Wellness Scott M. Rodgers, MD Associate Dean for Students Vanderbilt School of Medicine February 9, 2007

The Stress of Residency Inordinate hours Sleep deprivation Excessive workload Overbearing clerical and administrative responsibilities Inadequate support Difficult patients Family Finances Isolation

Internship Year What to Expect Anticipation/Excitement Self doubt and awareness of limitations Depression sometimes Recognition of new skills Gratification and anticipation of new experiences

House-officer Stress Syndrome Four occur in most residents Episodic cognitive impairment Chronic anger Pervasive cynicism Family discord Three others suggest serious impairment Depression Suicidal ideation and suicidal behavior Substance abuse

Burnout Emotional exhaustion Depersonalization Reduced sense of personal accomplishment All of the above leads to a drop in level of patient care

Common Sources of Stress Gender Women report higher levels of stress reaction to residency than do men Anxiety related to role stress Loneliness/depression Problems balancing family and career Lack of relationship development in residency Prejudice from patients, nurses Fewer role models

Stress Sources Continued Pregnancy Fatigue Too little time for partner Too much physical activity First year is most stressful time to be pregnant

Stress Sources Continued Family Partner is most influential person in the choice of residency Females more likely to sacrifice their needs for their partners Physicians have a lower divorce rate but higher rates of conflict, instability, and dissatisfaction. Certain specialties have higher divorce rates (i.e. orthopedic surgery, psychiatry)

Roy Menninger To paraphrase: Physicians work hard to prove their self-worth and take care of others, but have never learned how to have intimacy and receive support from others for themselves Marriages are subsequently particularly troubled

Financial Student debt burdens continue to rise Physician salaries are falling Residents feel compelled to moonlight

Empathy Relationship exists between enhanced resident well-being and empathy-one aspect of resident competency.

The Halstead Method William Halstead – deeply influenced by the German method of training in surgery in late 19th century Rigorous surgical training requiring exacting discipline and total dedication to the art and science of surgical care. Family not a priority. Young surgeons not allowed to leave the hospital (hence the term residents). Basic principles remained unchanged until recently What stimulated change?

The Libby Zion Case 1984 – an 18 year old woman in a New York hospital whose care was provided by residents who were on duty for more than 18 hours. Led to state legislation limiting resident working hours…in New York only June, 2002 – ACGME set new standards on resident work hours which have been strictly implemented since July, 2003

Medical Student Values Shift Controllable lifestyle, amount of work, and level of stress in future specialty have replaced altruism and self-sacrifice (one study only)

Protection from Stress High levels of job satisfaction Being a parent Having a physician parent Speaking about concerns with colleagues, friends, and family Support from training director and faculty Counseling services (psychological, financial, career) Reduced work hours – depends on the study you read Exercise/nutrition – no data

References The Effect of the 80 hour Work Week on Resident Burnout, Archives of Surgery, September, 2004. Relationship Between Increased Personal Well-Being and Enhanced Empathy Among Internal Medicine Residents, Journal of General Internal Medicine, January, 2005. Sources of Stress for Residents and Recommendations for Programs to Assist Them, Academic Medicine, February, 2001. Stress and Coping Among Orthopedic Surgery Residents and Faculty, The Journal of Bone and Joint Surgery, 2004. Burnout and Internal Medicine Resident Work-Hour Restrictions, Archives of Internal Medicine, December, 2005.