender, residency year, AMG/IMG, age group. Seventy-one percent of the residents felt that they would prefer getting admitted to their own hospital for any acute medical or surgical condition. Of the 216 residents who have had received health care in the past, almost half of them chose their own hospital because of the proximity, while 45% did not choose their own hospital despite proximity. Two out of three residents missed their doctors appointments or cancelled them due to demands of medical training. Only half of the residents have a primary care physician and almost 80% of them did not have their yearly health checkup. Close to 30% held back information regarding their social and sexual history from their provider because of privacy and confidentiality concerns. Eighty percent of residents never received information about barriers that physicians may face in obtaining care for their socially embarrassing conditions. Seventy percent felt that their performance then was suboptimal because of that health condition and also felt sick but did not drop the call. Half of the residents had concerns that they might be having a psychiatric illness, but only 5% of them received a formal evaluation at their own hospital and 23 (12.4%) at an outside hospital.

Conclusions

It is very important to have more studies to emphasize on resident's physical and mental health and encourage them to have a primary care physician. There are several reasons preventing residents from getting a formal evaluation, confidentiality reasons, lack of time – schedule constraints, fear of being labeled, and social repercussions are few of them. Program directors should encourage the residents to not only care of the health of their patients but also be enthusiastic about their personal health issues for upgraded, revised patient care, and ultimately for their overall well-being.

Mental health and stigma in the medical profession

Until recently, much of the recent upsurge in interest in physician health has been motivated by concerns about improving patient care and patient safety and reducing medical errors. Increasingly, more attention has turned to examining how the management of mental illness among physicians might be improved within the medical profession and one key direction for change is the reduction of stigma associated with mental illness. I begin this article by presenting a brief overview of the stigma process from the general sociological literature. Next, I provide evidence that illustrates how the stigma of mental illness thrives in the medical profession as a result of the culture of medicine and medical training, perceptions of physicians and their colleagues, and expectations and responses of health care systems and organizations. Lastly, I discuss what needs to change by proposing ways of educating and raising awareness regarding mental illness among physicians, discussing approaches to assessing and identifying mental health concerns for physicians and by examining how safe and confidential support and treatment can be offered to physicians in need. I rely on strategically selected studies to effectively draw attention to and support the central themes of this article.

Health-related quality of life predictors during medical residency in a random, stratified sample of residents

OBJECTIVE

To evaluate the quality of life during the first three years of training and identify its association with sociodemographicoccupational characteristics, leisure time and health habits.

METHOD

A cross-sectional study with a random sample of 128 residents stratified by year of training was conducted. The Medical Outcome Study -short form 36 was administered. Mann-Whitney tests were carried out to compare percentile distributions of the eight quality of life domains, according to sociodemographic variables, and a multiple linear regression analysis was performed, followed by a validity checking for the resulting models.

RESULTS

The physical component presented higher quality of life medians than the mental component. Comparisons between the three years showed that in almost all domains the quality of life scores of the second year residents were higher than the first year residents (p < 0.01). The mental component scores remained high for third year residents (p < 0.01). Predictors of higher quality of life were: second or third year of residency, satisfaction with the training program, sufficient time for leisure, and care of critical patients for less than 30 hours per week.

CONCLUSION

The mental component of quality of life was the most impaired component, indicating the importance of caring for residents' mental health, especially during their first year and when they are overloaded with critical patients.

Developmental challenges, stressors and coping strategies in medical residents: a qualitative analysis of support groups

OBJECTIVES

Stress and burnout are endemic in postgraduate medical training, but little research is available to guide supportive interventions. The identification of the longitudinal emotional and developmental coping needs of internal medicine residents could assist in the better design and implementation of supportive interventions.

METHODS

In this retrospective, exploratory study, six internal medicine resident support groups (n = 62; residents in postgraduate years [PGY] 1-3) were followed for a period of 2 years. Qualitative data were extracted from monthly support group process notes to identify common themes, stressors, emotions, coping strategies and developmental challenges faced during training. Quantitative questionnaire data were collected on burnout, group attendance and resident satisfaction.

RESULTS

Using professional identity development models and classic stress and coping theory as a starting point, a derivation of grounded theory was used to identify common themes and emotions documented in support group process notes. The most common themes included understanding resident roles and responsibilities, developing an identity as a resident and doctor, building professional confidence, cognitive and behavioural responses to stress, and concerns about flaws in local and national health care training and delivery systems. Anxiety and guilt were the most commonly reported emotions, followed by positive emotions and anger. Burnout scores were highest for the second half of PGY1, but improved over subsequent training years. Support group attendance and satisfaction were both high. Residents overwhelmingly pointed to peer relationships as the most critical source of support throughout postgraduate training.

CONCLUSIONS

Developmentally informed programmatic adaptations could better support the emotional growth and personal and professional development of postgraduate medical trainees. Future directions should include a controlled trial of resident support groups, assessments of 'active ingredients' (i.e. to establish which supportive interventions are most effective), and evaluations of programmatic adaptations.

Stress, personal characteristics and burnout among first postgraduate year residents: a nationwide study in Taiwan

BACKGROUND

Many studies have recognized that the first postgraduate year (PGY-1) of residency training is the most stressful year. Failing to cope with the stress will have negative impact on their work performance and the quality of patient care.

AIMS

To investigate stress and burnout in first postgraduate year (PGY-1) residents and to explore the relationship among stress, personal characteristics and burnout.

METHODS

A total of 555 PGY-1 residents completed the job stress questionnaire, a Chinese version of the Copenhagen Burnout Inventory, NEO-Five Factor Inventory, Positive and Negative Affectivity Schedule Scale and Coping Strategies Inventory. Working hours were also collected. The association among stress, burnout, personality, coping strategies and affectivity was examined by Pearson correlation. Hierarchical multiple regression was performed to analyze the contribution of predictors to burnout.

RESULTS

Residents identified their working environment and emotional pressures and demands from patients as their primary sources of stress. They exhibited less neuroticism, more conscientiousness and a propensity for positive affectivity, as well as a tendency to use engagement coping strategies. Burnout was positively correlated with stress, neuroticism, negative affectivity, disengagement coping and weekly work hours. Job stress and work hours explained 24.7% of variance in burnout; personality and coping strategies explained an additional 10.4% and 5.4% of variance, respectively. Besides job stress and work-hours, introversion, conscientiousness, having negative affectivity and using disengagement coping predicted burnout.

CONCLUSIONS

Resident's personal characteristics were closely related to stress and burnout. Therefore, in addition to assessing their work-related stress, exploring their personal characteristics should be taken into account for early identification of residents at risk of burnout.

[Social support and physicians' health]

OBJECTIVES

Over the last decades, social support (SU) has proved to be an important psychological health resource in the prevention of mental and physical illness as well as for the promotion and restoration of general health. This study evaluates the relevance of social support for the health and well-being of physicians.

METHOD

This is a systematic literature review using PubMed from 1970 to 2007 with the keywords "social support", "physicians", "physician's role", and respectively "medical staff, hospital" from medical subheadings (MeSH). From the retrieved articles the additionally relevant keywords "marriage", "spouse", "friends", and "self-help groups" (MeSH) were identified and researched.

RESULTS

Social support with distinct effects on physician's health could be shown in the areas of colleagues and professional network (30 sources), marriage/spouse (47), friends (3), and support groups (13). Female physicians appeared to seek and profit more from SU than did male physicians. Informal friendships have yet to be evaluated thoroughly.

CONCLUSION

In the light of a physician's daily stress, SU appears to be a jeopardized resource that could significantly contribute to the prevention of burnout or other profession-related symptoms or illnesses.

An exploratory study of resident burnout and wellness

PURPOSE

Physicians have a higher rate of burnout compared with the general population, and burnout's origin can be traced to residency training. Little evidence exists documenting the causes of burnout, and there is even less evidence on protective factors. The goal of this exploratory study was to determine which resident-identified stressors are associated with the presence of burnout and which resident-identified wellness factors are associated with the absence of burnout.

METHOD

In the fall of 2006, residents from 13 specialties completed a demographics questionnaire, a survey of factors that promote burnout and wellness, and the Maslach Burnout Inventory.

RESULTS

From a pool of 395 residents, 150 (38%) completed the questionnaires. Of 32 burnout factors, 27 were significantly associated with at least one burnout scale. Pessimism was the only burnout factor associated with all three burnout scales; 11 other burnout factors were associated with at least two burnout scales. Of 29 wellness factors, 25 were significantly associated with at least one burnout scale, indicating a lack of burnout. Use of prescription medications was the only wellness factor associated with all three burnout scales, indicating low burnout. Thirteen other wellness factors were associated with at least two of the scales.

CONCLUSIONS

Significantly more research is needed to further define and measure wellness. Program directors should consider multiple burnout and wellness factors associated with burnout (or its absence) when designing treatment interventions. The aim should be to identify and bolster wellness factors that protect from burnout while minimizing the stressors that cause it.

Counselling for burnout in Norwegian doctors: one year cohort study

OBJECTIVE

To investigate levels and predictors of change in dimensions of burnout after an intervention for stressed doctors.

DESIGN

Cohort study followed by self reported assessment at one year.

SETTING

Norwegian resource centre.

PARTICIPANTS

227 doctors participating in counselling intervention, 2003-5.

INTERVENTIONS

Counselling (lasting one day (individual) or one week (group based)) aimed at motivating reflection on and acknowledgement of the doctors' situation and personal needs.

MAIN OUTCOME MEASURES

Levels of burnout (Maslach burnout inventory) and predictors of reduction in emotional exhaustion investigated by linear regression.

RESULTS

185 doctors (81%, 88 men, 97 women) completed one year follow-up. The mean level of emotional exhaustion (scale 1-5) was significantly reduced from 3.00 (SD 0.94) to 2.53 (SD 0.76) (t=6.76, P<0.001), similar to the level found in a representative sample of 390 Norwegian doctors. Participants had reduced their working hours by 1.6 hours/week (SD 11.4). There was a considerable reduction in the proportion of doctors on full time sick leave, from 35% (63/182) at baseline to 6% (10/182) at follow-up and a parallel increase in the proportion who had undergone psychotherapy, from 20% (36/182) to 53% (97/182). In the whole cohort, reduction in emotional exhaustion was independently associated with reduced number of work hours/week (beta=0.17, P=0.03), adjusted for sex, age, and personality dimensions. Among men "satisfaction with the intervention" (beta=0.25, P=0.04) independently predicted reduction in emotional exhaustion.

CONCLUSIONS

A short term counselling intervention could contribute to reduction in emotional exhaustion in doctors. This was associated with reduced working hours for the whole cohort and, in men, was predicted by satisfaction with the intervention.

Medical students' experiences with medical errors: an analysis of medical student essays

OBJECTIVE

This study aimed to examine medical students' experiences with medical errors.

METHODS

In 2001 and 2002, 172 fourth-year medical students wrote an anonymous description of a significant medical error they had witnessed or committed during their clinical clerkships. The assignment represented part of a required medical ethics course. We analysed 147 of these essays using thematic content analysis.

RESULTS

Many medical students made or observed significant errors. In either situation, some students experienced distress that seemingly went unaddressed. Furthermore, this distress was sometimes severe and persisted after the initial event. Some students also experienced considerable uncertainty as to whether an error had occurred and how to prevent future errors. Many errors may not have been disclosed to patients, and some students who desired to discuss or disclose errors were apparently discouraged from doing so by senior doctors. Some students criticised senior doctors who attempted to hide errors or avoid responsibility. By contrast, students who witnessed senior doctors take responsibility for errors and candidly disclose errors to patients appeared to recognise the importance of honesty and integrity and said they aspired to these standards.

CONCLUSIONS

There are many missed opportunities to teach students how to respond to and learn from errors. Some faculty members and housestaff may at times respond to errors in ways that appear to contradict professional standards. Medical educators should increase exposure to exemplary responses to errors and help students to learn from and cope with errors.

A pioneering experience in Brazil: the creation of a support network for alcohol and drug dependent physicians. A preliminary report

OBJECTIVE: The objectives of this study are to present the creation and operation of a support network to help physicians in Brazil, describe the socio-demographic profile, and investigate the prevalence of mental disorders and chemical dependence among physicians seeking treatment. METHOD: Semi-structured interviews using ICD-10 criteria were conducted to obtain data regarding alcohol/drug dependence, and psychiatric comorbidity. Socio-demographic and occupational characteristics were obtained. RESULTS: 247 patients made contact and 192 attended the first evaluation visit. Of those, 158 were male, and most (55%) were married. The mean age was 42.4 ± 11.1 years. The reasons for seeking treatment were: comorbidity between mental disorders and chemical dependence (67.7%); chemical dependence (20.8%); mental disorders (7.8%); and burnout (4.2%). The mean interval between the detection of the problem and seeking treatment was 7.5 years. Factors associated with the severity of the problem included unemployment (21.6%), difficulties of practicing professional activities (63.5%), problems with the Regional Council of Medicine (13%), psychiatric hospital admission (31.2%), and self-medication (71.8%). In our sample, 9.3% of the physicians had changed their area of specialization. CONCLUSIONS: A high prevalence of psychiatric disorders was found in this sample as well as psychosocial and professional problems. Treatment networks focusing on the physicians' mental health could catalyze cultural changes in treatment-seeking behavior, thereby improving early detection and treatment.

Does a self-referral counselling program reach doctors in need of help? A comparison with the general Norwegian doctor workforce

BACKGROUND

Doctors have a relatively high degree of emotional distress, but seek help to a lesser degree and at a later stage than other academic groups. This can be deleterious for themselves and for their patients. Prevention programs have therefore been developed but it is unclear to what extent they reach doctors in need of help. This study describes doctors who participated in a self-referrral, easily accessible, stress relieving, counselling program in Norway, and compares them with a nationwide sample of Norwegian doctors.

METHODS

Two hundred and twenty seven (94%) of the doctors, 117 women and 110 men, who came to the resort centre Villa Sana, Modum, Norway, between August 2003 and July 2005, agreed to participate in the study. Socio-demographic data, reasons for and ways of help-seeking, sick-leave, symptoms of depression and anxiety, job stress and burnout were assessed by self-reporting questionnaires.

RESULTS

Forty-nine percent of the Sana doctors were emotionally exhausted (Maslach) compared with 25% of all Norwegian doctors. However, they did not differ on empathy and working capacity, the other two dimensions in Maslach's burnout inventory. Seventy-three percent of the Sana doctors could be in need of treatment for depression or anxiety based on their symptom distress scores, compared with 14% of men and 18% of women doctors in Norway. Twenty-one percent of the Sana doctors had a history of suicidal thoughts, including how to commit the act, as compared to 10% of Norwegian doctors in general.

CONCLUSION

Sana doctors displayed a higher degree of emotional exhaustion, symptoms of depression and anxiety as well as job related stress, compared with all Norwegian doctors. This may indicate that the program at Villa Sana to a large extent reaches doctors in need of help. The counselling intervention can help doctors to evaluate their professional and private situation, and, when necessary, enhance motivation for seeking adequate treatment.

Mental health in three generations of Iranian medical students and doctors. A cross-sectional study

OBJECTIVE

Despite research in Western countries finding high levels of psychological morbidity in medical students and doctors, little is known about difficulties faced by medical staff in the Middle East. The aim of the present study was to assess emotional disturbance and interpersonal attitudes in a representative sample of Iranian medical students and practitioners.

METHOD

A total of 82 medical students, 92 interns and 89 general practitioners (GPs) participated in the study. Participants rated the 28-item version of the General Health Questionnaire (GHQ-28) and a measure of interpersonal attitudes.

RESULTS

A total of 44% of participants scored above the threshold of the GHQ-28, indicating probable psychiatric disorder. The GHQ-28 scores were higher in students than interns or GPs and in women compared with men. Medical students and doctors had high levels of indifference and cynicism.

CONCLUSIONS

This study suggests that psychological morbidity was common in Iranian medical students and practitioners, particularly women. Women were at particular risk. A high prevalence of emotional disturbance among health care practitioners is likely to compound existing problems of health care provision.

Combating the stress of residency: one school's approach

Residency is a time of stress and turmoil for many residents. The stresses are varied and great, often involving both personal and professional issues. One institutional mechanism that has been shown to help residents cope with stress is the use of residents' wellness, or assistance, programs. The University of South Florida (USF) College of Medicine developed the USF Residency Assistance Program (RAP) in 1997, modeled after business employee assistance programs but tailored to enhance the well-being of residents. The program was developed in an organized, thoughtful manner starting with a Request for Proposals to all local employee assistance programs and the selection of one of these to run the program. The RAP is broad-based, readily available, easily accessible, totally voluntary and confidential, and not reportable to the state board of medicine. It is well integrated into all residency programs and has had excellent acceptance from the administration; information about access to the RAP is available to all residents through multiple venues. The cost is minimal, at only seven cents a day per resident. The authors present data from the eight years the RAP has been operating, including information on program use, referral rates, acceptance, and types of problems encountered. One suicide occurred during this time period, and the RAP provided a significant role in grief counseling. Assistance programs are critical to the well-being of residents. The USF program presents a model that can be used by other programs around the country.